An evaluation of professional development for staff working with nursing students in distress

INTRODUCTION

One in three higher education students is reported to experience anxiety or depression during their studies (Carter et al. 2017). Nursing students on clinical placement report clinical learning experiences as the most anxiety provoking component of their studies (Arkan et al. 2018; McCloughen et al. 2020). Many causes of their anxiety have been reported: encountering differences between classroom preparation and clinical staff expectations (Scully, 2011), witnessing staff conflict that student may, in turn, fear be directed at them (Birks et al. 2017), experiencing performance anxiety in the presence of clinical assessors (Arkan et al. 2018), and emotional responses related to the unpredictable clinical environment (McCloughen et al. 2020). With the onset of the COVID-19 pandemic mental distress has escalated (Singh 2020), where one definition of distress is ‘anxiety’ or ‘extreme anxiety’ (Oxford languages 2022). Healthcare workers are one population whose mental health and well-being have been impacted by COVID-19 with reports of students presenting in distressed states for their clinical learning citing increased levels of depression, anxiety, fear and stress (Muyladi et al. 2021).

Registered nurses (RNs) are the staff responsible for supporting nursing students during their clinical learning. These RN education support roles are known by a wide variety of titles; two of the more common are preceptor and clinical facilitator. The preceptor role is responsible for working alongside students whilst also providing direct patient care. The clinical facilitator role is normally supernumerary and is charged with supporting and assessing nursing students’ clinical learning. Studies exploring clinical facilitator experiences confirmed they may struggle to support student mental health and well-being during the clinical placement (Author 2019; Sanderson & Lea 2012). However, few studies have examined this group of RN’s challenges in detail.

McAllister et al. (2015) explored nursing academic experiences of supporting psychologically distressed nursing students and found academics may feel distressed themselves when unable to provide appropriate care to students. Earlier, Cleary et al. (2012) stressed the importance of academics understanding early intervention and appropriate referral systems for students at risk of mental health concerns. Oprescu et al. (2017) studied the capabilities of Australian nurse educators and recommended academics prepare nursing students for clinical learning so students themselves understand they may become anxious in the clinical settings and provide students with ways to reduce and manage their anxiety. Kurtović et al. (2018) reported that students may benefit from learning coping skills that develop individual agency in dealing with the demands of being a student. Protective factors include identifying and utilizing individual social supports, hobbies and interests and assisting an individual to adjust to life stressors so they can build individual strength and resilience (Macneil et al. 2012). Regarding self-care interventions, Moscaritolo (2009) suggested nursing students could benefit from learning mindfulness techniques in preparation for clinical learning experiences. Recent reviews have recommended students learn, and practice, positive thinking and self-affirmations before the clinical placement (Cant et al. 2021) after several nursing students reported the strategies assisted them to cope more effectively with their anxiety during clinical learning (Sun et al. 2020). Emerging works recommend universities better prepare nursing academics, and students for their clinical learning experiences by introducing them to well-being and anxiety management strategies such as the notion of regular practice of self-care activities (Cleary et al. 2020). Professional nurses have a responsibility to individual self-care and well-being as outlined in many countries’ standards for practice, see, for example, Nursing and Midwifery Board Australia, (NMBA) (2016) and American Association of Colleges of Nursing (AACN) (2008). Hence, most contemporary nursing undergraduate programmes introduce students to the concept and encourage them to develop a self-care plan (Brandon 2018). Few published studies, however, report on the preparation of RN facilitators and preceptors working in clinical settings to meet the expectation of working with distressed students.

One study set in regional Queensland, Australia, was designed to increase generalist nurses’ confidence when working with paediatric patients experiencing acute mental health concerns, after engaging in a workshop on foundations of mental health nursing (Moxham et al. 2010). Better preparation of nursing academics and generalist nurses working with distressed students could benefit both the professional nurse and the nursing student through enhanced support throughout their learning and teaching experiences.

METHODS

The two authors decided to adopt an action research informed approach to collaborate with a key group of stakeholders, to understand their experiences and challenges working with distressed students. All action research approaches are cyclical, incorporating inquiry methods and time for reflection to uncover challenges, and identify solutions to facilitate changes in practice (Kemmis 2009). This study utilized three cycles, referred to here as phases, that incorporated the five-step action research method ITDEM Identifying problems and Thinking of ways to tackle the problem, Doing it and Evaluating it and Modifying future practice (Norton 2018). In this study, Phase 1 saw researchers and clinical facilitator participants collaborate to identify pressing problems and initial solutions to include in a professional development activity, Phase 2 implemented and evaluated the professional development activity and Phase 3 was intended for the researchers to incorporate the findings and results to modifying the intervention for future offerings.

RESULTS

Forty-five participants completed the professional development activity and 34 completed matched pre- to post-tests were returned. Thirty-two participants answered the item “years working as a facilitator”. Most (24) identified as clinical facilitators: 10 declaring more than 6 years working in the role, 8 had worked between 1 and 5 years and a further 6 had worked for less than one year in the role. Eight (8) participants identified as preceptors, see Table 3.

The analysis showed high scoring means for all items, 1–8, see Table 2. There was a shift pre (22.85 ± 4.37, n = 34) to post (29.53 ± 3.43, n = 34) indicating a positive change in participants’ perceived knowledge and preparation for working with distressed students. The reverse scoring item I wish I could hand over students with mental health concerns to another clinical facilitator was adjusted accordingly.

One post-test item asked the participants to provide an overall evaluation of the professional development activity. Thirty-one (91%) of the completed matched surveys showed participants either agreed or strongly agreed the workshop content could improve their interactions with students. Twenty-four (73%) participants agreed or strongly agreed with the item, would you recommend others working with students attend this workshop. A third item enquired if the intervention motivated participants to undertake further professional development on the topic with 26 participants (84%) either agreeing or strongly agreeing they felt motivated to further my knowledge around mental health concerns for nursing students and other populations.

The feedback survey had 7 pre- to post-test matched Likert style items. Five of these returned statistical significance as shown in Table 4. Participants self-reported a statistically significant increase in their understanding of how to work with distressed students, as well as the university and local community referral processes available to them. The activity was statistically significant for improving participants self-reported confidence in caring for their own emotional well-being, see item 7, Table 2 that measured this construct. It can be hypothesized the item I wish I could hand over students with mental health concerns to another clinical facilitator/preceptor did not return statistically significant results because the professional development did not include activities that encouraged participants to critically examine individual assumptions around when and why such decisions may be appropriate.

A simple yes/no response item enquired of participants if they had a self-care plan. The pre-test results indicated a little over half (58%) of participants responded yes, and there was an increase to 79% post-test.

DISCUSSION

This study utilized a research approach informed by action research (Kemmis 2009; Norton 2018) that brought researchers and clinical facilitators together to co-design a professional development activity. In choosing an action research design approach for this study, the researchers hoped to offer suitable professional development to enhance clinical facilitators’ work with nursing students experiencing distress (anxiety). This approach has been recommended by other nursing researchers to overcome clinical facilitator/preceptors’ dissatisfaction with professional development that was designed without any regard for their learning needs, see, for example, work by Author (2020), McAllister and Osborne (2006); and Needham et al. (2016). An education feedback survey sought to understand the impact of the professional development activity for preparing clinical facilitators and preceptors for working with distressed students and the benefit of introducing participants in this study to self-care strategies.

Two participants had formal mental health qualifications with a further three having participated in mental health-related informal training. The lack of mental health skills and experience in RNs supervising students clinical learning has previously been identified (Author 2019; McAllister et al. 2015). Some studies have reported generalist nurses who completed mental health education gained confidence when caring for patients with mental health diagnoses (Moxham et al. 2010). Our study further extends these earlier findings. Participants in our study self-reported that the professional development activity could potentially positively impact their capability to respond to nursing students experiencing distress and mental health concerns. On completion of the professional development activity evaluated and reported in this paper, participants self-reported an increase in perceived comfort working with this student cohort. In addition, 84% felt participating in the professional development activity motivated them to seek further professional development for working with people experiencing mental health concerns, generally. Now, during the COVID-19 pandemic, where it is broadly recognized that the pandemic has increased RNs and student nurses’ levels of anxiety (Mulyadi et al. 2021; Singh 2020), our intervention could provide valuable insights for those wishing to increase mental health knowledge of clinical facilitators and preceptors, or to assist them to identify appropriate pathways to provide support to students in preparation for clinical learning (Cant et al. 2021).

It is known and well-reported nursing students experience exacerbations of anxiety during clinical learning (Arkan et al. 2018; Moscaritolo 2009), with studies arguing many students are reluctant to report their mental illness, causing academics to feel stressed by inadequate preparation for, and the time needed to support this cohort of students (McAllister et al. 2015; Wynaden et al. 2014). While understanding how to approach and work with distressed students could benefit clinical facilitators and preceptors, we also suggest that these nursing education roles should not expect nurses to counsel students (Author 2019) making it important for clinicians working in these roles to develop an understanding of when to refer on to other professionals.

Our evaluated intervention introduced participants to referral pathways for one regional university’s internal counselling and incident reporting services, as well as providing reminders of after-hours and crisis community services available to them. This information was well received with many participants indicating an improved understanding of the options available to them, following the intervention. Whilst this result is not surprising, it serves as an important reminder that clinical nursing staff who support students clinical learning must have some knowledge of higher education organizations’ policies, in order to work effectively in their role. This is especially important when supporting students who usually rely on university supports, and who may have reduced, or no access, to such services whilst undertaking clinical learning experiences. It only takes a quick search of the recent published nursing studies to confirm there is concern for RNs and nursing students’ mental health and well-being as a result of COVID-19 (Mulyadi et al. 2021). We argue our study is important as there appears to be little work undertaken to prepare clinical facilitators and preceptors to work with nursing students experiencing anxiety – a nursing curriculum requirement known to exacerbate student anxiety (Arkan et al. 2018) – even before the added challenges of COVID-19 Mulyadi et al. (2021) identified.

Participants in this study agreed the professional development activity could improve their interactions with students experiencing distress. Furthermore, most of the participants agreed staff working with students should be recommended to attend the professional development activity. We encourage employers of preceptors and clinical facilitators to offer and sanction staff time to attend professional development such as is reported on here so as they may learn how to support distressed students and enhance individual and group mental health literacy, and ability for working with this student cohort. Opportunities like the one reported on here are rarely available and evaluations if undertaken are rarely published. It is now time for such offerings to address contemporary issues, such as working with distressed students, and to be evaluated and shared with the wider nursing community.

The professional development activity in this study was designed with input from a key group of clinical facilitators who identified a need for individual and group self-care strategies because facilitators themselves were feeling stressed and underprepared for their work supporting anxious students (McAllister et al. 2015). Participants in our study were also introduced to and spent time practicing mindfulness, savouring and gratitude that are recommended for reducing anxiety (Moscaritolo 2009). In our study, there was a small increase in the number of participants who reported they were leaving the workshop with a self-care plan. More studies are now needed that introduce self-care and setting self-care goals with this group of clinicians and with nursing students and academics. Emerging studies recommend self-care plans and care of self as priority strategies to enhance health workforce staff well-being, stress and anxiety management (Cleary et al. 2020; Moscaritolo 2009). In this way, participants could draw on their own experiences of setting self-care goals and self-care planning, explore their own relationship with mental health and well-being, and giving them further awareness of how their self-health influences their practice.

LIMITATIONS AND RECOMMENDATIONS

While the study evaluation reported on here provides some tentative evidence of the effectiveness of this professional development intervention, there are limitations which must be acknowledged. We acknowledge that participants who choose to attend an educational activity will mostly self-report a change in knowledge. This study did not adopt an experimental design; therefore, it is possible that factors other than the intervention could have contributed to the changes in scores from pre- to post-test. The researchers and the key stakeholder group thought purposively excluding participants during our study by placing them in a control group would deprive them of the potential benefits. Follow-up observational studies would also be valuable to supplement the self-reported data, enabling researchers to better gauge change in behaviour and interactions with distressed students, as well as personal self-care practices. Data that evaluate return on investment and translation to practice regarding the educational content in the professional development activity would deepen understanding of best practice in developing and delivering professional development of this nature, in synchronous and potentially asynchronous modes.

CONCLUSION

This study evaluated a professional development activity that encouraged researchers to work with clinical facilitators and preceptors to understand their professional development needs for working students experiencing distress (extreme anxiety). Researchers were able to design professional development that was meaningful and relevant for the group. There was an apparent benefit to participants in introducing them to the importance of individual and group self-care plans, and well-being techniques and strategies. More importantly, the reported results appear to indicate that the professional development activity could benefit RNs’ mental health literacy, enhancing their ability to more effectively support nursing students experiencing anxiety during clinical learning experiences.

RELEVANCE FOR CLINICAL PRACTICE

RNs who support students’ during clinical placements may be under prepared for their work supporting distressed students. Professional development targeting mental health literacy for this important group of nurse educators is needed. This study offers readers a way of designing meaningful professional development opportunities and ideas for the type of activities that participants rated positively for supporting their work with anxious and distressed students. 4193/5000 (no references included).