Delivery of Mental Health Education in Undergraduate Nursing Programs: A Systematic Review Amanda Vandyk and Sabrina Merali

Funding received from the Registered Nurses Association of Ontario and the MOHLTC

The Team RNAO  Irmajean Bajnok, RN, PhD  Sabrina Merali, RN, MN NBPRC  Barbara Davies, RN, PhD

University of Ottawa  Erica Wright, MLIS

Supporting Best Practices in Mental Health & Addictions for Undergraduate Nursing Students Project Objectives: •To raise the profile of Mental Health and Addictions Nursing • To support Mental Health and Addictions implementation of Best Practices in undergraduate nursing educational settings • To conduct a systematic review regarding best practices in Mental Health and Addictions education (theory, clinical, simulation) • To develop a resource to support educators and students in using Mental Health and Addictions best practices

Background •

2008 RNAO Resolution from the Mental Health Nurses Interest Group re: Mental Health and Addictions curriculum and practicum opportunities

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2009 Canadian Federation of Mental Health Nurses Position Paper “Core Competencies in Psychiatric Mental Health Nursing for Undergraduate Nursing Education”

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2012 – 2013 RNAO Mental Health and Addictions Environmental Scan • • •

Environmental Scan consisted of: review of literature and key documents; focus groups; key informant interviews and validation and action planning meetings Core Competencies: Supporting consistent use of core competencies nursing education curricula. RNAO leads and supports enhancements to mental health and addictions practices by developing an evidence-based toolkit to support the uptake and implementation of best practices.

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Discussions with key stakeholders (MHNIG, CFMHN, COUPN, CASN)

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Initiated Systematic Review with Nursing Best Practice Research Centre

The Current Context 

Persons with mental health and addiction issues are cared for in all health settings

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Not all nurses feel preprared to care for persons with mental health and addiction concerns

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Need to better prepare nurses for the care of people with mental health and addiction issues regardless of practice setting

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New entry-to-practice competencies

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We will need to tailor education to ensure these competencies are learned and mastered by all students

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Before changing, we need to know where we are and what we do well

The Systematic Review Purpose: To systematically review and examine literature describing the ways in which educators are delivering mental health and addiction content (including theory, clinical, and simulation) in undergraduate nursing programs.

Objectives: 1.

To systematically review and examine literature on the delivery of mental health clinical education in undergraduate nursing programs;

2.

To systematically review and examine literature on the ways in which educators are using simulation to teach mental health and addiction content in undergraduate nursing programs;

3.

To systematically review and examine existing pedagogies for mental health nursing in undergraduate degree programs

Design 

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Three phase Systematic Review modeled on the Joanna Briggs Methodology PICO PRISMA reporting guidelines

MEDLINE

CINAHL

ERIC

EMBASE

PsychINFO

1331

1872

36

1424

708

Grey Search 5779

Total combined: 5371 Duplicates: Discarded after initial review: 5119 Full citations read to determine match with inclusion criteria: 253

Discarded after initial review: 5692

Discarded after complete review: 79

Discarded after complete review: 154

Hand search of reference lists of included citations: 5

Duplicates removed: 8

Final total included in review: (88 Database) (6 Grey) Theory (49), Clinical (14), Simulation (31)

Search Decision Tree

Data Extraction & Synthesis 



Clinical Review General Information

Authorship Date Country or origin Purpose Nursing student population

Study Characteristics

Design Sample size Results Recommendations

Clinical Characteristics

Clinical setting Description of placement Timeframe

Simulation Review Simulation Characteristics

Type of simulation Description of simulation Timeframe MH content covered Goals/Objectives of sim.

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Theory Review - Studies Pedagogy Characteristics

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Teaching strategy MH content covered

Theory Review - Discussion Information

Type of text Stated Bias Position Topic Purpose Data Presented Conclusions

Relevance - Clinical 

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Clinical education allows for students to consolidate their learning and use theoretical knowledge in practice (Wu, Enskar, Lee, & Wang, 2015) Safe environment fostering clinical competence through mentorship and teaching Many systems factors influencing clinical placements and their availability  Mental health placements amongst the most affected Students who participant in MH placements:  Less stigma  More interest in MH nursing as a career  Confidence and preparedness when caring for people with MI regardless of setting

Key Findings - Clinical 

Study Characteristics Total Studies

Date Range

14



2005-2014

Countries Australia Canada Brazil USA Belgium

Design 7 2 2 2 1

Quant. Qual. Mixed

5 7 2

Clinical Characteristics Mental Health Settings Adult IP Child IP Geriatric IP Community Rehab MH generally Addiction

9 1 2 6 2 3 1

Timeframe

Academic Year

6 days - 7 weeks

Year 2 Year 2/3 Year 3 Year 4 Not reported

Not reported: 6

5 2 2 1 5

Synthesized Findings  

Facilitators of a Positive Student Placement Barriers to a Positive Student Placement  Mentorship

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Placement Outcomes  Significant quantitative results  Categorized qualitative results

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Knowledge and Skills Learned

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Areas for Improvement/Recommendations

Facilitators and Barriers 

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Key Facilitators  Not just communication, but relationship  Students as valued members  Lots of time with small numbers Key Barriers  Negative attitudes  Inadequate learning opportunities  Poor mentorship What about mentorship?

Placement Outcomes 

Quantitative  Better attitudes  Increased confidence  Ability/Skill aquisition

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Qualitative  Better attitudes  Increased confidence  Ability/Skill aquisition  Understanding/Knowledge

Knowledge/Skills & Key Recommendations   

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Medication administration Communication Assessment Holistic approaches to care Key Recommendations:  Organizational/systems issues  Pedagogical improvements

Relevance - Simulation 

Simulation is defined as any activity that mimics the reality of a clinical setting, while providing a safe learning environment without the stress of a real patient (Jeffries, 2005).

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Provides students with the opportunity to receive immediate feedback on performance and practice in a safe and supportive learning environment (Jeffries, 2005).

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Mental health-specific barriers to student learning: Fear, anxiety and lack of student understanding of mental health illness and the biases and stigma of this population.  Simulation within mental health nursing education can improve therapeutic communication skills, critical thinking, self-confidence and risk assessment, as well as decreasing student fear related to working with this population (Brown, 2015).

What is Simulation 

There are several different types of simulation, such as computerbased simulation, virtual patients, partial-task simulators, human patient simulator and standardized patients (Li, 2007).

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Three major levels of simulation fidelity, low, medium and high.  A low fidelity simulator is often used to practice psychomotor skills, such as insertion of a foley catheter. An example of low fidelity would be a foam pad simulator used to practice intramuscular injections. 

A medium fidelity simulator more closely resembles reality when compared to a low fidelity simulator and can be used to provide more in depth learning opportunities, such as perfecting an understanding of heart sounds (Nehring &t Lashley, 2010).

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A high fidelity simulator is sophisticated and mimics real life. Examples are computer or instructor controlled mannequins.

What is Simulation 

Students typically participate in simulation learning activities in small groups in a simulation lab that is led by a facilitator (Garrett, MacPhee and Jackson, 2011).

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Three phases: the pre-briefing, simulation and debriefing (Jeffries, 2005). 1. Pre-briefing is the period before the simulation and it is when participants become familiarized with the technology and equipment used during the simulation (Page-Cutrara, 2014). Additionally, this time is used to discuss the learning objectives, participant roles, and details surrounding the simulation scenario (Riley, 2008).

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2.

Actual simulation scenario. During this time, the students work together in teams and actively participate in the decision-making processes related to the nursing care in the simulated clinical situation (Jeffries, 2005).

3.

Debriefing, is the time immediately after the completion of the scenario that is dedicated toward group discussion, feedback and integrated learning (Dufrene and Young, 2014). Debriefing is an activity that aims to strengthen the positive aspects of the experience and promotes reflective student learning (Jeffries, 2005).

The choice of using simulation and deciding which fidelity to use depends on the purpose of the simulation and the proposed learning objectives (Medley & Horne, 2005; Seropian et al., 2004).

Findings - Simulation What do simulations look like and do they work? Type of Sim

Standardized patient

Mental Health Content Schizophrenia /psychotic disorders Bipolar Depressive disorders Aggression Anxiety disorders Obsessive-compulsive disorder Borderline personality disorder Posttraumatic stress disorder

Dementia Addictions Boundary crossing Suicide Self-harm Emotional distress Communication Partner violence

Time Per Sim.

00:10-4:00

Audio simulation

Auditory hallucinations

00:05-1:00

Virtual world

Schizophrenia Major depressive disorder

00:45-1:00

Key Results ↑ confidence ↑ self-awareness ↑ therapeutic communication ↓ anxiety ↑ knowledge ↑ skill acquisition/ performance ↑critical thinking ↑ satisfaction ↑ empathy ↑ knowledge and comprehension ↑ therapeutic communication skills ↑ attitude Moderate educational effectiveness (60th pctl) ↑ perceived tech. diff = ↓ effectiveness

Findings - Simulation Studies … continued Type of Sim

Mental Health Content

High-fidelity simulator

Aggression Addictions Depressive disorders Suicide

Tabletop simulation

Searching/confiscating belongings

Time Per Sim. 00:10

Key Results ↓ anxiety Highly effective (METI Simulation Effectiveness Tool)

00:30

↑ knowledge High level of satisfaction

Simulated ward

Bipolar Depressive disorders Anxiety disorders Schizophrenia spectrum and psychotic disorders Self-harm Suicide

3:45

↑ confidence ↑ therapeutic communication ↑ critical thinking

Standardized workshops

Adjustment disorder Addictions Posttraumatic stress disorder Schizophrenia spectrum and psychotic disorders Mania Personality disorders Self-harm

2-day

↑ preparation and confidence -Positive student attitudes

Relevance - Theory 

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Currently, the delivery of mental health education in undergraduate nursing programs across Canada is inconsistent and no evidencebased best approach exists; Some institutions have mandatory mental health nursing courses, while others embed mental health learning across the curriculum; Different pedagogies around the world  UK: Service users need to be involved in both the design and delivery of nursing curriculum  Australia: Commitment to protecting the integrity of MH nursing within undergradute programs  Canada: New entry-to-practice competencies

Preliminary Findings: Theory What teaching strategies are being used and what are the results? Teaching Strategy Model-based approach Service-learning activity

Lived-experience led approach

Problem-based learning

Multimedia delivery of content

Reported Results ↑ Clinical reasoning ↑ knowledge ↑ enthusiasm ↑ groups skills ↑ Oral skills -Positive student response ↑ self-awareness ↑ understanding of suffering ↑ change in attitudes towards consumer capacity -Mainly positive experience -↑ capacity to care for individuals with MH issues -Interpersonal conflict affects learning ↑ attitude ↑ in all educational pillars ↑ behaviour ↑ critical thinking ↑ acceptability ↑ process ↑ active participation ↑ understanding -Positive experience -DVD as effective as live and less expensive

Preliminary Findings - Theory What mental health and addictions content are we talking about? Mental Health Content Clinical reasoning/decision making

Teaching Strategy Model-based approach Multimedia delivery of content Stigma Service-learning activities Recovery Lived experienceled approach Personality disorders Multimedia Mood disorders delivery of Eating disorders content Schizophrenia PTSD Addictions Domestic violence

Author Recommendations

-Need to evaluate this approach compared to standard approach; -May be used in place of current care plans - Students should be exposed to social interactions of ind. with MI. (live or DVD) RCT needed; Sustainability assessment needed Research on lived experience-led education should be a priority -Active participation in teaching-learning process is essential -Requires instructor support and involvement to direct discussion appropriately -Facilitation necessary to orient and focus discussion

Preliminary Findings - Theory Topic

Service user involvement in education

Key Author Conclusions -Students positively perceive service user involvement in their education; -Real-life stories help develop capacity for empathy; -Powerful and emotional experience; - Requires a series of cultural shifts; -Careful consideration and integration within a structured and supportive framework; -Evolutionary process requiring ample preparation and resources

Reflection/ Reflective practice

-Reflective exercises should be integral and congruent facets of the whole curriculum; -Educators need to be prepared for complexity and act as role models; -Trust and safety are essential; -Clear instruction and boundaries necessary; -Maturity, experience, and cultural backgrounds of student have to be realistically considered; -Reflective MHN practice can be risky and challenging for students; -Enhances self-awareness, meaningful professional practice, improved client care, & therapeutic relationships.

Concept-based learning

-Provides a teaching tool; -Facilitates understanding; -Teaching strategy + handout was effective in promoting student learning; -Course evaluations and grades improved.

Background •

Participation on the CASN/CFMHN Task Force on Mental Health Nursing to develop Entry-to-Practice Mental Health and Addiction Competencies for Undergraduate Nursing Education in Canada

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Co-Hosted a CASN/RNAO Educator Stakeholder Forum in March 2015 to identify supports and resources that could be provided through RNAO to support faculty in the provision of a competency based curriculum in mental health and additions in undergrad settings

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Development of Expert Panel to create educator resource guide to support faculty

Stakeholder Forum: Group Discussions Question: Based on the systematic review and Entry-to-Practice Mental Health Competencies for Baccalaureate Prepared Nurses in Canada Competencies, what resource gaps do we see in current curriculum? • • • • • • • •

No standardized educational criteria for faculty re: content Limited knowledge from faculty who teach mental health Lack of consistency who teaches mental health Mental health curriculum differs across education settings (i.e. integrated vs. specific course) Negative attitudes towards mental health (from RNs and nursing students) Gap between academia and practice (i.e. what is taught vs. what is practiced by RN in field) Lack of clinical placement opportunities Lack of lived experience (service user involvement)

Stakeholder Forum: Small Group Discussions Question: What resources would help fill these gaps? • • • • • •

• • •

Provide and nurture faculty development opportunities (i.e. support learning, opportunities for faculty to practice in clinical settings, etc) Provision of teaching supports based on competencies (e.g. tool-kits, respiratory of mental health simulations developed by experts) Standardized resources to support learning such as: on-line modules, ‘boot camps’, reservoir of tools and evaluation tools Practice opportunities in safe environment learning labs Potential for clinical supervision and supports (e.g. peer supervision) Clinical Placements: shorter in duration, increase in # of placements, across continuum of care, non-traditional mental health sites, inter-professional linkages for learning, creative way to extent how we qualify clinical placements Collaboration between academia and clinical institutions Involving people with lived experience (persons and family) Advocacy to make mental health courses mandatory in all nursing programs

Summary • Need for supports and resources to support faculty in integrating best practices and core entry-to-practice competencies for mental health and addictions – Consistent knowledge base (e.g. theories and content for entry level/generalist nurse) – Support with teaching and learning tools (including SIMS) – Support with clinical placements (e.g. type, location, etc) – Support with integration for faculty (e.g. support building knowledge)

RNAO Nurse Educator Resources