The need for mental health nurses is increasing, yet the field continues to be of little interest to graduates of nursing schools. Research has attributed this to lack of exposure and resultant anxiety. Lack of clinical site availability has complicated the issue by limiting the experiential exposure students receive during nursing programs. It has been well documented that lengthier clinical rotations and greater focus on mental health in theory courses results in improved perceptions of mental health nursing. A phenomenological approach was used to determine nursing students’ perceptions of mental health clinical experiences following preparatory role-play. The number of clinical hours assigned to mental health is diminishing, yet the need for nurses who are proficient in psychosocial care of patients is increasing. Role-playing in the simulation setting allows students to learn and practice interpersonal communication skills in a safe environment. A small qualitative study explored six students’ perceptions of their mental health clinical experience. Three of the students had participated in preparatory roleplayprior to the rotation, while the other three had not. Analysis of data suggested that role-play was effective in reducing feelings of fear and discomfort, and allowed students to assume more advanced roles than that of the group that did not participate in role-playprior to the clinical rotation. While this small study cannot be generalized outside of this university setting, it was used in subsequent years to successfully redesign the mental health course and associated simulations.

Colley SL (2014) Enhancing Mental Health Clinical Rotations with Preparatory Role-Play. Ann Nurs Pract 1(2): 1007.

 Mental health, Role-play, Simulation, Attitudes

The prevalence of mental illness in society and its debilitating effects on health and productivity creates an increased demand for nurses who can deliver mental health care in all settings [1]. Few nurses elect to pursue a career in mental health [2] this may be related to a shortage of clinical sites that limits the exposure students receive to this area during their nursing program. The literature indicates that students’ disinterest may also be associated with several interrelated factors including fear, stigma, and lack of knowledge regarding mental illness [3]. While more interaction with the mentally ill may aid in reduction of these factors and result in a more positive attitude toward mental health nursing, the decrease in clinical hours devoted to mental health makes this increasingly difficult [4]. One way to compensate for the limited clinical hours, is to ensure students are receiving quality theoretical education in the classroom. Happell and Gough [5] found that students who received a greater amount of theory preparation in mental health had significantly better attitudes toward mental health nursing, even prior to clinical rotations. In a later study, Happell and Gaskin [2] found that greater time spent in the classroom and clinical setting can improve student attitudes toward mental health nursing. Students’ attitudes toward mental health nursing may also be influenced by personal satisfaction with the theory content and lecturing style, combined with the clinical experience [6]. Happell and Platania-Phung [3] suggest that increasing the amount of mental health theory improves student attitudes, but variables such as the quality of the teaching could be the causative factor rather than the time allotted. This challenges educators to find ways to maximize students’ opportunities for positive classroom and clinical experiences in order to increase interest in the field.

Innovative approaches used by nurse educators may help students overcome fears related to actual clinical practice. One of these approaches has been the use of simulation in the form of role-playing. Literature supports the effectiveness of roleplay in preparing student nurses for actual client interactions [7, 8], but there is a gap in the research related to the use of roleplay preparation as a means of changing students’ perceptions of short mental health clinical rotations. This small study was conducted in an effort to determine student perceptions of how preparatory role-play influenced their attitudes toward mental health clinical rotations. A discussion of how this study inspired the researcher’s subsequent approaches to teaching mental health nursing is included.

A small sample of six pre-licensure nursing students was used in a phenomenological, qualitative study that explored indepth perceptions of short psychiatric clinical experiences. This was a convenience sample of a select clinical cohort. All subjects were female, and all were enrolled in a mental health nursing course and associated clinical, at a public state university in Michigan. The mental health nursing course included a short, clinical rotation of two, eight-hour days per week for a period of three weeks. Perceptions were explored with two groups of three. One group received preparatory role-play and the other group received no preparatory role-play.Both groups participated in a weekly two-hour didactic period over the semester as part of a required course in the nursing program. The didactic period included discussion of mental health theory, effective communication techniques, and interpersonal skills. Theroleplay group participated in a preparatory role-play session during the first two hours of the first day of their mental health clinical rotation. This consisted of students either acting out a particular illness while a peer assumed the role of nurse, or observing and providing feedback and suggestions as a member of the group. The faculty researcher also participated in the role-play and offered feedback to aid students in development of appropriate interaction approaches. Student subjects then began their clinical rotation. All students, including those in the group who did not participate in preparatoryrole-play, responded to openended questions during individual interview sessions conducted one week after completion of their mental health clinical experience. Interviews were recorded and transcribed verbatim for both groups. Subjects were allowed to review the transcribed interviews for accuracy prior to analysis. Analysis of qualitative date from both groups involved examination of responses, and identification of common themes that resulted in several categories. Coding and recoding occurred until completion of theme classification, and emergence of sufficient numbers of regularities resulted [9]. Intercoder reliability resulted from check-coding major themes with two other individuals who were unaware of the research question. Analysis of qualitative data studied students’ perceptions of their mental health clinical rotations. Of particular interest to future planning for the mental health didactic course was determining whether themes between the two groups varied.

As a small study at a single nursing school, the results cannot be generalized. There were a number of limitations that could have influenced results. Subjects were demographically similar and were familiar with the researcher from the school setting. It should be noted that the researcher was not a faculty at the time of the study and thus had no ability to impact student grades. However, this study was done to understand how an educational intervention was perceived by students and was intended to influence pedagogical approaches used in a mental health course and its associated clinical. In that sense, the study was valuable to one school of nursing in determining effective strategies that could potentially improve students’ experiences in the mental health setting.

Analysis of the interview data resulted in identification of consistent themes for the two groups including fear level, amount of interaction, and assumption of roles in the setting. However, perceptions related to these themes varied for subjects in the two groups. Subjects who did not have preparatory role-play voiced feelings of fear related to saying the wrong thing or provoking patients during their clinical rotation. “I was picturing the One Flew Over the Cuckoo’s Next kind of thing. The scary part was they looked like anybody.” Conversely, students in the group who did have preparatory role- play perceived readily achieving a level of comfort on the mental health unit. “I don’t have any of those fears anymore. They almost seem kind of silly.”

The amount of interaction with patients that students perceived having was more pronounced in the group that participated in preparatory role-play. Subjects described a number of positive interactions with patients, while the nonrole-play group perceived little ability to interact with patients. “We didn’t really talk to the patients much.” It may be that the lack of simulated role-play contributed to a hesitancy to engage with patients during the clinical rotation. This may also have led to subjects in the role-play group identifying characteristics of Peplau’s [10] roles in the setting. Subjects in the role-playgroup successfully facilitated a recreational group activity with patients, while subjects who did not participate in preparatory roleplay were more reticent to conduct a group activity and engaged in more observational activities.

Comparison of the perceptions of the two groups was of particular interest for informing future pedagogical approaches in the mental health course. Based on analysis of interview content, findings suggested that students who participated in preparatoryrole-play had fewer fears and overcame their fears more quickly than those who did not participate in roleplay. Findings also suggested that achievement of comfort levels differed for the two groups, with the role-play group perceiving a comfort level up to two days sooner than the non-role-play group. The role-play subjects perceived being more actively involved on the unit and engaged in more patient interactions. They also noted they were able to assume more roles in the clinical setting than the non-role-playsubjects. The role-play subjects indicated a greater interest in a longer mental health rotation. Interestingly, both groups perceived their interest in mental health nursing as being greater following their clinical experience.

Pursuant to this study, deliberate changes were made to incorporate role-play as an integral aspect of the face to face mental health class sessions. A blended course delivery allowed lectures to be recorded and placed into the online component of the course. Students were expected to complete required readings, view associated lectures in the online course, and then come to class prepared for active learning. Role-plays that incorporated the material covered in the weekly reading and lectures were developed and utilized. Role-plays were continuously reevaluated and assessed for currency, usefulness, and applicability. Several role-plays involved all students working as individuals or in groups to complete a case study using an active hands-on approach. Students would be assigned roles of patients with particular diagnoses, while others would be assigned to determine appropriate medications and side effects, as well as nursing interventions. To minimize student discomfort and align with the learner-centered concept of creating a comfortable learning environment, those who were more reluctant to take on a role participated by creating concept maps on the board based on the input from the class. Concept mapping effectively allows students to demonstrate organization of content by creation of visual representations of a knowledge area [11]. Immediate mastery quizzes were adapted to include both an individual and a group version so that students were able to demonstrate personal accountability, and then also discuss as a group the rationales for responses.

As a result of these changes, students were observed to be more engaged in the classroom setting, with less sidebar conversations and inattentiveness. There were fewer contentious responses to quiz or test questions as students provided rationales and feedback to peers on when, how, and why a given answer was correct. Student evaluations of the teaching approaches used were overwhelmingly positive. Anecdotal evidence based on student comments on instructor evaluations suggests that students feel more in control of their own learning, and are acquiring the necessary skills to be lifelong learners.

Further research is needed to determine how students are responding to these new learning approaches as it relates to comfort in the mental health setting, and in their acquisition of knowledge related to care of patients who have a mental health condition. Additionally, a retrospective review of previous test scores and course grades could be compared to current data to determine whether the new teaching approaches are making a positive impact. Recent research on how the brain learns suggests long-term retention of content is enhanced by use of multi-sensory teaching approaches [12, 13]. Additionally, repeating material in a variety of ways and using emotion to connect students to the material can also improve retention [13]. This suggests the need to explore the long-term retention of content related to mental health, with results on psychosocial components of the NCLEX-RN being one method of determining improvements over previous years’ results.

Due to the small sample size of this study and follow up application, results cannot be generalized. However, the personal perceptions of these two groups of students did provide indepth insights that inspired changes to teaching approaches within one mental health course in an undergraduate nursing program. It also stimulates ideas for future research that quantitatively explores outcomes based on specific teaching and learning approaches.

Providing quality mental health clinical experiences to nursing students is becoming increasingly difficult due to competition for sites. Enhancement of short mental health clinical experiences by the use of preparatory role-play may lessen students’ fears and provide a higher level of knowledge regarding illnesses. This may also aid the student in achieving comfort on the unit sooner, which is essential for short duration clinical rotations. It is important that educators consider methods that allow students to practice mental health interaction skills in a safe environment prior to entering the clinical rotation. Nursing students who feel confident in their interaction abilities with a wide range of individuals may provide care reflective of the diverse and changing environment in which they will work. It is important students have exposure to learning opportunities that enable them to meet the growing demand for nurses with the ability to interact at a level that demonstrates understanding of the mental health field. Innovative, active learning approaches in the didactic component of mental health nursing course may improve retention of material, affective skills, and overall interest in the area of mental health nursing. Creating optimal learning experiences in mental health nursing courses may help meet the demand for competent nursing care for the mentally ill in all areas of nursing.

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