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

Clinical learning experiences are known to exacerbate nursing student anxiety, causing them to present to clinical placement in distressed, meaning anxious, states. Students already living with anxiety are also more likely to suffer setbacks at this time. Supervising Registered Nurses (RNs), in the clinical settings, struggle to support this student cohort. A professional development activity was designed to introduce RNs to higher education and nursing students' known mental health concerns (such as anxiety) and to arm them with strategies for working with distressed students. A research approach that enabled researchers to collaborate with participants was employed to design the intervention. A study evaluated the impact of the educational intervention with 45 Australian RN supervisors. Two tailed T-tests were chosen to explore the statistical difference between pre- and post-test mean results across the survey items. A 95% confidence interval was used. Statistical significance was set at <0.05. The evaluation indicated the activity could be useful for improving supervising RNs' mental health literacy, thus enhancing their understanding of how to work with distressed students. Participants recommended the activity be offered to any staff supporting student clinical learning. Collaboration between nursing researchers and nursing clinical staff produced a meaningful professional development activity and motivated the participants to increase their mental health literacy and understanding of strategies to support distressed students. Future projects should adopt similar approaches that would support both RNs' ability to support students' during clinical learning and students in distress would also benefit.

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.

The impetus for the study reported in this paper arose during an earlier study of clinical facilitator challenges supervising students on clinical placement (Author 2020). The clinical facilitators in that study reported increased work burden and personal stress from supporting distressed students. This paper describes the research approach taken by the two researchers to first work with a team of clinical facilitators to design a professional development activity to support them to work with distressed students. Then the paper presents the results of a small‐scale research study aimed at evaluating the subsequent professional development activity, which was offered to a wider group of clinical facilitators, and preceptors, working in Southeast Queensland, Australia. Two research questions guided the study:

What is the impact of a professional development activity designed to prepare clinical facilitators/preceptors to work with students in distress?

Is there value in introducing clinical facilitators/preceptors to self‐care plans and positive psychology for their own well‐being?

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.

Phase 1: Identifying problems and designing the solutions

The two researchers convened a one‐hour focus group with the key group of clinical facilitators who had previously worked with the first author (Author 2020). This meeting revealed group challenges: 1) poor mental health literacy and understanding how to respond adequately to a student in distress (as an example, anxiety). This group expressed a need for deeper understanding the causes of higher education student anxiety and distress, and the community and university referral pathways available to them to support students access to counselling and mental health specialized supports. During this initial conversation, some clinical facilitators expressed a deficit in their individual and group self‐care and well‐being practices. This conversation guided the authors, both nursing researchers and one a mental health nurse, in the design of the professional development activity. The researchers used emails to regularly share suggested content with participants until consensus on the included activities and the design of the intervention was reached. Consensus was reached when the participants expressed the content was suitable for meeting their needs. Final approval was then provided by the organization’s Education Manager.

The resultant three‐hour professional development activity was framed around 24 PowerPoint slides, as summarized in Table 1. The authors were to co‐facilitate the activity face to face; however, before Phase 2 could be implemented, Author 2 relocated and travel logistics and budgetary restraints forced the pre‐recording of some of the content. In all, four short (less than 7 min) videos were produced in house.

Table 1

Programme outline

Session 1: Introductions, Setting the scene, Protective factors (30 mins)
Slides 1–4	Introductions Aims and objectives Activity – Icebreaker introducing a tool for participants to guage individual and immediate well‐being		10 min
Slides 5–6	Baseline group knowledge Present current Australian data on causes of higher education and nursing students anxiety and other common mental health concerns		10 min
Slide 7	Pre‐recorded video 1 protective factors Activity – understanding students’ protective factors Reflection – What is new learning for you? How might you change/improve on your practice?		10 min
Session 2: Crisis, Response model, Role play (1 h)
Slide 8–9	Defining emotional crisis to increase participant mental health literacy Activity – Understanding individual responses to crisis such as behaviours and verbal and non‐verbal responses		10 min
Slide 10	University first response model and referral pathways Crisis and community services referral pathways		10 min
Slide 11	Youtube – empathetic listening		5 min
Slide 12	Activity – Role Play. Roles: Facilitator, student and observer to provide feedback on facilitator performance Use the first response model and empathetic listening Reflection – What is new learning for you? How might you change/improve on your practice?		20 min
Slide 13	You Tube – Adolescent experiencing anxiety Reflection – What is new learning for you? How might you change/improve on your practice?		5 min
Session 3: University process, Positive Psychology (45 mins)
Slide 14–15	University policies and procedures – handouts and discussion		15 min
Slide 16 −17	Pre‐recorded video 2 – Flow Activity – Using flow when working with students to match challenge and skills Reflection – What is new learning for you? How might you change/improve on your practice?		15 min
Slide 18	Pre‐recorded video 3 – Introducing the concept of positive psychology Activity – Gratitude and Savouring		15 min
Session 4: Self‐care and conclusion (45 mins)
Slide 19–23	Activity – Self‐care strategies, develop a plan and optional contract Pre‐recorded Video 4 – Practising mindfulness techniques Activity – Mindfulness	30 min
Slide 24	Reflection – Last thoughts? Take home resources handouts and publications	10 min

The activity was designed to take three hours (180 min).

The first two videos addressed the problems of preparing participants to work with distressed students. Video 1 utilized a case study demonstrating the benefits of academics spending time with students to identify individual protective factors (MacNeil et al. 2012). An introduction to the flow model (Csikszentmihalyi 1990) in video 2 demonstrated the importance of choosing student learning opportunities that balance knowledge and skill level in order to stimulate and engage rather than increase their anxiety, related to performance confidence (Arkan et al. 2018). Both authors had previously used flow in the workplace for its usefulness in matching a person’s skills with the challenge of an activity. The aim is for people to work at a level that is not too boring that they become demotivated and disinterested, and not too challenging that they became stressed and unable to perform the work.

To address the problem of participants needing strategies to benefit their own well‐being, videos 3 and 4, respectively, introduced the participants to positive psychology concepts such as savouring memorable moments and practising gratitude (Sun et al. 2020) and a practical five‐minute mindfulness exercise (Moscaritolo 2009). In addition to the bespoke videos, two freely available commercial YouTube videos sensitized participants to the concepts of living with anxiety (Rienks 2016) and understanding empathy (Lifehacker 2017).

The remaining content addressed the participants identified need for understanding common mental health concerns university and nursing students might experience during clinical learning. Contemporary data around the incidence of mental health in higher education student populations; university referral pathways; models depicting ways to respond to people in mental distress were introduced and explained and role‐play activities and interactive small group work throughout invited participants to practice new learning. An observer role, also played by participants, provided peer feedback. Reflection points allowed for meaning making of new learnings as they applied to their context (McAllister & Osborne 2006). The PowerPoint is available on request from the corresponding author.

Phase 2: Implementation and Evaluation

The key group of clinical facilitators, who informed the design of the professional development activity, then participated in the intervention in February 2019. On completion, they were invited to informally share their experiences. Anecdotally, an overwhelming response was that the activity was of great benefit to them and should be formally evaluated with a larger group of clinical facilitators and preceptors.

Participants and setting

In June 2019, a series of six offerings of the professional development activity commenced to formally evaluate the intervention. Purposive recruitment was employed. Inclusion criteria were that the participants were working or had worked as a preceptor or clinical facilitator. Invitational emails were sent directly to clinical facilitators or organizational education managers email addresses available to the first author from the School of Nursing industry partner database. An outline of the professional development activity and the research study, as well as the research participant information sheet and consent forms, was included in the invitational email. The email informed participants they could complete the professional development without participating in the research. Consent forms were completed just prior to each offering of the professional development activity.

Data collection

Data were collected during Phase 2 to suffice both good practice in offering educational interventions and as a quality improvement measure (Kirkpatrick & Kirkpatrick 2007). Kirkpatrick’s first three levels of training evaluation guided the researchers in designing an educational evaluation and feedback survey. The first level measures learner reactions to the content and the delivery of the activity; the second, self‐reported changes in learner attitudes, knowledge and skills, and the third, self‐reported changes in confidence (Kirkpatrick & Kirkpatrick 2007). Researcher and participant time constraints impeded evaluating return on investment, the level in this model. The feedback survey was offered only in hard copy. The items were carefully written to address the aforementioned three levels of training evaluation and also served to inform quality improvement. All items utilized 5‐point Likert scales anchored from strongly disagree to strongly agree to measure participant responses to the intervention. One item was yes/no and three additional global satisfaction with learning items were included only in the post‐test survey (see Table 2). Participants completed the feedback surveys immediately before and after the intervention.

Table 2

Education feedback survey items

Pre‐ and post‐test items

I know how to respond to students with mental health concerns I know what to do when students share sensitive information during clinical placement I am comfortable responding to a student in distress I wish I could hand over students with mental health concerns to another clinical facilitator/preceptor I am aware of the university incident reporting processes I feel prepared to work with students with mental health concerns I am confident I know how to care emotionally for myself in my role Do you have a self‐care plan? (a yes/no item – not a Likert scale)

Extra post‐test only items to rate global satisfaction

I feel motivated to further my knowledge around mental health concerns in student and other populations The workshop content will improve my interactions with students experience mental health concerns. Would you recommend others working with students attend this workshop?

Front matter instructions in the feedback survey guided participants to create an individual code used for matching the pre‐ and post‐test surveys; thus, confidentiality was maintained. This study had University Higher Research Ethics Committee approval (HREC no. 21510). Forty‐five RNs who worked as clinical facilitators and preceptors attended. Demographic information is summarized in Table 3.

Table 3

Participant demographics

Participant demographics	No. of participants
Masters of Mental Health Nursing	2
Diploma of Social Science	1
Suicide prevention workshops	1
Understanding mental health	2
Facilitator/preceptor workshops	4
Years working in the roles
Working as a preceptor	8
<1 year as clinical facilitator	6
1–5 years as clinical facilitator	8
6–10 years as clinical facilitator	10

45 attended. 34 pre‐ to post‐matched surveys were returned. Only 10 participants answered the question about prior training. Only 32 answered the question about years of experience. Reasons for not participating in the research (n = 9) or not completing all items are unknown.

Phase 3: Improvements

Phase 2 evaluation data identified minor modifications and improvements that are still in progress in the final phase of the research design. Improvements include creating an immersive open access online version and planning and designing a subsequent research study to offer and evaluate the intervention with a wider audience.

Data analysis

Frequencies and percentages were generated for demographic items that were designed to be similar to other feedback surveys used in this population. The Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp & released 2019) was used to analyse data. Means and standard deviations were calculated for non‐demographic items. Visual inspection of the histograms showed the data were normally distributed. Therefore, to understand the impact of the intervention participants’ pre‐ and post‐intervention scores were compared using the paired sample t‐test (two tailed) to explore the statistical difference between pre‐ and post‐test mean results. A 95% confidence interval was used. Statistical significance was set at p < 0.05.

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.

Table 4

Pre‐ to post‐test Likert scale item results

Item	Pre		Post		T	df	Sig. (2‐tailed)
	Mean	Std Dev.	Mean	Std Dev
1. I know how to respond to students with a mental health concern	3.15	0.92	4.32	0.54	−7.08	33	0.000*
2. I know what to do when students share sensitive information during placement	3.50	0.92	4.15	0.86	−3.35	33	0.002*
3. I am comfortable responding to a student in distress	3.29	0.97	4.18	0.14	−5.26	33	0.000*
4. I wish I could hand over students with mental health concerns to another clinical facilitator/preceptor	3.62	1.074	3.85	1.019	−1.311	33	0.199
5. I am aware of the university incident reporting processes	2.18	1.21	4.35	0.644	−9.189	33	0.000*
6. I feel prepared to work with students with mental health concerns	3.18	1.11	4.24	0.55	−6.28	33	0.000*
7. I am confident I know how to care emotionally for myself in my role	3.94	0.694	4.44	0.660	−3.894	33	0.000*

Significance, p < 0.05 CI = 95%.

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).