Nurse Education Today 35 (2015) 760–764
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The impact of a mental health clinical placement on the clinical confidence of nursing students in Jordan Ahmad Yahya AL-Sagarat a,⁎, Faris ALSaraireh a,1, Rami Masa'deh b,2, Lorna Moxham c,3 a b c
Community and Mental Health Nursing Department, Faculty of Nursing, Mu'tah University, P.O. Box 7, AL-Karak Postal code 61710, Jordan Applied Science Private University, Amman, Jordan University of Wollongong, Faculty of Science, Medicine and Health, Northfields Ave, NSW 2522, Australia
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Article history: Accepted 13 February 2015 Keywords: Mental health Clinical confidence Clinical placement Nursing student Jordan
s u m m a r y Objectives: To examine the impact of clinical placement in a mental health setting on the clinical confidence of nursing students in Jordan. Design and setting: A non-experimental descriptive survey design was used. Data was collected using the Mental Health Nursing Clinical Confidence Scale (MHNCCS) in Jordan. Results: Data indicates that, as a result of clinical placement, nursing students had improved perceived confidence regarding the concept of mental health and mental illness, felt better able to conduct a mental health status examination, create nursing care plans, administer medication and provide health education to patients in mental health settings. Conclusions: Improving the clinical confidence among Jordanian nursing students in relation to mental health nursing skills may provide a safer environment for students and patients as well as lead to enhanced well-being and function of patients. In addition, the results of this study may have practical implications for positive changes to the mental health nursing curriculum clinical placement goals. © 2015 Elsevier Ltd. All rights reserved.
Introduction It has been widely acknowledged in the nursing literature that clinical placements are an important component of the nursing curriculum (Eick et al., 2012; Jokelainen et al., 2011; Sharif and Masoumi, 2005). Theory, which is learned at university but applied in the clinical setting, provides information that assists nursing students to develop an understanding and appreciation of the nurse's role and patients' needs (Townsend and Scanlan, 2011). Thus, theory informs practice, but theory alone does not provide the variety of professional opportunities afforded by clinical practice. Clinical placement, also known as work integrated learning (WIL) (Keleher et al., 2007) and internationally as clinical clerkships, provides students with the opportunity to apply theory to clinical practice competently and confidently in a hospital setting. Consequently, nursing theory can be applied and further understood in conjunction with clinical placement (Walker et al., 2012). Hagbaghery et al. (2004) argues that competence and self-confidence are the most ⁎ Corresponding author at: Community and Mental Health Nursing Department, Faculty of Nursing, Mu'tah University, P.O.Box 7, AL-Karak Postal code 61710,Jordan. Tel.:+962 32372380x6705, +962 772038527 (mobile), +962 797341546. E-mail addresses: [email protected] (F. ALSaraireh), [email protected] (R. Masa'deh), [email protected] (L. Moxham). 1 Tel.:+962 32372380, +962 798123856 (mobile). 2 Tel.: +962 796067657 (mobile). 3 Tel.: +61 2 4239 2559.
http://dx.doi.org/10.1016/j.nedt.2015.02.008 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
important factors that enable nursing students to make appropriate decisions related to patient care. Undertaking a clinical placement requires students to translate theoretical knowledge to real world clinical situations, in numerous clinical jurisdictions and discipline areas. For some students, this transition can be both frightening and filled with self-doubt (O'Connor, 2006). Lack of self-confidence in student nurses can interfere with their ability to acquire new knowledge and hinder their ability to deal with difficult and challenging situations. Students can experience a lack of confidence because individuals are typically guided by their beliefs and perceptions rather than reality (Pajares, 2007). Clinical nursing instructors both in the academy and in the workplace need to be cognizant of this phenomenon and intervene promptly to promote student confidence. Instilling confidence in student nurses early provides a foundation for the acquisition of knowledge and the successful implementation of newly acquired skills. According to Holland et al. (2012), professional confidence can be described as a dynamic, maturing personal belief held by a professional or student. This includes an understanding of and a belief in the role, scope of practice, and significance of the profession, and is based on their capacity to competently fulfill these expectations, fostered through a process of affirming experiences. Confident students will engage in challenging opportunities and skills, whereas their less confident peers will avoid the same tasks (Townsend and Scanlan, 2011). Confident students will also approach difficult skills and tasks with lower anxiety, perceive that particular
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skill as important, and possess a firmer commitment to use their clinical skills (Clark et al., 2004). Clinical confidence is difficult to gain in the classroom. Rather, it is enhanced in the clinical setting by applying and then mastering newly learned skills and experiencing success. Therefore, it is the role of clinical educators to foster confidence in their students through creating a more positive confidence-rich learning environment (Pajares, 2007). Educators need to be able to recognize a lack of confidence in individual students and plan appropriate teaching strategies that will enhance self-confidence. Like all nursing specialties, mental health nursing involves interaction between the nurse and patient. In mental health nursing, the nurse patient relationship is vital (Moxham et al., 2013). This inherently humanistic perspective enhances the importance of learning theory and mastering clinical practice. It is necessary for students to experience mental health clinical practice first hand, working with people who have lived experience of mental illness. With the opportunity to learn the nuances of psychiatric nursing afforded by a mental health clinical placement, students can implement theoretical learning and practice skills such as therapeutic communication techniques and relationship building and mental health assessments. Effective communication skills need to be refined in clinical practice with real patients (Arthur, 1999). These crucial skills, which underpin all components of effective mental health nursing practice, are one which students require in order to be able to effectively assess the needs of patients and demonstrate unconditional positive regard. Secker et al. (1999) have argued that well developed communication skills increase competency in the care of psychiatric patients and assist in developing therapeutic relationships. Within the population who use health care systems, people who present with mental illness present a challenge to the nursing profession (Chadwick and Porter, 2014) and given that statistics indicate that mental health issues are on the rise, a clinical placement in a mental health setting is an important component of mental health nursing education all over the world. There is substantial evidence regarding the importance of measuring and evaluating clinical skills for nursing students who undertake clinical placements (Townsend and Scanlan, 2011; Yanhua and Watson, 2011; Cant et al., 2013). With regard to evaluating clinical skills in mental health settings there is less evidence and none at all in Jordan, which is the study site of the research reported in this paper. The purpose of this study was to examine the clinical confidence of undergraduate mental health nursing students in Jordan. Examining the clinical confidence among Jordanian nursing students with regard to mental health nursing clinical skills provides an understanding of the areas in which students lack confidence, as well as those where they perceive their confidence to be high. As a result of this understanding, modifications can be made to curricula both theoretical and clinical, and core competencies can be evaluated and reinforced. Methods Design and Sample A descriptive, cross-sectional research design was used in this study. A purposive, non-probability sample of third-year level nursing students who were enrolled in a mental health nursing course in Jordan in the second semester 2013–2014 were invited to participate. The participating students completed a pre-test prior to attending their clinical placement and then a post-test questionnaire after attending 19 days of mental health clinical placement. Ethical approval was granted from the Research Ethics Committee in the Faculty of Nursing, Mu'tah University, Jordan. After that, recruitment of students was undertaken by research assistants who provided information about the study purpose and procedures to potential participants. In addition, a participant information sheet (PIS) was provided to each potential participant. The PIS clearly elucidated that participation was voluntary, participants could withdraw at any time without
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prejudice and that anonymity was assured. The PIS identified the researchers' contact details for availability to answer any questions or to clarify any salient aspects of the study. Nursing students were also assured that their non-participation, participation, or withdrawal from the study would not in any way affect their current or future relationship with the Faculty of Nursing of Mu'tah University in Jordan. Seventy two students consented to participate in the study. Inclusion Criteria The inclusion criteria required that participants be enrolled in the second semester of their third-year of the mental health nursing course within the Faculty of Nursing, Mu'tah University, Jordan. The participants were also required to be enrolled to complete the mental health clinical placement at the end of the same academic semester. A ‘research pack’, assembled by the research team included the participant information sheet, a consent form, and the mental health nursing clinical confidence scale (MHNCCS). The packs were distributed to nursing students by the research assistants. Although Arabic is the native language in Jordan, English is the official language for hospital documentation and for teaching in nursing schools. Therefore, English versions of the questionnaires were used. Study Instrument The Mental Health Nursing Clinical Confidence Scale (MHNCCS) (Bell et al., 1998) was used as the data collection instrument for this study. The MHNCCS is a self report questionnaire comprising 20 questions related to the evaluation of confidence in mental health nursing skills among undergraduate students. The 20 item questionnaire includes six domains covering areas such as, assessment, communication, education, medication knowledge, self-management and team work. It has to be acknowledged that these 20 items formed a single scale and not divided into multiple subscales (Bell et al., 1998). Responses to the 20 items are measured on a 4-point scale from 1 (not at all confident) to 4 (completely confident) (see Table 1 for MHNCCS individual item component). Process of Data Collection Like many countries, the mental health nursing course in Jordan consists of two components (i.e. the theoretical component and the clinical component). The clinical component requires students to attend 19 days (8 h per day) over ten weeks of the clinical practice. To commence data collection, the MHNCCS was completed by the mental health nursing students prior to the commencement of their clinical placement. Upon completion the questionnaires were returned to the research assistant for coding. The second round of data collection saw the research assistants distribute the questionnaire to the same students after they have completed their mental health clinical placement. The completed questionnaires were returned to the research assistant within one week after the completion of the clinical placement. All the participants were asked to complete the MHNCCS within 20 min. Any participant who requested assistance was supported by the research assistants to complete the questionnaire. In order to be able to match pre- and post-clinical responses, the students were instructed to provide a unique identification number and were reassured that the numbers would not be able to be linked to individual students. Completed questionnaires were returned by the participants to a sealed box which was placed in the main hall of the Faculty of Nursing at Mu'tah University, Jordan. Data Analysis The Statistical Package for the Social Sciences (SPSS-21) software was used for data entry and analysis. Only the primary researcher entered the data to ensure consistency. Measures of central tendency were used to describe the characteristics of the sample. Descriptive statistics were used to analyze demographic
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Table 1 The Mental Health Nursing Clinical Confidence Scale individual item component. Section A: This section seeks information concerning the confidence of nursing students to care for psychiatric patients following their psychiatric clinical placement. Questions
Not at all confident (1)
Sometimes confident (2)
Not sure (3)
Completely confident (4)
1. I can communicate effectively with clients with a mental health problem. 2. I can carry out a comprehensive psychosocial assessment of clients. 3. I can conduct a mental state examination. 4. I can develop a nursing care plan on the basis of my assessment. 5. I can assist clients with a mental illness to clarify treatment goals. 6. I am able to provide basic counseling for clients with a mental illness. 7. I am able to be empathic with a range of clients with a mental illness. 8. I can provide information and education for clients regarding their illness. 9. I am able to assist clients to develop living skills. 10. I have a basic knowledge of antipsychotic medications and their side-effects. As a result of my psychiatric clinical placement 11. I have a basic knowledge of antidepressants and their side-effects. 12. I have a basic knowledge of anti-anxiety medications and their side-effects. 13. I have a basic knowledge of mood stabilizers and their side-effects. 14. I am able to provide client education regarding the effects and side-effects of medications. 15. I can fit with the nursing team on a mental health clinical placement. 16. I can contribute client-related mental health information at a multidisciplinary meeting. 17. I can handle clients who are verbally aggressive. 18. I can handle clients who are physically aggressive. 19. I am able to establish my own personal boundaries when relating to clients with a mental illness. 20. I can seek support from other members of the mental health team.
data. Frequencies and distributions were used to describe the percentage of nursing students for each categorical demographic variable. A paired samples t-test was performed to answer the research question which was: Is there a significant difference in clinical confidence between pre- and post-clinical placement among nursing students in Jordan using the MHNCCS? Results Using a convenience sample, 76 undergraduate nursing students were invited to participate in the study. Of the 76 students, 72 students consented to take part in the study. Of the 72, 68 students (approximately 90% of the approached students) fully completed and returned both pre- and post-questionnaires that were considered in the analysis. Tables 2 and 3 present some characteristics of the respondents. The age of the participant students ranged between 20 and 30 years, with more than 97% less than 24 years of age. The number of female students was higher than male students (54 and 14, respectively). All of the participants (100%) had not previously attended a psychiatric clinical placement prior to this study. However, after the completion of the course, participating students had attended between eight and 19 days of the clinical placement with a mean of 16.76, SD (3.87). The total confidence score of the pre-clinical placement ranged between 20 and 74 with a mean of 43.44, SD (10.64). In contrast, the total confidence score after the completion of the clinical placement ranged between 30 and 80 with a mean of 58.76, SD (12.93). Table 4 presents the mean of each item of the MHNCCS pre- and post-clinical placement. There was a statistical significant difference in the mean at p b 0.05 in each individual item for all items except the last two (i.e. I am able to establish my own personal boundaries when relating to clients with a mental illness; and I can seek support from
Table 2 Characteristics of the students (continuous variables). Characteristics
Pre-clinical placement students n = 68 mean (SD)
Post-clinical placement students n = 68 mean (SD)
Age Completed days in clinical placement Total confidence score
21.00 (1.73) N/A 43.44 (10.64)
16.76 (3.87) 58.76 (12.93)
other members of the mental health team). However, the total score was calculated by adding all 20 items together with the total score then treated as a single scale, the higher total score equates to higher levels of confidence. After calculating the total score by summing all 20 items, a paired samples t-test was used to evaluate the impact of the psychiatric clinical placement on the confidence scores of participants. Findings demonstrate a significant difference in confidence scores for undergraduate nursing students (p b 0.001), with students at post-clinical placement having significantly higher confidence scores. The mean confidence score for students after completion of their clinical placement was higher compared to their score prior to the clinical placement (58.76 compared to 43.44). The mean difference between scores was 15.32 (95% CI: 11.86 to 18.79). The ETA squared statistic = 0.54 is indicative of a large effect size. In this study, in order to confirm the reliability of the confidence scale, internal consistency was assessed. Cronbach's alpha coefficients were calculated for the students before and after their clinical placement, and were found to be 0.89 and 0.90 respectively (Table 5), suggesting high internal consistency and reliability of the scale for this sample. Pallant (2007) stated that values above 0.70 are considered acceptable and above 0.80 are good. Table 6 illustrates that all values in the final column “Cronbach's alpha if item is deleted” were less than the final alpha, suggesting that all items were related to each other and contributed to the scale. It can be concluded that this confidence scale is a valid and reliable instrument to be used in the study of clinical confidence in undergraduate nursing students in Jordan. This supports the assertion by Bell et al. (1998) that the MHNCCS has well-established validity (Ross et al., 2013). Table 3 Characteristics of the students (non-continuous variables). Characteristics
Pre-clinical placement students n = 68% (n)
Post-clinical placement students n = 68% (n)
Male Female Never been to psychiatric clinical placement Last clinical placement less than a week
20.60% (14) 79.40% (54) 100.00% (68)
N/A
N/A
100% (68)
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Table 4 Mean pre- and post-clinical scores for individual items on the Mental Health Nursing Clinical Confidence Scale along with the paired t-test significance. Individual scale item
Mean (pre-clinical placement) Mean (post-clinical placement) P value
I can communicate effectively with clients with a mental health problem. I can carry out a comprehensive psychosocial assessment of clients. I can conduct a mental stat examination. I can develop a nursing care plan on the basis of my assessment. I can assist clients with a mental illness to clarify treatment goals. I am able to provide basic counseling for clients with a mental illness. I am able to be empathic with a range of clients with a mental illness. I can provide information and education for clients regarding their diagnosis. I am able to assist clients to develop living skills. I have a basic knowledge of antipsychotic medications and their side-effects. I have a basic knowledge of antidepressants medications and their side-effects. I have a basic knowledge of anti anxiety medications and their side-effects. I have a basic knowledge of mood stabilizers and their side-effects. I am able to provide client education regarding the effects and side-effects of medications. I can fit in with the nursing team on a mental health clinical placement. I can contribute client-related mental health information at a multidisciplinary meeting. I can handle clients who are verbally aggressive. I can handle clients who are physically aggressive. I am able to establish my own personal boundaries when relating to clients with a mental illness. I can seek support from other members of the mental health team.
2.22 2.10 2.01 2.04 2.40 2.12 2.68 2.31 2.49 1.72 1.62 1.68 1.71 1.87 2.31 2.32 2.29 1.94 2.68 2.94
Discussion The findings from this study revealed that perceived mental health nursing confidence increased as a result of exposure to the mental health clinical setting. Results demonstrate a significant difference in the Jordanian mental health nursing students' clinical confidence regarding their knowledge about various types of medications used in mental health post-clinical placement in comparison to their clinical confidence prior to clinical placement regarding the same issue. Dedicated clinical placements are important to enable students to acquire the appropriate skills, knowledge and attitudes necessary to engage with people with mental health problems (Henderson et al., 2007; Ross et al., 2013). Knowledge of medication is an important nursing role. The results of this study also indicated that the participants felt more confident to be able to conduct a mental status examination and to develop a nursing care plan. However, the Jordanian students in this study did not gain confidence in their ability to assist patients to develop living skills. This could be explained by the results from the Daradkeh (2009) study that found that Jordanian psychiatric hospitals lack practical activities which can prepare patients for vocational adjustment and jobs training. The paucity of practical teaching programs for clients related to their activities of daily living is influenced by the medical model of care which places strong emphasis on pharmacological methods of treatment rather than on psychotherapeutic methods of treatment in this region. The findings indicated that the students lacked confidence to contribute clinically related mental health information at multidisciplinary meetings. The lack of regular meetings in the Jordanian psychiatric wards could explain the reported lower level of confidence regarding contributions by the Jordanian nursing students at multidisciplinary meetings. With regard to treatment goals, the Jordanian nursing students' confidence to assist patients with mental illness to clarify treatment goals did not significantly increase after their clinical placement. Beazley and Gudjonsson (2011) found that psychiatric patients, when admitted, are commonly poorly motivated to engage with their treatment often because either they have little insight into their condition or they are
Table 5 Reliability of the scale. Cronbach's alpha coefficient of the confidence scale Pre-clinical placement Post-clinical placement
0.89 0.94
p b 0.001 p b 0.001 p b 0.001 p b 0.001 0.002 p b 0.001 0.011 p b 0.001 0.003 p b 0.001 p b 0.001 p b 0.001 p b 0.001 p b 0.001 p b 0.001 0.002 p b 0.001 p b 0.001 0.152 0.303
2.82 2.84 2.88 2.97 2.82 2.75 2.94 3.13 2.94 3.09 2.87 3.00 3.03 3.09 2.85 2.81 2.97 2.93 2.91 3.12
frustrated by being the recipient of mandated treatment. It is also reported by Sorensen (2006) and Usher et al. (2009) that clients with acute mental illness experience many barriers that prevent them from participating in the daily activities of the wards when they are admitted to hospital settings. These barriers include low self-worth and selfconfidence, loss of energy, interest and motivation, generalized fatigue, poor physical fitness, social fear, helplessness and hopelessness. In the current study, most of the patients admitted were acutely ill and may not have been motivated to engage in their treatment goals. This could have been as a result of their illness or side effects of their medication or lack of engagement with them by staff. As previously alluded to, Jordanian psychiatric hospitals emphasize medication management (Daradkeh, 2009). Numerous authors (Munch and Hamer, 2010; Muir-Cochrane et al., 2010; Usher et al., 2009) have identified that psychotropic medications can result in movement disorders, fatigue and sedation, metabolic syndrome such as increased appetite, weight gain and the development of Type 2 diabetes mellitus, sexual dysfunction and postural hypotension. These adverse reactions may be additional barriers preventing clients from participating in daily ward activities or engaging in their treatment goals.
Table 6 Cronbach's alpha if item is deleted. Confidence scale
Pre-clinical placement Cronbach's alpha if item is deleted
Post-clinical placement Cronbach's alpha if item is deleted
Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Question 9 Question 10 Question 11 Question 12 Question 13 Question 14 Question 15 Question 16 Question 17 Question 18 Question 19 Question 20
0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89
0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.93 0.94 0.94 0.94 0.94 0.94 0.94
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Moreover, Healy (2009) found that psychotropic medications negatively influence how a person perceives pleasurable sensations, leading to a severe reduction in feelings of desire and motivation. BootsMiller et al. (1997) on their research into the social climate in psychiatric hospitals, found a lower rate of involvement with ward activities in acute psychiatric wards related to the fact that when patients entered the ward they did not have the capacity or energy to engage. The researchers also reported that the nurses and nursing students during their clinical placement at this stage of the patient's illness were more focused on containment, rather than offering and encouraging involvement in daily activities and treatment programs (BootsMiller et al., 1997). The lower rating of confidence regarding offering engagement in the treatment programs among the Jordanian nursing students in this research could be explained by a potential lack of client motivation during the acute stage of their mental illness. Limitations Like all research, this study has limitations. One limitation is that the study used a sample of students drawn from just one of the public nursing faculties in Jordan. Therefore the findings cannot be generalized for students enrolled in mental health nursing programs at other nursing faculties in Jordan. Problems also arise when relying on participants to self-report due to recall bias. In future research, a combination of data sources should be used. Conducting this study again with a larger randomized sample would expand the knowledge of the impact of a mental health clinical placement on the perceived confidence of nursing students. Despite this, these findings may still be helpful for clinical educators and clinical staff in identifying students' needs, facilitating their learning in the clinical setting and developing effective interventions to improve their clinical confidence. Conclusion Student nurses describe their clinical placements as an opportunity to practice skills and apply knowledge. The findings of this study have shown that perceived confidence does increase as a result of exposure to a mental health clinical placement. Significant changes in the selfreported confidence levels of students were found at the completion of the clinical placement. This is important so as to support the continuation of mental health clinical placements in Jordanian nursing curriculum. Furthermore, with a growing body of literature suggesting that many students who enter undergraduate nursing courses do so with no or little interest in mental health nursing exposure to positive mental health clinical experiences could be one way to increase recruitment (Moxham et al., 2011). The findings of this research may also assist Jordanian health care providers in decision making about maintaining a clinical placement in a mental health setting and reviewing outcomes and expectations regarding current clinical practice. Thus, the findings provide evidence for the benefits of such a clinical placement in relation to students' perceived confidence in offering health care for people who have mental illness. Acknowledgments I am very grateful to the nursing students at the Faculty of Nursing at Mu'tah University, for their participation and support during this study.
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The impact of a mental health clinical placement on the clinical confidence of nursing students in Jordan Ahmad Yahya AL-Sagarat a,⁎, Faris ALSaraireh a,1, Rami Masa'deh b,2, Lorna Moxham c,3 a b c
Community and Mental Health Nursing Department, Faculty of Nursing, Mu'tah University, P.O. Box 7, AL-Karak Postal code 61710, Jordan Applied Science Private University, Amman, Jordan University of Wollongong, Faculty of Science, Medicine and Health, Northfields Ave, NSW 2522, Australia
a r t i c l e
i n f o
Article history: Accepted 13 February 2015 Keywords: Mental health Clinical confidence Clinical placement Nursing student Jordan
s u m m a r y Objectives: To examine the impact of clinical placement in a mental health setting on the clinical confidence of nursing students in Jordan. Design and setting: A non-experimental descriptive survey design was used. Data was collected using the Mental Health Nursing Clinical Confidence Scale (MHNCCS) in Jordan. Results: Data indicates that, as a result of clinical placement, nursing students had improved perceived confidence regarding the concept of mental health and mental illness, felt better able to conduct a mental health status examination, create nursing care plans, administer medication and provide health education to patients in mental health settings. Conclusions: Improving the clinical confidence among Jordanian nursing students in relation to mental health nursing skills may provide a safer environment for students and patients as well as lead to enhanced well-being and function of patients. In addition, the results of this study may have practical implications for positive changes to the mental health nursing curriculum clinical placement goals. © 2015 Elsevier Ltd. All rights reserved.
Introduction It has been widely acknowledged in the nursing literature that clinical placements are an important component of the nursing curriculum (Eick et al., 2012; Jokelainen et al., 2011; Sharif and Masoumi, 2005). Theory, which is learned at university but applied in the clinical setting, provides information that assists nursing students to develop an understanding and appreciation of the nurse's role and patients' needs (Townsend and Scanlan, 2011). Thus, theory informs practice, but theory alone does not provide the variety of professional opportunities afforded by clinical practice. Clinical placement, also known as work integrated learning (WIL) (Keleher et al., 2007) and internationally as clinical clerkships, provides students with the opportunity to apply theory to clinical practice competently and confidently in a hospital setting. Consequently, nursing theory can be applied and further understood in conjunction with clinical placement (Walker et al., 2012). Hagbaghery et al. (2004) argues that competence and self-confidence are the most ⁎ Corresponding author at: Community and Mental Health Nursing Department, Faculty of Nursing, Mu'tah University, P.O.Box 7, AL-Karak Postal code 61710,Jordan. Tel.:+962 32372380x6705, +962 772038527 (mobile), +962 797341546. E-mail addresses: [email protected] (F. ALSaraireh), [email protected] (R. Masa'deh), [email protected] (L. Moxham). 1 Tel.:+962 32372380, +962 798123856 (mobile). 2 Tel.: +962 796067657 (mobile). 3 Tel.: +61 2 4239 2559.
http://dx.doi.org/10.1016/j.nedt.2015.02.008 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
important factors that enable nursing students to make appropriate decisions related to patient care. Undertaking a clinical placement requires students to translate theoretical knowledge to real world clinical situations, in numerous clinical jurisdictions and discipline areas. For some students, this transition can be both frightening and filled with self-doubt (O'Connor, 2006). Lack of self-confidence in student nurses can interfere with their ability to acquire new knowledge and hinder their ability to deal with difficult and challenging situations. Students can experience a lack of confidence because individuals are typically guided by their beliefs and perceptions rather than reality (Pajares, 2007). Clinical nursing instructors both in the academy and in the workplace need to be cognizant of this phenomenon and intervene promptly to promote student confidence. Instilling confidence in student nurses early provides a foundation for the acquisition of knowledge and the successful implementation of newly acquired skills. According to Holland et al. (2012), professional confidence can be described as a dynamic, maturing personal belief held by a professional or student. This includes an understanding of and a belief in the role, scope of practice, and significance of the profession, and is based on their capacity to competently fulfill these expectations, fostered through a process of affirming experiences. Confident students will engage in challenging opportunities and skills, whereas their less confident peers will avoid the same tasks (Townsend and Scanlan, 2011). Confident students will also approach difficult skills and tasks with lower anxiety, perceive that particular
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skill as important, and possess a firmer commitment to use their clinical skills (Clark et al., 2004). Clinical confidence is difficult to gain in the classroom. Rather, it is enhanced in the clinical setting by applying and then mastering newly learned skills and experiencing success. Therefore, it is the role of clinical educators to foster confidence in their students through creating a more positive confidence-rich learning environment (Pajares, 2007). Educators need to be able to recognize a lack of confidence in individual students and plan appropriate teaching strategies that will enhance self-confidence. Like all nursing specialties, mental health nursing involves interaction between the nurse and patient. In mental health nursing, the nurse patient relationship is vital (Moxham et al., 2013). This inherently humanistic perspective enhances the importance of learning theory and mastering clinical practice. It is necessary for students to experience mental health clinical practice first hand, working with people who have lived experience of mental illness. With the opportunity to learn the nuances of psychiatric nursing afforded by a mental health clinical placement, students can implement theoretical learning and practice skills such as therapeutic communication techniques and relationship building and mental health assessments. Effective communication skills need to be refined in clinical practice with real patients (Arthur, 1999). These crucial skills, which underpin all components of effective mental health nursing practice, are one which students require in order to be able to effectively assess the needs of patients and demonstrate unconditional positive regard. Secker et al. (1999) have argued that well developed communication skills increase competency in the care of psychiatric patients and assist in developing therapeutic relationships. Within the population who use health care systems, people who present with mental illness present a challenge to the nursing profession (Chadwick and Porter, 2014) and given that statistics indicate that mental health issues are on the rise, a clinical placement in a mental health setting is an important component of mental health nursing education all over the world. There is substantial evidence regarding the importance of measuring and evaluating clinical skills for nursing students who undertake clinical placements (Townsend and Scanlan, 2011; Yanhua and Watson, 2011; Cant et al., 2013). With regard to evaluating clinical skills in mental health settings there is less evidence and none at all in Jordan, which is the study site of the research reported in this paper. The purpose of this study was to examine the clinical confidence of undergraduate mental health nursing students in Jordan. Examining the clinical confidence among Jordanian nursing students with regard to mental health nursing clinical skills provides an understanding of the areas in which students lack confidence, as well as those where they perceive their confidence to be high. As a result of this understanding, modifications can be made to curricula both theoretical and clinical, and core competencies can be evaluated and reinforced. Methods Design and Sample A descriptive, cross-sectional research design was used in this study. A purposive, non-probability sample of third-year level nursing students who were enrolled in a mental health nursing course in Jordan in the second semester 2013–2014 were invited to participate. The participating students completed a pre-test prior to attending their clinical placement and then a post-test questionnaire after attending 19 days of mental health clinical placement. Ethical approval was granted from the Research Ethics Committee in the Faculty of Nursing, Mu'tah University, Jordan. After that, recruitment of students was undertaken by research assistants who provided information about the study purpose and procedures to potential participants. In addition, a participant information sheet (PIS) was provided to each potential participant. The PIS clearly elucidated that participation was voluntary, participants could withdraw at any time without
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prejudice and that anonymity was assured. The PIS identified the researchers' contact details for availability to answer any questions or to clarify any salient aspects of the study. Nursing students were also assured that their non-participation, participation, or withdrawal from the study would not in any way affect their current or future relationship with the Faculty of Nursing of Mu'tah University in Jordan. Seventy two students consented to participate in the study. Inclusion Criteria The inclusion criteria required that participants be enrolled in the second semester of their third-year of the mental health nursing course within the Faculty of Nursing, Mu'tah University, Jordan. The participants were also required to be enrolled to complete the mental health clinical placement at the end of the same academic semester. A ‘research pack’, assembled by the research team included the participant information sheet, a consent form, and the mental health nursing clinical confidence scale (MHNCCS). The packs were distributed to nursing students by the research assistants. Although Arabic is the native language in Jordan, English is the official language for hospital documentation and for teaching in nursing schools. Therefore, English versions of the questionnaires were used. Study Instrument The Mental Health Nursing Clinical Confidence Scale (MHNCCS) (Bell et al., 1998) was used as the data collection instrument for this study. The MHNCCS is a self report questionnaire comprising 20 questions related to the evaluation of confidence in mental health nursing skills among undergraduate students. The 20 item questionnaire includes six domains covering areas such as, assessment, communication, education, medication knowledge, self-management and team work. It has to be acknowledged that these 20 items formed a single scale and not divided into multiple subscales (Bell et al., 1998). Responses to the 20 items are measured on a 4-point scale from 1 (not at all confident) to 4 (completely confident) (see Table 1 for MHNCCS individual item component). Process of Data Collection Like many countries, the mental health nursing course in Jordan consists of two components (i.e. the theoretical component and the clinical component). The clinical component requires students to attend 19 days (8 h per day) over ten weeks of the clinical practice. To commence data collection, the MHNCCS was completed by the mental health nursing students prior to the commencement of their clinical placement. Upon completion the questionnaires were returned to the research assistant for coding. The second round of data collection saw the research assistants distribute the questionnaire to the same students after they have completed their mental health clinical placement. The completed questionnaires were returned to the research assistant within one week after the completion of the clinical placement. All the participants were asked to complete the MHNCCS within 20 min. Any participant who requested assistance was supported by the research assistants to complete the questionnaire. In order to be able to match pre- and post-clinical responses, the students were instructed to provide a unique identification number and were reassured that the numbers would not be able to be linked to individual students. Completed questionnaires were returned by the participants to a sealed box which was placed in the main hall of the Faculty of Nursing at Mu'tah University, Jordan. Data Analysis The Statistical Package for the Social Sciences (SPSS-21) software was used for data entry and analysis. Only the primary researcher entered the data to ensure consistency. Measures of central tendency were used to describe the characteristics of the sample. Descriptive statistics were used to analyze demographic
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Table 1 The Mental Health Nursing Clinical Confidence Scale individual item component. Section A: This section seeks information concerning the confidence of nursing students to care for psychiatric patients following their psychiatric clinical placement. Questions
Not at all confident (1)
Sometimes confident (2)
Not sure (3)
Completely confident (4)
1. I can communicate effectively with clients with a mental health problem. 2. I can carry out a comprehensive psychosocial assessment of clients. 3. I can conduct a mental state examination. 4. I can develop a nursing care plan on the basis of my assessment. 5. I can assist clients with a mental illness to clarify treatment goals. 6. I am able to provide basic counseling for clients with a mental illness. 7. I am able to be empathic with a range of clients with a mental illness. 8. I can provide information and education for clients regarding their illness. 9. I am able to assist clients to develop living skills. 10. I have a basic knowledge of antipsychotic medications and their side-effects. As a result of my psychiatric clinical placement 11. I have a basic knowledge of antidepressants and their side-effects. 12. I have a basic knowledge of anti-anxiety medications and their side-effects. 13. I have a basic knowledge of mood stabilizers and their side-effects. 14. I am able to provide client education regarding the effects and side-effects of medications. 15. I can fit with the nursing team on a mental health clinical placement. 16. I can contribute client-related mental health information at a multidisciplinary meeting. 17. I can handle clients who are verbally aggressive. 18. I can handle clients who are physically aggressive. 19. I am able to establish my own personal boundaries when relating to clients with a mental illness. 20. I can seek support from other members of the mental health team.
data. Frequencies and distributions were used to describe the percentage of nursing students for each categorical demographic variable. A paired samples t-test was performed to answer the research question which was: Is there a significant difference in clinical confidence between pre- and post-clinical placement among nursing students in Jordan using the MHNCCS? Results Using a convenience sample, 76 undergraduate nursing students were invited to participate in the study. Of the 76 students, 72 students consented to take part in the study. Of the 72, 68 students (approximately 90% of the approached students) fully completed and returned both pre- and post-questionnaires that were considered in the analysis. Tables 2 and 3 present some characteristics of the respondents. The age of the participant students ranged between 20 and 30 years, with more than 97% less than 24 years of age. The number of female students was higher than male students (54 and 14, respectively). All of the participants (100%) had not previously attended a psychiatric clinical placement prior to this study. However, after the completion of the course, participating students had attended between eight and 19 days of the clinical placement with a mean of 16.76, SD (3.87). The total confidence score of the pre-clinical placement ranged between 20 and 74 with a mean of 43.44, SD (10.64). In contrast, the total confidence score after the completion of the clinical placement ranged between 30 and 80 with a mean of 58.76, SD (12.93). Table 4 presents the mean of each item of the MHNCCS pre- and post-clinical placement. There was a statistical significant difference in the mean at p b 0.05 in each individual item for all items except the last two (i.e. I am able to establish my own personal boundaries when relating to clients with a mental illness; and I can seek support from
Table 2 Characteristics of the students (continuous variables). Characteristics
Pre-clinical placement students n = 68 mean (SD)
Post-clinical placement students n = 68 mean (SD)
Age Completed days in clinical placement Total confidence score
21.00 (1.73) N/A 43.44 (10.64)
16.76 (3.87) 58.76 (12.93)
other members of the mental health team). However, the total score was calculated by adding all 20 items together with the total score then treated as a single scale, the higher total score equates to higher levels of confidence. After calculating the total score by summing all 20 items, a paired samples t-test was used to evaluate the impact of the psychiatric clinical placement on the confidence scores of participants. Findings demonstrate a significant difference in confidence scores for undergraduate nursing students (p b 0.001), with students at post-clinical placement having significantly higher confidence scores. The mean confidence score for students after completion of their clinical placement was higher compared to their score prior to the clinical placement (58.76 compared to 43.44). The mean difference between scores was 15.32 (95% CI: 11.86 to 18.79). The ETA squared statistic = 0.54 is indicative of a large effect size. In this study, in order to confirm the reliability of the confidence scale, internal consistency was assessed. Cronbach's alpha coefficients were calculated for the students before and after their clinical placement, and were found to be 0.89 and 0.90 respectively (Table 5), suggesting high internal consistency and reliability of the scale for this sample. Pallant (2007) stated that values above 0.70 are considered acceptable and above 0.80 are good. Table 6 illustrates that all values in the final column “Cronbach's alpha if item is deleted” were less than the final alpha, suggesting that all items were related to each other and contributed to the scale. It can be concluded that this confidence scale is a valid and reliable instrument to be used in the study of clinical confidence in undergraduate nursing students in Jordan. This supports the assertion by Bell et al. (1998) that the MHNCCS has well-established validity (Ross et al., 2013). Table 3 Characteristics of the students (non-continuous variables). Characteristics
Pre-clinical placement students n = 68% (n)
Post-clinical placement students n = 68% (n)
Male Female Never been to psychiatric clinical placement Last clinical placement less than a week
20.60% (14) 79.40% (54) 100.00% (68)
N/A
N/A
100% (68)
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Table 4 Mean pre- and post-clinical scores for individual items on the Mental Health Nursing Clinical Confidence Scale along with the paired t-test significance. Individual scale item
Mean (pre-clinical placement) Mean (post-clinical placement) P value
I can communicate effectively with clients with a mental health problem. I can carry out a comprehensive psychosocial assessment of clients. I can conduct a mental stat examination. I can develop a nursing care plan on the basis of my assessment. I can assist clients with a mental illness to clarify treatment goals. I am able to provide basic counseling for clients with a mental illness. I am able to be empathic with a range of clients with a mental illness. I can provide information and education for clients regarding their diagnosis. I am able to assist clients to develop living skills. I have a basic knowledge of antipsychotic medications and their side-effects. I have a basic knowledge of antidepressants medications and their side-effects. I have a basic knowledge of anti anxiety medications and their side-effects. I have a basic knowledge of mood stabilizers and their side-effects. I am able to provide client education regarding the effects and side-effects of medications. I can fit in with the nursing team on a mental health clinical placement. I can contribute client-related mental health information at a multidisciplinary meeting. I can handle clients who are verbally aggressive. I can handle clients who are physically aggressive. I am able to establish my own personal boundaries when relating to clients with a mental illness. I can seek support from other members of the mental health team.
2.22 2.10 2.01 2.04 2.40 2.12 2.68 2.31 2.49 1.72 1.62 1.68 1.71 1.87 2.31 2.32 2.29 1.94 2.68 2.94
Discussion The findings from this study revealed that perceived mental health nursing confidence increased as a result of exposure to the mental health clinical setting. Results demonstrate a significant difference in the Jordanian mental health nursing students' clinical confidence regarding their knowledge about various types of medications used in mental health post-clinical placement in comparison to their clinical confidence prior to clinical placement regarding the same issue. Dedicated clinical placements are important to enable students to acquire the appropriate skills, knowledge and attitudes necessary to engage with people with mental health problems (Henderson et al., 2007; Ross et al., 2013). Knowledge of medication is an important nursing role. The results of this study also indicated that the participants felt more confident to be able to conduct a mental status examination and to develop a nursing care plan. However, the Jordanian students in this study did not gain confidence in their ability to assist patients to develop living skills. This could be explained by the results from the Daradkeh (2009) study that found that Jordanian psychiatric hospitals lack practical activities which can prepare patients for vocational adjustment and jobs training. The paucity of practical teaching programs for clients related to their activities of daily living is influenced by the medical model of care which places strong emphasis on pharmacological methods of treatment rather than on psychotherapeutic methods of treatment in this region. The findings indicated that the students lacked confidence to contribute clinically related mental health information at multidisciplinary meetings. The lack of regular meetings in the Jordanian psychiatric wards could explain the reported lower level of confidence regarding contributions by the Jordanian nursing students at multidisciplinary meetings. With regard to treatment goals, the Jordanian nursing students' confidence to assist patients with mental illness to clarify treatment goals did not significantly increase after their clinical placement. Beazley and Gudjonsson (2011) found that psychiatric patients, when admitted, are commonly poorly motivated to engage with their treatment often because either they have little insight into their condition or they are
Table 5 Reliability of the scale. Cronbach's alpha coefficient of the confidence scale Pre-clinical placement Post-clinical placement
0.89 0.94
p b 0.001 p b 0.001 p b 0.001 p b 0.001 0.002 p b 0.001 0.011 p b 0.001 0.003 p b 0.001 p b 0.001 p b 0.001 p b 0.001 p b 0.001 p b 0.001 0.002 p b 0.001 p b 0.001 0.152 0.303
2.82 2.84 2.88 2.97 2.82 2.75 2.94 3.13 2.94 3.09 2.87 3.00 3.03 3.09 2.85 2.81 2.97 2.93 2.91 3.12
frustrated by being the recipient of mandated treatment. It is also reported by Sorensen (2006) and Usher et al. (2009) that clients with acute mental illness experience many barriers that prevent them from participating in the daily activities of the wards when they are admitted to hospital settings. These barriers include low self-worth and selfconfidence, loss of energy, interest and motivation, generalized fatigue, poor physical fitness, social fear, helplessness and hopelessness. In the current study, most of the patients admitted were acutely ill and may not have been motivated to engage in their treatment goals. This could have been as a result of their illness or side effects of their medication or lack of engagement with them by staff. As previously alluded to, Jordanian psychiatric hospitals emphasize medication management (Daradkeh, 2009). Numerous authors (Munch and Hamer, 2010; Muir-Cochrane et al., 2010; Usher et al., 2009) have identified that psychotropic medications can result in movement disorders, fatigue and sedation, metabolic syndrome such as increased appetite, weight gain and the development of Type 2 diabetes mellitus, sexual dysfunction and postural hypotension. These adverse reactions may be additional barriers preventing clients from participating in daily ward activities or engaging in their treatment goals.
Table 6 Cronbach's alpha if item is deleted. Confidence scale
Pre-clinical placement Cronbach's alpha if item is deleted
Post-clinical placement Cronbach's alpha if item is deleted
Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Question 9 Question 10 Question 11 Question 12 Question 13 Question 14 Question 15 Question 16 Question 17 Question 18 Question 19 Question 20
0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89 0.89
0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.94 0.93 0.94 0.94 0.94 0.94 0.94 0.94
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Moreover, Healy (2009) found that psychotropic medications negatively influence how a person perceives pleasurable sensations, leading to a severe reduction in feelings of desire and motivation. BootsMiller et al. (1997) on their research into the social climate in psychiatric hospitals, found a lower rate of involvement with ward activities in acute psychiatric wards related to the fact that when patients entered the ward they did not have the capacity or energy to engage. The researchers also reported that the nurses and nursing students during their clinical placement at this stage of the patient's illness were more focused on containment, rather than offering and encouraging involvement in daily activities and treatment programs (BootsMiller et al., 1997). The lower rating of confidence regarding offering engagement in the treatment programs among the Jordanian nursing students in this research could be explained by a potential lack of client motivation during the acute stage of their mental illness. Limitations Like all research, this study has limitations. One limitation is that the study used a sample of students drawn from just one of the public nursing faculties in Jordan. Therefore the findings cannot be generalized for students enrolled in mental health nursing programs at other nursing faculties in Jordan. Problems also arise when relying on participants to self-report due to recall bias. In future research, a combination of data sources should be used. Conducting this study again with a larger randomized sample would expand the knowledge of the impact of a mental health clinical placement on the perceived confidence of nursing students. Despite this, these findings may still be helpful for clinical educators and clinical staff in identifying students' needs, facilitating their learning in the clinical setting and developing effective interventions to improve their clinical confidence. Conclusion Student nurses describe their clinical placements as an opportunity to practice skills and apply knowledge. The findings of this study have shown that perceived confidence does increase as a result of exposure to a mental health clinical placement. Significant changes in the selfreported confidence levels of students were found at the completion of the clinical placement. This is important so as to support the continuation of mental health clinical placements in Jordanian nursing curriculum. Furthermore, with a growing body of literature suggesting that many students who enter undergraduate nursing courses do so with no or little interest in mental health nursing exposure to positive mental health clinical experiences could be one way to increase recruitment (Moxham et al., 2011). The findings of this research may also assist Jordanian health care providers in decision making about maintaining a clinical placement in a mental health setting and reviewing outcomes and expectations regarding current clinical practice. Thus, the findings provide evidence for the benefits of such a clinical placement in relation to students' perceived confidence in offering health care for people who have mental illness. Acknowledgments I am very grateful to the nursing students at the Faculty of Nursing at Mu'tah University, for their participation and support during this study.
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