Introduction

Globally, it is estimated that 792 million people suffer from mental disorders [1]. In the United States, it is estimated 50% of all Americans will be diagnosed with a mental illness or disorder at some point in their lifetime [2]. The prevalence of mental illness and its potential debilitating sequalae call for an increase in the number of nurses who can provide mental health care [3], yet few student nurses elect to pursue a career in mental health. Studies of students’ perceptions of psychiatric clinical rotation attributes the shortage of nurses to a general lack of preparedness for careers in the mental health field, which results in fear and stigma towards the mentally ill [4,5]. One study of recent nursing graduates found that limited clinical time and clinical exposure perpetuated students’ fear in relation to pursuing a career in psychiatric nursing [5]. Similarly, Webster, et al. [6] found that the ongoing stigma of mental illness and the constant portrayal of the mentally ill as aggressive intimidate nursing students. In addition, students’ attitudes towards psychiatric nursing may be influenced by the nurse educator’s lecturing style, as well inadequate mental health course content, which leads to a feeling of incompetency for the mental health field [5,7,8].

A recent study examined nursing students’ rating of their psychiatric clinical experience in relation to psychiatric lectures. Findings revealed that students who rated their psychiatric lectures as above average had better attitudes towards psychiatric rotation [9]. These findings were echoed by Rüsch, et al. [10] who found that education, together with increased clinical exposure to psychiatric patients, were related to better attitudes towards them. Nurse educators are therefore tasked with providing innovative ways to enhance students’ experiences with psychiatric clinical rotation in order to increase interest in pursuing a career in psychiatric nursing. Evidence supports the use of guided reflective journaling as an innovative teaching tool for educators and a learning platform for students [11-16]. Although there is a growing amount of literature on the use of reflective journaling, research on students’ perceptions of psychiatric clinical rotation by means of guided reflective journals is still in its infancy. The present study will address this gap in the literature by exploring students’ opinions in relation to mental illness and mental health nursing as expressed through guided reflective journals. Findings may highlight major themes that inhibit or enhance a student’s perception of mental illness. Knowledge of these themes may assist faculty in developing a better learning experience for students that addresses the fear and stigma surrounding mental illness and psychiatric mental health nursing careers.

Reflective Journaling

Nursing students often find themselves in a state of hesitation and apprehension prior to psychiatric clinical rotation. They begin the rotation with stigma, fear, and ignorance in relation to psychiatric patients [16]. Evidence suggests that such fears and ignorance can be better understood through reflection and reflective journaling before and after a psychiatric rotation [14]. According to the philosopher John Dewey, reflection is the “active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that supports it and the further conclusions to which it tends” [17]. Spalding, et al. [18] maintained that reflective thinking starts with a state of doubt or reluctance then through the act of searching to find evidence that will address the hesitation.

Reflective journaling allows for students to engage in an internal dialogue with themselves and to have a safe outlet for their thoughts and concerns [11,13,19]. Through reflective journaling, students can start to weave through their thoughts concerning psychiatric clinical rotation. Reflective journaling also benefits nurse educators in that it provides a window into students’ way of thinking and learning [13]. The National League for Nursing promotes the use of both reflective and critical thinking as incentives for nursing educators to use in facilitating learning [20]. Therefore, nursing educators can use reflective journaling as an evaluative tool for students’ learning needs within the psychiatric setting.

Despite the widespread emphasis on reflective journaling, studies on its use as a learning tool for students often yield contrasting reviews. For example, some studies have reported that reflective journaling leads to insightful progress towards the learning process and promotes critical thinking [21,22]. Other studies have indicated that reflective journaling is subjective in nature, thus rendering evaluation difficult [23]. Kennison, et al. [24] argued that students do not put valuable effort into journaling when journals are not graded. It is therefore important for faculty to identity the objectives of journaling (graded versus non-graded) and the type of journal format (Structured Versus Guided) [25] in order to optimize the students’ learning process. The task at hand is to develop a format that details the expectations of students regarding this type of writing, while still focusing on their learning outcomes. Research supports the notion that guided reflection helps students to actively engage in examining their experiences, thus enhancing the quality of their learning as well as debunking some of the myths associated with mental illness [12,13,15].

According to Craft, [26] guided reflection enables students to move past the telling of an experience towards a more thorough soul-searching and concept synthesis regarding clinical experiences. Through guided reflection, educators are able to pose questions that enhance critical thinking and deeper understanding of those afflicted with mental illness. A majority of studies have used quantitative methods and questionnaires to assess attitudes and perceptions of students towards psychiatric clinical rotation [27-29]. The present study will address this gap in methodology and knowledge by using qualitative method to explore students’ opinions relating to mental illness and mental health nursing through guided reflective journals.

Method Design

This study used a qualitative research design to explore students’ perceptions of psychiatric mental health clinical rotation by means of archival student narratives.

Sample and Setting

After receiving Internal Review Board (IRB) approval, student archival narratives from spring 2020 were retrieved from previous courses taught and utilized for this study. All participants were enrolled in the mental health theory course and mental health clinical rotation at a public state university in NJ. In order to protect the students’ privacy, direct identifiers (Students’ Names) were removed from the journals and replaced with numeric codes. Students were required to respond to four specific questions as part of their reflective journaling assignment in the clinical settings. The guided reflective journals were completed by a total of 25 students before and after the mental health clinical rotation. The four questions included the following:

Before Clinical Rotation

• What is your perception of mental illness and persons with mental illness?

• What concerns, fears, or beliefs do you have regarding this clinical rotation? After Clinical Rotation

• Which beliefs about mental health nursing have changed after the clinical rotation?

• Would you consider becoming a psychiatric nurse?

The reflective journals were kept in digital format. The hard copy journals were converted into digital form by scanning into the researcher’s university email. Once converted into digital format, all paper documents were returned to the general storage area with other students’ course work. All digital files were saved and kept in a password-protected computer folder in the secure university computer server. Only the primary researcher has access to the digital files. Minimal risk and burden were incurred because this study involved archival student narratives.

Data Analysis

Content analysis was utilized to identify major themes within the students’ responses in relation mental health clinical rotation. According to Berg, et al. [30], content analysis is a detailed and systematic examination and interpretation of data in an effort to identify patterns, themes, and special characteristics. To detect common themes in this study, all journals were read line-by-line by the primary researcher and processed with the classification program of AtlasTi 8. Data saturation was reached after the review of 15 reflective journals. The collected data were divided into four parts for each reflective question. Similar themes were identified and highlighted. Each of the highlighted themes was coded and transferred into one document. Coding was used to organize the content of the journals and to allow for easier retrieval of the themes [31]. To enhance credibility and authenticity, the students’ reflections on each question were maintained through the use of direct quotations.

Results and Discussion

The themes identified from the students’ journals are presented according to the guided reflective questions assigned before and after the mental health clinical rotation. These themes were supported by the students’ phrases which are presented in the following discussion of results.

Before Clinical Rotation

What is Your Perception of Mental Illness and Persons with Mental Illness?

Theme 1: Media Influence

One of the most commonly occurring themes in this section was “Media influence”.

Many students reported having a negative view of mental illness and people with mental illness due to the portrayal of this type of illness by the media. According to Stuart, [32], the media has presented sensitive and educational material on mental health and mental illness to society. However, such positive materials have been outweighed by the perpetual depiction of mental illness with horrifying images and barbaric psychiatric treatment. One student stated that people with mental illness “Are held under a different light, making them seem violent, less intelligent, and crazy”. Another student stated “These are ideas often expressed in Hollywood, where people with mental illnesses are depicted these ways, giving society a clouded, imaginative, and an incorrect version of those that suffer with mental illness”. These sentiments were echoed by another student who stated, “Stories I’ve heard in the news are the cause of my negative assumptions”.

The students’ reflections on mental illness are supported by various researchers who have purported that such negative exposure to mental illness by the media produces intolerance towards people with mental illness, ultimately leading to apprehension and negative evaluation of mental health issues [33-35]. Such studies enforce the need to further educate the public about mental illness and how the media has portrayed people with mental illness.

Theme 2: Assumptions from Other Students

Students’ perceptions of the mentally ill appeared to be influenced by other students who had already taken the psychiatric mental health clinical rotation. One student stated, “I’ve heard different reports from other students who have done the psych rotation”. One person said it was “Boring because the patients didn’t have any physical ailments, the work was less challenging”. Another student lamented that psychiatric nurses “do not do anything for the patients”. These responses from the students are echoed by several authors who stated that the view of psychiatric nursing as “less challenging and boring” is often perpetuated within the nursing profession. Mental health professionals are easily dismissed due to the perceived notion that their care is low-skilled work [36], and they are usually given the airy role of “Custodial Companionship” by nurses in other fields of nursing [37]. In a study by Halter, [38], mental health nurses were consistently looked down upon compared to nurses in other specialty areas in terms of being logical, skilled, self-motivated, and respected. Consequently, nursing students have also shown similar attitudes towards mental health nursing. It is important as nursing educators to not only show case the challenging work that psychiatric nurses encounter on a daily basis but also the fulfilling nature of being in this nursing specialty.

What Concerns, Fears, Or Beliefs Do You Have Regarding This Clinical Rotation?

Theme 1: Lack of Knowledge

A lack of knowledge about the care of patients with mental illness could fuel fear and create challenges and difficulties among students during these encounters. In this study, students expressed their concerns of “Not knowing what to do”. One student said “I am worried that I won’t know what to say to these patients or that I will not know how to interact with them”. These sentiments were reiterated by another student who stated, “I am just afraid of saying or doing something wrong that will offend a patient causing them to lash out verbally”. Some stated that they fear their lack of understanding of the various types of mental illness and not understanding what the patients are going through, and are “Afraid of Feeling Hopeless”.

Some authors have speculated that the lack of popularity of this field is due to inadequate mental health course content, as well as clinical experiences that are disconcerting, which ultimately lead to a general lack of preparedness for the mental health field. With the growing prevalence of mental illness, it is imperative for nursing students to be well equipped with adequate knowledge of mental health nursing so as not to succumb to the stigma that currently surrounds this field. Gouthro, [39] suggested that, to better prepare nursing students for this rotation, nursing faculty should re-examine how the theoretical and clinical components of the current curriculum address the lack of preparedness that students feel and evaluate the time allotted for the education of mental health.

Theme 2: Aggressive Patients

Many students were concerned about taking care of aggressive patients at the psychiatric hospital. One student stated, “My fear is being overpowered by a patient who possibly could get aggressive or agitated”. Other students expressed concerns of not having adequate techniques to protect themselves when a patient becomes angry and aggressive. They also reported that mentally ill patients were “strange and unpleasant to be around”. The stigma associated with mental illness and its association with aggressive behavior can be overwhelming to nursing students [6]. Moreover, due to the limited amount of time spent in the psychiatric unit, nursing students may lack the opportunity to experience how trained staff de-escalate a crisis, thus making it difficult to convince nursing students to pursue a career in psychiatric nursing [6]. Allowing nursing students to witness staff managing an aggressive situation using techniques such as one- on-one observation, provision of milieu environment with lesser stimulation, talk down techniques, and chemical restraints such as medication prior to employing physical intervention, can help ease the anxiety about aggressive patients [11].

After the Clinical Rotation

Which Beliefs have changed after the Clinical Rotation?

Theme: Regular Human Beings

After spending five weeks of the clinical rotation at the psychiatric hospital and interacting with patients, a majority of the students had a change of attitude regarding how they view patients with mental illness. They saw the patients as regular human beings. One student stated, “My patients looked like my friends, neighbors, friends and even family members. They could be any of us and I will never forget that”. Another student echoed this statement and said that some patients came across as someone you might run into at work and school. Other students discussed how mental illness is often out of someone’s control and it is unfair for society to treat them as less intelligent compared to other people. Collectively, the students believed that people with mental illness are just “Like Everyone Else”.

These results are consistent with those of O’Ferrall, et al. [40] who examined factors associated with the evolution of attitudes towards mental illness in a cohort of nursing students. The study found that students’ attitudes towards the mentally ill evolved positively over a short period of time. The authors attributed the change of attitude to extended theoretical training and clinical rotation. Other authors have also emphasized the importance of clinical experience in changing and improving students’ attitudes towards the mentally ill [29,41]. Many of the students in this study became acutely aware of their limitations in understanding mental illness. However, by the end of the clinical rotation, there was a marked improvement in their understanding of mental illness as evidenced by students change in attitude.

Would you consider becoming a psychiatric nurse?

70% Yes

30% No

Given the students’ attitudes prior to the psychiatric clinical rotation, it was surprising to find that 70% of them considered becoming psychiatric nurses. One student stated, “I would definitely consider becoming a psych nurse after this clinical experience. I loved it. I have built this immense empathy for these patients, especially the children, and really want to help them recover and lead a normal life”. Another student stated, “I would definitely consider psychiatric nursing in the future. I would absolutely need more education and more clinical experience, as I know I have much more to learn”. Others considered a career as a psychiatric nurse only after working in other clinical settings. One student summed it up by stating:

I was always certain I would hate the psych rotation but five weeks later, I don’t want to leave. In the future I would consider becoming a psychiatric nurse. Being a psychiatric nurse is not easy; it takes a special kind of person to become a psychiatric nurse. I would consider being a psychiatric nurse because as mentally exhausting as it is, in the end it is also extremely rewarding and self-fulfilling helping these patients meet their goals.

These findings are consistent with those of Thongpriwan, et al. [42] who determined that students with mental health experience and those who showed interest in an externship in mental health nursing also expressed great interest in a future in this field. Perlman, et al. [43] also showed that students with better academic performance in a theoretical course on mental health demonstrated positive attitudes towards mental health nursing. However, due to the nature of the current study, this finding was not confirmed. A plethora of studies have indicated that most nursing students favor other nursing careers over mental health nursing [28,41,44]. These findings are inconsistent with the current study in which only 30% of the participants said that they would not consider becoming psychiatric nurses. Most of these students lamented the lack of hands-on care between the nurse and the patient. One student stated, “I wouldn’t consider being a psychiatric nurse because I prefer more hands-on nursing. I noticed that most of the nurses on the different units mainly just sat at the nurses’ station all day and didn’t really interact with their patients”. Another student echoed these sentiments and stated:

I would not consider being a psychiatric nurse. If I were to choose a career working with mentally ill people, I would become a counselor… counselors spend more time with the patients. While the nurses clearly work hard and care about the patients, they don’t interact with their patients as much as I would want to. In addition, I would not want to work behind a plexiglass wall for most of the day.

Others stated that psychiatric nursing is boring and less challenging compared to other fields in nursing. There is considerable evidence that portrays psychiatric nursing as lacking hands-on and technological skills, thus making the specialty less lucrative [44-46]. The representation of psychiatric nursing in this manner has been related to a type of stigma by association or courtesy stigma [38,47], where nurses are stigmatized by virtue of association with another stigmatized individual. It is this stigma of association that also perpetuates the perceived negative characteristics of psychiatric nurses, where they are seen as the least liable ‘to be described as skilled, logical, dynamic and respected’ [38]. Given this description, it is not surprising that some students found the psychiatric clinical rotation less stimulating and boring, ultimately making it the least favorable specialty to pursue as a career choice.

Implications

The findings of this study highlight the importance of using reflective journaling in understanding students’ fears and hesitation towards psychiatric mental health clinical rotation. Students expressed their perceptions and beliefs about the mentally ill prior to and after the clinical rotation. Through reflective journaling, the students were able to weave through their fears and hesitation, and discovered that mentally ill patients are regular human beings with a brain disease. The major themes identified in this study suggest that, through clinical practice and interaction with the patients, some of the psychiatric myths that are mostly perpetuated by the media were debunked. Knowledge of these themes may assist faculty in developing a better learning experience for students and address the fear and stigma surrounding mental illness, as well as the shortage of psychiatric mental health nurses. As stated by Happell, et al. [4], a lack of preparedness and limited clinical exposure perpetuates students’ fears towards pursuing a career in mental health nursing.

Limitations

This study adds to the literature through its focus on using reflective journaling to assess students’ perceptions of psychiatric clinical rotation. Despite the strength of this qualitative study, there are several limitations that suggest valuable directions for future investigation. Firstly, the students in the study attended the same school, were taught by the same educators, and went to the same clinical site. Thus, the results may not be reflective of the varied experiences of students in different institutions. Future studies should include students’ reflections from different institutions across the country. Secondly, while the study revealed important themes that affect students’ perceptions of psychiatric clinical rotation, longitudinal studies are necessary to understand the changing perspectives of nursing students as they transition to becoming professional nurses. Lastly, given that the findings are based on reflective journals, students’ responses may have been influenced by their personality and background. Future studies may benefit from using a mixed methods design that uses both reflective journals and a quantitative approach to generate a more comprehensive data.

Conclusion

As noted from the reflective journals, a majority of students have a preconceived notion of what psychiatric clinical rotation is, based on the media and the assumptions of other nursing cohort groups. It is therefore important for nurse educators to assist in alleviating the anxiety and stigma that is often associated with mental illness. Gouthro, [39] argued that the process of destigmatization of mental health nursing should start with nursing educators’ self-reflection on how their personal teaching and perceptions have raised students’ consciousness of stigma. This could potentially make psychiatric nursing more appealing, while ultimately increasing the number of students choosing this specialty as a career option.

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