Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing EducationStudent Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
This section provides educators with an overview of the knowledge and skills required to promote, develop and support ongoing student reflective practice as a key process for advancing learning and clinical practice in mental health and addiction nursing. This section also demonstrates the importance of self-care and mental health
promotion strategies that are consistent with practices to enhance student personal and professional resilience and reduce occupational stress in mental health nursing practice.
At the end of this section, educators will support students in the following ways:
- Recognize the importance of reflective practice for developing nursing practice, including seeking new and innovative practices, as well as for engaging in lifelong learning, self improvement and professional development.
- Engage in ongoing critical reflection related to the study and practice of mental health nursing with persons and families across the lifespan.
- Use self-reflection as a primary learning modality for promoting knowledge and skill development in the provision of mental health care.
- Increase understanding and awareness of self-care concepts to enhance ongoing student personal and professional development in mental health nursing practice.
- Increase understanding and awareness about factors that contribute to occupational stress reactions (e.g., acute stress, PTSD, Secondary Stress, burnout) in the context of mental health nursing practice.
- Identify strategies and practices to decrease the impact and manage occupational stress reactions.
Reflective Practice Teaching activities and resourcesReflective Practice Teaching activities and resources
Reflective practice is a dynamic process that integrates theory with application thereby bridging the gap between professional knowledge and the demands of real-world practice (Tomlinson., Thomlinson, Peden-McAlpine & Kirschbaum, et al.,2002). As such, reflective practice is considered among the most promising teaching and learning modalities for developing mental health nursing care.
Faculty act as facilitators and stimulators of student self-reflection aimed at offering care that is collaborative, strengths-based and recovery-oriented. Faculty should engage in “learning together” approach in which they actively engage with students in the process of critical reflection and thinking about diverse clinical situations. In any case, educators seeking to support and promote the practice of recovery-oriented mental health care should (Meyer, Sellers, Browning, McGuffie, Solomon, & Truog, 2009):
- Create a safe and trustworthy learning environment.
- Emphasize ethical and relational dimensions of care.
- Suspend hierarchy among participants.
- Value reflection and self-awareness.
- Honour multiple perspectives.
Reflective practice may occur in individual and group formats; as well as in writing, through interactive discussions or other means. There are multiple strategies for reflection that can assist nursing students to develop the requisite knowledge, skills and competence.
Tools to support reflective practice
The following approaches and tools may be used to support students to engage in ongoing critical reflection.
Journaling. Since the early-mid 1990s, nurse education has embraced the notion of journaling as a way to move the theory of knowledge acquisition of student nurses in active practice. To that end, student nurses have been asked to reflect on their practice in order to make the links between theory and practice and develop critical thinking skills (Epp, 2008), as well as to develop a professional identity (Shapiro, Kassman & Shaffer, 2006). Other writers have used journaling to enhance reflexive practice.
Such journaling, as a form of reflective exercise, creates a safe space for students to critically analyze situations, consider theoretical perspectives and experiences allowing for further insight (Boud, D., Keogh, R., & Walker, D. 1985; Caldwell, L., 2013; Glaze, J. E., 2001). With the increased acuity of health care today, nurses with high level of knowledge and critical application of this knowledge in the lives of patients is key, and journaling is thought of as one way to achieve this objective.
Some authors suggest journaling is a learned skill that begins with descriptions of events and moving to more phenomenological descriptions about their perspectives and analysis of events (Usher, Francis & Tollefson, 2001). This cascading skill is often seen as a hierarchy, though these same authors argue for the beneficial role that different levels of journaling play in nursing practice.
The engagement of teaching faculty in the review of student journals plays a key role in the advancement of student thought. Strategies such as Socratic (critical) questioning and reflections also may be offset by the power differential between the student writer and faculty evaluator. Awareness of how this plays out in student journals is key, for “we as educators need to appreciate the concept of student/teacher entry negotiation and the power implicit in the game” (Harris, 2008).
For more information, see Resources and Appendix E.
Learning circles. Learning circles promote verbal reflection in an interactive manner and involve group discussion that allows participants to critically reflect on practices, promote growth and change, provide a safe, encouraging and empowering space where students can voice concerns, reflect on their practice, and collaborate with colleagues to learn and grow (RNAO, 2016e).
Peer sharing. Peer sharing is the use of partnership dyads to allow for sharing of clinical experiences, strengthening of confidence and clinical reasoning, providing student support and socialization and increased autonomy, accountability, responsibility and self-confidence (RNAO, 2016e).
Technology to support self-reflection. Communications via text message, online journaling, and listening to health-care stories via podcasts to generate reflections can be used as innovative strategies to promote dialogue and reflection. Nursing educational programs should ensure that adequate time, resources and opportunities (i.e., time, safe space, secure and confidential online forums) are provided to allow students to share and practice self reflection (RNAO, 2016e). For more information, see Resources in this section.
Teaching and Learning Activities
The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to reflective practice.
- Student critical reflections on practice
- Student role play and class discussion
- Interaction process recording and analysis (see Appendix B, C, D)
- Simulation (standardized patients) (see Section 7.2)
- Lived client experience/family experience (see Appendix H)
- Reflective writing and journaling (see Appendix E). Reflective practice through written journals, discussion groups or other means may also be used to acknowledge and address the emotional work of nurses and the moral distress that nurses and nursing students encounter in their clinical practice
- Response to video/film scenario or clinical scenarios:
- What are you seeing and hearing? How would you describe the person/family? What are their strengths? Formulate your assessment using strengths-based, person-first language. What do you know? What don’t you know? What do you need to know in order to nurse effectively in this situation? What can you do? What can’t you do? What mental health/mental issues can you identify? What interventions might you offer? What critical questions does this scenario raise?
Learner Engagement Questions
The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding self-reflective practice. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.
- What is your understanding of recovery oriented mental health care? Strengths-based care? Person/family-centred care? What are your beliefs, ideas and experiences regarding mental health? Mental illness?
- What aspect of mental health/mental illness are you most interested in and why?
- What are your concerns/preoccupations?
- What specific challenges are you facing in your nursing studies and practice?
- What are your strengths?
- What areas of practice do you feel most confident in? Least confident?
- What are your learning needs and goals?
- What would be most helpful to you at this time/in this situation?
Evaluation and Self-reflection
The following tools can be used to evaluate students in their understanding and application of selfreflective practice.
- Promote self regulation and critical reflection by including a student self-evaluationcomponent.
- Ensure a reflective practice component in summative coursework and evaluations; i.e., address application to practice versus testing rote (memorization based on repetition) knowledge/content with process recording assignment, responses to clinical scenarios and essay questions.
Reflection question: Are you critically examining your actions and experiences inorder to acquire a new understanding of the situation, and developing one’s practice and clinical knowledge?
- Registered Nurses’ Association of Ontario (RNAO). (2016). Practice Education in Nursing. Toronto, ON: Registered Nurses’ Association of Ontario.
- Registered Nurses’ Association of Ontario (RNAO). (2015). Person - and Family- Centred Care. Toronto, ON: Registered Nurses’ Association of Ontario.
- Resiliency Initiatives (2016). Mental Health Commission of Canada. (2009). Toward recovery and well-being: A framework for a Mental Health Strategy for Canada. Calgary, AB: Author.
- Health Experiences. This website has documented video and audio clips of client testimonials and perspectives of illness and health care experiences.
- Allen, F. M., & Warner, M. (2002). A developmental model of health and nursing. Journal of Family Nursing, 8(2), 96-135
- Allott, P., & Loganathan, L. (2002). Discovering hope for recovery from a British perspective: A review of literature. Canadian Journal of Community Mental Health, 21(3), 13-33.
- Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation journal, 16(4), 11.
- Boud, D., Keogh, R., & Walker, D. (1985). Reflection: Turning experience into learning. London: Kogan Page.
- Caldwell, L. (2013). The importance of reflective practice in nursing. International Journal of Caring Sciences, 6(3), 319.
- Carnevale, F. A. (2013). Confronting moral distress in nursing: recognizing nurses as moral agents. Revista Brasileira de Enfermagem. 66 (Spec):33-8.
- Doane, Gweneth Hartrick & Varcoe, C. (2007). Relational practice and nursing obligations Advances in Nursing Science, 30(3), 192–205.
- Fageberg, I., & Gustaffson, C. (2004). Reflection, the way to professional development? Journal of Clinical Nursing, 13, 217-280.
- Fryer-Edwards, K., Arnold, R. M., Baile, W., Tulsky, J. A., Petracca, F., & Back, A. (2006). Reflective teaching practices: an approach to teaching communication skills in a small-group setting. Academic Medicine, 81(7), 638-644.
- Gordon, J., Macleod, A., & Mann, K. (2009). Reflection and reflective practice in health professions education: a systematic review, 14(4), 595-621.
- Gottlieb, N.L., Feeley, N.& Dalton, C. (2005). The collaborative partnership approach to care: A delicate balance. Toronto, ON: Elsevier Health Sciences.
- Gottlieb, L. (2013). Strengths-based nursing care: Health and healing for person and family. New York, NY: Springer Publishing Company.
- Hyrkäs, K., Paunonen Ilmonen, M., & TerttuTarkka, M.(2008).Teacher candidates’ reflective teaching and learning in a hospital setting–changing the pattern of practical training: a challenge to Growing into teacherhood. Journal of Advanced Nursing, 33(4), 503-511.
- Foundation of Nursing Studies. (2013). Guidance for critical reflection on practice development. London: FoNS.
- Johns, C. & Freshwater, D. (2009). Transforming nursing through reflective practice. Oxfard, UK:Blackwell Publishing Ltd.
- Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445-452.
- Meyer, E. C., Sellers, D. E., Browning, D. M., McGuffie, K., Solomon, M. Z., & Truog, R. D. (2009). Difficult conversations: Improving communication skills and relational abilities in health care. Pediatric Critical Care Medicine, 10(3), 352-359.
- Moon, J. (1999). A handbook of reflective and experiential learning. London: Routledge.
- Mental Health Commission of Canada. (2015). Guidelines for recovery-oriented practice: Hope. Dignity. Inclusion. ON: Author.
- Paget, T. (2001). Reflective practice and clinical outcomes: practitioners’ views on how reflective practice has influenced their clinical practice. Journal of Clinical Nursing. 10(2), pp 204-214.
- Pugnaire-Gros, C., & Young, L. (2007). Teaching the McGill model of nursing and client-centred care: Collaborative strategies for staff education and development. Teaching nursing: Developing a student centred learning environment, 189–220.
- Schön, U.-K., Denhov, A., & Topor, A. (2009). Social relationships as a decisive factor in recovering from severe mental illness. The International Journal of Social Psychiatry, 55(4) 336-347.
- Tomlinson, P. S., Thomlinson, E., Peden McAlpine, C., & Kirschbaum, M. (2002). Clinical innovation for promoting family care in paediatric intensive care: demonstration, role modelling and reflective practice. Journal of Advanced Nursing, 38(2), 161-170.
Occupational Stress and Self-Care Teaching activities and resourcesOccupational Stress and Self-Care Teaching activities and resources
Occupational stress is a major health problem that can lead to burnout, illness, turnover, absenteeism, poor morale and performance (Coetzee, & Klopper, 2010; Nowrouzi et al., 2015). Providing opportunities for nursing students to explicitly explore and discuss occupational stress reactions and explore and practice self-care in curricula increases visibility and awareness of this important issue. It also provides a means to explore professional well-being and strategies to enhance career longevity in specialty nursing areas (i.e., mental health and psychiatric mental health practice) documented to increase the risk of experiencing greater levels of occupational stress as a result of the therapeutic interpersonal modalities used during interactions with patients over an extended period of time (Edwards & Bernard, 2003; Nowrouzi et al., 2015).
For more information, see Resources in this section.
Teaching and Learning Activities
The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to occupational stress and self-care.
- Lectures on occupational stress and self-care
- Small group work
- Focused discussions
- Exploration of self-care modalities
- Reflective journaling—Appendix E
- Evaluation of mind/body/spirit approaches to health
Strategies to promote self-care in collaboration with students:
- Consider open-book exams; allow study notes
- Offer flexible due dates/self-scheduling for assignments
- Keep summative evaluations to a minimum
- Offer formative feedback on assignments/exams; provide encouraging comment
Learner Engagement Questions
The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding occupational stress and self-care. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class exercises.
- What are occupational stress reactions?
- Identify the individual and organizational factors that may contribute to the experience of burn out and secondary trauma.
- What does self-care mean to you in the context of your professional identity?
- How does the literature define self-care?
- Why is it important for health-care professionals to understand and engage in self-care practices?
- What are the advantages for health-care professionals and organizations who address occupational stress and workplace mental health practices? Are there any disadvantages?
- Identify personal care strategies documented in the literature to support personal and professional resilience.
- What is your coping style?
- What self-care strategies and techniques do you currently practice?
- Identify some ways to enhance or improve your current self-care practices.
Evaluation and Self-reflection
The following is a tool that can be used to evaluate students in their understanding and application of occupational stress and self-care:
Completion of self-care plan and reflective activities (i.e., see Self-Care Starter Kit in Resources).
- RNAO (2011) Preventing and Mitigating Nurse Fatigue in Health Care. Toronto, ON. Registered Nurses’ Association of Ontario.
- RNAO (2014) Managing and Mitigating Fatigue: Tips and Tools for Nurses Nurses. Toronto, ON. Registered Nurses’ Association of Ontario.
- Bergerman, L., Corabian, P., & Harstall, C. (2009). Effectiveness of organizational interventions for the prevention of workplace stress (Report). Alberta, Canada: Institute of Health Economics.
- Blum, C. (2014). Practicing self-care for nurses: A nursing program initiative. Online Journal of Issues in Nursing, 19(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No3-Sept-2014/Practicing-Self-Care-for-Nurses.html
- Canadian Nurses Association. (2002). Supporting Self-Care: A Shared Initiative-1999-2002. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/supporting_selfcare_e.pdf?la=en
- Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 12, 235–243.
- Edwards, D. & Burnard, P. (2003), A systematic review of stress and stress management interventions for mental health nurses. Journal of Advanced Nursing, 42: 169–200.
- Kendell, E., Murphy, P., O’Neill, V., & Bursnall, S. (2000). Occupational Stress: Factors that Contribute to its Occurrence and Effective Management. Retrieved from: http://www.mentalhealthpromotion.net/resources/occupational-stress-fractors-that-contribute-to-its-occurrence-and-effectivemanagement.pdf
- Michalec, B., Diefenbeck C., & Mahoney M.(2013). The calm before the storm? Burnout and compassion fatigue among undergraduate nursing students. Nurse Education Today, 33, 314-320.
- Nowrouzi, B., Lightfoot, N., Larivière, M., Carter, L., Rukholm, E., Schinke, R., & Belanger-Gardner, D. (2015). Occupational stress management and burnout interventions in nursing and their implications for healthy work environments: A literature review. Workplace Health & Safety, 63(7), 308-315.
- The National Child Traumatic Stress Network.(2016). Secondary Traumatic Stress. Retrieved from http://www.nctsn.org/resources/topics/secondary-traumatic-stress
- University at Buffalo .(2016). Our self-care starter kit. Retrieved from http://socialwork.buffalo.edu/resources/self-care-starter-kit.html
- World Health Organization .(2016). Stress at the workplace. Retrieved from http://www.who.int/occupational_health/topics/stressatwp/en/