Clinical learning experience in nursing education provides students the opportunity to consolidate theory and practice together. It is through clinical placements that nursing students develop and refine their skills in therapeutic relationship, person and family-centred nursing care, among other foundations learned in nursing school.

Mental health and psychiatric nursing clinical placements among undergraduate nursing students have been successful in generating interest in this area (O’Brien, Buxton & Gillies, 2008). Studies regarding clinical learning have demonstrated that student satisfaction with mental health content is positively correlated to performance, as well as to a correlation between clinical placement in mental health and interest post graduation in working in mental health (Spence, 2012 & Happell,
Moxham & Platania-Phung, 2009). However the current challenge with securing clinical mental health and addiction placements presents a gap in placement opportunities in acute care inpatient psychiatric settings, according to the 3rd position paper 2016: Mental health and addiction curriculum in undergraduate nursing education in Canada (CFMHN, 2016).

There are a number of factors to consider when planning a clinical placement for students. CASN, with the input of nursing educators from across Canada, has developed recommendations for clinical placements and simulation. The framework for these recommendations is applied here. Many of the concepts in the content below can be demonstrated in the placements such as community, med surgical, acute care etc.

The following themes were identified in the literature with regards to timing and length of mental health and addiction clinical practice.

1. Theory preparation prior to placement.
Prior to clinic placement, it is important for nursing students to have some theoretical preparation to support implementation of evidence-based practice. For example, nursing students should receive some theory related to medication administration and be knowledgeable of the concepts of compliance and adherence, and be comfortable with the pharmacokinetics of psychiatric medications before administering medications in a clinical setting.

2. Length of placement.
The length of the placement should be sufficient to meet the learning objectives, e.g., traditional length placement (Fiedler, Breitenstein & Delaney, 2012); and short, intensive placement (Tratnack, O’Neil, & Graham, 2011). The CFMHN recommends a stand-alone course in psychiatric/mental health and a dedicated clinical placement in a psychiatric setting (CFMHN, 2016; Happell, Gaskin, Byrne & Welch, 2015).

The literature demonstrates positive outcomes related to reduction in stigma and fear when students are provided opportunities to interact with clients who experience mental illness and/or addiction, across all settings including psychiatric settings. Students who interact with these clients report less fear and stigma towards their patients. Outcomes related to placements in mental health and addiction placements include the following:

• Improved attitudes towards patients with mental illness;
• Increased confidence in caring for people with mental illness/mental health concerns;
• Increased understanding of psychiatric nursing;
• Safe medication administration;
• Improved therapeutic communication;
• Improved assessment skills; and
• Increased use of holistic approaches to care.

Collaboration between clinical instructors, simulation coordinators and faculty members who teach mental health theory courses improves consolidation of learning. As clinical instructors and preceptors play an important role in changing students’ attitudes towards mental health psychiatric nursing, clinical instructors and preceptors should have experience in psychiatric mental health nursing where possible.

Furthermore, preceptors should:

• Encourage diverse learning experiences;
• Help identify transferable skills;
• Foster a positive image of mental health nursing;
• Have regular contact with students; and
• Give consistent and regular feedback.

Student and preceptor difficulties arise when preceptors:

• Don’t understand their role;
• Have unrealistic expectations of the student;
• Have heavy work loads that limit their ability/time to interact with students; and
• Have negative attitudes to mental health/psychiatric nursing.

Source: O’Brien et al., Oudshoorn & Sinclair, 2015; Charleston & Happell2 005, 2006; Cleary, Horsfall, & De Carlo, 2006. Such obstacles provide challenges to student placements and can also create negative perceptions, attitudes and stigma among nursing students.

Orientation
A well thought out orientation promotes a positive student placement.

• Include orientation of the unit or site prior to the placement.
• Include a review of learning objectives.

Daily pre-conferences

• Ensure that students are prepared for their patient/client assignments.
• Highlight potential learning experiences that students may be able to engage in that day.
• Address student concerns.

Daily post-conference

• Reflect on clinical experiences.
• Engage in further learning.
• Share experiences among students.

Critical incidents

• Students should be debriefed according to workplace policy.

Reflective practice

• See Section Four: Student Reflective practice and Self-Care in Mental Health Nursing Education

Source: Woodley, 2015; Ganzer & Zauderer, 2013; O’Brien, 2008; Oudshoorn & Sinclair, 2015

Other important clinical placement considerations include:

• Ensuring the practice experience supports the learning objectives (Medley & Horne, 2005; Seropian et al., 2004);
• Facilitators play an integral role in student learning; and
• Efforts should be made to develop collaborative partnerships between health-care organizations and colleges/universities; consider the use of co-creating learning objectives where possible.

For more information, see Resources in this section.

According to the CASN’s Practice Domain for Baccalaureate Nursing Education: Guidelines for Clinical Placements and Simulations (2015), the challenge of securing clinical placements for students has driven a search for alternative strategies for practice experiences. Placements have become wide-ranging (Smith, Corso & Cobb, 2010), and simulation is being increasingly used to prepare students for practice. Some educators see simulation as valuable learning opportunities that are complementary to clinical placements, others have introduced it as a substitute.

“While both clinical placements and simulation provide opportunities for students to develop practice outcome expectations, there are some important differences in the practice experiences they offer. As a result, there are also some differences in the nature of the learning they foster” (CASN, 2015, p. 9). Students in clinical placements can experience unplanned, unpredicted and uncontrolled events that can provide teachable moments. This is helpful for experiencing reallife scenarios; whereas in a controlled simulation nurses can make mistakes without real-life consequences and learn from them. The expert panel recommends that simulation should be used to augment clinical placement opportunities and not replace them.

A useful tool that shows how the differences between the experiences offered by simulation and by clinical placements affect the nature of the learning they foster can be found in the CASN’s Guidelines for Clinical Placements and Simulations (2015), Table 3.

Students should have some foundational theory based concepts prior to engaging in a simulation experience. The length of the simulation is directly related to the type of simulation and the learning objectives. The following demonstrates the type of simulations, factors to be considered and proficiency of instructors in simulation and pedagogy approaches that can be used.

Selection of the simulation

There are three major levels of simulation fidelity: low, medium and high.

• Low fidelity—used to practice psychomotor skills, e.g., a foam pad simulator used to practice intramuscular injections.
• Medium fidelity—more closely resembles reality and can be used to provide more in-depth learning opportunities, e.g., perfecting an understanding of heart sounds.
• High fidelity—sophisticated and mimics real life, e.g., computer or instructor controlled mannequins.

When using simulation, the following factors should be considered:

• Live actors should be used when possible in place of mannequins;
• Caution against student role-playing that can reinforce pre-existing stigma;
• Consider the use of multiple simulations that increase in complexity; and
• Simulation doesn’t have to be expensive to be effective.

Simulation experiences are valuable learning opportunities for students that can help to consolidate their learning. It is important for educators to remember that simulation is not a replacement to clinical practice, however provides a resource to augment theory into the practice environment (RNAO, 2016e). Educators should determine compatibility and select the level of simulation in accordance with the learning objectives for nursing students. Educators may also consider the use of co-creating learning objectives, wherever possible to provide students the opportunity to identify their learning needs. It is also imperative that students are taught the fundamental basics/concepts prior to engagement in a simulation experience.

Quality of instruction

Collaboration between clinical instructors, simulation coordinators and faculty members who teach mental health theory courses improves consolidation of learning. Instructors should be comfortable and proficient with the types of simulation or technology being used. In addition to having knowledge of the learning outcomes, they should have the mental health knowledge and skills needed to integrate theory and practice and debrief with students.

Source: Happell, Gaskin, Byrne & Welch, 2015; Oudshoorn & Sinclair, 2015; RNAO, 2016

Pre-briefing

• Familiarize students with the technology and equipment.
• Discuss the learning objectives, participant roles, and details surrounding the simulation scenario.

Actual simulation scenario

• Students work together in teams and actively participate in the decision-making processes related to the nursing care in the simulated clinical situation.

Debriefing

• Time is dedicated toward group discussion, feedback and integrated learning.
• Debriefing is an activity that aims to strengthen the positive aspects of the experience and promotes reflective student learning.

For more information, see Resources in this section.