Balancing Technology With Face-to-Face Interaction

Reflective-Centered Framework

As a specialty, advanced practice psychiatric mental health nursing’s unique contribution to care is how it focuses on interpersonal processes that promote and maintain patient mental well-being while contributing to integrative functioning (Stuart, 2009). As such, we instituted a reflective framework as the foundation for the program that engages students in ongoing intrapersonal and interpersonal development in relation to self and others. Grounded in ideas on reflection from Dewey (1933), Mezirow (1981), Reed and Procter (1993), Schön (1983), Johns (2006), and Freshwater, Esterhuizen, and Horton-Deutsch (2008), we transformed our program using a reflection-centered pedagogy in which teaching approaches are aligned with clinical practice. Each psychiatric nursing core course requires weekly clinical reflections, online forum discussions that call for reflective responses, and a final reflective paper. The reflective assignments are intended to guide students toward continuous improvement through ongoing reflection on the quality of their interactions and learning over the course of their education. We learned that through systematic guided reflections students are more prepared to define and resolve their own learning needs and make ongoing improvements in the provision of care as they evolve into advanced practice psychiatric nurses. They are also more professional and insightful as they give and receive feedback in their working relationships with peers, faculty, and preceptors. Through the introduction of reflective models, theories, processes, and research approaches, students are now engaging in deeper levels of analysis and interpretation of the meaning of mental health nursing practice in the context of their clinical and virtual classroom experiences.

The reflective-centered approach is vital to professional role development, particularly in situations where there is limited face-to-face interaction among students and faculty. As we grappled with how to facilitate interpersonal growth and professional connectedness, we recognized the importance of integrating and weaving reflection throughout the curriculum to compensate for what students were missing in the classroom. Evidence of the interpersonal connections being formed occurred when the students instituted an end-of-semester luncheon following formal class discussions and invited faculty to attend. This informal gathering supported the growth and development of student interpersonal relationships; we observed them engaging in discussions and challenging each other’s points of view as they began to take on their new roles as advanced practice nurses.

ePortfolio

The ePortfolio was originally designed as a comprehensive electronic archive, a place to store and access student work. We foresaw using ePortfolio as a place where students would place two completed course assignments at the end of each semester and reflect on how these assignments related to course competencies, program outcomes, and the Standards of Practice for Advanced Practice Psychiatric Mental Health Nursing. In addition, as students progressed through the program, we envisioned them demonstrating intellectual growth by making connections about their learning across multiple courses and over time. What we learned was that students were tired at the end of the semester and viewed the ePortfolio submissions and reflective questions as tremendous burdens. As each semester drew to an end, students were busy completing clinical evaluations and course papers. They had little enthusiasm for yet one more assignment. Since students were already engaged in weekly clinical reflections, forum discussions that often involved reflective exercises, and a final reflective paper, they saw the submissions and accompanying reflections as redundant. From a faculty perspective, however, we saw value in students connecting their work to broader standards and building on these connections through time. Thus, we integrated the best of the ePortfolio reflective questions into our ongoing course assignments to retain this important component of professional development but dropped the end-of-semester assignment.

Through dialogue with students, we learned that they preferred end-of-semester class discussions face-to-face (either coming to class on the main campus or attending via visual teleconference from one of our university’s seven to eight distant campuses). We also learned that a number of distance students preferred to drive to our main campus at the end of the semester to engage in these broader discussions with peers and faculty in person. As a result, in fall 2010, we stopped requiring students to submit assignments and reflections to ePortfolio. The potential uses of ePortfolio certainly have expanded since we first developed our version; however, other electronic systems have evolved and offer the aspect of ePortfolio that we hoped to preserve (see Typhon below), whereas added face-to-face interaction instituted by the students has met their learning needs.

Online Preceptor/Graduate Student Training Module

Ensuring Preceptor and Student Success (ePASS) introduces students and preceptors to the program through an online training module. The module provides an overview of the program philosophy, outlines the student’s practicum, and explains student and preceptor roles and expectations. Designed to support learning in a distance-learning environment, ePASS has facilitated improved interactions among students, preceptors, and faculty. The module was initially viewed as time consuming and burdensome with little compliance from preceptors in Year 1. Beginning in Year 2, we placed increased responsibility on the students and encouraged them to complete the modules with their preceptors as part of orientation to their clinical experience. Completing the module within the context of their clinical time with students, preceptors readily saw the value of the information and how it supported their efforts as well as students’ achievement of clinical competencies. Students saw the value of reviewing the module with their preceptors because this facilitated face-to-face discussion. Since students often complete clinical experiences in settings close to where they live, having easy access to online information came to be viewed as both convenient and time saving. As students became the ambassadors, referring preceptors to the resources located on ePASS, the number of questions about clinical experiences from students and preceptors has significantly decreased. ePASS houses key materials on the development of clinical reasoning skills, parameters for supervision, and evaluation of clinical performance to be completed at the end of each semester. It also introduces our program’s reflection-centered framework as well as use of and a link to Typhon (described next).

Typhon

Typhon is an electronic data collection system that allows students to record patient encounters and clinical experiences. It also supports students’ learning related to informatics. Program directors, faculty, students, and preceptors have instant online access to enter data and view tallies and charts of cumulative clinical experiences. Students record all patient encounter information including demographics, clinical information, diagnoses and procedure codes, medications, and clinical notes. The system allows faculty to follow the progress of students and determine whether they are satisfactorily progressing in their clinical experience, thereby meeting the clinical objectives of the course. Student responses to Typhon have been mixed—those with strong computer skills and/or previous experience with electronic charting systems adapt more readily than those without. Though Typhon has clear and concise tutorials, we recognized that many students required hands-on demonstration. Beginning in summer 2010, we instituted a formal program orientation, with all students required to come to campus. Part of this day included Typhon demonstration and an opportunity for students to gain hands-on experience with the system. Students’ mastery of Typhon significantly improved, which showed the importance of face-to-face interaction with students around this integral piece of technology. Beginning fall 2010, we instituted midterm and final clinical encounter evaluations in which students analyze their data to create reports, such as charts illustrating the characteristics of the patients they have worked with, and we use these findings to develop plans to modify their clinical experiences in the future.

Each year Typhon updates and adds new features to its program in response to user feedback. One added feature is a place for clinical notes where students can log summaries of patient encounters as well as reflections. Importantly, Typhon has enabled us to collect data for formative and summative feedback from students and preceptors. We gather course and program evaluations through Typhon as well. Both the students and faculty use Typhon as an active learning strategy to assess the scope of practice experiences and to direct future learning activities while in the program.

Cultural Competence

Originally, we aimed to increase self-awareness and understanding of the importance of culture to providing quality health care by integrating cultural learning experiences throughout the program. These efforts were initially based on the work of Camphina-Bacote et al. (2006) through the Health Resources and Services Administration’s Centers for Excellence program on Transforming the Face of Health Professions through Cultural and Linguistic Competence Education (McNelis & Horton-Deutsch, 2008). Students learned about cultural theories, frameworks, and assessments. They also completed cultural assessments in their clinical practicum experiences and explored issues related to culture through online forum discussions. In their group therapy course, students were required to drive to campus and watch and respond to a powerful film on racism. Issues such as fear, poverty, and privilege, and how these factors related to health disparities, arose during discussions. From this learning activity, we learned that we were only scratching the surface of issues related to culture in health care and that this deep conversation would never have happened at a distance. Though the materials we were using offered students a structure and framework to guide their clinical encounters and knowledge development related to culture, we recognized that we were not getting at core issues leading to health disparities. Through face-to-face discussions, we discovered the need to consider how diversity efforts may exacerbate differences and strengthen the normative structure of health care and nursing. We now realize that it is not enough to add diversity content; we must create a more inclusive learning environment within nursing itself. This requires developing a space and means to carry out bold conversations and a commitment to changing the nursing education environment. As championed by Pharris (2009), it is time to turn the telescopic lens of diversity back on the nursing education system to make the structural and relational changes needed for a truly inclusive environment.

Future Plans

As a part of our program transition, we not only sought stronger connections with clinical preceptors but also with community partners. Through this outreach, we began working with the Indiana State Nurses Association to assist them to evaluate their Indiana State Nurses Assistance Program. This provided an opportunity for students to complete scholarly projects on these data, including reviewing literature, entering and analyzing data, and publishing findings (McNelis et al., in press). Others interviewed stakeholders to expand their understanding of nurses in recovery and to learn the importance of health care professionals working together. Our partnership with Indiana State Nurses Assistance Program enabled us to identify needs for curriculum development in substance use disorders and provided the stimulus for partnering with the our university’s School of Social Work to develop an interprofessional course. Beginning summer 2012, we will offer an interprofessional substance use disorders course that will be available to graduate students working in any area of health care.

Conclusion

These five initiatives were incorporated into our Advanced Practice Psychiatric Mental Health Nursing program in 2008. They were intended to improve access to psychiatric nursing education by expanding the teaching–learning environment beyond the traditional face-to-face classroom. We have successfully doubled the size of our program over a 3-year period. Equally important, we have recognized the need to balance the use of technology with face-to-face interaction to fully engage students in learning. At this point in time, students come together through the distance-accessible classroom every 3 to 4 weeks, and periodically, distance students drive to campus for intensive dialogue and reflection. We continue to use four of the five initiatives and have expanded our understanding and implementation of those retained. Equally important, these initiates have led to other important collaborations and community partnerships. As we persist in the evolution of our distance-accessible program, we are committed to an ongoing dialogue with students and collaborators that support interactive activities and engage all of us in deep discussions and learning about best practices in mental health care. We are confident through ongoing thoughtful dialogue and discussion that our initiatives will attract students, support ongoing partnerships, and result in increased numbers of reflective practitioners who deliver culturally competent mental health care.