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Nurse Education Today 34 (2014) 1232–1237

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Nurse Education Today journal homepage: www.elsevier.com/nedt

Supporting the development of interpersonal skills in nursing, in an undergraduate mental health curriculum: Reaching the parts other strategies do not reach through action learning Anna Waugh a,⁎,1, Lisa McNay a,1, Belinda Dewar b,2, Marie McCaig a,1 a b

University of the West of Scotland, Dudgeon House, Crichton Campus, Bankend rd, Dumfries DG12ZN, United Kingdom University of West of Scotland, Caird Building, Hamilton Campus, Almada Street, Hamilton ML30JB, United Kingdom

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Article history: Accepted 1 October 2013 Keywords: Mental health Student education Action learning Theory practice gap Professional competence Emotional aspects of learning The Francis report

s u m m a r y The centrality of therapeutic relationships is considered to be the cornerstone of effective mental health nursing practice. Strategies that support the development of these skills and the emotional aspects of learning need to be developed. Action learning is one such strategy. This article reports on a qualitative research study on the introduction of Action Learning Sets (ALS) into a Pre-registration Mental Health Nursing Programme. This teaching and learning methodology was chosen to support the emotional aspects of learning and mental health nursing skills. Four themes were identified: developing skills of listening and questioning in ‘real time’, enhanced self-awareness, being with someone in the moment — there is no rehearsal and doing things differently in practice. Students and lecturers found the experience positive and advocate for other Pre-registration Mental Health Nursing Programmes to consider the use of ALS within the curriculum. © 2013 Elsevier Ltd. All rights reserved.

Introduction The traditional paradigm in mental health nursing has been undergoing significant challenge in recent times. The influence of the Recovery Movement is gaining momentum in practice and in the theoretical preparation for practice. The Recovery Movement recognises that people are the experts in their own experiences (Scottish Recovery Network, 2006). This requires a shift for mental health nurses from ‘doing to’ to ‘working alongside’ service users for contemporary recovery focused practice. Central to this is realising that each person's recovery journey is individual and should be led by the person. This change in the position of power is a shift away from traditionally inspired medical approaches (Repper and Perkins, 2003). This direction of travel for mental health nurses was clearly articulated in The National Review of Mental Health Nursing in Scotland: Rights, Relationships and Recovery (Scottish Executive, 2006). Developed as an outcome from this came: The National Framework for Pre-registration Mental Health Nursing Programmes in Scotland (NHS

⁎ Corresponding author at: University of the West of Scotland Dumfries Campus, Crichton Campus, Bankend rd, Dumfries DG12ZN. E-mail addresses: [email protected] (A. Waugh), [email protected] (L. McNay), [email protected] (B. Dewar), [email protected] (M. McCaig). 1 Tel.: +44 1387 345800; fax: +44 1387 702111. 2 Tel.: +44 1698 2831000. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.002

Education for Scotland (NES), 2008), this has since been updated (NES, 2012). The Framework (NES, 2008) has a number of underpinning principles for Higher Education Institutions to take cognisance of when developing their Pre-registration Mental Health Nursing Programmes in Scotland including: ‘Enabling students to develop relationship, communication and interpersonal therapeutic skills should be a major emphasis of both the theoretical and practice components of pre-registration programmes.’ [p9] Thus, this re-affirms the centrality of therapeutic relationships which has long been considered to be the cornerstone of effective mental health nursing practice (Peplau, 1998; Barker, 2004). Central to the development of these interpersonal therapeutic relationships is the process of reflection, emphasizing the emotional aspects. Warne and McAndrew (2008) observe that emotion and learning are a powerful combination for personal and professional development. However, they say that just like nurses in practice can avoid exploring emotional issues with service users that some lecturers will not be comfortable and therefore also avoid the emotional aspects of learning with students (Warne and McAndrew, 2005). Emotional discomfort and avoidance by both students and lecturers was identified in Gould and Masters' (2004) study of facilitated reflective groups of mental health student nurses. They propose that lecturers need ongoing support for the facilitator role in reflection. Furthermore a

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formalized framework or structure would help students to reflect deeply as opposed to focus around the practical details related to an issue. Our challenge when developing our 2008 Programme was to consider teaching and learning strategies which would support the inter-related dimensions of the emotional aspects of learning as well as the development of mental health nursing skills. A number of lecturers had experience of action learning (AL) and this led to the consideration whether AL might meet the needs of the Pre-registration Mental Health Nursing Programme. Action learning is a process of learning and reflection that happens with the support of a group or set of colleagues working with real problems with the intention of getting things done (McGill and Brockbank, 2004). The process is cyclic and involves reflection and action. It is a structured process whereby participants work within a discipline which includes agreement to work within certain principles, such as an expectation to be challenged; this allows the development of new understanding about the situation, supporting participants to take new actions (Dewar and Sharp, 2006). Action learning provides a process where values and beliefs that underpin actions related to experiences and bringing about change can be explored. Real issues are presented and are the subject of scrutiny — allowing participants to call into question the rationale underlying their actions and to examine problems from multiple perspectives. Questions used in AL particularly relate to probing assumptions and encouraging empowerment (Marsick, 1990). Evidence of the effectiveness of this approach refer to outcomes such as enhanced critical thinking, finding creative solutions to problems in the workplace as well as increasing self-confidence and developing communication skills (Booth et al., 2003: Johnson, 1998). Several studies have found that there are positive benefits to using AL either in the curriculum or in project work (Dewar and Sharp, 2006; Hardacre and Keep, 2003; Rayner et al., 2002; Booth et al., 2003). Lamont et al. (2010) evaluated Action Learning Sets (ALS) with a group of staff in a mental health setting and found the benefits were consistent with those identified by other authors and included development of facilitation skills, increased ability to engage in reflective inquiry and a greater ability to problem solve. Jackson and Thurgate (2011) identify the benefits for students which include a range of knowledge and skills which are aligned, to develop and consolidate key skills in self-awareness, problem solving, emotional intelligence and other key interpersonal skills identified as supporting students to be agents of change in their sphere of responsibility (Aird, 2011; Jackson and Thurgate, 2011). Given this evidence and lecturers' positive experience of this approach a decision was made to introduce AL into the Pre-registration Mental Health Nursing Programme and to research the impact of AL from the perspectives of lecturers and students. Research Design and Methods Preparation for the Study and the Structure and Processes of Action Learning Prior to undertaking the research, a standardised approach was established through the training of lecturers in AL by an expert external facilitator and development of a facilitators pack. This preparation was seen as vital by the research team in terms of the lecturers modelling best practice through self-development. By developing and consolidating their own emotional learning, in their own ALS, lecturers were then able to understand and be prepared for supporting the student learning. Aim of the Evaluation The aim of the evaluation was to: Evaluate the effectiveness of ALS, as a teaching and learning strategy within a Pre-registration Mental Health Nursing Programme from the

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perspective of the students and facilitators who are mental health lecturers. In particular it sought to explore: • Perceptions of the learning process and its impact on the practice of nursing, education and personal and professional development. • The extent to which participants felt that the AL outcomes were achieved. • Ways in which this type of learning facilitated deliberate use of knowledge in practice. • The complexities of practice faced by students and considered in AL. • Future areas for development of AL in Pre-registration Nurse Education. Preparation for the Research Ethical approval was granted by University of the West of Scotland's (UWS) Ethics committee. Written informed consent was gained from participating students and lecturers. Sample Lecturers and students involved in teaching and learning using the approach of AL in two of the four UWS campuses were invited to participate in the study. The total sample size of students was 42 which comprised of five ALS. All of the students were invited to attend, with an option to complete all or some methods of data collection. The resulting sample for the focus groups which is reported in this paper was 10 students and 7 lecturers. Methods and Data Collection Three methods of data collection were employed. 1. Students and lecturers were asked to complete ‘reflection sheets’ after each ALS. The reflection sheets were designed to support a range of participants in ALS to engage in individual reflection after each ALS. A series of questions, which asked about learning in the set and planning for future learning and action were included. 2. Focus group discussions using emotional touchpoints and imagery with students and lecturers were utilized. Focus groups were selected as the most appropriate method primarily because of the efficient use of time and the ability to probe more deeply than other methods. The focus group was guided by the structure of emotional touchpoints (Dewar et al., 2010). This method provides a structure to the discussion and helps participants to share how they felt about their experience. This has particular advantages in that feelings cannot be disputed, they help the participant to take ownership of their statements and prompt a richer reflection on experience (Dewar et al., 2010). The touchpoints identified to provide structure for the focus groups were initially agreed with the researching team, resulting from early themes emerging from the reflection sheets and then the focus group participants themselves. Touchpoints used for students and lecturers are shown in Table 1. Participants were asked to focus on each touchpoint in turn and to select emotional words that summed up the experience of that touchpoint for them. They were then asked to share with the group why they felt this way. This method of exploration continued throughout the focus group until all touchpoints were explored. Each focus group lasted between 1 and 2 h. Notes were taken during the session and typed up immediately afterwards. For the student focus groups, participants were presented a verbal summary of the main points made to check for accuracy and clarification. For the lecturer

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Table 1 Emotional touchpoints for students and lecturers. Touchpoints for students

Touchpoints for lecturers

• • • • • • • •

• • • • • • • •

Expectations Preparation for the Set The structure of the Set Working with my fellow students in the Set Facilitation/support Asking questions/challenging others My learning The impact of my learning in practice

Learning the skills of facilitating AL Facilitating my set My learning about AL My learning about myself Progress of students Student learning Impact on practice Support

group, participants were sent themes, quotes and emergent initial analysis from the focus group discussion and invited to make changes. 3. Recounting positive stories. Lecturers were asked to prepare a narrative of a positive experience of facilitation of AL and bring this to the focus group. The first part of the focus group discussion included discussion around these narratives. Data Analysis A thematic content analysis was carried out where the process was to identify, analyse and report themes within the data. Each piece of data was read and initial coding was assigned to data extracts. These initial codes were collated. From this different codes were grouped together if they were related, to form a broader theme. The themes were then reviewed again with the data to check that they accurately captured what was said. The quotations used in the discussion of the themes are from the focus groups, as the results from the reflection sheets mirrored those from focus groups. Findings and Discussion Findings from the evaluation relate to the impact action learning had in relation to: • • • •

Developing skills of listening and questioning in ‘real time’ Enhanced self-awareness Being with someone in the moment — there is no rehearsal Doing things differently in practice environments.

Developing the Skills of Listening and Questioning in ‘Real Time’ A key outcome of participating in AL is to develop listening and questioning skills, essential attributes of interpersonal competence. Participants in AL develop these skills in ‘real time’ through enabling others in the group to explore their issue. These are complex skills and there are challenges in relation to how to support students to develop these in the curriculum. Students commented on how hard it was to develop questioning skills particularly in relation to not giving advice and asking leading questions. One student talked particularly on how the process of AL had helped her to ask questions about emotions: It has helped me to ask questions about feelings. Asking — how did that make you feel? How are you dealing with your feelings about this? I think in the past I avoided doing this or asked in a clumsy way. [Student Focus Group 1] Connecting emotionally with clients, families and staff is advocated as a key attribute in caring conversations that promote compassionate relationship centred care (Dewar and Nolan, 2013). However it can take courage to do this in practice, and the action learning process seemed to help students to feel more comfortable with experimentation in practice.

Several students and some lecturers shared their sense of achievement and the benefits when they could reframe advice in the form of a question: I understand now that by not giving advice, I am allowing the patient to be in control. [Student Reflection Sheet Campus 1 No. 27]

If I have a solution in the back of my head I find I am fighting to keep it suppressed. I have to work on this because I have seen the value when I do suppress it. [Lecturer Focus Group] Reframing advice giving in the form of a genuinely curious question is important in the therapeutic relationship as it helps the person to come to their own understanding about a situation (Dewar and Nolan, 2013; McGill and Brockbank, 2004). For some students AL also created an environment where they felt safe to develop their questioning skills to challenge others: I think this (challenge) can be hard — you want to help people but you don't want to upset them. I think I have learnt a lot about questions that I can use. Things like ‘what would have happened if…?’ [Student Focus Group 1]

I think we learnt to ask more direct questions that were not confrontational. [Student Focus Group 1] Feeling able to challenge others in a way that feels comfortable for both parties is an important skill. Supporting people to develop skills of challenge has renewed impetus in light of the recent recommendations from the Francis Inquiry (Mid Staffordshire NHS Foundation Public Inquiry, 2013). The report identifies that one of the factors that perpetuated poor care that was delivered in the Trust was the inability of staff to challenge others and raise concerns. AL is one way of supporting students to develop this skill. Lecturers welcomed AL as a method to develop the relational skill of interpersonal competence: The students really worry about their interpersonal effectiveness in practice. Action learning gives them a chance to practice it for real. [Lecturer Focus Group] The ‘real time’ experience was also commented on by students. They had previously been involved in role play and made comments about the way in which AL differed: I think it has taught us about the theory of therapeutic relationships. It is not like role play because what we did was practice our skills of developing relationships in a very real way — with real issues, real emotions and feelings. There are no emotions attached to role play — it is pretend and you don't necessarily get to see the impact of your actions. [Student Focus Group 1] Students thus felt that they were developing their skills in and for practice. They were able to see in real time the impact of their interventions. One lecturer also commented that it enabled them to assess interpersonal skill development more accurately: It's a good avenue to pick the interpersonal skills – we don't really have other opportunities for picking up on these skills – we get the mentors report and see them interacting in class but we don't have

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ways of explicitly picking up on how these skills are developing in students'. [Lecturer Focus Group] Thus, AL may be an important way in which to gauge student development in this area of practice. There may be more scope to consider the role of assessment explicitly aligned to AL. Supporting students to develop the skills of interpersonal competence is crucial but challenging. Evidence suggests that interpersonal competence is part of developing relational practice and that this can be taught but mechanistic models that focus on enactment of behavioural communication skills, such as listening and questioning aimed at goal directed communication and problem resolution do not adequately address the relationship that is crucial to effective practice (Doane, 2002). We need education with more emphasis on human relating where there is an acknowledgement of the common bonds of humanity with people through an appreciation of people's connectedness and an emphasis on being with people rather than doing for them (Dewar, 2011; Doane, 2002). Educational models that acknowledge the interconnectedness and interdependency among all involved in the delivery and receipt of health care, that promotes interactions across the organisation that enhance the potential for mindfulness, valuing of diversity, interrelating, effective communication, mutual respect and trust should be aspired to (Nolan et al., 2006; Safran et al., 2006; Tresolini and PewFetzer Task Force, 1994). Action learning as a method within the curriculum has the potential to address the development of relational practice. Enhanced Self-awareness Goleman (1998) describes self-awareness as one of the essential components of emotional intelligence, illustrating the role of emotional intelligence in supporting recognition of our own and others' feelings. Self-awareness impacts positively on the development of the therapeutic relationship, creating a nurse who is responsive to needs of others (Hewitt, 2009) and who is able to deal with stress (Faguy, 2012). Enhanced self-awareness also positively correlates with leadership (Avolio et al., 2004) and resilience (Bernard, 2004); these were attributes being mirrored in the Standards for Pre-registration Nursing Education (Nursing and Midwifery Council, 2010). Enhanced self-awareness was identified as a significant outcome from participating in AL. In particular students had much more selfawareness about how they felt about their own emotion in a situation and their feelings if others expressed emotion: I think if I see somebody is upset I tend to back off but then sometimes I think that is just me and the person who is upset wants to continue. I think I have learnt that just because somebody is emotional this is not a bad thing and it is not necessarily my fault — they should be allowed to express emotion. [Student Focus Group 1] Really understanding and hearing the perspective of another were something that other students felt they were more aware of: I know now that I was a bit blinkered and a bit narrow minded. I know we should know that we should consider other perspectives but I am not sure I was really doing this. It's changed my views and made me much more aware of what I think about something and how I go about finding out about how others think or view a situation. It has also helped me to hear what others have to say and even if it sort of clashes with my views I can hear and think about that now. I am more adaptable. [Student Focus Group 2]

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In this quote the student has articulated what having a nonjudgemental approach really meant to her in practice. Action learning thus created an opportunity for students to explore their espoused values and values in action and to become much more aware of where there was some dissonance between these. The process helped them understand the relationship between what they feel, think, and act, and their impact on others, a crucial step to greater personal and professional competence. Being With Someone in the Moment — There is no Rehearsal Being with someone in the moment and having the courage and confidence to respond appropriately requires skill and expertise. A key outcome of the process of AL for students was helping them to feel comfortable with uncertainty: It's given me really good experience to think quickly in the moment and respond to someone. People bring an issue and you really want to help them but you don't know in advance what the issues are or what questions will be best. This is just like practice. [Student Focus Group 2] Feeling more comfortable with uncertainty in the learning process was an aspect that a lecturer felt they had developed: Action Learning is different – you can't prepare – it's not like other teaching approaches — you have to be reactive. Although I was initially apprehensive about this — I feel comfortable now. It's like there is always a feeling of being on the edge a bit – the uncertainty – you don't know what is going to happen — I feel comfortable with uncertainty now. [Lecturer Focus Group] It seems that this was important learning that would be hard to teach other than through experiential methods where students are actively engaged rather than being passive recipients in their own learning (Weil and McGill, 1989). Doing Things Differently in Practice Environments The ‘doing things differently’ theme particularly highlighted issues around communicating with clients and staff in a different way, and ‘speaking out’ both in terms of the students' experience and the care that service users were receiving. Some students were aware of the fact that they were doing things differently in practice — particularly in the way they communicated with others. I remember I asked a client how long they had had a problem with drinking. I would not do this now. I would ask what they felt their problems were and try not to make assumptions. [Student Focus Group 1]

I really tried not to give advice. I would definitely have tried to jump in with advice in the past. I know I would have put words into people's mouths and they will have just agreed with me – I can hear myself saying oh that's terrible – what about trying this or that or that happened to me. I was not really listening. Now I ask different questions – I ask them how they feel about what happened – I might ask them what is getting in the way of moving forward or what would they like to happen? Action Learning has given me the chance to really sit and watch and learn from others and practice it myself in a safe place. [Student Focus Group 3]

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Table 2 Senses framework. Sense

Evidence of this being met within the action learning process

A sense of security — of feeling safe and able to deliver competent and sensitive care

It felt okay to make mistakes — you were not made to feel silly. We felt comfortable to challenge others — it was not just the lecturer that did this (Student Focus Group 2). I felt respected that people felt they could trust me. We had someone who presented a deep personal issue — she would not have done this if she did not trust the group (Student Focus Group 2). A sense of continuity — to experience links and connections I feel stretched. Some of the skills and techniques in AL I had developed in my practice — but I don't know if I was using them. We don't often get the opportunity in small groups. Action learning has kept these skills alive for me. I am aware I use them more in other situations now (Lecturer Focus Group). It's helped me to ask Socratic questions in my work. I now can really help people to try to identify what strengths they have and areas they might want to change, to ask how they felt about that and what they might do about that. I can see the benefit of this approach to all settings (Student Focus Group 2). A sense of belonging — opportunities to form meaningful I felt supported – out in practice it can feel very isolated – although you are in a team it is not really your team. relationships or feel part of a team Coming into do AL was good I felt part of a group and included (Student Focus Group 2). A sense of purpose — opportunities to engage in purposeful I think it has taught us about the theory of therapeutic relationships. It is not like role play because what we did activities or to have a clear set of goals to aspire to was practice our skills of developing relationships in a very real way — with real issues, real emotions and feelings. There are no emotions attached to role play — it is pretend and you don't necessarily get to see the impact of your actions (Student Focus Group 1). • A sense of achievement — achieving meaningful or valued goals I felt capable that I can help somebody come to their own understanding of a situation. Rather than just telling and feeling satisfied with one's efforts people. This is what I might have done in the past (Student Focus Group 1). There was a real change in my perspective about how I viewed this student (Lecturer Focus Group). • A sense of significance — to feel that you matter, and that you are I felt respected because people were really there for me and supported me through things (Student focus group 1). valued as a person

Some students did not just refer to the difference in questioning skills but to the confidence that they now had in being able to stick up for what they believed in: I feel that I would be able in the future to stand up for what I believe in. I was in a situation where a patient was being discharged and I did not think this was appropriate. I didn't do anything about this at the time but felt annoyed that I had not. After AL I developed a way of working that would help me to say what I felt in the future. [Student Focus Group 1] So, students were able to use the skills learnt during the ALS with their peers in practice environments. Some lecturers saw the process of AL as a ‘mirror’ of what happens in practice. The Set almost became a ‘test bed’ for the development of interpersonal and relational skills. Thus there was an important role of modelling that happened in AL which made transfer of these skills to practice more achievable. Indeed Fish and Purr (1991) argue that by engaging in the reflective process of AL, in relation to the person's own experience, people can begin to understand how to facilitate this process in others. The Creation of Enriched Learning Environments Action learning helped to create an enriched learning experience for students and lecturers. Nolan et al. (2006) suggest that in order to create an enriched experience the sense of security, belonging, continuity, significance, purpose and achievement needs to be promoted within the curriculum. Student nurses are at the centre of a network of complex relationships socially, educationally and professionally and achievement of these senses is important if relational components of their role are to be supported and developed (Andrew et al., 2011). The extent to which the senses were achieved for students and lecturers in this evaluation is illustrated in Table 2 where quotes are mapped against the senses. There is much evidence that the senses were achieved for students and lecturers. Conclusion The evaluation presents a very positive view of AL with few negative comments. This may be a reflection on the fact that the participants who agreed to take part were perhaps those that valued the approach. That said what this paper presents is valuable insights into the benefits of this approach to practice.

The interpersonal and relational skills required to develop positive therapeutic relationships with clients are complex. The process of AL helped to develop these specifically. There were many examples of where the learning had an impact on practice. For the lecturers, this related to an enhanced awareness of their own facilitation style and a more deliberate use of questioning in other teaching and learning experiences. For the students, the enhanced awareness enabled them to consider other perspectives, manage both their own and others' emotion, and question in a way that opened up dialogue rather than closing this down. Action Learning Sets not only help students engage in and develop reflective inquiry and critical thinking skills in a challenging and supportive environment but also offer one model for engaging in these processes. Mental health nurse educators should consider this model within the curriculum, due to the benefits of the development of these complex skills and ability to transfer this learning because of its relevance and meaning directly to the practice situation. Acknowledgements We would like to thank the staff and students who gave so freely of their time to support us to develop this work. In addition we would like to thank the University of West of Scotland for funding this study. References Aird, T., 2011. What is work based learning? In: Jackson, C., Thurgate, C. (Eds.), Workplace Learning in Health and Social Care: A Student's Guide. ΜGraw Hill, London, pp. 3–11. Andrew, N., Robb, Y., Ferguson, D., Brown, J., 2011. ‘Show us you know us’: using the senses framework to support the professional development of undergraduate nursing students. Nurse Educ. Pract. 11, 356–359. Avolio, B.J., Luthans, F., Walumbwa, F.O., 2004. Authentic leadership: theory-building for veritable sustained performance. Working Paper. Gallup Leadership Institute, University of Nebraska-Lincoln. Barker, P., 2004. The relationship, In: Barker, P. (Ed.), Assessment in Psychiatric and Mental Health Nursing, 2nd ed. Nelson Thornes Ltd., Cheltenham. Bernard, B., 2004. Resiliency: What We Have Learned. West Ed, San Francisco. Booth, A., Sutton, A., Falzon, L., 2003. Working together: supporting projects through action learning. Health Inf. Libr. J. 20 (4), 225–231. Dewar, B., 2011. Caring About Caring; An Appreciative Inquiry About Compassionate Relationship Centred Care. (PhD) Edinburgh Napier University, Edinburgh (accessed from http://researchrepository.napier.ac.uk/id/eprint/4845). Dewar, B., Nolan, M., 2013. Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting. Int. J. Nurs. Stud.. http://dx.doi.org/10.1016/j.ijnurstu.2013.01.008. Dewar, B., Sharp, C., 2006. Using evidence: how action learning can support individual and organizational learning through action research. Educ. Action Res. 14 (2), 153–159.

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