Background: Developing communication skills and therapeutic relationships are key components in baccalaureate nursing education. These skills and techniques are emphasized within mental health courses as student nurse interactions are seen as key interventions to foster patient coping, stabilization, and recovery. However, patients with mental illness are not an easy population to communicate with as related to their stress levels and disease processes. This situation is magnified for student nurses who are still learning ways to dialogue. In fact, establishing one to one interactions with mental health patients and experiencing moments of silence with them, both embedded in therapeutic relationships, may be very challenging for student nurses. This can possibly be related to inadequate or under-developed student nurse communication skills as well as a fear of saying the wrong thing. Communication and verbalizing healthcare concerns may play a major part in assisting mental health patients to develop positive coping skills for recovery and community independence. Difficulties in communicating with mental health patients may be further compounded by the nature of involuntary settings where the mental health nurse must negotiate relationships and set boundaries regarding angry or otherwise unacceptable patient behaviors. A significant issue here is that patients with mental health disorders often experience varying degrees of inactivity, boredom, perceptual disturbances, angry and isolative behavior making communication difficult for them. When working with this group, student nurses may lack self-confidence and be fearful of saying the wrong thing to the patient. Moreover, and of importance to this study, student nurses may find it very difficult to form therapeutic relationships with mental health patients related to a lack of targeted communication skills and techniques which they do not necessarily get in school for this special patient group. Art therapy is a recognized method of promoting mental health. Moreover, art therapy can re-direct patients’ mental suffering into positive forms of self-expression(s) that may improve their overall quality of life. To date, no research has been done to investigate how student nurses develop a therapeutic relationship with mental health patients using art therapy to facilitate communication. Of consequence, art therapy may be very helpful in assisting student nurses within clinical experiences in the mental health setting.
Purpose: The purpose of this study was to explore how undergraduate student nurses use art therapy to promote therapeutic communication with mental health patients. This was a qualitative study using principles of thematic analysis. The following research question was asked:
What is the effect of art therapy on the therapeutic relationship and communication between student nurses and mental health patients?
Participants: Participants in the study were undergraduate nursing students from a mid-western univeristy. Two of the researchers not affiliated with the university went to the students’ class to describe the study and ask for volunteers. Participants were offered a 25 dollar gift certificate for participating in the study. Thirty-two student nurses agreed to participate in the study. Participants in the study consisted of both male and female student nurses from diverse social and ethnic backgrounds.
Design and Methods: This was a qualitative study using principles of thematic analysis. Art therapy was rendered in each clinical setting in the form of crayons and paper or coloring books, whereby student nurses and mental health patients actively participated in coloring together on a one to one basis in an open, observed area such as in the dining room or in a group setting under the direction of a certified art therapist. A semi-structured interview was administered to undergraduate student nurses. Three primary interview questions with probes were asked of the students during all interviews in order to answer the research question:
1. What is it like to communicate with mental health patients?
2. Have you used art therapy when communicating with mental health patients? What was it like?
3. How does art therapy assist you to communicate with your patient during your mental health experience?
All student nurses took turns answering the interview questions; when responding to the questions they were assigned numbers rather than using their names. In some exchanges student comments supported those of others. In other exchanges student comments stimulated new insights among the group.
Data were collected via audiotape and then analyzed and summarized into themes for reporting according to principles of thematic analysis. The interviews were professionally transcribed verbatim and accuracy of the transcriptions verified by the primary investigator. The transcripts were read multiple times to identify commonly occurring words and ideas. These formed the basis for the analysis. Data were processed and analyzed using a software program. Discrete themes were initially identified by in vivo coding of the student nurse’s open-ended interview responses. Later, these codes were refined to reflect common elements and were named to capture the essential meaning of each theme. Subthemes were identified during this process. In addition, the investigator’s memos, hand written notes, and diagrams of the data were used in the data analysis. All themes were reviewed to ensure that they emerged from the data thus avoiding a prioriassumptions. Transcripts were read multiple times by all researchers. The in vivo codes and emerging themes were reviewed by the researchers and discrepancies were resolved by examining the transcripts to ascertain the meaning of the thoughts of the student nurses. The participants’ words in the transcripts provided final support of the results derived. Findings were compared with the original transcripts as well as the researchers’ memos and diagrams. To promote credibility of the findings a confirmatory analysis was done by a colleague expert independent of the study having a mental health clinical background and experienced in qualitative research methods.
Results: Art therapy facilitated student nurse and mental health patient communication. Art therapy also enabled a comfortable silence between student nurses and mental health patients where both could just bewith each other in a safe and non-judgmental relationship. Students overcame their fears of saying or doing the wrong thing. Patients began to share feelings and tell their stories; student nurses began to understand what was going on with them and grew professionally in learning more effective ways of gathering information. Silently being with the mental health patients and communicating non-verbally built on the student nurse’s professional experiences of presence, reflection, and intuition.
Conclusions: In conclusion, this study supports art therapy as a valuable tool in facilitating therapeutic communication between student nurses and mental health patients. Art therapy promotes patient self-revelation of thoughts and feelings as well as comfortable silences between student nurses and their patients where trust is established and positive relationships with the patient occurs. It allows for professional growth of student nurses in their communication skills. Most importantly, this study supports the incorporation of art therapy as a deliberate communication strategy in baccalaureate nursing education to enhance the professional growth and development of student nurses as practicing nurses today and tomorrow.
Implications: Research should be conducted with mental health patients and staff nurses regarding the efficacy of art therapy. This study also supports the intentional use of art therapy with mental health patients to enhance communication and suggests it be integrated into baccalaureate nursing education both in the classroom and clinical setting as well as in online curriculum design.
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