Cultivating students' appreciation for, understanding, and application of therapeutic communication techniques during a brief, three-day mental health clinical rotation can be a daunting task, even for an experienced clinical educator. Mental health clinical sites and clinical hours are limited. Maintaining a safe, meaningful, and evocative experience for nursing students and enabling them to achieve course competencies require clinical faculty to be flexible and creative.

We used a narrative pedagogic approach that involved the film "Wit" to transform an unsatisfying clinical experience into a clinical space of faculty-student sharing, reflection, and learning. Exploration about how we learn, what we focus on, and our language transformed our shared educational experience into an inspirational experience.

THE NEED FOR A PARADIGM SHIFT

Nielsen, Noone, Voss, and Matthews (2013) suggest that, in order to compensate for limited time and space in clinical rotations, faculty need to design clinical learning activities that bolster the developmental level of nursing students while addressing course competencies and refining related clinical judgments during the entire experience. The competencies for our clinical rotation included cultivating empathy and rapport with assigned patients, applying therapeutic communication skills with assigned patients, understanding recovery, understanding the role of the nurse as manager of the milieu, and understanding the contribution of the nurse to treatment team meetings. In our traditional experience, a brief overview of theory related to these competencies was presented to students after a preclinical exploration of their anxieties and concerns. Then, for the three days of the mental health clinical (over a period of three weeks), students individually conducted multiple one-on-one interviews with various patients and attended treatment team meetings and recovery groups. Interviews were processed in a group discussion format before lunch and at the end of the clinical day. The intent of the interview was to cultivate empathy and rapport through active listening.

After the rotation was completed, students wrote to the course coordinator about their dissatisfaction with the design of the clinical learning experience and the emphasis on practicing therapeutic communications skills. One student wrote, "She [the instructor] made us listen to patients and not talk to them"; another student complained, "We did not get to do what nurses on the unit do." Students had not experienced a relationship with faculty that offered the opportunity to explore how the teaching-learning process was unfolding in real time. In addition, some aspects of therapeutic communication, such as silence, were not well demonstrated or appreciated by the students. A shift in strategy was needed for subsequent cohorts in order for the holistic clinical experience to have relevance to students as future practicing nurses. Change was needed before the next cohort of students was introduced to clinical mental health education.

Ganzer and Zauderer (2013) reported success using structured preclinical activities that involved watching popular films and then engaging in discussion aimed at reducing student anxiety and heightening student awareness of therapeutic communication. These authors (Zauderer & Ganzer, 2011) provided a dynamic and highly interactive classroom cognitive and affective learning experience that strengthened students' conceptions of mental illness through the use of film. Others (Darbyshire & Baker, 2012) reported on engaging nursing foundations students with the use of the film "Wit" to highlight doctor-centric approaches to medicine, bioethical decisions, and end-of-life care.

"Wit" tells the story of a midlife, unmarried, renowned professor of metaphysical poetry whose life changes dramatically when told by her oncologist, a researcher, that she has Stage IV cancer. Always proud of her wit and the importance of research, Vivian, the professor now patient, encounters one of her former literature students who is now her physician and a proud cancer researcher on the oncology ward. Vivian's former student is incapable of seeing her as anything but data for his research. With flashbacks to her life, the film chronicles Vivian's horrific and lonely chemotherapy treatments. As the story progresses, the professor realizes that she yearns for human connection and comfort. Vivian finds this comfort in a relationship with a nurse who discusses with her life in general and guides Vivian in making the decision to refuse life support when the time comes that it is needed. Vivian asks the nurse to promise to not stop caring for her, and the film ends with the nurse rendering postmortem care to Vivian as she had promised.

Our clinical faculty selected "Wit" for preclinical discussion for the mental health nursing course and not films about mental illness, as our intent was to inquire about the universality of relationship building in nursing through therapeutic communication. Our goal was to explore how therapeutic communication is not linked exclusively to mental health settings. We also adopted narrative pedagogy as our approach to transform the clinical experience for future cohorts of mental health students.

Ironside (2015) emphasizes that narrative pedagogy may be seen as an instructional strategy that uses the sharing of stories to achieve course outcomes. However, she explains, it is a process that is enabled through faculty-student exchanges about what is being learned, how that learning is taking place, and the assumptions on which the learning is built.

THE NEW APPROACH

Both faculty and students view "Wit" separately the night before the first preclinical day. It is the only preclinical assignment, and no preset questions are assigned so as not to limit the potential of the first clinical day as a day of discovery for both faculty and students. The use of film serves as the medium for a deeper exploration of communicating about the human experience (McAllister, 2015). The film creates a safe space for students and faculty to share their diverse emotional and cognitive responses. It introduces an open-ended, exploratory tone for the clinical experience and the process of learning. The focus is on student and faculty reflection, not the content of the course (Briggs, 2011).

To encourage reflection and discussion, faculty use active listening, restatement, mirroring, and clarification, with the film as a common reference point for discussion. Faculty and students discover common concerns, such as not wanting to harm a patient by communicating in a nontherapeutic manner. Both faculty and students speak of anxiety as a normal response to a new clinical rotation.

Nursing education incorporates reflective activity, practical activity, and evaluative activity when using film as an educational medium (Oh, De Gagne, & Kang, 2013). Reflective, open-ended, and interactive dialogue about "Wit" during the first preclinical day yielded diverse student comments, for example, "When I watched the film I just thought the nurse was being nice; now I realize she was being therapeutic." Another student shared: "Too often we focus on getting things done and make sure we are gaining as much knowledge as possible. Wit taught me to be more concerned about the patient's feelings." Still another said, "I think developing that relationship prevents people in health care from looking at patients as scientific objects."

PRACTICAL ACTIVITY

With the new approach to the course, 15-minute, one-on-one interviews with diverse patients enable the convergence of theory and practice to become more evident to students. Faculty and students explore how to approach the learning experience, what groups to attend, and what treatment teams are most meaningful. Students express appreciation for the role of the nurse as manager of the milieu and active team member in treatment team discussions. In postconference one day, a student commented about the inpatient unit: "I think how easily nurses talk about suicide here is very important. It made me realize that nurses should all feel comfortable speaking about suicide and bringing it up. It's not only mental health patients that contemplate suicide. Many people do in all situations. It should be brought up easier and more often."

Students have expressed appreciation for "Wit" and have noted dehumanization they see on the unit. As a group, they redesigned the seclusion room to be a more therapeutic environment. In terms of honing clinical judgment, a student remarked, "Listening to the patient without having to ask the patient a thousand questions gives me more insight on the important things I need to know." Another commented, "I was able to pick up on mental disorders and understand the difference in patients who were trying to overcome their addictions and those who were not ready." Other than favorable course evaluations and discussion, no formal written evaluation was done.

CONCLUSION

Film can be an effective way for clinical faculty to enable course competencies and create meaningful experiences, despite existing constraints on mental health clinical rotations. Narrative pedagogy enabled a shared exploration of the clinical experience that transformed teaching-learning into an insightful endeavor for both clinical faculty and students.

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