Teaching psychology to student nurses : the use of ‘ Talking Head ’ videos

Psychology is a central part of undergraduate nursing curricula in the UK. However, student nurses report difficulties recognising the relevance and value of psychology. We sought to strengthen first-year student nurses’ application of psychology by developing a set of digital stories based around ‘Talking Head’ video clips where authentic patients relate their experiences of illness and nursing care. The aim of this article is to discuss the technological, organisational and pedagogical challenges, student and staff evaluations and our recommendations for the future of Talking Heads. First-year student nurses were shown a video clip of a patient talking about their illness experiences followed by a group learning situation linking main themes to psychology and nursing. Students and staff valued the authenticity of patient’s narrative, found the video clip easy to follow, reported a raised awareness of psychological concepts and improved empathetic understanding of chronic illness. Negative evaluations were related to a sanitised, untypical representation and limited internet access. This small-scale study highlighted how patient narrative may enhance students understanding of illness experience. It chronicles the development and evaluation of a Talking Head in a specific context but which may be useful across disciplines.


Introduction
Psychology is regarded as a crucial element of nursing undergraduate curricula, particularly in light of reports that highlight nurses' alleged shortcomings in meeting the personal, moral and organisational challenges in their work place (Frances 2013).However, student nurses report that learning psychology is challenging due to overly theoretical syllabuses and ambiguous 'facts' that contrast with their need for unambiguous and practical information (Jansen and Nicholl 2007).First-year nursing students struggle to recognise the relevance and value of theoretical concepts such as psychology when they are overly concerned with familiarising themselves with nursing tasks rather than with topics that have little immediate application (Benner 2000).A challenge for lecturers is to engage students who have minimal exposure to practice and have little experience upon which to pin psychological knowledge (Fitzpatrick and McCarthy 2014;Quinn 2007).
In consideration of this, an educational strategy was developed aimed at enhancing students' engagement with psychology, and which would encourage students to develop an awareness of patients' psychological and social experiences by which to explore first-hand the lived experience of patients and inform empathetic, individualised and holistic care (Cummings and Bennet 2012).Although the use of digitally-facilitated storytelling is thought to have an 'evolving role in nurse education' (Haigh and Hardy 2011), there is little evaluation of psychology teaching methods in undergraduate nursing curriculums (de Vries and Timmins 2012).Accordingly this paper reports on the technical, pedagogical and administrative challenges of developing a 'Talking Head' or patient digital story.We discuss student and staff evaluations of the facility in relation to their understanding of the role psychology plays in the first year of the nursing undergraduate programme.

Literature review
A key challenge for nurse educationalists is integrating theory with practice.An increasing number of texts illustrate the application of psychology to nursing; however, students may employ a narrow over-simplified application consistent with the example they have been exposed to (Goddard 2010;Jansen and Nicholl 2007;Meyhew 2000;Mulholland 1997).For learning and application to take place, psychology content should be relevant and meaningful with global application (Jansen and Nicholl 2007;Mowforth, Harrison, and Morris 2005).Case study scenarios are proposed as an effective method (Jansen and Nicholl 2007;Jordan 1998;Painter and Lemkau 1992).Nevertheless, a review of teaching methods to determine the effectiveness of one approach over another highlights that there is no one method that has a clear advantage (Thompson and Stapley 2011).Nonetheless, the use of service users in health education has gained momentum in recent years.The driver has emerged from two directions: first, UK governments' proposal to include person-centred partnerships in health and social care; and second the emphasis on service user experience in educational standards for nursing (DOH 1998;NMC 2010).The contribution of service users in nurse education is thought to provide students with first-hand knowledge and meaningful perspectives by which to facilitate patient-centred care (Perry and Linsley 2006).Schwartz and Abbott (2007) proposed that patients' stories led to a change of approach by students to the patients in their care and an improvement in the way that they sourced information about their patient.Rush reported that 'Live' service user-led sessions in mental health undergraduate education demonstrated transformative learning with all students reporting examples of actions or insights resulting from service user sessions.The main influences on learning were hearing the lived experience of the services users, the emotional impact of the condition, the reversal of roles (patient as teacher), reflection by the students and the training/preparation for service users (Rush 2008).Further research shows service user involvement in the design and implementation of educational sessions produces improvement in student knowledge around coping skills, communication and empathy, and promotes reflection in nursing students (Stickley et al. 2009).The benefits of storytelling itself include development of skills and imagination required to follow a narrative which may be complex, contradictory with multiple points of view: an ability to enter the storytellers' reality and to understand how the story teller makes sense of that reality and to gain insight into the use of image and metaphor (Charon 2005).
In comparison, Morgan and Sanggaran (1997) concluded that service users' opinions were not significant and Costello and Horne's respondents felt they had learned little or nothing from service users in the classroom (Costello and Horne 2001).Garrett (2006) reported students showed various levels of engagement with the stories and the storytellers, with some not appreciating the richness and diversity that the stories demonstrated.Students regard service user's stories as real and raw but students should be motivated, prepared and ground rules should be laid down to protect service users and guide students' behaviour (Abma 2003;Terry 2012).'Live' service users may value participation but repeated visiting of a distressful event has been associated with increased stress and anxiety of the service user (Costello and Horne 2001).Repeated use of service users also requires on-going financial and organisational commitment from institutions and from service users themselves who may feel overused, overburdened or simply may not appear due to a variety of reasons (Terry 2012).
As an alternative to 'live' service users, advancing technologies has led to increasing use of video clips of authentic service users in e-learning, either as standalone clips or in more complex learning resources (Mathews 2014).Remote learning opportunities offer a useful method of engaging service users in educational initiatives enabling students to gain insight into a patient's experiences, allowing students to visualise situations yet to be experienced, equipping students to relate patient care theory to practice, with added value of sustainability and reusability (Blake 2010;Bleiker, Knapp and Frampton 2011;Haigh and Hardy 2011).
Technology is often used to supplement more traditional teaching and may form part of a 'blended learning pedagogy' or combination of face-to-face and online approaches (Brodwski 2003;Garrison and Vaughan 2008;Klein, Noe, and Wang 2006).In this project, a decision was made to develop and evaluate alternative and complementary ways to deliver the psychology component of the pre-registration nursing course.It was envisaged that a combination of e-learning with a traditional lecture, that is, a 'blended learning pedagogy' to encourage engagement, active learning and problem solving would encourage meaningful application of theory to practice through the use of real-life experiences related by patients (Hwang and Kim 2006;Jones and Chen 2008).We took note of the NMC standard 'to produce graduates who are compassionate and caring' and recommendations for flexible, blended approaches to learning (NMC 2010).We were guided by Bruner's constructivist spiral model which advocates a reiterative pedagogy with students' revisiting and building on knowledge throughout the syllabus (Bruner 1986).In keeping with this, the permanency of our video clips enables naı ¨ve students to initially engage with an area of practice (chronic conditions) but that would feed into future clinical practice and allow them to reengage with the Talking Head in an increasingly informed way throughout the course.

Study aim
The aim of the study was to develop and evaluate a Talking Head video clip for use in a pre-registration nursing programme for first-year student nurses and as part of a blended learning approach to an introduction to applied psychology.

Study objectives
To evaluate the role of the Talking Head in facilitating student nurses' knowledge and application of psychological concepts to nursing practice and their understanding of chronic illness and its effect on sufferers To evaluate students and staff attitudes towards the Talking Head learning package

Study design
The project design was informed by principles of narrative inquiry and enquiry-based learning (EBL).EBL is a learning approach which may involve the exposure of students to clinically related scenarios which act as triggers for critical thinking, exploration and reflection (Rush and Barker 2006).The project also draws on principles of narrative where patients' stories are viewed as rich source of data and gives expression to peoples' lived experience (Huyler, Mason, 2005;Loeser 2005).Although patient stories may be chaotic, even contradictory (Strawson 2004), we propose that patient stories facilitate empathy and understanding within an educational setting (Bleakley 2005).The key psychological concepts to be explored in the teaching sessions related to recognising individuality and authenticity, culture and stereotyping, active listening and empathy.

Ethical approval
Following ethical approval focus group interviews were undertaken with students and staff in a UK-based university.Verbal and written approval for recruiting service users for the Talking Heads was gained from the 'Involving People' organisation (NHS Wales 2014).Ethical challenges included decisions about providing protected access to staff and students via the university online e-learning facility 'Blackboard' and assuring service users that the video would be revised yearly and deleted upon request.Although the service user was not concerned about anonymity, we felt comfortable using a pseudonym which also helped to safeguard her traceable identity.To avoid undue pressure to participate, students were provided with information and reassured about the voluntary, anonymous nature of the study 2 weeks beforehand.They were also assured that taking part would not influence the outcome of their assessment for this module.

Sample
This was a convenience sample of 100 undergraduate nursing students attending a module of learning entitled 'What is nursing?'The inclusion criteria required that only students and lecturers who had attended the session which involved the Talking Head were eligible to take part in the study.Online evaluation opportunities were also available for all the students who were registered for the teaching session.

Video clip recording and editing
The video clip was filmed by the university media department staff under the direction of the project leaders.The service users were asked to detail their chronic illness experiences, the more troubling aspects of their condition and how they managed their illness, they were asked to relate their experiences of nursing care.The original recording was edited to 7 minutes by the project lead.Thematic headings were inserted into the video clip so as to signpost different topics discussed by the patient volunteer.The edited version was approved by the service user prior to use.All video clips were transferred to the university online learning portal so they could be viewed by students using Windows 7.

Procedure: student and staff preparation
The intervention took place on two teaching sites.Students were informed about the intervention 2 weeks prior to the teaching session.Information sheets were disseminated with a tear off reply slip to be placed in a sealed box for those interested in attending focus group evaluations.The educational package was structured accordingly: (1) Pre-intervention online reading and knowledge quiz, (2) students exposed to the Talking Head followed by group work where students were given a worksheet focussing students' attention on the patient's illness experience in relation to psychological theories and nursing, and (3) post-intervention evaluations and opportunity to complete online knowledge quiz.

Methods of data collection Online demographic and attitudinal questionnaire and online quiz
The online demographic and attitudinal questionnaires used in this study have been described previously by Tait et al. (2008).They are designed to collect demographic data and to determine student attitudes to the e-learning intervention.The attitudinal data were collected by asking the respondents to indicate their level of agreement with statements on a five-point Likert scale (disagree strongly, disagree, no opinion, agree, agree strongly).An online multiple-choice questionnaire was also used to assess the students' knowledge and understanding of the themes discussed in the video clip.Anonymous responses to the questionnaires were saved automatically from the Web site to a Microsoft Access database.After collection, the data were transferred from Access to a Microsoft Excel spreadsheet for analysis.All the students were asked to complete Web-based questionnaires immediately after the intervention as part of good educational practice and in-line with the university policy on evaluation.

Focus groups
Focus groups were conducted with both staff and students so as to obtain a broad spectrum of feedback.Focus groups were considered to be well suited for this study because they offered opportunity for participants to freely articulate and share their individual experiences, which would generate rich data (Silverman 2000).The groups were facilitated by the project leads (SS) and (DT) with DT taking notes to aid the subsequent analysis.Each interview was guided by a semi-structured interview schedule designed from the project brief with an emphasis upon exploring student or staff views about the clarity, editing, content, utility and accessibility of the Talking Head along with suggestions for future development and applicability to practice.Each discussion began with an open-ended, broad 'lead-in' question, 'please tell me your views of the Talking Head' followed by prompts, when required, that related to the aim of the study.Each focus group lasted between 30 and 50 minutes.Focus group transcriptions were subject to a process of inductive thematic analysis involving two researchers independently identifying, ordering and coding relevant themes and agreeing on main thematic structure (Green and Thorogood 2004).

Online demographic and attitudinal questionnaire and online quiz
Twenty-nine students completed the online demographic questionnaire.Because of the low number of respondents, the online numerical data were not analysed beyond obtaining basic descriptive statistics.The results are shown in Table 1.These show that roughly half were female and half male, half were aged below 25 and half were older than this.When asked about their confidence in using information technology, half had either none or a low level of confidence and the other half had a medium or high level of confidence.
Nineteen students completed the online attitudinal questionnaire after using the Talking Heads resource.The results are shown in Table 2. Half of the respondents agreed that the video was easy to use and the majority (55%) agreed that the patient's story was easy to follow.Thirty-seven percent said that they had previous knowledge of caring for people with chronic illness.Sixty-three percent agreed that the Talking Head video clip helped them to understand the nature of chronic illness and to understand the psychological impact of being diagnosed with a chronic illness.Roughly half agreed that the video helped them to understand the role of the nurse in chronic illness and how basic nursing care can enhance the patient experience.However, only a quarter agreed that viewing the clip made them feel more confident that they can care for patients with chronic illness.No students completed the online pre-and post-multiple-choice questionnaires to assess their knowledge and understanding.

Focus groups findings
Two focus groups with students were planned following the Talking Head intervention.One of the focus groups consisted of three students from one educational site.Just one student attended the focus group call for the other educational site (adult nursing) and so we conducted an individual interview with this student.A simple thematic analysis of the findings revealed four themes.These included authenticity of the service user story, quality and accessibility of the learning resource, valuing and applying psychology to clinical practice and student learning opportunities.The staff focus group was conducted with five members of staff who had knowledge and experience of service user participation and who had undertaken sessions with the Talking Head.Lecturers were invited to review how the sessions had gone and to offer suggestions for future practice.Thematic analysis of the findings revealed authenticity of the service user story, quality of the learning resource, students awareness of psychological concepts, staff training and resources, and ethical issues.

Student focus group
Theme: authenticity of the service user story Within this, four sub-themes were apparent: service user authenticity; challenging stereotypical images and promoting empathy; representativeness; social and emotional context.The service user's account facilitated understanding of the challenges of chronic illness for individuals, dispelled stereotypical notions and facilitated empathy.In particular, it revealed how chronic illness may be experienced within an appearance of wellness.The students valued the service user's authenticity but also suggested she was unrepresentative of most patients; that her condition was rare and they may not see another patient with her condition again.Students agreed that they would like to know more about her social context and emotional responses to illness: Theme: quality and accessibility of the learning resource The video clip was generally viewed as easy to follow and understand despite the patterning of the narrative.Although students appreciated the quality of the video presentation, they required better access to the Talking Head and the online reading: Theme: valuing and applying psychology to clinical practice Students had difficulty recognising the link to psychology.Students tended to view the video as an opportunity to get closer to learning about practice rather than learning about applied psychology.They prioritise topics according to need and relevance in a densely packed first-year curriculum: Quality 'edited for pace and flow and bringing it together so it was easy to follow' 'It was difficult to follow at times, obviously, you had to edit it. ..but. . .then again she was a real patient, she was a real person, so. ..' Accessibility 'Easier access to Talking Head required along with pre-reading.You've got 80 odd people going like ''oh, no, I've got to read all this stuff by Friday and there are only three books in the library''.Even if it's just an extract from a chapter with the relevant information, as long as it doesn't break any copy rights then if that extract could be put into blackboard so that everyone could access it' Theme: student learning opportunities The video clip provided a powerful trigger for insights into patient experiences and future practice.The students also recognised the value of using different teaching approaches to encourage learning.The video enabled students to understand patient's feelings and thoughts as well as accommodating different learning styles:

Staff focus group
The following themes were identified from the analysis of the staff data: authenticity of the service user story, quality of the learning resource, students' awareness of psychological concepts, staff training and resources, and ethical issues.
Theme: authenticity of the service user story The staff suggested students benefited from having a 'real patient' talking about their illness and promoted awareness of psychological concepts 'A natural progression from written scenarios' (Staff four).However, they also questioned the representativeness of the service user: Theme: quality of the learning resource The Talking Head presentation was positively viewed in terms of clarity and structure but negatively in relation to duration and positioning in the curriculum: 'A good quality video. ..It was clear.' 'Quite well edited.'

Sub-themes Representative quotes
Valuing psychology 'Psychology is a low priority for overstretched students You sort of tend to prioritise.I just prioritised it down the list a bit' Applying psychology to practice 'No direct link to psychology.I wouldn't link it as such but you could see the psychological aspect of it as well as the physical. ..'

Sub-themes Representative quotes
Learning about chronic illness for future practice 'helping to understand the difference between acute and chronic illness early on in the course so you can recognise when the patient moves from one to the other Á a bit more insight for future placements' Understanding patient's feelings 'Not as sterile as reading texts but not as useful as a patient presenting to a small group it makes you think Theme: students' awareness of psychological concepts The staff commented that students' attention was drawn to previously unknown psychological concepts, for example, grief and bereavement.This was despite technical difficulties limiting access to the online Talking Head and the associated reading,

Theme: staff training and resources
Staff suggested further training in e-learning was required: Theme: ethical issues The ethics of streaming onto the World Wide Web and using children was of concern:

Discussion
The aim of this small-scale education intervention was to engage student nurses with psychology and develop their understanding of chronic illness.This was an exploratory study with low levels of online evaluative responses limiting the representation of the findings.We speculate that low levels of participation related to students' perceptions of demand and prioritisation of topics.A participating student commented, 'Psychology is a low priority for overstretched students'.Such views support suggestions that for first-year students, psychology is subordinate to acquiring more meaningful nursing knowledge and the adoption of a superficial learning style for more abstract topics (Snelgrove 2004).It is likely that attending to obvious and relevant practice topics rather than applied psychology reflects an imperative to 'fit in' to clinical situations (Benner 2000) and satisfy physical and psychological safety needs before developing a higher level of thinking and understanding (Maslow 1954).According to Benner, novices 'smell of the textbook' because they do not have enough experiential knowledge to make clinical decisions independently and creatively.In the absence of this experiential and tacit knowledge/ intuition, they have to rely on rules of practice and support their search for practice information rather than abstract theories (Benner 2000).Although Benner referred to nursing, it is possible that such a concrete orientation is uppermost in other health professional student populations.Despite the small sample, we suggest that the rich and informative focus group data offers valuable insight into how exposure to authentic experiences in a classroom setting enabled students to gain holistic understanding of chronic illness and enhanced empathetic listening skills.Of particular note was that the students engaged with the psychological and social impact of chronic illness rather than developing situated understandings of psychological concepts (Thorell-Ekstrand and Bjorvell 1995).
Moreover, student evaluations showed that the service user's narrative was judged as a more convincing modality than purely text book information but not as useful as a live service user.It is likely that the use of videos and patient narrative engages listeners because the narrator is delivering personal accounts of a complex, individual, lived experience not easily captured by text.Although emotional engagement is probably best captured by use of a face-to-face encounter, the operational drawbacks of using live service users have been well documented (Terry 2012).
Students were also alerted to the service user's reports of not being believed and 'felt stigma'.The students' perceived that this knowledge would be useful for future practice and acknowledged the video clip had encouraged them to look beyond the information given and consider patients' subjective understandings of their situation.Of particular importance were suggestions that the video clip helped students recognise their stereotypical attitudes towards people with chronic illness.These were not necessarily negative although it has been proposed that students enter the nursing profession with preconceived ideas about chronic illness which in turn may have a detrimental effect on patients' self-concept and illness experience (Cervantez Thompson, Emrich, and Moore 2003;Shaw 2010;Tervo 2004).Well-designed curriculums incorporating personal encounters and engagement with people with potentially stigmatising conditions outside the clinical environment as well as within may encourage professional attitudes and serve to negate any stereotypical ideas (Cervantez Thompson, Emrich, and Moore 2003;Packer et al. 2000;Seccombe 2007).We suggest the controlled exposure of students to patient experiences prior to clinical placements may act as a catalyst for uncovering judicial attitudes and promote reflection although may be insufficient to instigate significant attitudinal change.In addition, the students' engagement with the service user's story accompanied by group tasks and discussion encouraged students to take a reflective turn which is thought to promote self-awareness and professional growth (Bleiker, Knapp, and Frampton 2011;Mann, Gordon, and Macleod 2009).
Student feedback also showed that exposure to an authentic patient enabled empathetic understanding of living with a chronic condition.Empathetic nursing skills are effective responses to patient's needs and can be learned, (Cunico et al. 2012;Ozcan, Oflaz, and Cicek 2010).Empathy is more than sympathy or compassion as it implicates the ability to put oneself in the patient's situation and reassure them their concerns are understood (Eisenberg and Eggum 2009).Students may care 'for patients' but novices may exhibit little sign of caring 'with the patient' (Orland-Barak and Wilhelmem 2005).Conversely, the participating students in our institution reported feeling empathetic despite perceptions of a polished and unemotional rhetoric from the service user.The mechanisms of this are not clear although it is likely that the students were able to see beyond the rather rehearsed discourse by paying close attention and being empathetic which reflected their rapport with the service user.Furthermore, staff also commented upon the lack of emotionality expressed by the service user but agreed it would be inappropriate to encourage authentic service users to be demonstrable on cue.An alternative may be the use of actors enacting scenarios based on service users' accounts (Bleiker, Knapp, and Frampton 2011) but authenticity may be sacrificed.
There is very little written about the obstacles to successful implementation of technologies in the curriculum.In this study, we found three main obstacles: scarcity of resources (time); lack of IT skills and associated technical problems (Button, Harrrington, and Belan 2013).The latter may point to a failure to prepare the appropriate expert resources (Brodwski 2003).In our case, technical problems arose because of little support and unanswered queries relating to streaming options which in turn interfered with pre-session information and varied student accessibility to the Talking Head.Participating staff were wary of the technology and requested opportunities for gaining nursing informatics skills.Students were enthused but initial technical difficulties reinforced a general reluctance to participate in additional work (such as the online quiz and ad hoc observations of the Talking Head) outside their busy personal and institutional timetables.
The staff and student feedback fed into revising the video streaming arrangements, improving student online accessibility and the positioning of psychology in the curriculum.For the future, we would maximise learning opportunities by choosing a patient with a common clinical condition rather than a little recognised disease.This would enable wider use of the Talking Head across modules.We would consider providing a stronger bridge between theory and practice by integrating the Talking Head with relevant practice skills sessions.We learnt how a lack of pedagogical IT skills may hinder the development of educational practice and how IT skills sessions for staff could facilitate agency (Fangehanel 2007).

Conclusion
The study is a chronicle of the challenges of developing and evaluating a Talking Head in higher education.Although the project took place within a particular context, the findings may be of value across disciplines.A combined approach of narrative and EBL encased in a technological intervention allowed students to safely explore a patient's story in an empathetic and critical fashion within the context of their discipline and psychological concepts.Attention was drawn to the technological and ethical demands associated with developing online teaching facilities and points to the need for support and training resources for lecturers.Further research may be directed towards investigating how a Talking Head influences the application of psychology in practice.We suggest that Talking Heads are a useful pedagogical tool but further design and evaluative work is necessary.

Table 1 .
Results of demographic questionnaire.The questionnaire was completed online by 29 students.Not all numbers for each category add up to 100% as the respondents were able to withhold some information if they preferred.

Table 2 .
Results of attitudinal questionnaire.The questionnaire was completed online by 19Á20 students.The figure for '% agree' was calculated by combining agree and agree strongly responses.
then, actually, you know, that person looks ok but what are the. ..how are they actually thinking?What are they actually feeling?So, it did trigger things to make you think' Citation: Research in Learning Technology 2016, 24: 30891 -http://dx.doi.org/10.3402/rlt.v24.30891