Nurse education has traditionally focused on nursing skills and virtues. Nightingale, hospital-based nurse training reflected the role of the nurse as a caregiver and the physical skills required to deliver care safely, efficiently and virtuously. Formal discussion around nurse education moving into tertiary education began in New Zealand and Australia in 1972 following the Carpenter report (Carpenter, 1971), after which the shift to higher education took place. In the UK, Project 2000 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986) brought about a similar change of focus from technical training to universities, with the educational emphasis placed on physical, social and behavioural sciences.
Over the past 10 years, the emphasis in the UK, the Republic of Ireland and Australia has shifted back to the centre ground in recognition that skills taught in traditional training are essential (Grundy, 2001; An Bord Altranais, 2004; Nursing and Midwifery Council, 2005). Following the scandal of the care failures at Mid Staffordshire NHS Foundation Trust in the UK, the Francis (2013) report suggested that the teaching of emotional care might have been missed and had been partly responsible for serious failures in the delivery of nursing care. The report recommended that the focus of nurse education changed to a skills-based approach in the delivery of compassionate care, and a strong argument has developed calling for a return to the traditional, competency-based approach (Bradshaw, 2017).
Changes to service delivery and the move towards integrated models of care, including those set out in the Five Year Forward View (NHS England, 2014), may have also placed extra demands on nurses to develop a more generalist set of nursing skills to support complex patient needs (Tee and Böckle, 2012; King et al, 2018). Recommendations to incorporate interpersonal and interprofessional communication skills in nurse education (Howarth et al, 2006; Gilburt, 2016) may also have contributed to the need for changes in pedagogy towards problem-based learning or case-based inquiry and the use of simulation to assess competencies in therapeutic communication skills.
However, the standards prescribed by nursing boards remain more flexible for university-based courses than those for traditional training.
Meanwhile, the debate continues as to whether psychological care-giving skills might be more effectively learnt through exposure to real people with real problems, raising the critical question once again of how students can most effectively apply the study of social sciences to practice.
On the other hand, there are concerns that integrating psychology into skills-based teaching has diluted the subject, adding weight to arguments over the fractioning of the social sciences (Mowforth et al, 2005), resulting in the erosion of nursing care (de Vries and Timmins 2016).
Alongside developments in nursing, the past 20 years have seen significant changes to the way in which psychological care is delivered by all clinicians. Evidence-based psychological therapies, cognitive behavioural therapy, systemic therapies and positive psychology have swept away the mystery of psychotherapy, bringing the application of psychological strategies into the scope of nurses' professional practice. In England, the Department of Health has suggested that future nurses will have a central role in delivering evidence-based psychological therapies (Department of Health, 2006). A survey of practice nurses who had not received formal training in mental health found 82% have responsibilities for emotional wellbeing (Hardy, 2014), and there is a growing consensus that a person's emotional needs are more likely to be effectively addressed by a practitioner who is able to understand those needs using an evidence-based psychological framework, such as the process used in cognitive behavioural therapy (Currid et al, 2011).
Given these recent developments, one might expect this to be reflected in nurse education, and it is within this context that the author (a nurse, cognitive behavioural therapist and educator) decided to explore the current thinking and content of psychology awareness to undergraduate nurses by conducting a review of recent literature.
Method
A systematic, integrative review of two specific data sources was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews (Moher et al, 2009).
Integrative reviews are generally broad in their area of coverage, allowing different methodologies and diverse and varied data to be included, which means the reviewer can capture the context of two distinct data sources.
To ensure a degree of rigour, the theoretical framework of Wittemore and Knafl (2005) was used to inform this review.
Papers
A literature search was undertaken between February and April 2018. Because recent evidence was required, a time limit of 12 years was imposed to searches and articles. The review included searches on CINAHL, MEDLINE and PsycINFO of peer-reviewed scholarly journals published between 2005 and 2017 in English. The terms used were ‘undergraduate’, ‘nursing’, ‘education’, ‘psychology’ and ‘curriculum’. Inclusion criteria were both qualitative and quantitative studies that explored psychology content delivered within preregistration nursing curricula. Exclusion criteria were articles published before 2005, studies involving only registered nurses or those with only postgraduate nursing students as participants (Table 1).
| Textbooks | Articles |
|---|---|
| All current nursing texts |
Databases: |
|
Inclusion criteria
|
Inclusion criteria
|
|
Exclusion criteria
|
Exclusion criteria
|
Textbooks
As well as capturing recent evidence and thinking around the subject, the review was intended to provide an accurate context by reflecting what is currently being taught to students. Therefore, an additional search of current textbooks was conducted. The review took place in 2017 and looked at works published in the previous 12 years, including texts held in the author's university library and the popular data sources of Google Scholar and Amazon; sources had to be in the English language. Inclusion criteria consisted of textbooks that covered psychology, applied psychology, nurses, mental health nurses and allied health professionals. Initial searches were conducted by the researcher and school librarian and cross-matched for accuracy. See Table 1.
The combined search retrieval process, which is illustrated in Figure 1, yielded 137 articles and texts. Following title and abstract review, 25 articles and 11 textbooks were found to meet the inclusion criteria. A final eligibility filter for specific relevance and context of articles revealed that a large majority of the studies failed to address the original research question around generalist and comprehensive undergraduate programmes.
The Critical Appraisal Skills Programme (2018) qualitative checklist and the Critical Review Form (Law et al, 1998) were then applied as a final measure to all papers, resulting in the inclusion of the final nine papers and seven textbooks for review (Table 2).
| Journal Papers | Content | Teaching strategies | Application to practice |
|---|---|---|---|
| Christoffersen et al (2010) | Psychosocial skills |
Mental health lecturers to adult nursing students |
Integrating psychosocial skills into the medical/surgical curriculum. Skills identified include the therapeutic use of self and enhanced communication skills |
| de Vries and Timmins (2012) | Literature shows no consensus regarding content | Literature shows no consensus regarding teaching strategies, and finds both standalone/integrated approaches | Application to practice emphasised |
| McCarthy et al (2014) | Theoretical concepts of self etc applied through the teaching of communication | Traditional: lectures and tutorials with role-play, simulation etc | Psychology lecture followed by communication tutorial, applying the content to nursing practice with an emphasis on communication but in the context of thoughts, emotions and behaviour |
| Mowforth et al (2005) | Psychosocial skills |
Delivered in a comprehensive undergraduate nursing programme as (i) standalone units and (ii) in a curriculum integrated with other units | Focus groups and inductive thematic analysis of experience and relevance to practice following clinical placement of both groups |
| O'Donovan et al (2013) | Stress and empathy as psychological concepts pertinent to nursing | Formative assessment by students completing worksheets, for example a worksheet entitled ‘Stress’, where they have to discuss their own stress in relation to an incident or experience within a reflective model (using Stephenson's (1994) model of reflection) | Reflection assessed |
| de Vries and Timmins (2016) | Discussion paper: cognitive dissonance | Practice-based learning (PBL)/content-based instruction (CBI) | Structured critical reflection |
| Snelgrove et al (2016) | Empathy |
PBL/technology |
Used by staff and students to analyse scenarios |
| de Vries and Timmins (2017a) | Cognitive dissonance structured reflection | PBL |
Structured critical reflection and conceptualisation of cognitive dissonance in practice |
Results
Following inductive thematic analysis, three common themes emerged from the review of papers, which then became the focus of further content analysis of texts.
Content
Papers
The question of how much psychology is delivered within adult nursing programmes and what should be included has dominated historical studies. We can trace back almost a century to find this question being discussed by academics (Laird, 1923; Babcock, 1926). One of the papers reviewed, de Vries and Timmins (2012), provides a comprehensive review of the depth and coverage of psychology content in nursing education, and includes most of these seminal texts.
The findings show that there is universal acceptance that psychology should be included in adult nursing curricula, but there is very little agreement on the content and delivery. Debate in more recent years has tended to focus on specific areas of nursing where psychological content is relevant in clinical presentation, rather than the question of which psychological theories are more relevant to nursing and to what degree of depth they should be taught.
There were three main themes concerning the content of papers.
Therapeutic communication skills: empathy
Psychosocial and therapeutic communication skills are both considered relevant, and included as examples of where the application of psychology is most needed by nurses (Mowforth et al, 2005; Christoffersen et al, 2010; McCarthy et al, 2014); the importance of empathy in the context of patient physical and emotional wellbeing is still considered the cornerstone of effective nurse practice and essential for inclusion in preregistration education.
The teaching of empathy is often facilitated by actors and lecturers, which is labour and resource intensive. Therefore, the use of computer-aided patient simulation technology (which is generally perceived as devoid of emotion), is an obvious step for educators, and was demonstrated by a study on the effectiveness of ‘talking head’ computer-aided simulation (Snelgrove et al, 2016).
Self-awareness
The study by O'Donovan et al (2013) is based on the integration of psychological theory in the form of self and cognitive awareness, and the nursing theory of reflective practice. After this paper was published, the same group of researchers studied the application of psychology through the teaching of communication, the therapeutic use of self and the conceptualisation of thoughts, emotions and behaviour using a reflective model (McCarthy et al, 2014). While the study by Mowforth et al (2005) did not discuss specific content (as its focus was on the mode of teaching), the qualitative data reveal that cognition, emotion and behaviour and the concept of self were extracted during data analysis, suggesting the authors perceived them to be significant to nurse education.
Christoffersen et al's study (2010) was the only one reviewed where the focus was solely on psychosocial skills, and not taught psychological theory or both. Again, the indicative content here was on the concept of self and effective therapeutic communication skills.
Structured reflection as content
de Vries and Timmins (2016; 2017a) indicated critical reflection is an essential part of nurse education in a series of papers. The first discussion paper explores the relationship of cognitive dissonance to ‘care erosion’ in the wake of the Mid Staffordshire NHS Foundation Trust public inquiry, which highlighted a gradual decline in the standards of nursing care delivered (Francis, 2013). The need for a greater emphasis on the teaching of structured reflection to counter this decline in standards of nursing care is suggested and, once again, refreshes the question around why nurses do not appear to be applying psychological theory to build resilience towards lapses in compassionate nursing care (de Vries and Timmins, 2016).
Both papers argue for critical reflection to be included in and integrated into the psychological content delivered to undergraduate nurses. Reflection, of course, is not traditionally thought of as psychology content but more of as a skill incorporated into communication and nurse ‘survival’ skills. However, a crossover clearly emerges here, with the majority of studies reviewed strongly indicating the successful use of structured reflection as a ‘content tool’ that can be used to apply psychological concepts.
Textbooks
Three content themes arose from the view of textbooks.
Psychological theories
All of the major psychological theories of analytical, behavioural, humanist and cognitive areas are included in the textbooks reviewed to a greater or lesser extent. The greatest emphasis on theory is provided in Barkway (2014), which gives a comprehensive overview based in the form of a historical journey through major theories and applies these across the lifespan to common presentations such as pain, stress management and coping (Barkway, 2014).
A broad historical base is also included by Gross and Kinnison (2014), who highlight all of the major theoretical approaches to human behaviour and illness. Again, separate chapters cover stress and coping, pain, death/dying and development through the lifespan.
In both texts, no preference to theories is given and the text is presented in an evidential form (Barkway, 2014; Gross and Kinnison, 2014).
Less emphasis is placed upon psychological theories and schools of thought by Rana and Upton (2013), Upton (2013), and Walker et al (2012). While all theories are still covered, priority is given to those where relevance to nursing and caring is perceived as greater. For example, Rana and Upton (2013), target the biological basis of behaviour and personality, directing the reader away from social theory and emphasising giving priority to cognitive theories in patient care. Upton (2013) covers all theories but gives a more balanced view of the application of theory and evidence-based psychological therapies, which one would expect given that this publication is aimed at mental health nurses. In a pragmatic ‘here's the historical basis of psychological theory, but this is what we now use’ approach, this text succeeds in giving the reader a sense of evidential perspective. Walker et al (2012) also cover all major theorists but, because the book is intended for nurses and caring professionals, a greater weight appears to be placed on self-concept, social psychology and their relationship to patient behaviour and communication.
The books featuring less content about theoretical and historical perspectives (Russell, 2005; Goodman, 2015; de Vries and Timmins, 2017b), all aim to give a more applied, evidence-based feel. The de Vries and Timmins (2017b) textbook uses a no-nonsense, evolutionary, conceptual map of the development of psychology to visualise advances though history in a timeline, then leaves it right there, preferring to concentrate on specific areas related to healthcare, including development, consciousness, memory, health and stress.
Maybe because the intended audience of Russell (2005) is generic health practitioners, inclusion of major theories is limited and a greater priority is given to behaviourist and cultural theories, with an in-depth look at behaviour change models and health psychology to complement the health promotional theme. The inclusion of sociology and psychology sets the scene for Goodman (2015), who explores more specifically humanistic and cognitive theories, maybe as less scientific complements to sociology, and presenting theory in a dynamic and relevant evidential style.
Application to nursing
Content regarding specific presentations pertinent to nursing is common throughout all texts reviewed, with stress and stress management, coping/loss/bereavement and pain featuring in all of them (Walker et al, 2012; Rana and Upton, 2013; Barkway, 2014; Gross and Kinnison, 2014). These themes are also included in Upton (2013), but with greater attention given to wellbeing in the context of abnormal psychology, as one would expect given the mental health nursing readership.
The link with communication was evident in every text reviewed, all of which had separate chapters dedicated to it; Russell (2005) includes an opening section on communication in healthcare settings that explores the process/mechanics of therapeutic communication, giving the impression of priority and relevance to nursing.
Structured reflection
Unfortunately, the majority of current textbooks do not refer to structured reflection. The exception is that by de Vries and Timmins (2017b), which dedicates a chapter to the use of reflection and incorporates psychological concepts into a structured, reflective process. This is not surprising given the significance of studies performed by de Vries and Timmins (2012; 2016; 2017a), which all contribute significantly to this review as well as to current thinking.
All texts referred to evidence-based psychological therapies, with particular reference made to cognitive behavioural therapy in relation to the treatment of mental illness and pain, highlighting conceptual models as treatment strategies. The exception here is Barkway (2014), who adds a paragraph around the limitation of psychological models and their application.
Lecturing strategies
Papers
Who should lecture in psychology to nurses, and whether it should be delivered as ‘standalone’ or within ‘integrated’ units, continue to be discussed in recent literature, as the following two themes show.
Integrated or standalone?
The thorough review by de Vries and Timmins (2012) identifies that the issue of whether psychology should be taught as a separate subject or integrated into other units remains contentious; it concludes that the only agreement regarding this is that psychological theory should be applied directly to nursing.
The later discussion papers by de Vries and Timmins (2016; 2017a) argue that, in order for psychological theory to solve real life nursing issues, a move towards problem-based learning or case-based inquiry must be achieved. They suggest that previous didactic teaching methods of psychology may have added to student uncertainty, leaving graduates unable to deal with to emerging organisational and cultural issues in nursing (de Vries and Timmins 2016; 2017a).
Who should teach?
Whether psychology should be taught by psychologists or nurses and taught separately or integrated are discussed by both Mowforth et al (2005) and McCarthy et al (2014). In the former study, inductive thematic analysis of two groups of students taking integrated or standalone units were explored. While the limitations of the study are acknowledged, the quality of scholarship and richness of the qualitative data present a good case against the dilution and marginalisation of social sciences in nursing.
The study by O'Donovan et al (2013) provides an overview of the development of a reflective assessment to integrate nursing with psychological knowledge, which was then applied in the follow-up study by McCarthy et al (2014). Here, a psychology tutorial taught by a psychologist was followed by an interpersonal communications tutorial delivered by a nurse, and students understood the theory underpinning practice specifically on the therapeutic nurse/patient communication.
A recognition that general/surgical nurses were not graduating with confidence in psychosocial skills informed the study by Christoffersen et al (2010), who found that sessions led by specialist mental health nursing lecturers at a medical/surgical unit increased the confidence of students in the use of communication skills. Teaching strategies included the observation of real patients, which removed the need for actors and technology, followed by simulated workshops in the nursing lab.
Snelgrove et al (2016) tested the effectiveness of simulation within a problem-based learning programme and found that, through the use of a digital narrative or ‘talking head’ application, students were able to safely explore empathy critically in the context of psychological concepts.
Textbooks
Pedagogical approaches and critical thinking were the main themes in this area.
Pedagogical approaches
All of the textbooks reviewed appear to have embraced the concept of case-based inquiry and problem-based learning to varying degrees, incorporating this approach into each theoretical section. Case examples and scenarios are used as a method of applying content to practice, with a clear emphasis on guiding the student through what is considered relevant and aiding the teacher in developing and applying theory.
None of the books reviewed recommend whether they should be used for standalone or integrated units, although the more recent publications lend themselves to problem-based learning and the development of skills (Goodman, 2015; de Vries and Timmins, 2017b). This is particularly clear from a comparison of Barkway (2014) with de Vries and Timmins (2017b). The former, a relatively recent edition of the original publication (Barkway 2009), uses case examples to apply all theoretical approaches—analytical, behavioural, humanist etc—equally. This is done with a focus on the traditional standalone classroom application of behaviour change in the context of health promotion and communication skills to nursing. Case examples are followed by critical thinking exercises, which are reflective in essence, and often supported by a focus on research.
Encouragement of critical thinking
Goodman (2015), similarly, recognises the need to frame the text in the context of the current sociopolitical climate, focusing the student towards practical examples of clinical decision-making skills based on current evidence around cognitive bias. This gives the book a more dynamic feel that is aimed at keeping the student motivated to learning what is relevant to them as modern clinicians.
Walker et al (2012) present a series of case studies that include common emotional and physical conditions, to which the student is invited to apply various psychological theories.
Gross and Kinnison (2014) prompt critical discussion of theory throughout, which is applied to individual circumstances and nursing practice. In an attempt to clearly encourage critical thinking in the context of patient emotional wellbeing and self-care skills, this book aims to cover all bases in a ‘one size fits all’ approach (Gross and Kinnison, 2014).
The other text worth a mention here is Upton (2013), whose intended audience is the undergraduate mental health nurse. Reflection features extensively, and the inclusion of cognition, behaviour and emotion, formulated and applied to the patient within a particular scenario, totally lends itself to student-centred learning, possibly in the simulated environment.
Application to practice
Papers
A theme that has dominated this discussion in previous reviews has been the relevance of psychology to nursing. Success in measuring the applicability of psychology has emerged as a subtheme of this long-mulled debate, so that its use is a measure of its relevance.
Holistic nursing
The measurement of a holistic biopsychosocial nursing outcome, first termed by Engel (1977), remains a mysterious concept although, considering the term's repeated use in the papers reviewed here, there appears no doubt of its importance. de Vries and Timmins (2016; 2017a), McCarthy et al (2014) and O'Donovan et al (2013) all recognise and link to this through the use of structured reflection. McCarthy et al (2014) draw on the reflective model of Stephenson (1994), to aid students in the process of reflection, focusing on their thoughts, feelings and communication behaviour.
The application of structured reflection
de Vries and Timmins (2017a) reinforce the value of this approach while discussing the application of critical, structured reflection to conceptualise cognitive dissonance in practice. The argument that theory and skills can be applied only when students are confident is focused upon by Christoffersen et al (2010), who found that confidence can be improved with simulated communication practice.
Textbooks
The importance of the application of psychology to nursing practice is covered widely in all major texts and, in homage to the relevance debate, most texts open with a ‘why psychology?’ chapter that describes the application of holistic nursing care to practice, the use of therapeutic communication, and knowledge of stress, pain and their significance to effective caring.
Holistic nursing
The broad approach taken by Walker et al (2012), Rana and Upton (2013) and Barkway (2014) is to discuss psychology in the context of holistic care. Barkway (2014) specifically encourages an ‘eclectic psychological approach’, highlighting the need to identify the emotional needs of the patient and apply these to nursing care. Gross and Kinnison (2014) encourage the student to think critically in terms of a biopsychosocial model and how this might be delivered in practice, leaving the student to find a solution.
Application of psychological concepts
de Vries and Timmins (2017b) take the psychological element of holistic care and divide it further into concepts of thinking, motivation, feeling and action, describing these in simple terms to help the reader understand and differentiate between them, while highlighting their significance to effective reflection, and the assessment of psychological needs. The author clearly guides the student towards a skill that can be applied specifically to the practice of theory, so the emphasis is no longer on analysis, behaviourist, humanist or other theories but on evidence-based psychological strategies (such as positive psychology and cognitive behavioural therapy) and their application to practice through the use of a reflective model. The book therefore lends itself to an integrated teaching approach that recognises graduates' practical need for psychological skills.
Discussion
Work in recent years from the UK, Republic of Ireland and Australia is clearly in response to the perceived mistakes made in nurse education and the under-representation of skills, which have been attributed to the move into tertiary education and the classroom. Thus, it would appear from recent literature that the inclusion of psychology into nursing curricula and its relevance is no longer debated, and has moved to the question of how theory and practice can be combined to prevent a further decline in compassionate nursing.
In response to this, the need to focus on specific ‘psychosocial communication skills’ has taken precedence, with the measure of competence no longer tested by essay or examination but students' ability to apply these skills with confidence in simulated and practice settings (McCarthy et al, 2014). Structured reflection, a skill commonly taught to nurses, has traditionally been viewed as the bridge between theory and practice, and its potential to aid the understanding of psychological concepts and apply them to real life situations is beginning to be explored.
The question of who teaches psychology to nurses remains an issue for some. Students appear to benefit from the depth of scientific knowledge offered by a psychologist, but might relate this knowledge to practice more effectively when this is taught within a specific context and applied directly to nursing science by a nurse (McCarthy et al, 2014). This discussion may also be motivated by the question of ‘who is the expert?’ by some when it comes to theory and application of psychological caring skills.
The concept of ‘marginalisation’ (Mowforth et al, 2005), of psychology is an interesting one, because it indicates that the content is somehow separate and disconnected, running alongside the mainstream, which implies inequality or inferiority; this remains a genuine concern.
The work of de Vries and Timmins (2012; 2016; 2017a; 2017b) has evolved in significance from being a theoretical argument to the realisation that teaching of psychology should no longer be contested following the findings that nurses and a hospital had failed to respond to signs of a gradual decline of care and ‘compassion deficit’ (Francis, 2013). By introducing the concept of ‘care erosion’, de Vries and Timmins (2016), explain how cognitive dissonance theory—originally termed by Festinger (1957)—can be conceptualised and applied through the use of structured reflection. As a result, the literature and textbooks reviewed can almost be divided into pre- and post-Mid Staffordshire and Francis (2013), with a recognition now that psychological skills and strategies are required by nurses. Recent failures uncovered at Gosport War Memorial Hospital (Gosport Independent Panel, 2018) might suggest education in these skills and strategies are a priority.
Conclusion
It would seem that, although the argument around psychology's relevance to adult nursing has been largely won, debate continues around specific content and how it can be applied to adult nursing practice. There is a concern that the teaching of social sciences might be lost or sidelined in a return to skills-based, career-ready nurse education at a time when it is most needed. However, there is a renewed consensus that psychology skills are essential to the delivery of effective compassionate, emotionally sensitive care.
This review suggests that integrating psychological theory into problem-based learning and case-based enquiry units might be yielding results. This is particularly salient when focused on the nursing application of specific theory and concepts, taught by clinical specialists, which can be practised in role play with the help of clinical simulation and computer-aided technology.
Jansen and Nicholl (2007) commented that psychology needs to be meaningful to nurses, and the link between structured reflection and the practical application of psychological theory provides meaning through considering the relationship of cognitive dissonance to care erosion. So if understanding oneself through reflection allows the meaningful application of theory, the same might be assumed of understanding patients through the introduction of simple cognitive behavioural conceptualisation. This is touched upon by recent papers and certainly reflected in some of the texts that present psychological strategies as nursing interventions. However, evidence to support the inclusion of simple psychological conceptualisation in the nursing curriculum was found to be untested in this review, and therefore requires further investigation.