MENTAL HEALTH NURSING PRACTICUM : STUDENT AND MENTOR PERSPECTIVES ON STRESS AND SATISFACTION

Nursing students begin to complete practcum experiences during their frst year, increasing the number of applied credits as they progress toward degree completon. This contributes to integratng knowledge and skills from all of their courses and to obtaining the basic competencies of the nursing profession. It is also essental to identfy the student’s sources of stress in order to provide strategies to confront them and diminish the potental consequences. Therefore, it is a priority to ascertain the percepton of stress and the stressors. This study applied both quanttatve and quality methods to achieve its objectves: to analyze the percepton of stress and the stress-generatng factors faced by thirdand fourth-year nursing students during the mental health practcum, and to determine satsfacton with the new mental health practcum in a student survey and in a focus group of mentor nurses. Study results identfed four major stress factors before students began the practcum: the difculty of providing nursing care for the patent with a mental disorder, knowing how to react in an unfamiliar situaton, lack of knowledge about mental health services, and the possibility of patent aggression. Only the later remained as a stressor afer the practcum was completed. Student satsfacton with the mental health practcum was highly positve. Mentor nurses were partcularly satsfed with the changes in student follow-up and evaluaton, emphasizing the importance of refectve practce and students’ self-management of their learning experience as set out by the European Higher Educaton Area.


INTRODUCTION
The European Higher Educaton Area (EHEA)has implemented many regulatons emphasizing the acquisiton of skills and competencies in the new degree programs (Burjalés Mart, Ricomá Muntané, Maciá Soler & Ballester Ferrando, 2005). These competencies are introduced throughout the entre nursing degree program, but the practcum is the context within which they must be fully achieved and integrated into practce. For that reason, on the degree programs the evaluaton is based on these competencies.
Our program introduces practcum credits during the frst year, and progressively increases this requirement. Each practcum experience integrates knowledge and skills from all of the coursework up to that tme and helps students learn the attudes and behaviours that will be expected of them as members of the nursing profession. Therefore, every course the students have to atain more competencies or increase the standard assumed of them.
Students consider the practcum experience an essental training opportunity, while at the same tme perceiving it as a source of considerable stress (Timmins & Kaliszer, 2002). Several studies have reported that nursing students feel greater stress than those in other degree programs (Zupiria Gorostdi, Alberdi Erice, Uranga Iturrioz, Barandiarán Lasa & Sanz Cascante, 2003;López-Medina & Sánchez-Criado, 2005; TamPhun & Benedita dos Santos, 2010). Although a certain stress level may have some benefts with respect to heightened concentraton and efort invested in an actvity, poor stress management by nursing students is related to other negatve factors, such as excessive use of alcohol (Antolín Rodriguez, Puialto Durán, Moure Fernández & Quinteiro Antolín, 2007).
Most research on stress among students in health-related felds has applied the defniton of stress provided by Folkman and Lazarus (1988): Stress occurs when an individual perceives that the demands of an external situaton are beyond his or her perceived ability to cope with them and endangers his or her well-being. Some authors have claimed that stress afects students' academic success and their well-being (Pulido-Martos, Augusto-Landa & Lopez-Zafra, 2012), and that the study of student stress is a priority because stress increases the difculty of learning and achieving expected outcomes (Jiménez, Martnez & Vacas, 2009).
Other studies have classifed the sources of stress among nursing students (Zupiria-Gorostdi, Uranga-Iturrioz, Alberdi-Erice, Barandiaran-Lasa, Huitzi-Egileor & Sanz-Cascante, 2006) or measured stress levels during clinical practce using validated questonnaires such as the Sheu Perceived Stress Scale (Sheu, Lin & Hwang, 2002) or scales used by other authors (Admi, 1997;Sánchez, 1992;López-Medina & Sanchez-Criado, 2005). Some authors have concluded that the sources of stress decreased over the course of the program and at the end the remaining stressors were the same as those faced by new practcing professionals (Zupiria-Gorostdi et al., 2006). The sources of stress observed in nursing students have been grouped into three categories: academic stress factors(related to testng and evaluaton, fear of failure, and problems with the academic workload); clinical stress factors (related to the practcum, fear of commitng error, not handling patent sufering and death adequately, and relatons within the health care team); and personal or social stress factors (related to fnancial problems and balancing work, study, and family) (Jiménez et al., 2009;Pulido-Martos et al., 2012). Nonetheless, these two studies did not agree on which factors were most frequent, or the most prevalent among nursing students.
The consequences of stress experienced by nursing students have also been defned by various studies, and include anxiety, nervousness, depression, fear, frustraton, anger, despair, loneliness, and feelings of inferiority or exhauston (Jiménez et al., 2009). All of these factors could clearly afect the student's academic success and learning outcomes.
A recent review of literature atempted to identfy the major sources of stress among nursing students during the practcum. The authors afrmed the need to apply qualitatve research methods in order to explore the sources of stress in depth and concluded that identfying these sources was essental in order to help students acquire strategies that would assist them in confrontng stress and limitng its consequences (Pulido-Martos et al., 2012).
Although litle evidence is available with respect to the mental health practcum, research in other health disciplines has shown that students do not feel prepared for clinical experiences (Pulido-Martos et al., 2012), a situaton that increases stress.
For all these reasons, the proposed study was considered a priority for the implementaton of the new nursing degree program at our university, in order to determine the percepton of stress among students and the contributng factors during the mental health practcum, and to collect the perceptons of mentors concerning the practcum.
Vol. 4(2), 2014, pp 80 Given the importance of the new practcum requirements in nursing degree programs, and specifcally with respect to the mental health nursing practcum, the study aimed to safeguard the quality of care to be provided by future nursing professionals by addressing the following three objectves: • To analyze the percepton of stress and the stress-generatng factors faced by third-and fourth-year nursing students during the mental health practcum.
• To determine student satsfacton with the mental health practcum included in the nursing degree requirements.
• To determine nurse mentors' satsfacton with the mental health practcum included in the nursing degree requirements.

METHODOLOGY
This study used mixed qualitatve and quanttatve methods, combining a phenomenological two-tered followup study with descriptve and bivariate statstcal analysis. The study populaton was the students partcipatng in the Mental Health Practcum (MHP) from April to December 2012, distributed across four practcum periods, and a focus group of 5 nurse mentors from the partcipatng centres. 95 students partcipated in this study: 90 quanttatve methodology and 5 in qualitatve methodology. (Figure 1).

Figure 1. Study design
At the outset of the study, qualitatve data were collected from two focus group discussions with fve student volunteers, using a semi-structured interview about their perceptons of concerns and stress-generatng elements of the MHP. The frst occurred before students began the practcum and the second afer it had been completed. All volunteers were third-year students. Data were categorized and analysed using the Atlas-Ti program.
To quanttatvely assess student satsfacton with the MHP, the standard School of Nursing questonnaire was distributed to all students who completed theMHPin2012 (n=90). The average age is 24.53 years (SD=6.77). On a 10-point Likert scale, this anonymous, self-administered survey asked students to evaluate how the partcipatng clinical centre welcomed them, what they learned from the nurse mentor at the centre, and their Vol. 4(2), 2014, pp 81 general assessment of their mentor nurse during the practcum, their integraton into the nursing team and services provided, and how well the practcum met their expectatons. They were also asked to rate how useful the knowledge and skills acquired in the classroom had been in the clinical environment of mental health nursing, and their overall impression of the practcum. The Student test was applied to compare means, with standard deviatons (SD), in the descriptve and bivariate analysis; relatonships between variables or ordered ranges were assessed using the Pearson correlaton coefcient, Spearman rho, and Kendall tau-b. All analyses were done using the SPSSv19 sofware.
At the end of the study period, a focus group of nurse mentors at the partcipatng centres was convened to partcipate in a phenomenological study. The convenience sample was asked about their percepton of the new MHP implemented as part of the nursing degree. These data were categorized and analyzed using the Atlas-Ti program.

ETHICS APPROVAL
Students and mentor nurses, who are members of the university's teaching faculty, were informed of the study objectves and its academic intent, including the publicaton of study results. Confdentality was strictly respected, in accordance with all university and European policies related to classroom research, informed consent was obtained before sound-recording the focus group sessions, and reportng of results was anonymized.

Percepton of stress and stressors associated with the mental health practcum by third-and fourth-year nursing students
The stress-generatng factors antcipated by student partcipants in the pre-MHP focus group session were the difculty of providing nursing care for the patent with a mental disorder, the possibility of patent aggression, knowing how to react in an unfamiliar situaton, and a lack of knowledge about mental health services.
In the post-MHP focus group, the four expected stress factors had been reduced to just one: patent aggression. Students indicated that even before startng the MHP their conversatons with fellow students helped to lower their stress levels about their lack of knowledge of mental health services and the type of patents they would be caring for, but not in the categories of dealing with patent aggression and reactng to an unfamiliar situaton.

Student satsfacton with the mental health practcum in the nursing degree program
The response rate for this standard course evaluaton was 76.67% (n=69, 58 [84%] women and 11 [16%] men, ranging from 20 to 60 years of age). The mean age was 24.53 years (SD=6.77). The student distributon by type of MHP placement was 75% in hospital setngs and 25% in out patent mental health centres; 69.6% partcipated in the morning practcum and 30.4% in the afernoon.
Overall, students gave the MHP a mean score of 9.10 (SD=1.285), median of 9 and mode of 10 on the 10-point Likert scale (Figure2). Their welcome by the practcum site and the informaton received there received a mean score of 9.04 (SD=1.17); the informaton received from the nurse mentor was scored at 9.12 (SD=1.21), with the same mean score for the overall evaluaton of the training received from the mentor: 9.12 (SD=1.06) and 9 as both the median and mode values (Figure 3). Integraton into the nursing team obtained a mean score of 9.26 (SD=0.96), although integraton into the health care service team scored slightly lower, with a mean of 9.14 (SD=0.97). On the other hand, despite a mean of 9.03 (SD=0.85) for meetng their learning expectatons, the respondents assigned a mean score of just 7.25 (SD=2.37) to the queston about the usefulness of the knowledge and skills acquired in class.
A non signifcant diference also was observed in overall satsfacton with the MHP based on type of clinical setng, with students in out patent centres showing greater satsfacton (X=9.53; SD=0.7) than those working in hospital setngs (X=8.96; SD=1.4). A signifcant diference was observed in general satsfacton with the training received from mentor nurses: students whose MHP took place in outpatent centres were more satsfed (X=9.59; SD=0.8) than those working in hospitals (X=8.96; SD=1.1), (t(67)=-2.16; p=0.034).
Vol. 4(2), 2014, pp 83 There was a linear correlaton between age and overall student satsfacton with the MHP, shown in Table 1 the older the student, the greater the satsfacton.

Perceptons of nurse mentors about the mental health practcum in the nursing degree program
The nurse mentors focus group identfed fve key themes concerning their satsfacton with the new MHP.

Evaluaton of the current degree practcum, compared to the former diploma courses
The former curriculum was more structured, which facilitated the mentor's work: "I used to feel more oriented, because you knew that you had three weeks, and if you spend this week talking about this, and that week on that... But not now. Now you say, what do I tell [my student]? " Some partcipants referred to degree students as more motvated than the diploma students were. New teaching methods are also being used, and these are unfamiliar to the mentor nurses: "Now the students tell you that they have done a practce-based learning (PBL), on antpsychotc drugs...and you say to yourself, you don't even know what a PBL is!" (Note: None of the fve mentors interviewed had partcipated in the teaching methods class ofered by the School of Nursing, and only one was aware of its existence).

Student skills and competencies
In the analysis of data on pre-existng knowledge, the difculty of relatng theory to practce stands out. The mentors did not feel that the length of tme since students had completed theoretcal courses before their clinical practce was not a consideraton. Mentors ofen were unaware of the theoretcal outline of the course, and reported that the student was the one who told them about it.
One of the proposals was to improve the mentor's access to informaton about the arriving student's level of competency. In this sense, they underlined a lack of communicaton with university faculty, which sometmes was also perceived as a lack of support.
The intermediary role of the practcum professor was not always appreciated by the mentors. They commented that these professors either "abandon" the students or "keep asking about them incessantly". There were notable diferences between their opinions of the practcum professors, with a much higher opinion of those who belonged to the clinical unit (rather than teaching theoretcal courses). Another proposal for improvement was that the student reread or reviews the relevant theoretcal content before beginning the practcum.
Vol. 4(2), 2014, pp 84 Communicaton skills were discussed, recognizing that this depends on each student's personal characteristcs but generally agreeing this is an area that needs more work: "They have very poor communicaton skills." With respect to nursing care, mentors pointed out a major conceptual vacuum in areas such as treatment adherence, verbal strategies to calm an agitated patent, monitoring autolytc risk, etc. The students did not think of these interventons as part of nursing care because many associated nursing tasks mainly with drawing blood or putng in a line for intravenous therapy, oxygen, etc.

Evaluaton
The daily journal of refecton was evaluated positvely. Among the strong points, the possibility stood out of refectng on situatons the students would not normally encounter in the hospitalized populaton: suicide atempts, ethical aspects such as involuntary admissions, mechanical restraints, verbal patent management, drug addictons in patents their own age, etc.
In discussing instructor contnuity, the focus group noted that especially in the afernoon cohort (when the nurses have more tme available) the student may have more instructors than just the mentor nurse: " It's good for them to have various nurses around because they can take what they want to learn about each nursing acton, from each nurse, whatever appeals to them the most."

Impact of the mental health practcum on the student
Most mentors indicated that the students arrive very nervous, with certain beliefs about the mental health patent and the fear of possible aggression: "At frst they are very worried because they arrive in the acute unit and they hallucinate, yes, it's true, at frst they are scared. Later they see that it's not all that bad." "Many people arrive thinking that a mental patent is aggressive, that something could happen to them." They also commented that it is important for the university to make an efort to align the student profles to the practcum places available. However, they favoured making the MHP a universal requirement for nursing degree students.

Unique aspects of each practcum unit
There is a considerable diference in responses depending on whether or not the student has been in an acute, outpatent, or other type of unit: "They come to the acute ward and they have this idea that hospitalizing the psychiatric patent is normal. And you explain to them that this is the excepton." To address this problem, the partcipants suggested the possibility of a rotaton so that students could visit and be introduced to various diferent units.

DISCUSSION AND CONCLUSIONS
This study shows the need to inform students before they begin mental health clinical practce work and to explain aspects that generate greater stress, as in studies by other authors (Antolín Rodríguez et al., 2007;Jiménez et al., 2009;Pulido-Martos et al., 2012;Sanchez, 1992;López-Medina & Sanchez-Criado, 2005). Students should also review the knowledge and skills learned, with the goal of adaptng what they know to the health care reality they will experience in mental health units.
The experience of this inital study will allow us to work on these concerns in a variety of educatonal contexts, with the goal of decreasing the stress level for future students. This will help to improve the training and wellbeing of our students as they prepare for the MHP experience.
In relaton to student satsfacton with the MHP, we must highlight the excellent scores they assigned the experience on the standard survey. The lowest score -although stll approaching 80% --was related to the usefulness of knowledge and skills acquired in the classroom. It is necessary to take steps to raise awareness that not all competencies must be acquired on campus, using learning methods such as master classes, partcipatory methods, PBL, seminars, simulaton, and techniques and procedures. Some specifc competencies that are impossible for students to assimilate on campus must be acquired and consolidated during the MHP.
Vol. 4(2), 2014, pp 85 Most of our current nursing students are about 21 years old. However, we have a growing number of older students who have completed advanced technical training (Ciclos Formatvos Superiores) and are working in the health care environment at a lower job classifcaton or have completed other degrees and are turning to nursing. These individuals, above the mean age of the study group, were those who most highly valued the practcum experience. They usually had greater motvaton and beter tme management than the younger students.
Although non signifcant, we observed a trend toward greater satsfacton with their practcum experience among students completng the MHP during their fourth year, compared to third-year students. As also reported by Zupiria-Gorostdi et al. (2006), the additonal experience with diverse clinical practces in diferent setngs helps the student feel more secure and less stressed.
Practcum students scored the outpatent setng higher than the hospital mental health unit. All of the students had previous practcal experience in the primary care setng. Together with the specifcity of the care provided and the instruments and skills used by nurses in these out patent centres, there is also no risk of aggression, a factor that could have contributed to the lower score in the hospital units.
Students who did their MHP in the morning cohort were more satsfed. It has been demonstrated that nursing actvity is more intense and diverse in the morning shif. This leads to the importance of having students experience a variety of clinical experiences in the diferent health care shifs during their practcum.
The nurse mentors who work with practcum students value the recent changes in the follow-up and evaluaton aspects of the practcum. They emphasize the importance of refectve practce and of the student's management of his or her own learning, according to the European Higher Educaton Area recommendatons (Burjalés Mart et al., 2005).
The authors are aware that the study has limitatons, including the small sample and the limitatons inherent to survey research. We could not establish causal relatonships between variables nor directonality in the associatons observed. There is a possible social desirability bias in the responses because the instrument score was self-reported. Finally, the qualitatve aspects used a convenience sample and assigned partcipants using the snowball recruitment method.
Nonetheless, this study contributes several proposals for improvement in this new MHP in a newly minted degree program. Although it was scored highly, it is important to take into account the suggestons that were directly or indirectly suggested by the students and nurse mentors: • Improve the communicaton between the university and the health care centre.
• Increase the use of practcal case studies to teach theory.
• Strengthen the training in verbal expression and argumentaton.
• Ofer preparatory seminars before students begin the MHP.