Getting Started
Nursing school curriculum is designed to ensure students have the, “knowledge, skills and personal attributes to meet provincial and national regulatory and practical requirements of the [nursing] profession” (Canadian Nurses Association, 2017). Student nurse(s) (SN) are faced with anxiety and stress due to the overwhelming academic workload demanded by the educational institutes and clinical practicums (Melincavage, 2011; Timmins et al., 2011). Practice readiness for SNs consists of many domains that encompass the skills, knowledge and the ability to provide compassionate, respectful and non-judgmental ethical care to all (Lindh et al., 2008). Individuals with mental health challenges (IWMHC) are exposed to stigma within the communities they live in. This stigma also exists in the healthcare system and as SNs are transitioning to a career as nurses, it is important to prepare them for upcoming challenges and make sure the environment they are learning in reduces stigma instead of contributing to it. Currently, it is evident that nursing school does not prepare SNs for working in mental health settings after graduation, nor are they provided with the support needed to work with IWMHC. To address SN’s apprehension and anxiety of completing a clinical practicum on a mental health ward, this paper will explore clinical teaching strategies for nurse educators to build a supportive environment for SNs to develop competencies in mental health practice. This will result in a reduction of the stigmas portrayed around IWMHC and improving patient care.
The Importance of Reducing Student Nurse Stigma
Research indicates that many SNs have fears and anxieties about participating in the mental health clinical practicums. These fears and anxieties are often reinforced or influenced by how people with IWMHC are negatively portrayed in the media and stories from peers and family members (Karimollahi, 2012). This establishes a fear that people with mental illness are violent, unpredictable and dangerous. These fears are difficult to overcome and results in an apprehension with providing care in clinical settings when one feels their personal safety is at risk (Abraham et al., 2018). Subsequently, SNs report anxiety communicating to a person with mental illness when responsible for providing care. Fears include saying the wrong thing causing devastating results due to a lack of therapeutic skills to engaging in conversation and not knowing what type of responses they will receive from the patient (Mun, 2010; Abraham, 2018). SNs having cynical views of the recovery process also contributes to enforcement of mental health stigmas. Negative thoughts and perceptions on conditions that are persistent may decrease the value of care if a SN believes the patient will not recover (Knaak et al., 2017; Mårtensson et al., 2014). Knaak et al. (2017) reported a lack of insight to SN’s unconscious biases and the impact they have on the overall wellness of the patient. These fears and anxieties in SNs have residual effects after graduation as they report a lack of confidence providing care to individuals with mental illness. This discourages graduate nurses from working in departments specialized in mental health (Stevens et al., 2013; Thongpriwan et al., 2015). The image below represents the devastating cycle SNs experience in mental health practicums.
Stigma: Its Impact on the IWMHC
Stigmatization of IWMHC from healthcare professionals, including SNs, have profound negative impact on the overall health and wellness. Mental health resources are often sparse, and stigma causes IWMHC to avoid seeking help. Stigma is entrenched in the healthcare system and can be seen in many different avenues. Such avenues are: negative attitudes, adverse beliefs and a lack of skilled staff providing care. Patients who experience this feel dehumanized and devalued (Knaak et al., 2017). They report exclusion from decisions around treatment and feel that they are not provided adequate information about prognosis (Knaak et al., 2017). The results of stigmatization cause individuals to avoid or delay seeking for support which exacerbates both their physical and mental health symptoms. It can also lead to patients discontinuing their treatment, developing poor therapeutic relationships, causing patient safety concerns and delaying follow up on physical health concerns as they are often attributed to their mental health diagnosis (Knaak et al., 2017). These factors, stemming from stigma, jeopardize safe patient care and have negative impacts on the individual and their holistic wellness.
Philosophy and Guiding Principles
Strong guiding principles are required to develop learning and teaching strategies to decrease stigma around IWMHC. Pedagogy guides the development of educational curriculum by providing the facilitator conceptual frameworks to advance the learner’s knowledge. The theological underpinning guiding the framework of SN apprehension and stigmatizing thoughts and behaviours towards IWMHC can be guided through the progressive and humanistic theory of learning.
This progressive philosophy emphasizes a learner’s experiential and problem-solving approach to learning to gain practical knowledge while working through real life challenges (Melrose et al., 2015). The use of simulation-based education (SBE) exposes the learners to real life situations with the opportunity to apply critical thinking and practical knowledge to case scenarios to develop a plan of care without putting actual patients at risk (Coomes, 2019). Additional educational experiences allow the SN to gain clinical skills such as assessment, therapeutic relationships and communication skills to engage in care and to become informed of the impacts of healthcare stigma has on the patients. These experiences will help shape practical skill and knowledge on real-life problems. The relationship with the learner and facilitator is interactive.
The humanist approach supports learners through a self-directed holistic manner focusing on personal growth through independent study and internal motivation (Melrose et al., 2015). The use of case studies and individual and group reflection aligns with this philosophy. Students will have the opportunity to explore their own emotional response to the specialized education and learning opportunities while having the ability to determine how they will incorporate the learnings into their own practice. The facilitator will be present to support and provide the learners with information to allow for transformative learning.
Successful Learning Strategies to Decrease Stigma
To decrease stigma in SNs towards IWMHC, the philosophy of the progressive and humanist approaches must be applied to positively influence a student’s learning and guide an educator’s teaching strategy. The understanding of how adult learners learn needs to be considered by the educator to ensure SNs have the optimum opportunity to engage students learning activities. Learners want to be involved in engaging activities, higher order thinking, conversation, developing skills, unpacking their own values and attitudes around the learning process and material being covered which is completed through active learning (Palis & Quiros, 2014). Consideration around the different learning styles found in the VARK model allows for learners to participate in their ideal learning strategy, such as:
As an educator who facilitates education to adult learners, being mindful of specific learning styles promotes positive engagement with learners and the opportunity to gain the most from the learning session.
Teaching Strategies and Application
Historically, traditional classroom experience focused on knowledge gathering from the educator who was seen as the expert and transferred this knowledge to passive learners (Story et al., 2010). The following five teaching strategies (flipped classroom, simulation, case studies, reflective journaling and group reflection) moves away from this approach and allows learners and educators to build a partnership in knowledge transmission and engagement through critical dialogue, guiding and translating theory into practice, learner specific goals and education with the use of caring, comedy, creativity to strengthen and reinforce the learning process (Story et al., 2010). SNs require support in preparing for their mental health practicum such as theoretical, practical and emotional readiness to engage in nursing care (Ajani & Moez, 2011; Hatlevik, 2011). In the preparation stage, educators should take the time to address anticipated challenges and address SN concerns. The educators should also express well-defined learning objectives and expectations around clinical knowledge and competency. It is important for SNs to be aware of what their role is around certain patient behaviours. By clearly identifying certain tasks that the SN would not engage in, it will allow SNs to observe clinical staff completing tasks while safely gaining clinical knowledge. SNs must remember that they are part of the care team and do not have full responsibility of the patient’s care (Abraham et al., 2018). Additionally, SNs require ongoing practice support while navigating challenges in the practicum setting that they may be faced with throughout the clinical experience (Slemon, 2017). SNs require reassurance that the educator will be around to support them through any challenges faced and have an opportunity to debrief and situations which will increase the clinical experience and boosts their confidence and reduce their anxiety allowing for a more enriched learning environment and better patient care outcomes.
The following pedagogical tools focus on the SN’s behaviour and thoughts by equipping them with important clinical skills and knowledge on how to support individuals with mental illness through nursing competencies. These strategies will bring fears and misconceptions to the forefront, which will help guide the learning objectives and support for the SN (Slemon, 2017, Abraham et al., 2018, Binghyam & O’Brian 2018, Heim et al., 2019; Knaak et al., 2017). These strategies allow learners to engage with their peers in a safe learning environment to discover evidenced based practice through meaningful activities and engage in active learning to explore fears and anxiety around mental health clinical rotations. This will, in turn, decrease stigmatizing behaviours towards IWMHC.
1.0 Flipped Classroom. The flipped classroom teaching strategy requires the learners to complete certain learning activities prior to engaging in a scheduled learning session (McLaughlin et al., 2014). The flipped classroom approach enables educators to temporarily support students in their learning, but gradually remove support, also known as scaffolding. This process supports learning through activities which link theory to practice and promote critical reflection (Melrose et al., 2015).
Clinical suggestion. Educators should provide SNs with a list of resources and articles to read that would be applicable to the clinical site, such as policies and procedures, articles around stigma within healthcare, violence and aggression, assessment tools (mental status exam) and communication strategies. SNs should review these documents prior to the start of clinical and orientation to allow fruitful dialogue between students and educator to enhance the learning outcome and personal reflection.
Flipped Classroom Resources for Educators
2.0 Simulation. The use of mental health simulation-based education (SBE) would be an effective tool to engage students in preparation for the clinical rotation. SBE allows the learners to experience real life situations in a safe and controlled learning environment, with the opportunity to practice skills, think critically, reflect on the learning objectives and determine how they can transfer these skills into their workplace (Bogossian et al., 2019; Nystrom et al., 2017). Part of building psychological safety within simulation-based education is to have transparency between the facilitator and the learners. This includes highlighting expectations of SBE and how the learners will engage in the case scenario. This will help reduce anxiety and fears around the SBE process and increases engagement (Tyerman, 2016). By completing the flipped classroom approach first, it prepares the learners for the SBE by being aware of clinical resources and knowledge before engaging in the case scenario. This is important to help close knowledge gaps between actual knowledge and desired performance in SBE.
Clinical suggestion. SBE incorporates the use of case scenarios by having students and educator take turns role playing as a patient. As mentioned above communication is a strong source of anxiety for SNs as they are unsure how to engage in conversation, how to complete assessments, how to have difficult conversations around safety (such as suicidal ideations). By having students engage in these activities prior assessing a patient at the practicum site, it will allow the SN guidance in the approaches to use, how to engage in these conversation pieces and reduce the fear of the first-time approach covering the given material.It also bridges the takeaway learnings of SBE and how learners can apply it to future clinical situations. The final stage of SBE is the debriefing, which allows learners to express their personal experience through self/group reflection and to review what they physically engaged in and any emotional or mental experiences (Nystrom et al., 2017). SBE is an effective teaching method but does not replace a clinical rotation as students are not exposed to patients, staff and the clinical environment (Kameg, 2009).
Simulation Resources for Educators
- Live Person Simulation Scenario: Psychiatric and Mental Health Nursing
- Simulation Resource
- Skills Practice Home Visit
3.0 Case studies. Case studies allows students to learn, “from the process of working towards the understanding or resolution of a problem… promoting active learning” (Carleton University, 2020). This learning strategy provides a narrative format along with follow-up questions and activities to promote individual and group discussion while solving complex problems allowing for the opportunity to connect specific academic topics with real world issues and application (Bonney, 2015). This method of learning has been shown to increase student motivation and engagement by increase student performance and competency (Murray-Nseula, 2011).
Clinical suggestion. The development of mental health specific case studies can be used to help advance SN critical thinking, decision making and planning of care. Some common case study themes include ethical issues around patient certification, care planning around activities of daily living (personal care and hygiene), assessment of symptoms such as hallucination and PRN medication, and homicidal or suicidal ideations. Allowing students an opportunity to collaborate rationale for care planning and nursing actions will encourage teamwork and critical thinking around scenarios they may experience in their clinical setting allowing them the opportunity to be aware of potential interventions prior to being exposed to a real situation.
Case Studies Resources for Educators
4.0 Reflective Journaling. The pedagogical method of reflective journaling is used in nursing school to develop critical thinking skills, professional identity and growth, synthesized knowledge and advance self-awareness (Naber & Markley, 2017; Ganzer & Zauderer, 2013). In mental health practicums, reflective journaling allows students to unfold and discover their own biases and negative thoughts/emotions towards individuals with mental illness as they engage in clinical practice with their patients (Hwang et al., 2018). This process allows SNs to increase motivation and fully engage in providing care as they have the opportunity to recognize and understand the patient’s perspective and situation while gaining experience in the nursing competency and gaining personal growth and empowerment (Hwang et al., 2018; Langley & Brown, 2010). Journaling also allows instructors to provide feedback which in turn increases SN confidence in practice and is seen as encouraging (Kuo et al., 2011). Furthermore, it allows the instructor to assess the SN’s learning experiences, skills and knowledge competency (Kuo et al., 2011).
Clinical suggestion. Having students reflect and write down what their fears and anxiety are around the practicum, brings the concerns to the forefront and allows the educator to help tailor support and education to meet the student’s needs. Additionally, effective journals can focus on worst case scenarios that could occur during the rotation, focusing on reality and reducing stigmatizing thoughts that may occur. The use of reflection throughout the rotation will also allow SN to see self-growth, how competency has grown over the rotation and reflection on how they can continue to improve.
Journaling Resources for Educators
- Reflective Writing Example: Nursing
- A Guide to Nursing Students Written Reflection for Students and Educators
- Gibb’s Reflective Cycle
5.0 Group Reflection. Group reflection can be used to explore clinical practice through critical thinking and discussion, enhancing learning opportunities through challenging clinical practice and acquisition of new skills and knowledge (Bulman & Schutz, 2013). Bulman & Schutz, (2013) reports this form of reflection allows for increased problem-solving skills, improved patient care and for learners it is a less threatening exercise. Learners become less anxious around clinical skills that are unfamiliar, as learners share different experiences and collaborate in identifying the learnings from each situation (Bulman & Schutz, 2013).
Clinical suggestion. The use of group verbal reflection at the end of each clinical day will help SNs to see growth in their practice and share challenges with their colleagues and instructors to determine how they could improve in the future. Additionally, SNs are to be honest with their beliefs which will help uncover additional biases that may be present. The aid of the Gibbs Reflection Cycle can be used to prompt SN to explore their experience as observed in the figure below.
Optimizing the Gibbs reflection cycle, educators can prompt a SN about the beliefs or feelings they identify by asking, “Do your beliefs fit with a nurse or might it affect the healthcare of person with lived experience?” This allows the SN to use communication to understand their individual personal experience using the framework of interpreting and reflecting like a nurse.
Group Reflection Resources for Educators
Nursing School Challenges: Impeding SN Learning
Not only does fear and anxiety, which is entrenched in SN practice, lead to stigmatizing behaviours and thoughts which jeopardize the care of IWMHC; additional institutional factors boost discrepancies that increase barriers in the healthcare system. See image below for more details.
Nursing School Recommendations: Enhancing SN Learning
Incorporating the five previously outlined teaching strategies are effective ways to support SNs in mental health clinical practicums. Priority to allocate time and resources for mental health training is vital to decreasing stigma in mental health populations experienced in the healthcare setting. Staffing educators with knowledge and experience with mental health backgrounds are required to support SNs. Additionally, adjusting practicums earlier into the program will help address these challenges. Mental health rotations and education should be weaved into nursing curricula from the start of the nursing program. This will allow for SNs to have learning opportunities early in their studies, which will decrease stigma and fears of IWMHC. This early introduction will increase confidence and competency in the nursing practice when caring for IWMHC despite the ward they are treated on. Standards are required between colleges and universities to help build a solid foundation of knowledge for SNs in the field of mental health as IWMHC are not only located on psychiatric wards, but require ethical and supportive care no matter where they are experiencing assessment and care in the healthcare system.
Wrapping It Up
IWMHC face barriers in the healthcare system which impact their overall physical and mental health as well as their psychosocial wellbeing. Research shows SNs are a source of this stigmatisation and require education and support to overcome these biases. Abraham et al. (2018) reports that mental health clinical practicums help reduce SN stigma. Therefore, to help overcome stigma towards IWMHC, SNs must be supported and taught to provide ethical and compassionate care to IWMHC as they would care for non-mental health patients. The use of multi-modality teaching strategies and philosophical principles can positively guide nursing school curricula and future healthcare professionals away from promoting mental health stigmas in their practice and ensure SNs feel comfortable and competent taking on the care of IWMHC patients in the hospital system. The prevalence of Canadians experiencing a mental health challenge in any given year is 1 in 5 (The Centre for Addictions and Mental Health, 2020) and since nurses have a vital impact on the healthcare system, supporting SNs to reduce healthcare stigma towards IWMHC should be at the foreground of nursing school.
References
Abraham S., Cramer C., Palleschi H. (2018). Walking on eggshells: Addressing nursing students’ fear of the psychiatric clinical setting. Journal of Psychosocial Nursing and Mental Health Services, 56(9) 5-8. doi: 10.3928/02793695-20180322-01
Ajani, K., & Moez, S. (2011). Gap between knowledge and practice in nursing. Procedia Social and Behavioral Sciences, 15, 3927-3931. doi.org/10.1016/j.sbspro.2011.04.396
Bingham, H., & O’Brien, A. J. (2018). Educational intervention to decrease stigmatizing attitudes of undergraduate nurses towards people with mental illness. International Journal of Mental Health Nursing, 27(1), 311–319. https://doi.org/10.1111/inm.12322
Bogossian, F. E., Cant, R. P., Ballard, E. L., Cooper, S. J., Levett-Jones, T. L., McKenna, L. G., Ng, L. C., & Seaton, P. C. (2019). Locating “gold standard” evidence for simulation as a substitute for clinical practice in prelicensure health professional education: A systematic review. Journal of Clinical Nursing, 28, 3759-3775.
Bonney K. M. (2015). Case study teaching method improves student performance and perceptions of learning gains. Journal of microbiology & biology education, 16(1), 21–28. https://doi.org/10.1128/jmbe.v16i1.846
Bulman, C., & Schutz. (2013). Reflective practice in nursing fifth edition. Wiley-Blackwell. West Sussex, UK.
Canadian Nurses Association. (2017). Education. Retrieved 12 August 2017 from https://www.cna-aiic.ca/en/becoming-an-rn/education
Carleton University. (2020). Experiential Education. Retrieved from https://carleton.ca/experientialeducation/in-class-experiential-education/case-study/
Champlain Centre for Health Care Ethics. (2020). Case studies: Mental health. Retrieved from http://champlainethics.ca/case-studies-mental-health-2/
Centre for Addition and Mental Health. (2020). Mental illness and addiction: Facts and statistics. Retrieved from https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics
Coomes, G. (2019). Debriefing in simulation-based learning experiences: A concept analysis. The Midwest Quarterly, 60(3), 298-310.
Corrigan, P. W., Roe, D. & Tsnag, W. (2011). Challenging the stigma of mental illness: lessons or therapists and advocates. Oxford, England: Wiley-Blackwell.
Gamble, S. (2013). Live Person Simulation Scenario: Psychiatric and Mental Health Nursing. Retrieved from: http://www.apna.org/files/public/ac2013/1024-lintner-handout1.pdf
Ganzer, C.A., & Zauderer, C. (2013). Structured learning and self-reflection: Strategies to decrease anxiety in the psychiatric mental health clinical nursing experience. Nursing Education Perspectives, 34(4), 244-247.
Hatlevik, I.K.R. (2012). The theory-practice relationship: Reflective skills and theoretical knowledge as key factors in bridging the gap between theory and practice in initial nursing education. Journal of Advanced Nursing, 68(4), 868-877. doi:10.1111/j.1365-2648.2011.05789.x
Hwang, B., Choi, H., Kim, S., Kim, S., Ko, H., & Kim, J. (2018). Facilitating student learning with critical reflective journaling in psychiatric mental health nursing clinical education: A qualitative study. Nurse Education Today, 69, 159–164. doi. 10.1016/j.nedt.2018.07.015
Kameg, K., Mitchell, A. M., Clochesy, J., Howard, V. M., & Suresky, J. (2009). Communication and human patient simulation in psychiatric nursing. Issues in mental health nursing, 30(8), 503–508. doi.10.1080/01612840802601366
Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2), 111–116. https://doi.org/10.1177/0840470416679413
Karimollahi, M. (2012). An investigation of nursing students’ experiences in an Iranian psychiatric unit. Journal of Psychiatric and Mental Health Nursing, 19, 738-745. doi:10.1111/j.1365-2850.2011.01850.x
Kuo, C.L., Turton, M., Cheng, S.F., X & Lee-Hsieh, J. (2011). Using clinical caring journaling: nursing student and instructor experiences. Journal of Nursing Research19(2),141-149. doi:10.1097/JNR.0b013e31821aa1a7
Lindh, I.-B., Severinsson, E., & Berg, A. (2008). Exploring student nurses’ reflections on moral responsibility in practice. Reflective Practice, 9(4), 437-448.
Mårtensson, G., Jacobsson, J.W., & Engström, M. (2014). Mental health nursing staff’s attitudes towards mental illness: An analysis of related factors. Journal of Psychiatric and Mental Health Nursing, 21, 782-788. doi:10.1111/jpm.12145
Melincavage, S.M. (2011). Student nurses’ experiences of anxiety in the clinical setting. Nurse Education Today, 31, 785-789. doi:10.1016/j.nedt.2011.05.007
Melrose, S., Park, C. & Perry, B. (2015). Instructional immediacy: The heart of collaborating and learning in groups. In Teaching health professionals online: Frameworks and strategies. Athabasca, AB, Canada: AU Press.
Mind Tools. (2020). Gibbs’ reflective cycle. Retrieved from https://www.mindtools.com/pages/article/reflective-cycle.htm
Mun, M.S. (2010). An analysis of narratives to identify critical thinking contexts in psychiatric clinical practice. International Journal of Nursing Practice, 16, 75-80. doi:10.1111/j.1440-172X.2009.01803.x
Murray-Nseula M. (2011). Incorporating case studies into an undergraduate genetics course. Journal of the Scholarship of Teaching and Learning, 11(3),75–85.
Naber, J., & Markley, L. (2017). A guide to nursing students’ written reflections for students and educators. Nurse Education In Practice, 25, 1–4.doi.org/10.1016/j.nepr.2017.04.004
Nyström, S., Dalberg, J., Edelbring, S., Hult, H., Dahlgren, M.A. (2017). Continuing professional development: pedagogical practices of interprofessional simulation in health care. Studies in Continuing Education, 30(3), 303-319. doi.org/10.1080/0158037X.2017.1333981
Palis, A. G., & Quiros, P.A. (2014). Adult learning principles and presentation pearls. Middle East African Journal Ophthalmology, 12(2), 114-122. doi: 10.4103/0974-9233.12974
Registered Nurses’ Association of Ontario. (2017). Reflective practice teaching activities and resources. Retrieved from https://mharesource.rnao.ca/section-four/reflective-practice-teaching-activities-and-resources
Registered Nurses’ Association of Ontario. (2017). Simulation resource. Retrieved from https://mharesource.rnao.ca/section-seven/simulations-resources
Ryerson University. (2015). Skills Practice Home Visit. Retrieved from https://de.ryerson.ca/games/nursing/mental-health/game.html#/
Sabella D, Fay-Hillier, T. (2014). Challenges in mental health nursing: current opinion. Nursing: Research and Reviews,4, 1-6. https://doi.org/10.2147/NRR.S40776
Slemon, A. (2017). Nursing students’ experiences in mental health practicums: A narrative Inquiry. Retrieved from https://open.library.ubc.ca/cIRcle/collections/ubctheses/24/items/1.0354477
Stevens, J., Browne, G., & Graham, I. (2013). Career in mental health still an unlikely career choice for nursing graduates: A replicated longitudinal study. International Journal of Mental Health Nursing, 22, 213-230. doi:10.1111/j.1447-0349.2012.00860.x
Story, L., Butts, J.B., Bishop, S.B., Green, L., Johnson, K., & Mattison, H. (2010). Innovative strategies for nursing education program evaluation. Journal of Nursing Education, 49(6), 351-354. doi.10.3928/01484834-20100217-07
Timmins, F., Corroon, A.M., Byrne, G., & Mooney, B. (2011). The challenge of contemporary nurse education programmes. Perceived stressors of nursing students: Mental health and related lifestyle issues. Journal of Psychiatric and Mental Health Nursing, 18, 758-766. doi:10.1111/j.1365-2850.2011.01780.x
Thongpriwan, V., Leuck, S.E., Powell, R.L., Young, S., Schuler, S.G., & Hughes, R.G. (2015). Undergraduate nursing students’ attitudes toward mental health nursing. Nurse Education Today, 35, 948-953. doi:10.1016/j.nedt.2015.03.011
Tyerman, J., Luctkar-Flude, M., Graham, L., Coffey, S., & Olsen-Lynch, E. (2016). Pre-simulation preparation and briefing practices for healthcare professionals and students: a systematic review protocol. JBI database of systematic reviews and implementation reports, 14(8), 80–89. doi.10.11124/JBISRIR-2016-003055
The University of Edinburgh. (2020). Gibb’s reflective cycle. Retrieved from https://www.ed.ac.uk/reflection/reflectors-toolkit/reflecting-on-experience/gibbs-reflective-cycle
The University of Edinburgh. (2020). Reflection toolkit. Retrieved from https://www.ed.ac.uk/reflection/reflectors-toolkit/all-tools
University of South Australia. (2017). Reflective writing example: Nursing. Retrieved from https://lo.unisa.edu.au/pluginfile.php/1687716/mod_resource/content/0/Reflective%20tasks%20example_nursing_Sept_%202017.pdf
Watts, J. (2005). Case study: Mental health case series. Retrieved from https://www.thebodypro.com/article/teens-st-ds-often-not-treated-properly-er
Zeller. S. (2015). Understanding Agitation: De-escalation. Retrieved from https://www.youtube.com/watch?v=6B9Kqg6jFeI
Colleen (Widdis) Borralho 