The International Journal of Psychosocial Rehabilitation
 
 
Teaching CBT to Pre-Registration nurses:
A critical account of a teaching session to pre-registration mental health nurses
 on the subject of cognitive behavioural therapy and trauma

 James Binnie
Lecturer in Counselling Psychology
Senior Cognitive Behavioural Psychotherapist
BABCP accredited therapist, supervisor and trainer
NMC registered Mental Health Nurse
Senior Fellow of the Higher Education Academy

 
Department of Psychology
London South Bank University,
103 Borough Road, London, SE1 0AA
Email: jamesbinnie@lsbu.ac.uk 




Citation:
Binnie J. (2018)   Teaching CBT to Pre-Registration nurses: A critical accountof a teaching session
to pre-registration mental health nurses on the subject of cognitive behavioural therapy and trauma.
 International Journal of Psychosocial Rehabilitation. Vol 22 (1)  55-64


Abstract
Purpose: The role of the mental health nurse is changing. Expectations of what nurses can and should be practising are increasing. Mental health nurses are often involved in delivering cognitive behavioural therapy (CBT). Usually these skills are taught after qualification. However, given the changing climate it is proposed that these skills are taught pre-registration.
Approach: This paper reflects on a teaching session given to a group of pre-registration mental health nurses on the subject of CBT and trauma. The planning, delivery and evaluation of the session is described and recommendations are made.
Findings: It is put forward that this paper demonstrates an overview of effective teaching based on sound pedagogical theory.
Value: It is hoped that the reader will reflect on the wide scope for pre-registration training; in particular the role of CBT. The reader may also find the paper useful when considering their own teaching practice.

Keywords: Pedagogic practice,


Introduction:
The Chief Nursing Officer’s review of mental health nursing recommended that mental health nurses should work holistically, encompassing psychological needs; nurses needed to widen their skills in evidence based psychological therapies (Department of Health, 2006a). Furthermore, in a related document, it was suggested that a working knowledge of psychotherapy, in particular Cognitive Behavioural Therapy (CBT), is seen as one of the core competencies essential for mental health nurses at the point of registration (Department of Health, 2006b).

This paper will examine, evaluate and reflect upon a CBT teaching session delivered by the author, to pre-registration mental health nurses as part of their professional training at a London university (not the author’s current university). To facilitate this process the scientific methodology of the Plan-Do-Study-Act framework (Shewhart, 1939; Edwards Deming, 1986) is utilised to assist in the reflective structure of the assignment.



The main focus of the assignment is on how the teaching was planned as this can be seen as the vital component of any endeavour; to quote Winston Churchill: "He who fails to plan is planning to fail".

Plan
The pre-registration mental health nursing course curriculum was inspected in order to understand the competencies the students would have prior to their final year elective module on CBT. With this in mind the CBT module was examined, the aims of the module were to review the principles, methods and evidence base of CBT and to reflect on the applicability to mental health nursing practice. The learning outcomes were for the students by the end of the module to be able to discuss the principles underpinning CBT; to discuss the applicability of CBT to standard mental health nursing practice; and to be able to critically appraise CBT related literature. To achieve the aims and learning outcomes the module was offered over six weekly teaching sessions, each lasting four hours. The assessment of the module was through attendance and a written assignment on the integration of CBT into clinical practice. Through discussions with the module leader it was decided, due to clinical expertise, for the author to focus on CBT for trauma.

Before developing a teaching plan the needs and abilities of the learners was considered; this was done as teaching plans should match the developmental level of the learners (Hussey and Hirsch, 1983). As pre-registration students they would not have had much knowledge or experience of psychotherapy. In addition, they would not be expected to undertake formal therapy with service users at the end of their nursing training. This factor was made clear to the students by the module leader when they enrolled on the CBT module.

According to Bastable (2008) a complete teaching plan consists of eight basic parts: the purpose; the overall goal; objectives; an outline of the content; the instructional methods used; the time allotted for each objective; the resources needed; and the methods used to evaluate learning. Of these elements it has been put forward that the most important in the education process are the goals and objectives (Haggard, 1989; Mager, 1997).

Based on the aims of the module three goals were set: 1) to develop a critical knowledge of the theoretical and research literature relating to trauma; 2) develop an introductory knowledge and understanding of cognitive behavioural assessment, conceptualisation and treatment of trauma; 3) develop select skills in working with people who suffer from trauma. The first two goals were considered appropriate as they focused on knowledge acquisition. The third goal was included to help students incorporate new skills into their clinical practice; to increase the session’s applicability.

The objectives/learning outcomes of the teaching session were again based on the overall module’s learning outcomes. They were constructed inline with Mager (1997), who put forward that objectives should indicate the performance expected from the learner; the results of the learning rather than the process. Also influential were Jarvis’ (1983) domains of learning; basing the learning objectives on knowledge, skill and attitude. It was therefore intended that by the end of the session the students would be able to demonstrate their ability to explain what trauma is from a CBT perspective (knowledge/skills); acquire an understanding of the CBT process and applications when working with trauma (knowledge/attitude); and to be observed in delivering set, transdiagnostic, interventions (skill).

With the purpose, goals and learning objectives set it was then possible to design what was going to be taught. An outline of the teaching for the day was designed on PowerPoint in accordance with the learning objectives. The focus would be on trauma focused CBT and also the seminal work by Herman (1992). The planned presentation can be requested from the author.  

The instructional methods to be used throughout the morning and afternoon sessions were mixed and dependant on the topic being taught. It was planned that the majority of the day would be spent didactically explaining concepts and skills to the students; however a Socratic element would be interwoven that would hopefully enable the students to think independently. In addition, there would also be demonstration of skills and collaborative small group exercises. The students were to be told that the teaching session would be relaxed and that they could ask questions whenever they liked.  

The timing of the session was to be semi-structured. The PowerPoint presentation was to be used as a guide for timing purposes. However it was acknowledged that the focus of the session would flow based upon the student’s needs. The resources needed for the session are presented within appendix 1.

The session would be evaluated via three methods: direct observation, verbal feedback and an evaluation form. The student’s participation would be subjectively recorded by the author throughout the session; in particular during the exercises. At the end of the session students would be asked for feedback and to complete an evaluation form. The evaluation form was based on the work by Charleston and Goodwin (2004). These methods of evaluation were used to give a combination of qualitative and quantitative data.
The overall teaching plan can be found in appendix 1. From reviewing the plan it could be said to be appropriate to the needs of the students, it appears to fit together and to flow logically. Therefore the teaching plan has internal consistency (Bastable, 2008).

In essence the teaching session planned to adopt a ‘deep approach’ (Biggs and Tang, 2007). There would be an emphasis on the knowledge base and getting the students involved in the learning. As it could be assumed that the students were already motivated (the module was elective) strategies were not needed to ‘sell’ the teaching session. However, effort would be needed to be make sure that the students were more than mere spectators and adopting a ‘surface approach’ (Biggs and Tang, 2007). To include the students in the session the author planned to rely on his own CBT skills. This approach was highlighted by Padesky (1996), who explored the parallels between teaching patients to use CBT skills and teaching students to teach patients CBT skills.

Do
On the day of the teaching session the author arrived early and set up the room accordingly. All resources that were needed were available on the day. Time was spent ensuring that the room was fit for purpose; that the chairs were lined up and spaced apart to make the room seem more relaxed; that the air conditioning was on but not too loud. This attention for detail was considered important as the teaching environment is an integral part of the teaching process (Mackway-Jones and Walker, 1999).

It was expected that eight students would arrive. Six arrived on time and two were fifteen minutes late. All students appeared to be under the age of twenty five; five were female; four were from ethnic minorities.

The session started with introductions and the aims of the session. Some brief ground rules were then discussed. Namely, that the students would not be expected to implement trauma focused CBT after the session. Also, that there would be no role plays and that if any student was upset by the content of the session then they could discuss their concerns with the author afterwards. The need to practice safely was promoted. This is in line with the Nursing and Midwifery Council (NMC) Standards for Education that highlights an emphasis on student safety when engaging in learning experiences (NMC, 2010). The students were then asked to recount their experiences of working with people with a diagnosis of PTSD. Initially the students had some difficulty in thinking about cases they had worked with. However to aid their reflections the author expanded the question to include any patients that had suffered with trauma. This approach helped and some students gave good accounts. The author then widened the question again and asked the students if they had worked with patients who had a history of childhood abuse. This allowed all the students to think of examples and generated a discussion. It was important to focus on this as it included the students in the session from the outset. This approach follows an andragogical model to education (Knowles, 1970); in that the learners must know why something is important before they will learn it; learners need to be convinced of their need to learn and to be able to apply their knowledge to their life experiences (Knowles et al., 2005). From the outset the students were encouraged to think about the clinical applications of the days teaching. This approach was used throughout the day; examples were used that the students could relate to.

After the introductions the PowerPoint presentation was loosely followed. Student participation was encouraged and as the session progressed the students felt more relaxed and able to ask questions. The majority of the session seemed to be a group discussion rather than a lecture. Three exercises had been planned: explaining PTSD; grounding/safe place; and fear hierarchies. The first two went as planned but it was decided to teach the third rather than facilitate as a small group exercise; this decision was made due to time constraints. The student’s engagement in the exercises was good as was their overall level of engagement throughout the day. However it was noted that some students contributed more than others and that the quality of the questions asked differed between students. The ability and motivation in the class varied between students; according to Biggs and Tang, (2007) the range is likely to increase and become more of an issue as universities become more business focused.

Study
As the teaching session took an outcome based approach (Biggs and Tang, 2007), several evaluative methods were designed: student participation; verbal feedback; and an evaluation form.  

The student participation throughout the session was good; all students did ask questions and seemed to be attending. Some students engaged more than others; unsurprisingly the students in the front row engaged better. The first activity (explaining PTSD) was undertaken towards the end of the morning session. Initially there was some reluctance on behalf of some of the students; by this point in the session everyone seemed tired. The purpose of the exercise was to see if the morning session met its aims; if it had worked. Overall, the students gave good accounts of what trauma is. One pair had difficulty so the author went over to listen and advise. One student, although able to explain what PTSD is, said “who am I (young girl) to ‘tell’ someone what they are experiencing”. This comment was explored; her reluctance was understandable, however as a potential mental health nurse she would be expected to discuss (not tell) difficult and emotional concepts with patients. The second activity (grounding techniques and ‘safe place’ exercise) was again met with some initial reluctance; however again the timing could have been an issue (relaxation exercises not long after lunch). The students once motivated for the exercise engaged in it well and seemed to enjoy the learning process.

At the end of the session the students were asked to state three aspects from the day that they could take back into clinical practice. The students reported that the aspects they found most useful were firstly the theoretical elements of the theory, how in the CBT for PTSD formulation the memory is the event, and also the neurological processes related to PTSD. They also reported that skills such as psycho education on PTSD and grounding skills were aspects they could take back into practice.

The evaluation form was completed by seven out of the eight students (one student had to leave ten minutes before the end of the session). The raw data, mean scores and additional comments can be found in appendix 2. From the mean scores it can be claimed that the teaching session was received well by the students; all items on the evaluation form scored over eight out of ten. From examining the answers to the additional questions it can be put forward that the students believed that attendance at the session allowed them to recognise PTSD, gain knowledge, use relaxation techniques and apply basic principles. They recorded that they found the focus on neurology, the use of case examples and the exercises the most useful aspects of the session. Finally in terms of improving the session the students reported they would have liked more case examples.  

Overall, from reflecting on the teaching session and the feedback it could be said that the session flowed; it was paced well and the students all contributed. The author created an informal group atmosphere; facilitated authentic debate; had a personal interest in the subject matter; and prepared well. The students also invested in the session and showed confidence. These teacher and learner elements are, according to Anderson (2005), features that promote active participation and learning. It could be put forward that this was achieved through the author using his CBT skills; the ability to set agendas, time sessions and to be collaborative. The students were able to learn effectively as they were given freedom to be active and make decisions at the same time as having a clear and organised environment for learning; these aspects help learners learn (Biggs and Tang, 2007).

In terms of purpose, goals and learning outcomes the teaching session demonstrated that all were achieved. The students did acquire specific knowledge; they also demonstrated new skills and reflected on the applicability to mental health nursing practice. The teaching session fitted well into the overall curriculum.

Act
From examining the teaching session it can be put forward that it was successful in many ways. However, like any task it could have been improved.

The timing of the exercises was not ideal; the first exercise was too late in the morning and the students were initially resistant to engage in it. In addition, the afternoon session could have started with more of an active exercise rather than relaxation. In future teaching sessions exercises will be conducted in line with the physiological needs of the students.

Other methods of teaching could have been used. This could have involved sending reading material to the students beforehand. This was attempted in the teaching session being explored; however time constraints meant that the students did not get a copy of a paper (Elhers and Clark, 2000) until after the session. E learning could also have been an option; the students could have been asked to perform activities prior to the teaching session.

In terms of the content of the session there was not enough reference to the evidence base surrounding CBT for PTSD; for example the NICE guidelines for PTSD (NICE, 2005). This may have helped ‘sell’ the applicability to the students. In addition, it may have been wise to focus on the students existing strengths; anatomy for example. The references to neuroscience were well received; perhaps this could have been expanded upon.  

In regards to the practical teaching of skills it may have been more effective to base the teaching on an accepted methodology such as the four stage technique by Mackway-Jones and Walker (1999).

Although the teaching session was focused on CBT and PTSD it may have been fruitful to have also focused on career pathways. Goldberg (2000) puts forward that the arrival of nurse therapists has been one of the most important advances in mental health nursing; changing the role from supportive custodian to deliverer of effective interventions. By focusing on this aspect the students may have been inspired and this may have increased their motivation to learn during the teaching session.

From critiquing the teaching session it can be suggested that there could have been improvements made in the process, methodology and content. In future teaching sessions it is intended that E learning would be utilised more effectively, this would free up time as there would be less emphasis on theory during the teaching session; thus allowing a greater degree of experiential learning. In addition, rather than following a detailed teaching plan the students would be more involved; they would be asked what they wanted or needed to learn, the session would then be based on their requirements.  

Conclusion
This assignment has analysed a teaching session delivered by the author. The entire process has been critically discussed and recommendations for future teaching practice explored. Overall, the teaching session examined was effective. However, what will be learnt from this process is to make future teaching sessions more student led; to fully engage students in the learning and to design the teaching around their needs. This approach was only partly successful during the examined teaching session due to uncertainties about what may be asked for and the applicability to the CBT module.

As a cognitive behavioural psychotherapist the author has developed skills in teaching patients how to help themselves. These skills should not be minimised; they are generic skills that also allow effective teaching outside of the therapy room. What has been learnt from this process is to trust these skills and move away from a highly structured environment into one which is more student led and individualised.


Funding -None

Conflict of interest: None.


References
Anderson, C. (2005). Enabling and Shaping Understanding Through Tutorials. In: Marton, F., Hounsell, D. and Entwistle, N., (eds.) The Experience of Learning: Implications for teaching and studying in higher education. 3rd (Internet) edition. Edinburgh: University of Edinburgh, Centre for Teaching, Learning and Assessment.

Bastable, S.B. (2008). Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. 3rd Edition. London: Jones and Barlett

Biggs, J.B. and Tang, C. (2007). Teaching for quality learning at university. Maidenhead: Open University Press/Mc Graw-Hill Education.

Charleston, R. and Goodwin, V. (2004). Effective collaboration enhances rural preceptorship training. International Journal of Mental Health Nursing. 13, 225–231

Department of Health (2006a) From values to action: Chief Nursing Officer’s Review of Mental Health Nursing. DH, London.

Department of Health (2006b). Best practice competencies and capabilities for pre-registration mental health nurses in England: The Chief Nursing Officer’s review of mental health nursing. DH, London.

Elhers, A. and Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy. 38: 319-345.

Edwards Deming, W. (1986). Out of the Crisis. MIT Center for Advanced Engineering Study.

Goldberg, D. (2000). in Newell, R. and Gournay, K. (Eds). Mental Health Nursing: an evidence based approach. London: Churchill Livingstone. 

Haggard, A. (1989). Handbook of patient education. Rockville, MD: Aspen.

Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.

Hussey, C.G and Hirsch, A.M. (1983). Health education for children. Topics in Clinical Nursing. 5(1): 22-8.

Jarvis, P. (1983). Adult and continuing education: Theory and practice. London: Croom Helm.

Knowles, M.S. (1970). The modern practice of adult education: Andragogy versus pedagogy. New York: Associated Press.

Knowles, M.S., Holton III, E.F. and Swanson, R.A. (2005). The adult learner: The definitive classic in adult education and human resource development. 6th ed. Burlington: Elsevier.

Mackway-Jones, K. Walker, M. (1999) (eds). Pocket guide to teaching for medical instructors. London: BMJ Books.

Mager, R.F. (1997). Preparing Instructional Objectives. 3rd Edition. Atlanta: CEP Press.

NICE, (2005). Post-Traumatic Stress Disorder (PTSD): The Management of PTSD in Adults and Children in Primary and Secondary Care. Developed by the National Collaborating Centre for Mental Health

Nursing and Midwifery Council, (2010). Standards for pre-registration nursing education.www.nmc-uk.org

Padesky, C.A. (1996) Developing cognitive therapist competency: teaching and supervision models. In P.M. Salkovskis (Ed.), Frontiers of Cognitive Therapy. London: Guilford Press.

Shewhart, W.A. (1939). Statistical Method from the Viewpoint of Quality Control. New York: Dover.







Copyright 2018 ADG, SA. All Rights Reserved.  
A Private Non-Profit Agency for the good of all, 
published in the UK & Honduras