Teaching CBT to Pre-Registration
A critical account of a teaching session to pre-registration mental
on the subject of cognitive behavioural therapy and trauma
Senior Cognitive Behavioural
therapist, supervisor and trainer
Mental Health Nurse
Senior Fellow of the Higher Education Academy
London South Bank
103 Borough Road, London, SE1 0AA
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
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
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.
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
Keywords: Pedagogic practice,
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,
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.
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".
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.
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.
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,
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.
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
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.
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.
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).
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.
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.
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.
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.
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.
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.
examining the teaching session it can be put forward that it was
successful in many ways. However, like any task it could have been
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.
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
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.
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