Researching Nursing Students ' Engagement : Successful Findings for Nursing Publication History :

A nursing student’s level of engagement is extremely important for their sense of learning and assimilation, and their ongoing successful progression within the nursing profession. Students that are engaged, maintaining satisfactory levels of engagement throughout their courses and into their careers, may more likely remain within the nursing profession. How can we successfully keep students motivated and committed within tough curriculum, challenging opportunities, and the limitations of the depth and length of their formal nursing studies? This study evaluated the second level (of four) nursing students’ sense of engagement in both their current classroom and clinical settings. The findings highlight the need to provide a diverse range of stimulating learning opportunities. The need for insightful and supportive teachers and preceptors is critical for positive student attitude development and progression. Key qualitative aspects of engagement include teamwork, creativity, collaboration, intuition, commitment, active participation, attentiveness, and integrative thinking. These equally important aspects of engagement need to be present within learning to ensure maintenance of positive environments. Researching Nursing Students' Engagement: Successful Findings for Nursing Publication History: Received: October 06, 2015 Accepted: October 28, 2015 Published: October 30, 2015


Background
Engagement is an important aspect of quality nursing behaviors. Engagement is a meta-construct with three components, a) behavioral engagement, b) emotional engagement, and c) cognitive engagement [1]. These three aspects have numerous vital components [2], including: attentiveness, active participation, commitment, intuition, collaboration, teamwork, creativity, and integrative thinking ( Figure 1).
Students historically tend to be preoccupied by 'doing' as a nurse, rather than truly understanding 'how patients experience care' [3]. This important aspect of caring may be easier to educate students about if they are more engaged in their learning activities.
As students advance through their education, their personal values and ethical standards are refined and molded. The engaged student develops these personality traits within the complex roles they are undertaking [4]. Consistency with instructions and reliable nursing educators can engage students and assist them to form strong values and standards which can be assistive during difficult situations.
A high level of engagement is necessary for heightened levels of caring, understanding, and problem solving. Levels of engagement may have effectiveness limits. The favored approach of 'attached engagement' could ultimately be geared toward a more balanced 'analytical approach' when completing 'caring work' so as to not disengage when extreme overstimulation occurs [5]. These in-depth aspects of engagement still need to be explored.

Student Nurse Classroom Engagement
To entice engagement and higher levels of learning, nurse educators are exploring newer methods of teaching. These methods include group work and group projects, integration of core content adding additional content each semester, and active exercises and techniques to maintain interest. Nursing educators can create this opportunity by providing diverse settings and activities for creative learning. A strong sense of active learning is preferred by today's students [6]. Students' perspectives to incorporate engagement within their activities require they have a vested interest in the topic and they can see their responsibilities within each situation [7].
One form of active learning is using narrative approaches (personal narratives discussed alongside fellow student narratives) which provide insights into the different ways students learn [8]. This activity challenges traditional learning styles while sensitizing the students toward other ways of learning and understanding. This activity can promote various critical perspectives and tolerance for others' beliefs, which provides larger engagement levels with others outside of one's usual framework.
Student learning within groups can provide an engaging learning environment. The groups can be formed as 'teams' within either the classroom of clinical settings. Team-based learning also provides the opportunity for critical teamwork skill practice and fine-tuning of experiences. Currey et al. [9] found higher levels of student engagement with team-based learning via: a) increased satisfaction with the team experience over the individual experience, b) an increased quality of learning versus individual learning, and c) increased critical reasoning skills and professional development versus individual learning. Additionally, team-based learning is facilitated by four distinct attributes: engagement, learning effectiveness, critical thinking, and motivation to participate [10]. The greater opportunity to learn within a team meets today's practice environment needs, and can improve the quality and safety within clinical practice.
Problem-based learning can be interesting and assist student learning with focused problem solving strategies [11]. When problembased learning is not done well, problem-based learning can create disengagement problems for students [12]. As students progress, the content and level of learning need to be at an appropriate level (challenging, not too easy or difficult), both are important to maintain students' ongoing interest and motivation.
Skills labs can also be stimulating and/or create disenchantmentor disengagement [5,13]. The level of educators' direction and supportive guidance can be critical for effective skills lab learning to occur. This 'line of support' is difficult for some educators to determine and maintain during the progression of a course.
Student activities with peer assessment are opportunities for students to develop critiquing and critical thinking skills [14]. The component of peer assessment is a skill becoming more important for current practice and can provide constructive and healthy feedback. However, it can also be 'belittling' and devastating. To avoid this negative response, students need a sense of belonging and engagement 'with' their fellow students. Practicing constructive feedback and positive peer support are extremely important for future nurses to develop.
Students can be provided with different forms of performance testing, this includes individual and group work, quizzes, clicker response technology activities, clinical evaluations based on preceptor feedback, and anecdotal instructor notes from observations or discussions. This feedback also includes structured tests and return demonstration competencies. Students should be able to develop from this feedback into more complete and competent nurses.

Student Nurse Clinical Engagement
The clinical environment has a diverse range of patients and situations which can provide excellent experiential learning. When learning occurs, the best results involve a positive response from the care providers/preceptors, despite the clinical situation which can have negative or positive outcomes. Student preceptors need the support and development of skills from both the clinical and academic setting to provide a higher level of student development [15]. The quality of the interactions between academics and clinical preceptors are important for the success of students. Students should feel supported and comfortable discussing issues with both sources of their learning.
Students desire a personalize relationship with their clinical instructor [16]. Today's students want to have individualized and innovative opportunities within their clinical learning settings, however this is not necessarily safe or effective for ill patients within a busy clinical setting. Some alternative options can include care provision within manikin simulations, additionally via thorough debriefing after clinical activities, and, quality preceptors discussing options for patients during actual care delivery. These activities allow students to reflect and learn about providing care options for patients. This evolution within their decision making becomes well supported decisions when they become responsible for the specifics of their care delivery.
One strong deterrent of engagement in clinical settings is the occurrence of student bullying by other care workers. Bully requires responses that are effective, stop the events from happening, and maintain everyone's sense of integrity. Teaching students effective bullying response strategies and encouraging safe disclosure to clinical and educational leaders can and should be highlighted throughout the learning experience [17].
'Best evidence' decision-making is a necessary priority for students as they are learning. This can be done as an activity during debriefing. Full discussion of evidence, strengths and weaknesses, applicability to the current patient, and patients' perspectives, are all incorporated within the students thought processes as discussions evolve. Providing best evidence practice is motivating and can increase students' sense of engagement.
Students today are required to participate with others as they are learning their clinical practice. This is an effort to create more cross-collaboration and comfort within the decision-making within the clinical setting [18]. A curriculum that occasionally involves discussions with former patients in the educational process help facilitate student understanding and personalization of the patients' experiences [19].
Another learning strategy is the use of clinical mentor engagement [20]. Clinical mentors are used to engage and teach students (students which are embedded in the clinical environment with numerous support systems). Skills in compassion, cultural sensitivity, and advocacy are stressed, along with patient and family satisfaction. The clinical mentors function within clinical learning teams, which provides for an increased sense of engagement with the work environment. This style of teaching students is novel and not well established in general practice. This research investigates student nurses' sense of engagement early on in their development (students in the second semester of a four semester baccalaureate program). The purpose of this research is to identify the extent of the nursing students' sense of nursing engagement during their baccalaureate nursing program. The overall goal of creating and maintaining student engagement is important for their future work as nurses, providers and coordinators of health care for everyone within the population.

Study Methods
The study involved a second level undergraduate psychiatric mental health nursing course. This study utilized a mixed methods approach, including both post-intervention Likert scale quantitative questionnaire and 4 brief open-ended qualitative questions. The tool used, Student Engagement Questionnaire [21,22], seeks to assess the level of student engagement within their formal studies. The study was reviewed and accepted by the university's institutional review board, Dean of the School of Nursing, and our satellite school's local campus director of the nursing program.
The specific areas to be assessed included students' perception of their critical thinking, creative thinking, self-management, adaptability, problem solving, communication, interpersonal and

Hybrid course feedback
This undergraduate mental health course, a hybrid course design (a blend of face-to-face classroom engagement along with on-line learning management) was rated with a mean of 3.6 in assisting the students to understanding the course content. The course used a variety of assessment methods (mean 3.7). The results demonstrated the understanding of key concepts of the program (mean 3.9). Feedback on assignments (mean 3.7) and explanations for difficult learning materials (mean 3.8) were slightly lower than many other responses to other feedback questions.

Mental health course scores
The sense that the courses fit together was identified as well integrated (Mean 4.1), this provided a framework to form a coherent study for my major was positive at mean of 4.1. The students' response to the question of the university setting improving my sense of adaptability (Mean 4.2), and have become more willing to change my views and accept new ideas (mean 4.1) were also high. Students' reported becoming more confident in pursuing further learning (4.0).

Overall nursing program feedback
Many of the students felt unduly stressed when completing the overall nursing program (mean of 2.8). In response to 'The workload was considered reasonable, ' the students rated this question with a mean of 3.4.
In response to the question of: What are the best aspects of the program?
"The course helped us understand mental health and how to treat patients. " "The vigorous program prepares us for the real world of nursing and prepares us for different areas of nursing. " Highlighted as best aspects of the course were stated as, "structured environment, well thought out and planned to mesh together; combination of inclass/out-of-class learning, lecture recordings, class discussions, great resources for learning, variety of areas and ages during clinicals, good clinical experiences. " "The course incorporated class content and clinicals to learn how to apply the content. " One point made by a student was that, "the ability to communicate effectively was taught. " In relation to the style of being a blended class, one student noted, "that it was partially on line which allowed me to get more of the reading and concepts down to study for exams; when assignments are returned, feedback is helpful. " Other quotes include: "small class sizes with good student teacher ratio", and "small class size gives us more one-on-one time between student and teacher. " Multiple responses reported "teachers are helpful, willing to help whenever needed and with areas struggling in, face-to-face was more beneficial to me, cared a lot about our success in the program. " They reported, "teachers were knowledgeable, positive relationship between teachers and students: teachers care and listen, teachers were available for us to ask questions or concerns; encouraged to express my feelings and thoughts. " A student reported the teacher, "did a wonderful job of not being judgmental and had extreme patience with all of us, always available and made any confusion disappear. " In response to the question of: What aspects are most in need of improvement?
Testing was a prominent issue for students. They stated, "test match to class content; more help and explanation to judgment questions; things that can be done to improve test scores; how to decipher a test group work skills, active learning, teaching for understanding, feedback to assist learning, assessment, relationship with teachers and students, workload, cooperative learning, and coherence of curriculum. A content analysis was completed to portray common themes.
Participation in the study was offered to all second level nursing students enrolled in the Mental Health course during the fall 2014 and spring 2015 semesters. They were provided with an explanation of the study's purpose and requested to complete the 1 page (front and back) feedback tool, voluntarily and autonomously. The post-intervention feedback forms were completed at the end of each semester (22 students each semester), after experiencing the mental health course. A total of 44 students were in the course over the two semesters, and all agreed to participate.

Results
Data from the Student Engagement Questionnaire were compiled, with scores of (5) representing strongly agrees, (4) agree, (3) only to be used if a definitive answer is not possible, (2) disagree, and a (1) if the student's response was to strongly disagree. Questionnaire findings:

Self-managed learning
In relation to self-managed learning, students reported a very high average (mean 4.5) of taking responsibility for own learning. Reported self-improvement due to the ability to use knowledge to solve problems scored high, a mean 4.2. They reported the ability to bring information and different ideas together to solve problems also rated highly at a mean of 4.3. Good analytical skills were thought to be required to do well in their class assessments (mean 4.2).
In relation to critical thinking, almost all agree that this course assisted them to develop considering different points of view (mean 4.3), and increased their willingness to consider alternative perspectives (mean 4.1). A mean score of 4.3 was rated for creative thinking in response to encouragement to use their own initiative. The challenge to come up with new ideas rated with a mean 3.9.

Relationship with other students
Students felt a strong sense of belonging to their course group (mean 3.5), and frequently worked with others in classes (mean 3.4). The issue of cooperative learning was expressed as "frequently discussing ideas for this course with others outside of the class resulted with a mean of 3.9. They found discussing course material with others outside of the class helped their learning course material (mean 3.8).

Teaching staff
The relationship between teaching staff and students is very good at 4.3. Almost all of the students agree or strongly agree that they have developed the ability to communication effectively with others (mean 4.2); and confident in dealing with a wide range of people (mean 4.3); additionally almost all felt they had an opportunity to participate in classes (mean 4.2). With a majority (mean 4.0) responding they felt they had become an effective team or group member. The majority reported highly (mean 4.0) that they felt they improved their ability to convey their ideas. Teaching staff used a variety of teaching methods (mean 3.8), and were identified as being helpful when asked questions (mean 4.1). They also were identified as trying hard to assist with understanding the course material (mean 4.1). IJNCP students scored lower on questions related to their interactions with other students and this is an area to be focused on in future endeavors. Student interaction with positive team building activities such as small group activities centered on learning and interacting, team and trust building exercises, and improving psychomotor and cognitive skills should be maintained.
Their relationship with teaching staff was extremely high. This should be shifted to focus on 'their peer teams' to develop interpersonal leadership and confidence with their peers. The majority of students felt they had an opportunity to participate in activities, and the activities could be shifted more intensely to focus on more sophisticated teamwork.
The evaluation of the course, designed with both classroom and selfdirected learning (hybrid), had mixed student satisfaction. This is related to some preferred the course to be more traditional and others completely on-line. As nursing, in general, is shifting to more on-line courses, it is apparent these students preferred face-to-face classroom time to assist their learning. By using skills lab time, pre and post conference time, and encouraging students to assist in critiquing their peers (over simple things within the course), these can provide the necessary social interactions required to develop constructive psychiatric skills.
The success of the current course's variation and complexity assisted to enhance the students' sense of adaptability and confidence. The workload perception remained high and reflects the demands of high standard requirements when training to become professional nurses. Students are committed to learn and practice their psychiatric nursing skills which require interaction with others, feedback and refinement. The main psychiatric skills revolve around therapeutic communication. The classrooms have to be designed to ensure this learning can occur and evolve toward competency development.
This study's limitations involve the use of only one campus for investigation, which limited the sample size. The site usually has 20-30 students each semester. However, this small class size allows easy contact and readily available interactions between students and instructors, with interactions personalized for each learner. This small size may actually provide an enhancement opportunity for student engagement. Another limitation may have been the tool's format in that there was not an open-ended question for students to provide any additional comments they may have wanted to provide.
Recommendations for future mental health courses and nurse educators, supported by our findings, are: 1. Assess needs for a flexible course design that meets the diverse needs of both the self-motivated students along with the students that prefer direct contact with instructors.
2. Remember, students desire to receive direct contact with both course and clinical instructors to get high quality answers to questions that address core content, consistent feedback on their interactions with patients and their peers, and reinforced responses that repeat core content to prepare them to provide the critical information when caring for patients and preparing for exams.
3. Continue to use and explore more student-centered interactive classroom and clinical activities that reinforce application and retention of core course knowledge which can aid student modeling toward professional practice.
question if asking about a therapeutic communication, or another knowledge-based concept. " Some students preferred an on-line design stating, "Needs to be online; recorded lectures or in-class discussions, but not both. " Other students preferred an, "all face-to-face instead of hybrid; difficult material so I feel a hybrid class is not appropriate. " One student stated, "I really wish this course was 100% fade to face instead of hybrid, I feel like the weeks we did not meet a lot gets missed since we only have one semester of mental health it is very important and if should be given even more time than it is given. " A suggestion for class design was, "more class participation and real life scenarios in class setting. " In response to the question of: Describe any experience(s) with a person or caring for a person with mental illness prior to this class.
Some students (7 of 44, 16%) reported having a direct family member with a mental health diagnosis. "I have always had a heart for those with mental illness because of personal experience. " Two students (2 of 44, 5%) were employed caring for clients with mental illness.
When asked about their previous experience with mental health the follow responses were reported. "I have interacted with people who have a history of alcohol abuse I did not understand why they would want to live that way"; "Dealing with bipolar and manic depressive episodes and the role strain imposes on others"; "It is difficult sometimes, but self-assessment first and process to help is important. " Students also commented, "It would make me uncomfortable but now I understand them better, and do not worry"; "before this class I was very judgmental toward the mentally ill. I have come to realize that they need more care than other patients and are human just like me. " In response to the question of: How has class participation influenced your willingness/readiness to be caring for patient(s) with mental illness?
Of 44 potential responders, 3 students (7%) reported a negative response toward caring for mental illness, "this field is not for me", "I do not feel comfortable caring for a patient with mental illness", and "this class has made me more unwilling to deal with mental health patients. " In comparison of the total 34 responding to this question, 31 exhibited positive responses (31 or 34, 91%). These include, "I do feel more prepared to deal with mental illness", "it reinforced my tolerance to different mentalities' , "I know more what to expect", "it is given me a better understanding of different mental illnesses and how to approach people in their time of need", "it has made me more aware of how common it is in the general population", "it made me more willing than before this class' , "I will try to use the tools I have learned and have a more open approach", "it helped me to better understand how to respond to people with mental illness", it has opened my views-I understand that people do not always choose to live the way they do", "it will help me recognize early signs and symptoms of disease/ suicide risk", "greatly improved my willingness and readiness to care for mental health patients", "I feel confident and knowledgeable that I can care for a mental health patient. It would be an honor", and "considering trying mental health after graduation. "

Interpretation and Recommendations
Students overall enjoyed the course, with a few exceptions. The area of self-managed learning rated highly and reflects on the selfmotivated and dedicated nursing student body in general. The 4. Therapeutic communication goes beyond the mental health course, and should be reinforced and supported during all interactions as efforts are made to produce positive, and proactive professional health care providers. Design feedback to validate good communication habits and encourage constructive strategies when problem solving dialogues occur.
5. Mental health skills and knowledge require lifelong learning. New understanding of mental health disorders and effective treatments emerge and students/nurses should be ready to updateto the revised best practices.

Conclusion
Engagement is an important topic to review and reflect on as educators, organizations, and institutions. It enhances the bonds between the care providers (students, nurses, and other health professionals) and their patients. An engagement focused course can provide both individual and group learning skills and opportunities. Along with these, engagement allows for more positive and constructive strategies to be used in daily problem-solving of care issues. Nursing graduates can develop enhanced engagement in their nursing program. They would then provide a higher quality of engaged patient care within today's complex healthcare environment.