by DEBORAH L. MAY and CYNTHIA THOMAS
Ball State University, Indiana
Deborah May and Cindy Thomas are assistant professors at Ball State University School of Nursing in Muncie, IN. Deborah’s past work has demonstrated a return of service by students to individuals with mental health issues. In 2003 Deborah received an Indiana Campus Compact Faculty Fellowship to provide education to the mentally ill residing in group homes and has obtained numerous other grants to implement community work. Cindy works with nursing students to help them learn the skills of leadership and managing nursing care delivery. In the following article, they describe the dual mental health experiences they implemented on the campus over a semester with 16 nursing students.
The purpose of this article is to summarize two service-learning projects undertaken by 16 nursing students enrolled at Ball State University in Muncie, IN. Community is defined as any setting wherever there is a need. Because students on college campuses are at risk regarding mental health issues, student nurses planned and implemented two service-learning projects. The students worked in collaboration with the campus counseling center to provide depression screening; and, the students worked in collaboration with the National Alliance on Mental Illness (NAMI) to plan, develop and implement a NAMI on Ball State Campus affiliate that would provide education and support on campus for individuals with mental health concerns. Over 230 students participated in the depression screening that revealed occurrence of some depression in 25% of the students that participated. The student evaluations revealed that they strongly agreed that the projects enhanced their learning and agreed that they better understood how to address the needs of the community setting.
Needs and Benefits of Service-Learning Experiences on Campus
As nursing instructors, we have often incorporated service-learning in our courses because it allows students to apply learning from the classroom to active clinical experiences in the community. As we began the first week of classes in January at Ball State University in Muncie Indiana to begin teaching to a new group of nursing students enrolled in the psychiatric nursing course. We were excited about the service-learning projects the student nurses would be undertaking. Believing that community is defined as any setting where there is a need our community, this semester, would be students on Ball State’s campus and our area of service would be mental health issues. Under our facilitation, the student nurses would be implementing two service-learning projects: depression screening in collaboration with the Ball State Counseling Center; and, developing an on-campus student-led education and support affiliation group in collaboration with the National Alliance on Mental Illness (NAMI) in Indiana. We were working reciprocally with two organizations involved with college students about mental health issues. Also, the dual service-learning projects were needed to enhance active student nurse learning experiences about mental health issues in the community (Bringle & Hatcher, 2000).
Some students in college become depressed for no fault of their own. Based upon new research findings, we understood that some individuals are just biologically predisposed to depression and they can no more “snap out of a depression” than someone with diabetes can heal themselves without treatment. Early identification and treatment are encouraged. During the previous year, we had engaged in meaningful discussions with the National Alliance of Mental Illness (NAMI) at both the national and state level, as well as, the director of the campus counseling center and learned that suicide was the second leading cause of death on college campuses. The problem is worsened by the fact that many campus counseling centers often lack adequate resources to identify and treat students with depression and other major mental illnesses that first become apparent during a person’s college years.
From our direct service to the National Alliance on Mental Illness (NAMI) in NAMI Indiana, we faculty had learned that one of NAMI National’s initiatives was the establishment of NAMI on college campuses with goals of mutual support for students, education of the general student body about serious mental illness, overcoming the stigma surrounding mental illness and improving the mental health of the campus community. Organizations of NAMI on campus are student-run organizations that work to provide a setting where interested individuals on campus come together. For several years, we had been encouraged to establish a NAMI campus affiliate that is present in over 30 other colleges in the United States. Because we believed that students on campuses comprise a community setting in themselves, that our service-learning projects would benefit Ball State University students, as well as, the student nurses enrolled in psychiatric mental health nursing, we committed ourselves to planning and implementing these projects throughout the semester. Reflection entries were utilized by the student nurses to enhance their learning. Brittany’s and Megan’s reflections address the collaboration that was necessary between the two groups to effectively implement the service-learning projects:
“The process of combining two clinical groups to work together to get started
was a hard task and we started meeting together one hour every Monday before
class to develop a plan for implementing each project. I think our two groups
are working well together to get both projects started.”
And Megan reflected:
“It has been an awesome group collaboration. Everyone is playing their own part in some way. The process is stressful at times, but everyone is supportive of each other.”
The Depression Screening Service-Learning Project
An important teaching strategy we utilized was to provide intensive structure for the student nurses especially in the early stages of the service-learning projects. One hour each week prior to lecture, we and the students met to discuss the steps for each service-learning project.
Implementation of the depression screening project was planned for midpoint in the semester. However, before the students could implement the screening, they needed to learn about the many aspects of depression, select a valid depression screening questionnaire to capture depression, learn how to assess depression and implement the depression questionnaire, and develop steps to link affected students to treatment. The etiology of depression, signs and symptoms associated with it, and recommended treatments were presented and discussed in the classroom and during post-conferences following inpatient psychiatric clinical experiences. We utilized the strategy of tell, show, and do with the students nurses, first teaching them about depression, then modeling assessment of depression with patients in hospitals, and then supervising the students while they assessed more severe levels of depression in individuals in the hospital. They now were ready to more autonomously assess the presence varied levels of depression in individuals residing in the community of the campus.
As the students acquired skills of depression assessment, they began more in-depth planning of the depression screening project. One sub-group of the student nurses attended weekly meetings with the staff of the counseling center on campus to plan activities for implementation during suicide awareness week. They subsequently reported pertinent issues to their peers during the weekly planning meetings including the need to have a staff present from the counseling center during depression screenings.
A reflection by Megan who was a member of a student nurse sub-group that worked with the staff at the counseling center for planning the suicide awareness week demonstrates her awareness of the reciprocity and collaboration involved in implementing this project with others:
“I really enjoy meeting with the trauma team at the counseling center. I feel like we are a part of something really important. They are grateful for our help and collaboration in planning and implementing the depression screening for suicide awareness week and we are grateful for their support.”
Another sub-group addressed other aspects of communication associated with the projects. They developed flyers and distributed them to spread the word on campus, incorporated information onto posters about well-known individuals who had been treated for depression, and selected brochures that addressed approaches for dealing with the stress of campus life. A central location on campus was selected to conduct the depression screenings. Over several planning meetings the student nurse developed a schedule for implementing the depression screening to assure that it would be provided during the three-day period comprising the suicide awareness program.
A reflection by Sarah demonstrates the knowledge she gained during this service learning project:
“On April 2–4 we partnered up with the Counseling Center in the Atrium to host the spring Depression Screenings. I was amazed at the turn out of so many students and even faculty/staff members that participated by taking 5 minutes out of their day to fill out the questionnaire. There were a number of people that had scores in the mild to severe range of depression and this was somewhat of a shock to me, however in all reality I am not shocked at all with the statistic that suicide is the 2nd leading cause of death among college students. I felt that it was a good learning experience to see that by doing something so simple we could possibly save a life or save someone suffering from depression.”
Many of the students experienced consciousness-raising regarding important aspects of mental illness. Carrie’s reflection exemplifies her learning:
“The depression screening made it so real to be able to see mental illness in our own age group. I did not realize how many people are affected by mental illness until this project. The depression screenings blew my mind on how many college kids struggle with anxiety and depression. I think it was the best part about the whole experience. Later when the trauma at Virginia Tech occurred it made me realize how many people can slip through the cracks.”
Lindsay reflected on importance of addressing stigma in the posters that were developed and presented during the depression screening activity:
“Decreasing stigma is an important part. We used tactics such as pictures on posters and descriptions of celebrities suffering from various mental illnesses with the idea that those who openly seek treatment and discuss their experiences increase awareness and help make it easier for others to reveal their struggles with mental illness.”
During depression screening, the student nurses screened 348 students. Approximately 25% of the students who completed the depression questionnaire were found to be experiencing some depression. They were subsequently educated about treatment of depression in confidential interactions and provided brochures on the topic. Identified students were introduced to counseling staff or linked to the counseling center for location, available hours, and telephone number. The students believed they had contributed significantly to helping their peers who came from communities throughout the state, other states, and other countries. Indeed they had.
Development of NAMI on Ball State University Campus Service-Learning Project
Although the students began focusing on the project of developing NAMI on Ball State University the first week of class, completion of the depression screening project enabled them to focus their energy toward developing this student-run organization on campus. The depression screening had served to assess those with depression; NAMI on Ball State University would go beyond assessment to provide education and support for anyone addressing mental health issues on campus. In order to develop NAMI on campus, the student nurses needed to understand the basic purpose of NAMI and how NAMI worked with individuals with mental illness and their families in the community. Early in the semester we faculty had developed learning objectives to enhance the student nurses’ understanding of this community, state and national organization. NAMI was first founded in 1979 as a grassroots organization for people with mental illness and their families. It now has affiliates in every state in more that 1,000 local communities across the country. One of our teaching approaches was to make contact with the leaders of NAMI Indiana and arrange for their executive and education directors to meet with the students and present NAMI’s mission of improving the quality of life for persons of all ages who are affected by mental illness. We arranged for the student nurses to attend NAMI affiliate meetings in the communities of Muncie and Anderson, Indiana where they could meet with individuals with mental illness and their family members, hear their stories, and become educated about mental illness issues in the community from these individuals’ perspectives.
“I attended a NAMI meeting in the community and I think the members’ statements gave me more of a clear picture than the book for our class. They told their own stories which gave me vivid pictures of their mental diseases. I saw that mental illness has nothing to do with intelligence. I saw a very smart woman who got full scholarship at a good university and lost the chance to get her degree because of a bipolar relapse. She became a member of NAMI, and she said she found her value again in NAMI because she can help people here. One of the member’s sons had attended an Ivy League college before he was diagnosed with a mental disorder. As they talked they were not afraid to get stigma labels and they shared openly their own stories to help themselves and to help others. They showed me the good will to help others.”
“After attending a NAMI meeting, I had a greater grasp of NAMI’s programs and I was able to appreciate the work we were doing.”
“The NAMI group that I attended was one of the most touching experiences. I believe this was due to seeing the other side of things. We were constantly in contact with the mentally ill at the hospital, but to see parents pour their hearts out about their children cannot be taught”.
Students’ now possessed knowledge and skills enhanced by cognitive and affective NAMI experiences, and became focused on implementing the steps to develop NAMI at Ball State University.
“In order to get NAMI started on campus many logistics had to first be addressed. We attended a NAMI meeting/presentation at the state office that provided us with information on what steps we needed to take. In the presentation we learned that a study conducted among college students showed that nearly half of them reported they had not received ANY education regarding mental health issues from their college (WOW!) and that more than 2,000 college students die from mental illness every year! Education and awareness on our campus about mental illnesses and the many treatment options that are available has the potential to break the silence and hopefully will lower some of these staggering and heart-breaking statistics among our fellow peers.”
We all learned that NAMI on college campuses provide mutual support and advocacy, educate the student body about serious mental illness, works with other resources on campus to improve the overall mental health of the college community, and work to end the seclusion students feel when there is no one to talk to that can appreciate their problems of depression and/or other mental illnesses. Our student nurses undertook much discussion about what purpose NAMI on Ball State University should focus its attention; they chose to focus on education and support.
Additionally, we all learned the steps to obtain approval from NAMI Indiana, NAMI National, and from Ball State University Student Services to have a NAMI on campus. The student nurses undertook the steps for approval of the NAMI campus affiliate that included development of a constitution that included goals and objectives. Consistent with the national NAMI mandates, the students elected officers and applied Robert’s Rules to conduct each weekly planning meeting. They now focused on what the education topic should be addressed during their first meeting of NAMI on Ball State University. Their confidence and leadership skills increased as they developed the organization. Sarah summarized the work in which she and others participated:
“The first step in the process of becoming a NAMI on campus affiliate is to submit the NAMI Affiliation application for the initial endorsement by the NAMI state organization and the state. This application includes a statement of our purpose, roles and responsibilities, a list of the proposed affiliate members, affiliate bylaws (can be a draft), as well as a list of all affiliate officers. Once NAMI Indiana endorses our application, they will forward it to NAMI National who will then make the final endorsement of our new NAMI Affiliate on the Ball State Campus and within 21 days we will receive a welcome tool kit to begin our journey as an official NAMI Affiliate! Our group has already brainstormed and come up with several ideas about how to start something magnificent for Ball State University!”
One group of students worked with NAMI Indiana and NAMI National to develop the constitution. Another group of students initiated contact with students associated with other NAMI on college campuses to understand the benefits of the programs at their respective colleges. Another group led the communication aspect of the project to develop, print, and hang numerous fliers throughout the campus to spread the word about the student-run group they were working to create for students with mental health issues on campus. We had learned from the counseling center that an individual with mental illness several years previously had attempted to develop a NAMI at Ball State University but had been overwhelmed by the enormity of the steps. With the student nurses implementing these steps to establish the organization, those in need could benefit without facing the extensive work to get it up and going.
Teaching strategies we faculty undertook at this phase of the project included adjusting clinical schedules so that the active on-campus experiences could replace previously scheduled outpatient shadowing experiences at the hospital. Slowly all the planning steps were completed and NAMI on Ball State University conducted its first meeting in April. The elected president reflected on implementation of the first on campus meeting:
“When April 18th got her I was very nervous for our first meeting. I wasn’t sure what I was supposed to say as president of our NAMI on Ball State Campus or how I should conduct the meeting and really didn’t want to disappoint anyone after everything we have all done. But I was able to calm down and just breathe, and I think the meeting went pretty well. I was so happy that other students besides nursing students came to the first meeting along with the NAMI affiliate leader in Muncie and the education director of NAMI Indiana. I caught myself looking a lot at the other Ball State students that attended to see if I could get a feel whether or not the meeting was engaging to them at all and whether they were interested. I was a little nervous that we wouldn’t have as much time for the “support” part that they needed; but once we moved to the education part of our meeting and our speaker started talking about stigma, many actually took some notes and I saw some laughing a few times. This was a huge comfort to me because I figured that if there was even one thing that our speaker had said that helped the students, then we had selected the right topic and the right speaker for our first meeting.”
Other student reflections address the learning obtained from planning and implementing this service-learning project and its benefit to those in the community of Ball State University and NAMI:
Katie: “From this experience, I have learned the importance of community involvement first and foremost.”
Jena: “The biggest thing I learned was not to judge other people. The saying goes to never judge a book by its cover and it can’t be truer for me. I never really thought about how much I stereotyped people with mental illnesses.”
Katie: “The feeling of doing something positive on campus was really incredible.”
Megan 1: “This process has definitely been meaningful to me. I don’t think there is any better feeling than giving back to your community and we certainly achieved that by starting NAMI. I love knowing that we could really helped people on our campus find support.”
Rachel: “I think we learned more about mental illness than we would have if we had written a paper on it.”
Erica: “I’m not sure if it was the involvement in the projects, or the education about stigma or both, but when I was watching those shootings on TV and all my friends were making negative comments about the shooter at Virginia Tech, I saw myself thinking about what this guy must have been going through to do something like this.”
Megan 2: “The major thing I liked about this project was feeling that I had actually done something really worthwhile (or helped to do anyway) and that we would be benefiting those who needed the group.”
Carrie: “The topic we presented in the first NAMI on campus brought some meaning to me because it kind of hit home. Past experiences have made me look at mental illness with anger and misunderstanding. The projects helped the concepts presented in class clearer.”
Jill: “I makes me feel good as a student nurse and as a person to be participating in such an event that may help save someone’s life or at least make it easier, and for that I am glad that I was a part of this experience. If you would have told me in the beginning that I would have enjoyed this so much, then I would have said you were crazy, but I really did enjoy it.”
Katie: “It really helped decrease my stress knowing that I was making strong friendships by being a part of this group, and at the same time doing good for others in the community. It makes me feel really good that I have given back to the community at Ball State, and that many years from now this group will hopefully still be around. Then, I will be able to tell my children that I was a part of starting this group.”
Assessment of the Dual Service-Learning Projects
Assessment of the student nurses’ learning was captured through written reflections, classroom grades and feedback from the two organizations with whom we worked. Classroom test grades for the students were well above average. To further enhance faculty learning about the benefits of the service-learning projects (Driscoll, 2000), we undertook development of a Psychiatric Nursing Service-Learning Assessment Questionnaire and administered it to the student nurses at the end of the semester after the classroom grades were submitted. We wanted to learn the benefits of the projects and also to learn if there were obstacles to address before undertaking additional service-learning projects of this type and depth in a discipline such as nursing where the course assignments already are very time intensive. Responses of the students reflected that they were unsure the benefits of undertaking two time intensive service-learning projects simultaneously. However, they strongly believed that participation in the service-learning projects had increased their knowledge, skills and abilities in psychiatric nursing, had strongly shown them how they could become more involved in their community, and had strongly helped them realize the benefits of serving the community. We plan to use the questionnaire for evaluation of future service-learning projects. The findings helped us to realize that the campus can be viewed as a community that has needs and that community of the campus can be a meaningful setting to enhance student learning. We plan to implement depression screening on campus again next semester per request of the campus counseling center director and we faculty plan to continue as advisors to NAMI on Ball State University. The results revealed that both the students and the community of the campus benefited-the essence of successful service-learning.
Bringle, R. G., & Hatcher J. A. (2000). Institutionalization of service-learning in higher education. The Journal of Higher Education, 71(3), 273–290.
Driscoll, A. (2000). Studying faculty and service-learning: Directions for inquiry and development. Michigan Journal of Community Service Learning, 71, 35–41.
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