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Year : 2011  |  Volume : 24  |  Issue : 3  |  Page : 537

SMILE: Simple, Mental Health, Initiative in Learning and Education

Griffith University, Nathan, Queensland, Australia

Date of Submission23-Aug-2010
Date of Acceptance22-Oct-2011
Date of Web Publication08-Dec-2011

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Source of Support: None, Conflict of Interest: None

PMID: 22267348

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Context: SMILE is a Simple, Mental health, Initiative in Learning and Education. SMILE was a pilot project introduced into an undergraduate clinical nursing program, Southern Cross University, Australia 2010. The program aimed to improve the knowledge and skills of third-year nursing students participating in their first clinical placement in mental healthcare.
Methods: Complementary to the clinical nursing program and the university curriculum, SMILE provided further training and support for student learning in mental healthcare. The SMILE project was a structured 15-day education program that covered the following topics: suicide prevention; psychosis; drugs and alcohol education; mental state exam; families and carers in mental health; and the Mental Health Act. The education sessions were one hour in duration. The educational material and resources were created from current research, literature and health service policy. A problem-based learning approach was used to support this education project. The dynamic factor related to SMILE was that it was based 'in the field.' SMILE enabled the students to bridge a theorypractice gap and expand upon their current knowledge base as well as participate in ward activity. Twenty students attending their first clinical placement in mental healthcare participated in SMILE and were asked to complete a pre- and post- evaluation questionnaire before starting and upon completion of the 15-day project.
Results: The students participating in SMILE reported a greater understanding of mental healthcare issues and expressed a developing knowledge base and improved practical skill level.
Conclusion: SMILE was a positive initiative that provided valuable feedback and opportunity to improve on clinical education in mental healthcare.

Keywords: Clinical placement, innovative practice, Mental health, student learning

How to cite this article:
Ward L J. SMILE: Simple, Mental Health, Initiative in Learning and Education. Educ Health 2011;24:537

How to cite this URL:
Ward L J. SMILE: Simple, Mental Health, Initiative in Learning and Education. Educ Health [serial online] 2011 [cited 2022 Aug 15];24:537. Available from:


Undergraduate mental health nursing education has stumbled its way through various models of training and met numerous challenges attempting to provide undergraduate nursing students with a comprehensive clinical experience1. Happell2 concurs, stating that the debate and ‘controversy regarding the type of undergraduate education that would best serve the needs of the mental health nursing profession continues’ (p. 35). Experimentation and innovation is essential in resolving the issue and building a strong network of training options for students studying mental healthcare.

As current research consistently highlights the need for early intervention and prevention in mental healthcare3-5, generalist registered nurses are now ‘exposed to people suffering mental health illness or disorder’6 or are in the optimal position to identify the signs and symptom of declining mental health. Undergraduate nursing students, therefore, require a comprehensive mental health education to support their practice. Research and current literature must inform learning material and guide training in this specialized area of healthcare delivery. The Council of Australia (2006) recommends tertiary institutions enhance mental health course content and affirm that better education and awareness will assist in the future recruitment and retention of mental health nurses7. Yet, studies clearly indicate that nurses are failing to choose mental health as a career option because of the unpopular historical images associated with mental health nursing and the current media portrayal associated with patient violence and aggression2,8.

Clinical nursing education provides an opportunity for students to practice skills learned and apply nursing knowledge in practice9. As Glass and Ward confirm, it is critical that teachers are flexible in their approach to clinical education and are also responsive to the changing needs of the healthcare system10. In this context, SMILE was introduced as a pilot project that clearly identifies the integral link between theory and practice. Students participating in SMILE had differing levels of education and or understanding of mental healthcare prior to participating in the project. Their knowledge was primarily based upon the theoretical components of the curriculum, media and current affairs and personal experience.

The project incorporates the key elements of problem-based learning, identifying four phases as defined by Barrows11,12: reasoning through a problem; discovery through self-directed learning; application of knowledge to the problem; and summary and integration to solve the problem. Problem-based learning acknowledges brainstorming, critical thinking and reflection13. SMILE integrated these key elements into the project to encourage critical student enquiry and evidence-based practice supported by science and/or experience12. Involving students in their own learning could potentially motivate and empower them to achieve specific nursing competencies and clinical nursing skills7.

SMILE also focused upon developing effective communication skills and reflective practice. Students were encouraged to take part in the discussions, question current practices and debate various mental healthcare theories presented to them within the project. SMILE aimed to support students to adopt the principles and qualities of life-long learners7. As Hewitt13 confirms, reflective teaching:

…requires a shift in the status of experts and expert knowledge to one where there is no known monopoly on truth. It requires educators who are able to facilitate, rather than instruct and who are willing to engage students in a process of discovery without dictating the outcome. Success therefore depends on the process of delivery, the conditions of the learning encounter, freedom experienced by the learner, and the person or teacher in co-constructing the nature of enquiry (p. 376).

The SMILE program was based upon this philosophy and placed the student as central to his or her own enquiry through a process of personal and professional discovery.


Recruitment: Following ethical approval from the University Human Research and Ethics Committee, an information sheet outlining the project and a consent form to participate were made available by student administration. The forms were included in the student clinical orientation package. Fifty-six students undertaking their mental health clinical placement at the local health service were invited to take part in the research. Twenty students responded and were accepted into the study. Students were asked to participate in this pilot project upon commencement of their mental heath clinical placement. If students chose not to participate, they remained on the hospital ward in their usual duties.

Program delivery and content: The SMILE program was delivered over a 15-day clinical placement rotation. The students were scheduled on the morning shift over a three-week period. A clinical teacher provided the SMILE structured education program to the students for one hour in a small lecture theater on the health campus. The clinical teacher facilitated a debriefing session at the end of each day of placement for approximately 30 minutes. The debriefing session aimed to support the student’s clinical experience. It was an opportunity for students to reflect on their day in practice and discuss any issues or concerns they may have identified. The debriefing session can facilitate education, clarification and direction from the clinical teacher. It can also provide students with an opportunity to learn from the experiences shared by their peers building supportive and collegial relationships.

Through problem-based learning, case studies were presented for critique, engaging students in developing hypotheses, incorporating problem-solving and considering conclusions. The case study scenarios included suicide prevention, psychosis, drugs and alcohol education, mental state exam, families and carers in mental health and the Mental Health Act. A variety of resources highlighting current national and international research statistics were provided. The case study presentations were designed to stimulate discussion related to social stigma and mental illness, psychiatric practice and the future of mental healthcare.

Evaluation and analysis: The SMILE program was evaluated using a simple pre and post-questionnaire administered on day one and day 15 of the project. It was made available to students electronically. Four pre-evaluation questions were asked at the start of the program: Have you had a student placement in mental health?; If yes, did you consider it to be a positive experience?; If no, can you identify any issues or concerns related to commencing this current placement?; and Have you ever considered mental health nursing as a career choice?

Similarly, four post-evaluation questions were asked day 15: What did you consider positive regarding your mental health placement and the workshop model of education?; What did you consider was negative regarding your mental health placement?; Would you consider mental health nursing as a career option?; and What do you feel could be improved upon within the program?

All feedback and data collected were confidential, with student names withheld to provide anonymity. The student questionnaires were thematically analyzed to draw upon similarities and differences, looking for patterns in responses. Thematic analysis enables the key focus areas to be brought forward and emphasised in relation to the research findings. The themes are revealed through careful assessment of data and re-checking and validating with the participants throughout the study. The clinical teacher also kept a journal and recorded daily comments and student feedback provided throughout the education sessions.  


Twenty students agreed to participate in the project. Students ranged in age from 19 to 45 years old. There were 18 female and two male participants. They were diverse in their life experience and cultural backgrounds. Two students self-identified as indigenous Australian. The students disclosed their past work histories and the reasons they had chosen nursing as a career, however, none had previously worked or participated in a clinical placement in mental healthcare.

Pre-evaluation responses highlighted student apprehension associated with mental healthcare. One student wrote: I have never been in a mental health institution before. I am scared about going in. Another disclosed: My brother has bi-polar and I don’t think I am going to want to work in this area because I have had to watch my family go through so much with him. Another student reported being frightened of mental health because she felt she had forgotten what she had learned at university: I don’t think I will know what to say to anyone there. I don’t know enough about the diseases or their problems. In this regard, a key theme to emerge from the study was fear. The students reported in this pre-evaluation a fear in relation to mental health nursing. They expressed a ‘fear of the patient,’ a ‘fear of the nurses,’ a ‘fear of not knowing what to do,’ ‘what to say’ and a ‘fear about not knowing how they would react in the environment.’

In contrast, post-evaluation responses highlighted the students’ ability to incorporate reflective practice skills into their clinical experience and draw upon theory to enhance their ability to provide care to people suffering with mental illness. Clinical skills such as the Mental State Exam, nursing history, suicide risk assessment, drug and alcohol withdrawal scales and administering medication safely were taught to students. One student reported: SMILE gave me time to learn before returning to the hospital setting. I really understood more as it was explained to me in context of the illness or the problem the patient presented with. Another wrote: SMILE was great! It helped me learn about how many people are affected by mental health problems. Finally, one student reported that the SMILE program motivated her, and through learning about specific key areas she had developed a stronger interest in mental health nursing.

On the other hand, time constraints were a major limitation of the project identified by students and the clinical teacher. All 20 participants indicated that the one-hour lecture was too short. They felt they would have gained more knowledge and understanding from a two-hour lecture. Another constraint identified by 14 participants was that a workbook to guide the program and highlight the learning objectives would have improved the program. Overall, findings from the pilot SMILE program clearly identified student enthusiasm for greater education and training support. 


SMILE is a Simple Mental health Initiative in Learning and Education program supporting theory and practice within the clinical setting. It challenges students to question their knowledge and build on their skills and understanding in mental healthcare.

The SMILE program provided an opportunity for students to participate in group discussion and raise concerns identified on their daily shifts. They were then able to reflect back on the theory and evidence presented in SMILE gaining an even greater understanding of mental healthcare issues. After the one-hour session and on return to the ward, the students were able to discuss subsequent issues raised with the clinical teacher one-on-one, in relation to specific client diagnosis or care plan situations. The clinical teacher became a guide and a resource and through SMILE the students were able to build confidence and competence.

The students’ evaluations mirrored the Australian Workforce Advisory Committee, research 2003. The Australian Workforce Advisory Committee14 pointed out clinical placement concerns affecting student learning, such as limited training opportunities to manage or cope with the situations presented, finding mental health nursing too difficult, confronting or frightening and or being placed in a poor environment (e.g. old buildings in which to work). SMILE provided an opportunity for improvements in student learning and an opportunity to promote mental health nursing as a positive career choice. Improved undergraduate education offers greater potential for recruitment into the specialty and a strengthening of the current profession.

The project values the inherent skills necessary within mental health nursing and highlights many core elements such as reflective practice, collaboration and diversity that inform and strengthen practice. Research and current evidence is vital to include in clinical mental health education and essential in bridging the theory practice gap. The project is simple and time effective. It is also transferrable across various clinical practice settings.


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2 Happell B. Exploring workforce issues in mental health nursing. Contemporary Nurse, 2008; 29(1):43-51.

3Malvarez S. Global perspectives on mental health. International Society of Psychiatric - Mental Health Nurses (ISPN) Tenth Annual Conference, Louisville, USA. Retrieved 10 September, 2008, from

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6Sharrock J, Happell B. The role of the psychiatric consultation-liason nurse in the general hospital. Australian Journal of Advanced Nursing, 2000; 18(1):34-39.

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8Yang, HL, KaoYH, HuangY.C. The job self-efficacy and job involvement of clinical nursing teachers. Journal of Nursing Research, 2006; 14(3):237-248.

9 Glass N, Ward L. Advancing clinical nursing education in mental health: Student self-assessment of clinical competences. In M. Oermann & K. Heinrich (eds): Annual Review of Nursing Education, 2008: Vol 6.

10Ward L. A critical exploration of the workplace culture, experiences and practice of women mental health nurses within an acute inpatient facility. PhD Dissertation, Southern Cross University: 2009.

11Zubaidah S. Problem-based learning literature review. Singapore Nursing Journal, 2005; 32(4):50-55.

12Bellack J. Teaching for learning and improvement. Journal of Nursing Education, 2005; 44(7):295-296.

13Hewitt J. Redressing the balance in mental health nursing education: Arguments for a value-based approach. International Journal of Mental Health Nursing, 2009; 18:368-379.

14 Australian Health Workforce Advisory Committee. Australian Mental Health Nurse Supply, Recruitment and Retention. A joint project of the National Mental Health Working Group Australian Health Workforce Officials’ Committee and the Australian Health Workforce Advisory Committee: 2003.


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