Nurse Education Today 61 (2018) 25–27

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Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Contemporary Issues

Could we remedy the ‘crisis of care’ by incorporating mandatory group T

psychotherapy in nurse education?

A R T I C L E I N F O A B S T R A C T

Keywords: This paper suggests a tentative proposal for nurse education that may go some way to remedying the ‘crisis of
Emotional intelligence care’ described by Judge Francis and others. Any viable strategy to improve caring attitudes in nursing students
Empathy must involve activities across the curriculum that foster self-awareness and empathy. It is suggested that the best
Attachment theory way to do this is for all undergraduate nursing students to participate in regular, supervised group psychotherapy
Psychotherapy
sessions as a mandated requirement for registration. This strategy would be helpful in at least two main ways.
Stress
First, it would be enormously beneficial in terms of promoting emotional intelligence — a necessary requirement
for providing ethical, person-centred care. Second, it would also serve as an excellent form of student support,
which would likely improve student retention rates. This is because individuals with strong group support
systems are less likely to become mentally or physically ill and are, therefore, more resilient. Finally, some
possible objections to this proposal are considered.

In recent times it has been said that nursing (and the delivery of health care more generally) is going through a crisis of caring and compassion
(Francis, 2013; Darbyshire and McKenna, 2013). Research also suggests that standard ethics courses are not successful in turning out graduates that
are empathic and compassionate in health disciplines such as nursing and medicine (Coulehan, 2005). In this paper, a tentative proposal for nurse
education is sketched that may go some way to ameliorating this problem. In recent years, many scholars have argued that educators should
incorporate activities across the curriculum that foster self-awareness and empathy (Lewis et al., 2017, for example). This author concurs, and
proposes that all undergraduate nursing students should participate in regular, supervised group psychotherapy sessions as a mandated requirement
for registration. This proposal is undoubtedly controversial; nevertheless, there is a lot of evidence to suggest that such a strategy would be helpful in
at least two main ways. First, it would be beneficial in terms of promoting emotional intelligence — a necessary requirement for providing ethical,
person-centred care (Lewis et al., 2017). Second, it would also serve as an excellent form of student support across the duration of their degree. If
group therapy were part of nursing curricula, it would very likely improve the student experience both on campus and during clinical practicum.
Further, it has the potential to improve retention rates for nursing students, because individuals with strong group support systems are less likely to
become mentally or physically ill and are, therefore, more resilient (Ozbay et al., 2007).
The extent of the crisis in healthcare (at least in the United Kingdom) became clear with the release of the Francis report in 2013 that highlighted
egregious breaches of ethical and legal responsibilities, where nursing ‘care’ was routinely insensitive and disengaged. In response to his findings,
one of the recommendations made by Justice Francis was to:
Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing
and leadership positions, to integrate the essential shared values of the common culture into everything they do (p. 5, emphasis added).
And furthermore:
There should be an increased focus on a culture of compassion and caring in nurse recruitment, training and education. Nursing training should ensure
that a consistent standard is achieved by all trainees throughout the country. The achievement of this will require the establishment of national
standards. The knowledge and skills framework should be reviewed with a view to giving explicit recognition to nurses' commitment to patient
care and the priority that should be accorded to dignity and respect in the acquisition of leadership skills (p. 76, emphasis added).
There is clearly an urgent question to answer as to how educators can nurture the necessary affective and character traits in students to enable
them to provide truly ethical, person-centred and safe care. It seems that current undergraduate nursing curricula are not fit for this purpose
(Darbyshire and McKenna, 2013). The ethical content currently taught and the methods of teaching it do not seem to encourage, let alone ensure, the
appropriate moral and personal qualities needed by nurses. It is, therefore, worth considering whether there are practical strategies incorporated in
undergraduate curricula that cultivate the conditions in each individual that make ethical care possible.
Literature from psychology and psychoanalysis shows that one needs to intentionally cultivate knowledge of one's own values, in concert with

https://doi.org/10.1016/j.nedt.2017.11.001
Received 9 May 2017; Received in revised form 5 October 2017; Accepted 3 November 2017
0260-6917/ © 2017 Elsevier Ltd. All rights reserved.
Contemporary Issues Nurse Education Today 61 (2018) 25–27

feedback from empathic others, before one can attempt to understand another person's experience (Carr and Cortina, 2011). This suggests that
encouraging self-awareness, as a component of ‘empathy education’, would offer the best chance of promoting the requisite qualities in nursing
graduates. The possession of empathy is one of the primary indicators of emotional intelligence and the development of empathy largely depends
upon appropriate parental responsiveness to the infant. Attachment theory, developed by Bowlby (1969) and others, is a fruitful way to theorise the
acquisition of emotional intelligence by conceptualising patterns of attachment between infants and their primary caregivers. The theory suggests
that the pattern by which the infant bonded to their primary caregiver will persist into adulthood. Varying patterns of attachment can therefore
explain individual differences in how adults approach their relationships with others. Individuals who were ‘securely attached’ to their primary
caregiver will typically be able to regulate their emotions (for example, to reduce their levels of arousal when anxious or distressed and increase their
levels of arousal when feeling apathetic) while those who were ‘insecurely attached’ have more difficulty doing this (Williams et al., 2016).
A securely attached infant will eventually integrate their emotions into a coherent narrative of self-experience and form a robust sense of self. The
phenomenon of ‘mirroring’ initiates this process, and requires the caregiver to interpret the infant's desires and emotions, and to validate and affirm
the same (Carr and Cortina, 2011). However, if the caregiver lacks these intersubjective qualities, there will be a disruption in the formation of a
coherent narrative of self-experience. The individual's emotions become the source of a lifelong vulnerability to stressful events, and emotional
regulation will be challenging. They are also more likely to have interpersonal problems and subsequent difficulties in both their personal and
professional lives. If an individual's self is ‘fractured’ in this way, their relational abilities that allow them to validate and recognise the unique
characteristics of others will be severely curtailed. The capacity to see things from the point of view of others dovetails with these relational abilities;
therefore, they will also lack the capacity to empathise with other people and to validate and affirm their emotional needs. The implications for
nurses who have these difficulties are particularly stark; nurses will have difficulty caring compassionately if they have deficiencies in emotional
intelligence.
Insecure attachment and the associated dearth of emotional intelligence correlates with having a number of difficulties in life; difficulty coping
with stress, lower levels of self-confidence and difficulty solving problems (Lewis et al., 2017). Furthermore, there is a strong connection between
one's attachment style and their degree of self-worth. This further supports the claim that one's attachment style will be a good predictor of their
capacity (or lack thereof) to provide empathic care for others. There are limited studies on patterns of attachment in nursing students, but Williams
et al. (2016) found that nursing students scored highest across all insecure attachment styles and lowest on empathy scales when compared to
paramedic students and paramedic/nurse cohorts. They note that these results are consistent with other research that reports low levels of empathy
among nursing students. On the assumption that universities will continue to admit large numbers of students with minimal vetting, these findings
indicate nurse educators must change their thinking to ensure graduates possess appropriate levels of empathy and emotional intelligence more
broadly (Darbyshire and McKenna, 2013).
In light of these considerations, it is proposed that all undergraduate nursing students should participate in regular, supervised group therapy
with qualified psychotherapists. One of the main tenets of psychotherapy is that regular interaction with others who are empathic and provide
recognition can mediate emotional and relational disturbances over time (Carr and Cortina, 2011). This suggests that group psychotherapy across the
curriculum would be the best way to improve emotional intelligence and empathy in nursing students. A specific model of psychotherapy is not
offered here aside from suggesting that the psychodynamic group form would be particularly useful. This is because it aims to bring lasting
personality change, and benefits participants with a range of personality problems and interpersonal difficulties, as well as those with chronic
anxiety and depression (Montgomery, 2002).
The mechanism of the group is particularly effective, because it functions as a microcosm of members' relationships outside the group. For
example, someone who is timid and concerned about the impact she has on others is likely to recreate this tentative approach in the group. The
difference, however, is that the group also functions as a safe space where group members can reflect upon and analyse their relationships with one
another — something seldom done within nursing curricula. Many students communicate in narcissistic ways, with self-absorption blocking their
capacity to be open and responsive to others. This indicates that, at this point in their lives at least, they lack the capacity to provide ethical, person-
centred care. A well-functioning group, however, will quickly afford students the opportunity to develop emotional attunement to others. Each
participant will begin to explore their anxieties, fears, doubts and positive feelings, both internally and interpersonally. Over time, their sense of self
will start to align better with others' perceptions of them and any necessary adjustments can begin to occur. These changes occur because of the
individual's developing critical reflexivity in conjunction with the support and feedback of the group. In this way, the ‘training’ of the emotions starts
to become evident. It is this self-knowledge, accompanied by the training of the emotions, which makes openness to empathic caring possible.
In addition to cultivating the conditions within individuals that make ethical care possible, group therapy has the additional bonus of attenuating
stress. Studying for a nursing degree and clinical nursing are demanding activities; therefore, stress is something that both students and graduates
must learn to manage. In fact, the curriculum (and often the teaching methods) seems to foster anxiety and depression, along with feelings of
worthlessness in vulnerable students The reasons behind this are likely to be multifactorial, but research suggests academic staff and clinical staff do
not always model professional qualities in their dealings with students (Del Prato, 2013). Indeed, they may play a significant role in undermining
their confidence and self-esteem — particularly in those students who already have emotional difficulties. The job itself also requires high-level
cognitive and emotional effort, which students and recent graduates, in particular, tend to find very stressful.
One way to mitigate the anxiety students feel is for them to experience a sense of belonging, and therapeutic groups have excellent potential to
provide this. Extant studies of nursing students participating in group therapy indicate the group is a rich source of interpersonal information for
participants, which promotes a sense of inclusion (Scherer et al., 2007). The reduction of anxiety and an increased sense of connection that are by-
products of such processes imply that the strategy suggested will have the added benefit of improving retention and success rates. This is because
individuals with strong support systems have lower levels of exposure to the (potentially) damaging effects of the neurochemicals released as part of
the stress response. Overall, these individuals are more resilient and better able to cope with life's challenges, as they suffer lower rates of physical
and mental illnesses (Ozbay et al., 2007).
Before closing, it is important to highlight some potential barriers to implementing group therapy within the curriculum. First, there is stigma
attached to the notion of ‘therapy’ (in some countries more than others), and reactions would likely range from mirth to outright hostility.
Nevertheless, the evidence shows that group therapy has a profound effect on participants' lives; its usefulness not confined to individuals with
obvious mental illnesses. There have been several studies conducted that looked at the effects of group therapy on nursing students (albeit over a
short time period), which showed remarkable benefits in terms of self-knowledge and stress reduction (Scherer et al., 2007, for example). Likewise,
there are studies that demonstrate similar benefits for medical students (Sathanandan and Bull, 2013, for example). These studies indicate there are
precedents for the proposal presented, although there is no literature that documents such a program for the duration of the Bachelor of Nursing

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Contemporary Issues Nurse Education Today 61 (2018) 25–27

course. It seems likely that a cultural shift may be required to implement this, but the Francis recommendations may just provide the impetus for
such a shift.
Second, if group therapy were a mandatory component of the curriculum, there would undoubtedly be resistance from many students. One
response would be to point out that those who are most resistant are probably the ones who are most in need of therapy. Certainly, the fact that
students dislike certain subjects is not a reason for removing them from the curriculum. Nevertheless, one may justifiably argue that there are
significant ethical issues with imposing psychotherapy on an individual who is neither suffering nor exhibiting pathological behaviour (Ivey, 2014).
This constraint on student autonomy bears a higher burden of justification than imposing, say, statistics classes on students. This is because the
therapeutic process necessarily taps in to issues that go right to the heart of personal, perhaps painful, experiences where one's ‘true self’ is exposed.
Moreover, the idea of a group may generate anxieties about conflict, even violence, and the potential shame of talking in front of others — not an
inviting prospect overall. Instigating such a program would clearly require rigorous scrutiny in terms of ethical and health/safety considerations.
Naturally, participants would be required to adhere to certain rules, which may go some way to allaying concerns. For instance, they must abide by
the principle of confidentiality and maintain certain boundaries outside the group — rules, it may be emphasised, that are in place for practicing
nurses. This indicates that the group may well function as a training ground for various professional values that participants will be expected to
uphold once they are practicing.
While groups can be intimidating, they also offer opportunities for profound shared experiences where crucial shifts occur in both self-concept
and understanding others' perspectives. Working through the difficulties experienced in group therapy leads to a point of ‘internal cohesion’ where
the individual accommodates both difference and similarity between self and others. The individual eventually acquires an autonomous sense of self
that is simultaneously relational (Montgomery, 2002). The group members will begin to develop a stronger sense of identity and are better able to
assert their own ideas or values, rather than conforming to ‘group-think’. Engendering these capacities in our students is not only crucial for the
possibility of providing ethical care, but also if they are to resist, and act against, unethical practices in the workplace in accordance with Judge
Francis's recommendations.
In conclusion, this article proposed that incorporating mandatory group psychotherapy in nursing curricula would go some way to ameliorating
the ‘crisis of care’ described by Judge Francis. Psychotherapy assists in training the emotions by improving self-awareness, emotional regulation and
resilience over time. This is important, for such capacities make empathic, person-centred care possible. If group psychotherapy were a mandated
component in nursing curricula, it would support the requirement for nurses to exemplify certain professional and affective qualities that the public
and profession expects. In the coming years, it may be that students and academics will need to come to terms with group therapy being a
compulsory part of nurse education. Ultimately, this strategy has the potential not only to improve patient care, but also to improve the lives of
participating students. For these reasons it is worthy of consideration.

Funding Statement

This research did not receive any specific grant from any funding agencies in the public, commercial, or not-for-profit sectors. There are no
conflicts of interest to declare.

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Suzanne Bliss
School of Humanities, University of Tasmania, Locked Bag 1340, Launceston, TAS 7250, Australia
E-mail address: Suzanne.Bliss@utas.edu.au

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