Students’ perceptions of empathic instruction in a remote psychiatric nursing class: a phenomenological study

Abstract

Background

Psychiatric nursing is operated by nursing college students as it introduces abstract concepts and complex materials. The educational environment has undergone extreme changes due to the expansion of remote learning. Thus, it is important to devise strategies for operating psychiatric nursing classes.

Methods

In this study, students attended a psychiatric nursing class that used empathic instruction in a virtual space to examine their learning experiences employing a phenomenological research design. Eleven nursing students completed a remote 2-credit psychiatric nursing class offered in a college in Chungbuk, South Korea that used empathic instruction. Data were collected through individual interviews and analyzed using Giorgi’s phenomenological method of analysis.

Results

The following four themes were derived from the participants’ learning experiences: “Interaction as a tool for learning,” “Repetitive learning,” “Enjoyable but too detailed feedback,” “Chance of self-improvement.”

Conclusions

Our findings suggest that remote psychiatric nursing classes that use empathic instruction are an effective teaching method that can increase students’ interest and academic performance in the subject. Thus, they should create a systematic and structured learning environment according to students’ academic levels and promote their reflection.

Background

In the era of the Fourth Industrial Revolution, where various advanced technologies such as Information and Communication Technology (ICT), Artificial Intelligence (AI), and Big Data converge to create new value, the importance of non-cognitive skills like empathy — traditionally defined in health care as the cognitive ability to understand the experience of others, by “stepping into the shoes of another” — is increasingly emphasized. This is crucial for preventing social and ethical issues arising from technological advancements [1]. In the healthcare field, technologies that place humans at the center and protect humanity should be embraced, whereas technologies that undermine humanity should be rejected. This approach will ultimately enable the realization of human dignity, allowing for the provision of optimal care tailored to individuals. As a result, patients will experience more positive service encounters and higher satisfaction [1]. This connects with the necessity of learning psychiatric nursing, which involves providing therapeutic communication as a key nursing intervention using techniques such as empathy, reflection, and active listening. However, most nursing students find psychiatric nursing difficult and exhibit a low preference for it during course selection [2, 3]. This difficulty is often attributed to the introduction of abstract concepts, such as communication and cooperation [4], and complex materials [5], which are integral to psychiatric nursing education. Nursing educators are responsible for providing expertise in nursing content, educational transfer of knowledge, and teaching others to care for human life. These challenges can be particularly overwhelming for students who struggle to grasp the more theoretical and intricate aspects of the field.

Face-to-face mentoring has traditionally been an effective strategy for helping students grasp these complexities [6]. However, the shift to remote learning during the COVID-19 pandemic, driven by the need for social distancing, has presented additional obstacles for students [7]. While virtual learning has improved technical proficiency, the absence of in-person mentoring has the potential to exacerbate the difficulties that students already face, particularly when dealing with abstract and complex topics. Moreover, the lack of mentoring makes it a significant challenge to conduct effective psychiatric nursing classes in remote learning environments. The effectiveness of remote learning without adequate mentoring to address these challenges remains unverified [8]. However, there is evidence that mentoring positively impacts remote learning of medical knowledge and technical skills [9].

Furthermore, remote learning lacks a humanitarian approach in improving learning abilities and stress resistance [10]. Thus, instructors must integrate strategies that promote human connections and mentorship within the educational system [10]. Therefore, it is important for psychiatric nursing instructors to understand the limitations of remote learning and make efforts to compensate for them.

One effective strategy is empathic instruction, which involves instructors demonstrating empathy and fostering an empathic learning environment. Instructor empathy enhances students’ learning experiences, promotes positive attitudes toward school, and encourages active participation by creating a supportive classroom atmosphere [11, 12].

According to Lee and Kim [12] empathic instruction consists of three components: (a) cognitive empathy, which bridges the gap between instructors’ and students’ thought processes; (b) emotional empathy, which fosters positive emotions through goal-setting, planning, and achievement; and (c) behavioral empathy, which aligns values and thinking patterns between instructors and students. These approaches enable instructors to tailor their teaching methods to students’ needs, improving learning outcomes in psychiatric nursing [12].

Empathizing and caring for all learners is not possible for the instructors alone; thus, empathic instruction also includes creating an atmosphere of consideration and care through group activities among students. Studies related to team-based learning reveal better learning in groups. Group activities in which students empathize with and care for one another increases the opportunities to practice empathy and enhances the empathic ability of the group, leading to positive emotions [12]. The sudden shift to remote learning poses a threat by limiting opportunities for group activities and collaborative learning. However, faculty can play a key role in building and maintaining a sense of community [13]. They can implement active online learning strategies such as breakout rooms, video message sharing, virtual office hours, and regular feedback collection. Additionally, creative strategies such as discussion boards for students and assignments such as think-pair-share, where students share work to identify similarities and differences, can foster student-to-student engagement [13].

According to the theory of achievement emotions, positive-activating emotions, such as joy, pride, and hope, have positive effects on academic performance, while negative-inactivating emotions, such as frustration and boredom, impact it negatively [14]. In psychiatric nursing, education that utilizes positive emotions can have a significant positive effect on educational outcomes. Strengthening empathy is an essential educational goal in psychiatric nursing because when psychiatric nurses accurately perceive and understand a patient’s emotions, the patient feels understood and develops trust in the nurse [15]. Empathy, a core competency developed through psychiatric nursing, is significantly correlated with the experience of positive emotions in social interactions [16]. Therefore, the application of empathy instruction in psychiatric nursing is expected to help students experience positive emotions, leading to improvements in their academic performance in psychiatric nursing.

Therefore, the application of empathy instruction in psychiatric nursing allows students to experience positive emotions, which improves their academic performance in psychiatric nursing. However, owing to barriers such as technological issues, a lack of interaction, and insufficient faculty training, applying empathic instruction to virtual spaces has been challenging [9]. As a result, there is a lack of studies that have implemented empathic instruction in psychiatric nursing courses. This study explored the experiences of nursing students in a psychiatric nursing class using empathic instruction in a virtual space. A phenomenological approach was used to deeply understand students’ emotional responses, personal reflections, and how meaning is constructed in interactions with empathic instruction. This method extends beyond surface-level observations, making it ideal for exploring emotional engagement and complexities of psychiatric nursing education. This was applied to analyze the students’ learning experiences in depth.

Methods

Study design

This study explored the learning experiences of college students who participated in a psychiatric nursing class that used empathic instruction in a virtual space. Consequently, the descriptive phenomenological method by Giorgi [17] was utilized. This is suitable for describing individuals’ lived experiences and comprehending them from their perspective.

Participants and setting

The participants were juniors in a nursing college located in Jechun, Chungcheongbuk-do, who were enrolled in a psychiatric nursing class in the fall semester of 2021. The study utilized purposive sampling for participant selection. Of the 106 students enrolled in the course, 14 expressed their willingness to participate in the study. They were contacted and provided an explanation of the study procedure and interviews were conducted until data saturation was achieved. Consequently, 11 participants (female: 10, male: 1) were included in the final analysis. Their mean age was 23.3 years (21–26). The mean grade and overall grade in the psychiatric nursing class were 4.04 (2.5–4.5) and 4.01 (3.4–4.42) out of 4.5, respectively. All participants had attended a psychiatric nursing class in a lecture format (Table 1).

Table 2 summarizes the structure of empathic instruction applied in the psychiatric nursing class. The strategies of empathic instruction, as proposed by Lee and Kim [12], were employed throughout the course. The class structure consisted of pre-lesson activities, the main lesson, and post-lesson activities. In the pre-lesson activities, educational materials and video clips were provided to give students a preview of the lesson content. Students were asked to write down any questions or thoughts they had, allowing the instructor to better understand the students’ academic level and learning needs. In the main class, the instructor created and uploaded a video lecture that addressed the questions collected before the lesson. This approach ensured that the class content was directly related to students’ queries, making the learning experience more relevant and engaging.

For the post-lesson activities, students were instructed to jot down any further questions or reflections after watching the video lecture. This reflection process encouraged students to engage critically with the content. The instructor then summarized answers to the questions raised and created additional learning material, which was uploaded in a PDF format for further clarification. Furthermore, creative strategies were employed to promote student interaction and peer learning. These included discussion boards for students to engage in discussions and “think-pair-share” assignments, where students worked in pairs to identify similarities and differences in their responses. These strategies fostered an interactive and collaborative learning environment, enabling students to connect with one another and deepen their understanding of the material.

Table 1 Participants’ characteristics

Table 2 Structure of empathic instruction

Data collection

The data were collected between February and March 2022. Empathic instruction was applied in a 2-credit psychiatric nursing course over a 15-week period, including mid-term and final exams. After grading the students’ academic performance, the psychiatric nursing professor retired. Two months after the professor’s retirement, a research assistant sent the study’s description and consent forms for participation to the students via email. The students were assured that their participation would not affect their future grades. Written consent was obtained from all participants before the interviews.

The co-authors of the study conducted one-on-one semi-structured in-depth interviews with the participants. Each interview lasted approximately one hour. Although the interviews were initially planned to be conducted in person, due to the social distancing restrictions during the COVID-19 pandemic, the interviews were carried out through Kakao Messenger or video calls based on the interviewees’ preferences. The researchers maintained consistency by asking the same questions to ensure the conversation stayed on topic, and they shared the interview transcripts with each other to ensure a consistent approach to data collection.

Additionally, the researchers took precautions to avoid personal bias by recording and repeatedly reviewing their personal thoughts on empathic instruction, ensuring that these thoughts did not influence the interviewees. Follow-up interviews, lasting approximately 30 min, were conducted to address any further explanations or additional questions. All interviews were recorded with the participants’ consent, and the recordings were transcribed by research assistants. Participants were given the opportunity to review the transcriptions to ensure the accuracy of their responses. The initial interview question was, “Please describe your learning experience from the psychiatric nursing class you took in the fall semester of 2021.”

Ethical considerations

Ethical approval was granted by Semyung University in Chungbuk (Approval No: SMU-2022-02-001). Participants were provided with oral and written information describing the study’s objectives and procedures, anonymity, confidentiality, and the right to withdraw from the study at any time. A research assistant sent our study’s description and the consent forms for participation to the students via email. Written consent for the publication of potentially identifiable information was collected from all the participants before the interview.

Data analysis

The interview transcripts were analyzed using Giorgi’s [17] phenomenological research method. This process involves the following three steps. In the first step, each author read the transcripts several times to fully understand the interviews’ contents. The authors attempted to understand how participants experienced learning in the psychiatric nursing class without bias or preconceptions to the best extent possible. In the second step, the authors divided the transcripts into meaning units. A meaningful statement is called a meaning unit in the phenomenological method. Each author demarcated the meaning units in the interview transcripts independently.

In the third step, meaning units were transformed more explicitly in a language that revealed psychological aspects of the lived experience for the phenomenon under investigation [15]. The data were coded by the two authors individually. Each author transformed each meaning unit of the participants’ words into psychologically sensitive expressions. After completion of the first coding of data, the authors met once a week for several weeks to discuss the similarities and discrepancies among the identified codes to extract common themes. Examples of themes are presented in Table 3.

Table 3 Themes derived from the analysis

Trustworthiness

The trustworthiness of this study was ensured by utilizing Lincoln and Guba’s [18] criteria for credibility, fittingness, auditability, and confirmability. Interview data from the participants were transcribed by the researcher who conducted the interviews to enhance credibility. During the analysis, recurring themes and patterns were identified while maintaining the participants’ perspectives. Fittingness was confirmed through member checking, in which participants were asked to review interview transcripts and results to ensure that their experiences were accurately reflected.

Auditability was achieved by maintaining detailed records of decisions made during data collection, analysis, and interpretation and ensuring transparency in data processing and analysis. To ensure confirmability, the research team continuously discussed and reflected on biases and assumptions. Multiple team members cross-checked all interpretations to ensure that the results were based on the participant’s actual experiences rather than on the researchers’ preconceived notions to minimize researcher bias.

Additionally, the results were reviewed and revised multiple times to address any potential biases or assumptions. All co-authors cross-checked the final results to ensure that the conclusions reflected the participants’ actual experiences and were not influenced by external biases. This iterative process strengthens the trustworthiness of the findings.

Results

Four main themes were derived from the data: “Interaction as a tool for learning,” “Repetitive learning,” “Enjoyable but overly detailed feedback,” and “Chance of self-improvement.”

Interaction as a tool for learning

This maintheme highlights the significance of interaction between students and professors as a primary learning tool. It consists of two themes: “Modeling the professor” and “Motivation through interaction.” The participants reflected on how they learned to engage with others by observing the professor’s interactive teaching style, which included pre- and post-lesson engagements. Additionally, they adopted the professor’s passionate attitude, which inspired them to invest more effort in their studies.

I felt that the professor put in a lot of thought and effort so that we could focus on the subject instead of just studying for grades. Seeing him passionate about teaching the course motivated me to study hard. (Participant I)

I could learn good manners and attitude toward others through frequent interaction with the professor. I also realized the importance of paying attention to the context and logic in writing so that the readers can better understand the content. (Participant K)

Moreover, assignments given before and after lessons helped maintain consistent engagement with the professor and peers, motivating students to learn and interact. The professor’s feedback, despite remote learning, was consistent, which contributed to the students’ engagement. Furthermore, seeing various perspectives on the same topic contributed to a richer understanding.

When I saw his comment on my posting or found his comment different from the ones he wrote for others, I felt motivated to work harder on my assignments thinking that he was going through my work. (Participant G)

Repetitive learning

Repetitive learning comprised the “Effect of repetitive learning” theme and contained the following subthemes: “Opportunity for immediate review,” “Opportunity for sufficient learning,” and “Satisfying curiosity through discussions.” Participants perceived many opportunities to learn during the psychiatric nursing class in the pre-lesson, main lesson, and post-lesson stages. This allowed an immediate review of what was learned. This satisfied the students’ curiosity during the learning process.

Discussions were very helpful. Questions naturally arise when you listen to a lecture, and I could ask those questions during discussions and the professor gave me clear answers. At first, I was worried about whether I could take notes of the discussions every week. But over time, the discussions not only clarified and answered the questions I had but also helped me summarize what I learned that same day, allowing me to review the materials right away. (Participant F)

Enjoyable but overly detailed feedback

Enjoyable but overly detailed feedback comprised two themes: “Immersive lecture video” and “Too detailed explanation.” Most participants, except for A and E, expressed that the video lecture was fun and easy to comprehend. They were satisfied with the lecture’s structure, which was based on the students’ questions and the use of various examples for better understanding. However, participants A and E asserted that explanation for some of the easier materials was too lengthy and elaborative which led to boredom. Additionally, they felt that the overall duration of the video was long, which made it difficult to concentrate. The lecture clips usually lasted 40–50 min, but participants felt that it would be better to reduce the length of explanations for easy materials to 25–35 min, as this would help maintain focus and prevent students from feeling overwhelmed.

Interestingly, while most students appreciated the detailed feedback, the contradictory opinions from participants A and E highlight that overly detailed feedback could actually have a counterproductive effect, leading to disengagement. This finding suggests that while detailed feedback is generally seen as beneficial, it is essential to strike a balance to avoid overwhelming or losing the students’ focus, especially for more straightforward content.

The contradiction between students’ feedback regarding the effectiveness of detailed explanations versus their potential for boredom underscores the need for adaptability in teaching methods, indicating that different learners may respond differently to the same instructional strategy.

It was the only lecture that I enjoyed among all the lectures using LMS that I took. I got curious as to how to become a psychiatric nurse so I searched online. The professor gave us clear examples so it was easy to understand the materials without spending extra time studying. I could also concentrate on the lesson more easily as it felt like listening to a story rather than taking a lecture. However, I felt a little bored when there was too much explanation of details when the materials were easy to understand. The lecture clips usually lasted 40–50 minutes but I think it would be better to cut down on the explanation of easy materials and reduce it to 25–35 minutes. (Participant A)

Chance of self-improvement

This theme centers around the self-growth and transformation that participants experienced during the psychiatric nursing course. The participants reported initial discomfort, especially in writing assignments and sharing opinions. However, continuous participation and exposure to diverse perspectives gradually helped them reduce biases and increase their self-confidence.

Participants also reflected on how the class fostered desirable learning habits and self-motivation. Engaging in self-reflection and participating in class discussions contributed to an enhanced sense of autonomy in learning and greater self-awareness. These outcomes marked a shift from reliance on external validation to internal motivation for learning.

It was hard to write down my opinion at first, but I had to participate because it was part of the evaluation. But over time, repeated writing made me reflect on my thoughts and realize the prejudice I had. Reading others’ posts often also helped me become more receptive to different opinions. (Participant C)

I’m an introvert so I normally don’t ask questions during class and ask my friends or look for the answers from books. But the instructor gives us an opportunity to ask questions every week, so I got to experience the benefit of asking questions in class. I gained more confidence as they answered my questions and I got to come up with even more questions. I became more confident and I don’t hesitate to ask questions anymore. My attitude in class completely changed. (Participant G)

However, there were some contradictions in the responses regarding the overall impact of these changes. Some participants reported feeling increased self-confidence, while others experienced initial discomfort in writing and sharing opinions. Despite these mixed feelings, all participants reported growing confidence in their learning abilities, suggesting that self-reflection and participation in discussions were critical to the development of their self-awareness and learning strategies.

Discussion

This study examined the learning experiences of nursing students who took a virtual psychiatric nursing class that used empathic instruction. The following main themes were derived from the participants’ learning experiences: “Interaction as a tool for learning,” “Repetitive learning,” “Enjoyable but too detailed feedback,” and “Chance of self-improvement.”

The first theme derived from the participants’ responses was “Interaction as a tool for learning.” Through their interaction with other students and the professor, the participants developed an interactive attitude. The responses from the professor and other students also motivated their learning. Other studies have affirmed the positive effects of interaction with professors and other students. In a survey on an e-learning lesson in Austrian college students, it was shown that counseling and support from the professor were the most desirable predictive variables for academic achievement and course satisfaction. Cooperative learning was also associated with academic achievement [19].

For 59% of students who learned remotely due to the COVID-19 pandemic, empathy from an instructor was a major factor influencing their participation in the college course [9]. Specifically, a study with nursing college students showed that student–instructor and student–student communication strategies contributed to effective learning in an online nursing class [20]. Furthermore, a study analyzing the immersion experiences of Korean nursing college students taking a psychiatric nursing class revealed “instructor as a facilitator” as a major theme, verifying the essential role of nursing educators for students’ immersion in class [12]. Therefore, our study results suggest that specific strategies for online lectures that allow effective interaction among the attendees in the class should be designed [20].

The second theme was “Repetitive learning.” The participants were satisfied with the structure of the class that allowed repetitive learning. These results show that the structured class design from pre-lesson preparation to post-lesson assignments was effective in understanding the main concepts [21]. Therefore, our findings suggest that nursing educators should consider a structured class design characterized by repetitive learning of the major topics when offering nursing classes virtually.

The third theme was “Enjoyable but overly detailed feedback.” Although most participants were satisfied with the video lecture that was created based on the students’ questions, few felt the duration of the video lecture to be long with detailed description of some of the materials. Thus, the strategy for achieving cognitive empathy should be modified in psychiatric nursing classes. Feedback is crucial in online learning; it can sometimes be overly generalized or delayed, leading to student disengagement [20, 21]. A study examining Korean college students’ preferences for video lectures showed that students in their 20s considered 45 min to be the ideal length for video lectures, and a lengthy description contributed to their dissatisfaction with the lectures [21]. This suggests that delayed or overly detailed feedback can overwhelm students and detract them from the course’s overall effectiveness. This concern suggests that instructional design may need to balance depth and brevity to maintain students’ attention, especially in a virtual setting where the attention span can be shorter.

Although the video lecture in this study lasted 40–50 min, which met the standard of 45 min for video lectures, lectures of 25–35 min might be more suitable due to pre- and post-lesson assignments in addition to the video lectures. Therefore, the duration of video lectures should be reduced in accordance with the number of questions to be discussed in class. Most participants expressed satisfaction on receiving feedback regarding their questions from post-lessons. Hence, covering basic materials in class and offering opportunities to ask questions in post-lessons is a good alternative.

The last theme was “Chance of self-improvement.” Although at first the students were reluctant to participate in class, they began participating actively over time after experiencing its benefits. Consequently, not only did their learning abilities improve, but it also provided them the opportunity to improve their learning attitude, expand their thoughts, and begin self-exploration.

This study’s results support those of previous studies that active participation from students creates interest and insight into learning, and helps them pursue in-depth knowledge and expand their thoughts [22, 23]. Therefore, instructors should prepare specific plans for all attendees to participate in class and provide them with opportunities of active participation—especially for Asian students who tend to take on a passive role and are unfamiliar with open discussion [24]. Therefore, more systematic educational strategies are needed to increase Korean students’ participation in remote learning.

Limitations of the study

This study has some limitations. First, it specifically analyzed the learning experiences of Korean nursing students who took a virtual psychiatric nursing class that used empathic instruction; hence, the results cannot be generalized to nursing students from different sociocultural contexts. Further research is needed on applying the course in different sociocultural contexts. Second, the study had a gender bias as only one participant was a male. Although this reflects the nature of the female-dominant nursing college, the results may be influenced by gender as a factor. Additionally, the study’s focus on the structure of the course and the benefits of repetitive learning may have overlooked the challenges that students face when adapting to a virtual format, particularly in terms of motivation and participation, which may require further exploration.

Further research and implication for practice

The study findings demonstrate that an instructors’ thoughts and efforts regarding student interactions are necessary in virtual psychiatric nursing classes. Through efficient and effective interactions, instructors should aim for a state of cognitive, emotional, and behavioral resonance with students. Thus, they should create a systematic and structured learning environment according to students’ academic level and promote their reflection. Therefore, studies on achieving a state of cognitive, emotional, and behavioral resonance of nursing students by the instructor in remote learning, as well as development and evaluation of specific strategies in achieving this, are needed. Additionally, providing video lectures of an ideal duration and offering feedback considering individual differences in academic performances are critical in virtual psychiatric nursing classes. Hence, a follow-up study exploring the strategies used to provide feedback and the lecture’s effective design and length in a virtual psychiatric nursing class is needed.

Conclusions

This study described the learning experiences of nursing students who participated in a remote psychiatric nursing class that used empathic instruction. A phenomenological approach was employed to understand and describe the participants’ perspectives. Students’ learning had a positive impact through interaction with the professor and other students, repetitive learning, receiving answers to questions, and self-reflection. The most crucial aspect is the instructors’ understanding of the importance of efficient and effective communication and constant efforts to achieve a state of resonance with the students. Therefore, instructors should understand the importance of interaction and achieving a state of resonance with the students in virtual psychiatric nursing classes and thereafter develop effective educational strategies that complement the format of conventional lectures.

Relevance for clinical practice

Studies in which empathic instruction has been applied in virtual spaces for psychiatric nursing classes are scarce. Thus, in this study, empathic instruction was applied to a psychiatric nursing class in a virtual space. Students reported experiencing positive emotions that could improve their academic performance. The findings demonstrate that empathic instruction, reflected in an instructor’s thoughts and efforts, could facilitate student interactions in virtual psychiatric nursing classes.