A quasi-experimental research design was utilised to determine the study’s objective. The study was carried out at the Department of Nursing, College of Applied Medical Sciences, Shaqra University. This study was approved by Internal Review Unit, College of Applied Medical Sciences, Shaqra University (Unit number 20-202). Before conducting the survey, students were assured that the data were collected from questionnaires will remain confidential and that no personal identification was required. Students were informed that they could refuse to participate in the study, or withdraw from it at any time without giving any reason. Consent was acquired from every student who agreed to participate in the study.

The sample included 80 nursing students enrolled in the academic year 2019-2020 undergoing the psychiatric mental health nursing experience. A non-random sampling i.e., convenience sampling was used. All students in the college (n=156) were invited, the sample size was calculated using 95% confidence level and 5% margin of error to arrive at the required sample size which was found to be 72. The participants were exposed to the program as a stratified random sample according to their previous academic year. The eighty participants were classified into five groups, each group consisting of 16 students to help the researcher evaluate the students’ observational abilities and determine what they missed.

The following instruments were used for data collection:

The pre-test format was applied for assessing the students’ knowledge about observation. The time allotted for the pre-test was one hour and to be answered before and after the program. The pre and post-test contained two forms of questions; Questionnaire 1 contained theoretical form, which had multiple-choice questions and cross-matching related to definition, purposes, types, principles, importance of observation, advantages, disadvantages, process of observation, obstruction to view, steps to overcome this obstruction and psychological factors of consideration for psychiatric nursing.

The second part of the tool is an observational checklist for psychiatric patients in the clinical area. This checklist was designed by the researcher, which contained knowledge related to mental illness such as facial expression, appearance, dress, personal hygiene, posture, appetite, patient relationship, motor activity, orientation, consciousness, memory, thought, mood, affect, attention, speech and perception.

Scoring system: The scoring system for the answers was “1” for a wrong answer, and “2” for a true answer, the total score for this tool was evaluated as follows:

26=Poor knowledge

27-39=Average knowledge

40-52=Good knowledge

The observational rating scale for each student was the second tool designed by the researcher and was constructed basically for the following purposes: identification of minimal standards of performance of each ability to be developed in the clinical area, measuring and monitoring of the proficiency of the students’ performance.

This scale contained ten expected abilities, and each capacity was rated in three possible ways:

1) Weak means the students failed to reach the required level of performance for the skill.

2) Good means the students meet the standard performance.

3) Excellent means skills performance of the natural ability was perfected.

Scoring system: The scoring system for the answers was “1” weak performance “2” for good performance and “3” for excellent performance; the total score for this tool was evaluated as follows:

10-16=Weak performance

17-23=Good performance

24-30=Excellent performance

The operational design of the study includes the preparation phase, pilot study, and fieldwork for data collection.

Preparatory phase includes reviews of local and international related literature. Various aspects of the research problem, which helped the researcher to be acquainted with the magnitude of the problem, and prepare the required data collection tools. The researcher then tested the data collection tools for face and content validity using interrater agreement method by five experts from the psychiatristic nursing department. The interrater validity results were modest. On the other hand, the reliability test were performed using test retest method. Spearman’s rank correlation coefficient were showed acceptable reliable results.

Pilot study: During the preparatory phase, a pilot study was applied to 10 students, chosen randomly from the mental health nursing students. The pilot study aimed to evaluate the content of the pre-post format, clarity of language, and identify the validity and reliability of the items.

Fieldwork: The fieldwork was done on 80 students. They were classified into five subgroups, and each consisted of 16 students. Each session lasted approximately 30 to 60 minutes with a total of 24 sessions. The program was implemented in the form of brainstorming and group discussion. Suitable teaching aids prepared specially for the program were: booklet, flipchart, video, and real situations.

The first session contained an orientation to the plan and its purpose, second; students were informed about the items and place of the courses. Third session covered issues of booklet guidelines; the duration of each session was one hour. Twenty sessions were conducted and they included four activities:

The duration of each practice session was one hour, including a period of discussion:

1) Booklet guidelines

The researcher distributed booklet guidelines to help students identify some information about the observation.

2) Role-play

The main aim of the role play was to help students to live the experience, and to be able to analyse the situations. Providing students with the opportunity to work with and observe other students and encourage students to discriminate between functional and less ethical aspects of performance. The role play sequence included:

1) Read the context and goal

2) Enact the nurse/patient roles

3) Discuss the effectiveness of the observation demonstrated in playing the nurse role with feedback from the student observations.

4) Students’ questions in role-playing were redirected back to the students themselves for discussion during the role-play itself.

Learning activities: these were based mainly on the followings:

3) Group discussion

The main aim was to provide an opportunity for a small group of students to meet with the instructor at the end of a practice session in the ward for the following.

4) Actual clinical situation.

The main aim was to let the students examine their skills in the light of new ideas or change their attitudes about the way, they approach their work in a clinical area.

The observational exercises were done daily, and students were divided into five groups to help the researcher evaluate the students’ observational abilities.

Observational exercises done in the clinical area were:

The collected data were organised, coded, computerised, tabulated, and analysed by using the Statistical Package for Social Sciences (SPSS), version 24. The analysis performed included percentage distribution, chi-square (χ²) and correlation coefficient. A p<0.05 was considered as statistically significant.

Socio-demographic profile of the respondents showed that more than half of students were aged between 19-20 year-old and mostly single. Furthermore, all were full time students and 95% of them didn’t have any preparatory training on psychiatric nursing observation as reflected in [Table/Fig-1].

Comparison of pre-program and post-program scores in all items related to students’ knowledge revealed a highly significant improvement in student’s scores (p<0.001). Though the level of significance was high in all items, the χ² value ranged from 9.20 to as high as 47.216 showing variations in students’ response in different items. The results were an indication that knowledge related to observation and knowledge related to mentally ill patients were significantly enhanced due to training programs, as shown in [Table/Fig-2,3].

Similarly, a significant difference (p<0.001) in observational rating scale was observed in all ten items, when pre-program scores were compared with post-program scores. The χ² values ranged from 19.4 to 56.9 and this is shown in [Table/Fig-4]. As seen in [Table/Fig-5,6], a highly statistically significant improvement in post-nursing intervention results compared to pre-intervention (p<0.001) was also observed in prevalence of total knowledge score and total observational rating score of nursing students.

Observation for the nurse was defined by Al-Moteri MO et al., as a ‘new awareness of the whole situation, combined with the ability to control and direct attention towards correctly selected specific stimuli’ [7]. Observation is a common factor in all areas of nursing care. The technique of view is concerned with four facts: what to observe, how to follow, the implications of view and action following the observation [8].

Concerning the socio-demographic characteristics of the nursing students, more than three-fifth of nursing students were in the age group 19 to 20 years with a mean age of 20.45 and more than three quarters were single. Also, the highest percentage of them didn’t work besides studying and did not attend training courses about psychiatric nursing observation. Stress is known to affect observational skills. Stress depends on age, relationship and work [9]. Since, students were single and not working, it can be said that they had low levels of stress. Furthermore, students were from 4^th year nursing and they had experience, which also might have contributed to enhanced learning. It is known that making observations without knowledge is like seeing the patients through dark glasses [10]. So, training younger 4^th year students about observational skills led to enhanced score during post-program study. A similar result with training was reported by El-Salamony A et al., wherein students who had received training in dealing with different situations in the clinical area were able to observe accurately the actual mental state of the patients than those who had not [11].

The finding of the present study revealed a highly significant difference between the pre/post-training programs in all items of students’ observational rating scale. This indicates that students trained in observational skills succeeded in recording their observations comprehensively, intelligibly and accurately. Students’ enhanced score may also be due to student’s excursion into the field of experience through a series of group meetings. During these meetings, students exchanged accounts of their skills and discussed the content of each other’s written report on the patients. Students were also taught how to identify changes in patients’ physical state such as constipation or diarrhoea, as an indication of physical disease. In addition, they were guided that it is important for a psychiatric nurse to be thoroughly familiar with adverse effects such as nausea and vomiting that may result from administration of psychotropic drugs and that these should be reported to the medical staff [12].

According to George’s University Hospitals [13], observations by nurse would lose their value, if accurate and complete records of their findings are not kept. George’s University Hospitals also added that when observing the patient’s, the nurse should not only follow the patient’s conscious level, colour, vital signs at intervals but the nurse should remain receptive or sensitive to stimuli emitted by their patients. The results also showed that the students who were trained for observation had succeeded in describing patients’ signs and symptoms. It may be attributed to students’ view in a given situation such as selected experiences that were designed to provide increasingly complex observation of physical manifestation and students were also trained in role-play techniques to simulate events and behaviour. The present study design and its results provide a comprehensive methodology to increase nurses’ perception and this protocol can also be used by healthcare institutes to train future nurses.

A highly significant improvement in post-nursing intervention compared to pre-intervention (p<0.001) regarding the prevalence of total knowledge scores of nursing students was observed. This was due to role-play techniques that helped students to pick up minute cues, which added up to significant observation during real situations and activities.

This study presented a highly statistically significant improvement in post nursing intervention results compared to pre-intervention (p<0.001) regarding the prevalence of the observational rating scale of nursing students. It may be due to the situation enacted by the students to play the role of the patients during aggression, and other students observing them and picking up minute cues, which added up to the highly significant observation. It may also be due to the techniques that were used in the different situations such as brainstorming techniques, wherein student groups produced a list of everything they saw in a set of the case, and they were picking out the elements irrespective of value. This technique helped students to produce observational priorities as well as establishing a group of consensus on observation. Group discussions that were held daily during the clinical area to discuss essential items related to the situation that suddenly happened in the clinical area such as epileptic fit, aggressive or excited patients, and suicidal patients also contributed to increased observational scores. The students were trained in reporting all elements of change of the patient’s behaviour and not only the overt or observable behaviour but also the covert or hidden causes of the action.

Primarily the objective of the study brings the results of the study show that training program using the tools mentioned in this study will help future nurses in their observational skills for better understanding about the essential behavioural approach in dealing with patients with mental health illness. Furthermore, this will be beneficial for healthcare institutions and boast the confidence of the future nurses’ ability to provide optimal health care for all patients having mental illness.

To conclude, training program enhanced nursing students’ knowledge and performance in observational skills. A highly statistically significant difference was observed between pre/post-training programs in all items of psychiatric nursing students’ knowledge. All elements of students’ observational rating scale were also increased. This goes to show that early trainings for future nurses can be effective when the program will be adopted. Thus it would be beneficial for both the future nurses and the healthcare institutions, if the educational institutions would accommodate the training programs this study has provided.