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Implementation of Mental Health Simulations: Challenges and Lessons Learned
Clinical Simulation in Nursing (2013) 9, e157-e162
www.elsevier.com/locate/ecsn
Featured Article
Implementation of Mental Health Simulations: Challenges and Lessons Learned Shoni Davis, DNSc, RN*, Jayne Josephsen, RN, MS, Rosemary Macy, RN, PhD School of Nursing, Boise State University, Boise, ID 83725, USA KEYWORDS baccalaureate nursing students; challenges faced; lessons learned; mental health simulations; standardized patients; psychiatric nursing
Abstract: Boise State University School of Nursing faculty faced several challenges and learned important lessons in attempting to implement mental health simulations with standardized patients when clinical practicums with actual patients were no longer an option. Challenges faced included (a) establishing strategies to recruit a large pool of authentic standardized patients, (b) determining the optimal level of complexity for each simulation, and (c) providing useful feedback to students about noted deficiencies while at the same time making the reflections a positive experience. Important lessons are shared that may help other faculty avoid similar challenges. Cite this article: Davis, S., Josephsen, J., & Macy, R. (2013, May). Implementation of mental health simulations: Challenges and lessons learned. Clinical Simulation in Nursing, 9(5), e157-e162. doi:10.1016/ j.ecns.2011.11.011. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Introduction Boise State University (BSU) School of Nursing offers baccalaureate education to more than 70 students each semester. In the past, nursing students participated during their fourth semester in a three-credit mental health practicum that included placements in community mental health settings. However, as more health education programs compete for placement sites, mental health clinical placements have become difficult to secure. Shorter patient lengths of stay in acute care settings also make it harder for students to experience consistency with patient care (Brown, 2008). To further complicate matters, the state of Idaho has cut mental health funding over the years in efforts to balance its budget, resulting in mental health agencies’ being forced to shut down. As a result, it has become very difficult for BSU School of Nursing to maximize mental health learning opportunities for students. * Corresponding author: [email protected] (S. Davis).
In 2009 it became necessary to decrease the mental health practicum from 9 hours per week to a 3-hour-per-week observation-only experience. Although this approach helped with the placement dilemma, community mental health partners found this to be disruptive to staff and patients and did not feel this experience was conducive to student learning. Therefore, in spring of 2010, BSU School of Nursing replaced the mental health practicum with an inhouse lab that includes simulations with standardized patients. This transition from practicum with actual patients to simulated scenarios with standardized patients has been both rewarding and fraught with challenges in trying to create authentic and supportive learning opportunities for students.
Purpose The purpose of this article is to discuss challenges faced and lessons learned by BSU nursing faculty in attempting to develop and implement mental health simulations with
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2011.11.011
Implementation of Mental Health Simulations
e158
standardized patients in lieu of practicums with actual patients. Challenges included (a) establishing strategies to recruit the large pool of authentic standardized patients necessary to fill the number of simulations provided each semester, (b) determining the optimal level of complexity for each simulation, and (c) providing useful feedback to Key Points students about noted defi Thinking outside of ciencies while at the same the box can enhance time making the debriefings recruitment of standarda positive experience. ized patients for mental health simulations. To eliminate fear and Theoretical anxiety among stuFramework dents, keep goals and outcomes achievable According to Kaakinen and when developing menArwood (2009), a conceptual tal health simulations. framework should be used So that students to fowhen developing and implecus on actual learning menting simulations. Kolb’s experience and be (1984) experiential learning more open to receivtheory provides a theoretical ing constructive feedframework to guide the deback, avoid overly velopment and implementacomplex mental health tion of simulations for simulation scenarios. nursing education. According to Kolb’s theory, learning occurs in a four-stage process that includes (a) concrete experience, (b) observation and reflection, (c) abstract conceptualization, and (d) active experimentation. Kolb postulated that learning occurs when students are actively engaged in knowledge acquisition through hands-on experience with problem solving and decision making, followed by active reflection. The four-stage process defined in Kolb’s (1984) experiential learning theory provided the framework used in developing and implementing the BSU mental health simulations. As part of the mental health simulations, nursing students participate in concrete learning experiences in which they practice nursing skills with a high-fidelity simulated patient. Based on Kolb’s stages of experiential learning, student nurses acquire knowledge of mental health nursing through this reflective practice and the conceptualization of abstract ideas (Welch, Jeffries, Lyon, Boland, & Backer, 2001; Williams-Perez & Keig, 2002).
Background and Literature Review Assumptions and prevailing beliefs regarding mental health issues are often mired in stigmatization, which can result in fear and a lack of confidence among nursing students when interacting with mental health patients. This fear and a lack of confidence can hinder learning opportunities and the integration of knowledge and insight (Good & Moss-Racussin,
2010; Happell, 2008). Therapeutic use of self is a primary tool used in mental health nursing (Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009), and assessing students’ competency in therapeutic communication can be difficult when conversations with patients occur indiscriminately. Challenges posed in mental health make simulations especially beneficial to nursing practice. The advantages of simulation as a teaching pedagogy can overcome some of the disadvantages that occur when nursing students participate in mental health practicums, making simulations a viable option for instructing and mentoring students in the application of clinical nursing skills. All levels of mental health education have successfully applied simulation as a teaching strategy (McNaughton, Ravitz, Wadell, & Hodges, 2008). Simulations include the ability for faculty to pair course objectives with standardized patient encounters and to provide students with comparable chances for experiential learning opportunities (Becker, Rose, Park, Berg, & Shatzer, 2006). Further benefits of simulation include the ability to reconstruct a realistic clinical setting in which patient safety is not threatened, nursing students can participate in active learning, and errors can be corrected and discussed immediately (Fletcher, 1995). Mental health nursing is unique in that the core elements include therapeutic use of self, communication, and assessment skills. The traditional simulation using computerized manikins does not provide a realistic scenario in which to practice these essential skills. Instead, mental health simulations typically use standardized patients, defined as individuals trained to simulate an illness in an accurate and consistent manner (Becker et al., 2006; Wallace, 2007). Standardized patients are considered high fidelity because they replicate authentic patient care situations and provide credible interactions for students (Jefferies, 2007). Standardized patients were used in simulations as early as 1963 (Barrow & Abrahamson, 1964), and their use has progressed over the years to include an effective means for evaluating the competency of clinical skills (McNaughton et al., 2008). Additionally, the use of standardized patients has been shown to be an effective strategy for practice and evaluation of communication skills and assessment abilities (Shawler, 2008). Simulations with standardized patients can provide opportunities for students to explore, in a safe and nonthreatening environment, their fears and anxiety related to caring for mental health patients, and can provide experiential learning opportunities to enhance skill development.
Development and Implementation Strategies for Mental Health Simulations During the process of developing and implementing mental health simulations to effectively fill the gap that resulted from eliminating practicums with actual patients, BSU nursing faculty faced challenges that had to be overcome in
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order to make the simulations a positive and meaningful experience for students and faculty.
Challenge 1: Recruitment of Standardized Patients The first challenge to be addressed when developing and implementing mental health simulations was the recruitment of standardized patients. As many as 70 nursing students, assigned to small groups, partake in a series of six mental health simulations each semester. A large pool of standardized patients was necessary to accommodate the number of hours needed for the simulated activities. To be authentic, standardized patients must possess the capacity to portray a clinical situation in such a way as to guide student nurses into asking appropriate questions and practicing formative skills in order to develop comfort in managing sensitive patient issues (Becker et al., 2006). When trained effectively, standardized patients can report on the personal aspects of the nurseepatient encounter from the perspective of the patient and reveal whether the patient’s needs were met (Teherani, Hauer, & O’Sullivan, 2008). With these goals in mind, BSU School of Nursing set out to recruit a pool of competent and realistic standardized patients. The School of Nursing initially engaged in a partnership with the BSU Theater Department. Theater students were given the option of earning independent study credits for signing up to be standardized patients for the mental health nursing simulations. What was most appealing to the theater students was obtaining unprompted, improvised acting experiences, which the simulations offered. This approach proved to be an excellent source of standardized patients as the theater students were creative and eager to demonstrate their acting skills and came to the simulations well prepared to authentically portray their assigned patient role. The problem, however, was recruiting enough theater students to accommodate the number of hours needed for the simulations. While the option for theater students to participate as standardized patients in mental health simulations continues, it became apparent very soon that another strategy was needed to help fill the simulation slots. Taking advantage of the strong service-learning focus advocated by BSU, nursing faculty next initiated a partnership with the Department of Psychology through the BSU Service-Learning Department. Service-learning is a teaching and learning strategy that integrates community service with instruction and reflection to enrich the learning experience, teaches civic responsibility, and strengthens communities (Thompson, Smith-Tolken, Naidoo, & Bringle, 2011). Through a collaborative effort involving the School of Nursing, the Psychology Department, and the Service-Learning Department, undergraduate psychology students who are required to participate in service
learning as part of their course requirements can become standardized patients for the mental health nursing simulations as their service-learning project. Psychology students who assume standardized patient roles are responsible for creating, on the basis of the symptomatology that characterizes the mental health disorder, the ‘‘character’’ they agree to portray. To help them prepare, psychology students are provided with preparatory materials from the School of Nursing, as well as video and Web site resources. In addition, psychology students are required to participate in at least 1 hour of rehearsal time prior to each simulation, as part of their service-learning requirements. BSU nursing faculty knew that streamlined procedures would need to be developed in order to efficiently meet the demand of recruiting and training the large pool of standardized patients each semester. The Simulation Center Coordinator is responsible for organizing the recruitment of psychology students and ensures that all contract requirements are handled with the Psychology Department. The coordinator and mental health faculty work together to set up designated orientation and rehearsal times for psychology students. Several half-day rehearsal times are made available throughout the semester. Psychology students can schedule rehearsals during any of these time slots that best meet their schedules and can rehearse for multiple simulations at one time. To further streamline the process, standardized patients can rehearse in groups, which not only saves time but provides the opportunity to learn from each other. During postsimulation debriefings, standardized patients provide valuable feedback to student nurses about how the nursing care was perceived from the patient’s perspective. As noted by Teherani et al. (2008), the feedback provided by standardized patients regarding the empathic behavior demonstrated by nursing students provides the opportunity to identify and remedy deficiencies. Overall, both nursing and psychology students take away a deeper sense of awareness regarding mental health issues. The positive evaluations from psychology students have resulted in a significant increase in the numbers who choose the mental health simulations as their servicelearning project. In just two semesters, the number of psychology students signing up to be standardized patients increased from 5 to 12, and an additional psychology faculty member has included the mental health simulations as an approved service-learning project. Overall, the experience has been a win-win for both the BSU School of Nursing and the Department of Psychology.
Challenge 2: Determining the Most Effective Level of Complexity for Each Mental Health Simulation Because nursing students no longer participate in mental health practicums, the challenge for faculty was knowing
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how complex to make the simulations so that students have the opportunity to practice as many mental health nursing skills as possible, while still keeping the experience manageable. Mental health simulations can range from simple to complex, according to the level of uncertainty and the number of presenting patient problems (Jefferies, 2005). Studies suggest that to reinforce the reality of simulations, it is best to combine obvious signs and symptoms associated with specific medical problems with confusing and irrelevant data (Aronson, Rosa, Anfinson, & Light, 1997). Initially, faculty felt strongly that the simulations should be complex enough to provide the most advantageous learning opportunities for students. At first, the mental health simulations offered clinical situations that involved multifaceted concepts. For example, one simulation involved the nursing students having to decide, based on their assessment, the correct level of observation required for a patient admitted to the psychiatric unit following a suicide attempt. Based on their assessment data, the nursing goal was to determine whether the patient required restrictive, one-on-one observation or could be placed on a less restrictive treatment plan. To make the appropriate decision, the nurse had to obtain enough information to determine whether a suicide threat still existed and, if so, the lethality of the suicidal ideations. To complicate the scenario and make it more realistic, the standardized patient for this simulation had been trained to act in one of three ways regarding his or her failed suicide attempt: remorseful and embarrassed, angry that the suicide attempt had failed, or depressed and noncommunicative. The standardized patient could decide which of these three affects to display for each student nurse who participated in the simulation. The student nurse had to rely on theory and classroom knowledge to accurately interpret what the patient’s behavior might indicate. The standardized patient might also ask the nurse questions that required a knowledgeable response, such as ‘‘What will this medication the doctor wants me to take do to me?’’ It became apparent very quickly that students were struggling, as observed by their inability to progress through the simulations in a logical manner and to achieve the simulation goals. To aid in this endeavor, faculty attempted several different techniques, such as being present during the simulation to provide cues and to bookmark points during the video taping that could be used during debriefing to highlight positive interactions as well as areas needing improvement. Faculty members’ providing prompts and cues has been shown to be effective in redirecting students if they become stuck and do not know what to do next (Johnson, Zerwic, & Theis, 1999). Questions also arose about how to most effectively prepare students for each simulation. The amount of preparatory information to provide to students prior to simulations is controversial. There are those who recommend that to make simulations realistic, very little information should be provided (Barrow & Feltovich, 1987),
while others claim that providing detailed information to students before the simulation can decrease a student’s anxiety (Brown, 2008). BSU nursing faculty started off giving students detailed preparatory information, believing that it would help students come to a simulation prepared and feeling confident. As faculty saw that students were struggling during the mental health simulations, it was decided that too much preparatory information might be adding to perceived expectations and high levels of anxiety. Therefore, preparatory information was reduced to a short description of the presenting problem. In spite of efforts to support student success, all attempts by faculty appeared to add to the students’ anxiety, which quickly turned to frustration and a dislike for the simulation experience. Ultimately, the initial complex simulations were replaced with less complex scenarios. For instance, the suicide simulation described above was redesigned as a shorter vignette in which all student nurses have the opportunity to enter the patient’s room one at a time and practice assessing the patient’s suicidal ideations. As students are taught never to believe a suicidal patient’s first ‘‘no,’’ they are provided with a list of open-ended questions, obtained from the literature, that they can carry into the simulation on a clipboard and use to encourage the standardized patient to more openly discuss suicidal ideations and the available means of carrying out a suicide plan. An example of a question the nurse might ask is, ‘‘Walk me through how many times you have contemplated hurting yourself in the past week.’’ Although the standardized patient can still present a different affect for each interview, the less complex scenario allows the nursing students to become more comfortable about asking delicate questions and to delve deeper to encourage the patient to be more forthcoming. Because students do not feel as intimidated in these less complex simulations, they are able to gain a sense of accomplishment from the experience and as a result are more comfortable in discussing what they might do differently in order to improve. Student evaluations following these less complex simulations reflect a greater level of satisfaction, and many students have commented on the value of the experience and the applicable skills they gained.
Challenge 3: How to Conduct Debriefings That Can Provide Constructive Feedback while Allowing Students to Experience a Sense of Accomplishment Another challenge faculty faced was how to guide reflections following each simulation so that deficiencies could be brought up and discussed, while at the same time preventing students from feeling embarrassed and leaving the experience with a sense of failure. Postsimulation debriefing is important as it provides students with immediate feedback about their performance, their
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knowledge, and their decision-making capabilities (Aronson et al., 1997). Debriefings for the mental health simulations are especially important since they provide one of the only measurements of students’ mental health nursing skills. As a result, faculty felt torn between wanting to provide corrective feedback regarding noted deficiencies and wanting to make the debriefings a positive experience. Because students rarely felt successful in the initial complex simulations, they perceived the debriefings as stressful and embarrassing and were often unable to ‘‘hear’’ feedback as constructive. Faculty ended up feeling apprehensive about providing constructive feedback for fear of making students more anxious. As a result, students tended to miss opportunities to learn from their experience. Also during this time, standardized patients were providing feedback during debriefings, but with very little training on what to focus their feedback on. In their written evaluations of the simulations, students sometimes blamed standardized patients for making the simulation more difficult for the student nurse than necessary. Because of their discomfort level, students were unable to recognize that mental health patients often exhibit bizarre behaviors, are unable to cooperate effectively, and are often less than forthcoming in providing reliable assessment information. Bringing the simulations to a less complex level helped to transition the debriefings into a more positive experience. Allowing all students, rather than just a few, the opportunity to participate in the simulation and redefining the outcomes to be more achievable have resulted in students’ feeling less anxious and actually able to enjoy the experience. As a result, students have become more willing to discuss their own performance and ways they might improve for future simulations. This more relaxed atmosphere has allowed faculty the opportunity during the debriefings to offer students insights and constructive feedback that the students can perceive as helpful rather than critical. Faculty also began to work more closely with standardized patients in order to train them to provide feedback during the debriefing process. Rather than providing feedback that focuses on the patientenurse interaction, their feedback is now focused on their own emotional experience and whether their needs in the role of the patient were met during the simulation. This focus has been advocated by others for training standardized patients to provide feedback during the debriefing process (Teherani et al., 2008).
tapping into other student populations on campus, faculty was able to recruit a large pool of authentic standardized patients at no cost to the university. An added benefit is that the School of Nursing thus contributes to the learning experience of students outside nursing and brings students from other disciplines together with nursing students to share learning experiences. Mental health nursing is typically intimidating for students. Placing students in mental health simulations with no prior clinical experience adds to the level of anxiety. Students are not able to demonstrate the tools of mental health nursing such as caring and empathy when they are feeling anxious, fearful, inadequate, and confused (Hermanns, Lilly, & Crawley, 2011). Including all students, rather than a few, in each simulation and keeping goals and outcomes at achievable levels helped to make the mental health simulations more approachable and fun. Perhaps the biggest lesson learned was to keep it simple. Faculty’s toning down the complexity of each simulation has allowed students to focus on the actual learning experience and to become more open to receiving constructive feedback. This openness to learning and the willingness to reflect on the experience can lead to knowledge acquisition through what experiential learning theory describes as experimenting with different skills in order to improve one’s competency and conceptualizing abstract ideas (Kolb, 1984).
Conclusion We hope the lessons learned by BSU School of Nursing faculty can assist others to implement mental health simulations that can augment or substitute for mental health practicums. As mental health clinical placements continue to shrink and more and more restrictions are placed on allowing student nurses to participate in the care of mentally ill patients, simulations will need to play a bigger role in meeting the educational requirements of this specialty area of nursing. There is currently a lack of research that addresses the challenges of implementing simulations that can meet the educational needs of student nurses as effectively as actual practicum experiences can (Cioffi, 2001). More research is needed that focuses on the development and implementation of mental health simulations as alternatives to practicums.
References Lessons Learned This article has looked at challenges faced and lessons learned by baccalaureate nursing program faculty attempting to develop and implement authentic mental health simulations with standardized patients when clinical practicums were no longer an option. By being innovative and
Aronson, B., Rosa, J., Anfinson, J., & Light, N. (1997). A simulated clinical problem-solving experience. Nurse Educator, 22(6), 17-19. Barrow, H. S., & Abrahamson, A. S. (1964). The programmed patient: A technique for appraising student performance in clinical neurology. Journal of Medical Education, 39, 802-805. Barrow, H. S., & Feltovich, P. J. (1987). The clinical reasoning process. Medical Education, 21(2), 86-91.
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Becker, K. L., Rose, L. E., Berg, J. B., Park, H., & Shatzer, J. H. (2006). The teaching effectiveness of standardized patients. Journal of Nursing Education, 45(4), 103-111. Brown, J. (2008). Applications of simulation technology in psychiatric mental health nursing education. Journal of Psychiatric & Mental Health Nursing, 15, 638-644. Cioffi, J. (2001). Clinical simulations: Development and validation. Nurse Education Today, 21(6), 477-486. Fletcher, J. L. (1995). AANA Journal course: Update for nurse anesthetists: Anesthesia simulation: A tool for learning and research. Journal of the American Association of Nurse Anesthetists, 63(1), 61-67. Good, J., & Moss-Racusin, C. A. (2010). ‘‘But that doesn’t apply to me’’: Teaching college students to think about gender. Psychology of Women Quarterly, 34(1), 418-424. Happell, B. (2008). Barriers to implementing a nursing clinical development unit. Contemporary Nurse, 29(1), 53-59. Hermanns, M., Lilly, M. L., & Crawley, B. (2011). Using clinical simulation to enhance psychiatric nursing training of baccalaureate students. Clinical Simulation in Nursing, 7(2), e41-e46. doi:10.1016/j.ecns.2010.05.001. Jefferies, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 20(2), 96-103. Jefferies, P. R. (2007). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nursing. Johnson, J., Zerwic, J., & Theis, S. (1999). Clinical simulation laboratory: An adjunct to clinical teaching. Nurse Educator, 24(5), 37-41.
Kaakinen, J., & Arwood, E. (2009). Systematic review of nursing simulation literature for use of learning theory. International Journal of Nursing Education Scholarship, 6(1), 1-20. Kameg, K., Mitchell, A. M., Clochesy, J., Howard, V. M., & Suresky, J. (2009). Communication and human patient simulation in psychiatric nursing. Issues in Mental Health Nursing, 30, 503-508. Kolb, D. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall. McNaughton, N., Ravitz, P., Wadell, A., & Hodges, B. D. (2008). Psychiatric education and simulation: A review of the literature. Canadian Journal of Psychiatry, 53(2), 85-93. Shawler, C. (2008). Standardized patients: A creative teaching strategy for psychiatric-mental health nurse practitioner students. Journal of Nursing Education, 47(11), 528-531. Teherani, A., Hauer, K. E., & O’Sullivan, P. (2008). Can simulations measure empathy? Considerations on how to assess behavioral empathy via simulations. Patient Education and Counseling, 71, 148-152. Thompson, A., Smith-Tolken, A. N., Naidoo, A., & Bringle, R. (2011). Service learning and community engagement: A comparison of 3 national contexts. Voluntas: International Journal of Voluntary and Nonprofit Organizations, 22(12), 214-237. Wallace, P. (2007). Coaching standardized patients: For use in the assessment of clinical competence. New York, NY: Springer. Welch, J. L., Jeffries, P. R., Lyon, B. L., Boland, D. L., & Backer, J. H. (2001). Experiential learning: Integrating theory and research into practice. Nurse Educator, 26(5), 240-243. Williams-Perez, K., & Keig, L. (2002). Experiential learning: A strategy to teach conflict management. Nurse Educator, 27(4), 165-167.
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Featured Article
Implementation of Mental Health Simulations: Challenges and Lessons Learned Shoni Davis, DNSc, RN*, Jayne Josephsen, RN, MS, Rosemary Macy, RN, PhD School of Nursing, Boise State University, Boise, ID 83725, USA KEYWORDS baccalaureate nursing students; challenges faced; lessons learned; mental health simulations; standardized patients; psychiatric nursing
Abstract: Boise State University School of Nursing faculty faced several challenges and learned important lessons in attempting to implement mental health simulations with standardized patients when clinical practicums with actual patients were no longer an option. Challenges faced included (a) establishing strategies to recruit a large pool of authentic standardized patients, (b) determining the optimal level of complexity for each simulation, and (c) providing useful feedback to students about noted deficiencies while at the same time making the reflections a positive experience. Important lessons are shared that may help other faculty avoid similar challenges. Cite this article: Davis, S., Josephsen, J., & Macy, R. (2013, May). Implementation of mental health simulations: Challenges and lessons learned. Clinical Simulation in Nursing, 9(5), e157-e162. doi:10.1016/ j.ecns.2011.11.011. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Introduction Boise State University (BSU) School of Nursing offers baccalaureate education to more than 70 students each semester. In the past, nursing students participated during their fourth semester in a three-credit mental health practicum that included placements in community mental health settings. However, as more health education programs compete for placement sites, mental health clinical placements have become difficult to secure. Shorter patient lengths of stay in acute care settings also make it harder for students to experience consistency with patient care (Brown, 2008). To further complicate matters, the state of Idaho has cut mental health funding over the years in efforts to balance its budget, resulting in mental health agencies’ being forced to shut down. As a result, it has become very difficult for BSU School of Nursing to maximize mental health learning opportunities for students. * Corresponding author: [email protected] (S. Davis).
In 2009 it became necessary to decrease the mental health practicum from 9 hours per week to a 3-hour-per-week observation-only experience. Although this approach helped with the placement dilemma, community mental health partners found this to be disruptive to staff and patients and did not feel this experience was conducive to student learning. Therefore, in spring of 2010, BSU School of Nursing replaced the mental health practicum with an inhouse lab that includes simulations with standardized patients. This transition from practicum with actual patients to simulated scenarios with standardized patients has been both rewarding and fraught with challenges in trying to create authentic and supportive learning opportunities for students.
Purpose The purpose of this article is to discuss challenges faced and lessons learned by BSU nursing faculty in attempting to develop and implement mental health simulations with
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2011.11.011
Implementation of Mental Health Simulations
e158
standardized patients in lieu of practicums with actual patients. Challenges included (a) establishing strategies to recruit the large pool of authentic standardized patients necessary to fill the number of simulations provided each semester, (b) determining the optimal level of complexity for each simulation, and (c) providing useful feedback to Key Points students about noted defi Thinking outside of ciencies while at the same the box can enhance time making the debriefings recruitment of standarda positive experience. ized patients for mental health simulations. To eliminate fear and Theoretical anxiety among stuFramework dents, keep goals and outcomes achievable According to Kaakinen and when developing menArwood (2009), a conceptual tal health simulations. framework should be used So that students to fowhen developing and implecus on actual learning menting simulations. Kolb’s experience and be (1984) experiential learning more open to receivtheory provides a theoretical ing constructive feedframework to guide the deback, avoid overly velopment and implementacomplex mental health tion of simulations for simulation scenarios. nursing education. According to Kolb’s theory, learning occurs in a four-stage process that includes (a) concrete experience, (b) observation and reflection, (c) abstract conceptualization, and (d) active experimentation. Kolb postulated that learning occurs when students are actively engaged in knowledge acquisition through hands-on experience with problem solving and decision making, followed by active reflection. The four-stage process defined in Kolb’s (1984) experiential learning theory provided the framework used in developing and implementing the BSU mental health simulations. As part of the mental health simulations, nursing students participate in concrete learning experiences in which they practice nursing skills with a high-fidelity simulated patient. Based on Kolb’s stages of experiential learning, student nurses acquire knowledge of mental health nursing through this reflective practice and the conceptualization of abstract ideas (Welch, Jeffries, Lyon, Boland, & Backer, 2001; Williams-Perez & Keig, 2002).
Background and Literature Review Assumptions and prevailing beliefs regarding mental health issues are often mired in stigmatization, which can result in fear and a lack of confidence among nursing students when interacting with mental health patients. This fear and a lack of confidence can hinder learning opportunities and the integration of knowledge and insight (Good & Moss-Racussin,
2010; Happell, 2008). Therapeutic use of self is a primary tool used in mental health nursing (Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009), and assessing students’ competency in therapeutic communication can be difficult when conversations with patients occur indiscriminately. Challenges posed in mental health make simulations especially beneficial to nursing practice. The advantages of simulation as a teaching pedagogy can overcome some of the disadvantages that occur when nursing students participate in mental health practicums, making simulations a viable option for instructing and mentoring students in the application of clinical nursing skills. All levels of mental health education have successfully applied simulation as a teaching strategy (McNaughton, Ravitz, Wadell, & Hodges, 2008). Simulations include the ability for faculty to pair course objectives with standardized patient encounters and to provide students with comparable chances for experiential learning opportunities (Becker, Rose, Park, Berg, & Shatzer, 2006). Further benefits of simulation include the ability to reconstruct a realistic clinical setting in which patient safety is not threatened, nursing students can participate in active learning, and errors can be corrected and discussed immediately (Fletcher, 1995). Mental health nursing is unique in that the core elements include therapeutic use of self, communication, and assessment skills. The traditional simulation using computerized manikins does not provide a realistic scenario in which to practice these essential skills. Instead, mental health simulations typically use standardized patients, defined as individuals trained to simulate an illness in an accurate and consistent manner (Becker et al., 2006; Wallace, 2007). Standardized patients are considered high fidelity because they replicate authentic patient care situations and provide credible interactions for students (Jefferies, 2007). Standardized patients were used in simulations as early as 1963 (Barrow & Abrahamson, 1964), and their use has progressed over the years to include an effective means for evaluating the competency of clinical skills (McNaughton et al., 2008). Additionally, the use of standardized patients has been shown to be an effective strategy for practice and evaluation of communication skills and assessment abilities (Shawler, 2008). Simulations with standardized patients can provide opportunities for students to explore, in a safe and nonthreatening environment, their fears and anxiety related to caring for mental health patients, and can provide experiential learning opportunities to enhance skill development.
Development and Implementation Strategies for Mental Health Simulations During the process of developing and implementing mental health simulations to effectively fill the gap that resulted from eliminating practicums with actual patients, BSU nursing faculty faced challenges that had to be overcome in
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order to make the simulations a positive and meaningful experience for students and faculty.
Challenge 1: Recruitment of Standardized Patients The first challenge to be addressed when developing and implementing mental health simulations was the recruitment of standardized patients. As many as 70 nursing students, assigned to small groups, partake in a series of six mental health simulations each semester. A large pool of standardized patients was necessary to accommodate the number of hours needed for the simulated activities. To be authentic, standardized patients must possess the capacity to portray a clinical situation in such a way as to guide student nurses into asking appropriate questions and practicing formative skills in order to develop comfort in managing sensitive patient issues (Becker et al., 2006). When trained effectively, standardized patients can report on the personal aspects of the nurseepatient encounter from the perspective of the patient and reveal whether the patient’s needs were met (Teherani, Hauer, & O’Sullivan, 2008). With these goals in mind, BSU School of Nursing set out to recruit a pool of competent and realistic standardized patients. The School of Nursing initially engaged in a partnership with the BSU Theater Department. Theater students were given the option of earning independent study credits for signing up to be standardized patients for the mental health nursing simulations. What was most appealing to the theater students was obtaining unprompted, improvised acting experiences, which the simulations offered. This approach proved to be an excellent source of standardized patients as the theater students were creative and eager to demonstrate their acting skills and came to the simulations well prepared to authentically portray their assigned patient role. The problem, however, was recruiting enough theater students to accommodate the number of hours needed for the simulations. While the option for theater students to participate as standardized patients in mental health simulations continues, it became apparent very soon that another strategy was needed to help fill the simulation slots. Taking advantage of the strong service-learning focus advocated by BSU, nursing faculty next initiated a partnership with the Department of Psychology through the BSU Service-Learning Department. Service-learning is a teaching and learning strategy that integrates community service with instruction and reflection to enrich the learning experience, teaches civic responsibility, and strengthens communities (Thompson, Smith-Tolken, Naidoo, & Bringle, 2011). Through a collaborative effort involving the School of Nursing, the Psychology Department, and the Service-Learning Department, undergraduate psychology students who are required to participate in service
learning as part of their course requirements can become standardized patients for the mental health nursing simulations as their service-learning project. Psychology students who assume standardized patient roles are responsible for creating, on the basis of the symptomatology that characterizes the mental health disorder, the ‘‘character’’ they agree to portray. To help them prepare, psychology students are provided with preparatory materials from the School of Nursing, as well as video and Web site resources. In addition, psychology students are required to participate in at least 1 hour of rehearsal time prior to each simulation, as part of their service-learning requirements. BSU nursing faculty knew that streamlined procedures would need to be developed in order to efficiently meet the demand of recruiting and training the large pool of standardized patients each semester. The Simulation Center Coordinator is responsible for organizing the recruitment of psychology students and ensures that all contract requirements are handled with the Psychology Department. The coordinator and mental health faculty work together to set up designated orientation and rehearsal times for psychology students. Several half-day rehearsal times are made available throughout the semester. Psychology students can schedule rehearsals during any of these time slots that best meet their schedules and can rehearse for multiple simulations at one time. To further streamline the process, standardized patients can rehearse in groups, which not only saves time but provides the opportunity to learn from each other. During postsimulation debriefings, standardized patients provide valuable feedback to student nurses about how the nursing care was perceived from the patient’s perspective. As noted by Teherani et al. (2008), the feedback provided by standardized patients regarding the empathic behavior demonstrated by nursing students provides the opportunity to identify and remedy deficiencies. Overall, both nursing and psychology students take away a deeper sense of awareness regarding mental health issues. The positive evaluations from psychology students have resulted in a significant increase in the numbers who choose the mental health simulations as their servicelearning project. In just two semesters, the number of psychology students signing up to be standardized patients increased from 5 to 12, and an additional psychology faculty member has included the mental health simulations as an approved service-learning project. Overall, the experience has been a win-win for both the BSU School of Nursing and the Department of Psychology.
Challenge 2: Determining the Most Effective Level of Complexity for Each Mental Health Simulation Because nursing students no longer participate in mental health practicums, the challenge for faculty was knowing
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how complex to make the simulations so that students have the opportunity to practice as many mental health nursing skills as possible, while still keeping the experience manageable. Mental health simulations can range from simple to complex, according to the level of uncertainty and the number of presenting patient problems (Jefferies, 2005). Studies suggest that to reinforce the reality of simulations, it is best to combine obvious signs and symptoms associated with specific medical problems with confusing and irrelevant data (Aronson, Rosa, Anfinson, & Light, 1997). Initially, faculty felt strongly that the simulations should be complex enough to provide the most advantageous learning opportunities for students. At first, the mental health simulations offered clinical situations that involved multifaceted concepts. For example, one simulation involved the nursing students having to decide, based on their assessment, the correct level of observation required for a patient admitted to the psychiatric unit following a suicide attempt. Based on their assessment data, the nursing goal was to determine whether the patient required restrictive, one-on-one observation or could be placed on a less restrictive treatment plan. To make the appropriate decision, the nurse had to obtain enough information to determine whether a suicide threat still existed and, if so, the lethality of the suicidal ideations. To complicate the scenario and make it more realistic, the standardized patient for this simulation had been trained to act in one of three ways regarding his or her failed suicide attempt: remorseful and embarrassed, angry that the suicide attempt had failed, or depressed and noncommunicative. The standardized patient could decide which of these three affects to display for each student nurse who participated in the simulation. The student nurse had to rely on theory and classroom knowledge to accurately interpret what the patient’s behavior might indicate. The standardized patient might also ask the nurse questions that required a knowledgeable response, such as ‘‘What will this medication the doctor wants me to take do to me?’’ It became apparent very quickly that students were struggling, as observed by their inability to progress through the simulations in a logical manner and to achieve the simulation goals. To aid in this endeavor, faculty attempted several different techniques, such as being present during the simulation to provide cues and to bookmark points during the video taping that could be used during debriefing to highlight positive interactions as well as areas needing improvement. Faculty members’ providing prompts and cues has been shown to be effective in redirecting students if they become stuck and do not know what to do next (Johnson, Zerwic, & Theis, 1999). Questions also arose about how to most effectively prepare students for each simulation. The amount of preparatory information to provide to students prior to simulations is controversial. There are those who recommend that to make simulations realistic, very little information should be provided (Barrow & Feltovich, 1987),
while others claim that providing detailed information to students before the simulation can decrease a student’s anxiety (Brown, 2008). BSU nursing faculty started off giving students detailed preparatory information, believing that it would help students come to a simulation prepared and feeling confident. As faculty saw that students were struggling during the mental health simulations, it was decided that too much preparatory information might be adding to perceived expectations and high levels of anxiety. Therefore, preparatory information was reduced to a short description of the presenting problem. In spite of efforts to support student success, all attempts by faculty appeared to add to the students’ anxiety, which quickly turned to frustration and a dislike for the simulation experience. Ultimately, the initial complex simulations were replaced with less complex scenarios. For instance, the suicide simulation described above was redesigned as a shorter vignette in which all student nurses have the opportunity to enter the patient’s room one at a time and practice assessing the patient’s suicidal ideations. As students are taught never to believe a suicidal patient’s first ‘‘no,’’ they are provided with a list of open-ended questions, obtained from the literature, that they can carry into the simulation on a clipboard and use to encourage the standardized patient to more openly discuss suicidal ideations and the available means of carrying out a suicide plan. An example of a question the nurse might ask is, ‘‘Walk me through how many times you have contemplated hurting yourself in the past week.’’ Although the standardized patient can still present a different affect for each interview, the less complex scenario allows the nursing students to become more comfortable about asking delicate questions and to delve deeper to encourage the patient to be more forthcoming. Because students do not feel as intimidated in these less complex simulations, they are able to gain a sense of accomplishment from the experience and as a result are more comfortable in discussing what they might do differently in order to improve. Student evaluations following these less complex simulations reflect a greater level of satisfaction, and many students have commented on the value of the experience and the applicable skills they gained.
Challenge 3: How to Conduct Debriefings That Can Provide Constructive Feedback while Allowing Students to Experience a Sense of Accomplishment Another challenge faculty faced was how to guide reflections following each simulation so that deficiencies could be brought up and discussed, while at the same time preventing students from feeling embarrassed and leaving the experience with a sense of failure. Postsimulation debriefing is important as it provides students with immediate feedback about their performance, their
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knowledge, and their decision-making capabilities (Aronson et al., 1997). Debriefings for the mental health simulations are especially important since they provide one of the only measurements of students’ mental health nursing skills. As a result, faculty felt torn between wanting to provide corrective feedback regarding noted deficiencies and wanting to make the debriefings a positive experience. Because students rarely felt successful in the initial complex simulations, they perceived the debriefings as stressful and embarrassing and were often unable to ‘‘hear’’ feedback as constructive. Faculty ended up feeling apprehensive about providing constructive feedback for fear of making students more anxious. As a result, students tended to miss opportunities to learn from their experience. Also during this time, standardized patients were providing feedback during debriefings, but with very little training on what to focus their feedback on. In their written evaluations of the simulations, students sometimes blamed standardized patients for making the simulation more difficult for the student nurse than necessary. Because of their discomfort level, students were unable to recognize that mental health patients often exhibit bizarre behaviors, are unable to cooperate effectively, and are often less than forthcoming in providing reliable assessment information. Bringing the simulations to a less complex level helped to transition the debriefings into a more positive experience. Allowing all students, rather than just a few, the opportunity to participate in the simulation and redefining the outcomes to be more achievable have resulted in students’ feeling less anxious and actually able to enjoy the experience. As a result, students have become more willing to discuss their own performance and ways they might improve for future simulations. This more relaxed atmosphere has allowed faculty the opportunity during the debriefings to offer students insights and constructive feedback that the students can perceive as helpful rather than critical. Faculty also began to work more closely with standardized patients in order to train them to provide feedback during the debriefing process. Rather than providing feedback that focuses on the patientenurse interaction, their feedback is now focused on their own emotional experience and whether their needs in the role of the patient were met during the simulation. This focus has been advocated by others for training standardized patients to provide feedback during the debriefing process (Teherani et al., 2008).
tapping into other student populations on campus, faculty was able to recruit a large pool of authentic standardized patients at no cost to the university. An added benefit is that the School of Nursing thus contributes to the learning experience of students outside nursing and brings students from other disciplines together with nursing students to share learning experiences. Mental health nursing is typically intimidating for students. Placing students in mental health simulations with no prior clinical experience adds to the level of anxiety. Students are not able to demonstrate the tools of mental health nursing such as caring and empathy when they are feeling anxious, fearful, inadequate, and confused (Hermanns, Lilly, & Crawley, 2011). Including all students, rather than a few, in each simulation and keeping goals and outcomes at achievable levels helped to make the mental health simulations more approachable and fun. Perhaps the biggest lesson learned was to keep it simple. Faculty’s toning down the complexity of each simulation has allowed students to focus on the actual learning experience and to become more open to receiving constructive feedback. This openness to learning and the willingness to reflect on the experience can lead to knowledge acquisition through what experiential learning theory describes as experimenting with different skills in order to improve one’s competency and conceptualizing abstract ideas (Kolb, 1984).
Conclusion We hope the lessons learned by BSU School of Nursing faculty can assist others to implement mental health simulations that can augment or substitute for mental health practicums. As mental health clinical placements continue to shrink and more and more restrictions are placed on allowing student nurses to participate in the care of mentally ill patients, simulations will need to play a bigger role in meeting the educational requirements of this specialty area of nursing. There is currently a lack of research that addresses the challenges of implementing simulations that can meet the educational needs of student nurses as effectively as actual practicum experiences can (Cioffi, 2001). More research is needed that focuses on the development and implementation of mental health simulations as alternatives to practicums.
References Lessons Learned This article has looked at challenges faced and lessons learned by baccalaureate nursing program faculty attempting to develop and implement authentic mental health simulations with standardized patients when clinical practicums were no longer an option. By being innovative and
Aronson, B., Rosa, J., Anfinson, J., & Light, N. (1997). A simulated clinical problem-solving experience. Nurse Educator, 22(6), 17-19. Barrow, H. S., & Abrahamson, A. S. (1964). The programmed patient: A technique for appraising student performance in clinical neurology. Journal of Medical Education, 39, 802-805. Barrow, H. S., & Feltovich, P. J. (1987). The clinical reasoning process. Medical Education, 21(2), 86-91.
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Becker, K. L., Rose, L. E., Berg, J. B., Park, H., & Shatzer, J. H. (2006). The teaching effectiveness of standardized patients. Journal of Nursing Education, 45(4), 103-111. Brown, J. (2008). Applications of simulation technology in psychiatric mental health nursing education. Journal of Psychiatric & Mental Health Nursing, 15, 638-644. Cioffi, J. (2001). Clinical simulations: Development and validation. Nurse Education Today, 21(6), 477-486. Fletcher, J. L. (1995). AANA Journal course: Update for nurse anesthetists: Anesthesia simulation: A tool for learning and research. Journal of the American Association of Nurse Anesthetists, 63(1), 61-67. Good, J., & Moss-Racusin, C. A. (2010). ‘‘But that doesn’t apply to me’’: Teaching college students to think about gender. Psychology of Women Quarterly, 34(1), 418-424. Happell, B. (2008). Barriers to implementing a nursing clinical development unit. Contemporary Nurse, 29(1), 53-59. Hermanns, M., Lilly, M. L., & Crawley, B. (2011). Using clinical simulation to enhance psychiatric nursing training of baccalaureate students. Clinical Simulation in Nursing, 7(2), e41-e46. doi:10.1016/j.ecns.2010.05.001. Jefferies, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 20(2), 96-103. Jefferies, P. R. (2007). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nursing. Johnson, J., Zerwic, J., & Theis, S. (1999). Clinical simulation laboratory: An adjunct to clinical teaching. Nurse Educator, 24(5), 37-41.
Kaakinen, J., & Arwood, E. (2009). Systematic review of nursing simulation literature for use of learning theory. International Journal of Nursing Education Scholarship, 6(1), 1-20. Kameg, K., Mitchell, A. M., Clochesy, J., Howard, V. M., & Suresky, J. (2009). Communication and human patient simulation in psychiatric nursing. Issues in Mental Health Nursing, 30, 503-508. Kolb, D. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall. McNaughton, N., Ravitz, P., Wadell, A., & Hodges, B. D. (2008). Psychiatric education and simulation: A review of the literature. Canadian Journal of Psychiatry, 53(2), 85-93. Shawler, C. (2008). Standardized patients: A creative teaching strategy for psychiatric-mental health nurse practitioner students. Journal of Nursing Education, 47(11), 528-531. Teherani, A., Hauer, K. E., & O’Sullivan, P. (2008). Can simulations measure empathy? Considerations on how to assess behavioral empathy via simulations. Patient Education and Counseling, 71, 148-152. Thompson, A., Smith-Tolken, A. N., Naidoo, A., & Bringle, R. (2011). Service learning and community engagement: A comparison of 3 national contexts. Voluntas: International Journal of Voluntary and Nonprofit Organizations, 22(12), 214-237. Wallace, P. (2007). Coaching standardized patients: For use in the assessment of clinical competence. New York, NY: Springer. Welch, J. L., Jeffries, P. R., Lyon, B. L., Boland, D. L., & Backer, J. H. (2001). Experiential learning: Integrating theory and research into practice. Nurse Educator, 26(5), 240-243. Williams-Perez, K., & Keig, L. (2002). Experiential learning: A strategy to teach conflict management. Nurse Educator, 27(4), 165-167.
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