- Email: [email protected]
Using a Trained Actor to Model Mental Health Nursing Care
Clinical Simulation in Nursing (2014) 10, 515-520
www.elsevier.com/locate/ecsn
Featured Article
Using a Trained Actor to Model Mental Health Nursing Care David Jack, PhD, RNa, Angela M. Gerolamo, PhD, APRN, BCb, Dorothea Frederick, MSN, CNOR, RNFAc, Amy Szajna, MSN, RNc,*, John Muccitelli, PhD, MPH, MSN, RN, APHN-BCd a
Assistant Professor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA Associate Professor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA c Instructor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA d Clinical Adjunct Instructor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA b
KEYWORDS mental health nursing education; human patient simulation; actor; nursing education; psychiatric nursing; standardized patient
Abstract: Although nurse educators have integrated simulation with human actors into nursing curricula, simulation remains a relatively infrequent pedagogy in mental health nursing. This article describes the implementation of simulation using a professional actor to prepare students for their clinical rotation. Students were exposed to fundamental aspects of nursing practice such as therapeutic communication as well as high-risk clinical issues. Student feedback was overwhelmingly positive, and the simulation appears to be beneficial for conveying concepts regarding high-risk clinical issues that students will not likely encounter during their clinical rotations. Implications for continued use of simulation and directions for research are discussed. Cite this article: Jack, D., Gerolamo, A. M., Frederick, D., Szajna, A., & Muccitelli, J. (2014, October). Using a trained actor to model mental health nursing care. Clinical Simulation in Nursing, 10(10), 515-520. http:// dx.doi.org/10.1016/j.ecns.2014.06.003. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Although the use of simulation in undergraduate nursing education has grown substantially over the past decade, designing simulation experiences is a relatively new endeavor for mental health nursing educators (Brown, 2008). Changes in the delivery of mental health services such as widespread closures of inpatient psychiatric facilities and reduced inpatient hospital capacity continue to create significant challenges for mental health nurse
* Corresponding author: [email protected] (A. Szajna).
educators. Difficulty accessing clinical sites has propelled nurse educators to identify innovative strategies for exposing students to mental health clinical events (McGuiness, 2011). Some baccalaureate nursing programs have abandoned their mental health nursing clinical rotation due to the absence of psychiatric facilities that are geographically proximal for students. Moreover, nurse educators cannot guarantee exposure to uniform experiences during each student’s practicum due to variations in patient acuity and other hospital-related factors. With dwindling access to inpatient mental health services, it is
1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2014.06.003
A Novel Approach to Patient Simulation
516
paramount that educators develop innovative teaching strategies to ensure that nursing students understand the essential components of mental health nursing (e.g., therapeutic communication) and the management of high-risk clinical events. The purpose of this article is to describe the activities related to planning and implementing a simulaKey Points tion experience with a pro Although nurse edufessional actor so that this cators have integrated teaching strategy could be simulation with hureplicated by others interman actors into ested in using simulation for nursing curricula, a broad range of mental simulation remains a health nursing concepts. relatively infrequent Simulation has been pedagogy in mental defined as an educational health nursing strategy that uses guided education. experiences to replicate ele A role-play simulaments of reality in an intertion between a profesactive environment to sional actor and nurse achieve learning objectives faculty is an innova(Gaba, 2004). More tive way to expose broadly, simulation aims to students to funda‘‘recreate, imitate or mental aspects of amplify characteristics, pronursing practice such cesses and experiences of as therapeutic the real world for the purcommunication as poses of teaching, acquiring well as high-risk clinand assessing knowledge, ical issues. skills, and attitudes’’ The simulation effec(Guise, Chambers, & tively captured a large Valimaki, 2012, p.411). number of students Simulation is particularly and afforded them a well suited to mental health uniform and standardnursing due to the lowized learning experifrequency occurrence and ence in crisis unpredictable nature of management which high-risk events in a clinical they may not be setting (Brown, 2008). For exposed to in a clinexample, during their clinical setting. ical rotation, nursing students typically do not have the opportunity to manage high-risk events such as clients’ experiencing suicidal thoughts or elopement, defined as the departure of a patient without medical discharge. Simulation offers educators the ability to provide students with client encounters that are difficult, if not impossible, to arrange in the clinical setting. Moreover, the literature lacks explicit discussion of efficient ways to use human patient simulation to reach a large number of students. This omission is unfortunate given the potential value of human simulation in recreating critical elements of therapeutic communication, a skill critical to all nursing students (Brown, 2008). To address this gap, faculty at a private health science university in Philadelphia, Pennsylvania, developed and implemented a simulation experience for their undergraduate
baccalaureate student populations. Students from both the traditional baccalaureate program (n ¼ 154) and Facilitated Academic Coursework Track (n ¼ 97) program, those students who hold a bachelor’s degree in another field and complete the undergraduate-nursing curriculum in an accelerated 12 months, were exposed to the simulation before engagement in their mental health nursing clinical rotations. The purpose of this article was to describe the use of a simulation involving a professional actor and nurse faculty to educate undergraduate nursing students in therapeutic communication techniques and management of high-risk clinical events. Although this article describes implementation of human patient simulation for students in a mental health nursing rotation, the national focus on the integration of physical and behavioral health makes this experience applicable to nursing students more broadly (Hoge, Morris, Laraia, Pomerantz, & Farley, 2014).
Background Lecture is not a reliable method for generating high-level thinking or effecting change in students’ attitudes (Carrick, 2011). Mental health nurse educators need to identify teaching strategies that promote high-level thinking and facilitate learning how to interpret nonverbal behaviors and affects (Chaffin & Adams, 2013). The use of simulation in mental health nursing has emerged over the past few years, taking shape in a variety of formats including the use of role playing between a student and faculty member (Buxton, 2011) and between graduate theater students and undergraduate nursing students (Keltner, Grant, & McLernon, 2011). Other simulation in mental health includes a virtual technology program that was developed to enable students to practice communication and assessment skills (Kidd, Knisley, & Morgan, 2012). Although the integration of simulation activities with human actors, or standardized patients, into both medical and nursing curricula is becoming more evident, simulation remains a relatively infrequent pedagogy in mental health nursing courses. The Hearing Voices that are Distressing Curriculum created by Patricia Deegan, PhD, is a widely disseminated learning activity that includes simulations of auditory hallucinations such as nonvoice sounds (faint rhythmic sounds) as well as verbal phrases, whispering, and laughing (Deegan, 1996). The Hearing Voices curriculum is available at https://www.patdeegan.com/pat-deegan/training/hearing-voicestraining. This simulation is particularly useful in decreasing the stigma associated with mental illness by facilitating an understanding of what these patients experience in their daily lives (Brown, 2010). Chaffin and Adams (2013) examined whether students’ empathy increased after participating in the simulation developed by Deegan (1996). The purpose of the exercise was to teach students about the difficulty of completing tasks and communicating when hearing voices. For example, students were asked to complete tasks such as counting change and talking with a health care
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provider while listening to the audiotape. Results showed that there was a statistically significant improvement in self-rated empathy after participating in the simulation. Further, during the clinical rotation that followed the simulation exercise, students showed improved ability to listen to and observe clients, and they demonstrated greater kindness and patience with clients (Chaffin & Adams, 2013). To examine evidence of simulations using human actors in mental health nursing courses in baccalaureate programs, the authors searched the literature from 2004 to 2014 using the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, and PsychInfo. Search terms included ‘‘psychiatric nursing,’’ ‘‘simulation,’’ ‘‘standardized patients,’’ and ‘‘human actors.’’ Results revealed few articles describing the use of human actors in simulations designed for mental health nursing courses. A study conducted at Villanova University evaluated nursing students’ satisfaction with the use of a standardized patient for a mental health encounter; findings indicated that 45% of students reported the encounter as an effective method for practicing a real-life encounter (Robinson-Smith, Bradley, & Meakim, 2009). Other researchers evaluated the effectiveness of using standardized patients in undergraduate mental health nursing courses in Australia. These authors found that nearly two thirds of students reported that simulation was a useful method for developing communication skills, whereas over half described an improved understanding of common mental health disorders because of the simulation encounter (Alexander & Dearsley, 2013). In another study, researchers examined the use of standardized patients as a method for undergraduate students to practice therapeutic communication skills in a mental health setting. Although specific statistics were not provided, it was reported that overall, the students evaluated the experience favorably (King & Ott, 2012). In sum, the literature is sparse in its description of the use and evaluation of professional actors for human patient simulation in mental health nursing education.
Developing and Implementing Simulation with a Professional Actor Nursing faculty developed a human patient simulation experience for baccalaureate students as a strategy to prepare them for their mental health nursing clinical rotation. The key question that guided the development of the simulation is ‘‘Can the use of a professional actor as a standardized patient afford nursing students the opportunity to understand principles of therapeutic communication and the management of high-risk events that might occur in an acute psychiatric setting?’’ The goal of using simulation was to enhance the traditional teaching strategies used to introduce students to mental health concepts. Nursing students begin their senior year with a course that covers pediatrics, neurology, and psychiatry. The course begins
with Competency Day, which prepares the student with key concepts needed before clinical engagement. Traditionally, Competency Day for the neurology and mental health clinical rotations consisted predominantly of lecture. In the first 4 hours of the day, half of the class (about 75 students) would spend 2 hours in lecture covering neurological content such as cranial nerves and halo traction, whereas the other half completed a neurological return demonstration in the simulation center. The second half of the day was spent in the lecture covering mental health concepts such as therapeutic communication, aggressive behaviors, suicidality, the mental status assessment, and elopement precautions. Student feedback and observations indicated that about half way through the afternoon, students were overwhelmed by the content and exhausted from sitting in lectureda change in learning activities was needed. In the fall of 2013, the faculty reorganized the structure of Competency Day and incorporated simulation. The traditional class (n ¼ 154), which is composed of students in the third semester of an upper division, 2-year nursing program were divided into four groups; each group consisted of either 38 or 39 students. Similarly, during their Competency Day experience, the Facilitated Academic Coursework Track student group (n ¼ 97), students in their third quarter of a four-quarter academic program, were divided into four groups. One group was in the lecture hall for 2 hours and received didactic information about the nurseepatient partnership, therapeutic milieu, aggressive behaviors, suicidal thoughts and behaviors, and halo traction. A second group performed a neurological return demonstration with clinical faculty after reviewing focused content through VoiceThread. This educational software application is available online at http://voicethread.com/. VoiceThread is an interactive web-based tool that promotes collaboration and discussion (Pacansky-Brook, 2013). The third group participated in the Hearing Distressing Voices Simulation (1996) developed by Patricia Deegan (1996), and the fourth group participated in a simulation experience with a professional actor. Each activity lasted 1 hour and 50 minutes, allowing 10 minutes to rotate when transitioning between sessions. The planning of the day with such a large group was not without drawbacks including investing time in reserving rooms and developing the group scheduling for the various learning activities.
Recruit Nurse Faculty and Professional Actor The course faculty identified an adjunct faculty member to serve as the nurse in the role play and lead the development of the script. The adjunct faculty member was selected because of his extensive knowledge of mental health concepts and his ability to engage students and facilitate learning in the clinical setting. We requested and were granted departmental funding from administration for a professional actor to play the role of the patient. We also requested assistance from the director of simulation, who
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was experienced with professional actors and their skills. It is important to consider the cost of hiring and preparing a professional actor before beginning scripting or planning. The cost of the actor was $308; 11 hours ($28/hour). It is also important to understand that the skill of the actor is critical to the success of the simulation. We were fortunate to be able to hire a highly experienced dramatic actor with nearly 20 years of stage, screen, and television credits. Although the actor had never played a role of a patient experiencing a mental health crisis, her experience enabled her to adapt quickly to the part. The actor expressed that the intensity required for this role was exceptionally demanding. ‘‘It’s like doing only the climax of a play four times during the day with no other dialog.’’
followed Peplau’s (1991) phases of the nurseepatient interaction: orientation, working, and termination. Embedded within the script was a mental status assessment which allowed the students to observe how the nurse puts into practice the elements of the examination that were introduced during didactic instruction provided before the simulation activity. The interaction between the nurse (faculty member) and patient (professional actor) included both effective and ineffective therapeutic communication techniques. For example, seeking clarification from the patient that enhanced mutual understanding was an effective while providing false reassurance was ineffective. Table 1 includes an illustration of the interaction including therapeutic and nontherapeutic responses provided by the nurse. The final script comprised 11 pages of dialog including cues and directions.
Develop and Revise Script Train Actor Three faculty members developed the script and the simulated patient’s clinical profile. One faculty member playing the role of the nurse in the simulation developed an initial draft of the script; the other two faculty members reviewed and revised the script. This iterative process took approximately 16 hours to develop the script and another two hours to revise the final script during a 3-week time period. The clinical profile for the patient was designed to expose the students to behaviors and diagnoses commonly encountered in an acute inpatient psychiatric unit and included the patient’s symptoms, diagnostic classification, and medications. The patient was a 48-year-old white female with a diagnosis of major depressive disorder, recurrent episode, severe with psychotic features. She was experiencing classic symptoms of worthlessness, loss of interest in usual activities, guilt, decreased appetite, difficulty concentrating and making decisions, suicidal ideation, and hearing voices. Her current hospitalization was precipitated by her perceived inability to adequately care for her elderly father who had significant physical health problems. Her medication regimen included sertraline and clonazepam. The script gave instructors the opportunity to reinforce essential mental health nursing concepts and also served to expose the students to simulated unexpected real-world situations that they might encounter in their clinical practice and would usually be stressful for a new nurse (e.g., suicidial thoughts and behaviors). The general structure of the script
Table 1
The faculty coordinated with the simulation laboratory director to train the actor. The director provided the actor with the final script for review and facilitated training for the actor and adjunct faculty member chosen to play the role of the nurse. The actor and the nurse rehearsed the script twice during the initial meeting two days before Competency Day in a 3-hour session. During rehearsal, the faculty member playing the nurse provided additional information requested by the actor to enhance her role as the patient. For example, the actor requested clarification on types of behaviors exhibited when hearing voices, as well as on affect, posture, physical presentation including grooming and dress, and cues for suicidal ideation and elopement.
Implement the Simulation and Debriefing On the morning of Competency Day, the actor and the faculty member playing the nurse briefly met to discuss points of stage direction and to answer final questions about the script and/or role. The faculty member provided details on how the actor would be directed into the classroom and her expected behavior upon entrance. Before the simulation, the students received didactic information on therapeutic communication, elopement precautions, and mental status assessment. The faculty member did not inform the students that the upcoming interaction was a simulation.
Therapeutic and Nontherapeutic Responses
Therapeutic Response (Seeking Clarification and/or Verbalizing the Implied) Patient: No, I couldn’t (begins to cry). Look, I can’t deal with this. It’s all my fault. Oh, it’s just all my fault. RN: What’s your fault? Patient: That dad’s the way he is. RN: You feel that you’re to blame for your father’s illness?
Nontherapeutic Response (False Reassurance) RN: Have you thought about how you would hurt yourself? Patient: Not really. Maybe pills I guess. RN: Do you think you may act on these thoughts? Patient: Maybe. RN: You may not believe it right now, but the way you are feeling will change with some help.
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Although the actor was kept hidden from student view until the time of the simulation, if perchance the students observed the actor portraying the patient walking around, it would not concern them as the medical school at our educational institution uses standardized patients in their medical program. Students are used to coming to the laboratory and seeing standardized patients for the medical education. Standardized patients have not been used with the undergraduate nursing population. The actor was led into the classroom after the lecture. The actor was completely in character with costume comprising sweat pants, a hospital gown, ‘‘footies’’, and an identification bracelet. The nurse began the interaction with the orientation phase and continued into the working phase that included a mental status assessment, a no-suicide contract, and demonstration of both therapeutic and nontherapeutic communications. The termination phase included ‘‘unanticipated’’ elopement by the patient. The entire simulation lasted about 30 minutes with an additional 10 minutes for debriefing. The role-playing also simulated an elopement. The unanticipated elopement resulted in several students expressing immediate concern for the patient’s safety. Debriefing of the experience was conducted to assess students’ reactions to the observed simulation and to provide feedback to the instructor on the accuracy of students’ observations of the key points of the nursee patient therapeutic encounter. Debriefing began as soon as the students were reassured that they were witnessing a simulation and that an actor was playing the patient. Surprisingly, this response was common for all four groups observing the exercise, regardless of when they attended the session. Faculty assumed that students attending the first session would inform other students about the roleplay. The actor did not participate in the debriefing and used that time as a rest period in-between ‘‘performances.’’ A separate designated room was used as a ‘‘safe room’’ should a student experience any uncomfortable or unpleasant feelings or emotions. Throughout the learning activity, a mental health faculty member monitored the safe room. Additionally, students were informed and welcomed to approach faculty if they had felt any anxiety or discomfort after the observed simulation role-play. The debriefing questions and some typical responses are illustrated in the following Table 2. Based on student feedback, the simulation provided a meaningful learning experience by allowing them to observe in a safe environment more challenging aspects of a clinical encounter that occur infrequently in the clinical setting, for example, elopement. Students also valued the opportunity to observe the faculty member interact with the standardized patient. One student noted that the ability to observe the faculty interact with the standardized patient during the simulation was ‘‘very helpful and engaging.’’ Other students described the experience as ‘‘amazing’’ and ‘‘excellent.’’
Table 2
Debriefing Questions and Responses
Question
Typical Responses
What feelings were you experiencing during the simulation? What do you feel that the nurse did wrong?
1.) 2.) 3.) 1.)
What therapeutic communication techniques did you see the nurse employ?
How might this exercise prepare you for your clinical experience?
Nervous and/or uncomfortable Scared and/or fear Felt it was real Sometimes ignored the patient’s feelings 2.) Gave false reassurances 3.) Did not make eye contact with patient; appeared to read from the script Students correctly identified most techniques: 1.) Seeking clarification (asked what she meant when she said, ‘‘It’s all my fault.’’) 2.) Imparting information (about medication) 3.) Offering general leads (RN asked, ‘‘and then what?’’) Students had favorable impressions of the simulation. Examples include: 1.) ‘‘Yes. I never thought about having patients like this.’’ 2.) ‘‘I’m glad that it was just an actor and not a real patient.’’ 3.) ‘‘Yes. This was so intense.’’
Discussion This article summarizes a novel approach to the use of human patient simulation that effectively captured a large number of students and afforded them a uniform and standardized learning experience in mental health nursing practice. Student feedback was overwhelmingly positive with some students reporting that they enjoyed the active learning engagement and benefited by observing a modeled use of therapeutic communication techniques. Further, the students believed that the simulation was an actual nurseepatient encounter which is a key goal when designing and implementing simulation experiences. The cost of this simulation was about $1,065, approximately $6.92 per student based on the undergraduate cohort (N ¼ 154). The cost included compensation for the actor and an adjunct faculty member who conducted the role-play. The use of such teaching strategies warrants consideration by faculty when making decisions regarding financial and time investments. The opportunity for students to observe and engage in human patient simulation appeared to be beneficial for conveying concepts regarding high-risk clinical issues that most students will not encounter during their clinical rotation. Further, reduced access to inpatient mental health clinical sites makes the use of simulation in mental health nursing necessary.
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Our experience supports the use of human patient simulation for preparing a large group of students for their mental health clinical rotation. Nursing School administrators should evaluate the use of budgetary resources for standardized patients as an innovative pedagogy. Specifically, this strategy exposed students to fundamental mental health nursing skills and high risk events.
Acknowledgments The authors thank Gilda Ayala for her assistance in developing the script and implementing the simulation as well as John Duffy for overseeing the training of the actor. They also thank June Horowitz for providing thoughtful feedback on the manuscript and the administration at the School of Nursing at Thomas Jefferson University and Beth Ann Swan, Ann Phalen, and Mary Hanson-Zalot for supporting the use of simulation in the course.
References Alexander, L., & Dearsley, A. (2013). Using standardized patients in an undergraduate mental health simulation. International Journal of Mental Health, 42(2-3), 149-164. Brown, J. F. (2008). Applications of simulation technology in psychiatric mental health nursing education. Journal of Psychiatric and Mental Health Nursing, 15, 638-644. Brown, S. A. (2010). Implementing a brief hallucination simulation as a mental illness reduction strategy. Community Mental Health Journal, 46(5), 50-504.
Buxton, B. K. (2011). Interaction, unscripted: An effective use of drama to stimulate the nurseeclient relationship. Journal of Psychosocial Nursing, 49(5), 28-32. Carrick, J. A. (2011). Student achievement and NCLEX-RN success: Problems that persist. Nursing Education Perspectives, 32(2), 78-83. Chaffin, A. J., & Adams, C. (2013). Creating empathy through use of a hearing voices simulation. Clinical Simulation in Nursing, 9, e293e304. http://dx.doi.org/10.1016/j.ecns.2012.04.004. Deegan, P. E. (1996). Hearing voices that are distressing: A training and simulated experience. Lawrence, MA: The National Empowerment Center. Guise, V., Chambers, M., & Valimaki, M. (2012). What can virtual patient simulation offer mental health nursing education? Journal of Psychiatric and Mental Health Nursing, 19, 410-418. http://dx.doi.org/10. 1111/j.1365-2850.2011.01797.x. Hoge, M. A., Morris, J. A., Laraia, M., Pomerantz, A., & Farley, T. (2014). Core competencies for integrated behavioral health and primary care. Washington, DC: SAMHSA - HRSA Center for Integrated Health Solutions. Keltner, N. L., Grant, J. S., & McLernon, D. (2011). Use of actors as standardized psychiatric patients. Journal of Psychosocial Nursing, 49(5), 35-40. Kidd, L. I., Knisley, S. J., & Morgan, K. I. (2012). Effectiveness of a second lifeÒ simulation as a teaching strategy for undergraduate mental health nursing students. Journal of Psychosocial Nursing, 50(7), 28-37. King, M. A., & Ott, J. (2012). Actors needed: Clinical faculty get the call. Nurse Educator, 37(3), 105-107. McGuinness, T. M. (2011). Simulation in psychiatric nursing education. Journal of Psychosocial Nursing, 49(5), 9-10. http://dx.doi.org/10. 3928/02793695-20110329-05. Pacansky-Brock, M. (2013). How to humanize your online class with voicethread. New York: Amazon Digital Services, Inc. Peplau, H. E. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York: Springer. Robinson-Smith, G., Bradely, P. K., & Meakim, C. (2009). Evaluating the use of standardized patients in undergraduate psychiatric nursing experiences. Clinical Simulation in Nursing, 5(6), e203-e211.
pp 515-520 Clinical Simulation in Nursing Volume 10 Issue 10
www.elsevier.com/locate/ecsn
Featured Article
Using a Trained Actor to Model Mental Health Nursing Care David Jack, PhD, RNa, Angela M. Gerolamo, PhD, APRN, BCb, Dorothea Frederick, MSN, CNOR, RNFAc, Amy Szajna, MSN, RNc,*, John Muccitelli, PhD, MPH, MSN, RN, APHN-BCd a
Assistant Professor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA Associate Professor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA c Instructor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA d Clinical Adjunct Instructor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA b
KEYWORDS mental health nursing education; human patient simulation; actor; nursing education; psychiatric nursing; standardized patient
Abstract: Although nurse educators have integrated simulation with human actors into nursing curricula, simulation remains a relatively infrequent pedagogy in mental health nursing. This article describes the implementation of simulation using a professional actor to prepare students for their clinical rotation. Students were exposed to fundamental aspects of nursing practice such as therapeutic communication as well as high-risk clinical issues. Student feedback was overwhelmingly positive, and the simulation appears to be beneficial for conveying concepts regarding high-risk clinical issues that students will not likely encounter during their clinical rotations. Implications for continued use of simulation and directions for research are discussed. Cite this article: Jack, D., Gerolamo, A. M., Frederick, D., Szajna, A., & Muccitelli, J. (2014, October). Using a trained actor to model mental health nursing care. Clinical Simulation in Nursing, 10(10), 515-520. http:// dx.doi.org/10.1016/j.ecns.2014.06.003. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Although the use of simulation in undergraduate nursing education has grown substantially over the past decade, designing simulation experiences is a relatively new endeavor for mental health nursing educators (Brown, 2008). Changes in the delivery of mental health services such as widespread closures of inpatient psychiatric facilities and reduced inpatient hospital capacity continue to create significant challenges for mental health nurse
* Corresponding author: [email protected] (A. Szajna).
educators. Difficulty accessing clinical sites has propelled nurse educators to identify innovative strategies for exposing students to mental health clinical events (McGuiness, 2011). Some baccalaureate nursing programs have abandoned their mental health nursing clinical rotation due to the absence of psychiatric facilities that are geographically proximal for students. Moreover, nurse educators cannot guarantee exposure to uniform experiences during each student’s practicum due to variations in patient acuity and other hospital-related factors. With dwindling access to inpatient mental health services, it is
1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2014.06.003
A Novel Approach to Patient Simulation
516
paramount that educators develop innovative teaching strategies to ensure that nursing students understand the essential components of mental health nursing (e.g., therapeutic communication) and the management of high-risk clinical events. The purpose of this article is to describe the activities related to planning and implementing a simulaKey Points tion experience with a pro Although nurse edufessional actor so that this cators have integrated teaching strategy could be simulation with hureplicated by others interman actors into ested in using simulation for nursing curricula, a broad range of mental simulation remains a health nursing concepts. relatively infrequent Simulation has been pedagogy in mental defined as an educational health nursing strategy that uses guided education. experiences to replicate ele A role-play simulaments of reality in an intertion between a profesactive environment to sional actor and nurse achieve learning objectives faculty is an innova(Gaba, 2004). More tive way to expose broadly, simulation aims to students to funda‘‘recreate, imitate or mental aspects of amplify characteristics, pronursing practice such cesses and experiences of as therapeutic the real world for the purcommunication as poses of teaching, acquiring well as high-risk clinand assessing knowledge, ical issues. skills, and attitudes’’ The simulation effec(Guise, Chambers, & tively captured a large Valimaki, 2012, p.411). number of students Simulation is particularly and afforded them a well suited to mental health uniform and standardnursing due to the lowized learning experifrequency occurrence and ence in crisis unpredictable nature of management which high-risk events in a clinical they may not be setting (Brown, 2008). For exposed to in a clinexample, during their clinical setting. ical rotation, nursing students typically do not have the opportunity to manage high-risk events such as clients’ experiencing suicidal thoughts or elopement, defined as the departure of a patient without medical discharge. Simulation offers educators the ability to provide students with client encounters that are difficult, if not impossible, to arrange in the clinical setting. Moreover, the literature lacks explicit discussion of efficient ways to use human patient simulation to reach a large number of students. This omission is unfortunate given the potential value of human simulation in recreating critical elements of therapeutic communication, a skill critical to all nursing students (Brown, 2008). To address this gap, faculty at a private health science university in Philadelphia, Pennsylvania, developed and implemented a simulation experience for their undergraduate
baccalaureate student populations. Students from both the traditional baccalaureate program (n ¼ 154) and Facilitated Academic Coursework Track (n ¼ 97) program, those students who hold a bachelor’s degree in another field and complete the undergraduate-nursing curriculum in an accelerated 12 months, were exposed to the simulation before engagement in their mental health nursing clinical rotations. The purpose of this article was to describe the use of a simulation involving a professional actor and nurse faculty to educate undergraduate nursing students in therapeutic communication techniques and management of high-risk clinical events. Although this article describes implementation of human patient simulation for students in a mental health nursing rotation, the national focus on the integration of physical and behavioral health makes this experience applicable to nursing students more broadly (Hoge, Morris, Laraia, Pomerantz, & Farley, 2014).
Background Lecture is not a reliable method for generating high-level thinking or effecting change in students’ attitudes (Carrick, 2011). Mental health nurse educators need to identify teaching strategies that promote high-level thinking and facilitate learning how to interpret nonverbal behaviors and affects (Chaffin & Adams, 2013). The use of simulation in mental health nursing has emerged over the past few years, taking shape in a variety of formats including the use of role playing between a student and faculty member (Buxton, 2011) and between graduate theater students and undergraduate nursing students (Keltner, Grant, & McLernon, 2011). Other simulation in mental health includes a virtual technology program that was developed to enable students to practice communication and assessment skills (Kidd, Knisley, & Morgan, 2012). Although the integration of simulation activities with human actors, or standardized patients, into both medical and nursing curricula is becoming more evident, simulation remains a relatively infrequent pedagogy in mental health nursing courses. The Hearing Voices that are Distressing Curriculum created by Patricia Deegan, PhD, is a widely disseminated learning activity that includes simulations of auditory hallucinations such as nonvoice sounds (faint rhythmic sounds) as well as verbal phrases, whispering, and laughing (Deegan, 1996). The Hearing Voices curriculum is available at https://www.patdeegan.com/pat-deegan/training/hearing-voicestraining. This simulation is particularly useful in decreasing the stigma associated with mental illness by facilitating an understanding of what these patients experience in their daily lives (Brown, 2010). Chaffin and Adams (2013) examined whether students’ empathy increased after participating in the simulation developed by Deegan (1996). The purpose of the exercise was to teach students about the difficulty of completing tasks and communicating when hearing voices. For example, students were asked to complete tasks such as counting change and talking with a health care
pp 515-520 Clinical Simulation in Nursing Volume 10 Issue 10
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provider while listening to the audiotape. Results showed that there was a statistically significant improvement in self-rated empathy after participating in the simulation. Further, during the clinical rotation that followed the simulation exercise, students showed improved ability to listen to and observe clients, and they demonstrated greater kindness and patience with clients (Chaffin & Adams, 2013). To examine evidence of simulations using human actors in mental health nursing courses in baccalaureate programs, the authors searched the literature from 2004 to 2014 using the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, and PsychInfo. Search terms included ‘‘psychiatric nursing,’’ ‘‘simulation,’’ ‘‘standardized patients,’’ and ‘‘human actors.’’ Results revealed few articles describing the use of human actors in simulations designed for mental health nursing courses. A study conducted at Villanova University evaluated nursing students’ satisfaction with the use of a standardized patient for a mental health encounter; findings indicated that 45% of students reported the encounter as an effective method for practicing a real-life encounter (Robinson-Smith, Bradley, & Meakim, 2009). Other researchers evaluated the effectiveness of using standardized patients in undergraduate mental health nursing courses in Australia. These authors found that nearly two thirds of students reported that simulation was a useful method for developing communication skills, whereas over half described an improved understanding of common mental health disorders because of the simulation encounter (Alexander & Dearsley, 2013). In another study, researchers examined the use of standardized patients as a method for undergraduate students to practice therapeutic communication skills in a mental health setting. Although specific statistics were not provided, it was reported that overall, the students evaluated the experience favorably (King & Ott, 2012). In sum, the literature is sparse in its description of the use and evaluation of professional actors for human patient simulation in mental health nursing education.
Developing and Implementing Simulation with a Professional Actor Nursing faculty developed a human patient simulation experience for baccalaureate students as a strategy to prepare them for their mental health nursing clinical rotation. The key question that guided the development of the simulation is ‘‘Can the use of a professional actor as a standardized patient afford nursing students the opportunity to understand principles of therapeutic communication and the management of high-risk events that might occur in an acute psychiatric setting?’’ The goal of using simulation was to enhance the traditional teaching strategies used to introduce students to mental health concepts. Nursing students begin their senior year with a course that covers pediatrics, neurology, and psychiatry. The course begins
with Competency Day, which prepares the student with key concepts needed before clinical engagement. Traditionally, Competency Day for the neurology and mental health clinical rotations consisted predominantly of lecture. In the first 4 hours of the day, half of the class (about 75 students) would spend 2 hours in lecture covering neurological content such as cranial nerves and halo traction, whereas the other half completed a neurological return demonstration in the simulation center. The second half of the day was spent in the lecture covering mental health concepts such as therapeutic communication, aggressive behaviors, suicidality, the mental status assessment, and elopement precautions. Student feedback and observations indicated that about half way through the afternoon, students were overwhelmed by the content and exhausted from sitting in lectureda change in learning activities was needed. In the fall of 2013, the faculty reorganized the structure of Competency Day and incorporated simulation. The traditional class (n ¼ 154), which is composed of students in the third semester of an upper division, 2-year nursing program were divided into four groups; each group consisted of either 38 or 39 students. Similarly, during their Competency Day experience, the Facilitated Academic Coursework Track student group (n ¼ 97), students in their third quarter of a four-quarter academic program, were divided into four groups. One group was in the lecture hall for 2 hours and received didactic information about the nurseepatient partnership, therapeutic milieu, aggressive behaviors, suicidal thoughts and behaviors, and halo traction. A second group performed a neurological return demonstration with clinical faculty after reviewing focused content through VoiceThread. This educational software application is available online at http://voicethread.com/. VoiceThread is an interactive web-based tool that promotes collaboration and discussion (Pacansky-Brook, 2013). The third group participated in the Hearing Distressing Voices Simulation (1996) developed by Patricia Deegan (1996), and the fourth group participated in a simulation experience with a professional actor. Each activity lasted 1 hour and 50 minutes, allowing 10 minutes to rotate when transitioning between sessions. The planning of the day with such a large group was not without drawbacks including investing time in reserving rooms and developing the group scheduling for the various learning activities.
Recruit Nurse Faculty and Professional Actor The course faculty identified an adjunct faculty member to serve as the nurse in the role play and lead the development of the script. The adjunct faculty member was selected because of his extensive knowledge of mental health concepts and his ability to engage students and facilitate learning in the clinical setting. We requested and were granted departmental funding from administration for a professional actor to play the role of the patient. We also requested assistance from the director of simulation, who
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was experienced with professional actors and their skills. It is important to consider the cost of hiring and preparing a professional actor before beginning scripting or planning. The cost of the actor was $308; 11 hours ($28/hour). It is also important to understand that the skill of the actor is critical to the success of the simulation. We were fortunate to be able to hire a highly experienced dramatic actor with nearly 20 years of stage, screen, and television credits. Although the actor had never played a role of a patient experiencing a mental health crisis, her experience enabled her to adapt quickly to the part. The actor expressed that the intensity required for this role was exceptionally demanding. ‘‘It’s like doing only the climax of a play four times during the day with no other dialog.’’
followed Peplau’s (1991) phases of the nurseepatient interaction: orientation, working, and termination. Embedded within the script was a mental status assessment which allowed the students to observe how the nurse puts into practice the elements of the examination that were introduced during didactic instruction provided before the simulation activity. The interaction between the nurse (faculty member) and patient (professional actor) included both effective and ineffective therapeutic communication techniques. For example, seeking clarification from the patient that enhanced mutual understanding was an effective while providing false reassurance was ineffective. Table 1 includes an illustration of the interaction including therapeutic and nontherapeutic responses provided by the nurse. The final script comprised 11 pages of dialog including cues and directions.
Develop and Revise Script Train Actor Three faculty members developed the script and the simulated patient’s clinical profile. One faculty member playing the role of the nurse in the simulation developed an initial draft of the script; the other two faculty members reviewed and revised the script. This iterative process took approximately 16 hours to develop the script and another two hours to revise the final script during a 3-week time period. The clinical profile for the patient was designed to expose the students to behaviors and diagnoses commonly encountered in an acute inpatient psychiatric unit and included the patient’s symptoms, diagnostic classification, and medications. The patient was a 48-year-old white female with a diagnosis of major depressive disorder, recurrent episode, severe with psychotic features. She was experiencing classic symptoms of worthlessness, loss of interest in usual activities, guilt, decreased appetite, difficulty concentrating and making decisions, suicidal ideation, and hearing voices. Her current hospitalization was precipitated by her perceived inability to adequately care for her elderly father who had significant physical health problems. Her medication regimen included sertraline and clonazepam. The script gave instructors the opportunity to reinforce essential mental health nursing concepts and also served to expose the students to simulated unexpected real-world situations that they might encounter in their clinical practice and would usually be stressful for a new nurse (e.g., suicidial thoughts and behaviors). The general structure of the script
Table 1
The faculty coordinated with the simulation laboratory director to train the actor. The director provided the actor with the final script for review and facilitated training for the actor and adjunct faculty member chosen to play the role of the nurse. The actor and the nurse rehearsed the script twice during the initial meeting two days before Competency Day in a 3-hour session. During rehearsal, the faculty member playing the nurse provided additional information requested by the actor to enhance her role as the patient. For example, the actor requested clarification on types of behaviors exhibited when hearing voices, as well as on affect, posture, physical presentation including grooming and dress, and cues for suicidal ideation and elopement.
Implement the Simulation and Debriefing On the morning of Competency Day, the actor and the faculty member playing the nurse briefly met to discuss points of stage direction and to answer final questions about the script and/or role. The faculty member provided details on how the actor would be directed into the classroom and her expected behavior upon entrance. Before the simulation, the students received didactic information on therapeutic communication, elopement precautions, and mental status assessment. The faculty member did not inform the students that the upcoming interaction was a simulation.
Therapeutic and Nontherapeutic Responses
Therapeutic Response (Seeking Clarification and/or Verbalizing the Implied) Patient: No, I couldn’t (begins to cry). Look, I can’t deal with this. It’s all my fault. Oh, it’s just all my fault. RN: What’s your fault? Patient: That dad’s the way he is. RN: You feel that you’re to blame for your father’s illness?
Nontherapeutic Response (False Reassurance) RN: Have you thought about how you would hurt yourself? Patient: Not really. Maybe pills I guess. RN: Do you think you may act on these thoughts? Patient: Maybe. RN: You may not believe it right now, but the way you are feeling will change with some help.
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Although the actor was kept hidden from student view until the time of the simulation, if perchance the students observed the actor portraying the patient walking around, it would not concern them as the medical school at our educational institution uses standardized patients in their medical program. Students are used to coming to the laboratory and seeing standardized patients for the medical education. Standardized patients have not been used with the undergraduate nursing population. The actor was led into the classroom after the lecture. The actor was completely in character with costume comprising sweat pants, a hospital gown, ‘‘footies’’, and an identification bracelet. The nurse began the interaction with the orientation phase and continued into the working phase that included a mental status assessment, a no-suicide contract, and demonstration of both therapeutic and nontherapeutic communications. The termination phase included ‘‘unanticipated’’ elopement by the patient. The entire simulation lasted about 30 minutes with an additional 10 minutes for debriefing. The role-playing also simulated an elopement. The unanticipated elopement resulted in several students expressing immediate concern for the patient’s safety. Debriefing of the experience was conducted to assess students’ reactions to the observed simulation and to provide feedback to the instructor on the accuracy of students’ observations of the key points of the nursee patient therapeutic encounter. Debriefing began as soon as the students were reassured that they were witnessing a simulation and that an actor was playing the patient. Surprisingly, this response was common for all four groups observing the exercise, regardless of when they attended the session. Faculty assumed that students attending the first session would inform other students about the roleplay. The actor did not participate in the debriefing and used that time as a rest period in-between ‘‘performances.’’ A separate designated room was used as a ‘‘safe room’’ should a student experience any uncomfortable or unpleasant feelings or emotions. Throughout the learning activity, a mental health faculty member monitored the safe room. Additionally, students were informed and welcomed to approach faculty if they had felt any anxiety or discomfort after the observed simulation role-play. The debriefing questions and some typical responses are illustrated in the following Table 2. Based on student feedback, the simulation provided a meaningful learning experience by allowing them to observe in a safe environment more challenging aspects of a clinical encounter that occur infrequently in the clinical setting, for example, elopement. Students also valued the opportunity to observe the faculty member interact with the standardized patient. One student noted that the ability to observe the faculty interact with the standardized patient during the simulation was ‘‘very helpful and engaging.’’ Other students described the experience as ‘‘amazing’’ and ‘‘excellent.’’
Table 2
Debriefing Questions and Responses
Question
Typical Responses
What feelings were you experiencing during the simulation? What do you feel that the nurse did wrong?
1.) 2.) 3.) 1.)
What therapeutic communication techniques did you see the nurse employ?
How might this exercise prepare you for your clinical experience?
Nervous and/or uncomfortable Scared and/or fear Felt it was real Sometimes ignored the patient’s feelings 2.) Gave false reassurances 3.) Did not make eye contact with patient; appeared to read from the script Students correctly identified most techniques: 1.) Seeking clarification (asked what she meant when she said, ‘‘It’s all my fault.’’) 2.) Imparting information (about medication) 3.) Offering general leads (RN asked, ‘‘and then what?’’) Students had favorable impressions of the simulation. Examples include: 1.) ‘‘Yes. I never thought about having patients like this.’’ 2.) ‘‘I’m glad that it was just an actor and not a real patient.’’ 3.) ‘‘Yes. This was so intense.’’
Discussion This article summarizes a novel approach to the use of human patient simulation that effectively captured a large number of students and afforded them a uniform and standardized learning experience in mental health nursing practice. Student feedback was overwhelmingly positive with some students reporting that they enjoyed the active learning engagement and benefited by observing a modeled use of therapeutic communication techniques. Further, the students believed that the simulation was an actual nurseepatient encounter which is a key goal when designing and implementing simulation experiences. The cost of this simulation was about $1,065, approximately $6.92 per student based on the undergraduate cohort (N ¼ 154). The cost included compensation for the actor and an adjunct faculty member who conducted the role-play. The use of such teaching strategies warrants consideration by faculty when making decisions regarding financial and time investments. The opportunity for students to observe and engage in human patient simulation appeared to be beneficial for conveying concepts regarding high-risk clinical issues that most students will not encounter during their clinical rotation. Further, reduced access to inpatient mental health clinical sites makes the use of simulation in mental health nursing necessary.
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Our experience supports the use of human patient simulation for preparing a large group of students for their mental health clinical rotation. Nursing School administrators should evaluate the use of budgetary resources for standardized patients as an innovative pedagogy. Specifically, this strategy exposed students to fundamental mental health nursing skills and high risk events.
Acknowledgments The authors thank Gilda Ayala for her assistance in developing the script and implementing the simulation as well as John Duffy for overseeing the training of the actor. They also thank June Horowitz for providing thoughtful feedback on the manuscript and the administration at the School of Nursing at Thomas Jefferson University and Beth Ann Swan, Ann Phalen, and Mary Hanson-Zalot for supporting the use of simulation in the course.
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