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Using Unfolding Simulations to Teach Mental Health Concepts in Undergraduate Nursing Education



Background Nurse educators are challenged to find suitable clinical placements which allow students to develop understanding of the intricacies of mental health care. This article describes an educational innovation using simulation to teach undergraduate nursing students about mental health challenges, from diagnosis to maintenance. Methods A series of five unfolding scenarios replaced a traditional 6-week inpatient mental health placement. The content and process of these scenarios are described. Results This allowed students to gain understanding of the trajectory of mental illness, develop relationships with clients over time, and discover the complexities of providing care for those with mental health challenges. Students reported that these simulations were highly effective. Conclusions Unfolding simulations provide an opportunity to teach mental health nursing in a manner that optimizes the learning experience while ensuring consistency of student learning.
Featured Article
Using Unfolding Simulations to Teach
Mental Health Concepts in Undergraduate
Nursing Education
Abram Oudshoorn, RN, PhD
*, Barbara Sinclair, RN, MScN
Assistant Professor, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON,
N6A 5C1, Canada
Lecturer and Coordinator for Simulated Clinical Education, Arthur Labatt Family School of Nursing, Faculty of Health
Sciences, Western University, London, ON, N6A 5C1, Canada
nursing education;
mental health;
undergraduate nursing;
prelicensure nursing
Background: Nurse educators are challenged to find suitable clinical placements which allow students
to develop understanding of the intricacies of mental health care. This article describes an educational
innovation using simulation to teach undergraduate nursing students about mental health challenges,
from diagnosis to maintenance.
Methods: A series of five unfolding scenarios replaced a traditional 6-week inpatient mental health
placement. The content and process of these scenarios are described.
Results: This allowed students to gain understanding of the trajectory of mental illness, develop re-
lationships with clients over time, and discover the complexities of providing care for those with
mental health challenges. Students reported that these simulations were highly effective.
Conclusions: Unfolding simulations provide an opportunity to teach mental health nursing in a
manner that optimizes the learning experience while ensuring consistency of student learning.
Cite this article:
Oudshoorn, A., & Sinclair, B. (2015, September). Using unfolding simulations to teach mental health
concepts in undergraduate nursing education. Clinical Simulation in Nursing, 11(9), 396-401. http://
Ó2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.
Strong skills in communication, interdisciplinary collab-
oration, and crisis management are essential when working
with clients experiencing mental health challenges (Brown,
2008,Edward, Hercelinskyj, Warelow, & Munroe, 2007).
The development of these skills takes time and multiple
practice opportunities. The purpose of this article was to
describe the implementation of an educational innovation
using a series of five unfolding simulations to replace tradi-
tional in-hospital mental health placements for baccalau-
reate nursing students. Based on feedback from course
evaluations, this simulation innovation proved helpful in as-
sisting students to build mental health skills.
Clinical Simulation in Nursing (2015) 11, 396-401
The author(s) have no financial support to disclose.
* Corresponding author: (A. Oudshoorn).
1876-1399/$ - see front matter Ó2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
At Western University, mental health care is taught through
both theoretical and practice components. Mental health
placements in hospital settings have been thought to
provide students with a va-
riety of learning experi-
ences; however, course
evaluations have not always
confirmed this belief. Poor
role modeling and custodial
approaches to mental health
care are often cited as bar-
riers to learning in students’
evaluations of their experi-
ences. Students report in-
consistencies between what
is taught and what is actu-
ally occurring in their place-
ments. Clients in mental
health hospital settings
may be reticent to work
with students, limiting stu-
dent opportunities to learn
and refine their communica-
tion skills. Depending on
the agency setting, student
exposure to various mental
health conditions can be
limited. This means that
although students are in
real-world professional practice settings, faculty has no
way of guaranteeing that quality theory-based teaching and
learning opportunities are available. Additionally, students
may not gain appreciation or understanding of clients’
struggles with mental health beyond the confines of the
hospital setting.
In addition to the contextual challenges of in-hospital
mental health placements, it can be problematic for nurse
educators to evaluate and assist students to enhance their
communication skills. The sensitive nature of interactions
between students and clients, issues surrounding privacy
and confidentiality, and the often random nature of these
interactions can impair direct observation and evaluation of
practice (Alexander & Dearsley, 2013; Brown, 2008; Davis,
Josephsen, & Macy, 2013). In our experience, students have
reported feeling anxious in mental health placements, and
this can be exacerbated in hospital-based settings where a
single clinical instructor is working across a large physical
space attempting to supervise multiple complex discussions
between students and clients.
Faculty at Western University recognized the opportu-
nity for an improved educational experience, where stan-
dardized learning opportunities across settings would be
delivered and emphasis would be placed on quality
studenteclient interactions. Simulation, which has been
used effectively in other parts of the Western undergraduate
nursing program, was selected to replace the inconsistent
mental health hospital placements. Simulated professional
practice means that faculty can ensure that all students are
exposed to particular steps along the continuum of mental
health care and have multiple opportunities to enhance their
interpersonal skills. This article will describe the imple-
mentation of an educational innovation consisting of a
series of unfolding mental health simulations. These
simulations allow students to follow a client from initial
diagnosis of a mental illness, through a crisis, hospitaliza-
tion, and integration back into the community. This ability
to follow a client in this manner using simulation is unique,
as students are able to develop understanding of the mental
health trajectory and care needs beyond an inpatient setting.
Students are able to develop relationships with a client over
time, as they attempt to do in an agency setting but with the
evolution of the relationship be scripted to a degree.
Simulation also provides for more supported practice and
evaluation of communication skills (Robinson-Smith,
Bradley, & Meakin, 2009).
Literature Review
The use of simulation to teach mental health concepts in
nursing is not new. Examples are found throughout the
literature describing the use of simulation, particularly in
undergraduate nursing education. Simulation is well suited
to teach communication skills and clinical reasoning, two
important aspects of mental health nursing. According to
Alexander and Dearsley (2013), ‘‘It [simulation] provides a
comprehensive opportunity to engage in an immersive,
secure, and innovative learning environment where safe
clinical decision-making opportunities are abundant’’ (p.
152). Feedback is immediate, and errors can be corrected
in the moment (Jeffries, 2007).
In regards to mental health simulations, most have
traditionally revolved around one isolated incident, such as
a suicide risk assessment or alcohol withdrawal (Hermanns,
Lilly, & Crawley, 2011; Lehr & Kaplan, 2013; Maruca &
Diaz, 2013;Robinson-Smith et al., 2009). Alternatively,
the use of multiple simulations depicting various mental
health conditions offers a more diverse experience (Davis
et al., 2013, Edward et al., 2007). Such simulations provide
students with the opportunity to apply mental health theory
to practice in a safe environment and may provide exposure
to situations that are difficult to encounter in an agency prac-
tice setting. However, to date, the vast majority of these sim-
ulations have not involved cases unfolding over time and
therefore do not allow students to fully understand the pro-
cess from diagnosis through treatment and subsequent issues
nurses face when providing care for clients living with a
mental health challenge.
Key Points
Through the use of un-
folding mental health
simulations, students
are able to develop un-
derstanding of the tri-
als facing those with
mental health chal-
Students reported that
their therapeutic com-
munication skills were
greatly enhanced be-
cause of immediate
feedback and ability
to seek assistance as in-
teractions occurred.
The mental health
simulations provided
standardized learning
opportunities and for
quality theory-based
learning to occur.
Teaching Mental Health Concepts Using Unfolding Simulations 397
pp 396-401 Clinical Simulation in Nursing Volume 11 Issue 9
One report was identified of an unfolding, multisetting
simulation, in which a client with a cardiac condition is
followed by students providing home care through admis-
sion to hospital with subsequent alcohol withdrawal
symptoms and back home where he expresses suicidal
ideation and depression (Filner, Champlin, & Hunt, 2012).
This simulation differs from most, as it provides some op-
portunity for students to follow a client across a continuum
of care, providing opportunity to address physical and psy-
chological needs. Unfolding case studies allow students to
be directed through a purposely developed plot or story,
actively engaging them as information is presented over
time. Students are challenged to apply knowledge,
problem-solve, and think critically as new information is
provided as the case progresses, similar to real-world situ-
ations (Yousey, 2013). This method presents students with
the opportunity to see the big picture over time, offering
a chance to experience continuity of care, which may not
be possible with simulations focusing on a single concept
or aspect of care (Reese, 2011).
Mental health simulations are described in the literature as
being conducted using a variety of techniques. Simulations
involving the use of a human client simulator or manikin have
been reported (Lehr & Kaplan, 2013; Maruca & Diaz, 2013;
Hermanns et al., 2011). The use of standardized patients
(SPs) is commonly described, as SPs can provide a degree
of realism and nonverbal communication that cannot be
replicated with a simulator, while allowing students to practice
communication skills with an individual in a safe setting
(Keltner, Grant, & McLernon, 2011). Brown (2008) describes
how student role play of short vignettes is used to assist
students to develop communication skills. A combination of
a case study and interaction with a SP has been used to teach
students about posttraumatic stress disorder (Web s ter et al.,
2012). Virtual mental health patient simulation has also been
used to provide students with standardized learning experi-
ences (Kidd, Morgan, & Savery, 2012).
One report was identified of simulation being used as a
replacement for traditional mental health agency place-
ments (Davis et al., 2013). Undergraduate nursing students
engaged in a series of six mental health simulations, with
psychology students recruited as SPs. Both the nursing
and psychology students were reported to develop height-
ened awareness of mental health issues as a result of this
experience. This replacement of in-hospital placements
with simulation is supported by a groundbreaking study
exploring the use of simulation as a replacement for clinical
hours (Hayden, Smiley, Alexander, Kardong-Edgren, &
Jeffries, 2014). In this study, it was determined that up to
50% of traditional clinical hours could be substituted with
high-quality simulation experiences with ‘‘comparable
end-of-program educational outcomes and new graduates
that are ready for clinical practice’’ (Hayden et al., 2014,
p. 5). The findings from this study lend support for the
innovation described herein and the decision to replace
mental health in-hospital experiences with simulation.
Four mental health simulation cases were crafted that
represented different conditions and personalities; all
following the same clinical trajectory. The four cases
were: (a) a middle-aged woman experiencing an anxiety
disorder, (b) a young man experiencing the onset of
schizophrenia, (c) a middle-aged homeless man struggling
with substance use, and (d) an elderly widow experiencing
depression. These cases were thought to represent a
diversity across the life course, while also incorporating
the conditions most likely to be encountered by students
working in a mental health setting. The simulations were
developed by the simulation coordinator and sent for
review and revision to the theory course coordinator and
two other nurse clinical experts in the field. Revisions were
made to reflect current clinical practice, medications, and
interventions. The topics, along with corresponding weekly
assignments, are outlined in Table.
Each week, a brief description of the situation, with goals
for each simulation, required readings, and the client’s health
record with only as much detail as was required to be
prepared and not to give away the development of the case,
was posted on the university’s online learning platform. For
example, mental health assessment forms adapted from those
used at the local hospital were provided for the first
simulation, suicide assessment forms for the second simu-
lation, and a physician’s admitting history and a medication
administration record for the third.
The mental health simulations were conducted with a class
of 56 students during the summer academic term. These
students were enrolled in the Compressed Time Frame
Bachelor of Science in Nursing Program, a 19-month
program for students who already hold a university degree
or who have completed at least two years of university and
have completed specific prerequisite courses. Students were
divided into clinical groups of seven and were assigned a
clinical instructor. Students participated weekly for
six weeks. Each weekly simulation session was scheduled
for three hours. To date, there is little evidence to suggest
an ideal length of time for a simulation; however, based on
experience with simulation in other areas of the program, it
was decided by faculty that a 3-hour block was sufficient to
meet course goals. Each session consisted of 30 minutes of
briefing, 75 minutes of simulation (if required), 45 minutes
of debriefing with their own clinical group, and 30 minutes
of debriefing in collaboration with another clinical group to
gain exposure to other client situations. According to
Johnson-Russell and Bailey (2010), approximately one
hour of debriefing is required to support learning.
Four clinical instructors were hired. Each instructor was
assigned to two groups, one in the morning and one in the
Teaching Mental Health Concepts Using Unfolding Simulations 398
pp 396-401 Clinical Simulation in Nursing Volume 11 Issue 9
afternoon. All instructors were experienced mental health
nurses, currently working as staff nurses or in advanced
practice positions in mental health care facilities. All were
baccalaureate prepared; two had master’s degrees, and a
third one was in progress of completing her master’s
degree. Comprehensive orientation was provided for the
instructors, including a half-day orientation session with the
simulation coordinator and the professor who was teaching
the concurrent mental health theory course. During the
session, instructors were familiarized with the broader
course goals and expected learning outcomes for each
simulation, learned how to conduct a debriefing session,
and reviewed student evaluation methods. An instructor
resource manual, along with a copy of the textbook being
used in the mental health theory course, was provided for
each instructor. The resource manual contained specific
information to enable instructors to facilitate each simula-
tion. This included goals for each session; copies of the
scripts used by the SPs; information to be covered in each
briefing session; questions to support reflection during each
debriefing session; and a copy of the clients’ health history,
care orders laboratory values, physician’s notes, and
admittance forms that students would find in each health
record. To facilitate integration of theory into each session,
instructors were provided with the theory course syllabus
and student preparatory activities and readings. Contact
information for the simulation coordinator, who was avail-
able on site during every simulation, was also provided.
The simulation coordinator met separately with the
instructors and student groups weekly, before each simu-
lation, to ensure that expectations were clear and to answer
any questions. Students were also given contact information
should they wish to speak to the simulation coordinator
privately. The simulation coordinator met with each
instructor following each session to debrief for 15-30
minutes. On completion of the course, instructors met as
a group with the simulation coordinator for an hour of
debriefing and feedback.
The simulations took place in two locations. Simulated
examination rooms, located in the local medical school,
were used for the first two and the final simulation. One
wall of the examination room was made of one-way mirror
and had headphones to allow for observation of the
simulations by students and instructors. Once the clients
were admitted to hospital, the simulated hospital facility in
the nursing school was used. Some equipment was removed
from the hospital setting to give the appearance of a mental
health facility, rather than an acute care unit. The simula-
tions were staged in a supportive environment; any
participant, whether student, clinical instructor, or SP,
Table Unfolding Simulations
Simulation Learning Goal Weekly Assignment Simulation Location
Orientation session Review of course goals and
evaluation methods
Review of mental health
assessment form
None Classroom
1. Introduction to mental
health assessment
Performance of a mental
health assessment
Mental health assessment
Reflective practice review
Community health center
2. Suicide risk assessment Performance of a suicide risk
Report to physician
Completion of
interprofessional suicide
risk assessment form
Report to physician
Reflective practice review
Community health center
3. Supporting clients through
a crisis
Assessing clients with
psychosis, severe
depression or anxiety
SOAP note
Medication research
Reflective practice review
Inpatient mental health
4. Supporting clients through
a crisisdpreparation for
Assessment of client’s
readiness for integration
into the community
Discharge care plan
SOAP note
Reflective practice review
Inpatient mental health
5. Supporting clients living
with a mental health
Community resource
SOAP note
Reflective practice review
Community health center
Note.SOAP ¼subjective, objective, assessment, plan.
Teaching Mental Health Concepts Using Unfolding Simulations 399
pp 396-401 Clinical Simulation in Nursing Volume 11 Issue 9
could pause the scenario in midstream and ask for
assistance, or just gain time to gather his/her thoughts.
Although having SPs pause the scenario can detract from
the realism, it is our experience that it is best to allow them
a moment to gather their thoughts and provide quality
simulation versus going off-script and confusing students.
Students worked in groups of seven to provide care for a
client facing a significant mental health challenge. During
each session, two students in the group took on the role of
the nurse, interviewing the client, whereas the others
observed and documented the interaction. These roles
rotated through the course so that all students experienced
all roles evenly. All students were required to complete all
assessment forms to maintain focus on the simulation and
enhance learning for all participants.
Students completed a reflective practice review (RPR) or
journal on the week they were assigned the interviewer
role. RPRs are two-page reflections where students criti-
cally reflect on what they learned in professional practice.
All assignments were completed individually and submitted
to the instructor electronically through the university’s
online learning platform. Before the final simulation,
students created a community mental health resources
package for their specific client. This was done to help
students integrate knowledge from their community place-
ments, which were occurring simultaneously. Students were
to identify relevant community resources for their assigned
client or identify where gaps existed and present this
information during the final interview.
SP, trained by the local medical school, portrayed the
clients. The SP educator at the school was provided the cases
and selected the most appropriate SP. The same SP worked
with students in both the morning and afternoon sessions for
the full five simulations. This allowed for continuity in the
role and the development of studenteclient relationships.
Each SP received several hours of paid training from the
educator at the medical school. They were then paid the
standard hourly wage of approximately $20 per hour for each
simulation session, which was built into the budget for
simulation. Each SP interacted with students for approxi-
mately one hour, although 75 minutes were scheduled for
each interaction, as it was uncertain how much time students
would require to complete the interaction. Specific informa-
tion about appearance and mannerisms was included in the
scripts. Each script was detailed; SPs were encouraged to
follow the scripts closely to ensure consistency. The simu-
lation coordinator met with the SPs as a group before each
simulation to ensure that expectations were clear and
questions were addressed. Each SP met with the simulation
coordinator separately after each simulation to debrief. The
focus of this debrief was to see if they had further feedback
for students and if they had any needs to enhance the
completion of their role. SPs did not provide formal
evaluation of students, as this was the role of the clinical
instructor. The SP educator from the medical school was also
available should the SPs need further or different supports.
Students’ Perceptions
Student feedback was overwhelmingly positive, based on
ratings using a standard simulation course feedback
questionnaire. This was a course feedback form, not a
standardized research tool. This seven-item questionnaire,
developed by the simulation coordinator, assesses students’
perceptions of the effectiveness of simulation in promoting
learning and satisfaction with simulations using a Likert
scale ranging from one (not effective) to five (very
effective). Students could also provide comments at the
end of the form. On course completion, students were also
asked permission for the theory course coordinator to read
their final RPR, to understand how students integrated
theory into their simulated mental health practice experi-
ences. In their RPRs, students were again overwhelmingly
positive about the experience with the course.
Future Implementation
Based on information from the course feedback form and
instructor debriefing, several changes were made to the
simulations for future implementation. The number of
students per group was decreased from seven to four,
allowing each student to have two to three opportunities to
interview the client. Greater emphasis was placed on
documentation, as this was determined to be an area in
need of improvement by both students and instructors. A
nurse’s note is now required from each student each week,
with the most comprehensive note included in the client’s
chart. The interprofessional panel was eliminated. Interac-
tions with the physician during the second week when a
suicide assessment to be performed continue, because of the
positive response from the students. Students are now taught
to use the Situation, Background, Assessment, Recommen-
dation format (Dunsford, 2009) to report their assessment
findings to the physician, as this was something with which
students struggled. The amount of time allotted to each simu-
lation has been decreased to 50 minutes, as the original 75 mi-
nutes allotment was not required to complete interactions and
assessments. The cross-debriefing was removed, as students
found that learning was better supported when discussing
their own case with their instructor. Better integration of the
cases as examples in the accompanying theory course will
allow for understanding of how the concepts evolved in
different client care situations. Students found that exposure
to clients with mental health challenges in the simulated com-
munity setting was beneficial, as they lacked the knowledge
and skill to deal with this type of situation outside an acute
care setting. By working with clients in a simulated family
clinic, students were able to learn how to recognize mental
health concerns when faced with a seemingly physical health
concern. They also had opportunity to learn how to perform a
suicide risk assessment, something that was not readily avail-
able in an inpatient setting.
Teaching Mental Health Concepts Using Unfolding Simulations 400
pp 396-401 Clinical Simulation in Nursing Volume 11 Issue 9
There are some limitations to the use of these mental
health simulations. The ongoing cost of hiring SPs is high
compared with inpatient settings where compensation is not
required. However, in the context of this simulation, we had
experience with this pool of SPs by the local medical school
and found the quality to be very high. The financial cost of
recruiting and training SPs would likely be similar to simply
hiring those already available. Furthermore, opportunities
for interprofessional collaboration were limited within the
simulation. The only interprofessional component was when
students had the opportunity to provide report to a staff
member simulating a physician. Engaging a full range of
professionals to participate across multiple simulation
sections requires a high degree of coordination. There is
little in the literature at this time assessing the effectiveness
of the use of simulation in mental health nursing education
(Szpak & Kameg, 2013), so more evaluation is needed to
identify the benefits and drawbacks of using simulation to
teach mental health care. Future research could include
controlled trials in which students are randomized to either
hospital or simulated experiences. Furthermore, preepost
objective third party measures in addition to knowledge
and comfort with mental health practice would provide a
more rigorous review of simulation experiences. Lastly, to
explore opportunities to manage costs while maintaining
quality, other forms of SPs than those supplied through a
medical education program could be trialed and tested.
Mental health placements can be intimidating experiences for
undergraduate nursing students. The degree of relationship
skills required, combined with the limited availability of
registered nurse support in many settings means that students
at times feel insufficiently supported in meetinglearning goals.
Simulated practice in this context provides a real opportunity
for students to balance the comfort of educator support with the
pressures of working on cases in real time. Where students in
clinical practice are often assigned to work with easy-going
and agreeable clients and families, simulation provides an
opportunity to increase the difficulty of cases without putting
clients, families, or students at risk. Well-written cases ensure
realistic scenarios and expose students to mental health care
across the continuum of the health care system. Simulation
offered as a stand-alone course or provided in conjunction with
clinical practice offers the opportunity to educate students in
forward-thinking mental health practice that is recovery
focused and assists student to learn to meet the needs of clients
in both the hospital and the community.
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Teaching Mental Health Concepts Using Unfolding Simulations 401
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... Qualitative content analysis of responses to the two open-ended questions indicated that students were overwhelmingly positive about the SP experience. Students reported that the SP encounter helped them think critically and provided opportunity to practice different interviewing techniques; that the self-analysis of the videotapes aided in constructive self-critique and was the most meaningful learning aspect of the SP 109 records identified through database searching Medline: 44: PsychInfo: 24; Cinahl: 41 83 titles and abstracts screened 40 records excluded 21 full-text articles excluded Did not pertain to live simulation (n = 6) Insufficient information (n = 5) Students observed only/did not enact role of nurse (n = 2) Role play with classmates as SPs only (n = 2) Not focused on academic or PMH nursing (n = 2) Repeat of other included article (n = 1) Scripted skits only (n = 1) Editorial/Commentary (n = 2) 43 full-text articles assessed for eligibility 22 articles identified in initial database search (5 research; 17 program description) 83 records after duplicates removed 2 articles found in final search of PubMed inprocess articles: 1 research ( Goh et al., 2016), and 1 simulation description ( Oudshoorn & Sinclair, 2015) 24 articles included in review (6 research studies; 18 simulation descriptions) experience; and that the postencounter class discussion was an important contributor to their overall learning. Less positive aspects reported by students included anxiety related to the encounter and to the videotaping, and concern about the SP evaluation. ...
... The exceptions were the three graduate-level SP simulations in which students were allotted 30 minutes ( Shawler, 2008), 50 minutes (O' Connor et al., 1999), and 5 minutes each as part of a total 45-minute interview ( Felton et al., 2013). One article described student participation in a series of five unfolding psychiatric simulations of up to 75 minutes each over 6 weeks ( Oudshoorn & Sinclair, 2015). Two articles did not report simulation time length ( Brown, 2008;Fay-Hillier, Regan, & Gordon, 2012). ...
... Two articles did not report simulation time length ( Brown, 2008;Fay-Hillier, Regan, & Gordon, 2012). Six simulations had pairs of students share the nurse role ( Choi, 2013;Doolen, Giddings, Johnson, de Nathan, & Badia, 2014;Ellis et al., 2015;Fay-Hillier et al., 2012;Lang & Hahn, 2013;Oudshoorn & Sinclair, 2015), and one ( Felton et al., 2013) had eight students sharing the role of nurse in a 45-minute simulation, with each student in the role for approximately 5 minutes. Postencounter activities included faculty-led debriefing; feedback from SPs, faculty, and/or observers; group or individual video review; reflection papers; performance checklists; and self-evaluation forms. ...
Background: Simulations using standardized patients (SPs) are increasingly used to teach and assess competencies in psychiatric/mental health (PMH) nursing education. To advance the field, it is important to identify current knowledge, practice, and evidence. Objective: To determine the current knowledge, evidence, and practice of using SPs in PMH nursing education by conducting an integrative review of the empirical research on the use of SPs in PMH nursing education, and by providing a supplementary descriptive review of non-research articles on PMH simulations using SPs. Design: A comprehensive search using electronic databases was conducted to identify both research and simulation description papers meeting inclusion criteria. The research literature was reviewed using an integrative review approach and a simple descriptive review of the non-research simulation literature was also conducted. Results: Six research studies and 18 simulation description articles were included in the review. Although there are several PMH SP simulation descriptions in the literature, and anecdotal indications that they are a valuable educational tool, there is insufficient research evidence regarding their effectiveness as a method in psychiatric nursing education due to few published studies and methodological limitations of existing studies. Conclusions: Well-designed research studies are needed to develop an evidence base for this promising and increasingly employed teaching method.
... In order to prepare nurses, mental health nursing is an integral component of the undergraduate curriculum, which prepares them to work with patients in clinical settings. However, nursing students face challenging situations at clinical settings (Oudshoorn & Sinclair, 2015), where they encounter client(s) who are not willing to talk, intrude in their personal space, and are demanding due to their disease process. Furthermore, some patients experience extreme emotions and psychotic behaviors that need immediate intervention. ...
... The strategy was appreciated as an efficient learning pedagogy for enhancing students' communication skills as it enabled them to rehearse and improve communication with clients exhibiting various symptoms and behaviors. A similar strategy was utilized and appreciated in mental health nursing courses in baccalaureate programmes in universities based in the US (Davis, Josephsen, & Macy, 2013;Doolen et al., 2014;Fay-Hillier et al., 2012), Canada (Oudshoorn & Sinclair, 2015), Australia (Kunst, Mitchell, & Johnston, 2017) and Singapore (Yong-Shian, Selvarajan, Chng, Tan, & Yobas, 2016). Experiential learning (Kolb, 1984) underpinned each case scenario, as during this process, students encountered simulated cases that provided them a concrete experience of interacting with patients. ...
Simulation is an innovative teaching strategy that supports student centered learning. It improves therapeutic communication skills with clients. Additionally, it enhances critical thinking, problem solving, and confidence among students, in a non-threatening and safe environment, without posing a risk to actual patients. This paper describes the process of application of simulation for undergraduate nursing students enrolled in a mental health nursing course. The project aimed to determine the significance of simulation to improve the communication skills and confidence level, and to decrease the anxiety of undergraduate nursing students, prior to attending mental health clinical. The Experiential Learning (ELT), by Kolb in 1984, was chosen as a framework for the simulation strategy. The simulation experience was a stepwise process that comprised a briefing session with students to explain them the process and purpose of the simulation activity, followed by a two-day simulation experience. The experience comprised students’ interaction with Simulated Patients (SP), who had been prepared to manifest symptoms of depression, mania, and schizophrenia. The later part of the experience was a debriefing session, in which students were provided an opportunity for self-reflection and for thinking a way forward, to enhance their clinical competency, using their video recording. The students’ evaluation regarding the simulation experience was positive and they suggested that it be integrated in the mental health nursing course.
... 9 Ruh sağlığı hemşireliği ve psikoloji bölümü öğrencilerinin eğitimlerinde kullanılan simülasyon deneyimlerinin sonucunda ruh sağlığı konularında farkındalıklarının arttığı tespit edilmiştir. 10 Simülasyon eğitimleri her öğrenciye eşit yaklaşım fırsatı ve uygun ortamlarda yetişkin öğrenme ilkelerinin etkin olarak kullanımını sağlamaktadır. 11 Simülasyon aktiviteleri, insan dahil, hasta simülatörleri/mankenleri, standardize hasta rolünü oynayan insanlar, sanal hasta ve çevrelerin kullanıldığı bilgisayar odaklı modeller ile oluşturulmuş çeşitli mekanizmalar kurularak yapılmaktadır. ...
... 6,9 Hastanede, hasta ve öğrenci etkileşimlerinin olduğu alanlar olan psikiyatri klinikleri, gizlilik ve çevre sorunları nedeni ile öğrenciyi değerlendirebilmek ve bilgi becerilerini geliştirebilmek için eğitimciye yeterince gözlem yapma fırsatı vermemektedir. 10 Psikiyatrik simülasyon akut psikiyatrik hasta bakımında, hastaya verilen bakımın profesyoneller tarafından tartışılmasını, beklentilerin açıklanmasını, her öğrencinin verdiği bakımı gözlemleyebilmeyi, öğrencilerin güçlü ve zayıf yönlerini tespit ederek öğrenciyi güçlendirmeyi sağlamaktadır. 12 Öğrenme ...
... For example, a simulated patient may relay a story during a diagnostic session that features both critical and non-critical information (Keltner, Grant, and McLernon 2011;Nestel and Bearman 2014). Alternatively, the simulation itself may feature a narrative structure in which certain "plot points" will unfold at certain times, often based upon actions taken by students (Oudshoorn and Sinclair 2015). Overall, the addition of narrative elements to simulations may aid student immersion by producing the transportation effect. ...
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This paper synthesizes the different ways that players and theorists discuss immersion in role-playing games, establishing six major categories: immersion into activity, game, environment, narrative, character, and community. For the purposes of understanding typical modes of engagement, immersion concepts are considered alongside player motivation theories. Furthermore, this article applies these categories, which are drawn largely from game studies, to the field of health care simulation, categorizing specific practices within the simulation classroom according to types of immersion. The goal of this research is to enhance the understanding and design of simulation by appealing to multiple modes of immersion, which may assist in engaging a greater number of students. Diversifying the types of experiences within health care simulations in order to appeal to multiple modalities of immersion holds the potential to create more rich and layered experiential learning situations.
... Other approaches associated with high fidelity simulation such as group observation via video streaming can also be incorporated [24]. According to Oudshoorn and Sinclair [59] the development of skills to cope with mental health challenges and to prepare for a suicide risk assessment cannot be achieved in one attempt. Osteen et al. [10] also identified follow-up sessions as critical to support initial training in working with clients at-risk of suicide. ...
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Suicide risk assessment is a critical skill in preventing suicide. Yet most nurses do not feel confident in assessing suicide risk. Development of this potentially life-saving skill needs to begin at the undergraduate nursing level. As simulation is an effective pedagogical tool utilised within nursing education, the aim of this paper was to explore the potential of simulation in preparing student nurses' for suicide risk assessment. Literature was examined to identify what simulation modalities were employed within nursing education and the outcomes associated with these. The findings suggest that to varying degrees all simulation modalities have the potential to decrease student anxiety, and increase student confidence, knowledge and communication skills when working with people at risk of suicide. However the use of Standardised Patient (SP) simulation adds an authenticity to the experience and allows for the assessment of a wider range of human responses, including key nonverbal communication skills. The sense of realism provided by SP allows for more in-depth understanding into the person's experiences, which is critical in the assessment of a person's mental health needs and risk of suicide. The majority of simulations identified were located within a mental health setting. Given that student nurses may encounter a person who is suicidal in any clinical setting , further research is needed on simulation which integrates mental health assessments and suicide risk assessment into a variety of clinical areas.
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The most important phase of simulation-based learning is “debriefing”. The main purpose of a debriefing session is to have participants review their own performances and identify the attainments they achieved during the simulation. This study performed the validity and reliability test of the Turkish version of the “Debriefing Experience Scale”. The universe of the study consisted of students (N=303) from the Nursing Department of a university during the 2017–2018 academic year. Content validity, construct validity, and internal consistency reliability of the Debriefing Experience Scale were tested. The Cronbach’s alpha level of the scale was found to be 0.948 for “Experience with Debriefing” and 0.951 for “Importance of item”. The test-retest intraclass coefficient (ICC) was 0.999 (p
The growing demand of mental health services among the population and the stigma associated with mental health conditions have resulted in a shortage of skilled nurses competent in delivering quality care to persons experiencing mental health conditions. This suggests the need to develop a systematic and comprehensive curriculum to prepare nursing students for a career in mental health nursing. An integrative review on empirical studies was conducted based on Cooper’s five‐stage integrative review framework to investigate the different pedagogies and to highlight the elements of an effective curriculum for teaching mental health nursing. All quantitative, qualitative, and mixed‐method studies published between 2009 and 2019 that examined pedagogies in mental health nursing for nursing undergraduates were included in this review. Databases of interest included PubMed, Cochrane, PsycINFO, Embase, Scopus, Web of Science, and ProQuest Dissertations and Theses. To ensure methodological rigour and validity, the 23 included studies were independently evaluated by two authors through critical appraisal tools developed by Joanna Briggs Institute for quantitative and qualitative studies. Results from this review were categorized into three themes: (i) the deployment of simulation; (ii) pedagogies in enhancing critical thinking; and (iii) importance of consumer‐oriented educational experiences. These results suggested that students would benefit substantially from in‐depth discussions, critical reflections, and real‐life experiences. Mental health nursing curricula should incorporate simulations, pedagogies for critical thinking, and consumers’ lived experience to supplement the clinical rotations.
Background Clinical practice for pre-licensure nurses in obstetrics widely varies and many sites do not consistently present opportunities to meet course objectives or manage complex obstetric nursing care. To address this problem at our institution, we designed a large-scale obstetric simulation using recommendations for best practice in simulation design criteria. We designed an unfolding, obstetric simulation that allowed students repeated opportunities for deliberate practice after micro-debriefing. Method A convenience sample of junior level nursing students (n = 53) participated in a pre/post design evaluation to measure achievement of communication skills based on student perception of obstetric nursing self-efficacy and their ability to transfer those skills to a similar scenario. Results Scores for obstetric self-efficacy were significantly improved. Pre-simulation (M = 40.78), Time 1 (M = 61.0) and Time 2 (M = 69.27), F (2, 159), =112.12, p = .00. A significant difference was found (t (52) = −7.839, p = .000) when comparing the mean pre and posttest clinical accuracy and completion scores for SBAR forms (n = 53). Conclusion Our unfolding, obstetric simulation was effective in helping our students demonstrate the achievement of course objectives through improved obstetric self-efficacy scores and scores for shift to shift communication.
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Evidence on the use of simulation to teach psychiatry and mental health (including addiction) content is emerging, yet no summary of the implementation processes or associated outcomes exists. The aim of this study was to systematically search and review empirical literature on the use of psychiatry-focused simulation in undergraduate nursing education. Objectives were to (i) assess the methodological quality of existing evidence on the use of simulation to teach mental health content to undergraduate nursing students, (ii) describe the operationalization of the simulations, and (iii) summarize the associated quantitative and qualitative outcomes. We conducted online database (MEDLINE, Embase, ERIC, CINAHL, PsycINFO from January 2004 to October 2015) and grey literature searches. Thirty-two simulation studies were identified describing and evaluating six types of simulations (standardized patients, audio simulations, high-fidelity simulators, virtual world, multimodal, and tabletop). Overall, 2724 participants were included in the studies. Studies reflected a limited number of intervention designs, and outcomes were evaluated with qualitative and quantitative methods incorporating a variety of tools. Results indicated that simulation was effective in reducing student anxiety and improving their knowledge, empathy, communication, and confidence. The summarized qualitative findings all supported the benefit of simulation; however, more research is needed to assess the comparative effectiveness of the types of simulations. Recommendations from the findings include the development of guidelines for educators to deliver each simulation component (briefing, active simulation, debriefing). Finally, consensus around appropriate training of facilitators is needed, as is consistent and agreed upon simulation terminology.
The education of nursing students to use barcode medication administration (BCMA) and electronic medication administration record (eMAR) technologies has become an important subject for nursing educators. With the increased use of these forms of clinical technology within practice settings, generating best practices and directions for educators to embed and evaluate these forms of technology in educational settings is needed. This chapter will explore a range of topics related to BCMA/eMAR technology within nursing education, including: (1) the importance of the topic to nursing education; (2) implementation of a BCMA/eMAR platform for simulation; (3) best practices related to BCMA/eMAR education; and (4) observational, workflow analysis methods as a quality assurance tool to assist with BCMA/eMAR development and evaluation. With the use of BCMA/eMAR likely to increase in the coming years, nursing educators need to ensure students are educated with the skills, competencies, and knowledge to use these forms of medication administration technology safely and effectively.
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Purpose – Alcohol withdrawal syndrome (AWS) is a serious condition that can result in death if it is not recognized and treated appropriately. A high fidelity simulation scenario on AWS was created for psychiatric nurses in an educational setting that focused on the recognition of alcohol withdrawal, implementation of the Clinical Institute Withdrawal Assessment (CIWA) and initiation of appropriate treatment and management of AWS. Design/methodology/approach – A formative assessment teaching strategy was used to evaluate the development and implementation of a high fidelity simulation (HFS) on alcohol withdrawal syndrome. The HFS was part of a baccalaureate undergraduate psychiatric nursing education designed to reinforce classroom theory and clinical application. Results were measured using a self‐report survey completed by students that focused on the details of content and performance. Findings – Feedback from the 38 nursing students who evaluated the HFS was overall positive. Survey results showed that the HFS scenario reinforced the classroom theory on addiction and mental disorders while translating and supporting student's learning to clinical practice. The HFS provided opportunity for students to practice skills when they had not had this experience during the clinical rotation. Only four students felt uncomfortable with decision making and initiating the CIWA scale after the HFS. Originality/value – There is a gap in the development and use of standardized simulations for mental health and substance abuse scenarios as a teaching strategy in nursing programs. The results of this study supported using HFS as an educational strategy and set the stage for future complex simulations such as dual diagnosis and clients with comorbidities.
Nursing education programs are proliferating rapidly in the United States in an effort to meet demand for nurse professionals. Multiple challenges arise from this rapid expansion. One challenge is finding sufficient clinical sites to accommodate students. Increased competition for scarce resources requires creativity in clinical contracting. This paper examines the challenges associated with providing virtual clinical--experiences and environments rich in diversity and exposure, yet safe for experimentation and learning of mental health nursing students.
Background: Educational strategies are needed to prepare nurses to become sophisticated consumers of information and to apply that information in practice. Expertise in problem solving and clinic decision making skills is necessary if nurses are to function effectively in an increasingly complex health care environment. RNs entering programs leading to bachelor degrees (RN-BSN) have basic skills but need opportunity to develop higher level creative problem solving and critical thinking skills. The purpose of this article is to investigate the use of the “unfolding case study” as an innovative strategy to increase clinical decision making and problem solving skills in participants in a public health course in an online nursing program. Methods: Participants in a public health nursing course were assigned to develop a case study over time integrating concepts of chronic illness with public health nursing. This problem based learning method supported adult learning principles of motivation, autonomous learning, and application to practice, all elements of online learning. The unfolding case studies were evaluated using a rubric to insure that participants completed course objectives. A survey, administered at the end of the course, provided feedback on perceptions of learning using this strategy. Results: All students successfully completed the unfolding case study over a four week period through which they demonstrated integration of knowledge and application in the clinical setting. Feedback provided by participants confirmed an increase in knowledge of public health nursing, creative problem solving, and the ability to apply concepts of chronic illness using a public health framework. Conclusions: The “unfolding case study” in this public health nursing course served as a means of increasing nurses’ knowledge, complex critical thinking and problem solving skills in an online program for RN-BSN participants. While participants presented initially with a wide range of abilities in problem solving and clinical decision making, they demonstrated an increase in problem solving, awareness and application to practice through the use of the unfolding case study.
Simulation is a technique of reproducing the performance of a desired circumstance or procedure by means of an equivalent scenario for the purpose of observation or tuition. The overwhelming shortfall in this process is the absence of the human element—the individual patient's response to illness. Little is known about the use of simulation in the mental health component of an undergraduate curriculum. This pilot study aimed to explore the impact of an integrated-simulation approach on second-year undergraduate nursing students' preparedness for a mental health placement. Students completed a questionnaire pre- and post-clinical placement to determine whether the simulations improved their confidence about communication and assessment skill development. Students found the experience of engaging in a mental health simulation with standardized patients a positive experience. They noted that the experience increased their confidence, encouraged professionalism, enhanced their understanding of mental illness presentations, and was also clinically realistic. The benefits of using simulation to address mental health placement shortfalls mean that all students can be guaranteed a controlled and safe interaction with a mental health client. Simulation should not be seen as the "poor cousin" to hospital-based clinical placement. Rather it provides a comprehensive opportunity to engage in an immersive, secure, and innovative learning environment where safe clinical decision-making opportunities are abundant.
Background Baccalaureate student nurses entering their psychiatric or mental health clinical rotation are often fearful of their upcoming experience. Method To give students the opportunity to deal with some of these issues in a safe, nonthreatening environment, nursing faculty developed a Mental Health Simulation experience using two individual scenarios that included difficult-to-address behaviors and topics encountered in psychiatric as well as general hospital settings. Results A total of 54 students participated in this quality improvement educational project. Results showed overall decreases in anxiety levels and positive responses on all items in the Medical Education Technologies, Inc., Simulation Effectiveness Tool. Conclusion Simulation experiences in the psychiatric or mental health arena, both as participants and as observers, appeared to decrease students' anxiety about their upcoming clinical rotation and enhanced their clinical understanding.
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.
This article discusses a simulated attempted suicide scenario used in an inpatient psychiatric setting for an undergraduate psychiatric mental health nursing course. This simulation may be adapted for medical and nonmedical settings for continuing education. The experience was planned, implemented, and evaluated within a caring framework. Faculty, along with a clinical expert, designed the activity to minimize intrapersonal anxiety and to maximize individual learning, peer awareness, and cooperative responses to emergent leadership within the group.