Content uploaded by Abe Oudshoorn
Author content
All content in this area was uploaded by Abe Oudshoorn on Oct 17, 2019
Content may be subject to copyright.
Featured Article
Using Unfolding Simulations to Teach
Mental Health Concepts in Undergraduate
Nursing Education
Abram Oudshoorn, RN, PhD
a,
*, Barbara Sinclair, RN, MScN
b
a
Assistant Professor, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON,
N6A 5C1, Canada
b
Lecturer and Coordinator for Simulated Clinical Education, Arthur Labatt Family School of Nursing, Faculty of Health
Sciences, Western University, London, ON, N6A 5C1, Canada
KEYWORDS
nursing education;
simulation;
mental health;
undergraduate nursing;
prelicensure nursing
Abstract
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://
dx.doi.org/10.1016/j.ecns.2015.05.011.
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
www.elsevier.com/locate/ecsn
The author(s) have no financial support to disclose.
* Corresponding author: aoudsho@uwo.ca (A. Oudshoorn).
1876-1399/$ - see front matter Ó2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2015.05.011
Background
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-
lenges.
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.
Development
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.
Implementation
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
Documentation
Mental health assessment
form
Reflective practice review
(journal)
Community health center
2. Suicide risk assessment Performance of a suicide risk
assessment
Report to physician
Documentation
Completion of
interprofessional suicide
risk assessment form
Report to physician
Reflective practice review
(journal)
Community health center
3. Supporting clients through
a crisis
Assessing clients with
psychosis, severe
depression or anxiety
Documentation
SOAP note
Medication research
Reflective practice review
(journal)
Inpatient mental health
facility
4. Supporting clients through
a crisisdpreparation for
discharge
Assessment of client’s
readiness for integration
into the community
Discharge care plan
SOAP note
Reflective practice review
(journal)
Inpatient mental health
facility
5. Supporting clients living
with a mental health
challenge
Community resource
assignment
SOAP note
Reflective practice review
(journal)
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.
Conclusion
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.
References
Alexander, L., & Dearsley, A. (2013). Using standardized patients in
an undergraduate mental health simulation: A pilot study.
International Journal of Mental Health,42(nos. 2e3), 149-164.
http://dx.doi.org/10.2753/IMH0020-7411420209.
Brown, J. (2008). Application of simulation technology in psychiatric
mental health nursing education. Journal of Psychiatric and Mental
Health Nursing,15, 638-644. http://dx.doi.org/10.1111/j.1365-
2850.2008.001281.x.
Davis, S., Josephsen, J., & Macy, R. (2013). Implementation of mental health
simulations: Challenges and lessons learned. Clinical Simulation in
Nursing,9(5), e157-e162. http://dx.doi.org/10.1016/j.ecns.2011.11.011.
Dunsford, J. (2009). Structured communication improving client
safety with SBAR. Nursing for Women’s health,13(5), 384-390.
http://dx.doi.org/10.1111/j.1751-486X.2009.01456.x.
Edward, K., Hercelinskyj, J., Warelow, P., & Munroe, I. (2007). Simulation
to practice: Developing nursing skills in mental health: An Australian
perspective. International Electronic Journal of Health Education,10,
60-64, Retrieved from http://files.eric.ed.gov/fulltext/EJ794196.pdf.
Filner, D., Champlin, B., & Hunt, R. (2012). Creating and imple-
menting an unfolding, multisetting simulation on a postbaccalau-
reate nursing program. Clinical Simulation in Nursing,8(5),
e181-e186. http://dx.doi.org/10.1016/j.ecns. 2010.09.003.
Hayden, J., Smiley, R., Alexander, M., Kardong-Edgren, S., & Jeffries, P.
(2014). The NCSBN national simulation study: A longitudinal, random-
ized, controlled study replacing clinical hours with simulation in preli-
censure nursing education. Journal of Nursing Regulation,5((2)
supplement), S1-S40, Retrieved from https://www.ncsbn.org/JNR_
Simulation_Supplement.pdf.http://dx.doi.org/10.1016/S2155-8256(15)
30062-4.
Hermanns, M., Lilly, M. L., & Crawley, b (2011). Using clinical simulation
to enhance psychiatric nursing training of baccalaureate students. Clin-
ical Simulation in Nursing,7, e41-e46. http://dx.doi.org/10.1016/
j.ecns.2010.05.001.
Jeffries, P. (2007). Simulation in nursing education: From conceptualiza-
tion to evaluation. New York, New York: National League for Nursing.
Johnson-Russell, J., & Bailey, C. (2010). Facilitated debriefing. In
W. Nehring, & F. Lashley (Eds.), High-fidelity patient simulation in
nursing education (pp. 369-385). Sudbury, MA: Jones & Bartlett
Publishers.
Keltner, E., Grant, J., & McLernon, D. (2011). Use of actors as standard-
ized psychiatric clients. Journal of Psychosocial Nursing,49(5), 35-40.
Kidd, L., Morgan, K., & Savery, J. (2012). Development of a mental health
nursing simulation: Challenges and solutions. Journal of Interactive On-
line Learning. ISSN: 1541-4914, 11(2). ISSN: 1541-4914, 80-89.
Lehr, S., & Kaplan, B. (2013). A mental health simulation experience for
baccalaureate student nurses. Clinical Simulation in Nursing,9(10),
e425-e431. http://dx.doi.org/10.1016/j.ecns.2012.12.003.
Maruca, A., & Diaz, D. (2013). Does simulation enhance undergraduate
psychiatric nursing education? A formative assessment. Advances in
Dual Diagnosis,6(1), 14-23. http://dx.doi.org/10.1108/1757097131
1308999.
Reese, C. (2011). Unfolding case studies. Journal of Continuing Education
in Nursing,42(8), 344-345. http://dx.doi.org/10.3928/00220124-
20110722-04.
Robinson-Smith, G., Bradley, P., & Meakim, C. (2009). Evaluating the use
of standardized clients in undergraduate psychiatric nursing experiences.
Clinical Simulation in Nursing,5(6), e203-211. http://dx.doi.org/10.1016/
j.ecns.2009.07.001.
Szpak, J., & Kameg, K. (2013). Simulation decreases nursing student anx-
iety prior to communication with mentally ill patients. Clinical Simula-
tion in Nursing,9(1), e13-e19. http://dx.doi.org/10.1016/j.ecns.
2011.07.003.
Webster, D., Seldomridge, L., & Rockelli, L. (2012). Making it real: Using
standardized patients to bring case studies to life. Journal of Psychoso-
cial Nursing & Mental Health Services,59(5), 36-41. http:
//dx.doi.org/10.3928/02793695-20120410-06.
Yousey, Y. (2013). The use of unfolding case studies: Innovation in online
undergraduate nursing education. Journal of Nursing Education and
Practice,3(4), 21-29. http://dx.doi.org/10.5430/jnep.v3n4p21.
Teaching Mental Health Concepts Using Unfolding Simulations 401
pp 396-401 Clinical Simulation in Nursing Volume 11 Issue 9
