Issues in Mental Health Nursing
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: [Link]
Implementation of Simulation: A Contemporary
Strategy to Enhance Clinical Skills of
Undergraduate Students in Mental Health Nursing
Salima Farooq, Ambreen Tharani, Shamshad Begum & Yasmin Parpio
To cite this article: Salima Farooq, Ambreen Tharani, Shamshad Begum & Yasmin Parpio
(2020): Implementation of Simulation: A Contemporary Strategy to Enhance Clinical Skills
of Undergraduate Students in Mental Health Nursing, Issues in Mental Health Nursing, DOI:
10.1080/01612840.2019.1710011
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Published online: 06 May 2020.
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ISSUES IN MENTAL HEALTH NURSING
[Link]
Implementation of Simulation: A Contemporary Strategy to Enhance Clinical
Skills of Undergraduate Students in Mental Health Nursing
Salima Farooq, MSc EB, BScN, RN, Ambreen Tharani, MA EHPID, BScN, Shamshad Begum, MA EHPID, BScN, RN,
and Yasmin Parpio, MSc EB, BScN
School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan
ABSTRACT
Simulation is an innovative teaching strategy that supports student centered learning. It
improves therapeutic communication skills with clients. Additionally, it enhances critical think-
ing, problem solving, and confidence among students, in a non-threatening and safe environ-
ment, 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 stu-
dents’ 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 ses-
sion, 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’ evalu-
ation regarding the simulation experience was positive and they suggested that it be integrated
in the mental health nursing course.
Background Student anxiety can be converted into powerful learning
by engaging them in safe learning. One way that this can
Mental illness is an alarming health issue globally. Nurses
be done is by preparing/training students, before they
play a significant role, as a part of the interprofessional
encounter challenging cases in clinical settings (Fay-
team, in mental health care settings. In order to prepare
Hillier, Regan, & Gallagher Gordon, 2012), through util-
nurses, mental health nursing is an integral component of ization of volunteer simulated patients to dispel students’
the undergraduate curriculum, which prepares them to anxiety (Brown, 2015; 2008). Therapeutic communication
work with patients in clinical settings. However, nursing is a vital tool for clients’ well-being in a psychiatric setting
students face challenging situations at clinical settings for the provision of comprehensive care (Timothy, 2015).
(Oudshoorn & Sinclair, 2015), where they encounter cli- Hence, training them to utilize appropriate communica-
ent(s) who are not willing to talk, intrude in their personal tion skills via simulation is crucial for nursing students to
space, and are demanding due to their disease process. help them develop competency for client care
Furthermore, some patients experience extreme emotions and recovery.
and psychotic behaviors that need immediate intervention. The use of patient simulators in an undergraduate men-
These situations can be emotionally demanding and stu- tal health nursing course is a unique instructional method-
dents, at times, feel lost or incompetent. Moreover, the ology (Brown, 2015), as it facilitates replication of real life
stigma and fear attached with mental illness in our society experiences and development of competencies in commu-
further add to their apprehension of dealing with patients nication and clinical decision making (Brown, 2015; Guise,
in these clinical situations. As a result, nursing students Chambers, & V€alim€aki, 2012). Moreover, it facilitates stu-
often feel anxious and helpless (Stuhlmiller, 2005; dents to learn about the application of culturally diverse
Sunnqvist, Karlsson, Lindell, & Fors, 2016). Thus, there is a client centred care (Ndiwane, Koul, & Theroux, 2014).
need to develop innovative strategies that can assist stu- Furthermore, this strategy supports a student centred
dents in dealing with these challenging situations in a safe learning, and enables them to learn in a pseudo setting
environment. similar to the real world (Faulcon, 2015; Larew, Lessans,
CONTACT Ambreen Tharani [Link]@[Link] Aga Khan University School of Nursing and Midwifery, Karachi, Pakistan.
ß 2020 Taylor & Francis Group, LLC
2 S. FAROOQ ET AL.
Spunt, Foster, & Covington, 2006). In addition, it enhances
their positive clinical experience and strengthens their
emotional capacity (Kirkbakk-Fjaer, Hedelin, & Box 1. Scenarios.
Moen, 2016).
Simulation is a practical strategy for teaching critical 1. Bipolar Disorder: Crossing personal boundaries
thinking, problem solving, and self-directed learning, with- A 33-year-old patient with bipolar disorder, over talkative and
over familiar, overly groomed, invading the personal space of
out posing a risk to live patients (Brown, 2015). the interviewer by dragging a chair toward the interviewer’s
Simultaneously, this methodology helps students to learn chair and asking personal questions and insisting that the inter-
from their own mistakes before entering a real clinical viewer respond to personal questions, and making it difficult for
the interviewer to continue with the mental status examination.
setting, which enhances patient safety, and promotes thera- 2. Depression: Mute
peutic communication skills and confidence in students A 28-year-old male client diagnosed with major depression.
(Kirkbakk-Fjaer et al., 2016; Sunnqvist et al., 2016). The client admitted with symptoms of anhedonia, having a low
mood, and lack of energy, slow speech, low self-esteem, home-
The selected School Of Nursing (SON), Pakistan, less, having feelings of excessive guilt for more than two weeks,
offers a six-credit Mental Health Nursing (MHN) course and did not take part in activities and hygiene care, appears
to undergraduate nursing students in the third year of unkempt. He usually stays alone and does not talk to
other people
the programme. The course expects students to develop
3. Borderline personality: Suicidal behavior
communication skills to deal with the challenging behav- A 34-year-old female with borderline personality disorder and a
iors of clients with various mental disorders, and to fos- history of self-mutational behavior. On examination, there are
ter their recovery. Apprehension related to dealing with multiple scars on both wrists. During interview, the patient
stated, “I am worthless. Nobody needs me. Soon the burden will
clients having mental health issues were also shared by be gone.”
the students from earlier cohorts. In the light of afore- 4. Schizophrenia: Visual hallucinations
mentioned literature, MHN team took initiative to imple- A 31-year-old woman has been diagnosed with schizophrenia.
ment simulation project in 2017. Simulation in mental She has had a number of hospitalizations during that time; at
the time of the interview, she was admitted with complaints of
health is comparatively new in the Pakistani context; self-talk, aggressive behavior, and noncompliance with medica-
therefore, a pilot project was implemented to assess its tion. During the interaction, she frequently tells the nurse, “See
impact on students’ comfort and clinical performance. MR Z is here. Can you see him?”
Hence, this project aimed to determine the significance
of simulation to improve confidence, knowledge, and Scenario development and review process
communication skills of undergraduate mental health
nursing students. Four simulation scenarios that represented the mental
health conditions common in inpatient psychiatry unit were
prepared. These scenarios included: 1) 34-year-old female,
Theoretical framework with borderline personality disorder, had history of self-
The theoretical framework of the Experiential Learning mutilating behaviors and verbalizing of suicidal ideations, 2)
Theory (ELT), by Kolb (1984), was used as a guiding prin- 33-year-old client with Bipolar disorder, over talkative and
ciple for this simulation project. Experiential learning is over familiar, who is crossing personal boundaries, 3)
defined as, “the process whereby knowledge is created 31-year-old female with schizophrenia, experiencing visual
through the transformation of experience. Knowledge results hallucinations, and 4) 28-year-old male client diagnosed
from the combination of grasping and transforming experi- with major depressive disorder, admitted with the symptoms
ence” (Kolb, 1984). of anhedonia, low mood, and is currently mute. The
The ELT model emphasizes that learning is constructed scenarios were reviewed by the mental health course team
through a four-active cyclic mode, including concrete for required amendment and approval.
experience, reflective observation, abstract conceptualiza-
tion, and active experimentation. This process involves
Selection and training of simulated patients
active engagement of learners (students) that facilitates
application of knowledge and skills in actual clinical set- Volunteers were identified from the batch of senior
tings (Doolen, Giddings, Johnson, de Nathan, & Badia, students, who had already completed the mental health
2014; Kolb, 1984). nursing course in the past 2 years, and could serve
as simulated patients (SP). They were provided with a
half-day training to familiarize them with the simulation
Pre-implementation phase
process. The half-day training was sufficient, as the
The preparatory phase of simulation consists of creating and volunteers already had mental health related knowledge
reviewing scenarios (Refer Box 1), followed by training of and experience to be able to envision the cases. The train-
selected volunteers as simulated patients. ing included information about the simulation process
ISSUES IN MENTAL HEALTH NURSING 3
and a visit to the venue. The SPs were informed that at a made to visit the simulation facility at the venue (IC) to min-
time, one pair would interview them, while eight to nine imize their apprehension. In the next 2 days, the students
students would observe them from the recording room were provided exposure to the simulation of all four scen-
and maintain their observation sheets, from where the arios, and all these were followed by debriefing.
scenarios would be video During training, the SPs were
provided their respective scenario and its specific objec-
Simulation with standardized patient
tives that the students were expected to achieve. Each
scenario was reviewed and practiced with each SP for Each clinical group scheduled for simulation activity com-
clarification promoting comfort and addressing related prised 10-12 students; in all there were eight groups. Twelve
concerns. They were informed about the required dress- volunteers were prepared to serve as simulated patients, out
ing and were facilitated for rehearsal to ensure that they of which 10 were scheduled to interact with each pair of stu-
portrayed the symptoms precisely. dents for 10 minutes. Two of the SPs were retained in case
of last minute absence of any volunteer. While the pair of
students was communicating with the SP, the other mem-
Simulation venue
bers of the clinical group were required to make an observa-
The venue for the implementation of this strategy was the tion of the communication and fill the provided observer
Observation rooms at the Innovation Centre (IC). These checklist (see checklist Box 2). Each pair got exposure to
special rooms are equipped such that they allow the faculty communicating with a client and then to become observers
to make observations without hindering the students and for four to five pairs. The same activity was repeated twice a
patients during the simulation experience. The advanced day, for 2 consecutive days to provide each pair an oppor-
sound system allows faculty members to communicate tunity to work with all four clinical scenarios (four SPs).
during the simulation and provide real-time feedback. Additionally, the students were required to write nursing
notes for mental status examination that they conducted,
upon completion of each SP encounter.
Implementation
During the 10-minute interaction, each pair was asked to
The simulation exercise was scheduled over 4 days. On day make safe sitting arrangements, introduce themselves, and
one, students’ anxiety and apprehensions associated with their share the purpose of the interview with the SP, in the begin-
forthcoming experience in a mental health care setting were ning. Most of them finished their interview before the com-
discussed. Moreover, students were facilitated with sessions, pletion of their time limit (10 minutes) during first the
including self-awareness, therapeutic communication techni- interaction. However, for the next three interactions, stu-
ques, and mental status examination, that could minimize dents were able to utilize the maximum time given them for
their anxiety and provide them guidelines for communication completing the clinical interview.
and assessment. The objectives and schedule of the simulation
strategy, and peer-observation and interviewer (self) checklists
Students’ debriefing
were discussed. The students were asked to translate the pos-
sible questions that are used for conducting a mental status Debriefing is the key element in the simulation process
examination in the local language (Urdu). They were also to safeguard students’ learning experience (Dreifuerst, 2009).
Box 2. Observation checklist.
Observation checklist Satisfactory Needs improvement Not satisfactory Comments
Arranged the setting and seating for the interview
Introduced self and purpose of clinical interview
Began the interview with general history
Obtained information about the chief complaint
Addressed the nonverbal behavior of the client
Conducted suicide risk assessment
Ideation
Plan
Performed assessment for hallucination and delusion
Explored commanding hallucination, if required
Utilized therapeutic communication techniques: Paraphrasing, reflecting,
empathizing, use of silence, putting events in time frame, focusing,
raising doubts
Maintained professional boundaries and limit settings while
conducting interviews
Summarized the interview
Demonstrated enhanced self-awareness in clinical practice
4 S. FAROOQ ET AL.
After the simulation experience, four debriefing experts Experiential learning (Kolb, 1984) underpinned each case
and four mental health faculty members were assigned for scenario, as during this process, students encountered simu-
two-hour debriefing sessions. The eight clinical groups were lated cases that provided them a concrete experience of interact-
merged into four groups for debriefing. Each of the four ing with patients. The result was reflective observation, via a
groups comprised 20-24 students with one mental health self-reflection checklist, and was followed by a debriefing exer-
faculty and one certified debriefer. Literature suggests that cise, which was facilitated by four experienced mental health
debriefing must take place in a safe, comfortable environ- clinical faculty members and four trained debriefing experts.
ment where students feel valued and respected (Fanning & Based on self-reflection and debriefing, abstract conceptualiza-
Gaba, 2007). Hence, the school of nursing classrooms tion developed in students, regarding managing patients in a
were used. The debriefing process included reviewing the clinical setting. This process further included the observer com-
simulation experience via replay of video recording, and ment sheet, the faculty member’s feedback on their perform-
included reflection on performance, clarification of concepts ance, and the written mental status examination nursing notes.
and communication principles, exploring perceptions and All this led to active experimentation, as these students were
feelings, and promotion of self-awareness and culturally able to apply the new experiential learning in real clinical cases,
sensitive care (for details see debriefing guideline Box 3). after the completion of this simulation activity.
The students were able to identify the communication The students’ formative feedback and summative evalu-
techniques used and shared their strengths and areas for ation on the simulation-based teaching learning strategy was
improvement from the recorded videos. This helped the positive. According to the feedback the utilization of the
students to reflect on their past experience and pickup key simulation strategy had boosted their knowledge and skills.
learning points for future practice. The faculty and debriefer They reported improvement in their confidence and satisfac-
ensured that the concerns of all students were addressed tion level in engaging with real patients in their mental
and the key learning concept were summarized. health clinical rotation. The simulation experience served as
a buffer where they were able to apply theoretical knowledge
to clinical practice. Faculty also identified improvement in
Box 3. Debriefing guidelines. clinical performance and confidence in this cohort, as com-
pared to the students who were not exposed to this strategy
How would you evaluate your performance throughout before the mental health clinical.
the scenario?
Were you able to identify and address relevant issues related to
the scenario? Conclusion and implications for practice
What did you do differently to increase your effectiveness in deal-
ing with the particular scenario? Mental health clinical placements are often found to be anx-
Did you identify any issue which was difficult for you to iety provoking and threatening by the undergraduate nurs-
respond to?
What did you find new in this interaction?
ing students due to the nature of the mental health nursing
Which therapeutic and non-therapeutic communication techniques
clinical specialty. This was the first time that mental health
were used during the interaction? was taught through simulation in our context. The experi-
What were the gaps in history taking and mental status ence of simulation in the mental health course exhibited sev-
examination? eral potential benefits. Both the students and the mental
How will this simulation experience as a nursing student help you health clinical faculty members found this strategy effective
in real practical situations?
in terms of building confidence, and promoting therapeutic
communication techniques and assessment skills. Moreover,
simulation is a useful alternative strategy for accommodating
Discussion
large student classes, with limited clinical placements, for
Transformation from novice to competent nurse requires building their capacity in mental health nursing. Based on
clinical practice. Simulation is an innovative strategy that our experience, regarding mental health nursing clinical
strengthens the capacity of novice nurses to work effectively teaching in the undergraduate curriculum, we propose allo-
in real clinical situations. This project was the first to utilize cating 20% to 30% of clinical credits to simulated experience
the IC setting and the simulation strategy for enhancing the with standardized patients (SPs). This will, eventually, pro-
communication skills in mental health settings. The strategy mote learning related to more complex clinical scenarios in a
was appreciated as an efficient learning pedagogy for enhanc- safe environment, to enhance students’ decision making and
ing students’ communication skills as it enabled them to critical thinking. It is also vital to engage all health care pro-
rehearse and improve communication with clients exhibiting fessionals to be a part of this pedagogy, to enable students to
various symptoms and behaviors. A similar strategy was uti- learn about the multidisciplinary collaborative care approach.
lized and appreciated in mental health nursing courses in In addition, strengthening the feedback mechanism soon after
baccalaureate programmes in universities based in the US the interaction phase can be effective. Moreover, documenting
(Davis, Josephsen, & Macy, 2013; Doolen et al., 2014; Fay- clinical findings should be emphasized during simulation, to
Hillier et al., 2012), Canada (Oudshoorn & Sinclair, 2015), enhance reflective practices. It is also recommended that
Australia (Kunst, Mitchell, & Johnston, 2017) and Singapore debriefing should be limited to individuals rather groups, in
(Yong-Shian, Selvarajan, Chng, Tan, & Yobas, 2016). order to promote focused learning in a safe environment.
ISSUES IN MENTAL HEALTH NURSING 5
Lastly, future projects are needed to implement the simulation nursing education. Issues in Mental Health Nursing, 33(11),
pedagogy in order to improve the quality of health care in 718–726. doi:10.3109/01612840.2012.709585
Guise, V., Chambers, M., & V€alim€aki, M. (2012). What can virtual
our context, with limited availability of resources.
patient simulation offer mental health nursing education? Journal of
Psychiatric and Mental Health Nursing, 19(5), 410–418. doi:10.1111/
j.1365-2850.2011.01797.x
Acknowledgement Kirkbakk-Fjaer, K., Hedelin, B., & Moen, Ø. L. (2016). Undergraduate
Students, SPs, volunteers, debriefing experts, IC staff, and mental nursing students’ evaluation of the debriefing phase in mental health
health course faculty. nursing simulation. Issues in Mental Health Nursing, 37(5), 360–366.
doi:10.3109/01612840.2015.1136716
Kolb, D. (1984). Experiential learning: Experience as the source of learn-
Disclosure statement ing and development. Englewood Cliffs, NJ: Prentice-Hall.
Kunst, E. L., Mitchell, M., & Johnston, A. N. (2017). Using simulation
The authors declare no conflict of interest. to improve the capability of undergraduate nursing students in men-
tal health care. Nurse Education Today, 50, 29–35. doi:10.1016/j.
nedt.2016.12.012
References Larew, C., Lessans, S., Spunt, D., Foster, D., & Covington, B. G. (2006).
Innovations in clinical simulation: Application of Benner’s theory in
Brown, J. (2008). Applications of simulation technology in psychiatric
an interactive patient care simulation. Nursing Education
mental health nursing education. Journal of Psychiatric and Mental
Perspectives, 27(1), 16–21.
Health Nursing, 15(8), 638–644. doi:10.1111/j.1365-2850.2008.001281.x
Ndiwane, A., Koul, O., & Theroux, R. (2014). Implementing standar-
Brown, A. M. (2015). Simulation in undergraduate mental health nurs-
dized patients to teach cultural competency to graduate nursing stu-
ing education: A literature review. Clinical Simulation in Nursing,
dents. Clinical Simulation in Nursing, 10(2), e87–e94. doi:10.1016/j.
11(10), 445–449. doi:10.1016/[Link].2015.08.003
ecns.2013.07.002
Davis, S., Josephsen, J., & Macy, R. (2013). Implementation of mental
Oudshoorn, A., & Sinclair, B. (2015). Using unfolding simulations to
health simulations: Challenges and lessons learned. Clinical
Simulation in Nursing, 9(5), e157–e162. doi:10.1016/[Link].2011.11. teach mental health concepts in undergraduate nursing education.
011 Clinical Simulation in Nursing, 11(9), 396–401. doi:10.1016/[Link].
Doolen, J., Giddings, M., Johnson, M., de Nathan, G. G., & Badia, 2015.05.011
L. O. (2014). An evaluation of mental health simulation with stand- Stuhlmiller, C. M. (2005). Promoting student interest in mental health
ardized patients. International Journal of Nursing Education nursing. Journal of the American Psychiatric Nurses Association,
Scholarship, 11(1), 55–62. doi:10.1515/ijnes-2013-0075 11(6), 355–358. doi:10.1177/1078390305284274
Dreifuerst, K. T. (2009). The essentials of debriefing in simulation Sunnqvist, C., Karlsson, K., Lindell, L., & Fors, U. (2016). Virtual
learning: A concept analysis. Nursing Education Perspectives, 30(2), patient simulation in psychiatric care–A pilot study of digital sup-
109–114. port for collaborate learning. Nurse Education in Practice, 17, 30–35.
Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simu- doi:10.1016/[Link].2016.02.004
lation-based learning. Simulation in Healthcare: Journal of the Timothy, G. (2015). Utilization of therapeutic communication as a
Society for Simulation in Healthcare, 2(2), 115–125. doi:10.1097/SIH. widget for spiritually guided life force energy (SGLFE) in client care:
0b013e3180315539 A hope for the 21st century nursing practice. Journal of Ayurveda
Faulcon, R. Y. (2015). Innovative teaching strategies with simulation and Holistic Medicine (JAHM), 3(2), 33–40.
technology in nursing education. Journal of Bermuda College, 1, Yong-Shian, G., Selvarajan, S., Chng, M.-L., Tan, C.-S., & Yobas, P.
47–50. (2016). Using standardized patients in enhancing undergraduate
Fay-Hillier, T. M., Regan, R. V., & Gallagher Gordon, M. (2012). students’ learning experience in mental health nursing. Nurse
Communication and patient safety in simulation for mental health Education Today, 45, 167–172. doi:10.1016/[Link].2016.08.005