Meaningful Mental Health Simulation in Nursing: Human Scenarios

Clinical practice in nursing school is key to develop and practice new-found skills learned for the provision of patient care. In the mental health setting, these skill sets require an enhanced ability to assess the non-verbal cues of the patients, including body language and eye contact. Although consistent clinical experiences are desired, educators are aware that no two clinical rotations offer the same opportunities. Furthermore, in the mental health, clinical practice settings are few which means the clinical practice experience for the student may be lacking in rigor. Providing a hi-fidelity simulation is an option, but the depth of non-verbal cues from a mannequin are lessened. In order to provide a rigorous and consistent practice experience, a human simulation was created for nursing students and was a required component of their mental health clinicals. A script, scenario and setting was created and used for each student group. Although the scenario and the faculty actors were consistent, the behavior, responses, and interactions with each of the ten, student groups were delightfully diverse.


Introduction
Learning in the clinical setting is the cornerstone of nursing school. To take the new-found knowledge from didactic instruction and to apply it in practice is one of the first and most basic steps to achieving competency. In the mental health setting, the skill set required by the student to be successful includes strong ethics, empathy, active listening, and healthy boundaries. Although assessments, medication administration, and medication effectiveness evaluation are also performed, the cultivation of both mental and physical assessment skills is required. By creating a standardized, mental health simulation for all nursing students, patient safety is ensured, better preparation of new nurses is promoted, and the shortages of faculty and clinical sites is overcome [1].

Preparation
With the support of the department head and the program coordinator, preparation for the simulation experience began six weeks prior to the start of the semester. Tasks to be completed included the creation of the scenario, the selection of faculty, the rubric for evaluation, and the operational logistics.

Scenario
A thorough review of free access scenarios available on the internet was performed by the lead instructor. A simulation scenario involving a new admission with a history of schizophrenia was created after examples were synthesized. The scenario was written to ensure that each member in a group of nursing students could have an active role in the event. Nursing students in an Associate Degree of Nursing program were the participants. One hundred students in their final semester of a four-semester nursing school were assigned to complete this simulation in the spring of 2020. Although these students had experience both low-fidelity and highfidelity simulations for acute care in semester one and two, they had not experienced a simulation for mental health nor with human actors with a standardized scenario. This spring semester was their first experience with the subject of mental health in nursing.
The process began by grouping together, at random, ten groups composed to eight nursing student in each group. Each group was assigned a four-hour block of time on either a Monday or a Tuesday. The schedule was released at the beginning of Volume 03; Issue 09 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 the semester and little changes were allowed. Also released at the beginning of the semester was a homework activity on schizophrenia which was to be completed by the morning of their assigned simulation. The activity included a case study which gave the students an opportunity to immerse in a mental health situation.
The morning of the simulation, the student group gathered in a classroom. Each student was given an overview of the simulation patient background which included a brief medical history and a list of current medications. After reviewing the standardized patient, students selected a nametag at random which would identify their role. The nametags included primary nurse, charge nurse, security, physician/provider, nurse aid, social worker, certified med aid and a student reviewer. The group was then allowed fifteen minutes to discuss the patient together and develop a plan for caring for this patient. When completed, they would enter a separate room which was staged with the human patient in a hospital bed along with a medication closet and supply room.
The script revealed that the patient self-admitted themselves to the hospital. They had no recollection of how they got to the hospital but stated that they had been drinking and had a history of suicide attempts. In the patient's possession were prescription pain pills, unlabeled bottles of alcohol, and personal items such as a stuffed animal. The students were instructed to begin the simulation with a head to toe assessment for anewly admitted patient to the mental health unit. The resulting course of the simulation would be directed by the assessment data disclosed by the patient and through the nurse-patient conversation.
Keen assessment skills were needed by the staff. Potential hazardous items were strategically placed in the room before the simulation began. Some items were hidden from the nurse such as scissors that were left in a drawer and some items were in plain sight, such as a used IV line. One simulation session ended with an attempted suicide as the patient tried to strangle themselves with an IV tubing when the nurse left the room. Had the nurse identified the IV tubing as a hazard and removed it, the attempt would not have occurred. One simulation session involved a student who began an compassionate conversation using therapeutic and empathetic communication. This genuine, giving of self by the student nurse was so compassionate that the human patient began to open up about their past years of abuse and actually cried tears. It was moving for all to see.

Faculty
It is well known that clinical site availability can be difficult for a nursing school to secure. Mental health facilities can be more difficult to locate. Furthermore, securing faculty with mental health experience who are willing to instruct in the clinical setting is even more difficult. Fortunately, several faculty were willing to be recruited for this simulation commitment that was to last six weeks. The lead simulation instructor was a full-time nursing faculty who had psychiatric mental health specialty certification. Other involved faculty included a clinical lab instructor, a full time nursing faculty, two-adjunct faculty, and one social worker from a local counseling center. The faculty met twice prior to beginning the simulation experience in order to read the script and define the roles. The role of the patient alternated between three of the instructors. Although the script was the same, each of the actors acted uniquely with the script and were influenced by the student responses during the simulation. This allowed for each group's experience to be unique.
After the simulation experience, the simulation faculty and the students would meet for a debriefing session in a separate room. Discussing the events that took place during the simulation created very honest and vulnerable conversations. Faculty was committed to creating a supportive and encouraging debriefing session in which positivity was maintained. Positive reinforcement was the undertone for all of the debriefing sessions. During debriefing, a faculty would ask if an outcome would have been different if a question was worded differently or if another response had been given. Active dialogue between faculty and students was encouraged to create a best-practice vision for the scenario. Creating a positive learning environment that encourages mutual respect begins with the student-faculty relationship [2].
Mutual respect, a commitment to confidentiality, and promoting professional behavior enhance the simulation-based learning environment [3]. By encouraging participants to ask questions, there was no without fear of ridicule [4] which supported a positive learning environment

Rubric
A rubric with grading categories was provided to the students at the beginning of the semester. It was then used during the simulation to evaluate the event. The rubric was for commenting and evaluating each simulation experience and these results were combined to give each group an overall score. The observers for the simulation included faculty as well as assigned, student observers. Comments from the rubric were also shared during debriefing in other to emphasize, clarify, or reinforce a teaching point.

Operational Logistics
An asset for this simulation project was access to a classroom that had an adjoining room to be used as the staged hospital room. Students were able to comfortably sit in the classroom to talk together pre-simulation and during the debriefing event. The staged hospital room included a hospital bed, several chairs, bedside table, medication closet and supply closet. Props used included an IV pole, used IV tubing, sharp objects on the bedside table, and sharp objects in the table drawer. These props should have been identified by the simulation students as dangerous and should have been removed during the simulation, ideally. Because the environment was ample and readily available in the nursing school, there was no need to seek out additional resources. There was no substantial cost factor since the scripts were created at no cost, faculty was already employed by the school, and the simulation room already existed. This human simulation experience required little to no additional cost to the school.

Lessons Learned
During the course of the project, different faculty assumed different roles in the simulation. One session took a different twist and was noteworthy. When the lead mental health instructor took the role of the patient, it appeared to change the dynamics of the simulation group. Having this particular faculty as the patient appeared to change the focus from completing the assessment to focusing on the approval/disapproval from the simulation patient. One student even remarked to the instructor that "I just can't do this with you as the patient". It was discovered that having a social worker involved in the simulation was an extreme advantage. The simulation in which the social worker was a patient allowed for an enriching experience which the social worker brought from their counselling practice which was meaningful and practical.

Summary
A simulated patient is an individual that is trained to portray a patient with health-related conditions [5]. Simulations offer realistic experiences to students in a controlled setting and allows them to develop their interpersonal and clinical skills in a safe environment [5]. To offer a simulated patient experience to a nursing student in the mental health setting allows the student to apply their knowledge and skill without the underlying fear of doing harm. This clinical simulation experience for nursing students in mental health was a win-win situation. It allowed a meaningful, rigorous and realistic experience for the students and provided a consistent and controlled environment for the faculty which may have been difficult in diverse, mental health settings.