Students are expected to master a number of skill sets to meet the minimum standard of professional nursing practice. These skill sets require that students attain knowledge, incorporate critical thinking as well as psychomotor skills, cultivate self-awareness, develop self-confidence in their skills, and subsequently apply their knowledge in the clinical setting. Development of appropriate skills related to a psychiatric emergency presents a challenge in the current health care environment where clinical sites are limited and clinical experience may consist of observation and brief patient contacts or one-on-one encounters (Patzel, Ellinger, & Hamera, 2007). Therefore, it is imperative to explore and develop innovative, research-based learning experiences using all possible resources.
Cognitive, behavioral, and emotional exposure to psychiatric emergency situations is essential for novice nurses as they prepare for graduation and entry into the clinical milieu (The Joint Commission, 1998, 2010; Spunt, Foster, & Adams, 2004). While this kind of situation is relatively infrequent and students may not encounter a psychiatric emergency during their clinical experiences, in the real world, emergency events have a high impact in terms of patient, staff, and organizational outcomes. Patients and staff may be severely traumatized, and organizational exposure is high in areas of community relationships, branding, legal consequences, and staff morale. One example of such exposure was highlighted in a widely distributed report of findings on allegations of mental health safety issues on an inpatient unit. The Department of Veterans Affairs Office of Inspector General (2010) reported that “Inpatients were put at risk because staff did not comply with requirements for suicide risk assessments.... Additionally, we found inadequate policies related to contraband” (p. i).
Typically, students get acquainted with concepts integral to psychiatric emergency situations by completing assigned readings, attending lectures, and reviewing handbooks provided in various clinical settings. However, many concepts may remain dry and lifeless in the absence of some kind of experiential anchor. Simulation can provide this anchor, particularly for rare, infrequent, and/or high-impact clinical events.
Patzel et al. (2007) reported online survey results on the topic of psychiatric-mental health clinical experiences from 160 faculty respondents recruited from the Education Council of the American Psychiatric Nurses Association. The authors noted that approximately 23% of faculty respondents from baccalaureate, associate, and diploma programs communicated use of simulation as a clinical activity; the percentage of total clinical time spent as simulation ranged from 1% to 8%. Qualitative comments documented the use of role-play and case study to provide simulated activities on topics such as violence, aggression, and limit setting.
The purpose of this article is to report on the process and content of achieving the overall goal of integrating simulation into the psychiatric nursing clinical experience on a mid-sized Southern university campus. Supporting goals included (a) enacting and modeling the College of Nursing philosophy of caring through an experiential learning activity with undergraduate nursing students in a psychiatric clinical experience, and (b) partnering with a clinical expert in developing an evidence-based best practice simulation designed to convey the key concepts to novice nurses and staff in the psychiatric-mental health area. A related simulation on the concept of suicide by hanging was successfully enacted, evaluated, and reported by Hermanns, Lilly, and Crawley (2011b). The evaluation form for the current simulation report was adapted from the prior simulation activity.
Background and Significance
Research has demonstrated that certain outcomes are more readily achieved when simulation is used for student learning. For example, it has been shown that students retain knowledge learned from a simulation for a longer period of time compared with when the same skill is learned via traditional methods (Jeffries, Woolf, & Linde, 2003). Critical thinking and clinical reasoning are improved, and as a result, students experience increased self-confidence and improved problem-solving abilities (Benner, Sutphen, Leonard, & Day, 2010). In a landmark publication, Benner et al. (2010) identified important elements needed to transform the delivery of education to current and future generations of nurses. Integrating classroom didactic and clinical instruction in the service of learning how to “think like a nurse” is but one of the elements supported by Benner et al. Simulated learning scenarios and environments are important opportunities for blending of didactic and clinical instruction to approach the goals of thinking, doing, and feeling congruent with safe and effective nursing care.
Fortunately, we live in an era that affords students many settings and opportunities for practice of clinical skills, including learning resource centers, clinical skills laboratories, and actual clinical settings equipped for and amenable to simulated activities. Using these resources, students can grapple with theoretical concepts embedded in clinical scenarios and experience the “gut-level” emotional and behavioral responses they elicit, in a safe and supportive learning environment. Students can learn and practice skills and techniques prior to entering the clinical setting as a novice nurse or new employee. Safety and support are clearly important if students are to perceive, process, value, and retain clinically significant information, regardless of where the learning experience takes place.
No doubt many, if not all, faculty and clinical practice professionals can recall that first foray into a “psych unit” and particularly the intrapersonal anxiety experienced by the many unknowns in that setting. Reflecting on this internal state, and informed by Maslow’s (1998)hierarchy of needs, it is probable that in this novel situation, many of us focused on our anxieties and fears, and perhaps even on getting enough oxygen. In fact, Stuhlmiller (2005) reported on survey results from 419 undergraduate nursing students evaluating a revised mental health nursing course designed to stimulate interest in mental health nursing. Results indicated that nearly all respondents doubted their ability to manage their intrapersonal anxiety related to interacting with mental health clients.
Description of the Simulation
“Behind The Door” clinical simulation and training #2 (Hermanns, Lilly, & Crawley, 2011a) is one of a series of simulated clinical activities designed to promote the comfort and competence of baccalaureate nursing students in the psychiatric-mental health treatment setting. The following list outlines the essential components of the wrist-cutting simulation activity.
You open up the door to the patient’s room and find that the patient has smuggled in a knife and slashed the right wrist. You see arterial bleeding and realize the patient could “bleed out” and die.
- Critical action: Manage two active (i.e., radial, ulnar) arterial bleeds in a rapid manner.
- Available material: Emergency cart.
- Observation points: (a) elevation of extremities, (b) adequate pressure source to control bleeding, and (c) infection control and safety actions.
Wrist-Cutting Background and Significance
Wrist-cutting may be an act of self-harm rather than an intentional suicide attempt. To separate the act of self-harm from suicide attempt, it is necessary to evaluate the degree of injury and overall circumstances. Nevertheless, individuals with a suicide attempt of any kind are at greater risk of progressing to a completed suicide in subsequent years (Dewing, Mashadi, & Iwuagwu, 2010; Runeson, Tidemalm, Dahlin, Lichtenstein, & Längström, 2010; Suominen et al., 2004).
Events After the Cut
Relative to the severity and amount of bleeding, the patient can experience cardiac arrhythmias if the body is unable to compensate for the blood loss. If the exsanguination is allowed to continue, the resulting severe hypovolemia will cause shock, followed by cardiovascular collapse, cardiac arrest, and death. Related concerns after wrist-cutting include security of the treatment environment, management of other patients, and infection control.
Arterial bleeding is characterized by a rhythmic gush of blood (in unison with the heartbeat) that is bright red in color. Arterial bleeding from both the radial and ulnar areas suggests suicidal intent on the part of the patient, as significant self-inflicted trauma is necessary to produce such an injury. Venous bleeding, on the other hand, produces a continuous stream of blood of a darker red color. Venous bleeding typically originates from superficial cutting, and the injuries are relatively less severe.
The best first choice is application of pressure directly over the wound site to overcome the force of the heartbeats. However, if blood flow from the injury cannot be controlled after the application of direct pressure, then it may be necessary to apply indirect arterial pressure; for example, in a case of cut wrist, one might apply brachial artery pressure to reduce bleeding from the wound site (Cloonan, 2004). However, the effectiveness of this approach has been questioned (Markenson et al., 2010; Swan, Wright, Barbagiovanni, Swan, & Swan, 2009). It is important to keep in mind that pressure points should be used with caution because inadequate blood flow may cause severe damage to a limb.
In the worst case scenario, where risk of loss of life is impending, one can apply tourniquets but with extreme caution due to concerns about damage to vessels and tissue (Cloonan, 2004; Kragh et al., 2008; Markenson et al., 2010; Swan et al., 2009). For example, there is a military saying, “If you choose to use a tourniquet, be prepared to defend the loss of everything distal to the tourniquet” (B. Crawley, personal communication, April 16, 2010).
Preparation for the Simulation
Didactic content covered prior to psychiatric-mental health clinical exposure includes the role of the nurse in therapeutic interactions with individuals having altered mental status, use of critical thinking in assessment and for addressing ethical dilemmas in the psychiatric setting, and safety and infection control in the psychiatric arena. The topics of therapeutic communication/use of self, self-awareness, and reflection on practice, as well as avoiding dual or social relationships, are also included in the didactic content.
Simulation-specific preparation includes informing students that Behind the Door, they will find a patient (simulation mannequin) with a right wrist laceration and displaying arterial bleeding. They are asked to respond to the patient using the knowledge and behaviors gained from previous learning experiences, including working as a team to leverage all knowledge and experience available in the group.
Students are encouraged to “think out loud” and to seek and provide assistance to peers and from faculty throughout the scenario. Students are also reassured that faculty understand their level of clinical skills and recognize that some skills may be unfamiliar; however, the underlying purpose of the activity is to challenge their thinking, promote team interaction, and practice intervening in a high-stress, high-stakes clinical episode. Students are also advised that questions will be posed by faculty to further the critical thinking process. The state of “not knowing”—by a student or by the team—is considered normal, but the expectation is set forth that participants will actively help solve the problems posed by the clinical scenario presented in the simulation.
Setting and Equipment
The simulation takes place in the clinical skills laboratory or the actual clinical setting, depending on resources available. This scenario requires the availability of a simulation mannequin with arterial blood function, moulage (i.e., mock wound), emergency cart, proxy weapon, and proxy blood.
Desired learning outcomes include, but are not limited to, demonstrating communication and collaboration with peers and faculty, planning and implementing appropriate nursing actions using patient data and evidence-based interventions, evaluating outcomes, and revising plan and actions as needed. Participants are also expected to recognize and apply legal, ethical, and safety principles within the emergency care scenario.
A pre-briefing session clarifies the major components of the simulation activity, which include situation discovery and identification, situation assessment and management, and situation monitoring with patient management and maintenance until transfer to an acute care facility. Faculty presence alternates between guidance, participation, and observation, prompting individuals and the group to comprehend and complete the essential tasks for each component.
In the identification and discovery component, Behind the Door participants find the simulation dummy with a moulage right arm injury and arterial bleed. Bright red dye is pumping from the right lower arm of the mannequin, partially covered with a gown and offering a visually stimulating array. In all cases so far, the nursing students immediately focus on the bleed, at which point the facilitator (B.C.) asks the students to “freeze” in their positions. From under the patient’s gown, and obstructed from view, the facilitator retrieves the left arm bearing a knife; participants are informed that they have sustained a stab wound.
The impact of the overall clinical scenario is then processed with questions such as:
- What effect did the presence of active bleeding have on prioritizing the next best action?
- Was the likely presence, but unknown location of “sharps,” an element of concern?
- Did you have all of the knowledge you needed to prevent self-injury before you came into the room?
- How do you explain the injury to the nurse, if all necessary knowledge for situation management were available?
Observations and comments are summarized by noting that in many nursing schools the priority focus is the medical condition. While medical stabilization is crucial, in the psychiatric setting, assessment and intervention must encompass the whole problem, if safety is to be maintained (Delaney & Johnson, 2008; McCoy & Johnson, 2011). In this particular case, assessment begins with identifying the mechanism of injury, thinking through the ongoing danger of the contraband (weapon), and considering the possibility of other-directed aggression by a patient experiencing psychosis and/or delusions even as treatment efforts are initiated.
Simulation action begins again at this point, and students learn the medical aspects of assessing and managing a persistent arterial bleed, including monitoring the patient’s response to significant blood loss. As noted in the summary above, assessment and management are linked to hemostasis and prevention of further tissue injury. The preferred method for accomplishing this goal is identified as direct pressure to overcome two physical forces: gravity and the energy of the beating heart.
Assessment and management also include safety of the affected patient’s roommate and the first responders, as noted above. These goals will be accomplished through location of the instrument of injury, determination of the patient’s willingness to accept treatment, availability of sufficient staff to ensure containment of aggression, and implementation of universal (standard) precaution considerations. After the patient is stabilized, the following questions are appropriate for participants:
- What critical behaviors are necessary while awaiting transport to a higher level of care?
- What level of staff is most appropriate to remain in immediate attendance of the patient?
- What type of staff are needed to maintain safety and environmental security during the maintenance and transport period?
- What physical assessment parameters are needed during this period?
Debriefing and Evaluation
A debriefing conference lasting approximately 20 minutes provides all participants with the opportunity to dialogue about the content and process of the simulation. In our experience, students are eager to reflect on their thoughts, feelings, and behaviors, and to examine specific elements that might help or hinder their ability to provide care for themselves and others in high-stress clinical encounters. This is also a time for faculty to communicate the importance of each action, as part of an entire sequence of actions, in addressing and resolving a clinical situation. The debriefing and evaluation period is well suited for faculty sharing of past psychiatric emergency encounters and for appropriate self-disclosure about his or her performance at an earlier period of professional development. This kind of sharing accentuates faculty commitment to convey presence, attention, interest, and knowledge with students engaged in the crisis simulation. Further, faculty storytelling may highlight the idea of a lifelong process of professional development, rather than points of completion (Higgins, 1996; Kowsowski, 1995).
We have found it is possible to nurture students while conducting a well-designed, psychiatric-mental health clinical simulation, if it is based in Watson’s (2006, 2008) principles of caring and includes the best evidence available. Student evaluations (Figure) of the content and process of the learning activity have supported this claim. Specifically, the evaluation content items targeted students’ perceptions of learning in the areas of physiological parameters, nursing role, team behaviors, and opportunity to actively engage in motor skills relevant to a psychiatric emergency. Process items targeted the students’ internal experience, such as whether they felt supported and whether appropriate faculty guidance occurred. Feedback included in the students’ evaluations has provided both validation and direction in our ongoing integration of psychiatric-mental health simulations into baccalaureate nursing students’ clinical experience.
McGarry, Cashin, and Fowler (2011) provided an interesting review and discussion, informed by Roger’s model of diffusion of innovation, about the topic of high-fidelity human simulation in the arena of child and adolescent psychiatric-mental health nursing. While the example provided in this article does not use a high-fidelity simulator, the points made by McGarry et al. are pertinent to the purpose of this article. Specifically, they noted the promise of this teaching approach within psychiatric-mental health undergraduate education, particularly to address availability and reliability of clinical experiences. An additional positive aspect of simulation is the ability to modify and adapt the various levels of fidelity to a virtually unlimited number of scenarios, with faculty time, motivation, and training as limiting factors. However, as any faculty member understands, the time devoted to seeking, arranging, confirming, and completing psychiatric-mental health clinical experiences is also significant, and there is no guarantee as to the richness of any particular student clinical experience.
As indicated above, the student evaluations provide valuable information about learner perceptions of the content and process of the simulation activity. In our experience, students are overwhelmingly positive in their evaluations, supporting prior research by Nau, Dassen, Halfens, and Needham (2007) that nursing students desire information and practice in handling volatile patient situations. Additionally, the simulation activity incorporated suggestions from Bremner, Aduddell, Bennett, and VanGeest’s (2006), who proposed best practices for the use of human patient simulators with novice nursing students. Specifically, the simulation was planned and organized to address specific learning outcomes; course and clinical objectives were clearly linked to the activity; the faculty and clinical expert engaged in ongoing dialogue about the conduct of the simulation; the activity was evaluated and revised based on student comments; and debriefing occurred following the experience.
The Joint Commission’s (1998, 2010) Sentinel Event Alert addresses the issue of suicide, a familiar psychiatric crisis, which can occur in emergency departments, general medical hospitals, psychiatric hospitals, and residential facilities. Further, the Joint Commission’s (2011) National Patient Safety Goal 15.01.01 requires risk assessment, identification of safety needs, and care in the most appropriate setting. In the emergency department setting, Rossi, Swan, and Isaacs (2010) detailed clinical vignettes of violence and agitation involving failure to discover contraband and the consequences thereof. Similar to The Joint Commission, these clinical experts promote education in recognizing environmental and behavioral cues to an impending crisis and in responding to all elements of such a crisis. Likewise, McCoy and Johnson (2011) advised, “The primary goal in caring for a patient with a behavioral emergency is safety. Safety for the patient as well as the staff should be considered at all times” (p. 106). An important action proposed in these publications is to “Check the patient for contraband that could be used to commit suicide” (The Joint Commission, 2010, p. 3), or in the emergency setting, be aware of and develop standardized methods for detecting contraband and removing sharps from the environment.
The original simulation activity was implemented to improve code responses by nurses working in the psychiatric-mental health hospital setting. The activity was expanded to baccalaureate nursing students completing their psychiatric-mental health clinical rotation. A simulated psychiatric emergency of this type allows for exposure to situations of care that are infrequent and demanding, both cognitively and emotionally. Further, achieving this level of collaboration between a practice and university setting promotes enhanced learning opportunities for staff and students. These opportunities have real promise for yielding quality care for patients.
Even when a psychiatric emergency occurs during a clinical rotation, the nature and context of the emergency may preclude student participation in the management and resolution of the episode. A well-designed psychiatric-mental health clinical simulation, combining multiple emergency/crisis concepts, such as contraband, personal safety, and environmental assessment, is undeniably worthwhile in bridging this experiential gap for nursing students and novice nurses preparing to enter any clinical setting. While the resulting post-graduation clinical outcomes of these efforts are unknown at this time, a large body of cognitive, behavioral, and affective research suggests that students engaging in this kind of practice experience will have access to their prior learning in future clinical situations.
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