Ms. Christoffersen and Ms. Lynch are Assistant Professors, Dr. Barron is Associate Professor and Associate Chair of Undergraduate Nursing, Simmons College, Department of Nursing, Boston, and Ms. Caroline is Professor, Curry College, Milton, Massachusetts. Ms. Christoffersen is also Psychiatric-Mental Health Clinical Nurse Specialist, Beth Israel Deaconness Medical Center, and Dr. Barron is also Psychiatric-Mental Health Clinical Nurse Specialist and Faculty Nurse Scientist, Massachusetts General Hospital, Boston, Massachusetts.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Dr. Joellen Hawkins for her support and guidance.
Address correspondence to Jean Christoffersen, MS, PMHCNS-BC, Assistant Professor, Simmons College, Department of Nursing, 300 The Fenway, Boston, MA 02458; e-mail: firstname.lastname@example.org.
As psychiatric-mental health nursing faculty members, we were asked by our medical-surgical colleagues in the undergraduate program at Simmons College to assist them in the complex process of preparing students to respond to the sensitive and demanding interpersonal situations with patients and families that often present during the students’ clinical experiences. The focus in the psychiatric nursing course on therapeutic use of self and communication is critical but, often, insufficient to help students prepare for the wonderfully rich yet complex, demanding, and, at times, provocative world of nursing practice.
One of the authors (H.C.) had previously taught at Curry College, where a colleague had developed an innovative and effective program to help students gain confidence in responding to patients in challenging clinical encounters, such as caring for patients and family members who are delirious, angry, demanding, or sexually flirtatious. With the Curry College model of psychiatric consultation-liaison as a starting point, we have gone on to develop our own, two-tiered model.
Review of the Literature for the Simmons College Psychiatric Clinical Liaison Project
The use of role-play, or “low technology” simulation (Gaba, 2007), as a pedagogical tool has been documented in the educational literature for many years. Van Ments published a handbook for teachers and trainers on its effective use in 1989. Shearer and Davidhizar (2003) dated the historical, educational, and therapeutic roots of role play in Moreno’s (1947, as cited in Shearer & Davidhizar, 2003) theory of psychodrama. Welch and Welch (2008) dated the cultural and educational value of dramatic arts presentations to ancient Greek times. Our intent is to share these resources and model to demonstrate and develop the possibilities of using role-play as a powerful educational tool for mental health nursing students.
Although role-play may take many forms, we present the following inventive models for consideration and inspiration (Brown, 2008; Curtis, 2007; Jenkins & Turick-Gibson, 1999; Kuipers & Clemens, 1998; Lee & Lamp, 2003; O’Connell & Clerkin, 1997; Shearer & Davidhizar, 2003; Wasylko & Stickley, 2003; Welch & Welch, 2008). O’Connell and Clerkin (1997) described a pioneering and successful collaboration between nursing and theater arts students that benefitted both student groups. Carefully scripted videotaped interactions with acting students offered spontaneous and improvised role-play opportunities. These videotaped interviews, included in the nursing students’ portfolios, were used to measure outcome criteria for the development of communication skills.
Kuipers and Clemens (1998) described their early and well-received experiences with faculty role-plays that changed up the usual classroom lecture format. In another early model, Jenkins and Turick-Gibson (1999) used role-play as a way to meet the American Association of Colleges of Nursing (2009) and National League for Nursing Accrediting Commission (2008) criterion for critical thinking. The students made journal entries as they followed a specifically structured schedule of activities (finger-sticks, urine testing, meal and snack planning and preparation, exercise activities, limiting alcohol consumption) over the course of a weekend, as if they were newly diagnosed with diabetes mellitus. This exercise in realism engaged students in critical thinking and self-reflection and increased their sensitivity to the varied lifestyle changes involved.
Shearer and Davidhizar (2003) explored multicultural situations using role-play scenarios. Their focus was on developing conflict resolution communication skills and exploring cultural differences. They cautioned that careful planning and specific learning objectives are key, as role-play can absorb class time and unwittingly reinforce stereotypes. They recommended adequate debriefing time to counter any unintended aspects of the role-play.
Wasylko and Stickley (2003) had students enact a “critical incident” from their clinical practice. Some students became directors, whereas others were designated actors. Faculty assumed the role of facilitator as the drama created a “dialogue” that promoted “affective development of humanistic skills and attitudes” (Wasylko & Stickley, 2003, p. 443).
Lee and Lamp (2003) used role-play as a teaching strategy. The students recognized a very pregnant and distressed visitor who enters the classroom and interrupts the faculty member as another faculty member. Lee and Lamp (2003) noted “humor as a health benefit and coping strategy for healthcare professionals and their clients” (p. 61).
In another model (Curtis, 2007), a seasoned mental health clinician or drug and alcohol clinician assumed the role of a consumer who was interviewed by a nursing student. The student could call a time out to consult with peers. The faculty facilitator offered debriefing and groups of students wrote up a mental status examination (or drug and alcohol assessment) with a care plan. In addition, students wrote an initial nursing report and presented this to other students, simulating a shift handover of care. All of this was done in two day-long workshops prior to beginning the mental health clinical rotation.
Welch and Welch (2008) offered students an opportunity to view “Bearing Witness,” a play that conveys the complexities of the human experience. The students were afforded opportunities to recognize, self-reflect, and process circumstances of human vulnerability and suffering as they became actively engaged in observing the play.
Finally, Brown (2008) offered an extensive review of media—video clips, role-playing, and interactive games—that may be used to supplement course lectures. For example, students viewed faculty-made video vignettes demonstrating therapeutic communications, and then students identified and evaluated the communication skills used. Student pairs received a brief scenario and acted out the communication techniques. At the end of the course, faculty assessed students’ clinical competency using standardized patients. In these videotaped interactions, students were randomly assigned to interact with someone experiencing anxiety, depression, or a thought disorder.
Each of these models offered a unique role-play opportunity and although they are all different, the unifying themes are apparent and include active student engagement and participation; spontaneous real-time interactions that allow opportunities to safely and deeply explore specific content areas; and the artistry of unique individual interactions.
The Nurse-Faculty Toolkit for the Implementation of the Baccalaureate Essentials (American Association of Colleges of Nursing, 2009) substantiated the importance of integrative learning strategies. Simulated vignettes are one example.
The Psychiatric Clinical Liaison Project at Simmons College
Historically in nursing curricula, psychiatric nursing has been either totally integrated or separate and marginalized. The model created by H.C. at Curry College is an innovative solution to this dilemma by shifting to a combination of integration and separateness.
Psychosocial nursing concepts were integrated in the two medical-surgical nursing courses, including well-timed classroom presentations on normal human emotional responses to illness and vulnerability, and psychiatric nursing faculty consultations with each medical-surgical clinical group. During these consultations, the psychiatric nursing faculty role-modeled communication and interviewing with students’ patients. Patients willing to be interviewed by the faculty member reflected on their experiences with illness during the interviews as students observed. Many patients were open to that experience and reported enjoying the discussion.
This integrated teaching model had multiple benefits. Students’ ability to learn and practice complex skills with role models and repeat that learning over several semesters were the keys to students’ increasing sophistication of understanding and skill growth.
Even more powerful was the opportunity for students to observe these skills being used, identified, and valued in the medical-surgical clinical area. Two clinical days per semester during which the 8-student clinical group had access to 2 clinical instructors were an added benefit. The clinical faculty, working together, had the ability to be present with each student in very powerful ways.
Following this psychiatric consultation-liaison model, faculty at Curry College set aside 2 days in each semester of the medical surgical clinical rotations as psychiatric consultation-liaison days. Students had their usual medical-surgical experience, with the add-on of psychiatric consultation. The psychiatric nursing faculty visited clinical groups during the students’ orientation and presented a didactic review of the nurse-patient relationship and therapeutic communication skills. They then visited students in their clinical settings on two separate occasions and interviewed willing patients being cared for by students about the human experience of illness and hospitalization. The students observed the interviews and discussed their observations, impressions, and questions, both individually and in groups, with the psychiatric nursing faculty member. The psychiatric and medical-surgical nursing faculty members then co-facilitated the postconference, allowing the students to reflect on the issues and concerns that arose over the course of the day.
Following the first consultation, students submitted written narrative accounts of the interviews they had observed to the psychiatric faculty member with specific detailed description of strategies observed during the interviews, reflections on the meaning of the interviews, and descriptions of how their learning had been enhanced. Following the second day of interviews, students submitted narrative accounts of clinical situations where they themselves had applied therapeutic communication. Students also completed written assignments focused on therapeutic strategies they had observed and used as a result of the consultations. The students’ evaluations indicated their enhanced comfort and confidence responding to complex psychosocial situations. The medical-surgical faculty reported that they and the students felt supported in their teaching and practice as a result of the consultations. The model was embraced so enthusiastically that the faculty in the second medical-surgical nursing course requested consultations during their course as well.
Addition of a Psychiatric Consultation Workshop with Advanced Medical-Surgical Students
Because of heightened security requirements by all the hospitals, we decided to develop a psychiatric consultation-liaison workshop on campus in one of our nursing laboratories for the advanced medical-surgical students. The logistics were a bit overwhelming, but gradually, after joint meetings between the psychiatric and the medical-surgical faculty members, we had a plan.
Psychiatric faculty members collaborated with medical-surgical faculty to create an unfolding case, with four scenes. We psychiatric nursing faculty members eventually wrote out scripts, channeled our dramatic talents, and acted out the scenes.
Scene one introduced the class to Mrs. Brady, a 70-year-old woman with a history of lung cancer, who is yelling and agitated, a sudden change from her mental status the previous day. New nurse Nancy is trying to assess and reassure her when her nurse manager walks into the room, asking, “Nancy, what’s all the fuss in here? What’s going on with your patient?” We had already arranged the students into four small groups with a psychiatric faculty member facilitator. After watching each scene, we had the students break into their groups with questions to focus their discussions. For example, in scene one, one group focused on questions on delirium, the second group focused on dementia, the third group focused on depression, and the fourth group focused on universal nursing principles. The small groups discussed the scenario for approximately 15 minutes and then came back into the large group to hear a spokesperson from each group. The psychiatric faculty took turns facilitating the large group discussions.
In scene two, Mrs. Brady is snoring in bed. Students learn that she received haloperidol for acute agitation. At her bedside are her husband of many years and her daughter, Jill. The students learn through this conversation about their coping styles. Mr. Brady appears tired and sad; Jill is anxious and seems to deny the gravity of the situation. She hints that her sister Patsy will be joining them soon and is concerned about her arrival, as she is known to “have issues.” Eventually, an argument ensues between the patient’s daughter and husband and new nurse Nancy walks in on a heated, emotionally charged family. As scene two ends, students and faculty break out into the small groups, following the same format. The focus is on grief, anxiety, and coping styles and nursing care.
Scene three took down the house. Unbeknown to the faculty, an adjunct faculty member, Mary Beth Schmidt, had had some acting experience in college and she was quite theatrical! The scene opens with a disheveled Patsy, hair awry, lipstick smeared, stumbling into the hospital room, amid a lot of tears and slurred words. Nurse Nancy soon needs to have Patsy escorted out of the room and evaluated in the emergency department. Her blood alcohol level is high. In the emergency department, a psychiatric clinical nurse specialist asks Patsy about her alcohol use, among other things, after allowing enough time to elapse so that she is clinically sober. Questions after this scene focused on substance abuse, safety and universal nursing care principles, and implications.
Scene four shows a psychiatric clinical nurse specialist talking with Mrs. Brady and her family, who are now more pulled together and stable, about hospice care and do-not-resuscitate status. Discussion questions focused on having these difficult but necessary end-of-life conversations.
After the fourth large group discussion, we ended with a session on the importance of self-care followed by another session on meditation and relaxation. Faculty then gave the students evaluations and packets summarizing key points from each scene. Students knew they would be receiving these materials, so they could focus on the workshop without worrying about writing everything down.
Evaluations Lead to Changes and Commitment to Continue the Workshops
Feedback about the workshops was overwhelmingly positive. However, one criticism was that the day too long. As faculty, we had to agree. Faculty and students were tired at the end of the 6 hours. The psychiatric mental health faculty realized, too, that the medical-surgical faculty should have been present to ensure continuity with the important discussions that had occurred. The other request from the students (and again, faculty couldn’t have agreed more) was to change the day from Saturday to mid-week. Faculty altered the scripts slightly and took out the drunken daughter scene, as it seemed to shift the focus from the core nursing care principles and implications. We also let the students speak in the small groups alone, given that the students speak more freely and share personal and clinical stories without faculty members present.
The Current Workshop Model
Faculty now meet with between 23 and 30 students enrolled in the second medical-surgical course per semester. The faculty are prepared to present as many workshops as necessary, up to 3 per semester, to accommodate all of the students. Medical-surgical faculty members participate in the large group discussions and in small acting parts, if they are willing. Psychiatric faculty act out the scenarios and the students break out into small groups of 10 to 14 to consider the questions created for each scene. The psychiatric faculty members take turns facilitating the larger group discussions. Medical-surgical faculty members are present throughout the day, which has been moved to mid-week and kept at a total of 3 hours.
For the final scenario, students are asked to role-play a scene involving a new graduate nurse asserting herself with colleagues during a simulated team meeting. Faculty created one scene in which the students use the SBAR (Situation, Background, Assessment, Recommendation) Communication Framework simulating paging the harried, haughty medical intern to report an acute change in mental status (Institute for Health-care Improvement, 2009).
Future Directions for the Simmons College Psychiatric Clinical Liaison Workshop
A lengthy review of the literature and experiences accrued over approximately 8 semesters of workshops have led to many lively faculty discussions about future directions. Since the beginning of the project, the college has been constructing a dedicated simulation laboratory faculty hope to use for future psychiatric clinical liaison workshops. The simulation laboratory will consist of a room with built-in video and audio recording equipment, and a one-way mirror so groups of students can observe the players who realistically interact during a simulation patient scene.
The students’ and faculty members’ anecdotal responses and positive evaluations of the psychiatric clinical liaison project have convinced faculty that continuation of this program is vitally important for our future nurses. Faculty are planning a qualitative study to provide the evidence.
Authors of the current body of literature on simulation have documented that engaging students in a more active manner is essential to their learning. Giving students an opportunity to participate actively in whatever scenarios we want to construct will boost the efficacy of their learning. The plan is to have students interact with actors and receive immediate feedback from peers and faculty. Students will be encouraged to share their thoughts and feelings throughout the workshops.
The faculty prefer to have actors portray scenarios. Recently, faculty contacted a nearby college with a theater arts program and will pursue this collaboration. One goal is to have nursing students participate in each scene. A debriefing will follow each scene, so the actors and students can share how they were feeling as issues arose. As with the use of other simulations, faculty must be explicit about ground rules so students feel safe to share and take chances. Students would also be given the opportunity to take a break from a challenging scene and solicit help from peers before resuming. Simulations allow students to be exposed to difficult situations they may not encounter in their clinical experiences and to have an opportunity to practice and master clinical skills.
To keep the workshop fresh and relevant, faculty will solicit ideas from departing nursing students and faculty about difficult clinical scenarios they have encountered. Furthermore, faculty see these workshops as addressing generational differences that may exist among students and faculty (Prensky, 2001; Skiba & Barton, 2006). Learning is more active and immediate and students are pushed to think critically in real time. Students come away with an appreciation of the importance of human connection in an age of depersonalization, and faculty are proactively teaching students the importance of self-care, particularly meditation and centering techniques, and of fostering collegial relationships.
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