The use of simulation is supported as a clinical teaching modality (American Association of Colleges of Nursing, 2008) and is widely accepted as a means to supplement didactic and clinical learning (Jeffries, 2012; Sideras et al., 2013). Due to limitations and inconsistencies in clinical placements, innovative strategies are needed to provide nursing students with effective evidence-based learning (Hart & Chilcote, 2016). The use of standardized patients (SPs) has been cited in the literature as a means of teaching skills in a safe learning environment. SPs are actors trained to portray patients, family members, or health care providers. However, there are barriers to the use of SPs including recruitment, training, cost, and the maintenance of quality (Hart & Chilcote, 2016). Using a unique approach, a partnership was formed between the school of nursing and the theater department to create a series of Standardized Patient Experiences (SPEs) for use as a clinical teaching strategy for nursing students enrolled in a mental health nursing clinical course in a baccalaureate program. Although high-fidelity simulation is often used to teach nursing clinical skills, research indicates that clinical experiences using SPs produce realism that cannot be produced using high-fidelity manikins (Cowperthwait, Saylor, & Schell, 2014). Creating realism is of the utmost importance when teaching nursing students to use therapeutic communication skills to engage in interactions with and to care for individuals with mental illness. Nurse educators must also prepare nursing students for complex interactions with individuals with mental illness (Jacobs & van Jaarsveldt, 2016). Although SPs are pivotal in the learning process, careful attention must be paid to ensure that ongoing coaching consisting of feedback on accurate role portrayal by the SPs is maintained in order to provide realism for nursing students. This unique pilot project is described, and the successes and challenges are presented.
Forming the Collaboration
Initial brainstorming meetings were held between psychiatric mental health nursing and theater faculty to discuss the possibility of partnering to provide learning opportunities in their respective disciplines for both nursing and theater students. The overall objectives of this project were for nursing students to practice therapeutic communication skills in a safe learning environment and for theater students to acquire acting skills. When a formative feedback approach is used for SPEs, nursing students are able to reflect on learning (Sideras et al., 2013). As SPs, theater students have opportunities to gain expertise as they work with content experts (Sideras et al., 2013). Both nursing and theater faculty saw learning value for all students. Undergraduate theater students would have the opportunity to practice acting skills with ongoing feedback of performance and role portrayal allowing mastery. In addition, they would have the opportunity to apply learning related to makeup techniques and wardrobe. Nursing students would be able to practice communication and assessment skills in a safe environment where it is acceptable to make mistakes. They would also receive formative feedback from nursing faculty, allowing them to improve psychiatric mental health nursing skills. Thus, a collaboration was formed.
Implementation of the Project
Implementation of this project started with the creation of scenarios that met the learning outcomes for each discipline. Psychiatric mental health nursing faculty with 10 to 30 years of mental health and teaching experience who had already been using SPEs led in developing cases in which theater students became SPs. Case scenarios included portrayal of patients with a variety of mental health diagnoses, including paranoid schizophrenia, bipolar mania, depression with suicidal ideation, substance abuse, dementia, and posttraumatic stress disorder. SP training was provided by both psychiatric mental health nursing and theater faculty during the summer in preparation for the course offered in the fall. Although psychiatric mental health nursing faculty provided training specific to the authentic portrayal of the symptoms of each diagnosis, theater faculty provided coaching to make the scenarios come alive and to help actors develop acting techniques including improvisation. SPs were trained on symptoms associated with each diagnosis, behaviors to support the diagnosis, and how to respond to expected nursing student questions.
Each year, five theater students were hand-selected by the theater faculty and invited to enroll in a specially created independent study course in which they became SPs. Acting could be studied and practiced in this course. After the initial training by nursing faculty, each actor met throughout the semester with theater faculty to review video recordings of the SPEs and to complete assignments related to theater coursework. Onsite SP coaching by psychiatric mental health nursing faculty was provided throughout the semester to ensure realism and standardization of the cases. Faculty from nursing and theater corresponded as needed to review and made adjustments in the approach. Additional coaching was provided to any theater student who required help in accurately portraying symptoms associated with the diagnosis. During the 2-year period, 10 theater students participated in this project. Each theater student repeated the scenarios multiple times throughout the semester, allowing them to gain experience and perfect role portrayal of each diagnosis.
Over the course of the semester, every nursing student enrolled in the psychiatric mental health clinical course was assigned to engage in four different SPEs as a part of their clinical hours. Scenarios included engaging with SPs who displayed hallucinations and delusions, depression with suicidal ideation, bipolar mania, substance abuse, trauma, and cognitive deficits. In the past 2 years, 180 nursing students have participated. To prepare for each SPE, nursing students completed a tool kit designed to reinforce a core skill set. These tool kits—developed by the psychiatric mental health nursing clinical course faculty with experience ranging from 10 to 30 years—are available free of charge to nurse educators in Maryland. Each tool kit contained learning objectives; presimulation activities including reading, reflection, and critical thinking questions; and video vignettes. The brief video vignettes using SPs were created to demonstrate specific skills and were used to prepare nursing students for the live SP encounters. The tool kits and SPEs were aimed at helping students apply core skills, including therapeutic communication, maintaining professional boundaries, managing a patient with hallucinations and delusions, addressing safety for an individual with suicidal ideation, setting limits with a patient with mania, interprofessional collaboration for an individual suffering from trauma, managing conflict for families struggling with addiction, and working with individuals with cognitive deficits. Each SPE lasted 10 to 15 minutes and was video recorded in our simulation center for later viewing by the nursing student. This allowed the nursing student to self-reflect and to complete postassignment learning activities, including a review of strengths and limitations, identification of therapeutic communication techniques, and priority nursing diagnoses with a plan of care. Nursing students participated in the SPEs in clinical groups of seven to eight students. This allowed each nursing student to not only engage in an interaction with an SP, but to also watch his or her peer engage in an interaction. Rubrics were used by nursing faculty to provide students with formative feedback related to therapeutic communication, assessment skills, and care of individuals with mental illness using core skills. Faculty-led debriefing was also used with nursing students to aid in translation of theory to practice.
Nursing and theater faculty met on a regular basis to evaluate the project. Both nursing and theater students offered positive comments via anonymous surveys regarding the SPEs when asked to provide feedback on their learning experience as per university protocol. This included comments from nursing students that the SPEs “feel like the real thing,” “have helped me to be a better communicator,” and “prepared me to work with people with mental illness.” Many nursing students also commented that these simulations have been one of the best learning experiences they have had during the program. Theater students made comments about how this learning opportunity has “allowed me the opportunity to work on my acting skills” and “opened my eyes to employment opportunities I didn't know existed.” One recent theater graduate even went on to work as an SP in a medical teaching university.
Nursing faculty also provided positive feedback regarding the SPEs. This included improvements in nursing student confidence levels as they care for patients in the hospital and community mental health settings and use of therapeutic communication skills with patients and families. Improvements were also noted in the students' ability to engage in interprofessional collaboration advocacy for patients. Many students also demonstrated adeptness in managing conflict between the patient and family members. In addition to decreased anxiety, faculty noted that students were proficient in working with more challenging patients and providing care in more complex situations in the clinical setting.
Therapeutic communication, empathy development, the assessment of common mental health disorders, working with the interprofessional team to care for individuals with mental illness, and conflict management has improved for nursing students as the safe simulated environment has allowed students to practice and master core skills that are later applied in the clinical setting with real patients. A collaborative partnership between nursing and theater faculty with ongoing coaching of theater students is essential in creating and maintaining realism in this creative learning approach. Although this teaching strategy has demonstrated great results of allowing nursing students to meet course objectives, it has not been without challenges.
As we completed our second year and begin plans to enter our third year of this partnership, we take away many lessons learned. First, training must be thorough and include both nursing and theater faculty. Although master's- and doctorate-prepared psychiatric mental health nursing faculty with 10 to 30 years of experience are the experts on mental illness, theater faculty can provide coaching that is specific to acting skills. Both nursing and theater faculty are instrumental in helping the theater students to understand their role. This includes an accurate comprehension of the diagnosis, expected dialogue, accurate portrayal of symptoms, and physical characteristics including dress (Sideras et al., 2013).
Second, the use of props and moulage are necessary to add realism to cases. Specifically, alteration of appearance of young students who portray the older patient with dementia, alteration of their appearance is necessary. Wigs, canes, makeup, and clothing can be used to create a sense of realism in which the nursing student forgets that he or she is engaging with a young actor. Staging of the room and the use of props and moulage can be used with other cases to add realism as well. Many theater students have make-up application experience (Sideras et al., 2013) and when working with a simulation coordinator with training in the use of moulage, the creation of a realistic SPE is possible. This includes using moulage to create a wound on the wrist of the suicidal patient or the application of makeup to replicate the sadness of depression or flamboyance of mania. Wardrobe is also essential in creating realism. Ensuring that the SP dress the part when portraying mania, schizophrenia, or depression can create a sense of realism in which the nursing student forgets he or she is engaging with an actor in a simulated experience.
Third, ongoing coaching of theater students by faculty helps to ensure that cases remain standardized. Although the literature tells us that debriefing is an important step of the learning process for nursing students, we found that coaching is just as important for the theater students. We always provided debriefing for nursing students but did not provide ongoing coaching for our theater students. This was an important quality measure that we added in the second year of our project. As a result, we were able to maintain the integrity and realism of all cases. As actors, the theater students were interested in creating new characters once they became familiar with each role. As we continued to work with our theater students who were serious about their work, we found that providing them with a daily debriefing session with feedback about their portrayals ensured that scenarios were standardized and maintained a sense of realism. This allowed us to meet our learning objectives with the nursing students and enabled the theater students to become experts in the roles they portrayed. As a result, an enriched learning experience was created for both nursing and theater students.
A strategy gaining popularity is simulation using SPEs. This teaching strategy allows nursing students to practice core mental health nursing and communication skills in a safe learning environment, preparing them to care for real patients with mental health needs. Applying theoretical knowledge in a simulated environment allows nursing students to demonstrate the integration of didactic learning to clinical application (Goh, Selvarajan, Chng, Tan, & Yobas, 2016) and allows faculty to standardize the approach to teaching core mental health nursing clinical skills. However, SPEs must be created with realism. This requires that theater students are properly trained and provided ongoing coaching, moulage is used, and wardrobe and props are used to ensure the scene and case portrayal are realistic. Initial preparations and continued collaboration with the theater department must also occur. As with any new project, there must be faculty buy-in. Therefore, the inclusion of all nursing faculty who oversee the SPEs in the training process is necessary. Ensuring that there is regular communication and meetings to discuss the successes and challenges of the project is also important. Forming a collaboration between nursing and theater allows for a learning opportunity for students in two disciplines that, when properly designed and implemented, addressed issues related to recruitment, training, cost, and quality of using SPs as an educational tool. Future plans include a study to examine the effectiveness of this collaboration on the learning outcomes of both nursing and theater students.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacnnursing.org/portals/42/publications/baccessentials08.pdf
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