Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

The Suitcase Simulation: An Effective and Inexpensive Psychiatric Nursing Teaching Activity

Joan C. Masters, EdD, MBA, APRN, PMHNP-BC; Mary Frances Kane, RN, MSN; Mary Ellen Pike, PhD, APRN, ACNS-BC

Abstract

A tabletop simulation was developed as a patient safety activity that involved checking in a patient admitted to a psychiatric care unit. Students were second-degree (n = 79) and traditional (n = 53) BSN students. They were given suitcases or backpacks containing various items, and following a fictional hospital policy, they had to decide whether to give the items to the patient, place them in a secured area, or send them to the pharmacy or security personnel. The activity was evaluated using the Simulation Effectiveness Tool (SET) and two open-ended questions. Students reported that they found the simulation to be enjoyable and a good learning experience. Checking in a patient’s belongings is not an activity students typically perform, but the simulation can help prepare them for situations they will experience in the workplace. This inexpensive activity can easily be adapted for staff orientation and competencies. [Journal of Psychosocial Nursing and Mental Health Services, 52(8), 39–44.]

Dr. Masters is Associate Professor of Nursing, Ms. Kane is Clinical Nursing Educator, and Dr. Pike is Assistant Professor of Nursing, Bellarmine University, Louisville, Kentucky.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Joan C. Masters, EdD, MBA, APRN, PMHNP-BC, Associate Professor of Nursing, Bellarmine University, 2001 Newburg Road, Louisville, KY 40205; e-mail: jmasters@bellarmine.edu.

Received: February 21, 2014
Accepted: June 03, 2014
Posted Online: June 26, 2014

Do you want to Participate in the CNE activity?

Abstract

A tabletop simulation was developed as a patient safety activity that involved checking in a patient admitted to a psychiatric care unit. Students were second-degree (n = 79) and traditional (n = 53) BSN students. They were given suitcases or backpacks containing various items, and following a fictional hospital policy, they had to decide whether to give the items to the patient, place them in a secured area, or send them to the pharmacy or security personnel. The activity was evaluated using the Simulation Effectiveness Tool (SET) and two open-ended questions. Students reported that they found the simulation to be enjoyable and a good learning experience. Checking in a patient’s belongings is not an activity students typically perform, but the simulation can help prepare them for situations they will experience in the workplace. This inexpensive activity can easily be adapted for staff orientation and competencies. [Journal of Psychosocial Nursing and Mental Health Services, 52(8), 39–44.]

Dr. Masters is Associate Professor of Nursing, Ms. Kane is Clinical Nursing Educator, and Dr. Pike is Assistant Professor of Nursing, Bellarmine University, Louisville, Kentucky.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Joan C. Masters, EdD, MBA, APRN, PMHNP-BC, Associate Professor of Nursing, Bellarmine University, 2001 Newburg Road, Louisville, KY 40205; e-mail: jmasters@bellarmine.edu.

Received: February 21, 2014
Accepted: June 03, 2014
Posted Online: June 26, 2014

Do you want to Participate in the CNE activity?

The shortage of and competition for good clinical sites is well known in nursing, particularly in specialty areas such as psychiatry (Dapremont & Lee, 2013; MacIntyre, Murray, Teel, & Karshmer, 2009). One response to this shortage by schools of nursing has been to increase the use of simulation. However, at the authors’ university, accessing the simulation laboratory has become difficult, as many faculty want to use the laboratory. The difficulty in obtaining quality psychiatric clinical sites has been especially problematic with second-degree students, who experience long clinical days and for whom the long days sometimes yield diminishing returns. A partial solution was to develop a “table-top” simulation for second-degree and traditional BSN students in a second-semester, junior-year course in psychiatric nursing.

A tabletop simulation is a classroom exercise in which students work on a relevant, real-world scenario that would be impractical or impossible to conduct in the clinical setting. Because they are low stress activities, tabletop simulations support learning (Lehtola, 2007) and also prepare students for situations that they will face in the workplace. Although tabletop simulations are designed to be safe, the scenarios also require elements of danger and risk to add authenticity (Lehtola, 2007).

The scenario described in the current article involved checking in the belongings of a patient admitted to an acute psychiatric care unit. This procedure is not performed by students at the authors’ university, as staff have concerns about liability. Checking in patient belongings is also not a situation students who participated in the simulation had observed previously, as the action is probably performed by mental health technicians and is often done at times of the day and week when students are not usually present. The simulation described in the current article was based on the experiences that one author (J.C.M) had while working on adult, geriatric, and emergency psychiatric units.

Method

Evaluation Questions

Students were asked the following three questions to evaluate the simulation:

  • Did you perceive the suitcase simulation to be an effective way to learn about safety considerations when admitting a patient to an inpatient psychiatric care unit? (Question 1 was assessed using the Simulation Effectiveness Tool [SET; Cordi, Leighton, Ryan-Wenger, Doyle, & Ravert, 2012].)
  • What did you like best about the simulation laboratory experience?
  • What do you think could be done to improve the simulation laboratory experience?

Participants

Students who participated in the simulation were enrolled in a junior-level, semester-long course in psychiatric nursing at a private U.S. university in the South. One hundred thirty-two BSN students (79 second-degree and 53 traditional) in 18 clinical groups at five clinical sites participated over three semesters. Because it was new to the psychiatric nursing course, the simulation activity was evaluated as described here, in addition to the routine student course evaluations.

Procedure

The basic format of a tabletop simulation (Lehtola, 2007) includes (a) a description of the situation and its effect (i.e., who, what, when, and where); (b) a presentation of the simulation rules, if any exist; (c) an explanation of participant roles; (d) a description of simulation objectives; (e) an explanation of any complications or obstacles; and (f) a debriefing.

The authors of the current article wrote a “hospital policy” on the process for admitting patients based on policies available on the Internet and from several local facilities. The policy was designed to be neither so prescriptive that it did not allow for clinical judgment, nor so vague that it left students with little direction. Three additional forms were created and modeled after actual hospital forms. One form was used for logging in items to go to the pharmacy, the second form was used for logging in items going to security, and the third form was used for logging in items to be given to the patient or to be stored in the patient’s belongings bin in a secured area. Patients could access these items as needed or when discharged. The items used in the simulation are listed in Table 1.

Suitcase and Backpack Contents

Table 1:

Suitcase and Backpack Contents

Students were given verbal and printed instructions to examine belongings and decide if they were to be given to the pharmacy or security, placed in a belongings bin in a secured area on the unit, or given to the patient. They were also given a brief description of a patient being admitted to the inpatient psychiatric care unit. One patient was a 63-year-old woman who was a retired librarian diagnosed with a generalized anxiety disorder and hypochondriasis; she had no history of aggressive behavior. The other patient was a 56-year-old man with a history of multiple hospitalizations for suicide attempts and alcohol abuse; 3 hours earlier, he had slashed his arm with a pen that he grabbed from the emergency department triage nurse. One half of the students was given the first patient profile, and the other half was given the second patient profile. Students were unaware that two different patient profiles existed.

Students came to the simulation near the end of the clinical day with their clinical instructor. They had been assigned readings on the ethics of searching patients (Miller, 2012) and to review a report from The Joint Commission on inpatient suicides (Mills et al., 2010). They also had used the Mental Health Environment of Care Checklist (U.S. Department of Veterans Affairs, 2007) to assess any potential hazards on the units where they had clinical. No additional advance preparation was performed.

When students entered the classroom, backpacks and suitcases, patient belongings bins (14×16-inch plastic crates), policies, patient profiles, and instructions were on their desks. Before they began, students were randomly assigned to a partner using playing cards. This pairing off was not an essential part of the exercise, but having students work with individuals they do not choose themselves helps them avoid falling into predictable roles. Faculty were in the room and found the simulation was more effective if they kept busy (e.g., reading an article, checking e-mail), rather than standing at the front or walking around the classroom. Students were more likely to work on their own if faculty signaled that they should.

After approximately 30 minutes, students were ready to debrief. The debriefing is the most important part of the simulation, and students participated enthusiastically; debriefing was completed in approximately 30 minutes. Faculty asked students questions about specific items and how they decided what to do with them. Two students were asked to read the patient profiles; then they were asked if the patient profiles influenced their decision making. The patient profiles were found to influence students’ decision making, as students usually decided that certain items, such as eyeglasses, should be allowed for the librarian but taken from the patient who cut himself, until his risk for self-harm was reassessed. Clinical faculty shared their experiences (e.g., the time that family members brought firecrackers and matches to the state hospital layered in a Thanksgiving dinner), and this sharing enriched the experience. At the conclusion of the simulation, the students were asked to keep the experience confidential so that other students could have a similar experience.

Data Collection

The effectiveness of the tabletop simulation was evaluated with the SET, which is the same tool used in all departmental simulations at the authors’ university (Table 2). This tool is a 13-item, 3-point, ordinal scale instrument with established validity and reliability. A Cronbach’s alpha of 0.93 was reported by the researchers who developed the SET (Cordi et al., 2012). In addition, two open-ended questions (What did you like best about the simulation laboratory experience? and What do you think can be done to improve the simulation laboratory experience?) were administered at the same time. Space for additional comments was also available on the questionnaire.

Simulation Effectiveness Tool (SET) Questions

Table 2:

Simulation Effectiveness Tool (SET) Questions

Results

Question 1 Responses

“Did you perceive the suitcase simulation to be an effective way to learn about safety considerations when admitting a patient to an inpatient psychiatric unit?”

SET data were analyzed with SPSS version 21, a one-way analysis of variance was performed to identify significant differences between the groups, and a t test was implemented to determine item means. No significant differences were found at the p = 0.05 level between second-degree and traditional BSN students.

Mean scores ranged from 1.55 (SD = 0.61) to 1.98 (SD = 0.16) on the SET scale, which has a range of 0 to 2.

Question 2 Responses

“What did you like best about the simulation laboratory experience?”

This question generated the majority of comments. Students reported a high level of satisfaction with the simulation laboratory experience. An analysis of the comments resulted in the identification of four major themes.

A large number of comments acknowledged the “real-life” aspect of the simulation experience. Those comments were placed under various themes based on how the comment was stated. Some comments seemed to indicate that the realism of the simulation improved opportunities for learning and critical thinking, whereas others seemed to indicate that it added to the enjoyment and novelty of the experience.

Some comments could relate to one or more themes, but each comment was listed under only one theme. The hands-on learning and uniqueness of the experience resonated with students. Although they did not directly compare it to other types of learning experiences in their nursing classes, students stated that the simulation was effective and fun, as compared with other nursing experiences. Students liked that it was realistic and short.

Response themes and their respective comments follow.

  • Theme 1: Thrill of the search. “Thrill of the search” responses included: “It was like a scavenger hunt, and [it was] fun to try and find things”; and “Trying to find the hidden items, it isn’t something I would typically think about.”

  • Theme 2: Opportunity for critical thinking. These responses included: “Getting to critically think and decide what went where”; “Made me think about how harmful certain items can be to patients”; “Good use of the [Joint Commission] article prior to the simulation”; and “The simulation was very realistic. We were given real world items to evaluate and make decisions about.”

  • Theme 3: Opportunity for new insights. Responses included: “Talking about different items and if the patient can have them or not”; “The ‘street smart’ enhancing skills”; “This was a good experience. I learned a completely new skill”; and “Learning a process I will experience as an RN but not see as a student.”

  • Theme 4. Novelty of the experience. “Novelty of the experience” responses included: “It was different and fun”; “Being independent when making decisions about the safety of objects”; “How laidback everything was”; “Hands on, teamwork, and low pressure”; and “It was quick and to the point and actually helpful.”

Question 3 Responses

“What do you think could be done to improve the simulation laboratory experience?”

Few responses were given to Question 3. However, suggestions for improving the experience were varied, of merit, and did not indicate the need for any major revision. In response to student requests, more hidden items (e.g., safety pins embedded in lip balm) were added. No major differences were found between the two groups, although second-degree students wanted more direction and explanation of terms. Responses to question 3 included:

  • “Hide more things in the clothes.”
  • “Handouts would be helpful.”
  • “More warning of what to expect.”
  • “Provide gloves.”
  • “More intense items.”

A few students provided additional comments, such as “Cool simulation,” “This was fun!,” “I feel like I was able to learn a lot from this simulation,” and “Thank you!”

Discussion

The authors of the current article initially wanted each student to possess an individual suitcase or backpack; however, they realized that supplying and storing that much material would be difficult. As a result, the authors decided to create nine kits, which would accommodate two clinical groups, with students working in pairs, at one time. (The authors’ clinical groups usually have eight students each.)

Several strategies were used to collect materials for the activity. The simulation laboratory staff had surplus backpacks that were used, and faculty also contributed contraband to the simulation. A campus yard sale was the most important source of material, and thrift and dollar stores were used to round out the collection. Used items were washed at a laundromat. Although not all bags contained the same items, every bag contained materials that, according to the hospital policy, would not be allowed in the patient’s possession. The total cost of materials was approximately $120.00.

Students recognized that patient safety is an important issue, and they welcomed the opportunity to practice checking in patient belongings. The suitcase simulation allows all students to be successful, but it is still challenging enough so that no one student gets everything right. As a result, students believe the activity is worth their time, as it is not too simple. For example, in each group, less than one third of students found the hidden safety pin.

Several clinical instructors who work in psychiatry have suggested that this simulation would be good to use for hospital staff orientation and annual competencies. In addition, using real hospital policies and procedures would make it even more realistic.

Limitations

One limitation of the simulation is the need for significant storage space. The authors used a combination of departmental space and faculty offices. Another limitation is time, as repacking and hiding contraband in eight bags after each use takes approximately 1 hour.

Implications for Practice

Patient safety is an essential nursing responsibility; faculty and hospital educators need to prepare students and staff to meet this goal. Challenging but enjoyable simulations, such as the one presented herein, can help students and staff better understand some of the realities of patient safety concerns.

Conclusion

The suitcase simulation has provided students and faculty at the authors’ university with an engaging and educational experience that they value. As the shortage of good clinical sites continues to worsen, simulation will become an increasingly important alternative for psychiatric nursing education. For faculty and hospital educators who have not yet used simulation, this activity is an easy way to introduce it into the curriculum. For faculty and hospital educators with simulation experience, this activity may be useful as another option for teaching patient safety.

References

  • Cordi, V.L.E., Leighton, K., Ryan-Wenger, N., Doyle, T.J. & Ravert, P. (2012). History and development of the Simulation Effectiveness Tool (SET). Clinical Simulation in Nursing, 8(6), e199–e210. doi:10.1016/j.ecns.2011.12.001 [CrossRef]
  • Dapremont, J. & Lee, S. (2013). Partnering to educate: Dedicated education units. Nurse Education in Practice, 13, 335–337. doi:10.1016/j.nepr.2013.02.015 [CrossRef]
  • Lehtola, C.J. (2007). Developing and using table-top simulations as a teaching tool. Journal of Extension, 45(4). Retrieved from http://www.joe.org/joe/2007august/tt4.php
  • MacIntyre, R.C., Murray, T.A., Teel, C.S. & Karshmer, J.F. (2009). Five recommendations for prelicensure clinical nursing education. Journal of Nursing Education, 48, 447–453. doi:10.3928/01484834-20090717-03 [CrossRef]
  • Miller, D. (2012, April18). It’s time to stop strip searching psychiatric patients [Web log post]. Retrieved from http://www.clinicalpsychiatrynews.com/views/shrink-rap-news/blog/it-s-time-to-stop-strip-searching-psychiatric-patients/63bed88d2b1167b9761caf30e9c115b7.html
  • Mills, P.D., Watts, B.V., Miller, S., Kemp, J., Knox, K., DeRosier, J.M. & Bagman, J.P. (2010). A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. The Joint Commission Journal on Quality and Patient Safety, 36(2), 87–93.
  • U.S. Department of Veterans Affairs. (2007). Mental health environment of care checklist. Retrieved from http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp

Suitcase and Backpack Contents

Rubber daggers and plastic toy guns (that would not be confused for real weapons)
Matches
Eyeglasses and sunglasses
Over-the-counter and prescription medicationsa
Hooded sweatshirts with strings
Baseball caps (not allowed because patients have used them to hide their faces while attempting to leave the unit without staff permission)
Belts
Dice (not allowed because they are used for gambling)
Curling irons
Scissors (blunt tip)
Knitting needles and yarn
Tennis shoes with and without laces
Stiletto heels
Nail files and clippers
Baby powder (has been used to cover up cigarette odor and can be a fall risk if sprinkled on the floor)
Paper clips (can be used for self-harm and to start a spark in electrical sockets to light cigarettes)
Panty hose
Bras with and without underwire (used to point out how policies differ among local facilities, with some allowing underwire bras and some not)
Scrub top (Scrub pants are allowed in some facilities for patients who do not have their own clothes, but if patients wear them with scrub tops, they could be misidentified as a staff member.)
Bar soap (allowed in some facilities but not others; was put in a sock and used as a weapon at one hospital)
Toiletries in glass bottles
Catnip and baking soda in small plastic bags to simulate marijuana and cocaine
Costume jewelry (e.g., necklaces, watches, and rings, which were used when discussing how to document jewelry, disposition of valuables, and safety)
Ink pens and pencils
Wirebound notebooks
Cell phones with SIM cards removed (Cell phones, which could be used as cameras and video and audiorecorders, were used as a prompt to discuss why patients are not permitted to have them, as their use could violate other patients’ privacy.)
Toy dollar bills and coins
Safety pin hidden in the hem of an item a patient would be allowed to have (e.g., t-shirt)
Pillsa packed into a straw, which was then inserted into a toothpaste tube (The bottom of the tube was cut off and then crimped.)
T-shirts (some with inappropriate wording or designs), jeans, pajamas, socks, underwear, slippers, blouses, shorts, and skirts

Simulation Effectiveness Tool (SET) Questions

Question Do Not Agree Somewhat Agree Strongly Agree Not Applicable
The instructor’s questions helped me critically think.
I feel better prepared to care for real patients.
I developed a better understanding of the pathophysiology of the conditions in the scenario.
I developed a better understanding of the medications that were in the scenario.
I feel more confident in my decision-making skills.
I am more confident in determining what to tell the health care provider.
My assessment skills improved.
I feel more confident that I will be able to recognize changes in my real patient’s condition.
I am better able to predict what changes may occur with my real patients.
Completing the scenario helped me understand classroom information better.
I was challenged in my thinking and decision-making skills.
I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient.
Debriefing and group discussion were valuable.

Keypoints

Masters, J.C., Kane, M.F. & Pike, M.E. (2014). The Suitcase Simulation: An Effective and Inexpensive Psychiatric Nursing Teaching Activity. Journal of Psychosocial Nursing and Mental Health Services, 52(8), 39–44.

  1. The suitcase simulation does not require designated space, making it practical to use for nursing student clinicals, as well as hospital staff orientation and competencies.

  2. Simulation materials can be obtained through donations or purchased inexpensively at thrift and dollar stores; donations may trickle in slowly, so it is important to plan ahead.

  3. Students reported that they enjoyed the suitcase simulation because it made them think about potential hazards, and it was fun to hunt for hidden contraband.

  4. The simulation replicates a workplace experience that students would not ordinarily experience until they enter the workforce.

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@healio.com.

10.3928/02793695-20140619-01

Sign up to receive

Journal E-contents