Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

A Walk in My Shoes: Using Art to Explore the Lived Experience of Psychiatric–Mental Health Standardized Patients

Debra Webster, EdD, RNBC, CNE; Judith M. Jarosinski, PhD, RN


Use of standardized patients (SPs) to teach mental health nursing skills is increasing. Although the literature regarding the effectiveness of this teaching strategy supports its use, information regarding the effect of portraying mental illness on SPs is lacking. Using a qualitative approach incorporating art as expression, this effect was examined. Five SPs created an artistic expression to describe their work portraying an individual with mental illness while working with senior nursing students enrolled in a psychiatric–mental health clinical nursing course. Themes identified include: (a) Walking the Walk, (b) Listen to Me, (c) See Me as a Person, and (d) Letting it Get to Me. Immersion into the role of the SP with mental illness affects actors. The current article offers best practice approaches to address psychological implications for SPs portraying mental illness. [Journal of Psychosocial Nursing and Mental Health Services, 55(8), 39–47.]

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Use of standardized patients (SPs) to teach mental health nursing skills is increasing. Although the literature regarding the effectiveness of this teaching strategy supports its use, information regarding the effect of portraying mental illness on SPs is lacking. Using a qualitative approach incorporating art as expression, this effect was examined. Five SPs created an artistic expression to describe their work portraying an individual with mental illness while working with senior nursing students enrolled in a psychiatric–mental health clinical nursing course. Themes identified include: (a) Walking the Walk, (b) Listen to Me, (c) See Me as a Person, and (d) Letting it Get to Me. Immersion into the role of the SP with mental illness affects actors. The current article offers best practice approaches to address psychological implications for SPs portraying mental illness. [Journal of Psychosocial Nursing and Mental Health Services, 55(8), 39–47.]

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Standardized patients (SPs) are often used to teach therapeutic communication, assessment, and management of high-risk issues in psychiatric–mental health nursing in a safe, simulated environment (Jack, Gerolamo, Frederick, Szajna, & Muccitelli, 2014). In addition to these core skills, nurse educators have also used SPs to address issues related to bias, stigma, and fear (Brown, 2015). Teaching core skills while addressing these issues requires an authentic representation of the patient and scenario by the SP. The SP is instrumental in this process as he/she steps into the role and portrays a variety of mental illness scenarios. The nature of reality in simulation was studied by Dunnington (2014), who cautioned that any misrepresentation by SPs could be misinterpreted by students as reality. Thus, educators who incorporate simulations using SPs must ensure an authentic presentation that most closely represents the phenomenon, otherwise the misrepresentation could be misinterpreted, thus creating misunderstanding of mental illness and promoting stigma. According to Goffman (1959), an actor works to present him/herself in a manner as to represent an illness and is successful when seen by students as he /she intends to be seen. As SPs work toward presenting this authentic portrayal, they must immerse themselves in their role at that moment. This leads to the question of: what, if any, long-term effect does this authentic portrayal have on SPs?

The literature is lacking in recent studies aimed at exploring the lived experience of SPs portraying mental illness. SPs who portrayed patients with a variety of illnesses, but had not previously engaged in roles involving the depiction of mental illness, were reported to adjust to the role and create an accurate portrayal, but said the role was exceptionally demanding (Jack et al., 2014). It was also noted that the younger and more inexperienced the actor is, the more difficult it is to separate from the role (Jarosinski & Webster, 2016). Hochschild (1979) introduced the concept of emotional labor, in which she posited that individuals manage emotions. She suggested that three techniques are in play as humans manage emotions: cognitive, bodily, and expressive. Using these techniques, an individual attempts to change feelings, physical symptoms, and gestures. Actors are asked to demonstrate various emotions as they portray scenarios, but there is nothing in the literature examining the effect this has on them. Although not specific to SPs, other researchers have described the need to address psychological harm to students resulting from simulation events (Janzen et al., 2016), thereby leaving open the question of whether psychological harm could occur when SPs realistically portray mental illness scenarios. The purpose of the current study was to examine the effect of portraying mental illness on SPs.

Standardized Patients and Simulated Patient Experiences

Each year, actors are recruited and trained to portray mental illness to teach communication and assessment skills to senior nursing students enrolled in a psychiatric–mental health clinical nursing course. Recruited actors have included retired nurses; school teachers; former police officers; theater, psychology, and business students; and stay-at-home moms. Although some actors have acting experience through a local theater group or classes, many have no experience. Training for actors is conducted by three experienced psychiatric–mental health nursing faculty members and comprises a 3-day workshop that provides information about mental illness symptomology and client presentation. In addition to providing educational information, detailed scripts are included for actors to learn for each case. Movie clips are used to show portrayals of paranoid schizophrenia, bipolar mania, depression with suicidal ideation, chemical dependency and withdrawal, dementia, posttraumatic stress disorder, and anxiety disorders. Actors rehearse and perform the scripts, playing the role of the patient while faculty play the role of student. Critique and feedback are provided to ensure that actors are able to create the most realistic portrayal possible.

During the semester, actors engage in simulated patient experiences (SPEs) with individual nursing students in a simulation lab in one of two rooms designed to resemble an emergency evaluation room or counseling area of an inpatient behavioral health setting. Each SPE lasts approximately 12 to 15 minutes and is video recorded, allowing students to review and complete assignments related to the clinical experience. SPEs are viewed live using video streaming from a classroom with faculty and other students in the clinical group, allowing students to provide peer feedback. A group debriefing session is co-led by faculty, including a licensed professional mental health counselor and psychiatric nursing faculty member. Students and actors participate in the debriefing, in which actors provide feedback regarding how students did or did not demonstrate empathy and concern for the patient. Faculty trainers provide additional training and debriefing for actors on an as-needed basis throughout the semester.


After institutional review board approval, SPs were invited to participate in the current study, which specifically sought answers as to how SPs can step in and out of this role, and what, if any, effect playing roles involving mental illness has on them. Each SP was asked to create an artistic expression to detail his/her experience in the role of an individual with mental illness while engaging with nursing students. Using an interpretive phenomenological design in a semi-structured interview format, each SP was asked to present and describe his/her artwork in relation to his/her portrayal of mental illness. Accordingly, a phenomenological, interpretive method (Colaizzi, 1978) guided the analysis of this research and provided an in-depth exploration of SPs' experiences. Two psychiatric nurse researchers (D.W., J.M.J.) with doctorate degrees and experience using simulation strategies with SPs independently read transcripts and jointly categorized the thematic structure, ultimately arriving at final thematic groups.

Interviews and artwork were the primary means of inquiry. SPs met with one of two educators in the psychiatric–mental health nursing course. Individual interviews lasted 30 to 45 minutes and were conducted off campus in the simulation laboratory outside of normal use hours for privacy. The initial interview prompt was: Tell me about your experience as an SP when engaging with nursing students. One prompt and one question related to artwork: Tell me about your art work, and What does it mean to you? Questions and probes were guided by the progression of the interview in a semi-structured format (Table). Tapes were transcribed verbatim.

Semi-Structured Interview Prompts and Questions for Standardized Patients (SPs)


Semi-Structured Interview Prompts and Questions for Standardized Patients (SPs)

In the current study, artwork was used to gain a deeper understanding of the phenomenon of the lived experience of SPs. Hegge (2008) views “art as a catalyst for dialogue” (p. 308). In other words, artwork can pursue areas of inquiry not always easy for participants to describe. Using a self-selected art form (i.e., stories, poetry, comics, collages, photography, and pottery), each SP described feelings about his/her work as an SP while portraying sensitive mental illness diagnoses and issues related to stigma. Through guided reflection, researchers encouraged SPs to explore their own assumptions about mental illness and express the ways in which they believed they were treated by others while in these roles, allowing SPs to express what it was like to “walk in the shoes” of a mentally ill individual and provide an understanding of issues faced as the SP moved in and out of roles.


Interviews with participants, in which there is a high degree of emotionality, can challenge the stance of unbiased analysis. The inclusion of safeguards (e.g., bracketing, considerations of one's emotional involvement in the interviewing process, critically monitoring methods [reflexivity]) while maintaining an inductive approach was incorporated in the current study. Psychiatric–mental health nurses (PMHNs) and educators were open to their own biases. Similarly, it is possible they were sensitive to gaps in student learning (therapeutic communication) because they are educators. Bracketing can be one way to maintain objectivity; however, immersion in the data in which the true experience of the participant is derived means personal presuppositions are used in interpreting data. It is best to set aside biases, but also acknowledge that it is almost impossible to be completely unbiased (Heidegger, 1962). A continuous back-and-forth interplay was used between the two researchers (D.W., J.M.J.) to verify the validity of themes, incorporate member checking, and maintain an audit trail through reflective journals.


Five of eight invited SPs, including two males and three females with a range of 1 to 5 years' experience as an SP, participated in the study. Participants included two school teachers, one stay-at-home mom, a theater student, and one retired nurse. Private interviews were conducted and recorded with each SP. Despite the small sample, saturation occurred related to the richness of data and artwork. Morse (2000) underscores this richness, stating saturation is dependent on the “scope of study, the nature of the topic, the amount of useful information obtained from each participant, the number of interviews per participant, the use of shadowed data and the qualitative method and design” (p. 4). Interview transcripts, nonverbal communication observations, artwork, and field notes were sources of data. In conversations between researchers, meanings were extracted from data. With each succeeding interpretation, comments were reread and discussed, and preliminary themes identified. A process of refining continued. The two researchers continually examined the texts with constant attention paid to participants and their words. Ultimately, a delineation of final themes was derived from preliminary themes and compared to the transcribed texts. From a larger grouping of themes, four distinct themes emerged: (a) Walking the Walk, (b) Listen to Me, (c) See Me as a Person, and (d) Letting it Get to Me.

Walking the Walk

A strong desire to accurately portray an individual with mental illness was captured in the first identified theme, Walking the Walk. As SPs stepped into the role, they discussed taking on the feelings and emotions of the character they were portraying. Consistent with Hochschild's (1979) theory, each actor worked to manage his/her emotions to display symptomatology consistent with the diagnosis he/she was portraying. In an effort to be authentic, SPs “walked the walk,” becoming the patient with mental illness. In doing so, they described their feelings of loss of control, including paranoia, anger, depression, confusion, anxiety, loneliness, mistrust of others, frustration, elation, and shame, as they attempted to provide the most realistic portrayal of mental illness. They described interactions with students in which they felt as if they had the same challenges and unmet needs “as a real patient struggling with mental illness.” These emotions were expressed through their artwork and included a picture collage by one SP who described various images of individuals (Figure 1). He discussed how the collage represented his own work, moving from one role to the next, and the challenge of portraying depression and then mania, and how exhausting it was for him in “trying to get it right” for the student. He related this exhaustion to the experience of an individual with bipolar disorder and the exhaustion and frustration the patient and family must feel on a daily basis. He also discussed how his background as an actor in the field of education helped him move into the role and gave him the ability to step out of the role once the scenario was complete. This SP noted that he had observed and conversed with other actors who admitted they could not readily separate from the role after the scenario ended. According to Hochschild (1979), the awareness of emotional work is most apparent when the feelings of the individual are not aligned with the situation. This finding caused the current authors to further ponder the challenge SPs face as they immerse themselves in work to portray emotions that they are not feeling, and any resulting psychological implications as they separate from the role when the scenario ends.


Figure 1.


As they discussed the difficulty of removing themselves from the role (after scenarios were completed), SPs explained the challenges they faced in being immersed in the role and how this affected their mood the rest of the day. One particular challenge for SPs was playing the role of the depressed client. Three SPs mentioned their personal experiences with depression. One noted, “It puts you in a place that I do not wish to return.” Hochschild (1979) refers to this act of managing emotions when an actor is engaged in deep acting. All SPs discussed methods they used to become the individual they were portraying, often drawing on real past experience.

No matter which medium was chosen to describe the feelings one had while portraying mental illness, it was clear that SPs believed they captured those emotions shared by real patients. For example, one SP shared two photographs (Figure 2). He discussed how one photograph depicted his own view of the world and feeling alone, anxious, and misunderstood while wanting an escape from those feelings. The second photograph depicted the view of how others saw him: crazy, weak, helpless, and needing to be locked up and kept away from others. Using the art form of pottery to demonstrate her hallucinations while in role (Figure 3), another SP identified feelings of loneliness and isolation as a result of how others viewed her in the role of a patient with paranoid schizophrenia. She related how the individual with mental illness is mistrustful of others while others are mistrustful of the individual with mental illness. As SPs discussed their work, it became clear that they had stepped into the shoes and “walked the walk” of an individual with mental illness. Despite their difficulties portraying mental illness, SPs identified with the difficulties and challenges that individuals with mental illness and their families face daily.


Figure 2.



Figure 3.


All SPs related that the weight of responsibility of their effort to provide an authentic presentation came with some personal cost, with one mentioning, “That's what's different working with a student. There's no script.... You're on the spot.” Another SP added, “You want everyone to do well.”

In depicting the diagnostic prototypes, SPs elaborated on the need for authenticity so students can respond as if speaking with a real patient in a clinical setting. One SP noted:

When the patient senses a weakness, they play on that. [The patient] seems to sense that. So it's amazing how much you pick up from the student. So in terms of the experience…I would say it's 99% positive, and, even in the [students who] didn't do a very therapeutic job, I still feel that they gained something from it. Particularly if I had a chance to talk to them afterwards. Even if they feel that they “bombed” in their words, they still learned something. I would say…the whole artwork is the relationship.

Listen to Me

SPs discussed the various experiences they had while engaged with students. Four of five SPs discussed the positive results of an interaction in which they believed that the student had taken the time to listen to them and had not just gone through the motions of “asking questions as if completing a checklist.” Conversely, all SPs discussed times when they felt “diminished” and “not heard.” One piece of artwork that embodied this was a comic strip (Figure 4). In this comic strip, one SP talked at length about her frustration with not feeling heard by some nursing students. The SP used the comic strip format to exemplify an ongoing pattern of student responses, depicting a lack of interest and ability to engage with patients; she cited student distraction and non-empathetic responses. In one frame of the comic, she showed the SP waiting for the nursing student to enter the room and went on to describe that, although she was excited to have this interaction and hoped that the student would recognize the importance of the interaction, she was also frustrated by the lack of interest in learning about psychiatric nursing displayed by the nursing student through nonverbal communication. In another frame, the patient states, “I think I'm sinking. My life is hopeless. My husband left me. My daughter only calls when she needs money.” The student responds, “Have you tried a hobby?” Two other frames show interactions in which the student is absorbed in his/her own thoughts. Although the patient bubble reveals one who is potentially homicidal, the student bubble reveals a nursing student who is focused on obstetrics (“the babies are so cute”). In one of these frames, the SP tells the student she feels “useless, lonely…I don't want to leave my room.” The bubble above the student's head shows the student thinking, “Did I wash my hands? Did my friends see my Instagram® photo? I only had three likes. Boy, she whines a lot.” Meanwhile, in the background, the patient is desperately waving for attention. In a fourth frame, the SP highlights a student who is dismissive and not invested in the course, with a bubble above the student's head reading, “I want to work in the ED. Psych is such a waste of time.”


Figure 4.


Other SPs also discussed the importance of attentiveness to the patient. Although SPs were aware that this was a learning experience in which the student was placed in a safe environment to practice and make mistakes, they described their frustration when they believed the student was not listening to what they had to say. SPs consistently noted listening as a major skill for PMHNs.

In addition, all SPs described feeling a sense of accountability to provide opportunities for nursing students to exercise empathy, as one SP mentioned:

You have to go on their responses, their body language. I feel a sense of responsibility for that. I very much want this to be a good experience for them. It's to help them get the whole point of this.

Consequently, reflected in their desire to provide an authentic representation, there was the commensurate disappointment of encountering students who lacked the basics of empathy and were dismissive or casual in their assessment. Because it is an expectation that nurses demonstrate therapeutic communication skills, SPs felt a sense of responsibility to help students in this respect. Although actors are able to manage what is seen by an outsider, they cannot manage their inner feelings (Goffman, 1959). As SPs moved into their assigned roles, they visualized their role as one of teacher.

In effect, by not responding in a “here and now” context, the student missed nuances of the dialogue that can provide the nurse with critical information. In this theme, SPs recognized that the student failed to identify that the psychiatric nursing assessment comprises a line of engagement and questioning that is revelatory and incisive—all with an attitude of genuine respect and empathy. By focusing on an immediate solution (without a joint dialogue with the patient), the student misses the mark.

See Me as a Person

During the interviews, SPs discussed their work and how they wanted the student to see them “as a whole person, not just someone with mental illness.” Although SPs attempted to create the most accurate portrayal of the patient and symptoms of mental illness, all discussed a desire to still be seen as an individual with unique needs and not stigmatized because of their illness. Using poetry and a drawing (Figure 5), one SP described feeling weighed down and unable to rise to be the best one could be. She talked about the “pain associated with being looked down upon due to one's illness” and the importance of empathy in helping the individual with mental illness with recovery. Another SP discussed the lack of empathy noted in nursing students as she described her comic strip depicting nursing students engaged in conversations about not wanting to be a psychiatric nurse. Although students did not directly state this to her, she described that this was a feeling she had as she worked with some students and said that she had overheard this from a group of students discussing mental illness in general. She also related this feeling to her own personal experiences in health care as a patient and family member of a patient receiving care. Like other SPs, she discussed the importance of caring and empathy in nursing. All SPs identified feeling stigmatized or “less than” and related this to stigmatization experienced by individuals with mental illness, as explained by one SP:

The students are not always subtle. I don't preach but I saw it firsthand. My father had an illness, he had cancer—not mental illness, but the way he was treated was disheartening. Some were amazing and uplifting. But he had [Clostridium difficile]. I was left on my own cleaning my dad. There was a nurse, maybe a [certified nursing assistant] who closed the door to his room. I opened it. She closed it again. She said, “That smell…it's so bad.” She said, “Oh God, it's going out on the hallway—I don't want to smell that.” I thought, I'm dealing with my parent dying. And you're inconvenienced because you want to have your Coke and crackers. It's not her dad. I get that. I'm saying goodbye to my parent. He's in the throes of illness. And then mental illness. She kept closing the door and I kept opening it. It's moments like that, I feel it's really important as they go into the field…not knowing just the science, but the other piece…and that's the part, the role I play—the other piece. I think it's really important.

Poetry and drawing.

Figure 5.

Poetry and drawing.

This same SP linked this feeling to the student in the SPE interaction, who suggested, “You just need to think happy thoughts.” Another SP stated, “While we've come a long way in addressing stigma, we still have a ways to go,” and added, “I think that the research you are doing will help with this.” One SP clarified her understanding of stigma:

Ultimately it was really about…how the stigma we put on people with mental health issues and how we loosely use the word crazy…and again I love mental health. And there was a show about Andrea Yates and there was a cop on the scene who was ready to burn her on the stake. I was full of compassion. Don't get me wrong—she clearly needs to be punished. But she had a break with reality. It was they wanted her to be hung from the highest tree. She was clearly delusional; she had a psychotic break.

In this theme, one SP personally noted the dehumanizing effects of stigma: “I certainly have felt that before. It's very real. It's like someone is dissing you—it's a crappy feeling I'm tapping onto that really…it's very real...even though it's all fake.” Dehumanization, simply explicated, is the “denial of a person's humanness” (Haslam & Bain, 2007, p. 57). Zimbardo, Haney, Banks, and Jaffe (1971) sought to investigate the imprisonment experience by creating a simulated prison environment. Their study exemplified how easily individuals' self-identification changed to fit a role. Student volunteers were dehumanized as they stepped into the role of prisoners and were subjected to a series of punishments issued by student volunteers in the role of prison guards. Dehumanizing behavior construed as part of the role was made somehow acceptable by individuals who would not normally have engaged in this behavior. Ultimately, SPs articulated a sense of vulnerability in identifying too closely with their role.

Letting it Get to Me

Although the themes of stigma and empathy seemed to resonate through all of the artwork, each SP described the effect as if he/she had stepped directly into the shoes of the individual with mental illness in his/her effort to create an authentic portrayal for the student. One SP showed the many ways in which she believed she had been treated by nursing students who were distracted and did not listen to her concerns. Another SP described how his challenges with portraying someone with mental illness impacted the way others interacted with him as if “not wanting to set him off.” In his narrative, one SP noted, “I guess that's where acting morphs into reality, that interchange is so real that you experience the feelings as if you were a real person, a patient.” While immersed in these roles, actors portray mental illness so realistically they become the individual they are portraying. In doing so, they expect the student to respond accordingly and see them from a humanistic perspective, demonstrating a level of empathy.

Another SP spoke of the pain that mentally ill individuals must feel as they “try to fit in and are not accepted due to their differences,” and discussed the emotional toll she felt while portraying mental illness, which was clearly depicted in her artwork, in which she showed a yellow balloon being held down by a red weight. She explained, “The yellow balloon ball presents the healing and balance.” Using poetry, she summed her identification of the pain she believed existed for those with mental illness. Through her description of the need to take on the pain that the patient feels, she described her belief that it was necessary for her to feel this pain to accurately portray the patient. This level of engagement in the role showed how she had “let the role get to her at times.” All actors echoed this feeling of becoming so immersed in the role that it often took time and effort to walk away from it. They described challenges associated with “letting it go” once the scene was over. Likewise, the ways in which they were successful in being able to walk away without letting it get to them included debriefing with faculty and each other.

As SPs discussed what their artwork meant to them, it became clear that they were describing how an authentic portrayal had affected them. Using phrases including “letting it get to me,” “going to a place I do not want to ever go again,” “needing to find a way to remove myself from the character,” and “difficulty shaking it off,” SPs provided a glimpse into the world they had entered as they became the individual with mental illness. While discussing a collage, one SP discussed the difficulty of moving from one role to the next. He shared that his previous acting experience helped as he described the challenge of portraying mania in one scenario and then depression in another. This same challenge was described by other SPs, who said they prefer to leave the work day on a happier note. All SPs described the difficulty of “shaking off the feelings” of portraying depression, with one stating, “I don't like to leave the job on a sad note.” According to Hochschild (1979), individuals work to manage feelings to fulfill job requirements. Being immersed in roles portraying mental illness, actors take on the many emotions associated with mental illness: paranoia, depression, worry, confusion, apprehension, and more. As humans, they expect that they will be treated with a level of empathy in which they feel accepted by others. In taking on roles of mental illness, it must be considered how to help actors move in and out of the role so that they do not have lasting effects.

Discussion and Implications

SPs generally discussed their work in terms of acting within the role. In relating their experience with students, they were primarily objective and their concerns were easily identifiable; they viewed this experience as an extension of teaching and were more apt to discuss their personal experience within the framework of the artwork. Deep acting involves managing feelings or “emotion work,” whereas surface acting is more closely identified with behavioral expression (Hochschild, 1979, p. 561). The drawback of deep acting is its total immersion in the role to the point, as many SPs stated, “you live with it.” In addition, Hochschild, (1979) draws on Lazarus' (1966) and Lazarus and Averill's (1972) work that people have the capacity to control emotion; however, in controlling emotions they are also bound by social rules and mores. Therefore, when SPs are acting on a “deep level” by managing their feelings, they are framed by social convention. For example, portraying a depressed client with suicidal ideation requires that the SP respond as he/she would in a social context: hopeless, ashamed, and vulnerable. The Stanford prison experiment (Zimbardo et al., 1971) demonstrated that, for actors, these feelings are burdensome and “difficult to shake.” Implications for nursing education therefore suggest a focused approach. Given this immersion in their role, safeguards to protect SPs from emotional sequelae must be included, such as limited acting assignments, regular debriefing, refresher trainings, and support and appreciation of their work.

The current study highlights the burden of taking on the roles of individuals with mental illness and in providing students with opportunities to respond empathically and nonjudgmentally. Rogers (1967) described empathy as:

to sense the client's inner world of private personal meanings “as if” it was your own, but without ever losing the “as if” quality—this is empathy, and this seems essential to a growth-promoting relationship. (pp. 89–90)

Haslam and Bain (2007) suggested empathy goes beyond understanding the patient's emotions, and includes a response of awareness to the patient's plight. In the health care field, the capability to be empathic is synonymous with progression toward therapeutic outcomes (Alma & Smaling, 2006). Geldard and Geldard (2009) suggested health care providers can prevent any incursion of their own needs or motivations into the therapeutic interaction through personal awareness. Although self-awareness can be a precursor to empathy, teaching empathy is not easily accomplished. Rogers (1967) believed that empathy can be taught exercising positive regard in a nonjudgmental, client-centered approach. Burkes and Kobus (2012) suggested the use of narrative writing, self-refection, perspective-taking, and role modeling to teach empathy to medical students focusing on practicing therapeutic responses. In nursing, faculty are ideally positioned to create opportunities within the simulation experience to teach empathy as a therapeutic intervention. In the current study, students received feedback from each other, the actors, and their instructor; however, instructors must be attuned to a different level of student indifference, as illustrated by the art projects. Although unanticipated, the findings concerning SPs' perception of lack of empathy indicated that this must be addressed with future classes. It is equally important not to define the current findings as confirmatory of a generational problem; rather, they should be viewed as an ongoing problem not easily rectified by assessment tools, logarithms, concept maps, or nursing care plans.

The National League for Nursing “has advocated a curriculum revolution in nursing education to move away from the behaviorist, content-focused undergraduate curriculum to one that is participatory, active and experiential” (Shattell, 2007, p. 572). Crookes, Crookes, and Walsh (2013) identified simulation techniques as one of 10 teaching techniques that meets this objective. The gains identified by simulation-based education include: making mistakes without possibility of harm to patients, a relaxed environment for problem solving, the opportunity to practice best approaches (Dearmon et al., 2013), and standardization of the environment (Becker, Rose, Berg, Park, & Shatzer, 2006). However, an additional gain of simulation education may be in addressing ethical issues through the use of scenarios and simulated settings that invite introspection. In addition, the inclusion of feedback, debriefing, and post-simulation assignments curtails temptation to minimize the importance of the patient–nurse interaction. A level of self-awareness is necessary in the development of empathy toward others (Webster, 2009). Dunnington (2014) proposed that “high-fidelity human patient simulation (HF-HPS) may potentially amplify the real experience of human conditions” (p. 17). When simulation experiences are constructed thoughtfully with linked assignments that align with ethical issues, stigma and empathy can be addressed with additional care for SPs who take on these assignments. Although training is essential, debriefing must be implemented to help SPs move out of these roles.

Strengths and Limitations

Although the current study involved a small sample, the current authors believe it can be used as a stepping stone for future research because it provides insight into the lived experience of SPs portraying an individual with mental illness. With a dearth of research in this area, this small study provides information to better assist in the process of improved training to address (a) issues related to stepping into the role to accurately portray mental illness and (b) de-roling. The study also provides insight into the importance of education to address issues related to stigma and the development of empathy so that students are able to provide the best care for individuals with mental illness. Future studies should explore the inclusion of SPs in student debriefing.


With no current research on the effect of portraying mental illness, the current study provides a glance into the important work of SPs in mental health nursing. As nurse educators continue to use simulation with SPs to teach mental health nursing skills, it is important to consider the effect authentic role portrayal has on SPs and address their mental health needs through careful screening, training including de-roling, and debriefing. As SPs engage in realistic portrayals of mental illness for students, it is important that protections are in place to prevent harm (Jarosinski & Webster, 2016). The current findings can be used to teach students the importance of non-stigmatized care of all patients, which must include active listening. This teaching will ensure the best nursing care for individuals with mental illness. Having SPs involved directly with the debriefing process with students may also be an important means for students to understand the importance of listening and empathy, and exploring how bias may impact stigma.


  • Alma, H.A. & Smaling, A. (2006). The meaning of empathy and imagination in health care and health studies. International Journal of Qualitative Studies on Health and Well-Being, 1, 195–211. doi:10.1080/17482620600789438 [CrossRef]
  • Becker, K.L., Rose, L.E., Berg, J.B., Park, H. & Shatzer, J.H. (2006). The teaching effectiveness of standardized patients. Journal of Nursing Education, 45, 103–111.
  • Brown, A.M. (2015). Simulation in undergraduate mental health nursing education: A literature review. Clinical Simulation in Nursing, 11, 445–449. doi:10.1016/j.ecns.2015.08.003 [CrossRef]
  • Burkes, D.J. & Kobus, A.M. (2012). The legacy of altruism in health care: The promotion of empathy, prosociality and humanism. Medical Education, 46, 317–325. doi:10.1111/j.1365-2923.2011.04159.x [CrossRef]
  • Colaizzi, P. (1978). Psychological research as the phenomenologist views. In Valle, R. & King, M. (Eds.), Existential-phenomenological alternatives in psychology. New York, NY: Oxford Press.
  • Crookes, K., Crookes, P.A. & Walsh, K. (2013). Meaningful and engaging teaching techniques for student nurses: A literature review. Nurse Education in Practice, 13, 239–243. doi:10.1016/j.nepr.2013.04.008 [CrossRef]
  • Dearmon, V., Graves, R.J., Hayden, S., Mulekar, M.S., Lawrence, S.M., Jones, L. & Farmer, J.E. (2013). Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience. Journal of Nursing Education, 52, 29–38. doi:10.3928/01484834-20121212-02 [CrossRef]
  • Dunnington, R.M. (2014). The nature of reality represented in high fidelity human patient simulation: Philosophical perspectives and implications for nursing education. Nursing Philosophy, 15, 14–22. doi:10.1111/nup.12034 [CrossRef]
  • Geldard, D. & Geldard, K. (2009). Basic personal counselling: A training manual for counsellors (6th ed.). Frenchs Forest, Australia: Pearson Education Australia.
  • Goffman, E. (1959). The presentation of self in everyday life. Garden City, NY: Doubleday.
  • Haslam, N. & Bain, P. (2007). Humanizing the self: Moderations of attributions of lesser humanness to others. Society of Personality and Social Psychology, 33, 57–68. doi:10.1177/0146167206293191 [CrossRef]
  • Hegge, M. (2008). Literature and art as a prologue for moral energy. Nursing Science Quarterly, 21, 306–309. doi:10.1177/0894318408324335 [CrossRef]
  • Heidegger, M. (1962). Being and time (, Trans.). New York, NY: Harper & Row.
  • Hochschild, A.R. (1979). Emotions work, feeling rules, and social structure. American Journal of Sociology, 85, 551–575. doi:10.1086/227049 [CrossRef]
  • Jack, D., Gerolamo, A.M., Frederick, D., Szajna, A. & Muccitelli, J. (2014). Using a trained actor to model mental health nursing care. Clinical Simulation in Nursing, 10, 515–530. doi:10.1016/j.ecns.2014.06.003 [CrossRef]
  • Janzen, K.J., Jeske, S., MacLean, H., Harvey, G., Nickle, P., Norenna, L. & McLellan, H. (2016). Handling strong emotions before, during, and after simulated clinical experiences. Clinical Simulation in Nursing, 12, 37–43. doi:10.1016/j.ecns.2015.12.004 [CrossRef]
  • Jarosinski, J.M. & Webster, D.A. (2016). Acting with a purpose: The lived experience of actors in the role of standardized patients portraying mental illness. Clinical Simulation in Nursing, 12, 539–545. doi:10.1016/j.ecns.2016.08.005 [CrossRef]
  • Lazarus, R.S. (1966). Psychological stress and the coping process. New York, NY: McGraw Hill.
  • Lazarus, R.S. & Averill, J.R. (1972). Emotion and cognition: With special reference to anxiety. In Spielberger, D.C. (Ed.), Anxiety: Current trends in theory and research (pp. 242–283). New York, NY: Academic Press.
  • Morse, J.M. (2000). Determining sample size. Qualitative Health Research, 10, 3–5. doi:10.1177/104973200129118183 [CrossRef]
  • Rogers, C.R. (1967). The interpersonal relationship: The core of guidance. In Rogers, C.R. & Stevens, B. (Eds.), Person to person: The problem of being human (pp. 85–101). New York, NY: Pocket Books.
  • Shattell, M.M. (2007). Engaging students and faculty with diverse first-person experiences: Use of an interpretive research group. Journal of Nursing Education, 50, 572–575.
  • Webster, D.A. (2009). Addressing nursing students' stigmatizing beliefs toward mental illness. Journal of Psychosocial Nursing and Mental Health Services, 47(10), 34–42. doi:10.3928/02793695-20090902-05 [CrossRef]
  • Zimbardo, P., Haney, C., Banks, W.C. & Jaffe, D. (1971). The Stanford prison experiment: A simulation study of the psychology of imprisonment. Retrieved from

Semi-Structured Interview Prompts and Questions for Standardized Patients (SPs)

Tell me about your experience as an SP when engaging with nursing students.
How was this experience different from the first interaction to final interaction?
Tell me about your experience as an SP while engaging with faculty.
Tell me about your experience as an SP while engaging with staff.
Tell me about your experience as an SP when engaging with the others (public).
Tell me how these experiences were different based on the mental illness diagnosis you were portraying or with whom you were interacting.
How did your training prepare you for these roles?
Is there anything that you feel would have better prepared you?
Tell me about your artwork.
What does it mean to you?
Is there anything else you would like to share?

Dr. Webster is Associate Professor and Associate Chair, and Dr. Jarosinski is Associate Professor, Department of Nursing, Salisbury University, Salisbury, Maryland.

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

The authors thank the standardized patients for the work they do to help prepare students to work with individuals with mental illness.

Address correspondence to Debra Webster, EdD, RNBC, CNE, Associate Professor and Associate Chair, Department of Nursing, Salisbury University, 1101 Camden Avenue, Salisbury, MD 21801; e-mail:

Received: March 02, 2017
Accepted: May 18, 2017


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