1. Designing a Mental Health
Simulation Experience:
From Concept to
Implementation
Dr. Jeffrey K. Carmack, MSN, RN, CHSE
Sara Fruechting, RN, MNSc, CCRN
Debra Rurup, MNSc, RN, CNE
University of Arkansas at Little Rock
Department of Nursing
2. ANCC Required Disclosures
Conflict of interest
• Dr. Jeffrey Carmack
• Reports he is a member of the Board of Directors for INACSL
and a paid consultant for Wolters Kluwer Lippincott Williams
& Wilkins
• Sara Fruechting reports no conflict of interest
• Debra Rurup reports no conflict of interest
Successful completion
• Attend 90% of session
• Complete online evaluation
3. Objectives
• The participants will
– Understand the historical clinical methods
– Explore the concierge model of simulation based
learning experiences
– Examine the financial benefits of using a rotational
design for scheduling of students for simulation
based learning experiences.
4. So how does simulation fit in with Mental
Health?
A technique used “to replace or amplify
real experiences with guided
experiences that evoke or replicate
substantial aspects of the real world in a
fully interactive manner”
Gaba, D. (2007). The future vision of simulation in healthcare. Journal of the Society
for Simulation in Healthcare, 2(2), p. 126.
7. History – How this all began
• 2011
• No structured orientation for students
• Role-playing
• Then, off to the facilities
8. History, con’t
• Lack of full curriculum integration (Simulation
Across the Curriculum)
• Lack of resources
• Manikins are not the only way.
9. History, con’t
• The first step was to search for resources.
• Collaboration with theatre department
• Tried house-made videos first
10. History, con’t.
• Improving orientation with videos
• Two of nurse – patient interaction
– Focus on communication
– Mental status assessment
• One psychiatric emergency
• Orientation videos still used
• Positive student feedback
11. History, con’t.
• Communication
– Feedback from students “don’t know what to say”
– Faculty reported student struggles with
communication
• No formal evaluation of
communication skills
• Started planning simulation
12. Hooray! Funds! 2012
• Technology and grant funds
• Clinical includes one day of simulation
• Simulation planning
– Teaching team
– Simulation faculty
14. Scenario Selection
• Needs assessment based on program
assessment
– Evolve HESI sub-scores in Mental Health
– End of course evaluations
– End of program evaluations
– Clinical faculty feedback on student experiences in
facilities
15. Student Learning Outcomes
• High risk, low occurrence situations
• Focus on communication skills
• Simulation replaces first one, then two clinical
days
• Course team chooses scenarios that ‘every
student should have’
17. Simulation Development
• Funds for standardized participants
• Hearing Voices
• Full clinical day in simulation
– Interaction with SP and debrief with facilitator
19. Simulation, con’t.
• Learning objectives for simulation experience
– Effective communication techniques for
psychiatric patients
– Reinforces classroom content on communication
theory
– First clinical includes interaction process recording
with a real patient
20. Simulation, con’t.
• 2014: SBLEs expanded to two full clinical days
• Student learning objectives relate back to the
specific experience
• Three more scenarios were developed:
– Admission assessment of an alcoholic patient
– Communicating with a schizophrenic patient
– A psychiatric emergency, the “hanging man.”
21. Simulation, con’t.
• Communicating with a schizophrenic patient
• The “hanging man” psychiatric emergency
• Structure
– Experience
– Debrief
– Written reflection
24. Finding a Workforce. . . Cheap!
• Started with only a minimal budget
– 1st year departmental grant
• Covered one adjunct salary of $8,100
• Covered a some of the SP hours
• Encouraged to find funding within our normal budget
– After year one, SimCare had to cover all cost
• Had cover over 330 SP hours
• Did not have a formal training program in
place
25. Year 1
• SimCare faculty recruited SPs from other
programs, when not in use at their home
institution
• Faculty played the roles when needed
• Student volunteers
26. Year 1 Evaluation
• Volunteers were a weak area
– Priority Conflicts
• Paid Work
• Test Tomorrow
• Bad Weather
– Unreliable
• Faulty
– Did not create same stress as unknown SPs
27. Creating a Long Term Solution
• Needs Assessed
– Fund SPs
– Fund Adjuncts
– Reliable Workforce
28. Standardized Participants: Willing
Participants are Waiting
• Nursing had a long established set of Special
Topics courses
• Varied credit hours (1-3 credits per semester)
• Pass/Fail only
• Ratio was stated as 1:1
• Allowed only AAS Nursing students to enroll
• Meet special scholarship requirements
30. Year 3: A Plan Came Together
• Realized Special Topics courses created faculty
workload
• Knew simulation faculty needed workload
31. NURS4305 Standardized Patients in
Simulation
• Designed a course to be an upper level course
that. . .
– Was open to all majors
– Could be taken twice
– Moved from Pass/Fail to A,B,C Credit
– Could be staffed at a 1:24 ratio
32. NURS4305 Course Description
Students will be assigned to specific SimCare courses.
Under the guidance and direction of the simulation
faculty facilitators, students will participate in
simulation-based learning experiences (SBLE) as
standardized patients (SP) and embedded actors (EA).
Student will have opportunities to experience, practice
and model the essential nursing competencies; quality
improvement, teamwork/collaboration, patient-
centered care, evidence based practice, informatics, and
safety within the SBLE. 3 credit hours. Open to students
from many disciplines. Instructor approval required.
33. The SLOs
1. Verbalize and display individualized patients’ conditions, needs and
preferences. (PCC)
2. Provide patient perspective feedback to participants who are using the
nursing process, good judgment, the multidisciplinary team, delegation and
error prevention. (T&C )
3. Participate in debriefings using SimCare PEARLS*. (I, EBP)
4. Use + / Delta to uncover common errors that SimCare participants make.
(S)
5. Demonstrate effective use of SimCare equipment, scenarios, and virtual
and real personnel, including patients and family members. (I, T&C)
6. Explain how the SBLE relates to quality improvement in actual practice
areas. (QI)
(Key: S – Safety; EBP – Evidence-based practice; T/C – Teamwork and Collaboration; QI – Quality Improvement; PCC – Patient-
centered Care; I – Informatics)
*Promoting Excellence and Reflective Learning in Simulation
34. The Good
• Understood the monetary benefits
– Very low return
– Projected 1 or 2 students a semester
– Offered 3 times since approval
• Spring 2015 – 4 enrolled = 148 hours
• Summer 2015 – 6 enrolled = 222 hours
• Fall 2016 – 14 enrolled = 518 hours
36. UALR Simulation Curriculum Model
MH Simulation
Facilitator
• Designed cases in conjunction with course coordinator (This model was
limited to Mental Health Simulation only)
• Reviewed off the Shelf Curriculum.
Course Team
• Review in house development and approved
• Recommended purchases to Simulation Technology & Resources (STR)
Chairperson
MH Facilitators
• Implemented scenarios
• Staging
• Character development training
• Recommend changes post 1st implementation to Course Team
• Recommend new cases as requested by STR Chairperson
37. Pros of Current Model
• Worked well for initial adoption of simulation
– Single Champion
– Converts clinical content into simulation-based
learning experience
– Allows quick modification (trial and error)
• Clinical faculty primarily were simulation faculty
in the early days
• Low cost
– The champion takes on the added workload, often as
a trial, but may become the status quo
38. Cons of Current Model
• Simulation has advanced
– New recommendations (immersion training)
– Trained specifically in simulation
– Increase hours running simulation (50%)
– Decreased clinical workload in the acute
care setting
• No input from teaching team
39. Con’s of Current Model
• No oversight
• Single person
– Not updating skills across curriculum
– Not updating curriculum links between learning
outcomes & SBLEs
• Low cost
– The champion takes on the added workload and it
becomes the status quo
40. UALR Simulation Draft Curriculum
Model All Content Areas
Course
Team
Conduct needs assessment based on
End of course Evaluations
End of Course Standardized Testing
(HESI/ATI, Final Exams)
Facility evaluations by clinical faculty
Observational data relayed to team by
Simulation Facilitators
Updated EBP
Recommend new simulation-based learning
experiences
Recommend revisions to existing simulation-
based learning experiences
41. UALR Simulation Draft Curriculum
Model All Content Areas
Simulation
Technology
&
Resources
Review simulation-based learning
experiences
Validate INACSL Standards of Best
Practice: SimulationSM are present
Validate that SimCare Policy and
Procedures are meet
42. UALR Simulation Draft Curriculum
Model All Content Areas
Simulation
Technology
&
Resources
Validate simulation-based learning experience is
feasible given facility, facilitator, and equipment
limitations
Tech Sheets are completed
Mission, Vision, and Philosophies are
respected by the design
Extracts capital purchases needed to
complete the experiences and prioritizes
purchases
Recommended purchases to Simulation Technology &
Resources (STR) Chairperson
Forwards simulation-based learning experiences to
Curriculum Committee
43. UALR Simulation Draft Curriculum
Model All Content Areas
Curriculum
Committee
Review recommendations of SRT
committee
Reviews
Fit with Drugs across curriculum
Fit with Commonly Recurring
Health Conditions across curriculum
Fit with Skills across curriculum
Updated EBP
44. UALR Simulation Draft Curriculum
Model All Content Areas
Curriculum
Committee
Recommends
Approval without modifications
Revisions be completed and
resubmitted to Curriculum
Committee
Maintains a simulation-based learning
experiences in a central location
Validates that simulation-based
learning experiences are reviewed
every three years
Editor's Notes
Simulation is another teaching tool. Just as some content is best learned in the classroom, some content is best when it comes to life. Simulation creates a fully immersive learning pedagogy. Rich scenarios developed by faculty, a clinical picture presented with human patients or simulators, all debriefed by trained facilitators.
There was no structured orientation to the mental health course. A couple of hours were spent on role-playing short scenarios of patient behaviors in the psychiatric setting. Then, the students were placed in the psychiatric facilities with little introduction to the mental status assessment and the unique problems of communicating with mental health patients.
Med/Surg, Pediatrics, and Maternal-Child courses had incorporated simulation-based learning experiences which enhanced and reinforced the course content and clinical experience.
Mental Health at this time had few resources for simulation, because of lack of technology funds and lack of a clear vision of what experiences should be included.
We were fairly locked into the idea that simulation meant plastic manikins and had no mechanism to hire and train standardized participants (patients).
A meeting with the chair of the theater department proved educational; he had extensive experience with developing training scenarios for medical schools using standardized patients
As no funds were available in 2011, it was decided to focus on home-made videos to use as orientation tools in the mental health course
The focus was to be on the first clinical day of the course (6 hours), devoted to orientation.
Two patient-nurse interactions were created with specific learning objectives related to communication skills with psychiatric patients and a practice mental status assessment.
A third video depicted a psychiatric emergency – an angry, escalating patient.
These videos are still being utilized as learning experiences for orientation to the mental health course.
Feedback from students has been positive. Most state the time spent on communication skills and performing a mental status assessment is helpful prior to actual interaction with psychiatric patients.
A focus on communication skills was made a priority due to feedback from students that they “just didn’t know what to say” to psychiatric patients.
Also, faculty observed students in the clinical settings struggled with verbal and non-verbal interactions with these patients.
A limitation of the orientation learning experiences was that there was no formal evaluation process for communication skills.
Faculty were developing a plan for simulation-based learning which included an evaluation process.
In 2012, technology funds became available, through an increase in budget allocations and grant money.
The plan, jointly determined by mental health teaching team members and the simulation laboratory coordinator, was to devote one clinical day to simulation-based experiences for the mental health course.
Communication hard to evaluate in clinical, as the instructor cannot be there for every patient encounter for every student
And may or may not get in clinical
The funds that became available paid for standardized patients and a “hearing voices” audio activity.
One full clinical day was devoted to simulation, which included two patient-nurse interactions and the “hearing voices” activity.
These were followed by debriefing sessions with faculty and student reflection assignments.
Scenario 1: Interaction with a depressed/suicidal patient
Scenario 2: Interaction with a bipolar patient in a manic phase
Hearing Voices: students were given tasks to carry out while listening to the audio – viewing a tray of objects and recalling as many as possible, checking out a book in the library and reading a small section, and purchasing a drink in the student union. Started without formal debriefing of this scenario, found it really needed to be debriefed
The learning objectives for the patient-nurse interactions focus on effective communication techniques to use with psychiatric patients.
This reinforces the classroom content on communication theory.
The students’ first assignment in clinical consists of an interaction process recording (IPR) with a real patient, which also reinforces the classroom content and the simulation experiences.
SBLE = Simulation Based Learning Experience
Admission assessment of an alcoholic patient: Students attempt to complete an admission assessment while the standardized patient exhibits signs of withdrawal.
The objective is the same as with the other patient-nurse interaction scenarios. The students use effective communication techniques with a patient exhibiting psychosis.
The students enter a room with a mannequin hanging from the door frame by a bedsheet. The objective is to remove the bedsheet and initiate CPR.
The structure for these activities is the same as for the others: complete the activity, debriefing with facilitator, and reflection.
