Nurses' discomfort in caring for a person with mental illness on general hospital units is well documented in the literature. These feelings of unease are linked with a self-identified lack of the skills to confidently and competently care for these patients.1,2 Nursing students express the same discomfort related to caring for persons with mental illness. Students also indicate that communicating with this patient population is a significant source of anxiety.3
In 2015, an estimated 43.4 million adults 18 years or older in the United States experienced a mental health crisis. This number represents 17.9% of all adults in the United States. The probability that these individuals will need medical care in addition to emotional and psychiatric support is higher than average.4 Individuals with a serious mental illness have a statistically significant increased risk of having medical comorbidity, higher incidence of readmission, and tendency to access services only when the need is urgent.1 The inability to access services in the early stages of a medical event may contribute increased risk for suicide in this population. Suicide is the 10th leading cause of death in the United States and one of the most common hospital sentinel events.5 Inadequate patient assessments during intake and absent or incomplete reassessment have been identified as a significant contributor to this tragic patient outcome.5
During the psychiatric clinical rotation, students apply therapeutic communication and assessment skills from theory into clinical practice. Even though a positive experience during the psychiatric clinical experience has been identified as essential to the formation of skills needed throughout a nurse's career, a theory-to-practice gap persists.6,7 Many nursing students complete their psychiatric clinical practicum feeling unprepared to care for persons with mental illness.7,8
Simulation based on course objectives, desired learning outcomes, and didactic knowledge is supported in the literature as an educational strategy that decreases the theory-to-practice gap.9 Effective debriefing encourages self-reflection and encourages critical reasoning. Purposeful guided reflection through careful questioning is believed to be the essential component of the simulation experience.9,10 There are multiple methods of debriefing. However, most debriefing occurs after the simulation. The goal of this study was to create a formative learning environment that decreased student anxiety and supported the transfer of knowledge to practice. The researcher used standardized patient (SP) simulations with 2 debriefing methods. In-simulation debriefing, a method that provides immediate feedback during the simulation and allows the student to stop, rethink, and redo, was compared with postsimulation debriefing.
An extensive search of medical and nursing literature identified 3 research teams that compared in-simulation to postsimulation debriefing.11-14 No studies were found that involved nurses or nursing students. The research identified was conducted with medical students performing simulated tasks within the psychomotor and cognitive domains of learning. Each of the 3 research teams published findings supporting postsimulation debriefing as the more effective method to promote student learning. To date, in-simulation debriefing has not been discussed in the nursing literature.
This study focused on behaviors in the cognitive and affective domain. Learning is an active process where students construct new concepts based on past experiences. Simulation creates new experiences, and careful guidance from the instructor encourages the student to scaffold new knowledge with existing knowledge through action. The research questions explored the effects of in-simulation and postsimulation debriefing on students' knowledge, performance, anxiety, and perceptions of the debriefing process.
The study used a quasi-experimental, mixed-method 2-group design. Study participants were recruited from senior students enrolled in a psychiatric clinical rotation at a large public university (n = 67). They were randomly assigned to groups (in-simulation group [n = 32] or postsimulation [n = 33]) and simulation scenarios. Data were collected during the fall and spring semesters. The study was approved by the university institutional review board.
The objective was to provide students with a formative experience that allowed them to practice therapeutic communication and conduct psychiatric assessment interviews with a focus on patient safety. Four unfolding scenarios for each simulation were written and reviewed by content experts for validity. The simulations were (a) postpartum depression with a suicide attempt, (b) depression and alcohol abuse with overdose, (c) bipolar manic episode, and (d) chronic paranoid schizophrenia. Each simulation began with admission and progressed to discharge. Behaviors typical of each diagnosis were consistent throughout all simulations. Specific scripted response during the simulations maintained behavioral congruence of scenarios. For example, if the student asked why do you want to kill yourself (a nontherapeutic question), the patients would respond as appropriate for their diagnosis; for example, the patient with postpartum depression became more withdrawn.
The SP volunteers were senior students who had completed their psychiatric clinical experience. To maintain consistency, each SP volunteer was assigned to one of the unfolding scenarios. The SP volunteers were asked to review information related to their simulation diagnosis before rehearsing verbal responses, emotional reactions, and body language. In addition, each SP received coaching on providing subtle cues to guide the student. For example, if the student failed to ask about auditory hallucinations, the SP body language would progress from subtle to more visible. Each volunteer completed a minimum of 2 hours of practice before working with students.
Students received information on their assigned patient in the form of a medical record and nurse-to-nurse patient report. During the simulation, questions asked using therapeutic communication received appropriate responses. Standardized patients responded to nontherapeutic communication with increasingly uncooperative responses or behaviors such as responding to visual or auditory hallucinations, pacing, withdrawal, or increased agitation.
If the SP became uncooperative during the in-simulation debriefing, and the student was unable to proceed, the instructor called a time-out. Students did not have the option to call a time-out. Each mini debriefing lasted approximately 5 minutes and began by asking the student to reflect on the interaction and plan a different intervention. After a brief discussion involving the SP, instructor, and student, the simulation was restarted at a point before the time-out and restart. Simulation for the postdebriefing group continued until the student had completed the assessment or the SP had become so uncooperative that it was impossible to complete the interview.
Students' knowledge of psychiatric assessment and therapeutic communication was compared using a 30-item multiple choice pretest and posttest. Data were collected measuring changes in performance for psychiatric assessment and therapeutic communication during the first and last scenario using rubrics created by the researcher. Students' perceived anxiety related to a psychiatric clinical practicum was measured using a presimulation and postsimulation questionnaire. The questionnaire consisted of 3 open-ended questions related to working with psychiatric patients.
At the end, both groups completed a 7-item survey assessing their perceptions of the debriefing experience. The survey used a 5-point rating scale from 1 (do not agree) to 5 (agree completely). In addition, the survey contained a section for comments, and the in-simulation group was asked to comment on both debriefing methods.
Data were collected in 2 phases. During phase 1, all students completed the pretest anxiety questionnaire and therapeutic communication knowledge test. Simulation procedures were explained, and the in-simulation group was provided with additional information related to the debriefing. During phase 1, scenario 1, all participants received postsimulation debriefing. Baseline data on therapeutic communication and psychiatric assessment were collected using a rubric developed by the researcher. During the second and third scenarios, the groups were randomly assigned to in-simulation debriefing, and the postsimulation group continued with that debriefing method.
One week after the conclusion of phase 1, students returned for phase 2. After a brief reorientation to the simulation process, all students (n = 67) completed a final scenario with a postsimulation debriefing. During the simulation, data were collected for comparison to data collected during the first simulation. All participants were asked to review their answers from the pretest anxiety questionnaire and then answer the same 3 questions. Participants completed the 30-item multiple-choice psychiatric assessment, therapeutic communication knowledge posttest, and 7-item postsimulation survey.
Validity and Reliability of Instruments
The psychiatric assessment and therapeutic communication knowledge test items were adopted from the current textbook test bank.13 A 3-member panel of content experts reviewed the content, and minor changes were made. The revised test was piloted (n = 30), resulting in Cronbach's coefficient α of .66. The perceived anxiety questionnaire and 7-item post survey were evaluated by a panel of content experts for content validity.
A lack of suitable instrumentation to measure therapeutic communication and psychiatric assessment skills led to the creation of 2 rubrics. The psychiatric assessment rubric content followed the guidelines outlined in The Essentials of Psychiatric Nursing in the BSN Curriculum.15 The rubric consisted of 20 essential assessment behaviors divided into 7 categories. A team of content experts reviewed the rubric and suggested minor wording changes. The rubric was used to evaluate student behaviors during the first scenario (to establish a baseline) and the last scenario (for comparison). Student performance was rated using a scale from 1 (not met) to 4 (competent).
The therapeutic communication rubric was designed to count the number of therapeutic and nontherapeutic responses the student made during the first and last scenarios. The 2-part rubric consisted of a list of commonly used therapeutic and nontherapeutic responses compiled using textbooks required for the psychiatric theory course.13,16 The panel of content experts agreed unanimously that the rubric represented the most common therapeutic and nontherapeutic responses expected from nursing students.
Knowledge and Performance
The extent of change from pretest to posttest in knowledge was analyzed using independent and paired sample t tests and Cohen d. Both groups combined demonstrated statistically significant gains in knowledge (pre: mean [SD], 20.18 [3.69]; post: mean [SD], 26.02 [2.29]; t = 19.11, P < .05, effect size = 2.37). However, there were no significant differences between the groups in knowledge or assessment.
The psychiatric assessment rubric items were grouped into the following categories: introduction, patient history, symptoms, mental status, risk assessment. The results were analyzed using paired-sample t test and Cohen d; students had statistically significant differences and practically important gains from pretest to posttest, with effect sizes ranging from 1.45 to 3.30. There were no differences between groups (Table 1).
The therapeutic communication rubric tallied the number of therapeutic and nontherapeutic responses, and results were analyzed using paired-sample t test and independent-sample t test. The overall change from pretest to posttest for therapeutic communication for both groups combined was statistically significant and practically important with a large effect size of 1.34 (Cohen d). On average, both groups showed statistically significant improvement.
Analysis of between-group t test for therapeutic communication between pretest and posttest were statistically significant between groups. The in-simulation group demonstrated a greater increase in therapeutic-communication techniques and a larger decrease in nontherapeutic communication than their peers in the postsimulation group. Differences in means between the in-simulation and the postsimulation groups for therapeutic communication (mean, 1.39 and 0.83) were statistically and practically significant from pretest to posttest, with a very large effect size of 0.98. Differences in means between groups for nontherapeutic communication (mean, −1.95 and − 0.79) were also statistically and practically significant from pretest to posttest, with effect sizes of −1.50 (Table 2).
The results from the 7-item postsimulation survey indicated no significant differences between groups except for the item “the debriefing style was effective.” All of the participants in the in-simulation group rated the debriefing style as positive as compared with 78% of the postsimulation group.
Qualitative Postsimulation and Anxiety
One item on the postsimulation survey asked students to comment on the debriefing. Content analysis was used to identify themes. The students in the in-simulation group reported that being able to stop, rethink, and redo helped reinforce concepts and decrease anxiety. Second, students reported that the immediate feedback from the SP during the simulation provided them with a greater understanding of the patient's emotional state and thought process. One student noted, “I learned the importance of acknowledging the patient's reality.”
The anxiety questionnaire asked 3 open-ended questions. Themes identified by both groups presimulation were anxiety related to personal and patient safety and students' perceived lack of knowledge and ability to perform patient care. The same questions were asked after phase 2, and students were asked to reflect on changes that may have occurred in response to the simulation experience. Both groups reported similar changes presimulation and postsimulation experience. The first theme was that simulation decreased their fear of working with mentally ill patients. Seventy-eight percent of the participants reported feeling less anxious after the simulation experience.
The second theme that emerged was a greater understanding of psychiatric assessment and potential patient behaviors. One student wrote, “I never understood how real hallucinations were for the patient. Watching the patient [SP] respond to the voices was so real I forgot that it was a simulation. I understood that the voices were real, and the patient was afraid and upset.” Another student stated, “By watching the patient [SP] huddle under the blanket, not making eye contact, and sounding so sad and hopeless when she spoke, I understood how someone that [sic] feels that way would consider taking their own life.”
The repetitive performance of intended cognitive or psychomotor skills improves clinical skill acquisition.17 Students in the postsimulation group had the opportunity to clarify concepts during debriefing, whereas the in-simulation group had the opportunity to stop, debrief, and redo. The in-simulation debriefing provided repeated practice of appropriate communication skills and immediate feedback from the instructor and SP.3
Student performance on the psychiatric assessment and therapeutic communication knowledge pretest indicated that most participants possessed a working knowledge of these. However, the application of that knowledge was not always evident. The reflective questions used during the in-simulation debriefing provided students with the opportunity to rethink their responses and reformat their communication. Despite the importance of strong therapeutic communication skills, providing practice opportunities in clinical settings can be challenging. In-simulation debriefing allows students to correct errors and recall and apply existing knowledge, thus reinforcing cognitive content during an affective performance. The transmission of knowledge to action is a social process where knowledge is co-constructed among individuals.18
All participants reported that the simulations helped them understand the patient as a person with a mental health problem rather than someone who was “crazy.” However, students in the in-simulation group reported that understanding how to apply what they learned in theory to simulated patient situations increased confidence in their ability to create therapeutic relationships when they returned to the clinical setting. The results from the presimulation and postsimulation data suggest that both methods are effective for acquiring knowledge, improving performance, and decreasing anxiety. However, the significant differences between groups strongly suggest that in-simulation debriefing is a more effective tool for teaching therapeutic communication.
Currently, the literature offers few studies on the effectiveness of in-simulation debriefing. This study provides support for in-simulation debriefing as a method to increase therapeutic communication skills. Simulation is a rich learning environment that provides the opportunity for nursing faculty to create communities of practice that provide mentorship in the art of nursing. Students who complete their psychiatric clinical experience feeling confident in their ability to care for mentally ill patients may transfer their success to other clinical settings. More studies are needed to compare these 2 different debriefing methods including replication of this study.
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