Nurses are providing care to patients with increasingly complex health problems. Many of these patients have mental health needs in addition to the acute physical illnesses that prompted them to seek health care. Evidence suggests that, in general, mental health needs of patients are often underserved. For example, one study found that more than 57 percent of adults with a mental illness did not receive adequate treatment for it (Mental Health America, 2016).
Patients who encounter the health care system are often not identified as needing mental health services or are not referred for appropriate care. Among the first health care providers to come in contact with critically ill mental health patients, nurses are in an ideal position to play a key role in correcting this problem. Having the proper knowledge and skills to provide improved care is especially important when mental health patients and their family members face difficult decisions and emotions at the end of life.
In an effort to ensure nurses are adequately prepared to care for patients with mental illness, minimum competencies were established in the Essential Psychiatric, Mental Health and Substance Use Competencies for the Registered Nurse (Kane et al., 2012). These competencies are described as "foundational to quality nursing practice," and they highlight the mental health skills every nurse must have in order to provide competent care to all patients (Kane et al., 2012, p. 82).
BACKGROUND
Research shows that nurses often lack the confidence and skills necessary to communicate effectively with critically ill patients during the time preceding the end of life (Dosser & Kennedy, 2014; Erickson, Blackhall, Brashers, & Varhegyi, 2015; Gillett, O'Neill, & Bloomfield, 2016). Dosser and Kennedy (2014) found that strategies aimed at improving communication skills among nurses resulted in improved care for patients at the end of life in acute care settings. Erickson et al. (2015) examined intraprofessional communication between nursing and medical students who were providing end-of-life care. They found that, with skills training, both groups demonstrated improved attitudes toward teamwork but continued to lack confidence in communication skills. They suggested that further research and education are necessary to maximize the effectiveness of skills training. A study by Gillett et al. (2016) suggested that poor communication among health professionals often leads to dissatisfaction with end-of-life care by patients and their family members. The study showed that reflection can improve nurses' confidence when caring for these patients.
PILOT PROJECT
This article summarizes a pilot simulation conducted at a baccalaureate nursing program with junior-level students. The simulation used volunteer actors as standardized patients and was designed to assist nursing students to develop skills necessary to care for the critically ill mental health patient nearing the end of life. The project had four main objectives developed by the authors: a) increase students' confidence and competence at providing effective nursing care, b) increase use of therapeutic communication, c) promote collaboration as a member of a team, and d) assist students to engage in the process of self- and peer reflection.
Recruitment
The authors and a professor teaching the mental health nursing course recruited 19 nursing students during clinical experiences over three semesters. The simulation took place on three separate occasions with six to eight students. The students were informed that participation was voluntary and would not affect their mental health nursing course grade. The authors obtained consent from each student to collect notes during the debriefing process; to administer a short, author-developed qualitative survey directly after the experience; and to discuss the results and disseminate knowledge gained from the project.
Prior to each simulation, three students were randomly assigned active nursing roles (one charge nurse, two primary nurses). Students who were not assigned active nursing roles observed the simulation, acted as consultants, and provided assistance to their peers when asked. These students provided feedback during the debriefing period. Two faculty members (the authors) monitored students' performance and kept notes but offered no assistance. The simulation was substituted for a clinical day, lasted for about 45 minutes, and was followed by a 45-minute debriefing session.
The Simulation Experience
The scenario focused on Brett and his wife Nancy. Brett was portrayed as a middle-aged man with a long history of alcohol dependence; he had end-stage liver disease and was nearing the end of life. Nancy presented with extensive denial about the severity of her husband's health problems. Volunteer actors were utilized for both roles.
The simulation lab was arranged to simulate a hospital room with the patient lying in a hospital bed with his wife at his bedside. The patient was dressed in a hospital gown and exhibited early signs of alcohol withdrawal (tremors, diaphoresis, mild confusion, and headache) and liver disease (generalized jaundice and ascites). He had a simulated IV infusion and oxygen via nasal cannula. His wife presented as pale and tired. Early in the scenario, she exhibited signs of feeling stressed and anxious. To communicate what was required of the standardized patients, the authors generated a detailed script in advance of the simulation experience. The script provided the actors with dialogue, the clinical nature of the illness, and specific symptoms and behaviors to be dramatized.
The authors provided an instructional prebriefing session to each group of students to orient them to the simulation environment and communicate student outcomes. The students had previously been exposed to the concepts in lectures, readings, and clinical experiences. During the simulation, the students were expected to a) use principles of safe and effective nursing practice, such as maintaining a safe environment; b) conduct an assessment, including a Clinical Institute Withdrawal Assessment for Alcohol (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989); c) prioritize and implement a plan of care; d) respond therapeutically to the emotional distress of the patient and his wife; and e) collaborate with peers by dividing responsibilities equitably, utilizing shared decision-making and peer consultation as needed.
Debriefing and Evaluation
The debriefing process was facilitated by both authors to determine whether the objectives of the simulation experience were successfully achieved and to assist students to reflect on their performance. National League for Nursing (2015) guided debriefing/reflection questions were utilized to direct the debriefing process. Questions asked in the debriefing included: What was it like caring for this patient and what were the top priorities of care? What was it like interacting and communicating with the patient and his family members? How well did you work together as members of a team? Do you think you met the objectives of the simulation? What did you think of the experience?
Themes of students' responses during the debriefing included an overall positive feeling about the experience and their performance; however, students acknowledged they lacked confidence in their skills to communicate effectively with the patient and his wife. They indicated that they felt more prepared to meet the patient's physical needs than emotional needs. Although they found providing for both the physical and mental health needs of a patient challenging, they acknowledged that acquiring skills to do so was necessary as the scenario likely resembled what may exist in actual practice. Students also reported valuing working together as a team as it fostered meaningful sharing of ideas.
CONCLUSION
The students were given a qualitative survey that enabled the authors to gather information in the following areas: a) the most and least valuable aspects of participating in the simulation; b) ways in which it enhanced their learning, or not; c) how the experience could have been improved; and d) suggestions for the development of future simulations. The students reported the simulation was a valuable experience and they appreciated the opportunity to test knowledge they had acquired during the mental health course.
The authors agree that this simulation is a valuable teaching strategy. Additional research, with a rigorous design, is recommended to further develop this teaching method. The authors also suggest adopting a theoretical framework for debriefing; for example, using the PEARLS framework in future simulations (Cheng et al., 2016) could provide an opportunity to elicit the emotions and address the emotional needs of students. Faculty would then be in a better position to assist students in developing the coping strategies and skills that are so necessary when caring for patients at emotionally charged times such as at the end of life.
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