As psychiatric mental health (PMH) clinical practicum placements decrease, there is an increased demand for alternative equivalent clinical experiences. One possibility is to provide high-quality simulation experiences, which can replace up to 50 percent of clinical hours (Hayden et al., 2014). Simulations for PMH require a greater focus on the therapeutic use of self as the primary nursing tool (Davis et al., 2013). Although the literature related to PMH simulation is minimal (Felton & Wright, 2017), some proven methods exist, such as simulations with high-fidelity manikins, standardized patients, virtual reality, and hearing voices software (Brown, 2015). However, these methods are not always feasible because of costs or resource accessibility.
We sought to find an acceptable and cost-effective method for PMH simulation and identified cinematic simulation as a useful tool. With cinematic simulation, an entire movie/film is used to create a virtual or simulated clinical setting. Students engage in experiential learning using assessment tools or facilitation guides before, during, and after viewing the film. This article provides background on the development of cinematic simulation as an innovative strategy for PMH simulation, paving the way for future research.
DEVELOPMENT AND IMPLEMENTATION
For years, movies or cinema have had a place in academia, from showing video clips to entire videos to help participants learn various concepts (Zauderer & Ganzer, 2011). To date, no formal research exists related to the development of film as simulation. Although we have not formally researched this concept, anecdotal feedback provides early insight into how film application may provide positive outcomes as a high-quality simulation. Students wrote reflections that spoke of a decrease in their anxiety and fear and greater confidence in providing care for those who suffer from mental illness because of watching the film and participating in the activity. We developed this new modality of simulation, cinematic simulation, in response to early anecdotal reflections and the need for increased PMH simulation.
To promote the proper level of fidelity and design, we applied the 11 criteria presented by the International Nursing Association for Clinical Simulation and Learning (INACSL Standards Committee, 2016) to our lesson plans, using the NLN Jeffries Simulation Theory (Jeffries et al., 2016) as a framework. We began the development of cinematic simulation with an assessment of student needs, which revealed the need for replication of mental health patient care experiences focusing on assessment, care management, and the nursing role in PMH. Objectives for our cinematic simulation included the following: 1) apply the principles of assessment to patients from diverse backgrounds requiring inpatient mental health care; 2) analyze the care management process as it relates to assessment, goals, interventions, teaching, and outcomes in mental health nursing; and 3) perform the role of the professional RN in mental health nursing.
With careful consideration, the film "Girl Interrupted" (Kaysen et al., 2000) was selected as a film fitting the needs of participants and the established objectives. The film comprehensively develops several characters who suffer from PMH disorders, including borderline personality disorder, antisocial personality disorder, and major depressive disorder.
We developed presimulation activities that required watching a tutorial video on how to create a plan of care for a mental health patient; learning the instructions on completing ATI(R) templates for borderline personality disorder, antisocial personality disorder, and major depressive disorder; and reading assignments on the nursing role and mood/personality disorders. During prebriefing, we provided students with background on cinematic simulation and a summary of the characters. Learners were assigned to one of three characters and introduced to the assessment tool they would utilize. A prebriefing discussion on patient confidentiality, nursing role expectations, and developing a plan of care also preceded the activity.
Three well-developed characters with leading roles served as the patients of focus for the simulation activity: Susanna, Lisa, and Daisy. Students completed a thorough assessment of one character, using an assessment guide developed by faculty, while watching the movie. Students worked in teams on developing their plans of care but completed their assessments individually. Students used their guides to complete the plan of care for their assigned patients after viewing the film.
The plan of care had to include at least one complete nursing diagnosis with a population profile and the entire nursing process. Then, students shared their care management, with peers providing feedback and faculty present to provide dialogue when necessary and facilitate learning. Continuing with the same framework and standards, the end of the cinematic simulation included debriefing to evaluate the learning experience and ensure discussion of the objectives. This final step was essential to ensure that the learning experience was complete and met the standards of practice for simulation (Jeffries et al., 2016; INACSL Standards Committee, 2016).
EVALUATING THR CINEMATIC SIMULATION
In addition to integrating standards and frameworks, we participated in informal discussions to evaluate the effectiveness of the cinematic simulation experience for faculty and students. Upon examination of the experience, we noted that gaps existed and changes were needed. Among those were the need for facilitator guides and supplemental materials to ensure robust simulation experiences.
For interrater reliability, we created structured facilitator guides to ensure that each facilitator had a firm understanding of the concept of cinematic simulation and how to perform the role of facilitator of the simulation experience. The guides we created for prebriefing, the actual cinematic simulation experience, and the debriefing provided a set of expectations for the facilitators.
It also became apparent that students struggled to develop plans of care and required more information. For example, during the debriefing, students shared that they were missing critical elements that a patient chart might provide. Subsequently, we created patient charts for the three characters. Each chart emulated the patient charts found in the hospital where students did onsite clinical experiences and included history and physical, nursing notes, physician progress notes, social worker notes, medications, and laboratories.
IMPLICATIONS FOR THE FUTURE
Anecdotal reports from participants during open dialogue debriefing indicated that the cinematic simulation increased students' understanding of PMH disorders and the role of RNs working with this vulnerable population. Participants shared that the activity increased their knowledge of the care management process and the value of having strong therapeutic communication skills as an RN. Participants also reported a reduction in their anxieties and fears, along with an increase in confidence, about their mental health rotation as they had some idea of what to expect. Nurse educators facilitating the cinematic simulation shared that participants engaged in the cinematic simulation experience, suggesting its potential as an innovative PMH simulation modality.
During the development phase of cinematic simulation, reductions in cost and resources were evident. The cost to obtain the film was nominal, and the simulation can be offered in a regular classroom or web platform, without the added cost of standardized patients. Films offer other advantages. Actors may be able to portray patients with PMH disorders more skillfully than standardized patients may, and films portray settings, both inpatient and within the community, that can provide students with a realistic experience. Because of the versatility of cinematic simulation, sufficient simulation learning experiences can be available.
Nursing education researchers must contribute to the body of knowledge as it relates to the phenomenon of clinical simulation (Jeffries et al., 2016). Cinematic simulation is embryonic, but early applications suggest that this method may prove cost-effective while meeting INACSL standards and conforming to the definition of simulation by the Agency for Healthcare Research and Quality (Lopreiato et al., 2016). Early anecdotal information suggests that this method has the potential to promote positive learning experiences and the achievement of objectives and outcomes. However, further research is necessary to determine outcomes of this innovative simulation strategy based on evidence. It is our goal to conduct a pilot study to measure the effectiveness of this new and innovative method of simulation.
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