Delivering quality psychiatric clinical experiences to pre-licensure undergraduate nursing students can be an incredible challenge (Lane, Corcoran, Weare, & Perry, 2017). Nursing programs are tasked to find appropriate clinical placements that can position students to cultivate an understanding of the complexities of mental health nursing (Oudshoorn & Sinclair, 2015). This task is compounded for distance nursing programs when multiple, individual, geographically appropriate sites are needed.
In addition to the clinical placement needs are the varied and inconsistent clinical sites utilized. This diversity in clinical settings and mental health experiences can limit a student’s exposure to learning opportunities and the development of communication skills. And, these varied student experiences may not align to didactic course content.
These troublesome areas led to the decision to utilize psychiatric virtual simulations to provide a comprehensive mental health clinical experience. The disorder specific virtual simulations were incorporated as a replacement for traditional clinical hours. Technological innovation has provided conversation-based virtual simulations that are ideal for student learning in a mental health course.
As is known, simulation “opens doors for students to experience today’s complex and challenging patients and it enhances their critical thinking skills” (Davis, Kimble, & Gunby, 2014, p. 149) all within a safe, do no harm environment. Brown (2015) also found that “simulation is effective for increasing student’s skills in therapeutic communication . . . problem solving, decision making and risk assessment in mental health nursing practice” (p. 445). More specifically, Kidd, Knisley, and Morgan (2012) add that virtual simulation technologies can provide unique educational opportunities to learn and practice skills necessary for mental health nursing.
This decision is further supported by the determination that end-of-program outcomes can be met when some clinical hours are replaced with quality simulation (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). In addition, this change allowed for standardization and course alignment of content and an equitable clinical experience for all enrolled students.
Purpose
The purpose of this research is to illustrate a framework to provide comprehensive psychiatric clinical experiences for distance pre-licensure nursing students through the incorporation of multiple, content specific, virtually simulated mental health scenarios.
Methods
To best compare strategies of clinical education, student experiences were gauged by a clinical workbook submitted for evaluation in a dedicated mental health course in the baccalaureate curriculum, NURS 338, “Mental Health Nursing” specific to distance education students. The student workbook included primary patient diagnosis, full health assessment, nursing diagnosis, interventions, and evaluation of interventions. A total of 51 workbooks were reviewed with the following breakdown; depression (N=6), suicidal ideation (N=6), bipolar disorder (N=9), psychotic disorders (N=13), cognitive disorders (N=6), stress related disorders (N=4), substance abuse (N=4), non-suicidal self-injury (N=1), eating disorders (N=1), and attention deficit hyperactivity disorder (N=1). This evaluation allowed for a quantitative assessment of the type of clinical site as well as clinical focus. Although there is a wide variety of clinical encounters identified, experiences are limited based on patient population at specific clinical sites available to students based on their location.
Current, virtually simulated, clinical education has been aligned based on specific mental health conditions to optimize consistent, equitable clinical experiences utilizing simulations for all major psychiatric disorders. A final aspect was a linear review of consistent clinical practice assignments over past and current courses including participation in 12 step and community support meetings.
Results
Results indicate that past face-to-face clinical sites utilized to satisfy the 45 clinical hour requirement were diverse and inconsistent. Students attended clinical experiences at a variety of agencies including inpatient psychiatric facilities, outpatient psychiatric treatment centers, child and adolescent behavioral facilities, drug treatment units, facilities specific to dementia care, as well as other opportunities. Thus, with such a range and variance in clinical sites and patient exposure, student experiences were varied. Clinical workbooks were diverse with differing levels of focus including an inconsistent level of patient engagement within the major psychiatric disorders. This compares with current students who, via virtual simulation, engaged and communicated equally with patients who were suffering from post-traumatic stress disorder (PTSD), depression, anxiety, dementia, schizophrenia, alcohol dependency, and concerns with end of life care. Through the semesters in review, all students participated in a Screening, Brief Intervention, Referral to Treatment (SBIRT) simulated training funded by Substance Abuse and Mental Health Services (SAMHSA), attended both a 12 step and a community support meeting, and created a community resource of mental health services within their own communities.
The final comparison clearly illustrated a more meaningful, course aligned clinical experience for students. The ability to comprehensively meet course objectives was enhanced through a controlled means to offer clinical experiences of common psychiatric ailments. The clinical pass rates of students in the Mental Health Nursing course remained consistent with no change. Implementation of the simulations did not negatively impact students. In fact, they are obtaining a level of mastery in content areas where they lacked prior clinical exposure. Additionally, the simulation provides a relatively simple quantitative method to assess student achievement allowing for readily identifiable areas of individual strengths and weaknesses.
Conclusions
The data suggests that perhaps the controlled use of simulated psychiatric scenarios is an appropriate means to provide clinical experiences necessary to meet course objectives and to allow students a well-rounded, wider focus. In addition, the simulated scenarios can be aligned to map with the course content as it is covered versus the happenstance of the material being covered in a face-to-face clinical. As content is presented in the didactic portion of the course, the student is better prepared to participate in a simulation based on the subject matter.
Connecting with one’s community resources remains an important aspect. Retaining course requirements such as SBIRT and attendance to both a 12 step meeting and a community support meeting are essential. This allows for reality and face-to-face interaction within their local environment.
Recommendations for Future Research
Future research recommendations should include the use of tele-presence robots to bring online distance students into the simulation lab for live interviews with standardized psychiatric patients. The use of standardized patients allows the student to practice communication skills and develop confidence in conducting assessments such as a mental status exam or a suicide risk (Yong-Shian, MCouns, Chng, Tan, & Yobas, 2016). Comparing mental health standardized testing results between undergraduate nursing students completing face-to-face clinicals and those completing virtual simulated clinical experiences may provide revealing results. Likewise, to effectively structure virtual mental health simulations, assessing or evaluating student’s perceptions of learning may be valuable.