Evidence that simulation provides valuable opportunities to master new information and improve behavior has been well documented. Simulation has also been shown to improve therapeutic communication skills in psychiatric mental health nursing (Webster, 2014; Webster, 2013). However, there is limited research on the use of simulation, more specifically the use of standardized patients (SPs), to influence and change attitudes towards individuals living with mental illness. The purpose of this quasi-experimental study was to determine the impact of simulation on nursing students’ knowledge of and attitudes towards mental illness. Senior level baccalaureate students (n = 91) enrolled in a psychiatric nursing clinical course at Salisbury University were introduced to varying mental health disorders via encounters with SPs in a simulated learning environment.
In addition to the SP experiences (SPEs), students were required to complete a toolkit prior to each experience. Each toolkit consisted of learning objectives, reading assignments, a video vignette, and a post-simulation activity. The toolkit topics matched the SPE each week, providing students with the necessary background information on each topic and then giving them an opportunity to use their new knowledge with a standardized patient. Toolkit topics included therapeutic communication, management of hallucination and delusions, setting limits with manic clients, dementia care, and management of addictions and withdraw.
Student knowledge of and attitudes on varying aspects of mental health were assessed at the beginning and end of the semester using the 12-item mental health knowledge schedule (MAKS 10©) tool (Thornicroft, 2009). MAKS 10 © was developed to examines knowledge of and stigma related to common psychiatric mental health disorders among the general public. The MAKS 10© contains 6 stigma-related mental health knowledge items: help seeking, recognition, support, employment, treatment, and recovery, and 6 items that inquire about knowledge of mental illness conditions. Items are rated using a 5-point Likert-type scale with options of agree strongly, agree slightly, neither agree nor disagree, disagree slightly, and disagree strongly. A category of "don’t know" was also available. With acceptable internal consistency (.65) and test-retest reliability (.71), and content reviewed by an international panels of experts, the MAKS 10© was selected for its ability to assess and track stigma-related knowledge, its brevity, and ease of administration.
The first six items of the MAKS 10© assess attitudes towards people with mental illness. Respondents are asked to indicate on a 6-point scale, the extent to which they agree or disagree with various statements about people with mental illness, e.g., “people with severe mental health problems can fully recover” (Thorndike, 2009). The remaining six items assess knowledge of mental illness, e.g. whether respondents consider stress to be a mental illness (Thorndike, 2009). At the end of the semester, completed questionnaires were scored and all data were entered in SPSS ver. 24 for statistical analysis
Pre-test data were collected from 91 students, but only 65 completed the post-test. Consequently, all analyses were conducted using a final n of 65. A paired-samples t-test revealed a significant difference in overall MAKS 10© scores before simulations (M=46.95, SD=4.32) and after simulations (M=49.12, SD=3.05); t (64) = -4.05, p < 0.01. These results suggest that experiences with standardized patients increase student knowledge of mental health disorders and favorably influence attitudes towards individuals with mental illness. Specific items demonstrating the greatest change were knowledge of medications for treatment, ability to give advice on mental health issues, and beliefs that those with mental illnesses want to be employed.
The use of toolkit activities followed by SPEs has enabled nursing faculty to provide consistent clinical experiences for all students that focus on building knowledge and changing attitudes. With growing competition for “live” clinical experiences, educators need alternative opportunities that will provide equivalent outcomes. While data from this study must be interpreted cautiously, the findings are promising and lay the groundwork for future investigation. Limitations include a small sample size and single site location. The study design cannot infer causality and other variables may have contributed to the differences in pre-and post-test scores. For example, all students were concurrently enrolled in a psych/mental health theory course where they studied the same mental health disorders that were embedded in the toolkits and SPEs. It is unclear how the exposure to this content in multiple ways influenced the MAKS post-test scores. Additionally, the loss of nearly 1/3 of the data, from student absence on the day of post-test data collection is of concern.
Further research is needed to continue exploring nursing students’ knowledge of mental illness and to determine instructional methods that can be employed to change misconceptions that nursing students have regarding those living with mental illness. This presentation will provide an overview of the study, results, and implications for nurse educators.