As opposed to other medically focused disciplines, psychiatric-mental health nursing (PMHN) education does not emphasize recursive, skills-based instruction but focuses instead on therapeutic communication and mental status evaluation. The more nebulous nature of the techniques used in PMHN has seemingly resulted in their exclusion from recommendations for techniques to implement simulation activities throughout nursing curricula (Jeffries, 2005, 2009). Nevertheless, engaging in thoughtful, meaningful, and empathic conversations, as well as the ability to perform an accurate mental status or psychosocial assessment, is highly important when engaging with patients across the continuum of care (Ayers, 2016).
Because many schools of nursing do not schedule PMHN students for practice in the nursing resource laboratory setting, nurse faculty utilize the didactic classroom and clinicals as the most expedient outlets for exploration of PMHN techniques. As content provided to students within the didactic classroom highlights safety as a top priority in the PMHN clinical setting, clinical faculty are limited in their ability to expose students to interesting clinical scenarios involving acute psychopathology, psychopharmacological regimens, complex family dynamics, or challenging behaviors and high-risk situations that occur infrequently but may provide the richest opportunities for learning. When such situations do occur, clinical faculty are typically advised by floor staff to move students to a location that ensures safety but also interferes with direct observation or interaction (Lux, Hutcheson, & Peden, 2014). In comparison to medically based simulations, comparatively few products or resources are available to support faculty efforts to supplement PMHN experiences through classroom role play or simulation experiences in the nursing resource laboratory (Koch, 2017).
PLANNING
Recognizing the relative dearth of simulation products that recreate low-incidence/high-risk scenarios related to psychiatric-mental health, a faculty member authored several scripts and invited the nursing resource laboratory/simulation (NRL/Sim) manager to plan and execute them in a PMHN didactic classroom with an enrollment of 80 students. Both worked with the university school of theater to recruit five acting students to review the scripts and provide feedback about script development and stage direction.
Weekly rehearsals were conducted with three divergent scenarios piloted in the classroom at midsemester: a) issues of proxemics and safety related to a patient experiencing acute psychosis, b) therapeutic communication with a patient experiencing suicidal ideations as a result of major depressive disorder, and c) opportunities for interdisciplinary collaboration related to a college-aged man's mental health diagnosis.
To promote character authenticity, actor-patients were provided with background sketches, each of which included (as applicable) age, socioeconomic status, previous education, work history, history of mental illness, current psychopathology and psychopharmacology, and level of compliance. Because none of the actor-patients who portrayed the patient, nursing staff, and security guard had a medical background, they were encouraged to question nursing faculty about aspects of their character's illness during rehearsals. Much discussion ensued concerning psychopathology, psychopharmacology, nursing practice, safety, and health care setting policies. Clarifying misinformation assisted the actor-patients with portraying their characters in the most realistic manner possible.
Faculty provided nursing students with PMHN lecture-related classroom resources, but no other materials were provided to the actor-patients. To maximize opportunities to utilize mental status evaluation skills, students were instead granted access to the character's electronic medical record, which was created by the NRL/Sim manager. Each chart contained a list of medications, a brief history and physical, and narrative notes, all formatted in a manner similar to what would be found in a PMHN practice setting.
IMPLEMENTATION
On performance day, nursing faculty and the NRL/Sim manager reminded students to pay close attention to the performance, as they would be questioning the characters at the conclusion of the simulation in order to complete a follow-up homework assignment - a mental status evaluation and narrative note. The didactic course faculty reviewed the homework submissions and provided feedback to students within one week.
At the end of each 10-minute performance, the actor-patients - still in character - gathered at the front of the classroom to answer unscripted questions. With minimal Socratic prompting by faculty, the students rather fluently questioned the actor-patients about observed psychopathology, knowledge of psychopharmacology, and family dynamics. The students also asked about the impact mental illness had on their lives. Interestingly, the students also asked the actors who portrayed the nursing staff and security guards about their education, training, level of experience, and practice policies, making the total period of student questions and actor-patient improvisational responses approximately 20 minutes per scenario.
The actor-patients' ability to individually and collectively improvise thoughtful, meaningful responses to these questions was nothing less than extraordinary. For example, a number of PMHN students assessed an actor-patient's reticence as fear and sensed the patient may be withholding information. The PMHN students asked this actor-patient about a history of abuse - which was not included in the script character sketch or chart - and the actor-patient immediately engaged the student by admitting a long history of childhood physical and sexual abuse. The actor-patient portraying the patient's abusive father was also onstage and expertly responded, through improvisation, by first vehemently denying the allegations, then displaying outright rage, and then refusing to speak altogether. This provided the presumed victim actor-patient the chance to respond uninterrupted via an unplanned, fully improvised dialogue. The students remained at rapt attention while these complicated family dynamics unfolded. They remained equally engaged as the actor portraying the security guard discussed various topics with nursing staff, including training-orientation, safe staffing levels, proper methods for patient safety searches, and other hospital policies.
The improvisational technique utilized by the actor-patients is "yes[horizontal ellipsis]and" and is typically employed to respond to questions or assertions made by an audience member (Scruggs & Gellman, 2008). The initial sense of agreement with comments affirms the audience member's response and then allows the actor-patients to move the interaction thematically in the direction that best supports their character's development. This same "yes and[horizontal ellipsis]" affirmative technique is also used between the patient and the therapist during psychoanalysis to promote insight, reflection, and enhance the therapeutic alliance (Ringstrom, 2001).
NEXT STEPS
Student participation during periods of improvisation was highly robust and dynamic. Students were asked by nurse faculty to discuss their thoughts on traditional lecture, low-fidelity simulations, and these high-fidelity actor-based scenarios. This comparison of educational strategies was declared exempt from further review by the Case Western Reserve Institutional Review Board.
During the follow-up discussions, students stated an overwhelming preference for actor-based interactive learning scenarios over traditional classroom lectures and even low-fidelity, Socratically guided simulations using manikins. Furthermore, the students stated the actor-patients' improvisation enhanced their knowledge of both psychopathology, psychopharmacology, mental status evaluation, and therapeutic communication. The students were unanimous in their recommendation for continued use of actor-based scenarios and requested additional opportunities to engage actor-patients through improvisation. The low-stakes nature of interacting with the characters in the large-group classroom setting seemed to encourage student participation.
MOVING FORWARD
Based on the overwhelming positive student feedback, additional interactive scenarios have been authored that highlight other forms of psychopathology and include additional opportunities to explore complicated family dynamics. Ongoing collaboration between nursing faculty and the theater school's leadership may result in a for-credit course in acknowledgement of the acting students' efforts. Encouragingly, the student actor-patients have agreed to participate in PMHN interactive scenarios for the upcoming academic year so the live presentations with improvisation will continue. Given its noted role in promoting effective communication and collaboration during disaster/emergency preparedness within the business industry (Tint, McWaters, & van Driel, 2015), we will heed the call to deeply explore improvisation's impact as an innovation in PMHN nursing education.
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