In the early days of the COVID-19 pandemic, instruction in nursing programs across the nation shifted rapidly to online learning. This required faculty to identify innovative pedagogical strategies that combined meaningful faculty engagement with high-quality academic programming. In a school of nursing located at a regional university, a clinical simulation was designed to evaluate senior-level bachelor of science in nursing students' abilities to apply critical reasoning, demonstrate effective communication, and practice as competent and professional nurses. The use of standardized patients (SPs) during psychiatric mental health (PMH) clinical simulation scenarios can help close the theory-practice gap by increasing nursing students' clinical competence, reasoning, decision-making, and confidence (Vandyk et al., 2018). Our clinical simulation experience was originally designed to incorporate SPs portraying PMH disorders in a face-to-face setting. This article highlights the process and framework faculty used to shift from a traditional face-to-face simulated experience with SPs to an innovative approach using telehealth in response to health care delivery and practice model changes resulting from COVID-19.
The National League for Nursing (NLN) Jeffries Simulation Theory guided this experience with emphasis on simulation fidelity (Jeffries et al., 2015). Fidelity refers to the extent that simulation can mimic reality and is vital for participant engagement and subsequent learning. The use of SPs as a component of clinical simulation supports the critical, authentic human connection that facilitates the fidelity of PMH simulations (Donovan & Mullen, 2019). In 2016, van Houwelingen et al. identified 14 "nursing telehealth entrustable professional activities" (p. 50) that offer guidance on generally accepted competencies in the field of nursing telehealth. Three of these competencies were highlighted during the SP simulation (encouraging health promotion activities, providing health promotion remotely, and providing psychosocial support) and used as a framework for implementation.
DEVELOPMENT OF THE SCENARIOS
This pilot simulation experience involved a cohort of 16 prelicensure nursing students enrolled in a senior-level PMH nursing course. Two professionally trained SPs were employed to participate in the simulations. Two PMH scenarios were developed that focused on vulnerable and underserved client populations. The first scenario involved a veteran coping with alcohol misuse and anger. Priorities for this scenario included understanding the unique care needs of veterans; using the Cut, Annoyed, Guilty, Eye (CAGE) Substance Abuse Screening Tool; and assessing for homicidal ideation (Ewing, 1984). The second scenario involved a homeless female client who was depressed and suicidal. Priorities included understanding the barriers to mental health care for homeless clients, screening for suicide risk, and assessing for depression. Both scenarios required therapeutic communication, clinical decision-making, maintenance of a safe patient environment, and focused assessment skills.
Because of the pandemic, university buildings and the simulation center were closed. The simulation experience was transitioned to a virtual setting using telehealth competencies to guide implementation. Blackboard Collaborate(R) (BbC) was the delivery platform for this telehealth experience. BbC allowed students, SPs, faculty, and the simulation coordinator to meet synchronously using integrated cameras and microphones. The ability to record scenarios was essential to supporting simulation debriefings.
IMPLEMENTATION
A week before the SP simulation, students were randomly assigned to either the alcohol misuse or the depression simulation case. Students were given assignments specific to their case to complete prior to the start of the simulation. These assignments required students to familiarize themselves with focused assessment tools, relevant communication techniques, pathophysiology of the PMH disorder, and appropriate nursing care.
Simulation sessions began with a welcome message and brief introduction. Each SP simulation was scheduled for one-hour, synchronized partnered sessions. This allowed students to work with their assigned SP for 10 to 12 minutes, observe their partner's SP session, and then complete a team debriefing lasting 20 to 30 minutes. To protect fidelity and optimize efficacy of the simulations, students were instructed to not share information outside the debriefing sessions.
Debriefing was guided by the 3D model of debriefing, which outlines three steps to effectively debrief simulation experiences (Zigmont et al., 2011): defusing (exploring emotions and recapping simulation event), discovering (guided review of the simulation experience looking for cues to mental models of decision-making), and deepening (applying newly learned information into practice). These steps were accomplished in two separate synchronous debriefing sessions. The first session occurred immediately after the simulation and involved the student partners, SPs, faculty, and simulation coordinator to address the immediate need to defuse and discover events related to the simulation experience. To accomplish the defusing step, questions were asked about the students' feelings-what went well and what areas they could improve on. The discovering step was explored with questions such as these: "When the SP began crying, you seemed uncomfortable. What are your thoughts about this?" or "When you repeatedly asked the client what he meant by 'she'll be sorry,' what safety issue were you trying to address?"
The second synchronous debriefing occurred after 24 hours and involved all the students who completed the SP simulations. Faculty used the BbC to facilitate open discussion, anonymous surveys, and whiteboard activities to accomplish the deepening step from the 3D model. This second debriefing was useful for gleaning new insights from students. Students were able to connect with others who shared their case and explore mutual thoughts and feelings. Using a BbC whiteboard, students responded anonymously to three questions: 1) What is one thing you were pleased with related to your performance? 2) What is one thing you want to do better next time? 3) What did you learn about yourself in this experience? Student answers were used to explore how these skills could translate into professional behaviors that support or limit safe, effective, and compassionate care of clients with PMH disorders.
ANALYSIS OF STUDENTS' COMMENTS
Following institutional review board approval, results were compiled through qualitative thematic analysis of students' comments during both debriefing sessions. Based on the results, there was evidence that the goal of designing a realistic simulation experience that created an authentic interpersonal interaction was met. Forty-four comments were received from the 16 participating students; 27 comments (61.4 percent) reflected a positive perception of individual simulation performance. Interestingly, student comments revealed greater confidence and perceived success with focused assessments, use of therapeutic communication techniques, and rapport development than their ability to manage their emotional responses to the SP experiences (68 percent and 52 percent, respectively).
Eliciting a psychological response to a simulated experience was maximized by the fidelity of the simulations. Qualitative evidence demonstrated that students suspended their disbelief enough to experience authentic emotional responses while working with the SPs. Remarks such as these communicated authentic emotional responses to the SPs' distressing comments and behaviors: "I need to try to not panic when someone starts crying," "I need to not freeze when the patient says something unexpected," and "I was able to get through it without having a nervous breakdown!"
DISCUSSION AND CONCLUSION
When COVID-19 led to the need to cancel the original SP simulation design and required the use of telehealth competencies and educational technologies, designing a simulation experience that honored fidelity in the care of PMH clients was essential. The two virtual SP simulations offered students realistic experiences that supported their learning of key PMH concepts and explored their emotional responses to clients with PMH disorders. Using the NLN Jeffries Simulation Theory and the 3D model of debriefing to guide the simulation experience supported successful learning outcomes. Students' reflections and performances demonstrated growth in their abilities related to PMH nursing care. These findings are congruent with results of previous studies and add to the needed body of literature related to PMH simulation (Goodman & Winter, 2017). An opportunity to refine this simulation includes the future implementation of additional telehealth nursing competencies.
The use of SPs and the BbC facilitated the delivery of the simulation experience. Participation in the PMH telehealth simulations allowed students to identify their growth areas and clinical strengths. This knowledge will help students when caring for clients with PMH disorders and enable them to understand the importance of therapeutic communication and focused assessments.
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