BUILDING BRIDGES WITH SIMULATION

BETWEEN MENTAL HEALTH AND MEDICAL-SURGICAL

NURSING CONCEPTS

A Project

Presented to the faculty of the Department of Nursing

California State University, Sacramento

Submitted in partial satisfaction of

the requirements for the degree of

MASTER OF SCIENCE

in

Nursing

by

Janna Marie Le Page

Jean Patricia Savoia

SPRING 2017

ii

© 2017

Janna Marie Le Page

Jean Patricia Savoia

ALL RIGHTS RESERVED

iii

BUILDING BRIDGES WITH SIMULATION

BETWEEN MENTAL HEALTH AND MEDICAL-SURGICAL

NURSING CONCEPTS

A Project

by

Janna Marie Le Page

Jean Patricia Savoia

Approved by:

_______________________________, Committee Chair

Katherine A. Kelly, DNP, FNP, RN

_______________________________

Date

iv

Students: Janna Marie Le Page

Jean Patricia Savoia

I certify that these students have met the requirements for format contained in the

University format manual, and that this project is suitable for shelving in the

Library and credit is to be awarded for the project.

__________________________, Department Chair ______________________

Tanya K. Altmann, PhD, RN Date

Department of Nursing

v

Abstract

of

BUILDING BRIDGES WITH SIMULATION

BETWEEN MENTAL HEALTH AND MEDICAL-SURGICAL

NURSING CONCEPTS

by

Janna Marie Le Page

Jean Patricia Savoia

Qualitative research indicates patients with comorbid physical and mental illnesses

present unique circumstances for healthcare professionals (Giandinoto & Edward, 2015).

The 2001-2003 National Comorbidity Survey Replication (NCS-R) estimates 29% of

adults with a medical disorder have a comorbid mental health condition (as cited in Druss

& Walker, 2011). Challenges in patient care include clients whose mental health illness is

manifested by noncompliant, disruptive or unpredictable behavior; acute care settings

without the environmental safety features of a psychiatric facility; and healthcare workers

with limited knowledge of mental health pharmacology and behavior management

(Giandinoto & Edward, 2015).

Undergraduate and new graduate nurses must be prepared to function in a

vi

multidisciplinary system and offer patients safe, effective, patient-centered, and equitable

care as outlined in Crossing the Quality Chasm: A New Health System for the 21st

Century (Institute of Medicine [IOM], 2001). Synthesis and integration of behavioral and

physiological health concepts are needed to ensure the delivery of appropriate care to all

patients (Kameg, Englert, Howard, & Perozzi, 2013). Existing silos in undergraduate

nursing education with limited integration of psychiatric and medical-surgical nursing

contribute to learners’ inability to deliver effective care to patients with comorbid

physical and mental illnesses (Kameg et al., 2013).

One approach to integrate behavioral and physiological nursing education is the use

of high fidelity patient simulation (HFPS) (Kameg et al., 2013; Levine, DeMaria,

Schwartz, & Sim, 2014). Simulated clinical scenarios allow nursing students experience

with patient care situations they might not have the opportunity to encounter in the

clinical setting. Undergraduates in both medical-surgical and psychiatric nursing courses

can benefit from simulation education (Levine et al., 2014).

Benefits of simulation include a learning environment that poses no risk to an actual

patient, repeated practice of skills with opportunities for constructive feedback, and the

ability for educators to create scenarios that might be difficult to obtain equitably in

student clinical placements including sensitive mental health clinician-patient

conversations (Kameg et al., 2013; Levine et al., 2014).

A pilot study was completed in a HFPS pedagogy to integrate concepts of mental

vii

health and medical-surgical nursing constructs in the undergraduate nursing curriculum.

An unfolding case study utilized a standardized patient in two scenarios. Comorbidities

of post-traumatic stress disorder (PTSD) and liver cirrhosis, and interpersonal

communication dynamics were addressed.

The primary investigators’ main research question was: Will high fidelity

simulation scenarios integrating mental health and medical-surgical concepts be effective

as an adjunct pedagogy and allow second-semester Bachelor of Science in Nursing

(BSN) students to apply critical thinking constructs to patients with mental health and

medical-surgical comorbidities.

______________________________, Committee Chair

Katherine A. Kelly, DNP, FNP, RN

______________________________

Date

viii

DEDICATIONS

The completion of a master’s education has been a goal of mine for a while. This was

not a sole endeavor. First, I thank our heavenly Father for the blessing of this education.

Second, I thank my husband, Lynn Le Page, for his love, encouragement, and patience

with the schoolwork and many days and nights of assistance on the home front. Third,

thank you to all my wonderful men-children-Bryan, Mark & Michael, for your love,

support, and patience with their back-to-school mom and all her computer-formatting

issues. Next, to my best friends, Judy & Kelli– thank you for your love, encouragement,

and patience. Finally, a big shout out to Jean Savoia- my third-age nursing partner on this

endeavor! Thank you for all your friendship, wisdom, perseverance, and laughter in

completing this project.

The realization of my MSN was accomplished with the love and support of family

and friends. Paul, Erin, and Adair each contributed to my success. Paul’s encouragement

when the task seemed arduous was unwavering. He provided many a meal to me as I sat

in front of the computer attending class. Erin’s wizardry with Zotero and Adair’s

instruction on how to use a drop box are just two of countless assists they gave. Many

family vacations were impacted by my assignments and the dreaded 23:59 deadline. My

sister, Joan, provided me with presentation tips and extra time by taking on more

responsibilities. My project partner and friend, Janna, kept me on task throughout the last

three years. Janna’s humor and insight brought things back into perspective on many

occasions. It was a group effort and I love you all.

ix

ACKNOWLEDGEMENTS

We also would like to acknowledge and thank the following individuals from the

CSUS Nursing Program: Our nursing advisor, mentor, and educator, Dr. Katherine

(Kitty) Kelly for her wisdom, collaboration, and guidance on the project; Dr. Gail

Burmeister for her wisdom, guidance, participation, and belief in the project; Mr. Jovan

Lee, the best simulation lab technician, whose assistance helped facilitate the project to

fruition; finally, the nursing students from Fall 2016 N123 and N129 classes who

participated in our project – thank you for your willingness to venture forth, be

vulnerable, and help shape nursing education for the future.

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TABLE OF CONTENTS

Page

Dedications ................................................................................................................ viii

Acknowledgements ...................................................................................................... ix

Chapter

1. INTRODUCTION……………….……………………………………………… 1

Statement of Collaboration ............................................................................... 1

Purpose of the Project ...................................................................................... 1

Statement of the Problem ...................................................................................2

2. BACKGROUND OF THE STUDY ....................................................................... 5

Theoretical Concepts ........................................................................................ 5

Literature Review .............................................................................................7

Simulation as an Educational Pedagogy ........................................................... 8

Veteran-Centered Care.....................................................................................11

3. OVERVIEW AND ANALYSIS ............................................................................15

Project Overview .............................................................................................15

Implementation of the Project ........................................................................ 18

Analysis........................................................................................................... 20

4. CONCLUSIONS AND RECOMMENDATIONS .................................................23

Strengths ..........................................................................................................23

Opportunities for Improvement ........................................................................24

xi

Appendix A. Simulation Flowchart .............................................................................26

Appendix B. Objectives and Goals .............................................................................28

Appendix C. Simulation Patient Presentation ............................................................. 29

Appendix D. Simulation Timeline ..............................................................................32

Appendix E. Simulation Characters (four students) ....................................................33

Appendix F. Simulation Characters (five students) .....................................................34

Appendix G. Student Reading .................................................................................... 35

Appendix H. Self-Efficacy Assessment ..................................................................... 36

Appendix I. Knowledge Assessment ...........................................................................37

Appendix J. Demographic Sheet................................................................................. 39

Appendix K. Evaluation...............................................................................................40

Appendix L. Informed Consent ...................................................................................41

Appendix M. Scenario 1 Checklist ............................................................................. 42

Appendix N. Scenario 2 Checklist ............................................................................ 43

Appendix O. Counseling Flyer ................................................................................... 44

References ................................................................................................................... 45

1

Chapter One

INTRODUCTION

Statement of Collaboration

Collaboration on the project, Building Bridges With Simulation Between Mental

Health and Medical-Surgical Nursing Concepts by the authors Janna Marie Le Page and

Jean Patricia Savoia entailed the development, implementation, and validation of data

from an unfolding case study generated in simulation. Two scenarios were completed

with second-semester undergraduate nursing students in the N123 and N129 advanced

medical-surgical nursing and mental health nursing courses. The simulation activities

were completed at the California State University, Sacramento (CSUS) Simulation

Learning Center in Fall 2016. Faculty collaboration on the project was conducted with

CSUS Graduate Coordinator and instructor Dr. Katherine Kelly and CSUS Mental Health

Nursing instructor Dr. Gail Burmeister.

Purpose of the Project

The purpose of the project was to increase undergraduate nursing students’

knowledge and experience with the integration of physical and psychological health

concepts in the delivery of patient care through a simulation experience. The project was

designed to meet the students’ learning needs with the combination of three components:

clinical science constructs; the 2009 Quality Safety Education for Nurses (QSEN) project

pre-licensure knowledge, skills, and attitudes (KSAs); and communication components.

2

Goals for the project were:

To break down the silos between medical-surgical nursing and mental health nursing.

To enable second-semester student nurses to integrate and synthesize content from

both areas of nursing and practice by making critical decisions with a complex patient

with multiple comorbidities in simulation.

To encourage teamwork and collaboration between nurses in medical-surgical and

mental health nursing.

To facilitate safe patient-centered care.

To allow graduate student investigators to develop innovative curricular design.

Statement of the Problem

Nursing pedagogies utilized in the 20th century are inadequate to prepare pre-

licensure nursing students to deal with the healthcare demands and realities in the 21st

century (IOM, 2010). The majority of healthcare issues in the 21st century deal with

chronic diseases such as diabetes, hypertension, arthritis, cardiovascular disease, and

mental health conditions (IOM, 2010). The shift from acute illness to chronic conditions

is the result of the impact of the nation’s aging population, obesity epidemic, and

diversity of race and ethnicity (IOM, 2010).

People with mental health disorders experience disproportionately higher rates of

disability and mortality. For example, individuals with major depression and

schizophrenia have a 40% to 60% greater chance of dying prematurely than the general

3

population, owing to physical health problems that often are left unattended (World

Health Organization [WHO], 2013). As the complexities of patient population and care

environments continue to fluctuate, nurses’ roles have expanded rapidly beyond the

bedside to competencies in community, public health, and geriatric arenas (IOM, 2010).

In order to prepare students and new graduate nurses to work in a

multidisciplinary healthcare system, as ordered by the 2001 edict from the IOM Crossing

the Quality Chasm, the synthesis and integration of physical and psychological health

concepts are necessary to promote the delivery of appropriate care to all patients (Kameg

et al., 2013). Currently, curriculum designed in the silos of medical-surgical and mental

health nursing courses limit learners’ abilities to deliver holistic, effective care to many

patients. The structure of nursing curricula influences the manner in which students

assess and provide nursing care to people with physiological and psychological

comorbidities (Kameg et al., 2013). Qualitative research has indicated mental health

competencies and undergraduate training may not satisfactorily prepare nurses to care for

patients with comorbid physical and mental illnesses (Giandinoto & Edward, 2014). One

method to respond to the failure to integrate physical and mental health concepts in

patient care scenarios is through the utilization of HFPS.

The Carnegie Foundation Book Highlights From Educating Nurses: A Call for

Radical Transformation stipulated the redesign of nursing education as an urgent societal

endeavor (Gilliss, n.d.). Schools of nursing are tasked to develop teaching methods that

keep students focused on the patient’s experience (Gilliss, n.d.):

4

Support is needed for teachers to learn to scaffold their courses around patient

care. Medical pathology and disease mechanisms should be taught in direct

association with patients’ illness experiences, including the psychosocial aspects

of illness, patient-and family coping, and the teaching of self-care. By coaching

students to focus on patients in specific situations, teachers provide students

opportunities to rehearse the appropriate care for patients and their families.

Examples of such strategies include simulation exercises, the use of unfolding

cases, narrative structures for making a case, and interviews of patients in class.

Further, the authors recommend that regional and national resources be made

available for developing effective and sophisticated clinical simulation exercises

designed to help students integrate knowledge, skilled know-how, and ethical

comportment (Gilliss, n.d.)

The changing healthcare landscape in the United States requires clinicians to be

skilled to respond to various patient expectations and values, and provide ongoing patient

management to deliver and coordinate care across interdisciplinary teams, settings, and

time frames (Glasgow, Dunphy, & Mainous, 2010). The transformation of care, practice,

and education for the new nurse must arise from curriculum development and

professional socialization (Glasgow et al., 2010).

5

Chapter Two

BACKGROUND OF THE STUDY

Theoretical Concepts

Complexity science provides a theoretical foundation to develop a nursing

pedagogy that includes the care of patients with physiological and psychological

comorbidities. Complexity science describes organizations, including healthcare, as ever-

changing, nonlinear, and unpredictable (Crowell, 2016; Fenwick & Dahlgren, 2015).

Successful organizations do not operate with a top-down autocratic approach but rather

promote relationship-based behaviors (Crowell, 2016). Within the multidisciplinary team,

it is the nurse who is the “constant presence” for the client and already actively engaged

in relationship-based practice (Crowell, 2016, p.12). Graduate nurses must be prepared

to work in this fluid environment to provide effective care and be competent to make

sense of the unknown and unexpected (Crowell, 2016).

The value of complexity science in undergraduate nursing education is addressed

in the 2008 American Association of Colleges of Nursing’s (AACN) The Essentials of

Baccalaureate Education for Professional Nursing Practice. The rationale for “Essential

II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety”

states an understanding of “organizational and systems leadership, quality improvement,

and safety are critical to promoting high quality patient care” (AACN, 2008).

Recommendations for learners include incorporating complexity science into curricular

content (AACN, 2008).

6

Complexity science posits organizations are organic and evolve and change over

time, eventually ceasing to exist. Acknowledging healthcare systems as organic allows

complexity theory principles to be used to advocate for effective patient care (James,

2010). Nurses need to understand a patient’s illness from a physiological perspective to

provide effective care, but they also need to be able to work within the larger healthcare

system and include patients’ families and communities (James, 2010). The principles of

complexity science are relevant to postgraduate nurses who recognize their work

environments as uncertain and not fully in their control at times (Lindberg, Nash &

Lindberg, 2008).

Tenets of complexity theory used to design Building Bridges With Simulation

Between Mental Health and Medical-Surgical Nursing Concepts include emergence and

self-organization, and disturbance (Chandler, Rycroft-Malone, Hawkes, & Noyes, 2016;

Crowell, 2016; Fenwick & Dahlgren, 2015). Emergence describes the development of

new ideas as a result of relationship-based behaviors (Crowell, 2016). The system

evolves based on behaviors of the group and becomes more than the sum of its individual

parts (Chandler et al., 2016). In HFPS, emergence is fostered by allowing the

standardized patient to react to the specific actions of the learners (Lefroy & Yardley,

2015).

Self-organization signifies how individuals in organizations create informal teams

to accomplish goals (Chandler et al., 2016). The interactive relationships of team

members can allow for novel solutions when presented with unexpected scenarios

(Crowell, 2016). To encourage self-organization development within HFPS, objectives

7

and assessments must not be excessive and rigid (Fenwick & Dahlgren, 2015).

The concept of disturbance acknowledges the unexpected does happen, and

allows it to escalate in order to effect positive change to the complex system (Fenwick &

Dahlgren, 2015; Lefroy & Yardley, 2015). In clinical settings, unforeseen conflicts and

acute situations will arise. Embracing the possibility of a new response or solution can

improve patient care. In simulation, allowing the unplanned to be incorporated into the

unfolding case study can provide additional learning (Lefroy & Yardley, 2015).

Embracing complexity science as an integral part of undergraduate education can

foster a sense of empowerment in nurses. The concepts of self-organization and

emergence can encourage nurses to work toward change with the realization their actions

have the possibility of enacting change (Lindberg et al., 2008).

Literature Review

The literature review was approached from the concepts of simulation in

undergraduate nursing education, simulation with mental health and medical-surgical

nursing concepts, pilot studies in nursing education, innovative nursing pedagogies,

undergraduate nursing education in mental health simulation, prebriefing and debriefing

in simulation, veteran-centered care in nursing education, toolkits for substance-abuse

screening for nurses, PTSD education for undergraduate nursing curriculum, and

complexity theory in healthcare. Databases utilized were EBSCO, CINAHL, PubMed,

Ovid, and Cochrane. Inclusion criteria were publications limited to the English language,

published between the years 2010-2017, which were open source or peer-reviewed.

8

Key search terms used were nursing, education, simulation, mental health,

medical-surgical education, nursing pedagogies, pilot studies, nursing education

essentials, prebriefing and debriefing in simulation, veteran healthcare, substance-abuse

toolkits, PTSD nursing education, and complexity theory. Open sources searched were

Centers for Disease Control (CDC), American Nurses Association (ANA), National

Academies of Sciences, Engineering, and Medicine (formerly IOM), QSEN, and WHO.

Specific information related to the combination of mental and physical health in

undergraduate nursing simulation was limited in quantity and more difficult to locate.

Manual searching was done from the reference citations in like articles. Resources used

for design of the project paper are cited on the reference pages.

Simulation as an Educational Pedagogy

The globalization of healthcare in conjunction with increases in the complexity of

patient care, science and information technology, regulation, and professional standards

demands new educational pedagogies to decrease disparities in healthcare to all

populations (Murphy, Hartigan, Walshe, Flynn, & O’Brien, 2011). In light of this

context, innovative educational approaches to prepare pre-licensure nurses for current

and future practice are essential (Melnyk & Davidson, 2009). Simulation incorporates

several modalities, including interactive-learning packages, role players, task trainers,

and mid- to high-fidelity manikins, and standardized patients (SPs) (Murphy et al., 2011).

Technological advancements in HFPS provide healthcare scenarios that mimic what

students might encounter in a clinical setting (Kameg et al., 2013). HFPS promotes

9

enhanced opportunities for assessment and decision-making practice (Kameg et al.,

2013).

Effective patient-centered care must be delivered from a holistic perspective

(Kameg et al., 2013). HFPS enables pre-licensure nurses to acquire experience with the

whole person in an interactive, low-risk environment (Kameg et al., 2013). HFPS

addresses the QSEN competencies by strengthening the nurse-patient relationship

through communication and safety (Brady, 2011). Simulation is an appropriate

educational technique to implement the QSEN KSAs in each competency (Brady, 2011).

Simulation bridges the integration of classroom and complex health-environment

scenarios.

In order to prepare students and new graduate nurses to work in a

multidisciplinary healthcare system, as recommended by the 2001 IOM report Crossing

the Quality Chasm, the synthesis and integration of physical and psychological health

concepts are necessary to promote the delivery of appropriate care to all patients (Kameg

et al., 2013). Currently, curriculum designed in the silos of medical-surgical and mental

health nursing education has the potential to limit a learner’s ability to deliver holistic,

effective care to many patients. Programs in which behavioral and physiological illness

are separated create an environment where students and graduate nurses fail to apply the

principles of care for mental health patients in the acute care setting, and vice versa. Both

circumstances can critically impair the ability of student and graduate nurses to develop a

complete problem list and provide appropriate, comprehensive care.

10

Caring for patients experiencing medical and psychiatric comorbidities represents

a unique challenge for pre-licensure students (Kameg et al., 2013). Medical issues can

lead to mental health issues including depression and anxiety. Mental health issues can

place a person at higher risk for comorbid medical disorders (Druss & Walker, 2011).

Patients with mental illness are at a higher risk for tobacco use, alcohol and drug use,

poor nutrition, and lack of physical activity. All these behaviors increase the risk of

developing chronic illnesses and poor medical outcomes (Kameg et al., 2013).

The use of HFPS as a pedagogy to reduce student anxiety and enhance student

self-efficacy regarding communicating with patients experiencing mental illness has been

the subject of several studies (Kameg et al., 2013; Kameg, Howard, Clochesy, Mitchell,

& Suresky, 2010; Szpak & Kameg, 2013). The studies affirm simulation statistically

improves student self-efficacy and decreases student anxiety prior to communicating with

mental health patients. However, extrapolation of data that represents published studies

examining HFPS on student learning in both medical and psychiatric problems is

minimal (Kameg et al., 2013).

According to Sinclair & Ferguson (2009), more active forms of learning are

required within nursing curricula to build on student knowledge and skills (Murphy et al.,

2011). The technique of merging problem-based learning (PBL) and simulation suggests

a new active teaching-learning strategy (Murphy et al., 2011). The integration of a cross-

over case study and HFPS components meets the definition of an active-learning strategy

designed to promote critical thinking, communication, and self-efficacy skills in a safe,

patient-centered, holistic framework for pre-licensure nursing students.

11

Doolen, Giddings, Johnson, Guizado de Nathan, and O Badia (2014) indicated

when student nurses interviewed SPs trained to model psychiatric disorders, interview

and therapeutic communication skills were bolstered. Pre-licensure students who

experienced interaction with SPs in simulation demonstrated a significant increase in

communication skills (Stroup, 2014; Yoo & Yoo, 2003). Communication is a vital

nursing skill that often is overshadowed by psychomotor skills (Stroup, 2014; Yoo &

Yoo, 2003). Communication skills are essential for patient education and to construct

nurse-patient rapport (Stroup, 2014; Yoo and Yoo, 2003). Simulation with utilization of

SPs can assist pre-licensure students in the delivery of safe, effective care for patients

with psychiatric comorbidities prior to clinical experience.

The psychosocial well-being of the patient is relevant in all types of nursing

practice. A foundation of trust is important to the nurse-patient relationship, based on

strong communication and clinical reasoning skills. (Sunnqvist, Karlsson, Lindell, &

Fors, 2016). The mental health needs of the patients should be considered in all facilities:

medical-surgical, maternity, and community settings.

Veteran-Centered Care

The increased awareness of people diagnosed with comorbid physical and

psychological conditions (Giandinoto & Edward, 2015) parallels an increased rate of

comorbid diagnoses in U.S. veterans (McKenzie, Freiheit, Steers, & Noone, 2016). Of

the more than 21 million living veterans, approximately 40% receive their healthcare

through a Veterans Health Administration facility (U.S. Department of Veterans Affairs,

2016). The remaining millions of veterans receive healthcare services in civilian facilities

12

from civilian healthcare providers. Non-military healthcare providers may not be familiar

with the complex physical, psychological, and emotional needs of military personnel

(Anthony, Carter, Freundl, Nelson, & Wadlington, 2012). The necessity for healthcare

providers in all clinical settings to understand the impact of military service on the

veterans and their families is paramount (McKenzie et al., 2016). The AACN encourages

nursing schools to augment their curriculum for undergraduates with education on

veteran-centered care (AACN, 2015).

The CSUS undergraduate nursing program incorporates veteran-centered care

concepts into the mental health nursing curriculum while cirrhosis with end-stage liver

disease (ESLD) is examined in the medical-surgical curriculum. The structure of nursing

curriculum can influence how students assess and provide care to patients with comorbid

physical and psychological illnesses (Kameg et al., 2013). One avenue to address the

fusion of physical and mental health constructs in nursing education is the application of

HFPS (Kameg et al., 2013).

Evidence demonstrates a strong association between alcohol use disorders (AUD)

and PTSD (Ralevski, Olivera-Figueroa, & Petrakis, 2014). PTSD and AUD co-occur

with rates from 28% to 85% in the general public and up to 58% in veterans exposed to

combat (Ralevski et al., 2014). The co-occurrence of PTSD and AUD lends to an

unfavorable prognosis in both disorders (Ralevski et al., 2014).

Alcohol abuse is one of the most common causes of liver cirrhosis (Starr &

Raines, 2011). Cirrhosis is a major risk factor for the development of hepatocellular

13

carcinoma, which has tripled in incidence from 1975-2005 (Starr & Raines, 2011;

Thomas et al., 2010). The Department of Defense (DoD) surveys of health-related

behaviors among military personnel conducted from 1980 to 2008 reveal parallel

increases with binge and heavy drinking (National Academies Press [NAP], 2013). Binge

drinking is specified as five or more drinks per occasion for men, four or more for

women, at least once in the past month (NAP, 2013).

Awareness of the increase in prevalence of PTSD and AUD among returning

veterans from recent military conflicts has spurred national efforts to educate nurses with

evidenced-based resources and training to recognize veterans’ health issues (American

Nurses Foundation [ANF], 2014). An unfolding case study that encompasses PTSD, liver

cirrhosis, and AUD in veterans is an innovative way for pre-licensure students to gain

clinical experience with a complex yet common healthcare scenario.

Simulation is a technique to introduce veteran-centered care to undergraduate

students (McKenzie et al., 2016). An unfolding case study with physical and

psychological components in a SP lends to the complexity of the learning construct. Live

actor patient simulations are associated with increased mastery in student competencies

compared to traditional learning methods (McKenzie et al., 2016; Shin, Sok, Hyun &

Kim, 2015). Simulation experiences help address challenges related to stigma, safety, and

liability within the psychiatric setting (Williams, Reddy, Marshall, Beovich, &

McKarney, 2017). Simulation lends to many opportunities for pre-licensure students to

develop skills, knowledge, and abilities in mental health settings (Williams et al., 2017).

14

The Building Bridges With Simulation Between Mental Health and Medical-

Surgical Nursing Concepts unfolding case study involves a complex medical-surgical

patient with comorbid mental health and psychosocial issues of alcoholism, cirrhosis, and

PTSD which align with the concepts of patient-centered care, safety, teamwork, and

collaboration as outlined in the QSEN framework for undergraduate BSN education.

.

15

Chapter Three

OVERVIEW AND ANALYSIS

Project Overview

Building Bridges With Simulation Between Mental Health and Medical-Surgical

Nursing Concepts was designed as a pilot study. Pilot studies provide an assessment of

the efficacy of project methods and recruitment criteria used to test a small sample group

of participants similar to those targeted for a larger study (Doody & Doody, 2015; Leon,

Davis & Kraemer, 2011). A pilot study can be a preliminary step used to ascertain the

viability of a larger study (Doody & Doody, 2015) and can help predict the expected

success of a future intervention (Thabane et al., 2010). Pilot studies can be instrumental

in the identification of elements of the simulation that might be confusing or ambiguous

and allow for redesign as needed (Lioce et al., 2015).

General objectives for the Building Bridges With Simulation Between Mental

Health and Medical-Surgical Nursing Concepts were:

1. Help students identify and anticipate the needs of a patient with comorbidities.

2. Employ effective strategies to keep patient safe.

3. Perform priority-nursing actions based on clinical information.

The Building Bridges With Simulation Between Mental Health and Medical-

Surgical Nursing Concepts unfolding case study was designed based on current evidence-

based practice. The script and agenda for the simulation day (prebriefing, patient

16

scenario, simulations, debriefing, and evaluation tools) were designed by the primary

investigators and approved by the graduate advisor (Appendix A, Appendix B, Appendix

C, Appendix D). In addition, the prebriefing, simulations, and debriefings were reviewed

with the CSUS simulation learning center coordinator. Both simulation scenarios were

designed for either four or five participants in anticipation of unplanned absences

(Appendix E, Appendix F).

Students were recruited from CSUS Fall 2016 Nursing 123 and Nursing 129

courses. CSUS is a public university located in an urban setting in Northern California.

The students were in the second semester of the traditional BSN track.

A brief presentation was given to the class by the principal investigators. Students

were invited to volunteer for the pilot study to test two high fidelity simulation scenarios

integrating mental health and medical-surgical nursing concepts. Students were told

participation was voluntary and would involve an unfolding case study in a simulation

setting. Students were not told of the SP component. Signups were done online and

monitored by the graduate advisor.

Participants who completed the simulation would earn professional development

points based on fulfillment of the course objectives. Students who did not complete the

pilot study would not be penalized. In addition to their normal course work, students who

volunteered for the pilot study were asked to complete a pre-reading assignment

(Appendix G). The material was posted on the CSUS student web portal. Students were

advised of the time commitment and date of the high fidelity simulation experience.

17

The simulation design was rehearsed on two occasions with the assistant

professor of mental health nursing, who enacted the part of the live actor patient. After

each rehearsal, the simulation was redesigned with collaboration between the primary

investigators and the assistant professor of mental health nursing.

The pilot study presented no real or perceived conflicts of interest. The primary

investigators had no access to, or input into, the course grade book and did not have the

ability to impact students’ grades. The primary investigators did not know student

identifiers and did not connect results to individual students.

Prior to the implementation of the project, the primary investigators submitted an

application for human subject research, which was reviewed and approved by members

of the CSUS Nursing Department Research Review Committee. Since the simulation

involved themes of PTSD, alcoholism, and complicated family dynamics, the primary

investigators also had several personal communications with the CSUS Student Health &

Counseling Services (SHCS) clinical director to inform him of the project content.

The value of the project for participants included exposure to enhanced content on

the disease process for PTSD, alcoholism, veteran-centered care, and liver cirrhosis. For

the community of nursing educators, there would be more evidence of the usefulness of

high fidelity simulation in facilitating critical thinking for students caring for complex

patients with physiological and psychological comorbidities.

Of the 11 students who signed up to participate (10 primary and one alternate),

eight completed the pilot study. One student dropped out due to a work conflict, one due

to illness, and the third for unknown reasons. This represents 10.25% (8/78) of the class.

18

Of the eight students, five identified as female, two as male and one as transgender. The

participants ranged from 18 to 41 years of age, with five aged 29 years or younger and

three aged 30 years or older.

Assessment tools developed by the primary investigators were administered

before and after the two 20-minute simulations involving a female military veteran with

comorbidities of liver disease and PTSD. Tools included anonymous and confidential

pre- and post self-efficacy assessments and a post-simulation knowledge assessment

(Appendix H, Appendix I). Question 6 of the self-efficacy tool was a negatively keyed

item and reverse scoring was used in analysis. The knowledge assessment tool included a

question to determine if the assigned pre-reading had been completed. The investigators

reviewed several simulation assessment templates including one that focused on end-of-

life care (Moreland, Lemieux, & Myers, 2012). Study participants completed a

demographics questionnaire and an evaluation of the simulation experience (Appendix J,

Appendix K). The evaluation included a Likert Scale and open-ended responses.

Implementation of the Project

During prebriefing, the eight students were given an individual exempt research

informed consent, which stated the rights and responsibilities pertinent to the pilot study

(Appendix L). Identifiers were not collected, therefore participants’ signatures were not

required. Consent forms were kept by the participants as informational sheets.

Participation in the simulation served as consent.

19

Before the start of the two simulations, the eight students were divided into two

groups. Each student randomly picked one of four possible roles from an envelope:

emergency department (ED) registered nurse, student nurse (SN), patient’s daughter, and

scribe. The four participants active in the first simulation were each given a copy of the

unfolding case study as well as background on their roles. The remaining four students

observed the simulation from the debriefing room (Appendix M, Appendix N).

During each simulation, the primary investigators completed checklists to

document observed students’ skills. Expected clinical skills included: hand washing,

correctly identifying the patient, confirming patient allergies, and introducing self to

patient and family. A planned “emergency” Code Blue announcement was incorporated

into the second scenario to elicit a dramatized response from the SP.

The first simulation was completed and followed by debriefing. The participants

in debriefing included the eight students and the primary investigators. After a brief break

the second simulation was done and followed by debriefing. Again, the eight students

and primary investigators took part in the debriefing. At the conclusion of the second

debriefing the SP joined the students and primary investigators. The SP shared their

perceptions of the experience. After this discussion students were given the post-

simulation self-efficacy and knowledge assessments, followed by the course evaluation.

All tools were anonymous and confidential.

At the conclusion of the simulation participants were given contact information

for the primary investigators in case they wanted to discuss the simulation further. In

20

addition each student was given a flyer with the SHCS contact information and the

availability of weekly drop-in counseling in Folsom Hall, CSUS (Appendix O).

Analysis

Investigators analyzed both qualitative and quantitative data. A paired t test was

run on a sample of eight nursing students to determine if there was a statistically

significant mean difference between self-reported self-efficacy levels before participants

did the simulation compared to after. In this quantitative analysis mean self-efficacy

scores increased from pre-simulation (4.08) to post-simulation (4.73), a statistically

significant increase of 0.65 (95% CI [0.34, 0.95] p = .0028.

The qualitative data was coded and the following themes emerged: enhanced

learning with simulation pedagogy and the value of transformational learning with

skillful RNs and pre-licensure students. The National League of Nursing (NLN) supports

simulation as an evidence-based design that provides realistic patient-care experiences

and fosters critical thinking skills in students (NLN, 2015). Students are able to make

clinical decisions in a supportive environment that poses no harm to the patient. With the

increased complexity of patient care, nursing education must include quality simulation

experiences (NLN, 2015).

Comments supporting the value of pilot simulation providing enhanced learning

include:

21

“I think this was a great simulation and a great learning opportunity. I can say that

I felt very anxious and nervous going in but I’m glad I did it because it really was

a great learning experience.”

“Even though I felt unprepared … went into the room, I believe it is a real and

great experience.”

“I definitely think students learn much more effectively when working with a live

patient rather than a manakin [sic] in SIM.”

“Was a good learning experience.”

Strong clinical leaders are needed in nursing to “connect people with purpose” to

“improve outcomes for patients, organizations, and communities” (White, Dudley-

Brown, & Terhaar, 2016, p.116). Transformational leaders focus on relationships rather

than tasks and inspire others to commit to a shared vision (Goleman, 1998; White et al.,

2016). Learning in context is promoted in simulation settings and allows for experiential

learning (NLN, 2015).

Comments supporting the value of transformational learning with skillful RNs

and pre-licensure students include:

“You guys were great at making us feel comfortable and at ease.”

“Thank you for answering questions and your helpful insites [sic] to us as

students.”

“I enjoy [sic] this simulation experience, and I find it well-organized as well.”

22

“Was a good learning experience. Thoughtfully prepared lesson.”

23

Chapter Four

CONCLUSIONS AND RECOMMENDATIONS

Strengths

The project addresses a gap in undergraduate nursing education related to the care

of patients with comorbid physical and mental illnesses. It also supports the use of SPs as

an effective pedagogy for student learners. Live actor patients provide an enhanced

experience over manikins. SPs allow for more realistic human interaction, including the

opportunity to read nonverbal cues and engage in spontaneous dialogue (Benner,

Sutphen, Leonard, & Day, 2010). Simulation allows each participant to experience a

scenario that may not be encountered in their clinical placements.

The SP used in the simulation was a CSUS assistant professor of mental health

nursing. The professor’s subject expertise enhanced the learning environment. Further

investigation would be needed to assess how having a SP who is also an instructor

impacted the students.

In the second simulation, the primary investigators incorporated a Code Blue

announcement into the unfolding case study. Dealing with the patient’s heightened

anxiety relative to the emergency overhead page provided additional learning for the

students. Complexity science acknowledges acute situations can arise and effect positive

change in complex situations (Fenwick & Dahlgren, 2015; Lefroy & Yardley, 2015).

The primary investigators had each participant pick a random role to portray

24

during the simulation. This allows for students to take part in simulation in different roles

than they may pick if given a choice. Post-simulation comments from a student support

this premise: “I don’t usually do the whiteboard (scribe),” “I don’t usually look at labs,”

and “I usually talk with the patient.”

Standards of best practice related to simulation call for realistic scenarios to

ensure participants have a relevant, engaged experience (Lioce et al., 2015). The primary

investigators made a concerted effort to provide the students with an unfolding case study

that replicated conditions found in the acute care setting. A detailed patient history and

presentation, including psychological and physiological findings, were developed and

reviewed for authenticity by the graduate advisor. In addition, an intensivist at a

Sacramento Valley hospital reviewed the case study laboratory values and test results.

The simulation physical environment, including patient appearance, medications, and

monitors, was assiduously constructed to provide a setting consistent with an actual

emergency department. The introduction of distractions including family dynamics,

interactions with other health team members, and competing priorities of the patient’s

psychological and physiological condition were utilized to ensure simulation fidelity

(Lioce et al., 2015).

Opportunities for Improvement

The role of the family member could be assigned to a live actor to allow for more

realistic interpersonal communication practice. A script given to the live actor would help

guide the simulation experience for students. It was a challenge for the study participants

25

to step out of their role as a student nurse and portray a member of a dysfunctional family

unit.

The primary investigators are skilled registered nurses in their respective clinical

practices; however, they are novice simulation educators. Additional experience in the

development and design of undergraduate simulation education would be beneficial.

The positive increase in participants’ self-efficacy scores may be difficult to

replicate with a larger pool of students.

The CSUS School of Nursing has achieved many of the National Council of State

Boards of Nursing (NCSBN) recommended guidelines for simulation. These guidelines

include: appropriate simulation facilities, faculty and staff qualified to conduct

simulation, and a commitment to include simulation in the curriculum (Alexander et al.,

2015). Opportunities for growth include the synthesis of mental health comorbidities into

the already developed medical-surgical case studies. Additional education for faculty in

simulation instruction and increased use of SPs is also recommended (Alexander et al.,

2015). The additional faculty responsibilities required to integrate mental health and

medical-surgical concepts may be constrained by limits of time and resources.

Recommendations for future education development include the involvement of

an interdisciplinary team into the simulation experience. In addition, research is needed to

assess whether students retained and applied the KSAs learned from the simulation

experience into their graduate nursing careers. The limited number of students in the pilot

study may not allow similar results to be replicated in actual practice.

26

Appendix A:

Simulation Flowchart

Welcome

Introduction of graduate students

Informed Consent: Acceptance of form signifies students are willing to participate in

the study and may withdraw at any time without penalty.

Sim Schedule Handout

Self-efficacy assessment handout: complete pre-sim to assess your beliefs on

your capabilities to accomplish a task. There is no right or wrong answer.

Emphasize this is a supportive learning environment.

Debrief Room Transition

Drawing for roles: Unfolding case study with a standardized pt in 2 scenarios.

o Treat the standardized patient as an actual patient.

Handout student sim packet (includes sin schedule timeline).

Take three questions about sim before the start.

Transition to Sim#1

Group One students to sim door and await instructions (investigator 1 at door)

Scenario #1: “Start of sim-begin.”

15 min, sim session

“End of sim- go to debriefing room”

27

Transition to Sim#2

Group Two to sim room, Group 1 stays in debrief room.

Group Two students at door- Jean to hand out red folders for Group Two students.

Scenario #2: “Start of Sim-Begin”

7 min into the sim#2- RUN CODE BLUE tape.

5 min left to sim#2: Scribe #1 from debrief room to go to sim lab and announce “I’m here

to receive report.”

End of sim.

Exit to debrief room.

Announce “5 min to the end of debriefing.”

Post sim activities:

Standardized patient into post sim for patient perspective.

Hand out flyer for CSUS counseling services.

Complete demographic sheet (anonymously).

Knowledge Assessment Form.

Complete 2nd self-efficacy form (remember to sign paper with correct anonymous

identifier)

Complete evaluation of sim

28

Appendix B:

Objectives and Goals

General Objectives

1. Help students identify and anticipate the needs of a patient with comorbidities.

2. Employ effective strategies to keep patient safe.

3. Perform priority-nursing actions based on clinical information.

Simulation Specific Goals

1. Use therapeutic communication techniques to establish rapport with Ruth and

family.

2. Perform a focused mental health assessment appropriate for patients to assess for

alcohol use.

3. Identify noteworthy assessment findings present in the patient.

29

Appendix C:

Simulation Patient Presentation

Ruth White

MR# 357849

DOB 12.22.62

Case Scenario:

A 53-year-old female presents to the Emergency Department with RUQ pain x 2 days. Pt

is A/O x 4, anxious appearing. Pt has not voided since this morning. Pt has not eaten in 2

days due to complaints of nausea and vomiting.

Objective findings: Distended, taut abdomen with palpable liver. Skin pale.

Past medical history: CAD, former smoker, ETOH abuse (according to patient she

stopped drinking 3 months ago, PTSD, and liver cirrhosis.

Home medications:

Paxil 20 mg 1 p.o. daily

Ativan 0.5 mg 1 p.o. twice daily prn anxiety

Lactulose 20 grams/30ml p.o. daily

Atenolol 25 mg p.o. daily

Family history: No known family history

Social history: Widowed and currently living with daughter. Former smoker for 30 yrs,

and alcohol use starting at the age of 15; per patient has not drank for the last 3 months.

Military veteran.

Previous surgery: TAH; Gravida 2, Para 2

Code: Full Allergies: No Known allergies

Initial Vital Signs in ED: Temp 37 Pulse 114 BP 146/88 Resp 24 SpO2- 94% on RA MAP@ 107

Ht- 5’6” Wt-75 kg

30

Labs

Ruth White

MR# 357849

DOB 12.22.62

Initial Lab in ED:

WBC 9.0 PT 23.6 BUN 19 T bili 5.0 Alk Phos 140

RBC 1.99 INR 2.17 CRT 0.91 AST 115 Ammonia 61

H/H 9.8/28 APTT 35 Na 132 ALT 300 Albumin 2.0

PLT 93 Lactate 0.8 Cl 105 Lipase 31 Glucose 108

K 3.2 GGT 200

Orders

Scenario #1

Ruth White

MR# 357849

DOB 12.22.62

Morphine Sulfate (MS) 2 mg IV for pain 1-3; MS 3 mg IV for pain 4-6; MS 4 mg IV for pain 7-10. Zofran 4 mg IV for nausea q 6 hours prn STAT complete abdominal ultrasound (US) After pain meds and antiemetic, Ruth states pain 3/10; nausea improved. Ruth to radiology for US

31

Orders

Scenario #2

Ruth White

MR# 357849

DOB 12.22.62

Ativan 1 mg IV prn agitation.

Admit Ruth to MS

NPO

Morphine Sulfate (MS) 2 mg IV for pain 1-3; MS 3 mg IV for pain 4-6; MS 4 mg IV for pain 7-10. Zofran 4 mg IV for nausea q 6 hours prn Ativan per CIWA protocol Give report with SBAR to floor nurse receiving Ruth.

32

Appendix D:

Simulation Timeline

9:00-9:30 Breakfast 9:30-9:45 Pre-sim instructions Pre-sim student evaluation 9:50-10:05 Sim #1 Group A (Scenario #1 in lab) Group B (Scenario #1 in debrief room) 10:05-10:25 Debrief Scenario #1 10:30-10:45 Sim #2 Group B (Scenario #2 in lab) Group A (Scenario #2 in debrief rom) 10:50-11:10 Debrief Scenario #2 11:10-11:45 Wrap up Post-sim students’ assessment Course evaluation Health service counseling brochure

33

Appendix E:

Simulation Characters (four students)

#1 ED Registered Nurse You are the primary nurse. You have a second semester student nurse orienting with you today.

#2 Student Nurse (precepting with #1) You are a second semester nursing student. You are doing a clinical day in the emergency department.

#3 Ruth’s daughter – Kristie You are 26. You are a schoolteacher and live 2 blocks away from your mother (Ruth, the patient). Although Ruth lives in her own apartment, she calls you frequently (3-4 times a week) to ask for help with medical questions, her property owner, bills and accounts, etc. Ruth called you this morning when she was not feeling well.

#4 Scribe (will not be involved with direct patient care) You are a staff RN who will not be doing direct patient care, although you can make suggestions to clinical staff. You will be recording pertinent information on the whiteboard and will have access to the labs.

Not present Ruth’s son – Bobby Bobby is 24, was in the military for 4 years and now works as a mechanic. Bobby lives 200 miles away. His mother (Ruth, the patient) feels Bobby is more sympathetic to her behavior. Bobby is very attentive to Ruth when he is around, but he visits infrequently, perhaps twice a year.

34

Appendix F:

Simulation Characters (five students)

#1 ED Registered Nurse You are the primary nurse. You have a second semester student nurse orienting with you today.

#2 Student Nurse (precepting with #1) You are a second semester nursing student. You are doing a clinical day in the emergency department.

#3 Ruth’s son – Bobby You are 24. You were in the military for 4 years and now work as a mechanic. You live 200 miles away, but were in town for a visit. Your mother (Ruth, the patient) feels you are more sympathetic to her behavior. You are very attentive to Ruth when you are around, but you visit infrequently, perhaps twice a year.

#4 Ruth’s daughter – Kristie You are 26. You are a schoolteacher and live 2 blocks away from your mother (Ruth, the patient). Although Ruth lives in her own apartment, she calls you frequently (3-4 times a week) to ask for help with medical questions, her property owner, bills and accounts, etc. Ruth also called you this morning when she was not feeling well, although Bobby is also in town.

#5 Scribe (will not be involved with direct patient care) You are a staff RN who will not be doing direct patient care, although you can make suggestions to clinical staff. You will be recording pertinent information on the whiteboard and will have access to the labs. You will be the floor nurse receiving report at the end of Scenario 2.

35

Appendix G:

Student Reading

PTSD/Female Veterans

● Halter, M. J. (2014). Varcarolis’ Foundations of Psychiatric Mental Health

Nursing: A Clinical Approach. Trauma, Stressor Related, and Dissociative

Disorders. Chapter 16 (Read Adult PTSD section.) p. 310-313.

● http://www.nurseptsdtoolkit.org/_/whatIsPTSD/1.php

● http://www.womenshealth.va.gov/WOMENSHEALTH/docs/WV_Profile_FINAL

.pdf

● PC-PTSD Screening Tool:

http://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp Alcohol Content

● Halter, M. J. (2014). Varcarolis’ Foundations of Psychiatric Mental Health

Nursing: A Clinical Approach. Substance-Related and Addictive Disorders.

Chapter 22. Read: Screening, p 418 thru 421 Table 22-3 AUDIT Tool

● AUDIT Screening Tool:

https://www.drugabuse.gov/sites/default/files/files/AUDIT.pdf Liver

● Lewis, S. L., Dirksen, S. R., Heitkemper, M. M. & Bucher, L. (2014). Medical-

surgical Nursing: Assessment and Management of Clinical Problems. Liver, pancreas, and biliary tract problems. Chapter 44.

● Management of patients with complications of cirrhosis by Fowler ○ http://journals.lww.com/tnpj/Fulltext/2013/04000/Management_of_patient

s_with_complications_of.6.aspx DOWNLOAD AS pdf. doi:10.1097/01.NPR.0000427610.76270.45

Additional (optional)

● https://medlineplus.gov/cirrhosis.html

36

Appendix H:

Self-Efficacy Assessment

Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

I can give professional nursing care to patients with comorbidities including alcohol abuse

I can use the AUDIT screening tool

I can deal with complex patient family dynamics

I employ effective strategies to keep my patients safe in the context of psychological and physiological comorbidities

I can utilize effective therapeutic communication techniques with patients with comorbidities

I am concerned with my emotional reaction when I learn my patient has not been truthful

37

Appendix I:

Knowledge Assessment

Please answer the following questions with the BEST answer:

1) PTSD signs & symptoms include:

a) symptoms that can occur a month after exposure

b) anticipation of disaster

c) self-mutilating behaviors

2) A common PTSD Screening tool includes: a) Patient Health Questionnaire-9 (PHQ-9) b) PC-PTSD c) Hamilton Rating Scale of Anxiety 3) Pharmacologics used in PTSD include:

a) diuretics

b) antipyretics

c) SSRIs (Selective Serotonin Reuptake Inhibitors)

4) AUDIT screening tool would be utilized as a:

a) referral for alcohol and drug intervention

b) screening for alcohol use and alcohol related problems

c) referral to inpatient psychiatric facility

5) The most common causes of cirrhosis in the United States are:

a) alcohol-induced liver disease and hypotension

b) hepatitis A infection and hepatitis C infection

c) hepatitis C infection and alcohol-induced liver disease

6) Ascites is a late indication of cirrhosis. Ascites develops when:

a) portal hypertension causes an increase in the resistance of blood flow through the liver

b) impaired water excretion occurs due to low serum levels of antidiuretic hormone (ADH)

c) portal hypertension causes a decrease in the resistance of blood flow through the liver

7) Which classifications of jaundice are found with cirrhosis?

a) hemolytic and hepatocellular

b) hepatocellular and obstructive

c) obstructive and hemolytic

38

Did you do the pre-reading? YES NO

If no, what kept you from completing?

39

Appendix J:

Demographic Sheet

What is your age: (please circle)

18-23 years old

24-29 years old

30-35 years old

36-41 years old

42-47 years old

48-53 years old

54 years or older

Prefer not to answer

Race/Ethnicity: please fill in: ______________________________ To which gender do you most identify: (please circle) Female Male Transgender female Transgender male Gender variant/Nonconforming Not listed Prefer not to answer

40

Appendix K:

Evaluation

Please choose a number from 1 to 5 using the

following criteria to answer each question:

1.Strongly

Disagree

2.Somewhat

Disagree

3.Neutral/No

Opinion

4.Somewhat

agree

5.Strongly

Agree

1. The lesson presentations were organized

2. The instructors showed enthusiasm and

knowledge of the content

3. The curriculum helped learners gain

competency in the nursing process related to a

client with comorbidities (liver disease/PTSD)

4.Instructors encouraged learners to be involved

with the learning process (simulation and

debriefing)

5. Instructors provided opportunities for

learners' questions.

6. Please list any theory courses, clinical placements, projects, or other life experiences

that prepared you for this simulation experience:

Please provide any additional comments below:

41

Appendix L:

Informed Consent

Building Bridges With Simulation Between Mental Health and Medical-Surgical

Nursing Concepts: A Master’s Project Proposal

You are invited to participate in a research study, which will involve a high fidelity simulation of a standardized patient with physiological and psychological comorbidities. Our names are Janna Le Page and Jean Savoia and we are graduate student investigators at California State University, Sacramento, School of Nursing. The purpose of this research is to determine if high fidelity simulation will be an effective pedagogy to integrate concepts of mental health and medical surgical nursing. If you decide to participate, you will be asked to commit to two simulation labs and complete pre and post assessments as well as a course evaluation. Your participation in this study will last 2-2 ½ hours. Risks associated with this study are not anticipated to be greater than those risks encountered in daily life. Your participation in this project is voluntary. You have the right not to participate at all or to leave the study at any time without penalty or loss of benefits to which you may otherwise be entitled. Participation points for N123 will be granted to those involved. Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission. Measures to ensure your confidentiality include: all data will be presented as aggregate values and data will be kept on a password-protected computer. The data obtained will be maintained in a safe, locked location for a period of three years after the study is completed. If you have any questions about the research at any time, please contact us at (jannalepage@csus.edu or savoia@csus.edu or kkelly@csus.edu. If you have any questions about your rights as a participant in a research project please call the Office of Research Affairs, California State University, Sacramento, (916) 278-5674, or email irb@csus.edu.

42

Appendix M:

Scenario 1 Checklist

1A

ED RN

2A

Student

Nurse

3A

Ruth’s

son

4A

Ruth’s

daughter

5A

Scribe

Students foam in

Students ID themselves

to Ruth and family

Check Ruth’s ID band

Confirm any known drug

allergies

Assess Ruth’s pain for

location, description,

onset and duration

Elicit a pain rating level

with a numeric pain

scale

Prioritize treating Ruth’s

pain and nausea with

medications

43

Appendix N:

Scenario 2 Checklist

1A

ED RN

2A

Student

Nurse

3A

Ruth’s

son

4A

Ruth’s

daughter

5A

Scribe

Students foam in

Students ID themselves

to Ruth and family

Check Ruth’s ID band

Confirm any known drug

allergies

Review lab including

blood alcohol result

which is now available

Explore patient’s recent

alcohol history

Screen Ruth using

AUDIT tool for ETOH

Staff Nurse to remain at bedside to ensure Ruth’s safety

44

Appendix O:

Counseling Flyer

Let's Talk

Worried?

Stressed?

Can’t Focus?

Feel Like You're Losing Control?

Let’s Talk is a chance for you to come by and discuss whatever

concern you may have that is making life difficult. Let’s Talk is:

• Confidential Private. No records of your visit are kept

• Conversational Let's Talk is not formal counseling or psychotherapy, just

helpful conversation, guidance, and strategies for

maintaining a healthy balance.

• Drop-in No appointment; no commitments for ongoing counseling

• No Charge

Thursdays 11:00 to 1:30

Folsom Hall Room Debriefing Room

Offered by Student Health and Counseling Services (SHCS)

45

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