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
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.
x
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.”
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
● 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
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 ([email protected] or [email protected] or [email protected]. 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 [email protected].
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
References
Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-
Edgren, S., … Tillman, C. (2015). NCSBN simulation guidelines for prelicensure
nursing programs. Journal of Nursing Regulation, 6(3), 39–42.
doi:10.1016/S2155-8256(15)30783-3
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate
education for professional nursing practice. Washington, DC: Author.
American Association of Colleges of Nursing. (2015). Joining Forces. Retrieved from
http://www.aacn.nche.edu/joining-forces
American Nurses Foundation. (2014). Joining Forces and the PTSD toolkit. Retrieved
from http://anfonline.org/PTSD
Anthony, M., Carter, J., Freundl, M., Nelson, V. & Wadlington, L. (2012). Using
simulation to teach veteran-centered care. Clinical Simulation in Nursing, 8(4),
e145–e150. doi:10.1016/j.ecns.2010.10.004
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for
radical transformation. San Francisco, CA: Jossey-Bass.
Brady, D. S. (2011). Using quality and safety education for nurses (QSEN) as a
pedagogical structure for course redesign and content. International Journal of
Nursing Education Scholarship, 8(1), 1-18. doi:10.2202/1548-923X.2147
46
Chandler, J., Rycroft‐Malone, J., Hawkes, C., & Noyes, J. (2016). Application of
simplified complexity theory concepts for healthcare social systems to explain the
implementation of evidence into practice. Journal of Advanced Nursing, 72(2),
461–480. doi:10.1111/jan.12815
Crowell, D. M. (2016). Complexity leadership: Nursing’s role in health-care delivery.
Philadelphia, PA: F. A. Davis Company.
Doody, O., & Doody, C. M. (2015). Conducting a pilot study: Case study of a novice
researcher. British Journal of Nursing, 24(21), 1074-1078.
doi:10.12968/bjon.2015.24.21.1074
Doolen, J., Giddings, M., Johnson, M., Guizado de Nathan, G., & O Badia, L. (2014). An
evaluation of mental health simulation with standardized patients. International of
Nursing Education Scholarship, (11)1, 1-8. doi:10.1515/ijnes-2013-0075
Druss, B.G., & Walker, E. R. (2011). Mental disorders and medical comorbidity (The
Synthesis Project). Retrieved from Robert Wood Johnson Foundation website
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf69438/subas
sets/rwjf69438_1
Fenwick, T., & Dahlgren, M. A. (2015). Towards socio-material approaches in
simulation-based education: lessons from complexity theory. Medical Education,
49(4), 359–367. doi:10.1111/medu.12638
47
Giandinoto, J.-A., & Edward, K.-L. (2014). Challenges in acute care of people with co-
morbid mental illness. British Journal of Nursing, 23(13), 728–732.
doi:10.12968/bjon.2014.23.13.728
Giandinoto, J.-A., & Edward, K.-L. (2015). The phenomenon of co-morbid physical and
mental illness in acute medical care: The lived experience of Australian health
professionals. BMC Research Notes, 8(295). doi:10.1186/s13104-015-1264-z
Gilliss, C. L. (n.d.). Book highlights from educating nurses: A call for radical
transformation. Retrieved from
http://archive.carnegiefoundation.org/elibrary/educating-nurses-highlights
Glasgow, M. E. S., Dunphy, L., & Mainous R. (2010). Innovative nursing educational
curriculum for the 21st Century. Nursing Education Perspectives, 31(6), 355-7.
Retrieved from
http://journals.lww.com/neponline/Citation/2010/11000/INNOVATIVE_NURSI
NG_EDUCATIONAL_CURRICULUM_FOR_THE.5.aspx
Goleman, D. (1998). Working with emotional intelligence. New York, NY: Bantam
Books.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the
21st century. Washington, DC: The National Academies Press
Institute of Medicine. (2010). The future of nursing: Leading change, advancing
health. Washington, DC: The National Academies Press.
48
James, K. M. G. (2010). Incorporating complexity science theory into nursing curricula.
Creative Nursing, 16(3), 137–142. doi:10.1891/1078-4535.16.3.137
Kameg, K. M., Englert, N. C., Howard, V. M., & Perozzi, K. J. (2013). Fusion of
psychiatric and medical high fidelity patient simulation scenarios: Effect on
nursing student knowledge, retention of knowledge, and perception. Issues in
Mental Health Nursing, 34(12), 892-900. doi:10.3109/01612840.2013.854543
Kameg, K., Howard, V. M., Clochesy, J., Mitchell, A. M., & Suresky, J. M. (2010). The
impact of high fidelity human simulation on self-efficacy of communication
skills. Issues in Mental Health Nursing, 31(5), 315–323.
doi:10.3109/01612840903420331
Lefroy, J., & Yardley, S. (2015). Embracing complexity theory can clarify best practice
frameworks for simulation education. Medical Education, 49(4), 344–346.
doi:10.1111/medu.12662
Leon, A. C., Davis, L. L., & Kraemer, H. C. (2011). The role and interpretation of pilot
studies in clinical research. Journal of Psychiatric Research, 45(5), 626–629.
doi:10.1016/j.jpsychires.2010.10.008
Levine, A. I., DeMaria, S., Schwartz, A.D., & Sim, A.J. (Eds.) (2014). The
comprehensive textbook of healthcare simulation. New York, NY: Springer
Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: Nursing in the age of
complexity. Bordentown, N.J: PlexusPress
49
Lioce, L., Meakim, C. H., Fey, M. K., Chmil, J. V., Mariani, B., & Alinier, G. (2015).
Standards of best practice: Simulation standard IX: Simulation design. Clinical
Simulation in Nursing, 11(6), 309–315. doi:10.1016/j.ecns.2015.03.005
McKenzie, G., Freiheit, H., Steers, D., & Noone, J. (2016). Veteran and family health:
Building competency with unfolding cases. Clinical Simulation in Nursing, 12(3),
79–83. doi:10.1016/j.ecns.2015.12.011
Melnyk, B., & Davidson, S. (2009). Creating a culture of innovation in nursing education
through shared vision, leadership, interdisciplinary partnerships, and positive
deviance. Nursing Administration Quarterly, 33(4), 288-295.
doi:10.1097/NAQ.0b013e3181b9dcf8
Moreland, S. S., Lemieux, M. L., & Myers, A. (2012). End-of-life care and the use of
simulation in a baccalaureate nursing program. International Journal of Nursing
Education Scholarship, 9(1), 1-16. doi:10.1515/1548-923X.2405
Murphy, S., Hartigan, I., Walshe, N., Flynn, A. V., & O’Brien, S. (2011). Merging
problem-based learning and simulation as an innovative pedagogy in nurse
education. Clinical Simulation in Nursing, 7(4), e141–e148.
doi:10.1016/j.ecns.2010.01.003
National Academies Press. (2013). Substance use disorders in the U.S. Armed Forces.
Retrieved from: https://www.nap.edu/read/13441/chapter/7
National League for Nursing. (2015). A vision for teaching simulation. New York, NY:
Author
50
Quality and Safety Education for Nurses. (2009). Retrieved from
http://qsen.org/competencies/pre-licensure-ksas/
Ralevski, E., Olivera-Figueroa, L.A., & Petrakis, I. (2014). PTSD and comorbid AUD: A
review of pharmacological and alternative treatment options. Substance Abuse
and Rehabilitation, 5, 25-36. doi:10.2147/SAR.S37399
Shin, H., Sok, S., Hyun, K. S., & Kim, M. J. (2015). Competency and an active learning
program in undergraduate nursing education. Journal of Advanced Nursing, 71,
591-598. doi:10.1111/jan.12564
Sinclair, B., & Ferguson, K. (2009). Integrating simulated teaching/learning strategies in
undergraduate nursing education. International Journal of Nursing Education
Scholarship, 6(1), 7-1. doi:10.2202/1548-923X.1676
Starr, S.P. & Raines, D. (2011). Cirrhosis: Diagnosis, management and prevention.
American Family Physician, 84(12), 1353-1359. Retrieved from
http://www.aafp.org/afp/2011/1215/p1353.html
Stroup, C. (2014). Simulation usage in nursing fundamentals: Integrative literature
review. Clinical Simulation in Nursing, 10(3), e155-e164.
doi:10.1016/j.ecns.2013.10.004
Sunnqvist, C., Karlsson, K., Lindell, L., & Fors, U. (2016). Virtual patient simulation in
psychiatric care – A pilot study of digital support for collaborate learning. Nurse
Education in Practice, 17, 30–35. doi:10.1016/j.nepr.2016.02.004
51
Szpak, J. L., & Kameg, K. M. (2013). Simulation decreases nursing student anxiety prior
to communication with mentally ill patients. Clinical Simulation in Nursing, 9(1),
e13–e19. doi:10.1016/j.ecns.2011.07.003
Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila, A., Rios, L. P., … Goldsmith, C. H.
(2010). A tutorial on pilot studies: The what, why and how. BMC Medical
Research Methodology, 10(1). doi: 10.1186/1471-2288-10-1
Thomas, M. B., Jaffe, D., Choti, M.M., Belghiti, J., Curley, S., Fong, Y., … Venook, A.
(2010). Hepatocellular carcinoma: Consensus recommendations of the National
Cancer Institute Clinical Trials Planning Meeting. Journal of Clinical Oncology
28, (36), 3994-4005. doi: 10.1200/JCO.2010.28.7805
U. S. Department of Veterans Affairs. (2016). Department of Veterans Affairs: VA
facilities statistics at a glance. Retrieved from
https://www.va.gov/vetdata/docs/Quickfacts/Homepage_slideshow_06_04_16
White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2016). Translation of
evidence for leadership. Translation of evidence into nursing and health care (pp.
115-136). New York, NY: Springer.
Williams, B., Reddy, P., Marshall, S., Beovich, B., & McKarney, L. (2017). Simulation
and mental health outcomes: A scoping review. Advances in Simulation, 2(1), 1-8.
doi:10.1186/s41077-016-0035-9
52
World Health Organization. (2013).Mental health action plan 2013-2020. Retrieved:
http://www.who.int/mental_health/publications/action_plan/en/
Yoo, M. S., & Yoo, Y. (2003). The effectiveness of standardized patients as a teaching
method for nursing fundamentals. Journal of Nursing Education, 42(10), 444-
448.
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