Clinical Simulation in Nursing (2016) 12, 209-214

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Mental Health Clinical Simulation: Therapeutic

Communication
a, b
Carolyn Thompson Martin, RN, FNP, PhD *, Neelam Chanda, RN, PhD
a
Associate Professor, School of Nursing, California State University, Stanislaus, Turlock, CA 95382, USA
b
School of Nursing, California State University, Stanislaus, Turlock, CA 95382, USA
KEYWORDS Abstract
simulation; Background: The article describes a mental health simulation that encourages student nurses to
standardized patients; use therapeutic communication while assisting patients with mental illness in a clinical setting.
mental health nursing; Method: A quasi-experimental, one group, preepost test design using simulation during a mental
therapeutic health clinical orientation; data were analyzed using dependent t tests.
communication; Results: There was significant improvement (p ¼ .000) in student’s self-reported confidence
undergraduate nursing
with their communication skills and knowledge following a mental health simulation
students experience using standardized patients.
Conclusions: Although more research is needed, a therapeutic communication mental health
simulation given before students participating in their clinical experience should be integrated
into undergraduate nursing education.

Cite this article:

Martin, C. T., & Chanda, N. (2016, June). Mental health clinical simulation: Therapeutic communica-tion.
Clinical Simulation in Nursing, 12(6), 209-214. http://dx.doi.org/10.1016/j.ecns.2016.02.007.

2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.
Background and Significance
The goal of communication is to develop a common
understanding between people to develop a relationship
(Peplau, 1997). Therapeutic communication is holistic and
patient centered and engages the following aspects of pa-
tient caredphysiological, psychological, environmental,
and spiritual (Peplau, 1997). The practice of therapeutic
communication helps form a health-focused and stress-
reducing collaborative relationship between the nurse and
the patient; its primary goal is to establish trust to create a
meaningful exchange between the nurse and patient
* Corresponding author: cmartin2@csustan.edu (C. T. Martin).
(Peplau, 1997). Ideally, in a functioning relationship, the
patient communicates his or her experience and shares
necessary data, thoughts, and feelings with the nurse who
observes and listens carefully to the patient’s expression of
holistic needs (Peplau, 1997). Encouraging health-
promoting behaviors begins with successful communica-
tion and relationship building. Psychiatric nursing
emphasizes the use of therapeutic nursing communication
in dealing with patients, thereby enhancing the care given.
Simulation is commonly used in most areas of nursing
education, with the exception of mental health nursing. Few
studies have examined the use of a therapeutic communi-
cation simulation in mental health education. Effectiveness
using standardized patients has been reported in terms of
1876-1399/$ - see front matter 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2016.02.007
Mental Health Clinical Simulation 210
confidence enhancement, improving communication skills, before the students were to participate in their mental
satisfaction with the learning experience, overall decreased health clinical simulation. The use of a quasi-experimental
anxiety of individuals with mental illness, and increased design assists with identifying, examining, and clarification
self-reflection and availability of immediate feedback of causal relationships (Grove et al., 2013).
(Hermanns, Lilly, & Crawley, 2011; Lang & Hahn, 2013;
Marken, Zimmerman,
Kennedy, Schremmer, &
Smith, 2010; Webster, Sample
2014). Simulation can pro-
vide students with a safe The convenience sample size consisted of 28 prelicensure
setting in which they can nursing students enrolled in a mental health nursing theory
learn from their mistakes and clinical course. The courses were delivered through a
(Crider & McNiesh, 2011; public university Bachelor of Science in nursing program
Gore, Hunt, Parker, & located on the west coast. The mental health nursing course
Raines, 2011). is a 15-week course taken in the fourth semester of a six-
Exposing students to semester program.
therapeutic communication
techniques requires the use
of standardized patients. Description of Instruments
Barrows (1993) defined a
standardized patient as a Previous Knowledge and Demographic
person who is trained to Questionnaire
represent the characteristics
of a patient. A standardized Demographic data collected included age and gender. The
patient allows the student to extent of the experience these students had with simulation
be exposed to immediate and their communication knowledge was measured by
feedback of the success or asking the students if they had participated in a previous
lack of success of the simulation experiences and/or taken a communication
communication strategy be-ing used. In other words, the course.
student will know immedi-
ately if their approach is working or not working because Confidence With Communication Skills Scale
of how the patient is responding.
Communicating with mentally ill patients can be Student confidence with their therapeutic communication
challenging for nursing students. Each psychiatric client is skills was measured using a visual analogue scale. A visual
different, and interacting with patients may be anxiety analogue scale is a self-reporting device used to measure
provoking. Students taking mental health nursing theory subjective phenomena such as patient symptoms, affect,
and clinical courses express severe anxiety and fear before function, and quality of life (Miller & Ferris, 1993). A vi-
the start of the clinical rotation with the anticipation of sual analogue scale typically consists of a 100-mm
dealing with these patients. Their fears and doubts often horizon-tal line anchored at both ends with words that are
persist throughout their clinical rotation and assignments. descriptive from one end of the scale to the place where the
The anxiety expressed by students may be related to ‘‘not subject marked the line. Respondents report their level of
knowing what to say’’ (Melrose & Shapiro, 1999, p.1455). agreement to a statement by indicating a place along a
In an attempt to reduce the stu-dent’s anxiety, students continuous line between two end points. The use of single
were introduced to scenarios that they may be exposed to item measures, which are simple to rate, increases
in the mental health clinical setting. This article aims to construct validity (Patrician, 2004). The visual analogue
introduce therapeutic communication simulations with Confidence with Communication scale used in this study is
particular emphasis on symptoms related to psychiatric located in Table 1.
disorders as a part of mental health theory and clinical Using a visual analogue scale, the students rated their
courses. confidence in their communication skills pre and post
simulation. The scale ranged from 0 to 100 with zero
demonstrating ‘‘no confidence with communication’’ and
Methods 100 the ‘‘highest possible confidence with communica-
tion.’’ The visual analogue scale was administered the
A quasi-experimental, one group, preepost evaluation week before and immediately after the student’s mental
design was used for this study (Grove, Burns, & Gray, health clinical orientation, which used standardized patient
2013). The study took place two weeks (February, 2015) simulation.
pp 209-214 Clinical Simulation in Nursing Volume 12 Issue 6
Mental Health Clinical Simulation 211

Table 1 Visual Analogue Confidence With Communication Scale

0 )——————————————————————————————————————————————————/100
No confidence with communication Confidence with communication
Therapeutic Communication Pretest and Posttest
Questions for a ten-item pretest and posttest were selected
from the mental health course textbook question bank by
two experienced mental health faculty (Varcarolis & Halter,
2010). The questions were chosen with the purpose of eval-
uating therapeutic communication skills that would occur
during the standardized patient encounters. The questions
were administered to students to test the students’ knowl-
edge and application of therapeutic and nontherapeutic
communication techniques the week before and immedi-
ately after the mental health clinical orientation. The same
ten multiple-choice questions were used in both the pretest
and posttest. The questions focused on difficult
communication situations such as giving advise; the use of
silence, transference, empathy, and compassion; seeking
clarification; and dealing with patients who have suicidal
ideations.
Data Collection
University institutional review board approval was
obtained. Participation in the study was voluntary, and
students were assured that their grades would not be in
jeopardy if they did not participate in the research.
All 28 students were administered the pretest and the
Confidence with Communication Skill scale before being
assigned therapeutic and nontherapeutic communication
reading material in their mental health textbook or
attending a two-hour lecture on communication techniques.
During the preclinical daylong orientation, which occurred
post the lecture and the reading assignment, each student
was assigned to two standardized patients (a patient with
schizophrenia and another with depression) and a case
study (a patient with bipolar disorder) session guided by
therapeutic communication questions. The standardized
patient actors used moulage and were encouraged to
improvise while remaining in character to make the
scenario realistic. In total, students participated in two
mental health simulations and a case study session, each
lasting 45e50 minutes.
Each standardized patient volunteer was given a history of
the patient and their presenting symptoms. One volunteer was
a nurse and the other a simulation technician, both had
experiences with acting as a standardized patient with mental
illness. The mental health faculty gave the actors verbal
feedback post the initial simulation related to authenticity of
their portrayal of patients with mental
illness. These same mental health faculty were present
during the current standardized patient simulation and
observed student interactions during the experience.
An orientation to the simulation objectives was provided to
the students. Although participation in the orientation was
mandatory, to reduce anxiety and to allow students to practice
in a safe environment, they did not receive a grade or
evaluation for participating in the simulation. The students
were divided into two groups of nine students each and one
group of ten students. One group was assigned to the patient
with depression scenario, the second to the patient with a
schizophrenia scenario, and the third group was required to
read a case study and answer questions related to a patient
with bipolar disorder. Students were instructed to use
therapeutic communication skills while interviewing the
standardized patient. Students were required to interview each
patient for five minutes, while the other members of the group
observed the conversation and noted what they thought went
well during the scenario, what could be improved, as well as
their questions or concerns. Students rotated through each
simulation and the case study session. Mental health faculty
observed the students in each simulation and took notes in
preparation for the debriefing.
Once the two simulations and the case study session
were complete, students returned to the classroom and
were administered the posttest and the Confidence with
Commu-nication Skills scale. After the students completed
these two documents, they participated in a simulation
debriefing session, which lasted for approximately an hour.
The program’s simulation coordinator guided the
debriefing. The two standardized patients and two mental
health faculty were present during the simulation
debriefing and available to answer student questions. The
mental health faculty recorded student comments.
Statistical Analysis
Data were entered and coded using the statistical package
for the social sciences program, SPSS version 20.0 (IBM
Corp, Armonk, NY, USA, 2011). A coding system was
developed before running an analysis. There were no
missing data or participant attrition. Dependent t tests were
performed to assess for changes in the student self-report
of their confidence in their communication skills on the
visual analogue scale between time one and time two and
the pretest and posttest. Demographic and previous
knowledge with communication and simulation data were
analyzed using percentages and mean scores.
pp 209-214 Clinical Simulation in Nursing Volume 12 Issue 6
Mental Health Clinical Simulation 212
Results
Of the 28 undergraduate nursing student participants,
21.4% (n ¼ 4) were male and 78.6% (n ¼ 24) were
female. The mean age was 26.35 with a range of 21-41
years. These results mirror most undergraduate nursing
programs. The results of the students’ previous knowledge
with communication and simulation questionnaire are
listed in Table 2.
The results of the dependent t test demonstrate a signif-
icant improvement in students’ (n ¼ 28) confidence with
communication skills as self-reported on the visual
analogue scale after the simulation experience (p ¼ .000).
Pretest and posttest scores also revealed significant results
(p ¼ .000). The mean pretest score was 6.64 (standard
deviation 1.5) and the mean posttest score was 8.78
(standard deviation 1.03).
Discussion
The results of this study indicate that students self-report of
their confidence in their communication skills improved
post a standardized patient mental health simulation, which
was measured by the Confidence with Communication
Skill visual analogue scale. Pretest and posttest results
demon-strate that student’s scores on the therapeutic
communica-tion test increased after simulation. The
findings support the use of standardized patient mental
health simulation combined with debriefing to enhance
students’ confidence with their communication skills.
The students were clearly engaged and enthusiastic to
participate in a mental health simulation before attending
clinical simulation. Their response was most likely influ-enced
by their previous exposure to simulation in their nursing
program; with 89.3% of them reporting previous exposure to
simulation experiences. However, even with previous
experience they perceived the simulation chal-lenging due to
their lack of experience interacting with mental health
patients. It was clear that having students participate in a
simulation using a standardized patient with mental illness
was well received. In the debriefing, that followed the
simulation, students reported that they felt that they had an
opportunity to practice their communications skills and had
decreased anxiety are a result of the
Table 2 Previous Knowledge With Communication and
Simulation (n ¼ 28)
Descriptor Percentile
Previous communication course 35.7% yes
64.3% no
Previous simulation experience 89.3% yes
10.7% no
simulation. Overall, they felt that the simulation experience
gave them confidence to communicate with a ‘‘real
patient.’’
During the debriefing, students reported that they felt
helpless and ill equipped to help the patient. Students
reported that it was a low-pressured environment, which
allowed them to reflect. They discussed how hard it was
not to pull on their own personal experiences and to share
that with the patient. One student stated that she was
terrified and did not know what to do during the simulation
interaction. Another reported that it put them ‘‘on the
spot’’. Many students stated, ‘‘I just didn’t know what to
do.’’ Although challenging and frustrating at times, it was
clear that the students felt that the simulation was a helpful
tool to practice their newly learned communication skills.
Students reported that using ‘‘real people’’ versus
mannequins improved their ability to practice their
commu-nication skills. It allowed them to ask questions
relevant to the patient’s diagnosis. In the beginning they
were ‘‘ner-vous’’ and did not know how ‘‘to frame the
questions’’, but this changed as they progressed in the
simulation. They stated that it was important for them to
see the ‘‘signs and symptoms’’ of a patient with mental
illness. During the debriefing they discussed strategies for
‘‘breaking the ice’’ that they felt improved their ability to
communicate effectively with the ‘‘patient.’’ Most
importantly, they learned that ‘‘silence can be helpful’’
when they were not sure what to say. Ultimately, they
reported that they felt that is was very important to have
the simulation before their first clinical day.
Student’s feedback included recommendations for
improvement. They admitted fear of being judged by their
peers and suggested that they have the opportunity to do the
simulation alone followed by individual feedback. They
wanted more time to ‘‘interview the patients.’’ They requested
follow-up assessment of their therapeutic commu-nication
skills in the clinical setting and felt that this strategy would
reinforce what they learned in the simulation.
Mental health faculty, while observing the students
during the simulation, were able to note which students
would need more assistance in the clinical environment. As
a result, safety concerns were identified before placing the
students in the clinical setting. Examples of safety issues
included, being ‘‘too close’’ to the patient, not setting
boundaries or being able to redirect unsafe behavior, and
lack of follow-up when the patient reported that she
wanted to hurt herself.
Common nontherapeutic approaches used by students
were identified and discussed during debriefing such as,
talking to their patient while standing and keeping their
hands in their pockets, and avoidance of eye contact. As in
the clinical setting, it is common for students to struggle
with using silence as a communication technique and
similarly during the simulation they frequently did not wait
long enough for the patient to answer their questions. They
explained that they felt like they had to talk or ask
pp 209-214 Clinical Simulation in Nursing Volume 12 Issue 6
Mental Health Clinical Simulation 213
questions all the time. It was clear that students were
uncomfortable at times, which was exemplified by them
smiling, laughing, and looking at each other or away from
the patient. The debriefing allowed rich discussion related
to common nontherapeutic communication used by
students in the clinical setting.
Reflection and Recommendations
Reviewing objectives and giving students a brief over-
view of the patient before the start of each simulation
helped the students focus on the learning outcomes.
A simulation schedule is vital for success, it assures
that everyone knows where he or she needs to be and
how much time they have.
Advanced preparation via reading assignments and lec-
ture prepare the students for the simulation experience.
In this simulation, students knew the actors. To
enhance authenticity, the students recommended that
the stan-dardized patients be unknown to the students.
They reported that this would make it easier to identify
the actor as a patient.
Students asked for individualized debriefings versus a
group debriefing. Because of time restraints only a group
debriefing occurred, but it is clear that students would like
to have input on how they performed individually.
Videotaping the simulation may assist with student de-
briefing by allowing them immediate recall and review
that enhances feedback.
Inclusion of the standardized patient actors during the
debriefing can add reality to the simulation by allowing
them to share their own experiences and feelings dur-
ing the event. Webster (2013) supported the inclusion
of the actors and reported that it allowed students to
better understand how ‘‘the patient’’ felt during the
simulation.
The daylong event required student and faculty
commitment. Having access to a full-time simulation
coordinator is vital to the success of the simulation
event and reduces faculty load. Faculty are more likely
to participate in a simulation if they know they have
the support of a simulation coordinator.
Finally, repetition of the simulation allows faculty to
improve on and add to the learning experience.
Limitations
Students were able to observe their peers interact with the
standardized patients, doing this may have influenced how
they formulated their questions or communicated with their
patient. This strategy may enhance learning commu-
nication skills through repetition. Unfortunately, it may
also reinforce the use of nontherapeutic communication
skills and increase anticipatory anxiety, which is not
conductive to learning. During the debriefing students
reported that it was helpful for them to see other students
struggling with communicating with the patients, which
made them want to try a different strategy when it was
their turn. Allowing students to observe allows them the
opportunity to think critically and engage in solutions
(Hammer, Fox, & Hampton, 2014). Because the purpose of
the simulation was to learn how to communicate, it was
felt that this approach was advantageous. As far as re-
inforcing nontherapeutic communication, the debriefing
allowed the instructors the opportunity to point out exam-
ples and discuss and reinforce alternate therapeutic
communication strategies.
Students were allowed only one encounter with the
standardized patient. It is unclear if having multiple
encounters with mental health communication simulation
may be needed for a more effective communication
training. Future studies are needed to enhance the under-
standing of multiple encounters with simulated patients at
different times during the semester, which may increase the
ability of the students to communicate with their patients.
The small convenience sample size and choosing
students from one nursing program are major limitation
that negatively influences the generalizabilty of the
findings. Larger samples sizes from different nursing
programs should be considered in future simulation-based
studies. Confounders include the student’s personal
experience with people who are mentally ill, including
exposure to patients with mental illness in earlier clinical
experiences and previous exposure to psychology courses.
It is clear that most students (89.3%) had exposure to
simulation activities in their previous course work, which
likely resulted in the students having increased comfort and
willingness to participate in this study. Almost 36% of the
students took a communication course before their
therapeutic communication simulation experience, which
may have increased communication skills overall. In
addition, the students were assigned a therapeutic commu-
nication reading and exposed to lecture before the
simulation, which may contribute to the improved posttest
and Confidence with Communication Skills scale scores.
The development of more standardized simulation evalu-
ation tools is needed to enhance the body of knowledge
related to this emerging pedagogy. Overall, more rigorous
studies are needed to assess efficacy (Nehring & Lashley,
2004; Hammer et al., 2014).
Recruitment of standardized patients may be difficult,
time consuming, and expensive compared to exposure to
‘‘real’’ patients during the clinical experience. It is
important to assure that the standardized patient is accurate
in their depiction of a patient with mental illness because it
is easy to slip into a stereotypical generalization of a
patient with mental illness. This can be avoided by giving
the person playing the role a history describing the patient
and assuring that a mental health expert is observing the
patient-student simulation interaction.
pp 209-214 Clinical Simulation in Nursing Volume 12 Issue 6
Mental Health Clinical Simulation 214
Conclusion
Nurses are challenged to prepare future nurses with a high
level of communication skills. These findings provide
evidence that a mental health simulation combined with
debriefing in preparing students for their clinical
experience is an essential component of preparing future
nurses. A therapeutic communication mental health
simulation given before students participating in their
clinical experience should be integrated into undergraduate
nursing education to better prepare students for patient
interactions and to assist with decreasing anxiety related to
entering a perceived challenging clinical setting (Gore et
al., 2011). Most importantly, faculty can observe
student/patient inter-actions in a safe environment allowing
early intervention to assure student success in the clinical
setting. More research is needed to obtain broader insight
into best pedagogical practices in mental health nursing.
Ultimately, our goal in teaching mental health nursing is to
prepare nurses who provide quality care to this vulnerable
population. Mental health simulation is another tool that
assists us in accom-plishing this outcome.
Acknowledgments
The authors acknowledge the contributions of Wendy
Matthew, Jennifer Serratos, and Jennifer Stonecipher.
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