Nurse Education Today 45 (2016) 167172

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Using standardized patients in enhancing undergraduate students'

learning experience in mental health nursing
Yong-Shian GOH PhD, MN, Senior Lecturer a,b,, Sunil Selvarajan MCouns, Senior Lecturer a,b,
Mui-Lee Chng MN, Assistant Director of Nursing c,
Chee-Shiong Tan MEd, Senior Nurse Educator d, Piyanee Yobas PhD, Associate Professor a,b
a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b
Alice Lee Centre for Nursing Studies, National University Health System, Singapore
c
National University Hospital, National University Health System, Singapore
d
Institute of Mental Health, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Background: Conducting mental status examination and suicide risk assessment is an important skill required of
Received 19 April 2016 nurses when they are in the clinical setting. With nursing students often expressing the anxiety and lack of con-
Received in revised form 12 July 2016 dence in doing so, the use of standardized patients provide an excellent opportunity to practice and become
Accepted 3 August 2016 procient with this skill in a simulated environment.
Objectives: To explore the learning experience of undergraduate nursing students using standardized patients while
Keywords:
practising their mental status examination and suicide risk assessment skills in mental health nursing module.
Mental health nursing
Simulation
Design: A pre- and post-test, single group quasi experimental design was used in this study. A standard didactic tu-
Standardized patients torial session and a standardized patient session was conducted to evaluate the learning experience of undergrad-
Mental status examination uate nursing students learning mental status examination and suicide risk assessment. Outcome measures for this
Suicide risk assessment study include Student Satisfaction and Self-Condence in learning scale.
Qualitative comments in the form of open-ended questions were also collected in this study.
Settings: A University offering nursing program from undergraduate to postgraduate level.
Participants: A convenience sample of Year 2 undergraduate nursing students undertaking the mental health nursing
module was included in this study.
Results: The use of standardized patient session had signicantly increased students' satisfaction and condence
level before they are posted to a mental health setting for their clinical attachment. There was a signicant difference
on students' self-condence level for those who have taken care of a patient with mental illness after adjusting for
pre-test on score in learning. Qualitative feedback obtained from students showed a positive outlook towards the
use of standardized patient as an effective tool in augmenting didactic learning into practical skills.
Conclusions: Using standardized patient in mental health nursing education enhanced the integration of didactic
content into clinical setting allowing students to practice their assessment skills learned in classroom and transfer
it to the clinical area. The benets of using standardized patient include allowing students to practice their commu-
nication skills and improving their condence level in conducting mental status examination and suicide risk assess-
ment by reducing anxiety as compared with traditional classroom and textbook-based pedagogy.
2016 Elsevier Ltd. All rights reserved.

1. Introduction such as administration of intravenous uid, application of oxygen ther-

The use of high delity simulators (HFS) in either the form of adult
or pediatric mannequins is becoming a common pedagogy among nurs-
ing faculties when teaching clinical skills to nursing students. With the
ability to respond physiologically to medical or nursing interventions,
Corresponding author at: Alice Lee Centre for Nursing Studies, National University of
Singapore, Singapore; Clinical Research Centre (MD 11), 10 Medical Drive, 117597,
Singapore.
E-mail address: shawn_goh@nuhs.edu.sg (Y.-S. GOH).
apy and emergency resuscitation, this has brought about realism in
teaching clinical skills in a classroom environment. HFS has been around
for many years (National League for Nursing, 2006) as it allows students
to perform nursing interventions in a safe environment while improv-
ing their condence as well as decreasing anxiety level (Kaddoura,
2010). With simulation, the learning environment replicates all poten-
tial circumstances students may encounter in the clinical area, which
helps them to develop critical thinking skills (Kaddoura, 2010; Lehr
and Kaplan, 2013; National League for Nursing, 2006). Although HFS
has been incorporated into most healthcare courses, this trend has yet

http://dx.doi.org/10.1016/j.nedt.2016.08.005
0260-6917/ 2016 Elsevier Ltd. All rights reserved.
168 Y.-S. GOH et al. / Nurse Education Today 45 (2016) 167172
to be widely adopted into mental health nursing modules. With
preconceived ideas on associated violence and the unpredictability of
mental health patients remaining high among nursing students,
(Brown, 2008; Kameg et al., 2009, 2010) this will impede the learning
process as teaching cannot take place until students feel safe and rela-
tively comfortable in the situation (Iezzoni et al., 2006). With this in
mind, mental health faculty needs to explore the possibility of incorpo-
rating HFS into their teaching pedagogy. However, many mental health
faculties still nd it challenging to adopt HFS fully as the mannequins
used need to be able to reect reality required in the mental health en-
vironment such as providing non-verbal cues, body language, facial ex-
pressions and physical movement (Doolen et al., 2014). Therefore a
different form of HFS, such as the use of standardized patients (SP) en-
counters may be required when teaching mental health nursing.
SP are individuals trained to simulate patients with health condi-
tions in an accurate and consistent manner with the help of a case sce-
nario (Gliva-McConvey, 2009; Wallace, 2007). This methodology was
rst described in the work of Barrows and Abrahamson (1964) where
a standardized patient was used to simulate a neurological condition
in order to appraise the clinical competences of medical students.
Such SP encounters are considered high-delity simulation experiences
as SP are able to provide credible interactions for students (Bosek et al.,
2007; Bradley, 2003; Hetzel-Campbell and Daley, 2013; Lehr and
Kaplan, 2013; Robinsons, 2009) allowing them to fulll their learning
objectives (Brown, 2008; Robinson-Smith et al., 2009). Since the
1960s, SP methodology has been used in many countries worldwide,
particularly in the United States since its value is apparent (Barrows,
1993). In Asia, this methodology remains fairly new. In a study conduct-
ed in Taiwan, SPs were used to train students in the Advanced Practice
Nurse program in interpersonal and communication skills where it
showed positive outcomes (Lin et al., 2013). Similarly, a study in
Singapore, showed that the use of SP helped nal-year undergraduate
nursing students improve their inter-professional skills, collaboration,
management, and condence (Liaw et al., 2014).
Learning to listen to the patient is a critical communication tech-
nique within mental health nursing. However, most didactic lessons
do not provide the avenue for students to practice this skill (Fay-
Hillier et al., 2012) therefore the use of SP will provide a safe setting
for students to practice professional communication, collaboration,
and peer evaluation as well as a practice setting for patient feedback
(Fay-Hillier et al., 2012). Since communication is the foundational skill
required in mental health nursing, it would be essential that simulations
within the mental health course focus on more effective and structured
communication skills (Kameg et al., 2009). With the use of SP encoun-
ters, this further complements the didactic mental health nursing con-
tent as it allows nursing students to interact with SP with realism in a
less threatening environment (Flanagan et al., 2004). Nursing students
can then use therapeutic communication, assessment and planning
skills to provide nursing care for their patients (Lehr and Kaplan,
2013; Robinson-Smith et al., 2009). Furthermore, nursing students can
also gain experience of working with SP who might mimic mental
health symptoms that they might not have encountered during their
clinical practicum (Brown, 2008; Kameg et al., 2009).
This study uses John Dewey's experiential learning philosophy as the
theoretical framework where Dewey states that learning cannot come
through memorization and knowledge is gained from experience
(Dewey, 1902). The SP encounters provide nursing students with active
participation in communication skills within a safe learning environ-
ment. This study is based on the theory of experiential learning sug-
gested by Kolb (1984) as it concludes learning being a process, not an
outcome and the development of new knowledge is a result of
transforming real-life experience. There are two processes in the trans-
formation of experience: (1) grasping the experience (apprehension)
and (2) transforming the experience (comprehension). According to
many studies (Jeffries & Rogers, 2007; Lisko & O'Dell, 2010; Rowles &
Russo, 2009), learners should be given a debrief immediately following
the SP encounter as it provides them the opportunity to self-reect on
their performance and transform the learning experience into new
nursing knowledge.
2. Teaching and Learning Activities
The main objective of the Mental Health Nursing module is to pre-
pare undergraduate nursing students with theoretical knowledge and
skills in taking care of patients with mental illnesses in institutional
and community settings. The main emphases of the module are: assess-
ment, early intervention, health promotion and prevention and the
identication of at risk behaviours among patients. Based on the objec-
tives, the module consists of two pedagogical approaches; one being di-
dactical lecture and the other being tutorial discussion. In this study,
mental status examination and suicide risk assessment (MSE/SRA)
were selected by the research team as both skills require the nurse to
develop communication and clinical judgment which is difcult to ac-
quire through didactical teaching. A case scenario was developed, and
SP were used in providing the simulated practice during the session.
The SP were trained by the module coordinator and educator from the
University simulation centre. The simulations were conducted in the tu-
torial room which simulated the interview room of the hospital. The un-
dergraduate students were informed and asked to volunteer a week
before the session. All students were blinded to the case scenario. The
case scenario and important points to note during MSE/SRA were
discussed with the students during the debrieng session. All students
participated in the session were consecutively conducted in August
2015.
2.1. Aim of Study
This study aimed to explore undergraduate nursing students' learn-
ing experiences with the use of SP for mental health nursing. Research
questions for the study were:
1. Is there a signicant change in nursing students' satisfaction level fol-
lowing participation in the SP session?
2. Is there a signicant change in nursing students' condence level fol-
lowing participation in the SP session?
3. Methods
3.1. Design and Setting
In this study, the team seeks to explore the learning experience of
students using standardized patients for their MSE/SRA skills in mental
health nursing module among the undergraduate nursing students. A
pre and post-test, single group quasi experimental design was used
with a standard didactic tutorial session on the topic on MSE/SRA con-
ducted for all students enrolled in the module. The SP experimental ses-
sion was conducted as an extra session in order to evaluate its
effectiveness in teaching MSE/SRA. SP in this study were provided by
the Standardized Patient Program from the Centre for Health Simulation
in a University in Singapore. A case vignette was provided to all SP in
order to ensure a standardized response during the interaction with
the students in the intervention phase of this study.
3.2. Participant Recruitment and Procedure
A convenience sample on all students enrolled in the module was in-
vited to participate in the study. Upon ethical approval, the Head of De-
partment was informed regarding the commencement of the study.
Students were informed of the purpose of this study during their rst
lecture when the semester starts. After the standard tutorial being con-
ducted for all the students, a Participant Information Sheet (PIS) and con-
sent form were given to all interested participants who fulll the inclusion
 Y.-S. GOH et al. / Nurse Education Today 45 (2016) 167172
criteria. They were then invited to ll up the self-report questionnaire and
return it to the researcher. Subsequently, the experimental tutorial using
the SP were conducted for all students and the post-test data using the
same self-report questionnaire were collected from participants who
had previously participated during the pre-test.
The inclusion criteria for the study were as follows:
a. Undergraduate nursing students, irrespective of gender and pro-
cient in English.
b. Currently undertaking the mental health nursing module in Aca-
demic Year 2015/2016.
3.3. Ethical Considerations
This study was reviewed and approved by the University Institution-
al Review Board (IRB). The aims of the study, possible risks and benets
as well as participants' rights were explained to all students. The partic-
ipants were reassured on voluntary participation and their ability to
withdraw at any time without any prejudice. An independent teaching
member was engaged to collect both the pre-test and post-test data as
there is a presence of dependent relationship between study partici-
pants and research team which might reduce the participation rate
and increase the risk in conict of interest.
3.4. Outcome Measures
Data were collected using a self-report questionnaire containing the
following information:
Section A: A demographic sheet was used to collect the student's per-
sonal data such as age, gender, ethnicity as well as any expe-
rience interacting or taking care of people with mental
illness.
Section B: The NLN Student Satisfaction and Self-Condence in Learning
scale (NLC scale) (National League for Nursing, 2006) was
used to collect student's satisfaction and self-condence
level in learning after using simulation. It is a 13-item,
Likert-style scale using response options ranging from one
(strongly disagree) to ve (strongly agree). Scores range
from 13 to 65 where higher scores indicating more satisfac-
tion and more self-condence, respectively (National League
for Nursing, 2006). The NLC scale consists of two subscales;
Satisfaction with instruction (ve items) and self-condence
with learning (eight items) (National League for Nursing,
2006). According to Hoadley (2009) the Cronbach's alpha co-
efcient of NLN Student Satisfaction and Self-Condence in
Learning scale ranged between 0.84 and 0.97, respectively
(Hoadley, 2009; Jeffries and Rizzolo, 2006; King, 2012) indi-
cating good reliability.
Section C: Qualitative questions were added to the self-report ques-
tionnaire allowing the exploration of student's strength
and perception on areas of improvement on implementing
standardized patients in their learning journey.
3.5. Data Analysis
The IBM SPSS Statistics for Windows, Version 23.0 was used to ana-
lyse all data (IBM Corp, 2013). Demographic variables were explored
using descriptive statistics. A parametric approach was used in
data analysis as the dependent variable demonstrated a normal distri-
bution on histogram diagram (Chan, 2003). Qualitative feedback in
this study was read, classied, abstracted, labelled, and categorized
using systematic classication process (Cresswell, 2015). Quotations
were presented based on their representativeness in terms of their
169
signicance, similarities, and differences of the descriptions of their in-
dividual learning experience.
4. Results
4.1. Sample Characteristics
A total of 95 students took part in the study, giving an overall re-
sponse rate of 79.1%. Table 1 showed that most of the participants
were female (86.3%), with majority being Singaporean (94.7%), Chinese
(82.1%) with almost half of them (47.4%) having experience interacting
with person suffering from mental illness. However, only a small per-
centage of them (16%) having to take care of people with mental illness
as a nurse.
4.2. Nursing Students' Satisfaction/condence Level
A paired sample t-test was conducted to compare the differences in
student's satisfaction in current learning in mental health nursing with
or without the use of standardized patient. There was a signicant dif-
ference in student's satisfaction before the use of standardized patient
(M = 17.07, SD = 2.47) and after the use of standardized patient
(M = 22.7, SD = 2.24); t (94) = 15.12, p b 0.000 (Table 2). These results
suggested that the use of standardized patient had increased student's
satisfaction towards their learning. The eta squared statistic (0.07) indi-
cated a small effect size (Polit, 2010).
Results from a paired sample t-test comparing the differences in
student's condence in current learning in mental health nursing with
or without the use of standardized patient showed a signicant differ-
ence in student's condence before the use of standardized patient
(M = 30.22, SD = 3.93) and after the use of standardized patient
(M = 32.77, SD = 3.50); t (94) = 5.29, p b 0.000. These results sug-
gested that the use of standardized patient had increased student's con-
dence level. The eta squared statistic (0.23) indicated a large effect
size.
4.3. Nursing Student's Prior Experience on Satisfaction
Results from the One-way ANCOVA showed that there was no signif-
icant difference in the students' satisfaction on learning score among
those who had interacted with the mentally ill before. However, the
group of students who had taken care of the mentally ill as a nurse re-
ported a signicant difference on their students' satisfaction on learning
score after adjusting for pre-test on satisfaction score in learning, F(2,
92) = 0.001, p b 0.001, partial eta squared = 0.11. From the analysis,
students with experience of taking care of a mentally ill patient as a
nurse reported a higher satisfaction level ( = 2.02, p = 0.001, 95%
CI: 0.821, 3.21) compared to those who did not (Table 3).
4.4. Nursing Student's Prior Experience on Condence
Results from the One-way ANCOVA showed that there was no signif-
icant difference in the students' self-condence on learning among
those who mentioned that they have interacted with the mentally ill.
The group of students who had taken care of the mentally ill as a
nurse reported a signicant difference on their self-condence score
after adjusting for pre-test on self-condence score in learning, F(2,
92) = 0.046, p = 0.46, partial eta squared = 0.043. From the analysis,
students with experience of taking care of a mentally ill patient as a
nurse reported a higher condence level ( = 1.96, p = 0.046, 95% CI:
0.036, 3.89) as compared to those that do not have that experience
(Table 4).
170 Y.-S. GOH et al. / Nurse Education Today 45 (2016) 167172

Table 1 practical lesson even before they were being posted to their clinical
Characteristics of the study population. attachment.
Characteristics n (%) Characteristics n (%)

Gender Ethnicity S5: Standardized patients really challenge us to be exible while apply-
Female 82 (86.3) Chinese 78 (82.1) ing what we have learnt.
Male 13 (13.7) Malay 13 (13.7)
Indian 02 (2.1)
Citizenship Others 02 (2.1) S15: I really got a feel of how a patient with such a condition will be-
Singaporean 90 (94.7) have it also made me think about the gaps in my understanding of the
Others 05 (5.3) Experience interacting content and what I need to work on.
with the mentally ill
Experience taking Yes 45 (47.4)
care as a nurse
Yes 15 (15.8) No 50 (52.6)
4.5.4. Valuable Session
No 79 (84.0)
Finally, students also gave positive feedback as they mentioned that
it was a valuable session which could be extended to more students to
practice.
4.5. Qualitative Comments on the Use of Standardized Patients
S57: It was a really good experience. The scenario was very real and
A qualitative question was used to explore students' view following good for us if we wish to apply and master the skills/lessons we have
the use of standardized patients in the learning journey. The question learnt in nursing school.
aimed to explore students' perceived strength in using standardized pa-
tient. The open-ended student evaluation responses were mostly posi- S83: It was a good form of learning; however more scenarios can be
tive. A content analysis was performed on the open-ended responses conducted allowing more students to practice and experience.
to identify broad themes which were grouped into the following catego-
ries: Applicability, Condence, Knowledge Integration and Valuable Ses-
sion (Table 5).
5. Discussion
4.5.1. Applicability
There is a complex array of learning issues nursing students face
Many students responded positively towards the use of SP as they
when they rst start to learn about mental health nursing. With nega-
mentioned it brings about realism towards their learning.
tive attitudes, fears and anxiety from interacting with mental health pa-
tients, this will hinder students' learning and development of a
S34: Using standardized patient makes it easy for me to visualize on
therapeutic relationship with their patients (Kameg et al., 2009;
how to conduct MSE examination. I feel that this will prepare us for
Stuart, 2013). In this study, the SP session facilitated students to gain
the future.
knowledge in a safe environment, reducing the psychological burden
and anxiety. Our ndings suggested that using SPs in undergraduate
S36: By using a SP, it is far more applicable as compared to reading mental health nursing education had signicantly increased both stu-
from the book or notes, it helps to understand. dents' satisfaction as well as condence level before they are posted to
a mental health setting for their clinical attachment. This result is similar
to the studies conducted by both Kameg et al. (2010) and Choi (2012)
4.5.2. Condence where students who went through SP session reported an increase
Some students also brought up issues on improving their condence with their condence level in engaging actual mental health patients
level and interviewing skills for their clinical attachment. in the clinical area (Lin et al., 2013). As one of the tenets towards effec-
tive MSE/SRA is having therapeutic communication skills (Stuart, 2013),
S19: It is more interactive and I get the opportunity to build my con- the use of SP session is important in helping to achieve this purpose.
dence in communicating with mental patients. Since attending SP session can help to improve communication pro-
ciency among students in clinical nursing practice (Robinson-Smith
et al., 2009), the SP sessions together with the actual clinical practicum
S43: It would be useful if I come across patients with such condition in will provide students' with additional opportunities for patient interac-
future. I would be able to deal with the patient more effectively. tions, which is essential for gaining interpersonal competence.
Qualitative data obtained from the open-ended questions were gen-
erally positive. Themes emerged from the open-ended questions in-
4.5.3. Knowledge Integration cludes realism from the SP session, the ability of integrating the
Students also reported that they were able to see the theory and knowledge and the condence to interact with mental health patients
practice gap being narrowed during this SP session as they could in- which is similar to ndings seen in many other studies (Hermanns et
tegrate the knowledge obtained from the didactic session into a al., 2011; Lin et al., 2013; Robinson-Smith et al., 2009). One plausible

Table 2
Descriptive statistics and t-test results for student's satisfaction on learning and condence.

Pretest Posttest Mean of differences 95% CI for mean difference Eta squared t

Outcome M SD M SD

Satisfaction 17.07 2.47 22.70 2.24 5.09 4.43, 5.76 0.07 15.12
Condence 30.22 3.93 32.77 3.50 2.55 1.59, 3.50 0.23 5.29
p b 0.000.
 Y.-S. GOH et al. / Nurse Education Today 45 (2016) 167172 171

Table 3 taking care of mental health patients (Szpak and Kameg, 2013). With
One-way ANCOVA results on comparing pre-existing experiences on students' satisfaction students being more condent when engaging with mental health pa-
on learning.
tients, they are more likely to be able to report an improved learning ex-
Satisfaction 95% CI for mean p value Partial eta perience (Alexander and Dearsley, 2013; Lin et al., 2013; Stuart, 2013).
difference squared However, it is also important to note that around half of the study pop-
Experience interacting Yes 0.66 0.26, 1.58 0.156 0.022 ulation already have previous contact with mental health patients dur-
with Mentally ill No Ref ing other clinical practicum. Therefore, it is important to consider the
Experience taking care of the Yes 2.02 0.82, 3.21 0.001 0.11
potential effect of confounding variables that may already have inu-
mentally ill as a nurse No Ref
ence the results of this study.
p b 0.001.
The use of SP is not without its challenges. Issues such as the avail-
ability of resources, related nancial costs and faculty competency
in simulation methodologies are faced by many institutions when
Table 4
they consider incorporating and maintaining such teaching pedagogy
One-way ANCOVA results for comparing pre-existing experience on students' condence
in learning. (Galloway, 2009). Yet, our ndings as with many studies around sug-
gested that the benets that simulation can provide in mental health
Condence 95% CI for mean p value Partial eta
nursing education seem to support such as an investment (Galloway,
difference squared
2009; Kameg et al., 2009, 2010; Shawler, 2008). One clear benet is
Experience interacting Yes 0.52 0.90, 1.94 0.47 0.006
the potential of increasing the number of students choosing mental
with Mentally ill No Ref
Experience taking care of the Yes 1.96 0.04, 3.89 0.046 0.043
health nursing as their choice of future career. Currently, there is consid-
mentally ill as a nurse No Ref erable amount of research supporting the notion that undergraduate
p b 0.05. nursing students do not regard mental health nursing as a viable career
choice (Gough and Happell, 2009; Happell, 2008). Therefore, positive
interactions during clinical placement may contribute positively to re-
explanation for this could be because with the use of SP session, stu- cruitment of future mental health nurses (Happell, 2008).
dents are given the opportunity to practice communication skills within
a supportive environment. This non-threatening and safe environment 6. Limitations and Methodological Considerations
to make mistakes follows the educational viewpoint suggested by
Dewey (1902), where students need to be feel safe with the environ- Several limitations were identied in this study. First, the use of
ment in order to experience experiential learning (Dewey, 1902; quasi-experimental design leads to the lack of random assignment
Knudson, 2013; Kolb, 1984). Students also expressed an increased in which may result in selection biases in the sample. This could be im-
self-awareness of their communication and clinical strengths and weak- proved with the use of an adequate sample size, random selection, a
nesses, which is an important aspect within mental health nursing comparison group incorporated in future study. Second, the research
(Brown, 2015; Shemanko and Jones, 2008). Furthermore, students felt was designed for all students to complete both the didactic tutorial as
that the SP session was helpful as it integrate the knowledge learnt in well as simulation session with no control group for comparison. This
school and augment their didactic learning into practical skills during in turn will result in the students building up experience in MSE/SR dur-
their simulation session (Shawler, 2008). ing their didactic tutorial thus limiting the possibility to evaluate the ef-
Our results were comparable with other studies where students re- fectiveness in using SP session. Third, four faculty members conducted
ported feeling more satised (Kameg et al., 2010; Szpak and Kameg, the SP sessions, although training was for the SP was conducted by
2013) and condent prior to their clinical placement after participating the principal investigator however, it will be difcult to control for var-
in the SP session (McGaghie et al., 2006; Shepherd et al., 2010). A recent iability during the SP sessions.
study conducted by Martin and Chanda (2016) further afrmed that
condence in their communication skills improved after a SP mental 7. Conclusion
health simulation where the pre-test and post-test results demonstrate
an increase on the student's scores on the therapeutic communication. Using SP in mental health nursing education is considered an inno-
With unfamiliarity and potentially confrontational situation which is vative exploration in teaching undergraduate nursing students the skills
often associated with mental health patients, students tend to report a needed in providing comprehensive care for patients experiencing
poorer learning outcome during the clinical attachment (Brown, 2008; mental illness. Our study explored the effect of using the SP session in
Kameg et al., 2010; Lehr and Kaplan, 2013). The use of SP had somewhat teaching MSE/SRA to undergraduate nursing students. This approach
mitigated and demystied the anxiety that can be associated when enhanced the integration of didactic content into clinical setting and

Table 5
Qualitative themes and exemplars.

Themes Student comments & exemplars

Applicability S1: Good exposure to relate and have an idea on how patients are like. Better understanding and good preparation before clinical practice.
S34: Using standardized patient makes it easy for me to visualize on how to conduct MSE examination. I feel that this will prepare us for the future.
S36: By using a SP, it is far more applicable as compared to reading from the book or notes, it helps to understand.
Condence S10: We can know how it is like in real life situation and will make us be prepared for it.
S19: It is more interactive and I get the opportunity to build my condence in communicating with mental patients.
S43: It would be useful if I come across patients with such condition in future. I would be able to deal with the patient more effectively.
Knowledge Integration S5: Standardized patients really challenge us to be exible while applying what we have learnt.
S15: I really got a feel of how a patient with such a condition will behave it also made me think about the gaps in my understanding of the content and what I
need to work on.
S32: I felt that my senses were heightened; more aware of patient's non-verbal cues.
Valuable Session S57: It was a really good experience. The scenario was very real and good for us if we wish to apply and master the skills/lessons we have learnt in
nursing school.
S83: It was a good form of learning; however more scenarios can be conducted allowing more students to practice and experience.
S23: Increase number of sessions. So more people can attempt. More detailed and extensive feedback session after each SPs session too.
172 Y.-S. GOH et al. / Nurse Education Today 45 (2016) 167172
allowed students to practice their assessment skills learned in the class-
room and transfer it to the clinical area. Our study further provided the
evidence to support the benets in using SP allowing students to prac-
tice their communication skills and improving their condence level
in conducting MSE/SRA by decreasing anxiety as compared with tradi-
tional classroom and textbook-based pedagogy. For nursing faculties,
the use of evidence-based pedagogy is crucial as each learning session
helps to promote and enhances skills of students within a supportive
environment where it is non-threatening for their learning. Further
studies can be conducted to explore the benets from the simulation
session through follow-up during students' clinical attachment by pro-
viding an opportunity for them to write a reection on how the simula-
tion session impacted their actual clinical practice (Cato et al., 2009).
Finally, the cost of using different teaching pedagogy could also be
quantied.
Funding
Teaching Enhancement Grant, National University of Singapore -
2015.
Author Contributions
Study design: YSG, SS, MLC, CST and YP.
Data collection and analysis: SS and YSG.
Manuscript preparation: YSG, SS, MLC, CST and YP.
Conict of Interest
The author(s) declare that they have no conict of interests.
Acknowledgements
The authors would like to thank the Centre for Health Simulation,
Yong Loo Lin School of Medicine, National University of Singapore for
their support in the standardized patient program. The authors would
also like to acknowledge Mr Yan Ben Wei and Ms Joelyn Chee for their
effort during the data collection and data entry phase for this study. Fi-
nally, Dr Wilson Tam for the statistical consultation.
References
Alexander, L., Dearsley, A., 2013. Using standardised patients in an undergraduate mental
health simulation: a pilot study. Int. J. Ment. Health 42, 149162.
Barrows, H.S., 1993. An overview of uses of standardized patients for teaching and evalu-
ating clinical skills. Acad. Med. 68, 443451.
Barrows, H.S., Abrahamson, S., 1964. The programmed patient: a technique for appraising
student performance in clinical neurology. J. Med. Educ. 39, 802805.
Bosek, M.S., Li, S., Hicks, F.D., 2007. Working with the standardized patients: a primer. Int.
J. Nurs. Educ. Scholarsh. 4, 112.
Bradley, C., 2003. Messages from the eld: nurses' views on the shortage, the workplace,
and their careers. Nurse Lead. 2629.
Brown, J.F., 2008. Application of simulation technology in psychiatric mental health edu-
cation. J. Psychiatr. Ment. Health Nurs. 15, 638644.
Brown, A.M., 2015. Simulation in undergraduate mental health nursing education: a liter-
ature review. Clin. Simul. Nurs. 11, 445449.
Cato, M.L., Lasater, K., Peeples, A.I., 2009. Nursing students' self assessment of their simu-
lation experiences. Nurs. Educ. Perspect. 10, 105108.
Chan, Y.H., 2003. Biostatistics 102: quantitative data parametric & non-parametric tests.
Singap. Med. J. 44, 391396.
Choi, Y.-J., 2012. Exploring experiences of psychiatric nursing simulations using standard-
ized patients for undergraduate students. Asian Nurs. Res. 6, 9198.
Cresswell, J.W., 2015. Educational Research: Planning, Conducting, and Evaluating Quan-
titative and Qualitative Research Pearson Education Inc, Philadelphia.
Dewey, J., 1902. The Child and the Curriculum. The Univeristy of Chicago Press, Chicago.
Doolen, J., Giddings, M., Johnson, M., Guizado de, N., G. O, Badia, L., 2014. An evaluation of
mental health simulation with standardized patients. Int. J. Nurs. Educ. Scholarsh. 11.
Fay-Hillier, T.M., Regan, R.V., Gordon, M.G., 2012. Communication and patient safety in
simulation for mental health nursing education. Issues Ment. Health Nurs. 33,
718726.
Flanagan, B., Nestel, D., Joseph, M., 2004. Making patient safety the focus: crisis resource
management in the undergraduate curriculum. Med. Educ. 38, 5666.
Galloway, S., 2009. Simulation techniques to bridge the gap between novice and compe-
tent healthcare professionals. Online J. Issues Nurs. 14, 19.
Gliva-McConvey, G., 2009. Denition of an SP.
Gough, K., Happell, B., 2009. Undergraduate nursing students' attitude to mental health
nursing: a cluster analysis approach. J. Clin. Nurs. 18, 31553164.
Happell, B., 2008. Changing their minds: using clinical experience to convert undergrad-
uate nursing students to psychiatric nursing. Int. J. Psychiatr. Nurs. Res. 14,
17761784.
Hermanns, M., Lilly, M.L., Crawley, B., 2011. Using clinical simulation to enhance psychi-
atric nursing training of baccalaureate students. Clin. Simul. Nurs. 7, e41e46.
Hetzel-Campbell, S., Daley, K., 2013. Simulation Scenarios for Nurse Educators: Making It
Real. second ed. Springer, New York.
Hoadley, T., 2009. Learning advanced cardiac life support: a comparison study of the ef-
fects of low- and high-delity simulation. Nurs. Educ. Perspect. 30, 9198.
I.B.M. Corp, 2013. IBM SPSS Statistics for Windows. IBM Corp, Armonk, NY.
Iezzoni, L.I., Ramanan, R.A., Lee, S., 2006. Teaching medical students about communicating
with patients with major mental illness. J. Gen. Intern. Med. 21, 11121115.
Jeffries, P.R., Rizzolo, M.A., 2006. Designing and Implementing Models for the Innovative
Use of Using Simulation to Teach Nursing Care of Ill Adults and Children: A National,
Multi-site, Multi-method Study. National League for Nursing, New York, NY.
Jeffries, P.R., Rogers, K.J., 2007. Theoretical frameworks for simulation design. In: Jeffries,
P.R. (Ed.), Simulation in nursing education: From conceptualization to evaluation. Na-
tional League for Nursing, New York, NY.
Kaddoura, M., 2010. New graduate nurses' perceptions of the effects of clinical simulation
on their critical thinking, learning, and condence. J. Contin. Educ. Nurs. 41, 506516.
Kameg, K., Mitchell, A.M., Clochesy, J., Howard, V.M., Suresky, J., 2009. Communication
and human patient simulation in psychiatric nursing. Issues Ment. Health Nurs. 30,
503508.
Kameg, K., Howard, V.M., Clochesy, J., Mitchell, A.M., Suresky, J.M., 2010. The impact of
high delity human simulation on self efcacy of communication skills. Issues
Ment. Health Nurs. 31, 315323.
King, J., 2012. Nursing Student Satisfaction and Self-condence as Related to High-delity
Simulation, Nursing. Ball State University Muncie, Indiana.
Knudson, L., 2013. Integrating simulation into student learning experiences. AORN J. 97,
56.
Kolb, D.A., 1984. Experiential Learning: Experience as the Source of Learning and Devel-
opment. Prentice-Hall, Edgewood Cliffs, New Jewsey.
Lehr, S.T., Kaplan, B., 2013. A mental health simulation experience for baccalaureate stu-
dent nurses. Clin. Simul. Nurs. 9.
Liaw, S.Y., Koh, Y., Dawood, R., Kowitlawakul, Y., Zhou, W., Lau, S.T., 2014. Easing student
transition to graduate nurse: a SIMulated professional learning environment (SIM-
PLE) for nal year student nurses. Nurse Educ. Today 34, 259264.
Lin, E.C., Chen, S.L., Chao, S.Y., Chen, Y.C., 2013. Using standardized patient with immedi-
ate feedback and group discussion to teach interpersonal and communication skills
to advanced practice nursing students. Nurse Educ. Today 33, 677683.
Lisko, S.A., ODell, V., 2010. Integration of theory and practice: Experiential learning theory
and nursing education. Nursing Education Perspectives 31, 106108.
Martin, C.T., Chanda, N., 2016. Mental health clinical simulation: therapeutic communica-
tion. Clin. Simul. Nurs. 12, 209214.
McGaghie, W.C., Issenberg, S.B., Petrusa, E.R., Scalese, R.J., 2006. Effect of practice on
standardised learning outcomes in simulation-based medical education. Med. Educ.
40, 792797.
National League for Nursing, 2006. Designing and Implementing Models for the Innova-
tive Use of Simulation to Teach Nursing Care of Ill Adults and Children: A National,
Multi-site, Multimethod Study. National League for Nursing, New York.
Polit, D.F., 2010. Statistics and Data Analysis for Nursing Research. second ed. Pearson Ed-
ucation Inc, Boston.
Robinsons, J.E., 2009. 10 suggestions for orienting foreign-educated nurses: an integrative
review. J. Nurses Staff Dev. 25, 7783.
Robinson-Smith, G., Bradley, P.K., Meakim, C., 2009. Evaluating the use of standardized
patients in undergraduate psychiatric nursing experiences. Clin. Simul. Nurs. 5,
e203e211.
Rowles, C.J., Russo, B.L., 2009. Strategies to promote critical thinking and active learning.
In: Billings, D.M., Halstead, J.A. (Eds.), Teaching in nursing; A guide for faculty, 3rd
ed. Saunders Elsevier, St Louis, MO, pp. 238261.
Shawler, C., 2008. Standardized patients: a creative teaching strategy for psychiatric-
mental health nurse practitioner students. J. Nurs. Educ. 47, 528531.
Shemanko, G., Jones, L., 2008. To simulate or not to simulate: that is the question. In: Kyle,
R., Murray, W. (Eds.), Clinical Simulation: Operations, Engineering and Management.
Elsevier, Inc, New York.
Shepherd, C.K., McCunnis, M., Brown, L., Hair, M., 2010. Investigating the use of simulation
as a teaching strategy. Nurs. Stand. 24, 4248.
Stuart, G.W., 2013. Principles and Practice of Psychiatric Nursing. 10th ed. Mosby Books,
St. Louise.
Szpak, J.L., Kameg, K., 2013. Simulation decreases nursing student anxiety prior to com-
munication with mentally ill patients. Clin. Simul. Nurs. 9, e13e19.
Wallace, P., 2007. Coaching Standardized Patients: For Use in the Assessment of Clinical
Competence. Springer, New York.