Research September 2017, Vol. 9, No. 3 AJHPE 107 Quality nursing education must go beyond the imparting of information. Teaching strategies must link theory to practice, foster critical thinking, be relevant and stimulate students. The strength of a pedagogical approach is the intentional integration of knowledge, clinical reasoning, skills practice and ethical comportment across the nursing curriculum.[1] When students implement their skills and knowledge, they become aware of the professional role their career entails. Professional nursing, through the action of its members, demonstrates accountability and responsibility towards society.[2] Psychiatric nursing practice is a complex interpersonal process that requires a professional nurse to be interpersonally competent. This competence needs to be incorporated into a systematic process of care, which demands not only integration of theory and practice, but also an in-depth understanding of the complexity of human interaction. Therefore, it is important to thoroughly prepare psychiatric nursing students before their first encounter with a real patient. Nursing simulations using standardised patients (SPs) have proven effective in creating realistic learning opportunities to enhance the students’ competencies necessary for mental health clinical practice.[3] Increasingly, simulation is being seen as a way to support the transfer of theory to practice and there is evidence that simulated contextual practice can prepare professionals for safe practice. Furthermore, evidence suggests that exposure to simulation decreases anxiety towards clinical practice among student nurses.[4] The process of simulated practice learning can help students to develop confidence, professional aptitude and competence before they deliver nursing care to a real patient.[5] Psychiatric nursing is often not the ultimate goal of students when enrolling in a nursing course and they may experience more anxiety due to their unfamiliarity with the psychiatric setting.[6] SP simulation can assist these students by decreasing their anxiety and increasing their confidence. An SP is a person who acts as a patient in a standardised manner. Not only do SPs present the specified healthcare scenario, they also give constructive feedback to the students. SPs can teach student nurses to take a patient history, perform a mental status examination, practise psychiatric interventions and develop communication skills.[7] Several challenges in psychiatric nursing education can be addressed with SP simulation. One can ensure that all students are exposed to the same clinical situation or experience, and a specific situation or diagnosis is available on demand without having to wait for it. Students receive realistic feedback from a simulated patient in an honest and objective way, which is not easily available in the clinical practice situation.[8] Simulation as a learning strategy is new to South African (SA) nursing education, and therefore scenarios need to be developed to be aligned with learning needs. Research in the use of SPs in undergraduate nursing in SA, especially in psychiatric nursing, is sparse, but evidence suggests that it is an effective learning strategy.[9] The question is whether the scenarios for psychiatric nursing that we develop address the student nurses’ learning needs. Objective It was deemed necessary to investigate the undergraduate student nurses’ learning experiences after SP simulation. The purpose of this study was to explore and describe undergraduate nursing students’ experiences of conducting a psychiatric assessment on an SP presenting with a mental health problem. Background. Nursing education needs to adapt to be relevant to student nurses’ learning needs. This study investigates the use of standardised patients (SPs) in a simulated patient interview as a learning strategy to bridge the theory-practice gap. Simulation helps students to develop skills such as communication, higher cognitive thinking, decision-making and problem-solving. There is evidence to support the use of SP case scenarios to enable students to develop their clinical and interpersonal skills in a controlled environment before encountering patients in a clinical setting. Objective. To explore and describe students’ experiences of the developed SP scenario for the mental health nursing interview. Methods. A qualitative approach was taken and data were gathered using structured open-ended questions to gather information from 33 under- graduate nursing students after they encountered the SP simulation. Participants’ responses were thematically analysed. Results. Nursing students experienced the simulation as challenging, but felt that being able to practise their skills within a safe simulated environment built confidence. They indicated that the experience was not only enjoyable, but that it helped them to integrate theory with practice, develop communication skills and feel professional. Conclusion. SP-simulated practice combined with classroom teaching is important in improving nurses’ professed ability to respond to patients’ needs. Nursing students need to be interpersonally competent before engaging with mental health users. SP-simulated learning helps student nurses to participate actively in a positive learning process; they then begin to understand the need for linking theory with practice. Afr J Health Professions Educ 2017;9(3):107-110. DOI:10.7196/AJHPE.2017.v9i3.806 Standardised patient-simulated practice learning: A rich pedagogical environment for psychiatric nursing education A Jacobs, MSocSc Nursing; I Venter, PhD (Nursing) School of Nursing, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: A Jacobs (jacobsac@ufs.ac.za) This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. Research 108 September 2017, Vol. 9, No. 3 AJHPE Methods This is a qualitative descriptive study that explored nursing students’ experiences. An open-ended questionnaire consisting of five questions aimed to explore student nurses’ learning experiences. An explorative interview that acted as a pilot study was conducted with students who had participated in an SP simulation earlier in the year. This was to ensure that the questions were formulated in a manner that was clear and would elicit the appropriate responses. The questions were refined after the interview. Population and sampling The study population comprised 34 fourth-year student nurses registered in the baccalaureate nursing programme. A purposive sampling technique was used and 33 student nurses, who signed informed consent forms, comprised the unit of analysis. The inclusion criteria were registration in the psychiatric nursing module and having participated in the SP simulation. SP-simulated learning process As soon as possible after the procedure of conducting a psychiatric assessment had been taught, the students were exposed to an SP learning experience related to the theory. The simulation laboratory has individual interview rooms, allowing for 7 students to be accommodated simultaneously. On arrival, small groups of 7 students were briefed on the scenario and the outcomes, after which they participated in the SP simulation. Directly after the conclusion of the simulation, students were given feedback by the SPs on how they experienced the nursing care (from a patient’s point of view), which was followed by a debriefing session led by an experienced facilitator. The debriefing questions were based on Pendleton’s method, which assists the students as a peer group to reflect on their own learning while exploring the link between theory and practice.[10] For simulation to be effective, its authenticity must reflect the clinical situation as well as possible.[11] We use senior drama students of the Department of Drama and Fine Arts, who have been briefed on and trained in the scenario. In the case reported here the nursing students had to assess SPs who portrayed a student suffering from depression. They were given the following written instructions and objectives that had to be achieved: Do a psychiatric assessment of a mental healthcare user in this clinic by means of: • an interview (structured and unstructured) • observation • demonstrating interpersonal skills to lay the foundation of a relationship of trust • completing the psychiatric assessment form (included). After receiving the instructions and having had an opportunity to ask for clarification, the students interviewed the SPs. Data collection Directly after the debriefing session the students were asked to complete the following open-ended questionnaire: • How did you emotionally (personal and professional) experience the participation in the SP scenario? • What in the scenario did you experience as most valuable and what can you do differently next time? Please motivate your answer. • How did the SP experience help you in closing the gap between theory and practice and in which area in this learning experience did you benefit most? Please explain your answer. • How will this SP experience help you in the working environment? Please explain your answer. • What suggestions can you make in order for us to give you a better learning experience? Data analysis As this was a qualitative study, the authors adhered to the acknowledged inductive data analysis as described by Creswell,[12] according to the following steps: examining the patterns of meaning; categories and themes; and working back and forth between the themes and the data. Trustworthiness Trustworthiness is addressed by adhering to the principles of credibility, dependability, confirmability and transferability, according to Creswell.[12] By describing the stated parameters, using purposive sampling and an explorative interview, credibility was enhanced. Triangulation of data from all the groups increased the confirmability of the results, and an indepen- dent co-coder corroborated the trustworthiness of the study. Finally, a literature search was conducted as a basis for comparing, contrasting and contextualising the findings of the data. Ethical principles The researchers adhered to the ethical principles of beneficence, respect for human dignity and justice. The participants were informed about the study and asked to sign a document indicating that they participated voluntarily and that they had been informed about the nature of the research.[12] The questionnaire was completed anonymously. The necessary institutional permission (ref. no. ECUFS NR 34/2011) was obtained to conduct this research. Results and discussion Six themes emerged from the participants’ responses, i.e. positive learning experience, realistic and safe environment, integrating theory with practice, professionalism, confidence and processing skills in communication. Theme 1: Positive learning experience Many of the participants stated that they remembered more from a simulation session than from a lecture. In the process they found learning to be enjoyable, exciting and motivating. The following responses are evidence of this: ‘Best way of education.’ ‘I learned more in this situation than just sitting in a class listening to people talking about the work.’ ‘Learned more in one hour in the lab than three hours of lecture, because you’re having fun.’ ‘I really enjoyed it, I felt emotionally calm and content; a little bit of stress but it went away quickly.’ ‘It was great and motivating.’ A recurring theme was that the participants wanted more time in the simulation suite because it was challenging and pleasant: ‘It was challenging but joyful. It was good to have practical experience.’ ‘Very exciting to be in a new situation not knowing what to do or what to expect.’ Research September 2017, Vol. 9, No. 3 AJHPE 109 ‘Wonderful experience. Allow us to evaluate our competence.’ ‘The experience was really exciting and good. It really made me put myself in the situation and it also helped trigger my mind.’ Shawler[13] describes SP simulation as a creative teaching strategy for psychiatric nursing and proclaims simulation use as important to ensure competency and quality nursing education. Functioning at a high cognitive level is required from students, as they learn to elicit information from patients with mental disorders in a controlled, realistic and safe environment. Theme 2: Realistic and safe environment To comply with the requirements of an SP learning experience it is important to create a realistic but safe environment. Campbell and Daley[14] describe three levels of enacting a reality-based simulation. First, the simulation must seem credible to the students. They need to feel the responsibility of a nurse providing nursing care to the patient and acknowledge their actions in this regard. Second, the simulation must address the teaching outcomes of the module; and third, the simulation must help the student nurse to retrieve the theory and to integrate it into practice. The participants commented on the realism of the situation and also stated that they felt free to develop their skills: ‘The fact that the patient was real. I got a chance to like really put my skills into practice, my communication skills and I also liked the environmental setting. It really ensured privacy and it instilled confidence in me.’ ‘The experience was realistic enough to implement all the aspects of theory. Very good!!’ The feedback from the ‘patient’ (SP) had a definite impact on the students’ learning. The students learned how the SPs experienced the encounter from a patient’s point of view and the SP made suggestions to help the student to be more competent in the future: ‘The chance to be me in the scenario and to deal with the patient in the same way as I would in practice and the honest feedback given after the session.’ Obtaining insight into how one is perceived by the patient is invaluable. Patients often do not know what the correct actions are – they only know how they experience the nurse. This kind of feedback is special because it rarely occurs in clinical practice. It is awkward to ask for this kind of feedback, as patients might not be able to or be too intimidated to convey their perceptions clearly and openly. SP feedback is a powerful teaching strategy to change students’ behaviour.[15] Theme 3: Integrating theory with practice Through integration of theory and practice, student nurses’ skills in health promotion, counselling, empathetic communication, and health screening improve, and they will adhere to practice guidelines.[13] The theory made more sense when they could apply their knowledge in a practical session. It is a way of cementing the theory and ingraining the knowledge and skills. The essentiality of a thorough theoretical grounding for skills is instilled in the students’ understanding and approach to practice: ‘Making the knowledge and skill your own.’ ‘It was of great value. It lets you think out of the box and generate your own way of approaching a patient and what you want to achieve.’ ‘It really helped me link what I learned during the week in class into practice now (today).’ ‘With the theory you learn more of what may be but with the practical part you get to bring what theory taught you and do it practically.’ The participants found they could link theory and practice. Theme 4: Professionalism McCormack and McCance[1] describe a professionally competent person as one who has skills that reflect a holistic approach, demonstrating knowledge and attitudes in a person-centred manner. One of the principles of practice in simulation is to encourage professional behaviour.[9] The SP learning situation gave the participants the opportunity to build a therapeutic relationship with the patient – experiencing themselves as professional nurses. The following responses indicated that the participants had started the process of building a therapeutic relationship with the patient, managing the patient’s emotions as well as their own: ‘Fact that the patient acted the scenario out, really is valuable because you feel you are with a real patient, which then automatically changes your perception with [sic] the whole scenario. You then start being serious and do your optimum best in bringing out the professionalism in you.’ ‘In the practical part I gained a lot and in learning the standards of professionalism.’ ‘It was really nice because the patient (actor) really looked real. That showed me the manner of professionalism I should have.’ Many participants commented on nursing being a hands-on profession, with one respondent suggesting: ‘I know I will not forget now as practice makes perfect.’ Milisen et al.[16] indicate that a person’s self-image and self-respect influence his or her professional aptitude. Student nurses will move towards independence and then gain experience, confidence and autonomy. Theme 5: Confidence As stated above, confidence is very important for the development of skills, and the SP experience gave the students just that: ‘It showed me where I should do more reading and practice. But gave me confidence to do it.’ ‘The feedback from the patient gave me confidence in doing the same in practice and to correct my mistakes.’ ‘It helped me build more confidence practising what I have learned in almost a real situation.’ ‘I felt more comfortable in doing this and the teaching method is more relevant to the subject, it also brings confidence.’ ‘I learn self-confidence, interpersonal skills, and patient-interaction skills.’ Students who were exposed to a simulation learning approach found that their learning needs were met and they experienced increased confidence; in the process the safe practices of individuals were improved. Confidence is closely linked to independence and the motivation to learn. SP-simulated learning ensures an interactive, safe and productive learning environment that fosters student nurses’ security and confidence.[14] Theme 6: Processing skills in communication Student nurses need to practise their verbal communication in a nurse-patient relationship for them to grow and develop from novice to expert. They need to be aware of how their own behaviour affects the patient and that Research 110 September 2017, Vol. 9, No. 3 AJHPE communication is essential to understand the patients’ needs with regard to providing effective nursing care.[2] The importance of communication skills in nursing, and especially in psychiatric nursing, is critical. The participants reflected on their own skills and limitations, gaining an understanding of their abilities. In the process they discovered the value of empathy and listening skills: ‘Being an active listener is very important. Even hearing what is not being said.’ ‘Next time I will try to not repeat questions and give more attention or active listening to my patient in order to create trust between us.’ ‘Active listening to the patient such that I got absorbed in her story and went beneath just her answers but what she was communicating to me as well on a deep personal level.’ The value of therapeutic communication is a key component in a therapeutic relationship. Shawler[13] advises students to examine their own verbal and non-verbal communication. Conclusion Nursing educators need to be aware of their students’ learning needs and that the use of different learning strategies will help the students to gain knowledge and master skills. The integration of nursing theory with practice is crucial for becoming independent, autonomous registered nurses. SP-simulated learning helps student nurses to participate actively in a positive learning process and to understand the need for linking theory with practice. Nursing students need to be well grounded in therapeutic communication before engaging with mental health users. By providing a realistic, true-to-life experience for the development of competence in clinical skills, students are assisted to understand how they need to function in clinical practice. This allows them to acquire and process skills in communication and gain confidence in a safe environment in which they can learn by making mistakes, thus enhancing patient safety. The learning experience should include opportunities to question personal frames of reference that could hinder therapeutic engagement. Considering the limited research on the use of SPs in mental health nursing, especially in Africa, it was important to know whether the scenario resulted in effective learning. We can be cautiously confident that the scenario rendered a useful learning experience, as the students clearly stated that they found the experience very useful to master the skills necessary for a clinical situation. Further research should be done on the transfer of SP-simulated learning to clinical practice. Recommendations Future studies should encompass the views of more training schools regarding the use of simulation as a learning strategy. The perceptions of nursing edu- cators and staff in clinical practice, who interact with student nurses, should be ascertained so that potential shortcomings can be identified and addressed. Study limitations The data are closely bound to the context and are therefore not generalisable. Only students of one institution in a single study year were involved. This limits the broader applicability of the results even further. Acknowledgements. We wish to thank the School of Nursing, University of the Free State, for financial and logistical support, as well as the students who participated in the study. Author contributions. AJ: primary researcher, pilot study for a PhD dissertation. IV: supervisor, co-coding and co-author of article. Funding. None. Conflicts of interest. None. 1. McCormack B, McCance T. Person Centred Nursing: Theory and Practice. Oxford: Wiley-Blackwell, 2010:41-84. 2. Benner P, Sutphen N, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass, 2010:155-167. 3. Jacobs AC, van Jaarsveldt DE. ‘The character rests heavily within me’: Drama students as standardized patients in mental health nursing education. J Psychiat Mental Health Nursing 2016;23(3-4):198-206. https://doi. org/10.1111/jpm.12302 4. Lehr ST, Kaplan B. A mental health simulation experience for baccalaureate student nurses. Clin Simulation Nursing 2013;9(10):e425-e431. https://doi.org/10.1016/j.ecns.2012.12.003 5. Berragan L. Conceptualising learning through simulation: An expansive approach for professional and personal learning. Nurse Educ Pract 2013;13(4):250-255. https://doi.org/10.1016/j.nepr.2013.01.004 6. Jansen R, Venter I. Psychiatric nursing: An unpopular choice. J Psychiat Mental Health Nursing 2015;22(2):142-148. https://doi.org/10.1111/jpm.12138 7. Szpak JL, Kameg KM. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clin Simulation Nursing 2013;9(1):e13-e19. https://doi.org/10.1016/j.ecns.2011.07.003 8. Anderson M, Holmes TL, LeFlore JL, Nelson KA, Jenkins T. Standardized patients in educating student nurses: One school’s experience. Clin Simulation Nursing 2010;6(2):e61-e66. https://doi.org/10.1016/j.nedt.2015.03.004 9. Doolen J, Giddings M, Johnson M, de Nathan G, Badia OL. An evaluation of mental health simulation with standardized patients. Int J Nursing Educ Schol 2014;11(1):1-8. https://doi.org/10.1515/ijnes-2013-0075 10. Timmis C, Speirs K. Student perspectives on post-simulation debriefing. Clin Teach 2015;12(6):418-422. https:// doi.org/10.1111/tct.12369 11. Davis S, Josephsen J, Macy R. Implementation of mental health simulations: Challenges and lessons learned. Clin Simulation Nursing 2013;9(5):e157-e162. https://doi.org/10.1016/j.ecns.2011.11.011 12. Creswell JW. Research Design. 4th ed. London: Sage, 2014:183-213. 13. Shawler C. Standardized patients: A creative teaching strategy for psychiatric-mental health nurse practitioner students. J Educ 2008;47(11):528-531. https://doi.org/10.3928/01484834-20081101-08  14. Campbell SH, Daley KM. Simulation Scenarios for Nurse Educators. New York: Springer, 2009:8-10. 15. Wallace P. Coaching Standardized Patients for Use in the Assessment of Clinical Competence. New York: Springer, 2007:216-218. 16. Milisen K, de Busser T, Kayaert A, Abraham I, de Casterlé BD. The evolving professional nursing self-image of students in baccalaureate programs: A cross-sectional survey. Int J Nursing Studies 2010;47(6):688-698. https:// doi.org/10.1016/j.ijnurstu.2009.11.008  Accepted 13 December 2016. https://doi.org/10.1111/jpm.12302 https://doi.org/10.1111/jpm.12302 https://doi.org/10.1016/j.ecns.2012.12.003 https://doi.org/10.1016/j.nepr.2013.01.004 https://doi.org/10.1111/jpm.12138 https://doi.org/10.1016/j.ecns.2011.07.003 https://doi.org/10.1016/j.nedt.2015.03.004 https://doi.org/10.1515/ijnes-2013-0075 https://doi.org/10.1111/tct.12369 https://doi.org/10.1111/tct.12369 https://doi.org/10.1016/j.ecns.2011.11.011 https://doi.org/10.3928/01484834-20081101-08 https://doi.org/10.1016/j.ijnurstu.2009.11.008 https://doi.org/10.1016/j.ijnurstu.2009.11.008