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Kim, Kim, Lim, Chang, Lee, and Kim: A Systematic Review and Meta-Analysis of Studies on Psychiatric Nursing Simulation Program-Focused on Scenario

Abstract

Purpose

This study aims to systematically review the literature and conduct a meta-analysis to thoroughly analyze the outcomes of studies on simulation programs in psychiatric nursing.

Methods

We conducted an initial search from January 1, 2000, to September 30, 2023, using databases such as PubMed, EMBASE, CINAHL, the Cochrane Library, and Web of Science. A total of 2,571 articles were reviewed based on inclusion and exclusion criteria. We selected 35 articles for systematic literature review and subjected 20 of them to meta-analysis. Data analysis was conducted using descriptive statistics and the Comprehensive Meta-Analysis program.

Results

The number of psychiatric nursing simulation programs has increased since 2015. The most common programs used Standard Patients (SP), but studies using Virtual Reality (VR), audio, video, and other methods have recently been reported. The programs addressed various mental health issues, including depression, suicide, violence, alcohol problems, and mood disorders. Overall, considering all the studies, a significant effect was observed with a pooled Hedges’s g value of 0.56 (95% CI: 0.35~0.78; p<.001).

Conclusion

These findings highlight the importance of incorporating simulation-based education into nursing curricula to equip professionals with the skills to provide high-quality care to individuals with mental health problems. Further research is needed to explore the long-term benefits of these educational interventions on patient care.

INTRODUCTION

Globally, there is an increase not only in the aging population and the prevalence of chronic illnesses but also in the incidence of mental disorders. The prevalence of mental disorders characterized by significant impairment in cognition, emotional regulation, or behavior was approximately 1 in 8 individuals in 2019[1]. However, with the onset of the COVID-19 pandemic in 2020, the rates of anxiety and major depressive disorders increased by 26% and 28%, respectively, within a year [1]. As a result of these trends, the role of experts in the field of mental health is becoming increasingly crucial. Moreover, with the rapid integration of core technologies of the 4th Industrial Revolution into the healthcare sector, there is a demand for advanced education and training [2]. In the field of nursing education as well, there are efforts to attempt with various teaching methods to meet these contemporary demands and foster the development of competent nurses.
Nursing education is designed to prepare graduates to become proficient nurses, incorporating diverse coursework for theoretical knowledge and clinical practice. Clinical practice integrates theoretical knowledge into practical situations, enhancing graduates’ adaptability to clinical settings and boosting their confidence as nurses [3]. The effectiveness of clinical practicum often depends on the exposure to diverse clinical cases. However, due to the unpredictable nature of clinical situations, there are challenges in conducting planned practical training compared to theoretical education [4].
Psychiatric nursing practicum, in particular, provides students with opportunities to build relationships with individuals with mental disorders. It is an essential process that fosters confidence and trust in their interactions [5]. However, nursing students encounter heightened stress in their clinical practice of psychiatric nursing, driven by prejudices, fear, and anxiety toward mental illnesses [6,7]. Additionally, while they encounter a diverse array of patient interactions, faculty members may not consistently observe these encounters, limiting opportunities for crucial feedback and reflection [8]. Furthermore, as awareness of patient safety and rights continues to rise, nursing students find diminishing opportunities for handson nursing experiences. The unexpected situation of the COVID-19 pandemic has resulted in restrictions on practice in psychiatric wards or mental health welfare centers. As a result of these factors, nursing students have experienced a reduction in opportunities to establish trust relationships with individuals with mental disorders and practice and learn communication skills [9].
Simulation program can be valuable in addressing these issues. It promotes experiential learning and reflective practice, offering timely feedback. It proves especially valuable when addressing challenging and anxiety-inducing clinical scenarios, enhancing students’ clinical, critical, and reflective thinking [10,11]. Nevertheless, implementing simulation program remains challenging for educational institutions, mainly due to the logistical constraints associated with both physical and human resources, especially when dealing with large class sizes [11]. In mental health nursing curriculum, a vital learning objective is to build therapeutic relationships with clients and promote their mental well-being through effective therapeutic communication [3]. Additionally, it involves the prevention and management of stress stemming from illnesses [3]. To achieve these learning objectives in mental health nursing, it is essential to implement strategies that effectively leverage the advantages of simulation education while ensuring efficient operation. To accomplish this, the first step is to systematically review the current status of simulation programs in the psychiatric nursing field and evaluate their effectiveness.
Existing systematic literature reviews on mental health nursing simulation programs have either focused exclusively on nursing students [12,13] or restricted their scope to healthcare staff in acute care hospitals, specifically targeting programs for certain psychiatric behavioral symptoms [14]. Piot and colleagues [15] conducted a systematic review (SR) and meta-analysis of simulation education literature, encompassing nursing students and graduated nurses. However, the literature was limited to sources up until August 2020.
Currently, various information and communication technologies, such as artificial intelligence and augmented reality, are rapidly advancing every year [2], influencing the methods of simulation education. Therefore, reviewing and evaluating mental health nursing simulation programs at this time can contribute to the development of effective educational strategies for mental health nursing practice amid evolving trends.

METHODS

1. Research Design

This study aims to conduct a SR and meta-analysis with the primary objective of comprehensively examining the research findings related to mental health nursing simulation programs.

2. Inclusion and Exclusion Criteria for the Literature

This study was conducted following the guidelines outlined in the Cochrane handbook for SR of interventions 5.1.0 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (https://prismastatement.org/PRISMAStatement/, 2020). After compiling a list of studies retrieved through the databases, the references were organized using the citation management program, EndNote X9. The specific literature inclusion criteria were: 1) Studies measuring the educational effectiveness of simulation programs in the field of psychiatric nursing, 2) Studies targeting nurses or nursing students, 3) Studies including randomized controlled trials, experimental designs, or quasi-experimental research designs. Exclusion criteria for literature were as follows: 1) Studies outside the field of psychiatric nursing, 2) Studies not utilizing simulation, 3) Studies not targeting nurses or nursing students, 4) Studies that were not randomized controlled trials, experimental designs, or quasi-experimental research, 5) Gray literature (proceedings, theses, dissertations, etc.), 6) Studies with selectively reported experimental results, 7) Studies not written in Korean or English.

3. Search Strategies

The flow of this study was described using the PRISMA flow chart, outlining the step-by-step process of literature selection. The initial search period was from January 1, 2000, to September 30, 2023. The databases utilized were EMBASE, OVID Medline & PubMed, Web of Science, CINAHL, and the Cochrane Library. The search primarily focused on title/abstract, and the main keywords used for the search were (Nurse OR nurse practitioner OR Nursing Students) AND (Augmented reality OR Virtual reality OR Simulation OR standardized patient) AND (psychiatry OR psychiatric OR mental health OR mental illness) AND (Nursing) AND (Education).

4. Data Extraction

A total of 2,571 studies were initially identified through the following databases: 449 from EMBASE, 1,309 from PubMed, 492 from CINAHL, 166 from Cochrane Library, and 155 from Web of Science. Among these, there were 826 duplicate records. Following the duplication process, 1,745 records were examined by their titles and abstracts to remove any literature that did not fit within the defined scope. Consequently, 1,570 records were excluded, and a review of full-text was conducted for 149 records. After the full-text review, 140 records were further excluded based on the following criteria: 8 were not related to mental health (psychiatric) nursing, 3 did not utilize simulation, 11 did not focus on nurses or nursing students, 102 were not experimental studies, 7 were gray literature, 2 were not reporting research results, 3 were no control group (single group study), and 4 were duplicates. In the end, a total of 35 records were included for systematic literature review, and among them, 20 records were subjected to meta-analysis.

5. Data Evaluation

For organizing the literature, relevant information pertaining to research design, country, sample size, type of simulation, contents of simulation, variables, and results was extracted and recorded in a coding table.
The data collection and selection process involved four researchers independently reviewing all studies included in the analysis. In cases where opinions differed, the researchers reviewed and discussed the literature together, following the selection and exclusion criteria until a consensus was reached. When assessing the quality of the literature, evaluations for randomized controlled trials utilized the revised Cochrane Risk of Bias 2.0 (RoB 2.0) tool [16]. For nonrandomized comparative studies, the evaluation was carried out using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool [17], which examined eight items.

6. Data Analysis

All statistical analyses regarding the effect sizes of the specified program variables were performed using Comprehensive Meta-Analysis (CMA, V4) software version 4.0. The effect sizes were interpreted according to Hedges’ g criteria [18], classifying values of 0.2~0.5 as small, 0.5~0.8 as medium, and≥0.8 as large, while maintaining a significance level of 95%. Considering that meta-analyses entail consolidating findings from diverse studies to interpret the effect size, evaluating the uniformity or diversity of the research findings becomes pivotal. In this regard, we utilized the I-squared for assessment. The I-squared within the range of 0~24% indicate no heterogeneity, 25~49% signify low heterogeneity, 50~74% represent moderate heterogeneity, and values≥75% indicate high heterogeneity [19]. To investigate the possibility of publication bias, we employed both funnel plot analysis and the trim-and-fill method [20]. We suspected the presence of publication bias if the effect size, particularly the adjusted measure quantifying the intervention’s impact while accounting for potential publication bias using the trim-and-fill method, deviated by 10% or more compared to the previous estimate [20]. The adjusted effect size offers a more precise depiction of the genuine effect, accounting for any potentially absent studies. This approach entails the removal of asymmetric effect sizes from the initial funnel plot (trimming), followed by estimating missing studies presumed to have been excluded. This estimation relies on studies that fill in the gaps, aiming to attain symmetry around the newly calculated mean effect size [21].

RESULTS

1. General Characteristics of the Selected Studies

All the papers utilized for the SR were published in academic journals, summing up to a total of 35 articles. The publication year of the articles included in the SR was highest in 2017 with 8 articles (22.9%), followed by 2018 (14.3%) as the second highest. The years 2010, 2015, and 2022 had the lowest number of publications, each with only 1 article (2.9%). In terms of the nationality of the research papers, the USA led with 16 papers (45.7%). South Korea followed with 8 papers (22.9%), Australia with 4 papers (11.4%), the UK with 3 papers (8.6%), Türkiye with 2 papers (5.7%), and both Malaysia and Singapore had 1 paper each (2.9%). Regarding research design, Non-Randomized Controlled Trials (NRCT) were the most common at 22 articles (62.9%), followed by Mixed-Methods Studies (MMS) with 11 articles (31.4%). When it came to the participants of the studies, a vast majority of 28 papers (80.0%) were focused on Nursing Students (SN). Meanwhile, 4 papers (11.4%) exclusively targeted Registered Nurses (RN). There were also 3 papers (8.6%) that involved a mixed group comprising nurses and other professionals, such as psychiatrists, social workers, and occupational therapists. In relation to the type of simulation, the Standardized Patients (SP) simulation was the most prominent, represented in 24 studies (68.6%). Within this category, the High-Fidelity Patient (or Human) Simulation (HFPS) was the subject of 7 studies (20.0%), the Interprofessional Mental Health Simulation (IPMHS) was covered in 3 papers (8.6%), and the Video Module Simulation (VMS) was utilized in 3 studies (8.6%). Notably, out of the VMS studies, 2 (5.7%) implemented the Flipped Learning technique. Additionally, research on Voices Simulation (VS) encompassed 2 papers (5.7%), while Virtual Reality (VR) simulation was the focus of 3 papers (8.6%). Concerning the research environment, a majority of 28 studies (80.0%) were conducted offline, while 2 (5.7%) combined both online and offline methods, and 5 (14.3%) were solely online. Among the offline studies, the majority, 23 papers (65.7%), were based in school classrooms or simulation rooms. Furthermore, 4 studies (11.4%) used the simulation rooms of Professional Training Centers (PTC), and 1 study (2.9%) was conducted in a ward setting (Table 1).

2. Systematic Review of Studies on Psychiatric Nursing Simulation Program

In psychiatric nursing simulation scenarios, the most frequently measured variable was Knowledge, appearing in 18 out of 35 scenarios, making it the most common. Following Knowledge, Confidence was measured in 14 scenarios, and Attitude was the next most frequent, appearing in 7 scenarios. In studies on mental health nursing simulations, the most frequently utilized theoretical/conceptual framework was Jeffries’ Simulation Model, which was applied in 4 out of 35 studies. Following this, both self-efficacy Theory and Kolb’s theory of experiential learning were employed in 3 studies each. However, there were also 15 out of 35 studies that did not apply any theoretical/conceptual framework.
A total of 20 studies recorded statistics that could confirm effects. When standardizing the effect sizes of these studies to Hedges’s g (p), significant effects were revealed in several studies, including: Graves et al. (2020) (g=0.98, p=.040), Im & Jang (2019) (g=0.59, p=.017), Kameg et al. (2010) (g=0.64, p<.001), and Koetting & Freed (2017) (g=0.73, p<.001), among others. On the other hand, the following studies were found to have no statistically significant effects: Kunst et al. (2017) (g=0.19, p=.052), Lee & Jang (2021) (g=0.47, p=.074), Luebbert R et al. (2023) (g=0.11, p=.484), Soccio (2017) (g=0.09, p=.769), and Yang & Kang (2023) (g=0.35, p=.182), among others. These outcomes highlight the range of effectiveness across different studies, with some showing significant impacts and others indicating no significant effects. Detailed information can be found in Table 2.

3. Analysis of the Psychiatric Nursing Simulation Scenario

The content analysis of the psychiatric nursing simulation scenario is shown in Table 3.
In an analysis of psychiatric nursing simulation programs, the study by Evans et al. (2015) had the highest number of participants, totaling 256. This was followed by Ng et al. (2017) with 206 participants, and Luebbert R et al. (2023) with 178 participants. On the other hand, the study by Martinez (2017) had the fewest participants, with only 15. Lee & Choi (2023) had 20 participants, and Chambers et al. (2018) had 24 participants, making them among the studies with the lowest number of participants.
Among the types of simulators, SP was the most common, featured in 22 out of 35 papers, making it the most frequent. HFPS followed as the second most common, appearing in 8 papers. In studies using SP simulators, the most common approach involved hiring trained or professional actors for simulation training, accounting for 9 studies. There were 4 studies that utilized trained individuals or lay people as SP. However, there were also 5 studies that used SP patients but did not specify the type of SP involved.
The longest-running psychiatric nursing simulation program was conducted by Choi et al. (2016), which was operated over 5 weeks in two sessions. Similarly, the study by Lee et al. (2021) also ran a program over 2 weeks, spanning a total of 10 days, and divided into four sessions. On the other hand, the shortest psychiatric nursing simulation program was by Ng et al. (2017), which consisted of watching a 5-minute educational video. Next, the study by Ok et al. (2020) was the second shortest program, operating scenarios that lasted approximately 10~12 minutes.
Results of reviewing a total of 35 scenarios, scenarios that allow training in therapeutic communication skills during interactions with subjects showing significant psychiatric symptoms such as anxiety, depression, aggression, auditory hallucinations, delusions, and suicidal thoughts were the most common, with a total of 15 (42.9%). To train therapeutic communication skills, various psychiatric problems were covered, including psychological problems such as anxiety and depression, psychotic symptoms such as auditory hallucinations and delusions, and behavioral problems such as aggression and suicide attempts. Among them, there were two scenarios (5.7%) that applied both the nursing process and therapeutic communication to solve patients’ problems in emergency situations. Mental illnesses commonly observed in clinical settings include schizophrenia, bipolar disorder, depression, suicide, alcohol use disorder, and substance addiction. There were a total of 10 studies (28.6%) that evaluated the mental status of patients showing the main symptoms of these diseases and psychological problems such as anxiety and agitation and applied the nursing process to solve nursing problems. In these studies, SP mainly implemented the behavioral characteristics of patients, showing the main symptoms of each disease and the side effects of drugs, and applied the nursing process to solve the patients’ health problems. One was designed to evaluate patients and use therapeutic communication in emergencies. There were three scenarios (8.6%) dealing with suicide attempts, such as poisoning, hanging, and self-harm, impulsive behavior due to auditory hallucinations, and coping with emergencies due to alcohol withdrawal symptoms. This is a psychiatric emergency, and the ability to respond to it is crucial. It was a program to train. There was one scenario (2.9%) about the evaluation and response to a patient with complex psychiatric symptoms such as suicide and hallucinations along with physical problems such as fractures, diabetes, and respiratory problems that can be experienced in the emergency room. In addition, there were two studies (5.7%) that focused on auditory hallucination experiences that provided voices to understand the problem of auditory hallucinations and empathize with patients’ experiences. Four scenarios (11.4%) also dealt with collaboration between family members and experts in the field to treat mentally ill patients.
Out of a total of 35 studies, 16 had a control group. Among these 16 studies, 6 mentioned using conventional and traditional educational methods for the control group, including educational materials on depression. The remaining studies differentiated the educational methods between the experimental and control groups by using online lectures, video lectures, and other methods. Meanwhile, there were also 5 studies that did not specify what educational methods were provided to the control group, or if any were provided at all.

4. Risk of Bias

The quality assessment results of studies using ROB2 and ROBINS-I are as presented in Figure 1. The RCT studies analyzed by ROB2 totaled four, with the overall evaluation showing a low risk of bias in 75% of the cases and a moderate risk in 25%. However, some concerns were noted in specific domains, particularly in deviations from intended interventions. In contrast, the studies assessed by ROBINS-I numbered 31, making up the majority. The overall evaluation indicated varying levels of risk, with no studies showing a severe risk of bias. However, there were studies that exhibited serious bias in participant selection, and moderate risk was frequently observed in domains related to intended interventions. Overall, the assessment revealed that while many studies maintained a low or moderate risk of bias, there were recurring concerns in specific areas such as intended interventions and participant selection (Figure 1).

5. Results of a Meta-Analysis on Psychiatric Nursing Simulation Programs

The studies with the largest effect sizes were Martinez (2017) and Sarikoc et al. (2017) with Hedges’s g values of 1.47 (95% CI: 0.74~2.20; p<.001) and 1.15 (95% CI: 0.69~1.61; p<.001) respectively. On the other hand, no significant effects were observed in the studies by Choi et al. (2016), Kameg et al. (2021), Kunst et al. (2017), Lee et al. (2021), Lubbert et al. (2023), Soccio (2017), and Yang & Kang (2022). Overall, considering all the studies, the effect sizes (Hedges’s g) ranged from -0.16 to 1.47, with a pooled Hedges’s g value of 0.56 (95% CI: 0.35~0.78; p<.001), indicating a significant effect (Figure 2). The I-squared which measures the percentage of variation across studies that is due to heterogeneity rather than chance, was 86.80%. This high I-squared suggests substantial heterogeneity among the included studies. This indicates that the effect sizes vary significantly across studies, likely due to differences in study design, populations, interventions, and other factors. Such high heterogeneity warrants careful interpretation of the pooled effect size, as it reflects the variability in the effects of psychiatric nursing simulation programs across different contexts. The distribution of effect sizes, the confidence intervals, and the heterogeneity of the included studies are summarized in Figure 2.

6. Funnel Plot and Trim-and-Fill for the Publication Bias of the Studies

In our assessment of 20 studies through a funnel plot, we examined the symmetry to evaluate the presence of any publication bias. The funnel plot exhibited a generally symmetrical distribution around the central axis, suggesting an absence of publication bias. The outcomes of the trim-and-fill analysis further corroborated this by showing zero studies required trimming. This implies that none of the studies were deemed to have a biased representation that necessitated adjustment or exclusion. Consequently, the effect sizes and confidence intervals maintained their initial estimates. From this, we deduce that any potential publication bias in the included studies exerted negligible influence on the overall results, leaving the original findings on effect sizes and confidence intervals intact.

DISCUSSION

This study conducted a comprehensive analysis of simulation programs for psychiatric nursing for nursing students and nurses. Despite the recognized need to enhance psychiatric nursing competencies, there is a lack of research in developing and objectively evaluating the effectiveness of simulation training programs for psychiatric nursing. Research in this area is being conducted in various countries, including the United States and South Korea. Among the simulation education methods, the use of SP was the most common, exceeding 75% when including HFPS and IPMHS. Especially when compared to the results of a study analyzing pediatric nursing simulation programs, where SP accounted for only 7.0%, it can be said that SP simulation is a very meaningful educational method in psychiatric nursing [22]. SP simulation methods have been utilized to expand nursing students’ confidence and strengthen interprofessional collaboration [23-25]. Such SP simulation practices have provided an opportunity to become familiar with clinical situations before actual clinical experience, aiding in confidence and knowledge enhancement [23]. However, recent simulation programs are undergoing significant changes from traditional education methods, including incorporating advanced technologies such as VR. In the field of psychiatric nursing as well, there appears to be a need for the development of safer and more realistic immersive learning programs [22]. Especially in the area of psychiatric nursing, where communication and attitudes are crucial, it is necessary to provide a safe environment for students to practice and learn from mistakes without endangering real patients [26]. Despite these advantages, the application of VR in psychiatric nursing has still been inadequate. It seems that practical studies on the use of VR and other technologies are necessary for effective learning in the field of psychiatric nursing. To verify the effectiveness of psychiatric nursing simulation education, most looked at knowledge enhancement, followed by attitudes and confidence. Globally, the increase in mental health patients is posing a serious burden on healthcare professionals. Moreover, nurses who care for these patients are facing a shortage of psychiatric nurses due to negative perceptions of working in psychiatry, stress, and psychological burdens [3]. Nurses struggle with a lack of confidence, negative perceptions towards mental health patients, and unease from being unprepared when caring for mental health patients. There is a desperate need for practical education to address these issues.
The scenarios in the psychiatric nursing simulation studies included situations of auditory hallucination, delirium, depression, and suicide risk, which were reproduced by trained SP, inducing therapeutic communication, empathy, and actions from nurses or nursing students. These results were similar to the effects of SP simulation education in the field of psychiatric nursing confirmed in previous studies [23,24]. For instance, studies by Martinez [27] and Sarikoc et al. [28] showed significant improvements in confidence and self-efficacy among participants.
However, only about three studies in this analysis included crisis scenarios, such as suicidal crises, panic attacks, agitation, and acute psychotic disorders. These scenarios are crucial as they prepare medical professionals to act differently in crisis interventions compared to non-crisis situations. Effective psychotic crisis intervention requires setting boundaries and providing clear direction with a firm and confident attitude. Simulation education for these situations is essential, as it allows nursing students and nurses to practice and develop these critical competencies in a safe environment.
Most scenarios in the analyzed simulation programs, excluding those involving SP but including HFPS, VMS, and IPMHS, realistically depicted situations involving psychiatric patients with physical problems, such as fever, respiratory issues, or self-harm (Appendix 1-7, 12, 18, 25). The recent inclusion of VR technologies in simulation education methods is particularly useful in psychiatric nursing. VR allows for repetitive and progressive learning in a comfortable and safe environment, enhancing the learning experience and effectiveness of psychiatric nursing education.
The meta-analysis of this psychiatric nursing simulation program confirmed it to be an effective educational program through the integration of 20 studies. Particularly, the study by Martinez [27] showed a large effect size. Martinez [27] planned a simulation program that allowed nursing students to assess and apply nursing processes to schizophrenia patients expressing anxiety. The confidence of nursing students significantly increased after 4 hours of simulation. Sarikoc et al. [28] was an RCT that had students engage in therapeutic communication with a patient with suicidal ideation and depression or perform necessary crisis interventions for a patient with hallucinations, confirming their confidence and self-efficacy. It was also found to be very effective. Thirteen of the analyzed studies were confirmed to be effective, while seven did not show statistically significant effects.
Overall, psychiatric nursing simulations have been utilizing SP, predominantly employing trained actors. Additionally, the use of simulators such as HFPS was largely found in scenarios involving psychiatric patients with physical symptoms. The programs were generally aimed at improving therapeutic communication skills and confidence in nursing students and nurses when dealing with mental health patients. However, there remains a lack of standardized programs for SP in psychiatric nursing simulations, resulting in a lack of consistency due to individualized education and training. Efforts to standardize scenarios based on psychiatric nursing competencies appear to be necessary. Furthermore, the development of additional simulation training for crisis intervention for mental health patients is needed.

CONCLUSION

Based on the findings of this comprehensive analysis, simulation programs in psychiatric nursing have shown potential in enhancing the educational experience of nursing students and nurses. Particularly, some studies have indicated that utilizing SP can increase confidence and improve therapeutic communication skills, which are critical in psychiatric nursing. The incorporation of advanced technologies, such as VR, into simulation education may offer promising avenues for creating more realistic and immersive learning experiences, although further research is needed to confirm these effects without risking patient safety. While some studies showed no significant effects, the overall trend suggests that simulation programs can be effective in enhancing knowledge, attitudes, and confidence among participants. There is a recognized need for further development and standardization of simulation programs and scenarios that can adequately prepare nursing students and nurses for the complex and often crisisdriven environment of psychiatric care.
The findings highlight the potential role of simulation in psychiatric nursing education as a tool to address the shortage of psychiatric nurses and to equip them with the necessary skills and confidence to care for mental health patients effectively.

CONFLICTS OF INTEREST

The authors declared no conflicts of interest.

Notes

AUTHOR CONTRIBUTIONS
Conceptualization or/and Methodology: Kim, GM, Kim, EJ, Lim, JY, Jang, SJ, Lee, OK, & Kim, SK
Data curation or/and Analysis: Kim, GM, Kim, EJ, & Kim, SK
Funding acquisition: Kim, GM, Kim, EJ, Lim, JY, & Jang SJ,
Investigation: Kim, GM, Kim, EJ, Lim, JY, Jang, SJ, Lee, OK, & Kim, SK
Project administration or/and Supervision: Kim, GM
Resources or/and Software: Kim, GM, Kim EJ, & Kim, SK
Validation: Lim JY, Jang SJ, Lee OK, & Kim, SK
Visualization: Kim, GM, Kim EJ, & Kim, SK
Writing: original draft or/and review & editing: Kim, GM, Kim, EJ, Jang SJ, & Kim, SK

Fig. 1.
Risk of bias summary.
jkpmhn-2024-33-2-150f1.jpg
Fig. 2.
Total effect size.
jkpmhn-2024-33-2-150f2.jpg
Table 1.
General Characteristics of Selected Studies
Characteristics Categories n (%)
Year of publication 2010 1 (2.9)
2013 3 (8.6)
2015 1 (2.9)
2016 3 (8.6)
2017 8 (22.9)
2018 5 (14.3)
2019 2 (5.7)
2020 4 (11.4)
2021 4 (11.4)
2022 1 (2.9)
2023 3 (8.6)
Nationality USA 16 (45.7)
South Korea 8 (22.9)
Australia 4 (11.4)
UK 3 (8.6)
Türkiye 2 (5.7)
Malaysia 1 (2.9)
Singapore 1 (2.9)
Research design RCT 2 (5.7)
NRCT 22 (62.9)
MMS 11 (31.4)
Participants Nursing student 28 (80.0)
Registered Nurse 4 (11.4)
Nurse+Other professionas 3 (8.6)
Type of simulation SP 18 (51.4)
HFPS 2 (5.7)
SP/HFPS 4 (11.4)
SP/IPMHS 2 (5.7)
HFPS/IPMHS 1 (2.8)
VMS/FL 3 (8.6)
VS 2 (5.7)
VR 3 (8.6)
Research environment Offline School 23 (65.7)
PTC 4 (11.4)
Ward 1 (2.9)
On & offline 2 (5.7)
Online 5 (14.3)

HFPS=high-fidelity patient simulation; IPMHS=interprofessional mental health simulation; MMS=mixed methods study; NRCT=non-randomized controlled trials; PTC=professional training center; RCT=randomized controlled trials; SP=standardized patient; VMS=video module simulation; VR=virtual reality; VS=voices simulation.

Table 2.
Systematic Review of Studies on Psychiatric Nursing Simulation Programs
No Author (year) Design Country Variables Results Theoretical/Conceptual framework Hedges’s g (p)
1 Chaffin & Adams (2013) MMS (NRCT, P-P test, CA) USA Empathy Significant Tanner's clinical judgment model
2 Chambers et al. (2018) NRCT (P-P test) USA Knowledge None significant Jeffries' simulation model, MSR model Anon (developed by the Israel Center for Medical Simulation) 0.01 (.986)
Attitude Significant
3 Choi et al. (2016) MMS (NRCT, P-P test, CA) South Korea Empathy Significant NA
Mental illness prejudice None significant
Self-efficacy Significant
Satisfaction None significant
4 Corrigan et al. (2018) RCT USA Confidence Significant Gather analyze summarize framework
5 Donovan & Mullen (2019) NRCT (P-P test) USA Confidence Significant Constructivist learning theory
Satisfaction Significant
Preparedness Significant
6 Evans et al. (2015) MMS (NRCT, P-P test, CA) Australia Perception Significant Learning theory for adults
Knowledge Significant
7 Fernando et al. (2017) MMS (NRCT, P-P test, CA) UK Knowledge Significant NA
Attitude Significant
Confidence Significant
8 Goh et al. (2016) MMS (NRCT, P-P test, QED, CA) Singapore Satisfaction Significant John Dewey's experiential learning philosophy
Confidence Significant
9 Graves et al. (2020) NRCT (QED, P-P test) USA Attitude Significant NA 0.98 (.040)
10 Im & Jang. (2019) NRCT (RetS, QED, P-P test) South Korea Competence Significant Flipped learning model 0.59 (.017)
Communication Significant
Knowledge None significant
Satisfaction Significant
11 Kameg et al. (2010) NRCT (QED, P-P test) USA Self-efficacy Significant Self-efficacy theory 0.64 (<.001)
12 Kameg et al. (2013) NRCT (RMQED, P-P test) USA Knowledge None significant Kolb’s theory of experiential learning
13 Kameg et al. (2021) NRCT (QED, P-P test) USA Attitude None significant NA -0.16 (.112)
Satisfaction NA
Confidence NA
14 Kim & Choi (2022) NRCT (N.P-P test) South Korea Knowledge Significant Sharing explore notice support expansion model
Competence Significant
Self-efficacy Significant
15 Koetting & Freed (2017) NRCT (P-P test) USA Confidence Partial significant Self-efficacy theory 0.73 (<.001)
Knowledge Significant
16 Kowalski et al. (2017) MMS (NRCT, P-P test, FGI, CA) UK Confidence Significant NA
Attitude Significant
17 Kunst et al. (2017) MMS (NRCT, CPD, FGI, CA) Australia Confidence Significant Self-efficacy theory 0.19 (.052)
Ability Significant
Knowledge Significant
18 Lavelle et al. (2017) MMS (NRCT, P-P test, FGI, CA) UK Knowledge Significant NA 0.34 (.015)
Confidence Significant
Attitude Significant
19 Lee & Jang (2021) NRCT (RetS, P-P test) South Korea Knowledge Significant NA 0.47 (.074)
Performance None significant
20 Lee et al. (2021) NRCT (QED, P-P test) South Korea Knowledge Significant NA 0.43 (.045)
Communication None significant
Confidence None significant
Self-efficacy Significant
Problem-solving process Significant
Learning immersion None significant
21 Lee & Choi (2023) NRCT (P-P test) pilot study South Korea Burden Significant NA
Anxiety Significant
22 Luebbert R et al. (2023) NRCT (P-P test) USA Knowledge Significant NA 0.11 (.484)
Satisfaction Significant
23 Martin & Chanda (2016) NRCT (QED, P-P test) USA Confidence Significant Peplau's interpersonal relationship theory
24 Martinez (2017) NRCT (P-P test) USA Confidence Significant Kolb’s theory of experiential learning 1.47 (<.001)
25 Ng et al. (2017) NRCT (CSS, P-P test) Malaysia Attitude Significant NA 1.12 (<.001)
Help-seeking & Disclosure Significant
Social distance Significant
26 Ok et al. (2020) NRCT (N.P-P test, QED) Türkiye Anxiety Significant NA 1.05 (<.001)
Communication Significant
27 Olasoji et al. (2020) NRCT (CSD, P-P test) Australia Therapeutic engagement Significant Pendleton's feedback model
Assessment skills Significant
Preparedness Significant
28 Sarikoc et al. (2017) RCT (P-P test) Türkiye Motivation Partial significant NA 1.15 (<.001)
Perceived learning Significant
Self-efficacy Significant
Preparedness Significant
Anxiety Significant
Learning experience Significant
29 Seo & Kim (2020) NRCT (N.P-P test) South Korea Knowledge Significant Jeffries' simulation model 0.71 (.006)
Self-efficacy Significant
Performance Significant
30 Soccio (2017) MMS (RCT, PS, CA) Australia Confidence Significant NA 0.09 (.769)
Knowledge None significant
31 Speeney et al. (2018) NRCT (QED, P-P test) USA Competence Significant Jeffries' simulation model 0.71 (<.001)
Knowledge Significant
32 Szpak & Kameg (2013) NRCT (QED, P-P test) USA Anxiety Significant Jeffries' simulation model 0.74 (<.001)
33 Yang & Kang (2023) NRCT (p-p test) South Korea Learning satisfaction Significant NA 0.35 (.182)
confidence Significant
Critical thinking ability Significant
Learning self-efficacy Significant
Knowledge Significant
Communication Significant
34 Whited et al. (2021) MMS (NRCT, P-P test, CA) USA Knowledge Partial significant Kolb’s theory of experiential learning, good judgement model
35 Witt et al. (2018) MMS (RCT, P-P test, CA) USA Knowledge None significant Nursing education simulation framework, international nursing association clinical simulation, learning standards of best practice

CA=content analysis; CPD=convergent parallel design; CSD=cohort survey design; CSS=cross-sectional study; FGI=focus group interview; MMS=mixed methods study; NA=not available; NRCT=non-randomized controlled trials; N.P-P test=non-equivalent control group pre-post test; P-P test=pre-post test; PS=prospective study; QED=quasi-experimental design; RCT=randomized controlled trials; RetS=retrospective survey; RMQED=repeated-measures quasi-experimental design.

Table 3.
Analysis of the Psychiatric Nursing Simulation Program
No Author (year) No. of Ps Ps Type of simulation Role of SP Setting Duration Session Scenario content Learning objectives Program for Cont. or Comp.
1 Chaffin & Adams (2013) Exp.: 67 SN VS - Off line (school) 18~20 m 1 The "Hearing Voices" simulation aimed to enhance nursing students' empathy towards psychiatric patients, especially those experiencing auditory hallucinations. This simulation involved students performing simple tasks while experiencing simulated auditory hallucinations, helping them understand the difficulties faced by patients with mental health conditions. Experience of auditory hallucination NA
2 Chambers et al. (2018) Exp.: 12 SN SP Trained individuals Off line (school) 20 m 1 The scenario content involved a SP portraying a patient with chronic dementia who has recently developed symptoms of delirium and a SP acting as a family member who brings the patient to the emergency department. An interprofessional simulation was designed to improve nursing and medical students' ability to differentiate between dementia and delirium, a common challenge in healthcare. Interprofessional relationship Cont.: NI
Cont.: 12
3 Choi et al. (2016) Exp.: 22 SN SP Not specified Off line (school) 5 w 2 10-minute One-on-One Communication Simulation: This simulation was designed for students to practice therapeutic communication skills with clients experiencing common psychiatric symptoms such as anxiety, depression, aggression, hallucinations, and delusions. Four scenarios were provided, each focusing on a different set of symptoms to mimic diverse patient experiences in psychiatric settings. Therapeutic communication Cont.: NI
Cont..: 22 20-minute Complex Case Simulation: This scenario involved a more intricate case of an alcoholic patient experiencing withdrawal symptoms. The simulation was designed to cover not only therapeutic communication but also critical thinking in managing complex patient care. The scenario required students to interact with a simulated family member and healthcare team members, focusing on a patient who had been drinking heavily and was experiencing acute alcohol withdrawal symptoms and delirium tremens.
4 Corrigan et al. (2018) Exp.: 21 RN HFPS, SP - Off line (PTC) 30 m NA The fictitious scenario described a 26-year-old male Veteran previously deployed to a combat zone in Iraq and Afghanistan. He had a prior diagnosis of PTSD, amphetamine dependence, heroin dependence, and chronic back pain, and he now presents to the outpatient clinic to see his provider. Application of nursing process Cont.: Only provid scenarios Comp.: SP & not debriefing
Comp: 20
Cont.: 19
5 Donovan & Mullen (2019) Exp.: 160 SN SP Not specified Off line (school) 1 h NA The standardized patient scenario utilized for the simulation involved a patient experiencing depression following the recent death of a spouse. The focus was on ensuring students could engage in meaningful, therapeutic interactions with patients suffering from mental health issues, specifically depression in this context. Therapeutic communication NA
6 Evans et al. (2015) Exp.: 256 SN VS - Off line (school) 1h NA The scenario utilized iPods loaded with recordings developed by Janssen Pharmaceutica, simulating the experience of hearing distressing voices. The simulation aimed to replicate the auditory hallucinations often experienced by individuals with schizophrenia, including voices that were hostile, demeaning, and sometimes issued commands or made derogatory comments. Experience of auditory hallucination NA
7 Fernando et al. (2017) Exp.: 63 Nurse & Other Pro. SP, IPMHS Trained actors Off line (PTC) 1 d 1 Scenario 1: Assessment of a distressed patient with a first episode of psychosis in the Emergency Department, possibly due to auditory hallucinations and cannabis use, following a fall/jump from a window resulting in a potential leg fracture. Problemsolving physical and psychological problems NA
Scenario 2: De-escalation of the same patient due to acute agitation after admission to an inpatient general ward awaiting surgery for the leg fracture. Interprofessional approach
Scenario 3: Management of medical deterioration in the same patient, now transferred to an inpatient psychiatric unit.
Scenario 4: Assessment of suicidal ideation in a new patient in a General Practitioner's surgery, including engagement, risk assessment, and management planning.
Scenario 5: Recognition and management of delirium in the same patient following an Emergency Department presentation and admission for rehydration.
Scenario 6: Management of a difficult discharge and anxiety in the same patient, formulating collaborative discharge plans and addressing repeated hospital presentations.
8 Goh et al. (2016) Exp.: 95 SN SP Trained actors Off line (school) NA NA Constructing a scenario related to mental status examination and suicide risk assessment (MSE/SRA). Application of nursing process NA
9 Graves et al. (2020) Exp.: 9 Nurse & Other Pro. SP, IPMHS Not specified Off line (PTC) NA NA The simulation scenario developed for this study focused on an individual with a mental health diagnosis and with health/social issues that health professionals may encounter in an outpatient mental health setting. Interprofessional relationship Cont.: ME-IPC
Cont.: 111
10 Im & Jang. (2019) Exp.: 34 SN VMS, FL - On & Off line (school) 2h 6 Using the iPad® application called "Explain Everything" (version 3.2.0.1) for practical sessions, including six video modules covering topics such as orientation, therapeutic communication, schizophrenia, antipsychotic medications, and patient-provider communication. Therapeutic communication Cont.: TL
Cont.: 36
11 Kameg et al. (2010) Exp.: 38 SN HFPS, SP - Off line (school) NA NA Scenario 1: Involves Kim, a 30-year-old divorced white female admitted to the psychiatric unit with increasing anxiety and panic symptoms, possibly related to stress, financial difficulties, and suspected alcohol abuse. Students, playing the role of the nurse, were tasked with addressing Kim's immediate needs and concerns, emphasizing therapeutic communication techniques. Therapeutic communication NA
Scenario 2: Centers on Mrs. Smith, a 69-year-old married white female admitted to the psychiatric unit following a suicide attempt due to overwhelming depression, partly triggered by her husband's cancer diagnosis. This scenario aimed to provide students with an opportunity to practice communication skills focused on empathy, support, and safety assessment.
12 Kameg et al. (2013) Exp.: 35 SN HFPS - Off line (school) 8h over 4d NA Care of the Patient Experiencing Trauma Related to Intimate Partner Violence (IPV): This scenario placed students in an emergency department setting where they had to identify signs of IPV in a patient and navigate the care plan while dealing with the presence of an abusive partner. Application of nursing process NA
12 Kameg et al. (2013) Exp.: 35 SN HFPS - Off line (school) 8h over 4d NA Care of the Patient Experiencing Trauma Related to Intimate Partner Violence (IPV): This scenario placed students in an emergency department setting where they had to identify signs of IPV in a patient and navigate the care plan while dealing with the presence of an abusive partner. Application of nursing process NA
Care of the Patient Experiencing Postpartum Depression (PPD): Set in an outpatient clinic, this scenario focused on assessing a postpartum woman for signs of depression over a routine postpartum visit, demonstrating the integration of psychiatric evaluation in a primarily medical setting.
13 Kameg et al. (2021) Exp.: 97 SN SP Trained actors Off line (school) 1h NA Major Depressive Disorder Scenario: This scenario depicted an individual experiencing symptoms of major depressive disorder. Students were expected to conduct history gathering and employ therapeutic communication skills. Therapeutic communication NA
Bipolar Disorder Scenario: In this scenario, standardized patient actors portrayed patients suffering from bipolar disorder. The objective was similar, focusing on history taking and the provision of therapeutic communication.
Panic Disorder Scenario: The third scenario involved an individual with panic disorder. Students had to apply their knowledge and communication skills to interact effectively with the patient.
14 Kim & Choi (2022) Exp.: 10 RN SP Not specified Off line (school) 4 h 3 The simulation scenario began with a nurse meeting a female patient experiencing anxiety following an evacuation due to a disaster involving hazardous chemical leaks. The learner was tasked with providing one-on-one psychological support and nursing care to the standardized patient over a 12-minute period. This was followed by self-directed learning using a workbook on disaster mental health nursing and psychological support in a separate room. The scenario aimed to reflect a realistic situation that nurses might encounter in the aftermath of a chemical disaster, focusing on addressing the immediate psychological needs of adolescent patients. Application of nursing process Cont.: NI
Comp.: 10 Comp.: TL
Cont.: 10
15 Koetting & Freed (2017) Exp.: 59 SN VR - Online 50 m over 4d NA The simulations involved responding to a patient who was strangulated by a ligature, assessment and management of a benzodiazepine overdose, responding to a patient in hypovolemic shock due to self-inflicted laceration, and administering and subsequently managing a patient who has been rapidly tranquilized. Psychiatric emergency NA
16 Kowalski et al. (2017) Exp.: 105 Nurse & Other Pro. SP Trained actors Off line (PTC) 90~120 m NA Scenarios focused on practical issues that arise when working with the families and networks of patients with mental illness. Examples included managing challenging family dynamics in consultations, working with different belief systems around mental illness, and maintaining confidentiality when working systemically. Interprofessional relationship NA
17 Kunst et al. (2017) Exp.: 112 SN HFPS - Off line (school) 240~320 m NA The simulation scenarios were developed with an acute emergency nursing practice and acute mental health intervention focus. The patient role was portrayed by nurses with experience in mental health or emergency nursing and simulation education. Psychiatric emergency NA
17 Kunst et al. (2017) Exp.: 112 SN HFPS - Off line (school) 240~320 m NA Students were exposed to experiences such as undertaking an alcohol withdrawal assessment and communication in a challenging environment. The scenario was designed to engage students in clinical decision-making, particularly regarding the administration of medications with variable doses, and to encourage reflection on drug-seeking behavior versus clinical need. Psychiatric emergency NA
18 Lavelle et al. (2017) Exp.: 53 RN HFPS, IPMHS - Off line (ward) Half-day 8 Respiratory Arrest: Simulating a scenario where a patient experiences respiratory failure, requiring immediate intervention. Interprofessional relationship NA
Exp.: 37 Diabetic Hypoglycemia: A scenario depicting a patient with dangerously low blood sugar levels, necessitating quick identification and treatment.
Hanging: Simulating the emergency management of a patient who has attempted hanging, focusing on immediate life-saving measures and post-incident care.
Choking: A scenario involving a patient choking, emphasizing the need for rapid response and the application of first-aid measures to clear the airway.
19 Lee & Jang (2021) Cont.: 37 SN VMS, FL - Off line (school) 3h over 2w 4 Situation-Background-Assessment-Recomm endation (SBAR) simulation, which uses a flipped learning method, improves undergraduate nursing students’ academic performance and core competencies when applied in the mental health nursing practicum, as compared with traditional in-person simulations Application of nursing process Cont.: TL
Exp.: 35 Scenario 1: Schizophrenic patient on Clozapine with high fever
Scenario 2: Schizophrenia patient on Clozapine with abdominal
Scenario 3: Schizophrenic patient with diabetes mellitus complaining dizziness
Scenario 4: Schizophrenia patient on Clozapine with abdominal pain
20 Lee et al. (2021) Cont.: 33 SN VR - Online 10 d duaring 2w 4 Application of nursing process to depressed patients: adolescent depressive disorder, Menopausal depressive disorder, geriatric depressive disorder patients Application of nursing process Cont.: Educational materials on depression
Exp.: 10
21 Lee & Choi (2023) Cont.: 10 SN SP Trained individuals Off line 90 m NA The scenario used in the simulation involved a female SP presenting with moderate levels of anxiety and depressive mood over chemotherapy after a mastectomy. This scenario was designed to reflect a realistic situation that nurses might encounter in a general ward, requiring them to assess physical symptoms related to anxiety and depressive mood and provide initial nursing care to alleviate these symptoms. Application of nursing process Exp.: Simulation based education program
Exp.: 104 Cont: NI
22 Luebbert R et al. (2023) Cont.: 74 SN SP, HFPS Theater students Off line (school) 1h 8 Alcohol Withdrawal: A middle-aged adult experiencing symptoms of alcohol withdrawal. Application of nursing process Exp.: SP
Episode of Psychosis: A young adult showing signs of an acute psychotic episode. Cont.: HFPS
23 Martin & Chanda (2016) Exp.: 28 SN SP Nurse and simulation technician Off line (school) 90~100 m 2 The scenario consisted of applying therapeutic communication with patients with depression, schizophrenia, and bipolar disorder. NA
24 Martinez (2017) Exp.: 15 SN SP Trained individuals Off line (school) 4h 2 The simulation scenario included a standardized patient portrayal of an anxious psychiatric patient diagnosed with schizophrenia. Nursing students apply nursing processes, including nursing assessment to standardized patients. NA
25 Ng et al. (2017) Exp.: 206 SN VMS - Online 5 m NA Anti-stigma Awareness Video: A clip showing an accident victim treated with stereotyped negative attitudes towards people with mental illness to highlight stigma. Therapeutic communication NA
Common Myths: Addressed common myths regarding people with mental illness.
Celebrities with Mental Illness: A video clip featuring celebrities who have mental illness to challenge stereotypes and show successful individuals living with mental health conditions.
Testimonies: Filmed testimonies by a patient with mental illness and her visiting community nurse, focusing on the patient's struggles and perseverance against stigma.
Interview with a Successful Individual in Recovery: Showcased an interview with a person in recovery from mental illness, emphasizing that despite mental health challenges, individuals can lead successful lives.
Personal Testimony: A layperson's account of a colleague with mental illness who is in recovery and gainfully working, reinforcing the message that individuals with mental illness are like anyone else.
Mental Health Facts: Provided facts to correct myths, disconfirm stereotypes, and promote mental health awareness, along with tips on how to help people with mental illness.
26 Ok et al. (2020) Exp.: 52 SN SP Trained actors Off line (school) 10~15 m over 2d NA The simulation scenario was based on interactions with a standardized patient displaying symptoms and findings related to schizophrenia. Therapeutic communication Cont.: TL
Cont.: 33
27 Olasoji et al. (2020) Exp.: 89 SN SP Professional actors On & Off line (school) 8 h NA Therapeutic communication with patients with schizophrenia, bipolar affective disorder (manic episode), major depressive disorder, and borderline personality disorder Therapeutic communication NA
28 Sarikoc et al. (2017) Exp.: 43 SN SP Lay people Off line (school) NA 8 Experience therapeutic communication with the patient in the following case: A patient with depression having suicidal ideation: This scenario focused on a patient exhibiting signs of depression and expressing thoughts of self-harm or suicide. Therapeutic communication Cont.: Video lecture
Cont.: 43 A patient with hallucinations: This scenario involved interacting with a patient experiencing hallucinations, a common symptom in various psychiatric disorders such as schizophrenia.
29 Seo & Kim (2020) Exp.: 31 SN SP Experienced members of the Psychodrama Association Off line (school) 3 h 2 Module I: A lecture on schizophrenia, its symptoms, causes, and therapeutic communication skills. Application of nursing process Cont.: TL
Cont.: 33 Module II: Case-based team learning involving a case of schizophrenia, focusing on nursing diagnosis and intervention.
Module III: Standardized patient-based simulation learning, which involved assessment and intervention for hallucinations, delusions, mood, suicidal ideation, the risk of violence, attitudes, and side effects on drugs.
30 Soccio (2017) Exp.: 24 SN SP Drama students Off line (school) 3w NA The simulation labs included scenarios of posttraumatic stress disorder, bipolar disorder, mania, hearing voices, psychosis, depression, and wrist-cutting psychiatric emergencies. Psychiatric emergency Cont.: NI
cont.: 24
31 Speeney et al. (2018) Exp.: 52 SN SP Actors Off line (school) 1 h NA The simulation scenario involved students interacting with a patient diagnosed with schizophrenia who was experiencing delusional thinking and taking an antipsychotic medication. Therapeutic communication NA
32 Szpak & Kameg (2013) Exp.: 44 SN SP Not specified Off line (school) 2h 1 Depression with Suicidal Ideation: This scenario likely involved a standardized patient portraying signs of depression, possibly expressing thoughts of self-harm or suicidal ideation. Therapeutic communication NA
HFPS Anxiety and Alcohol Withdrawal: In this scenario, the standardized patient exhibited symptoms of anxiety alongside signs of alcohol withdrawal.
33 Yang & Kang (2023) Exp.: 29 SN VR (metaverse) - Online (lecture) 5 h NA Scenario 1: An initial interview with a 17-year-old girl on her admission day to a pediatric ward in the psychiatric department, displaying symptoms of early onset schizophrenia. Therapeutic communication Exp.: On-line lecture + metaverse based schizophrenia simulation program
Cont.: 29 Scenario 2: An interview with the mother of the patient with early onset schizophrenia, focusing on the day of hospitalization and addressing the caregiver's perspective and therapeutic communication needs. Cont.: On-line lecture
34 Whited et al. (2021) Exp.: 60 SN SP The motherdaughter actor team Online 8h 1 Focused on adolescent psychiatric assessment via telehealth, the scenario depicted a mother and her 15-year-old daughter, "Jamie," experiencing depression with suicidal ideation and self-harm behavior. Nursing students evaluate the patient's mental state using tools such as PHQ9 while viewing the patient's screen provided online. This includes the process of communicating with the patient in an emergency situation. Therapeutic communication NA
Psychiatric emergency
35 Witt et al. (2018) Exp.: 17 SN SP Professional and student actors Off line (school) 2 h 2 The module includes six mental health scenarios: (a) mental health assessment, (b) therapeutic communication skills, (c) cognitive processes, (d) assessment of mood/affect. Each scenario is structured with specific learning objectives, a description of the nurse's role, scripts for standardized patients (SP), and guidelines for facilitators to provide cues. Therapeutic communication Cont.: TL
Cont.: 15

Comp.=comparison group; Cont.=control group; d=days; Exp.=experimental group; FL=flipped learning; h=hours; HFPS=high=fidelity patient (or human) simulation; IPMHS=interprofessional mental health simulation; m=minutes; ME-IPC=minimal; MSE=mental state assessment; SRA=suicidal risk assessment; NA=not available; NI=no information; Exposure=interprofessional collaboration; Pro.=professionalist; Ps=participants; PTC=professional training center; SP=standardized patients; TL=traditional learning; VMS=video module simulation; VR=virtual reality; VS=voices simulation; SN=student nurse; RN=registered nurse.

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Appendix

Appendix 1.

Studies Selected for the Analysis

1. Chaffin AJ, Adams C. Creating empathy through use of a hearing voices simulation. Clinical Simulation in Nursing. 2013; 9(8):e293-e304. https://doi.org/10.1016/j.ecns.2012.04.004
2. Donovan LM, Mullen LK. Expanding nursing simulation programs with a standardized patient protocol on therapeutic communication. Nursing Education Perspectives. 2019;37: 126-131. https://doi.org/10.1016/j.nepr.2019.05.015
3. Evans J, Webster S, Gallagher S, Brown P, Sinclair J. Simulation in nursing education: iPod as a teaching tool for undergraduate nurses. Issues in Mental Health Nursing. 2015;36(7):505-512. https://doi.org/10.3109/01612840.2014.1003667
4. Fernando A, Attoe C, Jaye P, Croos S, Pathana J, Wessely S. Improving interprofessional approaches to physical and psychiatric comorbidities through simulation. Clinical Simulation in Nursing. 2017;13(4):186-193. https://doi.org/10.1016/j.ecns.2016.12.004
5. Goh YS, Selvarajan S, Chng ML, Tan CS, Yobas P. Using standardized patients in enhancing undergraduate students’ learning experience in mental health nursing. Nurse Education Today. 2016;45:167-172. https://doi.org/10.1016/j.nedt.2016.08.005
6. Kameg B, Fradkin D, Lee H. Effect of standardized patient simulation on nursing students’ attitudes toward psychiatric nursing and patients with mental health problems. Journal of Psychosocial Nursing and Mental Health Services. 2021;59(8):15-21. https://doi.org/10.3928/02793695-20210513-01
7. Kameg K, Howard VM, Clochesy J, Mitchell AM, Suresky JM. The impact of high fidelity human simulation on self-efficacy of communication skills. Issues in Mental Health Nursing. 2010;31(5):315-323. https://doi.org/10.3109/01612840903420331
8. Kameg KM, Englert NC, Howard VM, Perozzi KJ. Fusion of psychiatric and medical high fidelity patient simulation scenarios: effect on nursing student knowledge, retention of knowledge, and perception. Issues in Mental Health Nursing. 2013;34(12):892-900. https://doi.org/10.3109/01612840.2013.854543
9. Koetting C, Freed P. Educating undergraduate psychiatric mental health nursing students in screening, brief intervention, referral to treatment (SBIRT) using an online, interactive simulation. Archives of Psychiatric Nursing. 2017;31(3):241-247. https://doi.org/10.1016/j.apnu.2016.11.004
10. Kowalski C, Attoe C, Ekdawi I, Parry C, Phillips S, Cross S. Interprofessional simulation training to promote working with families and networks in mental health services. Academic Psychiatry. 2018;42:605-612. https://doi.org/10.1007/s40596-017-0840-z
11. Kunst EL, Mitchell M, Johnston ANB. Using simulation to improve the capability of undergraduate nursing students in mental health care. Nurse Education Today. 2017;50:29-35. https://doi.org/10.1016/j.nedt.2016.12.012
12. Lavelle M, Attoe C, Tritschler C, Cross S. Managing medical emergencies in mental health settings using an interprofessional in-situ simulation training programme: a mixed methods evaluation study. Nurse Education Today. 2017;59:103-109. https://doi.org/10.1016/j.nedt.2017.09.009
13. Martin CT, Chanda N. Mental health clinical simulation: therapeutic communication. Clinical Simulation in Nursing. 2016; 12(6):209-214. https://doi.org/10.1016/j.ecns.2016.02.007
14. Martinez AJS. Implementing a workplace violence simulation for undergraduate nursing students. Journal of Psychosocial Nursing and Mental Health Services. 2017;55(10):39-44. https://doi.org/10.3928/02793695-20170818-04
15. Ng YP, Rashid A, O’Brien F. Determining the effectiveness of a video-based contact intervention in improving attitudes of Penang primary care nurses towards people with mental illness. PLoS One. 2017;12(11):e0187861. https://doi.org/10.1371/journal.pone.0187861
16. Olasoji M, Huynh M, Edward KL, Willetts G, Garvey L. Undergraduate student nurses’ experience of mental health simulation pre-clinical placement: a pre/post-test survey. International Journal of Mental Health Nursing. 2020;29(5):820-830. https://doi.org/10.1111/inm.12715
17. Speeney N, Kameg KM, Cline T, Szpak JL, Bagwell B. Impact of a standardized patient simulation on undergraduate nursing student knowledge and perceived competency of the care of a patient diagnosed with schizophrenia. Archives of Psychiatric Nursing. 2018;32(6):845-849. https://doi.org/10.1016/j.apnu.2018.06.009
18. Szpak JL, Kameg KM. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clinical Simulation in Nursing. 2013;9(1):e13-e19. https://doi.org/10.1016/j.ecns.2011.07.003
19. Whited TM, Stickley K, de Gravelles P, Steele T, English B. Using telehealth to enhance pediatric psychiatric clinical simulation: rising to meet the COVID-19 challenge. Online Learning. 2021;25(1):230-237. https://doi.org/10.24059/olj.v25i1.2485
20. Seo DH, Kim SJ. The effect and development of a simulation learning module based on schizophrenic patients care of nursing students. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 2020;29(2):106-118. https://doi.org/10.12934/jkpmhn.2020.29.2.106
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