Issues in Mental Health Nursing, 31:315323, 2010 Copyright Informa Healthcare USA, Inc.

. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840903420331

The Impact of High Fidelity Human Simulation on Self-Efcacy of Communication Skills

Kirstyn Kameg, DNP, PMHNP-BC and Valerie M. Howard, EdD, RN
Robert Morris University, Moon Township, Pennsylvania, USA

John Clochesy, PhD, RN, FAAN

Case Western Reserve University, Cleveland, Ohio, USA

Ann M. Mitchell, PhD, RN, FAAN

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University of Pittsburgh, Pittsburgh, Pennsylvania, USA

Jane M. Suresky, NC, APRN-BC

Case Western Reserve University, Cleveland, Ohio, USA

Communication is a critical component of nursing education as well as a necessity in maintaining patient safety. Psychiatric nursing is a specialty that emphasizes utilization of communication skills to develop therapeutic relationships. Nursing students are frequently concerned and anxious about entering the mental health setting for their rst clinical placement. High delity human simulation (HFHS) is one method that can be used to allow students to practice and become procient with communication skills. The purpose of this study was to compare the effectiveness of two educational delivery methods, traditional lecture and HFHS, on senior level nursing students self-efcacy with respect to communicating with patients experiencing mental illness. The results of this study support the use of HFHS to assist in enhancing undergraduate students self-efcacy in communicating with patients who are experiencing mental illness.

Communication is a critical component of nursing education as well as a necessity in maintaining patient safety. Teaching communication skills is a challenge for nurse educators due to higher patient acuity, difculty securing appropriate clinical sites, and increased student to faculty ratios. In addition, there is no guarantee that students assigned to a clinical site will care for patients with diagnoses that will be similar to those they encounter in independent practice as registered nurses. Psychiatric nursing is often particularly difcult as patients may refuse to talk with students or students may express anxiety related to not knowing what to say (Melrose & Shapiro, 1999, p. 1455).
Address correspondence to Kirstyn Kameg, Robert Morris University, School of Nursing, 6001 University Blvd., Moon Township, PA 15108. E-mail: kameg@rmu.edu

Nursing students are frequently concerned and anxious about entering the mental health setting for their rst clinical placement. Prior to the start of the rotation, most students have little or no experience with this population of patients, which may include those who are suicidal, manic, aggressive, or delusional. Additionally, psychiatric nursing involves therapeutic use of self that is different from other nursing courses that emphasize application of psychomotor skills. One way to address the students fears and anxieties is through the use of high delity human simulation (HFHS). Fidelity is the term used to describe the accuracy or realness of the simulation. High-delity simulators are the most realistic in both outward appearance and their realistic reactions to student interventions (Seropian, Brown, Gavilanes, & Driggers, 2004). HFHS is one method that can be utilized for students to practice communication skills that has several advantages. HFHS ensures that students have the opportunity to interact with a variety of patients that they may not have had the opportunity to encounter in the clinical setting, including agitated or aggressive patients, patients experiencing a manic episode, and patients experiencing auditory hallucinations. The faculty member also has the advantage of directly observing the interaction between the student and the simulator as well as providing the student with immediate feedback. This often is not possible in the clinical setting. In this study, the instructor, using a wireless microphone, simulated two different scenarios, a patient experiencing depression as well as a patient experiencing anxiety and possible substance abuse, through a high delity simulator. The purpose of this study was to compare the effectiveness of two educational delivery methods, traditional lecture

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and HFHS, on senior level nursing students self-efcacy with respect to communication skills.

REVIEW OF THE LITERATURE Communication is a central component of the nursing process and is necessary to ensure quality care. Accrediting bodies for undergraduate and graduate programs have mandated that students acquisition of interpersonal communication competencies is a critical educational outcome (American Association of Colleges of Nursing, 1996, 1998); therefore, nurse educators must identify strategies to ensure that students are given the opportunity to practice and receive immediate feedback related to their use of communication skills. Ensuring that students are utilizing appropriate communication skills is difcult due to higher patient acuity, shorter hospital stays, and increased faculty to student ratios in the clinical setting. The clinical component in the psychiatric nursing specialty is an opportune time for students to practice communication skills as these patients are generally medically stable, however, it is difcult for faculty to assess the students communication skills as a third party observer hinders the development of a therapeutic relationship. Numerous studies have indicated that students negative attitudes, fear, and anxiety can hinder both learning and development of a therapeutic relationship (Bower, Webb, & Stevens, 1994; Marley, 1980; Melrose & Shapiro, 1999; OBrien, 1994). Researchers have sought to identify options such as videotaping student interactions with standardized patients and role playing to assess students communication skills. Festa, Baliko, Mangiaco, and Jarosinski (2000, p. 44) videotaped students interactions with a standardized patient; this was a clinical requirement for the course. In a focus group following the interaction, students described varying degrees of apprehension related to the simulation that ranged from being unprepared, wanting to do the right thing, and it was painful. Several students acknowledged performance anxiety related to being observed, however, at the end of the course, students spontaneously acknowledged the value of the videotaping experience. Kruijver, Kerkstra, Bensing, and van de Wiel (2001) videotaped admission interviews between nurses and simulated cancer patients to distinguish between instrumental (task-oriented) and affective communication by nurses in a clinical oncology setting. The results of the study revealed that 62% of the communication behaviors utilized by the nurses were instrumental and 38% were affective. Even though the simulated patient was acting in a distressed manner, the nurses used limited nonverbal behaviors, such as leaning forward and touch, that are important in establishing a trusting relationship. Kruijver, Kerkstra, Bensing, and van de Wiel (2001) recommend that in the future nurses should be provided with ongoing continuing education programs to learn how to explore and openly discuss emotions and feelings and nd a balance between instrumental and affective communication techniques.

There have been a multitude of studies examining selfefcacy from both a clinical as well as a nursing education perspective. Studies of undergraduates have focused on selfefcacy expectations related to math and science (Andrew, 1998; Hodge, 1999; Maag, 2004) and clinical skills (Dilorio & Price, 2001; Madorin & Iwasiw, 1999; McConville & Lane, 2006). Although numerous studies have investigated the effects of simulation on student learning, there have not been any studies that have examined the effects of HFHS on nursing students self-efcacy related to utilizing communication skills. Researchers have examined interventions such as the use of video clips, computer assisted instruction, case studies, and role playing on student self-efcacy. McConville and Lane (2006) reported on the successful use of video clip materials for enhancing nursing student self-efcacy to effectively communicate with difcult patients. Madorin and Iwasiw (1999) described a signicant increase in baccalaureate nursing students self-efcacy following completion of computer assisted instruction in caring for surgical patients in the clinical environment. A group of educators at the University of Western Ontario conducted a descriptive study to investigate the effect of classroom simulation on third-year baccalaureate nursing students self-efcacy in health teaching and found statistically signicant improvement in student self-efcacy related to health teaching (Goldenberg, Andrusyszyn, & Iwasiw, 2005). Jenkins, Shaivone, Budd, Waltz, and Grifth (2006) reported a signicant improvement in condence levels related to performance of genitourinary examination skills in nurse practitioner students following a genitourinary teaching associate (GUTA) activity. The researchers concluded that the students increased condence and high levels of comfort after the activity better prepare them for performing these examinations with real patients in clinical settings, that contributes to students competence and, ultimately, to better patient care (Jenkins et al., 2006, p. 37). Although HFHS has become an increasingly popular method as an instructional and evaluation strategy for heath care educators, there are limited studies investigating the use of HFHS as a method for students to practice and become procient with communications skills (Anonymous, 2003; Gaba, 2004; Long, 2005). A recent study conducted by Sleeper and Thompson (2008) provided students the opportunity to utilize communication skills with a high delity human simulator. The simulation scenario involved a patient with depression and suicidal ideation who needed to be assessed for safety prior to being discharged. Ten students completed a faculty-developed evaluation form. Based on the results of the study, the researchers concluded that simulation could be helpful in augmenting theory and practice, providing timely student feedback, and enhancing transferability of skills to clinical practice (Sleeper & Thompson, 2008). Gaba (2004) noted that although most of the attention on simulation has focused on technical and procedural skills, simulation techniques can be useful for addressing non-technical skills such as communicating with patients and coworkers or in addressing issues such as ethics or end of life care.

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METHODOLOGY Design and Sample Banduras (1977, 1986) self-efcacy theory provided the theoretical structure for this study. A non-random assignment, quasi-experimental design was used to compare two teaching strategies, traditional lecture and HFHS, on nursing students self-efcacy of communication skills. Based on past simulation research that suggests a positive effect, an effect size of .75 was placed in G Power 3 (Faul, Erdfelder, Lang, & Buchner, 2007) with a resultant sample size of 46 (Ravert, 2002). The sample size in this study consisted of 38 pre-licensure nursing students enrolled in the psychiatric nursing course at a private university in western Pennsylvania. The small sample size is discussed later as one of the limitations in this study. Students were divided into two groups based on the curricular arrangements. The psychiatric nursing course is a 7.5 week course taken in the senior year. Students were assigned to either psychiatric nursing or community health nursing and then were required to change rotations at mid-term. There were 21 students in Group 1 and 17 students in Group 2. Of the 38 total participants, 10.5% (n = 4) were male and 89.5% (n = 34) were female. Table 1 describes demographic characteristics related to the studys participants. Measures The independent variable for this study was the method of teaching. Clinical simulation is the re-creation of a clinical situation in an articial environment for the purpose of student clinical education. In this study, clinical simulation was dened as the use of a high delity human simulator, SimMan, a computerized mannequin that, through wireless microphone technology, speaks using the words and voices of the nurse educators; SimMan R was used to re-create scenarios depictTABLE 1 Demographic Characteristics by Group (N = 38) Descriptor Gender Female Male Ethnicity African American/Black European American/White Age (years) Experience with simulation Exposure to patients with mental illness Group 1 19 (90.5%) 2 (9.5%) 1 (5%) 20 (95%) 23.1 21 (100%) 17 (81%) Group 2 15 (88.2%) 2 (11.8%) 1 (5.8%) 16 (94.1%) 23.41 15 (88.2%) 15 (88.2%)

ing patients with mental illness. Traditional teaching delivery is communication of content through classroom-based lecture and discussion. In this study, traditional teaching was the provision of a two hour lecture on communication skills in a classroom setting. The dependent variable was self-efcacy, which is dened as belief in ones capabilities to overcome successfully the demands of a situation in order to achieve a desired outcome (Bandura, 1977, 1986). The following is the operational denition in this study: students belief in their own capacity to successfully communicate with patients with mental illness as measured by a single-item visual analogue scale. Description of Instruments Sample Descriptors Sample descriptors included gender, age, race, ethnicity, experience with simulation, experience with mental illness, and international opportunity. Self-Efcacy of Communication Skills Self-efcacy of communication skills was measured with a single-item visual analogue scale (VAS). A VAS is a selfreporting device used to measure subjective phenomena such as patient symptoms, patient affect, function, and quality of life (Miller & Ferris, 1993). A VAS typically consists of a 100 mm horizontal line anchored at both ends with words that are descriptive of the phenomenon being measured. The VAS is then scored measuring the distance from one end of the scale to the place where the subject marked the line. The result is an objective representation of a previously subjective phenomenon thus permitting the objective scores to be evaluated by traditional statistical testing (Miller & Ferris, 1993). The reliability of the VAS has been reported in many studies. Acceptable testretest reliability has been reported for single-item measures in nursing research surveys that measured quality of life, anxiety, depression, and dyspnea (Youngblut & Casper, 1993). There is evidence to support single-item measures as generally valid and sensitive to the change in the phenomenon under study (Youngblut & Casper, 1993). The simplicity of single-item measures enhances their construct validity (Patrician, 2004). Table 2 depicts the VAS that the students completed. Self-Efcacy (General) Self-efcacy, in general, was measured by the General SelfEfcacy Scale, which is depicted in Table 3. The scale was created to assess a general sense of perceived self-efcacy with the purpose of predicting coping with daily hassles as well as adaptation following experiencing all kinds of stressful life events. The General Self-Efcacy Scale scores range from 1040, with 40 indicating the highest possible score. Internal consistency as measured by Cronbachs alpha ranged from 0.760.90, with the majority in the high 0.80s (Jerusalem & Schwarzer, 1993).

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TABLE 2 Self-Efcacy Visual Analogue Scale Self-efcacy is dened as a belief in ones capabilities to overcome the demands of a situation in order to achieve a desired outcome. Please place a perpendicular line through the line below indicating your level of self-efcacy regarding your ability to communicate with a patient diagnosed with a mental illness. No Condence With Communication Highest Possible Condence With Communication

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Simulation Evaluation Survey Students were also given a Simulation Evaluation Survey to complete to evaluate their perceptions related to the simulation experience. This 4-point Likert-type survey was developed by Howard (2007) based upon a review of literature and discussions with experts in the eld of simulation education. After development, the tool was reviewed by nurse educators for content validity and then revised based on this feedback. After revisions were made, the tool was pilot tested with a group of ve students. Internal consistency was determined by Cronbachs alpha (0.87), suggesting that the instrument was reliable. Procedures All students enrolled in the course were required to attend the lecture on communication skills, to participate in both the simulation activity and the videotaped debrieng, as all were included as requirements in the course syllabus. Participation in the research study was voluntary and involved completion

of a sample descriptors questionnaire, the General Self-Efcacy Scale, two self-efcacy visual analogue scales, and the Simulation Evaluation Survey. As mentioned above, only half of the senior students were enrolled in Nursing Care of Psychiatric Clients course in the rst 7.5 weeks of the semester. Following Institutional Review Board approval, these students were provided with an informed consent letter explaining the study at the rst class meeting. Forty-eight hours later, students were provided with a two hour lecture on communication skills in a classroom setting. A graduate research assistant then provided the students with a piece of paper with a four digit code. The students were asked to remember the codes and write the codes at the top of each of the following instruments: sample descriptors questionnaire, the General Self-Efcacy Scale, and the self-efcacy VAS. The VAS was a 100 mm line anchored on one end with no condence in communication and at the other end with highest possible condence in communication. Students were asked to place a perpendicular line to indicate how condent they felt

TABLE 3 General Self-Efcacy Scale Instructions: Below is a list of statements dealing with your general sense of perceived self-efcacy. The aim in mind is to predict coping with daily hassles as well as adaptation after experiencing all kinds of stressful life events. If you feel the statement is o not true at allcircle 1 o hardly truecircle 2 o moderately truecircle 3 o exactly truecircle 4 1. I can always manage to solve difcult problems if I try hard enough. 2. If someone opposes me, I can nd the means and ways to get what I want. 3. It is easy for me to stick to my aims and accomplish my goals. 4. I am condent that I could deal efciently with unexpected events. 5. Thanks to my resourcefulness, I know how to handle unforeseen situations. 6. I can solve most problems if I invest the necessary effort. 7. I can remain calm when facing difculties because I can rely on my coping abilities. 8. When I am confronted with a problem, I can usual1y nd several solutions. 9. If I am in trouble, I can usually think of a solution. 10. I can usually handle whatever comes my way. 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4

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TABLE 4 Simulation Scenarios Scenario 1 Kim is a 30-year-old divorced white female admitted to the psychiatric unit with complaints of increasing anxiety and panic symptoms. Panic symptoms consist of shortness of breath, racing heart, and feeling as if she is going to die. She reports that she has been stressed lately related to being a single parent of a 12-year-old son. She also reports nancial difculties and that she drinks at night to help calm her nerves. She reports feeling depressed and overwhelmed. She has been admitted to the unit in the past with suicide attempts and a history of alcohol abuse is suspected. You are the nurse that is assigned to Kim today. Scenario 2 Mrs. Smith is a 69-year-old married, white female who was admitted to the psychiatric unit from the ICU following a suicide attempt by overdosing on her blood pressure medication. She reports increased symptoms of depression over the past few months. She informs that she has been more stressed since her husband was diagnosed with prostate cancer. Depressive symptoms include sadness, anhedonia, sleep problems, and decreased appetite with 12-pound weight loss. You are the nurse that is admitting her following her transfer from ICU.

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with communication. Completion of the instruments indicated the students consent to participate in the study. All students consented to participating in the study. Students were then provided with an orientation to HFHS and a clinical report of the patients status that included patients gender and age, admitting diagnosis, past psychiatric history, pertinent medical history, and current symptoms. During the HFHS educational intervention, the instructor was located in an adjacent room speaking through a wireless microphone and assumed the role of the patient. The interaction between the student and the simulator was unscripted. The instructor, in the role of the patient, responded spontaneously based on what type of communication the student utilized. There were two alternating HFHS scenarios: one patient who was experiencing symptoms of depression and suicidal thoughts and another patient who was experiencing anxiety and possible substance abuse. See Table 4 for simulation scenarios. Students were assigned the role of the nurse and engaged in therapeutic communication based on the information that was provided to them in the communication skills lecture. Students were videotaped during their interaction with the high delity human simulator and then the students and the instructor completed a debrieng. This provided the students an opportunity to reect and receive feedback on their performance as well as their peers performances. Following the debrieng activity, students completed a second self-efcacy VAS and a Simulation Evaluation Survey. Again, as mentioned above, the students changed rotations at mid-term and the students who had been in community nursing now had psychiatric nursing. The same process was repeated with the second group of students. Statistical Analysis Data was entered and coded utilizing the statistical package for the social sciences (SPSS) program. A coding system was created and data were entered and cleaned prior to running an analysis. There was no missing data nor was there attri-

tion of the participants. A dependent t-test was performed to assess for changes in self-efcacy between Time 1 and Time 2. Cronbachs alpha was calculated to determine internal consistency of the General Self-Efcacy Scale and the Simulation Evaluation Survey. Pearson correlation was done to assess for a relationship between the scores on the General Self-Efcacy Scale and the self-efcacy related to communication at Time 1. The responses from the Simulation Evaluation Survey were analyzed using descriptive statistics, that is, mean, standard deviation.

FINDINGS Background data obtained from the students included prior experience with high delity human patient simulation and prior exposure to individuals diagnosed with a mental illness. In Group 1, 100% (n = 21) and in Group 2, 88.2% (n = 15) of the students reported prior experience with human patient simulation. In Group 1, 81% (n = 17) and in Group 2, 88.2% (n = 15) reported being exposed to individuals with mental illness. There were not statistically signicant differences in relation to prior experience with human patient simulation or exposure to individuals with mental illness and self-efcacy of communication skills. When grouping all students together (n = 38), results of the dependent t-test demonstrated a signicant change in students self-efcacy following the simulation experience (p = .000). When assessing the two groups separately, the students in Group 1 (n = 21) had a signicant change in self-efcacy following the simulation experience (p = .005) as well as the students in Group 2 (n = 17) (p = .036). The results are summarized in Table 5. Cronbachs alpha of the general self-efcacy scale was .852 indicating that the scale was reliable. The mean score on the General Self-Efcacy Scale for students in Group 1 was 3.1381 and the mean score for students in Group 2 was 2.7353, thus

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TABLE 5 Results of Dependent Samples T-Test on Self-Efcacy at Time 1 and Time 2 (N = 38) n All Students Group 1 Group 2

M(VAS 1) 48.58 50.90 45.71

M(VAS 2) 59.20 62.40 55.20

t 3.936 3.183 2.290

p .000 .005 .036

38 21 17

Signicant at p < .05.

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demonstrating that students in Group 1 had higher levels of general self-efcacy compared to the students in Group 2. A Pearson correlation was done to assess for a relationship between the scores on the General Self-Efcacy Scale and the self-efcacy related to communication at Time 1. There was a signicant moderate correlation (r = .419, p = .009) between the two variables for all 38 students. Considering each group separately, there was a signicant and moderately strong correlation (r = .578, p = .006) between the General Self-Efcacy Scale and the self-efcacy related to communication at Time 1 for students in Group 1, but the correlation was non-signicant for students in Group 2 (r = .274, p = .288). Responses to the Simulation Evaluation Survey revealed that students responded favorably to the simulation experience, with the highest item being that they viewed the simulation as a valuable learning experience (3.63). They also felt that simulation should be included in the curriculum (3.58) and that the knowledge gained from the simulation can be transferred to the clinical setting (3.58). The item that the students disagreed on was that simulation can be a substitute for experience in the hospital (1.92). See Table 6 for these ndings. Students also had the opportunity to answer an open ended question, please add any additional comments regarding the educational experience at the end of the survey. Fifty percent (n = 19) of the students responded to the open ended questions. Table 7 lists the openended comments from students on the Simulation Evaluation Survey.

increase as evidenced by p = .036. The ndings support the use of HFHS to enhance student self-efcacy of communication skills. Students in Group 1 scored higher on the general self-efcacy scale compared with the students in Group 2. There was also a strong correlation (p = .006) between the General Self-Efcacy Scale and the self-efcacy related to communication at Time 1 for students in Group 1. There was not a correlation (p = .288) between the General Self-Efcacy Scale and the self-efcacy related to communication at Time 1 for students in Group 2. This is an interesting nding to consider as students in Group 2 had psychiatric nursing the second 7.5 weeks of the semester and, therefore, when they began the psychiatric clinical rotation, they already had an additional 7.5 weeks of community nursing. This is unusual; it would seem that the students in Group 2 who had the benet of taking community nursing the rst half of the semester would have had a correlation between the two measures.

TABLE 6 Results of Descriptive Data from Simulation Evaluation Survey (N = 38) Mean Helps to better understand nursing concepts Was a valuable learning experience Helped to stimulate critical thinking abilities Simulation was realistic Knowledge can transfer to the clinical setting Nervous during simulation experience Will be less nervous in clinical because of simulation Simulation can be a substitute for experience in the hospital Simulation should be included in the curriculum

SD .506 .489 .507 .594 .500 .609 .636 1.024 .500

3.53 3.63 3.50 2.84 3.58 3.18 2.97 1.92 3.58

DISCUSSION The results of this study indicate that experience with HFHS enhanced student self-efcacy of communication skills as measured by the self-efcacy VAS and are consistent with other simulation studies (Goldenberg, Andrusyszyn, & Iwasiw, 2005; Jenkins, Shaivone, Budd, Waltz, & Grifth, 2006; Madorin & Iwasiw, 1999; McConville & Lane, 2006). For all students, the mean score on the self-efcacy VAS at Time 1 was 48.58 and at Time 2 was 59.20. This was signicant at p = .000. The mean score on the self-efcacy VAS at Time 1 for students in Group 1 was 50.90 and increased to 62.40 at Time 2 following the simulation experience. This was a signicant increase as evidenced by p = .005. The mean score on the self-efcacy VAS at Time 1 for students in Group 2 was 45.71 and increased to 55.20 following the simulation experience. This was also a signicant

Scores are based on a Likert-type scale where 1 indicates strongly disagree and 4 indicates strongly agree. Scores above 2.5 indicate agreement with the statement.

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TABLE 7 Open-Ended Responses from Simulation Evaluation Survey (N = 19) It was helpful in regards to approaching a new patient and putting our questions together to know what we wanted to ask and how to ask it. I was nervous about what to say in a mental health situation. This activity gave me lots of insight on what I did wrong and what others did that I could possibly use to help me. I feel the experience gave everyone a good chance just to experiment with what they could say in an actual situation. The words I am suicidal are not ones that a person hears everyday and can be a little unnerving. I think it was very valuable in providing me with an experience before clinical, thus helping me to become more condent because I was able to see what I did well and needed to work on going into my rst day. It really helped. I think it was a great learning experience. I think this was a really good idea and experience. It was a little embarrassing but I believe that it helped out a lot. Though the simulation was not entirely realistic, I think it helped because it forced me to think about what I would say in response to a patients verbalizations. It made me feel more comfortable, but I will still be nervous for clinical. But better prepared. It was a good learners tool toward communication. Although I was somewhat nervous, I did feel the practice with the simulation and review of the video were helpful in how to approach communication. The simulation experience helped me to understand the importance of speaking to those with psychiatric problems with respect and dignity. The simulation experience gave me a pretty good idea about what I will be experiencing in clinical. I feel it helps get rid of the anxiety someone might have with the unknown. I felt it was a very good experience, but not realistic because being taped makes you more nervous. If I wasnt taped, I would have felt better. I feel that based on the simulation experience that I will be more condent when entering the clinical setting with psychiatric patients for the rst time. It denitely boosted my condence level. I was glad we did it before actually dealing with a real patient. I thought that it was a great learning experience and I can transfer this experience to better communicate with my patients. I felt that the simulation was a great learning experience and it should be utilized more often. If we were shown an example of how to properly communicate with a psychiatric patient, I would have been able to practice the right way to talk to the patient instead of learning from my mistakes. It was a great experience; will help me to be more comfortable in clinical. Also helped prepare me for uncomfortable situations. This was a good learning experience and was very benecial. The ndings also support the theoretical framework of the study. Bandura (1977) posits that expectations of self-efcacy are derived from the following four principal sources of information: performance accomplishments, vicarious experiences, verbal persuasion, and emotional arousal. Students practiced communication skills with a high delity human simulator providing them with the opportunity to achieve mastery of the techniques prior to entering the clinical setting. One student responded to the open ended question from the evaluation survey with the statement, It was helpful in regards to approaching a new patient and putting our questions together to know what we wanted to ask and how to ask it. Additionally, interacting with a high delity human simulator in a controlled setting may have decreased physiological arousal, thus increasing the students self-efcacy. Another open ended response from the survey revealed, The simulation experience gave me a pretty good idea about what I will be experiencing in clinical. I feel it helps get rid of the anxiety someone might have with the unknown. Students were provided with the opportunity to watch their peers interact with a high delity human simulator (vicarious experience) and one student responded, I was nervous about what to say in a mental health situation. This activity gave me lots of insight on what I did wrong and what others did that I could possibly use to help. Finally, students were given positive feedback regarding their performance (verbal persuasion) and one student stated, Although I was somewhat nervous, I did feel the practice with the simulation and review of the video were helpful in how to approach communication. Survey data results revealed that students were generally satised with the simulation experience, particularly in relation to feeling as if the simulation was a valuable learning experience (3.63), and believed simulation should be included in the curriculum (3.58) and that the knowledge gained from the simulation could be transferred to the clinical setting (3.58). Students

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did not agree that simulation should be a substitute for experience in the hospital setting (1.92). This nding is consistent with Bearnson and Wikers (2005) results that revealed that students felt the simulation experience should be in addition to, as opposed to taking the place of, the clinical experience. One area to consider for future research is rephrasing the question on the survey; students may have interpreted it using simulation as a substitute for the entire clinical experience. Perhaps rephrasing the question as using simulation as a substitute for a portion of the clinical experience would have yielded different results. There are several limitations with using a high delity human simulator as a mechanism for students to practice communication skills. One of the biggest limitations is the inability of the simulator to display facial expressions, an important nonverbal behavior. It also takes time for faculty to learn to use the simulation technology. Finally, students may not have taken the interaction with the high delity human simulator seriously and therefore may not feel that the simulation experience increased their condence in communicating with patients experiencing psychiatric problems. Other limitations of the study included the small sample size and the lack of diversity among the participants, particularly in relation to age, gender, and ethnicity. Another limitation included potential researcher bias as the researcher was also the instructor who provided the lecture-discussion on the communication skills content, as well as facilitated the simulation experiences. Since this was a convenience sample, these limitations were acknowledged and controlled for by the researcher who implemented the study design as objectively as possible; however, according to Jeffries (2005) framework, use of the researcher as a facilitator could be justied, as this framework viewed student-faculty interactions as essential to the success of the simulation experience.

students were given positive reinforcement during the debriefing process and allowed to share their feelings and concerns regarding the simulation experience. Despite the ndings of this study, there continues to be limited research available validating the use of high delity human simulators in relation to effectiveness on student learning outcomes. Another limitation of this study is the measurement of a single concept, self-efcacy. Duplicating this study evaluating students use of therapeutic and nontherapeutic communication techniques would certainly generate more information on the use of HFHS and student learning outcomes in relation to therapeutic communication. Following the simulation experience, students in both groups had a statistically signicant improvement in self-efcacy of communication skills. Students also responded favorably to the simulation and recommended that simulation be included throughout the curriculum. Simulation provides for fun and interactive learning, involves teamwork, and integrates technology, all characteristics that the millennial learner (people attending college from 2001 and on) values and which comprise the description of the traditional undergraduate nursing student. Finally, simulation provides the opportunity for students to practice skills in a safe environment without presenting danger to patients. There are benets to incorporating HFHS in the nursing curriculum; nursing schools should continue to explore opportunities to incorporate simulation into the curriculum and continue to assess the impact on student learning outcomes. Declaration of interest: The authors report no conict of interest. The authors alone are responsible for the content and writing of this paper. REFERENCES

CONCLUSIONS The results of this study support the use of simulation to assist in enhancing undergraduate students self-efcacy in communicating with patients who are experiencing mental illness. The results of this study are consistent with other studies conducted in relation to simulation enhancing student satisfaction with learning and/or improved self-condence (Alinier, Hunt, & Gordon, 2004; Bremner, Aduddell, Bennett, & VanGeest, 2006; Jefres & Rizzolo, 2006). Students felt the simulations assisted them in learning communication techniques, improved their condence, and should be utilized more often as a learning experience. One area that the students responded negatively to was being videotaped, which some felt increased their anxiety. Faculty conducting the simulations should clearly explain the objectives of the simulation experience and whether the objectives are strictly an educational intervention or an evaluative measure. Students in this study were assured that the objective was strictly an educational experience and that they were not being graded on their use of communication skills. Additionally,

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