Auditory Hallucination Simulation & Nurse Empathy

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research-article2017
JAPXXX10.1177/1078390317750749Journal of the American Psychiatric Nurses AssociationMarshall et al.
Research Paper
Fostering Transformation by
Hearing Voices: Evaluating a
6-Second, Low-Fidelity Simulation
Journal of the American Psychiatric
Nurses Association
1–7
© The Author(s) 2017
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https://doi.org/10.1177/1078390317750749
DOI: 10.1177/1078390317750749
japna.sagepub.com
Brenda Marshall1, Julie Bliss2, Benjamin Evans3, and Oksana Dukhan4
Abstract
BACKGROUND: The stigma of psychosis, with the accompanying symptoms of auditory and visual hallucinations, can
affect a nurse’s ability to provide safe, effective care. Increasing knowledge of the patient’s perspective during auditory
hallucinations can increase the nurse’s ability to be empathetic and engage in a therapeutic alliance. OBJECTIVE: To
evaluate the efficacy of a six-second auditory hallucination simulation to increase empathy in preclinical undergraduate
nursing students. DESIGN: This descriptive, content analysis, qualitative study evaluated narratives written by students
in a pre-licensure baccalaureate nursing student population, assessing empathy, insight, knowledge, and therapeutic
communication. Students experienced the 6-second auditory hallucination simulation as part of preclinical instruction,
and then they wrote a self-reflection. RESULTS: More than 200 self-reflections were collected, with a randomized
final sample of 82 narratives evaluated. CONCLUSION: Self-reflections indicated that the experience of the 6-second
hearing voices simulation increased efficacy, insight, knowledge, and intention to use therapeutic communication.
Keywords
simulation, auditory hallucinations, undergraduate nursing education, qualitative research
Background
The World Health Organization projects that by 2020, 15%
of the disease burden will be associated to mental Illness
(World Health Organization, 2008, 2011). There are
155,000 nurse practitioners working in the United States,
with only 3% choosing psychiatric/mental health nursing
(American Association of Nurse Practitioners, 2012).
There are no statistics reflecting the number of registered
nurses working in the field of psychiatric nursing.
Engagement in the skills of psychiatric mental health nursing will be expected of all nurses, regardless of which specialty they enter, as patients with mental illness also need
medical attention for routine medical issues, metabolic diseases, and traumatic injuries. Nurses will need to be able to
connect with their patients in order to engage them in the
therapeutic alliance. Ward, Cody, Schaal, and Hojat (2012)
demonstrated that there is a significant decline in nursing
student empathy calling for nursing education to provide
more learning experiences that can foster and cultivate
empathetic responses (Ward et al., 2012).
Educators and researchers have proposed that it is the
pedagogical approach and assessment of learning that
promotes knowledge gains for over 25 years (Clark,
Threeton, & Ewing, 2010; Draper, 2009). The older
paradigm of nursing education relied on transmission of
knowledge through lectures and clinical experiences,
with learning assessment in the form of examinations,
presentations, and clinical observation.
More recently, simulation has been utilized to increase
knowledge and skills in the academic preparation of health
care providers, including nurses (Fossen & Stoeckel, 2016;
Langham, Jones, & Terry, 2017). Simulation teaches
nurses about urgent situations without posing any threat to
the patient during the learning session. Ziv, Small, and
Wolpe (2003) identify health care education using simulation as an ethical imperative. Simulation provides a tool
that allows students to engage in high-risk scenarios, make
1
Brenda Marshall, EdD, APRN-BC, ANEF, William Paterson
University, Wayne, NJ, USA
2
Julie Bliss, EdD, RN, William Paterson University, Wayne, NJ, USA
3
Benjamin Evans, DD, DNP, APRN-BC, Felician University, Lodi, NJ,
USA
4
Oksana Dukhan, BSN, MA, RN, William Paterson University, Wayne,
NJ, USA
Corresponding Author:
Brenda Marshall, William Paterson University, 305 Terhune Drive,
Wayne NJ 07470, USA.
Email: [email protected]
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Journal of the American Psychiatric Nurses Association 00(0)
decisions that, in reality, could have dire consequences.
Simulation allows the student to engage in situations that
demand collegiality, cooperation, and communication,
without placing any actual patient in harm’s way (Kameg,
Howard, Clochesy, Mitchell, & Suresky, 2010).
Simulation has been demonstrated to provide a best
standard in education, placing students in constructive
learning experiences that can be safe, standardized, and
debriefed after the experience (Kameg et al., 2010; Ziv,
Wolpe, Small, & Glick, 2003). Simulation has also been
identified as an efficient method to practice collaboration
within nursing and with other disciplines (Jeffries &
McNelis, 2008). Hi-fidelity simulation, which uses a
mannequin as the patient, provides a safe environment for
students to experiment with new skills and prepare for the
health care force requiring collaborative practice (Brown,
2008; Jeffries & McNelis, 2008).
McNaughton, Ravitz, Wadell, and Hodges (2008) discussed the impact of live simulation in psychiatric evaluating 20 years of psychiatric simulation techniques. When
introducing the construct of live simulation, the authors
explain that it “involves the performance of a role, as part
of an interaction, either through role play or enactment,
by a trained simulated or trained patient” (p. 86). These
kinds of simulation provide the student with opportunities to work with a psychiatric patient, maintaining the
role of the care provider. Brown (2008) identifies the
three major methods of using simulation in psychiatric
mental health nursing education: mannequins, role-play,
and use or creation of virtual environments. The evaluation of the efficacy of the simulation experience, however, often rests on student anecdotal responses, without
empirically confirming the efficacy of academic simulation in psychiatric mental health nursing education
(Brown, 2008). Psychiatric hi-tech simulations can be
costly and can provide opportunities to interview a virtual
bipolar patient or “see,” using special eyeglasses, visual
hallucinations, but the rigorous evaluation of efficacy of
these tools is not provided in the literature. The stigma of
psychosis, with the accompanying symptoms of auditory
and visual hallucinations, affects the nurses’ ability to
provide safe, effective care. Providing students with
access to videos that represent the psychiatric client more
realistically can help reduce the fear and stigma of mental
illness (Brown, 2008). A review of the literature identifying the application of psychiatric simulations revealed
that simulation is used to identify and reinforce therapeutic communication skills, present patient symptoms and
appropriate interventions, debunk media portrayal of
mental illness, develop self-awareness, practice medication administration and education, experience patients in
withdrawal, and engage in clinical assessments (Brown,
2008). These simulations do not help the student gain
insight into the difficulties a psychiatric patient has
engaging in dialogue or developing trust with the health
care provider, and can result in an increased desire for
social distance (Ando Clement, Barley & Thronicroft,
2011). In order to achieve this goal, a transformative
learning experience is required, one that has the ability to
generate knowledge through making the student question
his/her preconceived beliefs (Brown, 2008; MathewMaich, Ploeg, Jack, & Dobbins, 2010; Parker & Myrick,
2010). This kind of experience is referred to as a disorienting dilemma, an experience that makes us question our
perceptions, beliefs, knowledge, and heartfelt assumptions (Mathew-Maich et al., 2010).
Mathew-Maich et al. (2010) propose that research that
affects actual practice is not well utilized. Too often the
models do not reflect the needs in the clinical realm, or
are not thoroughly evaluated for efficacy in practice. In
order to implement programs that are successful in sustaining changes in attitudes and beliefs, transformative
learning that includes the disorienting dilemma is imperative (Jeffries & McNelis, 2008; Mathew-Maich et al.,
2010). Increasing the nurse’s knowledge of the patient’s
perspective during auditory hallucinations can increase
the nurse’s ability to be empathetic and engage the patient
in therapeutic techniques that support the therapeutic alliance (Dearing & Steadman, 2009).
Dearing and Steadman (2009) evaluated a voice simulation program that required the student to hear voices
simulating auditory hallucinations through a headset for
45 minutes. The sample of 28 nursing students between
the ages of 18 and 55 years reported feeling stressed, vulnerable, fearful, and anguished during the experience
(Dearing & Steadman, 2009). Dearing and Steadman
(2008), when evaluating the effect of the voice simulation
experience (VSE) reported, “The participants described
how difficult the VSE was on them physically. Most of
the participants described physically becoming weak and
exhausted from the experience (p. 63).” The ethical question of requiring students to experience intense emotions
for a period of 45 minutes in an effort to increase empathy
for a patient with auditory hallucinations must be examined. As educators, we have a responsibility to also protect the emotional well-being of our students during their
clinical education and experience.
Psychiatric nurse practitioners represent only 4.2% of
all nurse practitioner, even though it is projected that
mental illness will be the leading cause of morbidity in
the next 10 years (American Association of Nurse
Practitioners, 2017). All nurses, regardless of the nursing
specialty, will be working with patients diagnosed with
co-occurring mental disorders, as the prevalence of mental illness in the United States is 20%. Undergraduate
nurses, on their psychiatric rotation, enter our field with
many media-fed, strong misconceptions about our hospitals, our consumers, and our roles as psychiatric nurses.
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Marshall et al.
These biases can interfere with providing the best level of
evidenced to our patients, and the longer simulations
could increase student stress. Therefore, a shorter, less
intensive experience with students should be implemented and evaluated for efficacy, which provided the
foundation for this study.
Method
The present study was conducted between 2010 and
2013 during the sixth semester of a pre-licensure
Baccalaureate Nursing Program at an Eastern United
States public university. The research question was the
following: “Can a 6-second, low-fidelity simulation
increase empathy for patients experiencing auditory hallucinations?” Participation in the experience was voluntary and part of the pre-psychiatric nursing clinical
rotation preparation.
The aim of this study was to implement and evaluate a
cost-effective, brief intervention that exposed students to
the minimum level of emotional distress, while engaging
them in a deep learning experience of a disorienting
dilemma.
A qualitative content analysis design was used to evaluate themes from past hearing voices reflective narratives
collected after the lived experience of a 6-second simulation of an auditory hallucination.
Protection of Human Subjects
Institutional review board approval was obtained from
the teaching institution, and all student participation was
voluntary.
Data Analysis
Self-reflections from each of the participants were collected electronically and underwent a content analysis to
identify recurring themes and words, using the qualitative
software package ATLAS.ti 7 (ATLAS.ti Scientific
Software Development, Berlin, Germany) for evaluation
of data. Three independent evaluators (the principal
investigator, a graduate student, and the evaluator)
reviewed 10 randomly chosen narratives for review to
establish interrater reliability, while identifying repeating
phrases, statements, and words. Each reviewer identified
repeating themes, either stated (i.e., I learned for knowledge acquisition) or inferred (i.e., I felt for empathy).
No student identifiers were on the reflections. Each
narrative was provided a number (1-212) when inputted to
Atlas.ti 7 software. Due to the large amount of qualitative
data generated through the 212 narratives, 85 numbers,
representing 85 self-reflections, were randomly selected
from the total pool using an online list randomizer.
Emergent themes were discussed and defined after being
identified through the preliminary review of the data, and
then assigned codes and placed into categories.
Procedure
The two investigator/instructors, both certified psychiatric nurse practitioners, conducted the simulation in
junior-level, BSN psychiatric nursing education classes.
The simulation experience was described prior to the
experience, and students who chose to participate either
volunteered to be the “voices” or the participants. The
study was conducted over a 3-year period (2010-2013).
The setup for the simulation joins two chairs facing
each other in front of the class. The student chair faces
the class while the instructor chair faces the student
chair. Then three volunteer students stand behind the
student chair facing other students in the classroom.
Each of the volunteer students is given a statement to
repeat. “Don’t listen to her, listen to me” or “It’s ok I
like you, I am your friend” or “Just get up and walk
out,” representing three auditory hallucinations. Where
possible, a mix of genders in the voices is optional. One
by one, each student may volunteer to sit in the student
simulation chair, with the three classmates standing
behind them, out of visual field. This student is instructed
to look at the three people standing behind the chair,
then to turn back to the instructor. The instructor then
asks if he/she is comfortable and ready to begin. Once
the student states that he/she is comfortable, the instructor says, “If, at any time you want to stop this experience, put your hand on your chest like this.” The
instructor demonstrated putting the hand to the chest
and asked the student to provide a repeat demonstration
of this motion. The instructor instructed “the voices,”
“When you see me do this, you must immediately stop
talking.” The instructor then asked the student, “Are you
ready to begin?” When the student said yes, the instructor told the voices to start speaking. Instructor says, “Hi,
my name is. What is your name?” and waits for an
answer from the volunteer. If the volunteer cannot
answer, or appears in distress, the simulation stops. If
the volunteer states his/her name, the instructor says,
“What did you have for breakfast/lunch today?” “What
did you have for lunch today/yesterday?” or “What did
you have for dinner yesterday?” If the student cannot
answer, or appears in distress, the simulation stops. If
time permits, within the 6-second time period, the
instructor asks a brief follow-up question on the food(s)
identified. The instructor placed his/her hand up to stop
the voices after 6 seconds, or at any time the student
indicates a desire to have the simulation stop. The student returned to his/her chair in the class and the next
volunteer sat to the chair. The same simulation was
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Journal of the American Psychiatric Nurses Association 00(0)
repeated until all student volunteers had an opportunity
to experience the simulation. The students who provide
“the voices” were the last three to participate and were
all replaced at the same time.
After the demonstration, the student participants
were asked to write a one-page, self-reflection on the
experience. The narrative required the student to
describe the simulation set up, explain what the participant thought would happen and what the participant
experienced, and reflect upon what kind of change in
thinking or practice (if any) that occurred by participating in the experiment.
and value in the experience. Many of the statements combined the themes, demonstrating insight, knowledge, and
empathy.
In the 82 self-reflections, 301 instances reflective of
insight were identified.
Results
A total of 212 reflections were collected. Three investigators collaboratively reviewed five randomly chosen reflections, identifying and concurring on five common themes:
insight, knowledge, empathy, therapeutic communication,
and valuable experience. These themes emerged from
inductive category development secondary to emersion in
the narratives, with the only preconceived category of
empathy established prior to the review. The five themes,
emerging directly from the narratives, were then defined in
context. The purpose of this approach was to explore the
students’ experience as stated, without inferring meaning
to their descriptions. Insight was described as gaining a
deeper understanding into one’s own perceptions or beliefs.
Knowledge was identified as learning something concrete
and new about schizophrenia or psychosis. Empathy was
defined as being able to feel or sense the emotions or experiences of another person. Statements reflective of therapeutic communication required evidence of utilization of
one of the communication skills taught in class or
included in the psychiatric nursing textbook. Narratives
that expressed or used the words value, valuable, or
important when referring to the simulation were coded
under valuable experience. Sentences, phrases, and
words were then tagged using the Atlas.ti 7 and reviewed
in context for topic-specific reliability and validity
(Corbin & Strauss, 2015; Friese, 2017).
Evaluations were then conducted independently on 10
randomly chosen narratives with results establishing
theme interrater identification reliability of 87%. From the
set of 212 numbered reflections, a random sample of 85 narratives was identified for review. Eighty-two narratives from
the sample of 85 responded to all the criteria in the selfreflection and made up the final sample (N = 82). No identifiers were left on the narratives, so although there were
males and females participating, there is no report on the
distribution of gender, age, or other personal information.
The following themes were identified across all 82 narratives: insight, knowledge, empathy, professional commitment to engage in therapeutic communication techniques,
I felt like I wasn’t able to control my thoughts. I usually don’t
have to think so hard or concentrate that much to answer any
type of questions but I found it very hard. I learned what it would
be like to be inside of a patient’s head that is hearing voices.
It was very confusing to try to focus on the individual in
front of me because of these “voices” or other thoughts
filling my head. I could not see them but their opinions were
very clear. They were confusing to listen to all at once and I
wasn’t sure which to believe. It was difficult and could
easily make someone very uneasy.
I wasn’t expecting it to be so difficult, but it was.
The constant competition of trying to think of these voices
causes confusion and an increased alertness to the
conversation trying to be held.
Before this class I didn’t know how it would feel to have
many voices running through my mind, distracting me from
decision making. I had no idea how it felt, nor had I ever
imagined it before.
The amount of concentration and focus needed to handle both
what you will be saying next and blocking out the voices in
your mind is a skill that takes multitasking to the next level. It
is one that requires a lot of strength and concentration—which
was hard for me to do even for a mere 5 seconds.
Knowledge statements (n = 153) were identified in the 82
reflections.
I learned how difficult it could be to remain focused and how
someone could easily lose touch with reality. One wouldn’t
be able to tell what was actual happening from a hallucination
and this could be very frightening.
It taught me that many of the clients I intend to help will
have many illnesses across a very wide spectrum and it is
very hard to feel the way they constantly feel—and every ill
person may come across many different challenges.
By observing my classmates I was able to see the way their
expressions changed, some became flustered and others
seemed to have to concentrate very hard.
I see why command hallucinations can be very dangerous.
I now know how hard it is for them to do simple tasks like
answer a question or think clearly and why they are very
anxious and get agitated easily.
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Marshall et al.
Empathy statements (n = 158) were abundant in all of
the self-reflections, often combined with a reflection of
deeper understanding of the underlying pathology of
psychosis.
Now that I was able to experience a little insight with this
simulation, my fear and anxiety from the whole thing will
help me remain calm and give people with mental disorders
the empathy and respect they deserve.
Just being in the head of a patient that hears multiple voices,
for only 6 seconds, allows me to appreciate them more.
There is always a stigma with patients like this, but putting
me in this situation, being able to experience what they
experience on a daily basis, allows me to better understand
what goes on in their heads.
He she fights battles every day to conduct basic everyday
tasks like talking.
I was able to step into their shoes—it was a reminder to me
that their lives are not easy and that there are many things
they will have to overcome in a single day.
Examples of therapeutic communication technique recognition follow.
I realized the importance of therapeutic communication. It is
important to speak with patients slowly and in a calm voice
because it is more relaxing.
By being a patient advocate, and an overall good nurse, we
must always be aware of the needs of these patients and
apply our nursing communication in calming them whenever
needed and exercising general care and concern for their
wellbeing.
If I was talking to them loud and fast while they were
hallucinating, it would only elevate their already high
anxiety levels that they might be experiencing.
Now that I was able to o experience a little insight with this
simulation, my fear and anxiety from the whole thing will
help me remain calm and give people with mental disorders
the empathy and respect they deserve.
A valuable experience was acknowledged (n = 89) in sentences of the 82 self-reflections.
This was the most important experience so far in clinical.
I found this experience to be very valuable, and to help me
in working with patients with psychosis.
By experiencing what these patients go through, we can
provide better care because of our increased understanding.
Ninety-eight percent of the students reported increased
empathy for the schizophrenic patient hearing auditory
hallucinations. One hundred percent of the narratives
reflected gaining an increase in knowledge about, and
interest in, auditory and visual hallucinations. One hundred percent of the respondents identified an increased
insight into the experience of the patient experiencing
psychosis. A deeper understanding of the stress and anxiety related to auditory hallucinations by the schizophrenic
patient and increased professional determination to utilize therapeutic engagement was expressed by 88% of the
self-reflections with 92% identifying the short experience
as an important clinical experience.
Discussion
This study provides self-reported evidence supporting the
efficacy that a brief intervention that caused a disorienting
dilemma successfully increased critical reflection, empathy, and academic discourse. Over 200 students participated in the simulation during the study period, with no
student reporting any experience of undo stress related to
the experience. Students who chose not to participate also
provided a self-reflection on the experience; however,
those reflections were not included in the study sample for
randomization. The investigators felt that having psychiatric nurse practitioner implementing this simulation was
an important aspect, allowing the instructor to assess the
student response in real time, truncating the simulation if
any distress appeared. A limitation of this study was that it
was conducted in one university, with undergraduate students who had no experience in a psychiatric clinical or
working with patients with psychiatric disorders. The students’ preconceived beliefs about people with psychiatric
disorders evolved from the media or personal experience.
All students were invited to stay and observe the simulation, even if they chose not to participate. Over the 3 years,
less than 1% of students opted out of the simulation.
Psychiatric nursing is based on the tenet of creating
the patient–provider therapeutic alliance. The nurse
patient alliance is built on respect, trust, and empathy.
Studies have demonstrated that the level of empathy in
modern nursing students has significantly decreased from
past years (Ward et al., 2012). Nursing education has
fully embraced the technology-driven pedagogy that
includes distance learning, high-fidelity simulations, and
video gaming, all of which decrease the student’s ability
to engage, experience, and reflect on the impact of the
human connection (Ward et al., 2012). Ward et al. (2012)
also cited the increase in nontraditional clinical settings,
which do not foster relationship building or development
of empathy, as a possible variable in the decline of student nurse empathy levels.
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Journal of the American Psychiatric Nurses Association 00(0)
The demonstrated efficacy of this inexpensive, lowfidelity simulation can support future implementation of
this intervention in populations of nonstudent, practicing
nurses. This simulation can also be implemented and
evaluated for efficacy with nonnursing populations, to
increase empathy for the psychiatric patient. Including
pre/post quantitative measures to indicate changes in the
level of knowledge about and/or stigma against the mentally ill, psychotic individual could strengthen the evidence of efficacy for use of this strategy. Follow-up
studies to evaluate the changes in behavior related to
increased empathy and insight gained in the simulation
could indicate long-lasting effects of the 6-second hearing voices experience.
article: Support for this research was received from William
Paterson University’s College of Health and Science.
Conclusion
The 6-second simulation experience provides educators
with a different kind of simulation experience that is easily implemented, nonaggressive, safe for the students,
cost-effective, and delivers changes in attitudes and beliefs
that can lead to sustained behavior change. In affording
the student the opportunity to have a 6-second lived experience of auditory hallucinations, we succeed as educators
in facilitating the acquisition of knowing oneself in a brief,
controlled, altered condition. According to Hanna and
Finns (2008, p. 267), “The only way it is possible to know
another human being as a human being, though, is first to
really and profoundly know oneself as a human being,”
which is the best foundation to engaging in a respectful,
honest patient–provider therapeutic alliance.
Acknowledgments
The authors thank Dr. Ken Wolf for his support and sage advice
provided during this project.
Author Roles
Dr. Marshall: Principal investigator and primary writer, editor,
and revisionist of the manuscript. Dr. Bliss: part of the initial
team for document review, evaluation, and ongoing writing,
editing, and rewriting of the manuscript. Dr. Evans: involved in
implementation of research and writing and reviewing initial
manuscript. Ms. Dukhan: Student research assistant, involved
in all aspects of research and evaluation and engaged in initial
drafts of manuscript development.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this
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