353CHAPTER 30
Assessing a Patient With a Mood Disorder
This chapter presents a simulation activity that incorporates the students’ knowledge of psychiatric illness and risk assessment with a focus on mood disorders and substance abuse. The simulation exercise builds on skills in therapeutic communication, lethality assessment, and recognition of signs and symptoms of major depression and alcohol abuse. Postscenario discussion can assist in clarifying issues in documentation, patient rights, and legal requirements of mental health nursing practice.
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Faculty in baccalaureate nursing programs face many difficulties in their efforts to connect theory to practice for students. In a mental health nursing course, the difficulties can be compounded by the abstract nature of the content and the students’ potential discomfort with the unique processes associated with mental health nursing care. Taking a broad-based approach to simulation allows the mental health nursing instructor to incorporate a variety of highly interactive strategies, many of which have traditionally been used to set the stage for the students’ entrance into clinical sites. For example, I have frequently relied on role play exercises to sharpen communication techniques and build confidence in students as they prepare for their initial exposure to acute care psychiatric patients. The creative use of case studies has also provided a means for students to demonstrate their skill in comprehensive and interdisciplinary care planning. As mental health nursing students need to integrate multiple sources of information on a patient, including observations on affect (e.g., facial expression) and speech (e.g., tone, rate, patterns, etc.), creation of a high-fidelity simulation using a human patient simulator (HPS) may not be the most effective teaching strategy. The following scenario has been created for use with a standardized patient (SP)—a human actor, paid or volunteer—who brings the situation to life and challenges the students to draw on diverse areas of theoretical knowledge as the interaction progresses. Students can also be assigned auxiliary roles, such as that of a family member, employer, or roommate.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The scenario can be run in a number of settings and requires minimal preparation or setup. At the Fairfield University Marion Peckham Egan School of Nursing and Health Studies (SONHS) Robin Kanarek Learning Resource Center there is a home health area designed for 354simulations in mental health or community/public health care. Accessories include a twin bed, a table with lamp, an upholstered chair, a throw rug, a floor lamp, and a phone. If students in the mental health nursing course have the opportunity to conduct psychiatric home visits, the scenario may be run in this setting as a mobile outreach, with roles for family members or friends to be involved in the interaction; otherwise, the scenario may be run as an interaction in an employee health clinic, a walk-in clinic, or the urgent care section of the emergency department (ED). The setting for these situations requires either two chairs and a desk, or an examination table and a chair or stool for the nurse conducting the assessment interview. Blood pressure (BP) cuffs, a breathalyzer machine, and a “clinic” phone should be available. Intake forms (including mental health assessment), substance use screening forms, depression screening forms, and a suicide lethality scale should also be present. There are substance use (Ewing, 1984a, 1984b) and depression screening (Zung, 1965) forms available on the web, as well as a sample suicide lethality scale, as shown in Appendix A.
C. SPECIFIC OBJECTIVES OF SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The main objective of the scenario is accurate assessment of psychiatric symptoms and risk factors for self-harm. The nursing process is used to identify priorities among patient needs and an evidence-based plan of care is established. Students at SONHS who are taking mental health nursing are either in the second semester of the second year of the baccalaureate program or in the first semester, third year of their baccalaureate program. Before this course, students would have completed chemistry, anatomy and physiology, and pathophysiology/pharmacology. In addition, they have taken or will be concurrently taking courses in health assessment, developmental psychology, and microbiology. Students are beginning to work on the integration of content across courses, particularly in the areas of communication and health assessment. The simulation activity presented in this chapter specifically helps students to meet objectives for the mental health nursing course in the following areas: identifying risk factors for psychiatric disorders, developing therapeutic communication skills and planning appropriate evidence-based care for psychiatric patients, recognizing ethical and legal issues as they present in patients with psychiatric illness, and understanding the role of the nurse based on the American Nurses Association (2014) standards of practice for psychiatric–mental health nursing.
D. INTRODUCTION OF SCENARIO
A human actor plays a 28-year-old female who presents to the employee health clinic with complaints of a migraine headache and fatigue. The nursing students are responsible for conducting the initial intake and assessment. They are given the standard forms used for routine clinic visits and are told that they may also make use of any other equipment present in the examination room. The students’ goal is to complete an initial assessment and establish a plan of care based on the data collected within 15 minutes. They are evaluated on their skills in conducting the interview, their ability to gather necessary information, and to determine the priority of needs at this time, their appropriate use of equipment/supplies, and the establishment of a comprehensive plan of care for the patient. Additional roles for students may include a coworker or supervisor, family member, or friend.
355E. RUNNING OF THE SCENARIO
Before running the scenario, the human actor playing the SP is given details about the patient’s background, including medical and psychiatric history, work and school history, current stressors, and behavioral patterns. She is instructed to provide minimal information until prompted by the student. There is no past medical record available. Students are given access to a phone to allow for contact with other health care providers (e.g., mental health care crisis workers) or a hospital ED as needed. In addition, students can use their personal digital assistants (PDAs) to access information on evidence-based practice related to depression and substance abuse. Although they are unable to access/communicate with the instructor or other students during the scenario, they are given the opportunity to identify additional sources of information they would have liked to use on completion of the interview (e.g., family members).
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Assessing a Patient With a Mood Disorder (for second semester, sophomore year or first semester, junior year baccalaureate students in Nursing 305—Mental Health Nursing)
Focus Area
Psychiatric/mental health nursing, health assessment, risk assessment
Scenario Description
Tina Hall is a 28-year-old, single, African American female who comes to the employee health clinic complaining of a migraine headache and fatigue. She has been an employee in the information technology department for the past 6 years, having started immediately after graduating with honors from college. She is currently working as an interim department manager while her supervisor is on medical leave. She lives alone in her own apartment and recently became engaged. Although she has experienced migraines on occasion in the past, they are now happening more frequently (1–2 per week) and are becoming more severe (7/10 self-report of pain accompanied by nausea and light sensitivity). She has been feeling extremely stressed and fears being unable to cope with the responsibilities of her job. She has had several recent conflicts with the employees under her supervision. She is having increasing trouble sleeping and has recently begun to have two or three glasses of wine before going to bed every night. She feels edgy and distressed, and wants to be given “something like Ativan” to help calm her nerves and get her through the day. She has no other medical problems and no known allergies.
Scenario Objectives
Students who successfully complete this scenario exercise have demonstrated their ability to do the following four tasks: (a) communicate effectively with a distraught client, (b) recognize the signs and symptoms related to a mood disorder, (c) conduct a lethality assessment using scale in Appendix A, as well as a substance use assessment with the CAGE scale (Ewing 1984a, 1984b), and (d) offer some appropriate nonpharmacologic interventions to reduce the client’s level of stress.
356Successful completion of the simulation activity would also allow the student to meet several of the revised American Association of Colleges of Nursing (AACN; 2008) Essentials of Baccalaureate Education, including:
Essential I (objectives 2, 3, 5)
Essential II (objectives 1, 2, 7, 8)
Essential III (objectives 1, 6)
Essential VI (objectives 2, 6)
Essential VIII (objectives 1, 2, 4, 6, 9, 10)
Areas of the 2016 National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan categories that are covered in the exercise include (National Council of State Boards of Nursing, 2015):
Safe and effective care: Management of care (advocacy, establishing priorities); Health promotion and maintenance: (health screening, high-risk behaviors); Psychosocial integrity: (behavioral interventions, chemical and other dependencies/substance use disorder, coping mechanisms, crisis intervention, cultural awareness/cultural influences on health, mental health concepts, stress management, support systems, therapeutic communication, and therapeutic environment).
Setting the Scene
Equipment Needed
Examination table, chair or stool for nurse, BP cuff, breathalizer machine, phone, intake and assessment forms, and patient information brochures on anxiety and depression. Students are informed that they will be allowed to use a PDA to access information on evidence-based practice related to the treatment of depression and associated risk factors such as suicide (American Psychiatric Association [APA], 2010; University of Michigan Health System, 2011; U.S. Preventive Services Task Force, 2014, 2016). The SP and the student are the only required participants, but additional roles may be developed for a coworker, family member, or friend.
Scenario Implementation
The SP was instructed to present with a moderate level of agitation and to focus on physical complaints and her sense of being overwhelmed. All other information would be divulged only in response to students’ questions. Students are required to respond appropriately to the level of agitation displayed by the SP, use effective communication techniques, conduct a thorough health history (physical as well as psychological), perform a lethality assessment and alcohol abuse assessment to determine priorities for care, and implement a short-term plan of action to meet identified needs. The instructor facilitated the students’ learning through the debriefing process on completion of the scenario.
Evaluation Criteria
Students are evaluated on the basis of their effective integration of theory with practice (i.e., their ability to elicit the necessary information, gain a thorough understanding of the client’s needs, determine the priorities for care, and establish a reasonable plan based on clinical evidence). Their ability to conceptualize the main issues is captured in their efforts to present a plan of care to the client.
Checklist of Interventions and Assessments
___Introduces self
___Establishes therapeutic relationship with patient
___Demonstrates therapeutic communication skills
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