Issues in Mental Health Nursing, 36:112–117, 2015 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.953278

Mindful Teaching Practice: Lessons Learned through a Hearing Voices Simulation Lori I. Kidd, RN, PhD, Kathleen R. Tusaie, PhD, APRN-BC, Karyn I. Morgan, MSN, RN, Linda Preebe, MSN, RN, and Michelle Garrett, BSN, RN Issues Ment Health Nurs Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/22/15 For personal use only.

The University of Akron, School of Nursing, Akron, Ohio, USA,

A hearing voices simulation (Deegan, 1996) was conducted with mental health nursing students (N = 87) at a large Midwestern university. The goals of this simulation were to change attitudes and decrease stigma. Students used mp3 players to listen to an audio simulation while simultaneously engaging in activities requiring focus and concentration. The Attitude toward Mental Illness Questionnaire (AMIQ; Cunningham, Sobell, & Chow, 1993) was administered pre-and post-simulation and open-ended questions about the experience also were asked. Responses to questions demonstrated increased patience, tolerance, understanding, and empathy among participants. Statistical data demonstrated significant changes in participants post-simulation. However, although students reported increased comfort being around persons hearing voices, they were less likely to acknowledge individual behavior as indicative of recovery. In this article, we discuss how these unexpected outcomes may be related to a subtle illness versus recovery focus. We emphasize how educators must be mindful and reflective about beliefs and attitudes that inform their teaching, and ultimately, their students’ learning.

Hearing voices is assumed by the general public to be a symptom, of serious mental illness—most often, schizophrenia. It is a symptom much talked about, joked about, and feared. Those who hear distressing voices frequently must encounter the negative consequences of stigma: discrimination in housing, work, and societal participation; rejection; isolation; low self-esteem; fear of reaching out for professional help and treatment; potential hopelessness; and the worsening of the burden of disease (Serafini et al., 2011). In a keyword search targeting stigma and mental illness, J. Brown (2009) found over 500 articles. Stigma also extends beyond the general public. Less experienced mental health nurses prefer less social contact with clients with schizophrenia than those with more experience, and those working in a community setting were significantly more likely to have positive attitudes than those working in inpatient settings (Linden & Kavanaugh, 2011).

Address correspondence to Lori Irene Kidd, The University of Akron, School of Nursing, 209 Carroll Street, Mary Gladwin Hall, Akron, OH 44325-3701 USA. E-mail: [email protected]

For this article, faculty at a large Midwestern university adapted an audio simulation of “Hearing Voices that are Distressing” (Deegan, 1996) for use with undergraduate mental health nursing students. Goals for the simulation were to change participants’ attitudes toward those with this acute psychiatric symptom. In addition to determining whether these goals were met, as an extension of the simulation, faculty sought to implement a feasibility study—to gather evidence as to whether the simulation was feasible to use with other student groups and to integrate into the psych-mental health curriculum. In recent years, nursing practice and nursing education have emphasized building knowledge through evidence. The acceptable definition of “evidence-based practice” has been interchangeable with “research” and the “scientific method.” Carper (1978) identified multiple ways of knowing; therefore, the evidence-based approach—while important and necessary—may not be sufficient in and of itself. Although evidence-based practice and reflective practice are not new concepts—having been discussed for years—nursing education courses have been highly skewed towards the empirical approach and the research method. This trend has, at times, led to a benign neglect of more reflective methods of teaching. Following initiation of the Hearing Distressing Voices Audio Simulation, we set out to gather traditional evidence that the simulation was an effective teaching strategy. As we analyzed our empirical and statistical results, we realized that our initial intent—to report our educational research—had instead become a process of evaluating our teaching strategy and reflecting upon our teaching practice. Therefore, this article presents lessons learned from using quantitative, qualitative, and reflective methods of evaluation of a teaching strategy. LITERATURE REVIEW Hearing Voices Simulations Simulations provide powerful experiences that imitate reality, but are free of the risks that may occur in actual practice settings (Dearing & Steadman, 2009). In experiential learning theory, Kolb (1984) noted that the individual learner transforms

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MINDFUL TEACHING PRACTICE: LESSONS LEARNED

his or her experience, leading to a change in attitudes and perceptions. Educational interventions using simulations help learners change attitudes and perceptions in a variety of ways, including increasing empathy (Mann & Himelein, 2008). In qualitative studies completed with nursing students, researchers found that participants reported increased empathy and understanding. Participants also anticipated a reshaping of their attitudes toward those hearing distressing voices and they recommended continued use of the simulation in the curriculum (Dearing & Steadman, 2009; Wilson et al., 2009). Some quantitative studies found less evidence for the benefits of audio simulations. S. Brown (2008) found that negative emotions increased after a simulation, and that participants were more likely to want increased social distance from those hearing voices (S. Brown, Evans, Espenschade, & O’Connor, 2010; Kalyanaraman, Penn, Ivory, & Judge, 2010). These effects persisted even when measured one week after the simulation.

Mindful Practice/Reflective Teaching Refocusing of educational priorities requires deliberate, mindful action. Mindful practice—self-awareness in the moment with the purpose of achieving standards of excellence—develops as one creates or sets aside opportunity for reflection. Reflection or cognitive synthesis of one’s experiences, in turn, forms a sort of hermeneutic circle and leads to a “path of self-awareness” (Johns & Freshwater, 2005, p. 8). Mindful practice is self-awareness or self-reflection that leads to wise, compassionate care (Johns & Freshwater, 2005). Being mindful of one’s preconceived ideas, negative emotions, and stigmatizing attitudes lays the foundation for sound critical thinking and clinical decision making (Johns & Freshwater, 2005). Educators have found that activities that require nursing students to self-reflect about their perceptions of the mentally ill help them understand not just changes in their own attitudes, but the impact of stigma as a whole (Webster, 2009). As important as it is to build sufficient time in simulation experiences for activities that promote student reflection, it is equally important for those designing and guiding the experiences to be mindful of how they design those experiences. They must be aware of any bias they carry into planning and implementing the learning activities. An important question for the educator to ask is whether the seeds of mental health recovery are contained within the simulation activity. The concept of holistic nursing—an approach that emphasizes wholeness and humanness rather than seeing the patient as his or her illness— has been foundational to nursing practice for generations. Nursing faculty who fail to present recovery principles in the classroom or lab do a disservice to future nurse caregivers and to their clients. They may inadvertently skew nursing students’ perceptions and attitudes towards greater stigma. Faculty who designed and conducted the Hearing Distressing Voices Audio Simulation research in this study worked backwards to learn

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important lessons about being mindful in their own teaching nursing practices. Although many studies have evaluated the responses of nursing students to simulation, few have used other than a traditional empirical or evidence-based approach and even fewer have considered more than one way of knowing to build our nursing knowledge. This study, therefore, takes a unique approach and helps to fill a gap in our nursing knowledge. RESEARCH QUESTIONS We had two primary research questions. After the Hearing Distressing Voices Audio Simulation, would undergraduate psychiatric nursing students: (1) demonstrate a significant change in attitudes towards those hearing distressing voices? (2) recommend that the Hearing Distressing Voices Audio Simulation be offered to other students? A related research question was: (3) Is this Hearing Distressing Voices Audio Simulation a feasible teaching strategy to incorporate into the psych-mental health curriculum? METHODS This was a descriptive feasibility study using mixed methods. Instruments used to collect data were a well-validated attitudes questionnaire (quantitative) and open-ended questions about the experience of participating in the study (qualitative). A convenience sample of 78 undergraduate psychiatric nursing students in groups of 8–10 students participated in the Hearing Distressing Voices Audio Simulation during clinical conferences. Procedure The authors’ IRB gave approval for this project. All students signed a consent form. Six clinical faculty members were trained using the standard instruction guide provided in simulation materials. While listening to the simulation, students performed a mental status exam, completed word and number search puzzles, or read a scholarly article or textbook chapter. Following the simulation experience, the instructor facilitated a debriefing session, discussing reactions, questions, and thoughts. An evaluation of the participants’ experiences was obtained through quantitative and qualitative techniques. Pre- and postcompletion of the self-report, Attitude toward Mental Illness Questionnaire (AMIQ; Cunningham, Sobell, & Chow, 1993) produced quantitative findings. The AMIQ poses a brief scenario of a client with schizophrenia who hears voices, receives intramuscular (IM) medication, and has been involuntarily hospitalized, but is currently functioning well; users are then to report their degree of agreement with statements about the client. The AMIQ is a self-completion, five-question instrument with good reliability and validity (Cronbach’s alpha = .78, test-retest correlation r = 0.702, and factor analysis indicating that stigmatization was responsible for 80% of the variance) (Luty, Fedaku, Umoh, & Gallagher, 2006). The questions are rated on a five

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TABLE 1 Means for Individual Questions Attitude toward Mental Illness Questionnaire (AMIQ; Cunningham et al., 1993)

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FIGURE 1 Pre- and Post-Total Means for Attitude toward Mental Illness Questionnaire (n = 78).

point Likert scale (+2 highest, –2 lowest). Post-simulation discussion, as well as written responses to two questions, produced qualitative results. Instructors for each group were asked to record themes that emerged from post-simulation debriefing sessions. In addition, students were asked to respond in writing to two questions: (1) What is your reaction to this experience? and (2) Would you recommend this experience for other students?

DATA ANALYSIS To answer the first two research question descriptive statistics, paired t-tests of total AMIQ scores, and each question totals were calculated. The question of feasibility was answered through evaluation of quantitative and qualitative data and analysis of the logistic strengths and weaknesses of conducting the simulation. Quantitative Findings There was a statistically significant difference between preand post-total AMIQ means (p = .015) (see Figure 1). Means and standard deviations also illustrated changes pre- and postsimulation (pre-simulation M = –2.11, SD = 2.99; postsimulation M = –3.08, SD = 3.47). Means for each of the individual questions (Table 1, Figure 2) produced varied results. While students seemed to report slightly greater comfort post simulation about John being a coworker or social companion as indicated by lower means for Q2 and Q3, higher means for for Q3, Q4, Q5 post simulation indicated increased expectations that John would have more negative career, marital, and legal outcomes.

5 4 3 2 1 -1.5

-1.3

-1.1

-0.9

-0.7

-0.5

-0.3

-0.1

FIGURE 2 Attitude toward Mental Illness Questionnaire: Means for Individual Questions (n = 78).

1. Do you think this would damage John’s career? 2. I would be comfortable if John was my colleague at work 3. I would be comfortable inviting John to a dinner party 4. How likely would it be for John’s wife to leave him? 5. How likely would it be for John to get in trouble with the law?

Mean pre-test

Mean post-test

−0.99

−1.3

−0.13

−0.091

−0.24

−0.22

−0.28

−0.60

−0.55

−0.77

Qualitative Findings Nursing students reported a change in attitude. Overall the majority of themes in the discussion, as well as the written responses to the two questions, demonstrated the students’ predictions of changes in their own behavior, such as being more patient, more tolerant, more considerate, more empathetic, more understanding, and becoming more knowledgeable about the experience of patients. However, negative themes were identified in approximately 10% of respondents and included feeling overwhelmed, anxious, spooked, scared, distressed, and debilitated. Although the majority of respondents reported they would recommend the use of this simulation for other students, saying it was “helpful,” “valuable,” “realistic,” “eye opening,” “vital,” and “beneficial,” a small group (approximately 6%) reported that the experience was “not effective,” was “hard to understand,” of “no impact,” and that they “learned nothing” and were now sure that they did not want to work with this population. DISCUSSION Findings This study demonstrates that the use of a brief simulation experience can bring about significant change in attitudes toward individuals with mental illness who hear voices. The AMIQ demonstrated statistically significant differences in attitudes pre- and post-test, with the overall mean becoming more negative. When examining the specific questions, it seemed that students developed more empathy and were more comfortable with being around individuals who heard voices at work or at a dinner party (Q2 and Q3). Although not specifically measured by an instrument, these findings suggest decreased social distance, which runs counter to findings of other simulation studies conducted with students (S. Brown, 2010; Kalyanaraman et al.,

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2010). But the remaining questions (Q1, Q4, & Q5), which addressed predictions about the individual’s behavior (trouble with the law, wife leaving, career destroyed), became more negative. So, it seems that although students became more aware of the experience of hearing voices and more empathetic to those who do, the students’ beliefs about the possibility of functioning and recovery decreased. This finding was unexpected, and contrary to the desired outcome of improving attitudes toward those who hear voices. As we investigated further, commonalities were discovered between the current study and previous studies. Other wellconducted studies measured changes in attitudes or desire for increased social distance pre- and post-simulation (S. Brown et al., 2010; Kalyanaraman et al., 2010). These other studies’ findings that the use of simulation alone reinforced stigma were congruent with the present study. No other studies measured attitudes using the AMIQ (Cunningham et al., 1993), however. In a meta-analysis of simulated hallucinations, Ando, Clement, Barley, and Thornicroft (2011) found that post-simulation reflective activities, such as listing thoughts, writing reflectively, viewing filmed personal contact (interviews), or participating in focus groups reduced desire for social distance. Qualitative studies reviewed by Ando et al. (2011) did not find that participants had a greater desire for social distance, but the difference between qualitative and quantitative outcomes may be attributed to different methodologies (i.e., instruments, length of study, etc.). The present study did require students to reflect and respond to two questions post-simulation; however, an instrument specifically measuring social distance was not used.

Recovery Focus Mental health recovery is defined as “a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2006; para 4). SAMHSA has named recovery as the United States’ most important goal for the mental health care delivery system (SAMHSA, 2006). Leading psychiatric mental health nursing organizations such as the American Psychiatric Nurses Association (APNA) and the International Society of PsychiatricMental Health Nurses (ISPN) have adopted integrating person-centered recovery-oriented practices into nursing practice standards (American Nurses Association, 2012) as a priority. Recovery should include these components: self-direction; empowerment; individualized and person-centered care; a holistic approach; a nonlinear course; strengths-based treatment; peer support; respect; responsibility; and hope (SAMHSA, 2006). To reach this goal, future health care providers must be aware of the possibility of recovery and committed to promoting recovery for those with mental illnesses. Therefore, it is critical for nurse educators to move away from a more traditional focus on

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illness care and incorporate mental health recovery principles into undergraduate nursing curricula. Nursing education literature supports the recovery approach. Morrison (2009) used a reflecting team approach to differentiate between “thin” descriptions of lives (i.e., one dimensional with a focus on problematic symptoms) and “thick” descriptions (i.e., broadening conversations to include aspects such as talents and achievements). He posits that thick descriptions engender hope and empowerment for professional caregivers and clients, and narratives or stories of clients with serious mental illness challenge stigma. A stand-alone hearing voices simulation could be viewed as a “thin” description.

Limitations Primarily limitations of the study were that the sample was a convenience sample and that there was no control group. Additionally, there was no follow-up beyond the initial data collection, so it is not possible to know whether attitude changes were maintained over time. The sample was very homogenous, with little cultural diversity present, so the ability to generalize findings is limited. There were a number of technical difficulties with the equipment used for the audio simulation. (Some mp3 players lost their charge partway through the simulation, requiring students to share equipment, with each using one earpiece; several students were not able to hear the simulation in its entirety.) Unfortunately, these technical issues persisted intermittently for the duration of the study, and led to increased frustration and decreased ability to focus on the simulation for some participants. Finally, each faculty member structured the experience differently—tasks assigned to students while listening to the audio simulation varied from group to group. Although these variations are usual and customary in teaching practice and acceptable in a feasibility study, results cannot be generalized to external populations.

FUTURE RECOMMENDATIONS FOR TEACHING AND RESEARCH Curricular content in undergraduate nursing programs has been traditionally driven by quantifiable parameters, such as AACN and Board of Nursing accreditation standards or passing NCLEX licensure exams, with supra-structures, such as nursing theoretical frameworks and the nursing process, providing prescriptive guidelines. Tracking empirical evidence is essential for ensuring success and yet, personal, more reflective knowing also provides valuable learning to students. Following mindful reflection, and believing that our reflections yield insights important to other mental health nursing educators who are considering a hearing voices simulation, we have organized this section on a continuum of recommendations to adopt ranging from optional to critical (could, should, and must include).

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Could Include A helpful strategy would be to have students review a website such as http://www. hearing-voices.org. On this website, “information (beyond a strictly medical approach), support, and understanding” about hearing voices is provided (Hearing Voices Network, 2013; para 1–2). In addition, it provides an open forum for those who hear voices or have experienced other types of hallucinations to talk about their experiences and share their coping mechanisms. Another recommendation would be expanding the activity to incorporate more activities suggested in the complete training manual provided by Deegan (1996) as a means of broadening context. Should Include Future research should maintain consistency in the simulation experience through one specific set of directions for implementation. Additionally, taping the experience for evaluation of the integrity would increase generalizability and validity of the study. Using a control or comparison group would yield additional data about the simulation itself. It would also be illuminating to gather longitudinal data with the students who participated in the simulation as they continued to have additional clinical experiences and contacts with mental health clients in the nursing program. This would provide useful information about whether additional exposure to those with mental illnesses and who hear voices would lead to any additional change in stigmatizing attitudes. Technical difficulties should be resolved through the use of new or different equipment. Supplementing the audio recording of distressing voices with filmed personal contact or other means of engaging with persons actively in recovery who may hear distressing voices would put human faces on this symptom and may help to decrease stigma. Must Include Planning by educators must allow personal reflection about recovery beliefs and include a holistic and recovery focus. First, there must be a more holistic focus (a “thick” description) upon the individual who hears voices. It is important to contextualize the experience of hearing distressing voices for the learner and to incorporate recovery principles. The focus then becomes the individual, who has a distressing symptom that needs not be disabling. Faculty need to clarify that the experience of hearing voices varies in frequency, duration, and intensity; that voices are not a constant for many individuals and may only be heard during episodes of acute illness or stress; that persons who hear voices frequently develop myriad adaptive coping mechanisms to self-manage the experience; and that many persons who hear voices function well. Future simulations must include having students watch the DVD included in the training materials or a video of individuals who have the experience of hearing voices discussing their functioning prior to the simulation. Providing greater contact as

well as additional information will help students gain a more contextualized and realistic perspective. Increased mindfulness about incorporating recovery principles during planning stages will result in better outcomes related to expectations of functional ability of persons who hear voices, and will likely result in holding more positive attitudes about those with serious mental illness.

CONCLUSION This study adds to the body of literature, documenting that simulation of auditory hallucinations used as a sole experiential strategy may have the opposite effect of the desired outcome of decreasing stigma in the participant. The simulation may be perceived as a traumatic experience by some, with accompanying negative emotions and desire for greater social distance from those who hear voices. Participants also may emerge from the simulation with the sense that persons who hear distressing voices are so disabled by this symptom that they cannot function well in relationships and career settings. Although nursing students gain understanding and empathy for the experience of hearing voices, filmed contact, guest lectures by persons with mental illness, and personal contact achieved through clinical interactions may be more likely to decrease stigma. An even more important, albeit serendipitous, finding of this study was what faculty learned about the importance of being mindful in the planning and implementation of simulations. Self-reflection by students and faculty may be even more instrumental in helping to decrease stigma (Gouthro, 2009). Although it is vital to teach nursing students the principles of care for the acutely mentally ill, too much focus on illness and its symptoms—without equal time and attention focused on recovery—may inadvertently contribute to stigma building instead of stigma busting. Faculty practicing in acute or chronic settings need to reflect on their own subtle attitudes and biases, as these will filter through to students. If faculty emphasizes illness rather than integrates recovery principles, students will incorporate a bias towards illness and chronicity. To present a fair, genuine, and comprehensive portrait of the individual living with and recovering from a serious mental illness (including hearing voices) to our nursing students, a mindful balance is required.

ACKNOWLEDGMENT The Margaret Clark Morgan Foundation provided funds for purchase of mp3 players used in this study. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

MINDFUL TEACHING PRACTICE: LESSONS LEARNED

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Mindful teaching practice: lessons learned through a hearing voices simulation.

A hearing voices simulation (Deegan, 1996) was conducted with mental health nursing students (N = 87) at a large Midwestern university. The goals of t...
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