Enhancing Empathy and Self-Awareness in Psychiatric Nursing Students Through High-Fidelity Simulation: A Quasi-Experimental Study
Abstract
Background: Positive patient outcomes result from increased empathy and self-awareness. One of the strategies utilized to improve empathy and self-awareness was a high-fidelity simulation (HFS).
Purpose: This study aimed to see how HFS impacted students’ empathy and self-awareness before and after HFS intervention in Jordanian university psychiatric nursing classes.
Methods: A quasi-experimental research with a pretest–posttest design was conducted on 235 undergraduate students registered in a psychiatric course at Al al-Bayt University’s Faculty of Nursing from September to December 2023. The HFS was held in the form of 5 weeks’ scenarios. The study data collection tools included a demographic questionnaire, The Empathy Toward the Mentally Ill Scale and the Self-Consciousness Scale: A Revised Version. The data were analyzed using descriptive statistics (frequency, mean, and standard deviation), and inferential statistics (t-test).
Results: Before and after the HFS intervention, a significant difference in students′ empathy (t234 = −26.90, p < 0.001) and self-awareness (t234 = −19.70, p < 0.001) was found.
Conclusions: HFS interventions, particularly in psychiatric courses, can be used to close the gap in nursing education and enhance traditional clinical learning.
Summary
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Relevance to Clinical Practice: HFS can bridge the gap in clinical training by providing nursing students with realistic scenarios to develop empathy and self-awareness, crucial for patient-centered care.
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Patient or Public Contribution: No patient or public contribution. This study focused on evaluating an educational intervention among nursing students and did not involve patients or the public in its design or implementation.
1. Introduction
Psychiatric and mental health nursing students are typically taught through a combination of classroom lectures and hands-on clinical experiences in a hospital or community setting. However, traditional clinical experiences often lack the structure and control needed to effectively teach essential skills such as empathy and self-awareness, which are central to mental health nursing [1, 2]. These methods may not consistently expose students to the emotional and interpersonal aspects of patient care, leaving gaps in their development of empathy and self-awareness.
Actors who are trained to act as standardized patients have been used by psychiatric and mental health nursing faculty in the past to help students learn assessment communication skills by acting out a simulated client care situation [3, 4]. In addition, role-playing methods and standardized patient care scenarios can be used to teach physical skills and competencies in the field of mental health nursing [1].
Faculty members can use simulation to strengthen interpersonal, psychomotor, technical, and interprofessional cooperation abilities, as well as relate course objectives and clinical competence to learning outcomes [5]. Prelicensure nurses are taught the fundamental knowledge they will need to make effective decisions while caring for patients in inpatient-, outpatient-, and community-based settings through integration of didactic lectures, discussion groups, in-class activities, and clinical experiences. Actual nursing hands-on practice is becoming increasingly difficult to come by for new nurses because of a lack of clinical settings, limited student nurse activities, inflation in nursing students, a shortage of qualified faculty, competent nursing educators, and limited time availability [1, 6].
However, meeting psychiatric client needs through the formulation of patient-centered care plans is central to nursing practice [7]. Patient-centered care plans are founded on empathy and healthcare providers’ self-awareness [7]. Nurses’ perceptions of self-awareness and empathy could hinder therapeutic interaction. Furthermore, because self-awareness is derived from self-discovery, it helps nurses and psychiatric patients communicate more effectively which is the fundamental basis of high-quality care [8]. In addition, self-awareness allows nurses to recognize their emotions and potentials, ultimately assisting them in understanding their patients’ strengths and limitations and assisting patients in recognizing their own strengths [1]. Thus, it enhances nurses’ critical thinking and decision-making abilities [1].
One of the most important skills for psychiatric nurses to master is empathy. This attitude enables the nurse to realize the significance and consequences of the patients’ feelings and thoughts, as well as express and reflect that understanding to them [9, 10]. Understanding what the patient is going through does not indicate that the nurse has empathy for the patient’s plight. Nevertheless, the nurse might imagine the patient’s thoughts about the experience by listening to and recognizing the meaning of the patient’s feelings [11]. Empathy does not mean feeling what another person is feeling; it means perceiving, understanding, and relating one’s feelings about another person’s experience. People need to be able to understand each other to deal with the needs of each person, as well as their feelings and thoughts when there are tragic events [11]. People with mental illness have showed to become more empathetic through in-class activities and assignments that encourage students to observe how differences challenge them [12]. The following activities have all contributed to an increase in empathy among medical students: high-fidelity simulation (HFS) [13–15], guided reflective writing [16], and creative drama [17].
HFS addresses the gap in the development of empathy and self-awareness by providing realistic, controlled scenarios that promote empathy and self-awareness through repeated practice and reflective learning. Recent studies underscore HFS’s effectiveness in enhancing student satisfaction, self-confidence, and clinical judgment. For example, Toqan et al. [18] demonstrated the positive impact of HFS on self-satisfaction and self-confidence, while Ayed et al. [4] highlighted its influence on clinical judgment among nursing students. These findings underscore HFS’s value as a tool for cultivating essential skills that traditional methods may fail to address. Though studied in regions such as Palestine, the benefits of HFS extend to diverse cultural contexts. HFS’s structured and adaptable design provides culturally relevant training that promotes empathy and self-awareness in various healthcare settings globally, making it a valuable asset in enhancing the quality of nursing education across regions. HFS, therefore, plays a critical role in bridging these gaps in nursing education, providing an innovative solution for cultivating empathy and self-awareness in future mental health professionals.
Empathy, a learned skill, has successfully improved through targeted training courses. For instance, a two-day, four-hour empathy training course for Iranian nurses, incorporating creative drama techniques, significantly enhanced participants’ empathetic skills [19]. In a similar vein, a reflective writing intervention in the United States, spanning six sessions, led to increased empathy among physicians [16]. Ayed et al. [14] investigated the impact of HFS on pediatric nursing students’ empathy, revealing a significant improvement in empathy levels. These interventions collectively highlight the teachability of empathy, emphasizing its rapid acquisition through HFS.
The HFS serves as a realistic and versatile tool for teaching, testing, investigating, and fostering collaborative healthcare teams [13]. Technological advancements have augmented the realism of simulations, facilitating interaction with manikins or trained simulated patients for teaching safe clinical-care techniques [20, 21]. These technological enhancements contribute to boosted learning outcomes, encompassing reactions, cognitions, moods, and psychomotor skills [22]. Simulations of clinical practice not only enhance skills but also promote self-awareness, leading to increased empathy and improved patient care.
Jordan, situated in the Middle East, is a developing country with a predominantly Arab population characterized by a collectivist nature that influences social norms. The power of collectivism is evident in individuals working within social norms. Self-awareness becomes crucial in this context, with an emphasis on recognizing one’s characteristics when exercising it within community groups. The uniqueness of the family unit is prioritized over individuality, necessitating empathy for individuals to conform and thrive in such a society. However, a literature gap exists regarding how HFS experiences impact nursing students’ self-awareness and empathy when dealing with mental illness patients. This study aims to address this gap, shedding light on the importance of HFS intervention in promoting empathy and self-awareness among nursing students in clinical practice.
2. Methods
2.1. Design and Sample
This quasi-experimental study was conducted from September to December 2023 with a pretest–posttest design. Undergraduate nursing students registered in a psychiatric course at Al al-Bayt University’s Faculty of Nursing participated in this study. The sample size was calculated with a t-test using the G power analysis program and the following parameters: effect size = 0.40, p < 0.05 and power = 0.90. The needed sample size was 136. The convenience sampling was used to choose participants for this study. This interventional study enrolled a total of 235 students, and none of them declined. Demographic data were collected, including age, gender, and prior experience, specifically “previous academic psychiatric experience” and “occupation,” to understand the participants’ educational backgrounds and potential exposure to mental health settings.
2.2. Simulation Scenarios and Debriefing
The HFS is an educational method that provides nursing students with realistic, interactive patient care scenarios. Over 5 weeks, four main scenarios were developed to assist students in managing mental health conditions: schizophrenia, substance abuse, bipolar disorder, and panic disorder (see Table 1). Study participants were first-time users who had never paired a simulator session with a traditional didactic technique. As a result, during the first week of the experiment, all trial participants were required to attend a two-hour introductory meeting to learn about the HFS as well as the components, advantages, actions, and processes of the study-related intervention. The simulated learning objectives were explained to the students by the mental health nursing instructor.
| Week: 1 | |
|---|---|
| Introducing participants to HFS, as well as the components, advantages, actions, and procedures of the experimental study | |
| Week 2 | |
| Scenario 1: schizophrenia | Time: 45 min |
| Overview: | Scenario objectives: |
| Danny, a 32-year-old military veteran, is currently facing peculiar occurrences, including instances where he perceives communication from the pigeons near his residence. Simultaneously, he has developed heightened concerns about being under government surveillance, leading him to avoid technologies such as cell phones and laptops that he believes might be used for tracking. About a year ago, he started hearing things unnoticed by those around him, fueling anxiety about government scrutiny. These experiences have taken a toll on his employment and interpersonal relationships, contributing to increased conflicts with his girlfriend. During interactions, Danny displays limited emotional expression, maintaining a consistent tone of voice and facial expressions | 1. Evaluate the influence of a high-fidelity simulation program on nursing students′ self-awareness, empathy, and patient-centered care perspectives in mental health course at AABU |
| 2. Investigate the enhanced empathy levels in Arab nursing students following their engagement in three group scenarios of high-fidelity simulation and draw a comparative analysis with the empathy levels of Chinese nursing students | |
| 3. Explore the relationships among heightened empathy, increased self-awareness, and enhanced patient-centered care outcomes resulting from the incorporation of high-fidelity simulation into the curriculum of a mental health course | |
| 4. Investigate the correlation between the integration of high-fidelity simulation within a mental health course and the advancement of patient-centered care scores in nursing students | |
| Week 3 | |
| Scenario 2: substance abuse | Time: 45 min |
| Overview: | Scenario objectives: |
| Juan, a 34-year-old Mexican-American construction worker, details his experiences working in high temperatures while repairing interstate roads. He notes that his alcohol consumption, primarily in the form of cool beers, is on par with his colleagues, with up to eight beers consumed during a typical 10-h workday to cope with the heat. Despite asserting that it has not affected his work performance, Juan acknowledges sustaining a few minor injuries while under the influence. He reflects on a shift from lesser alcohol intake when he started in the profession to a gradual increase, now finding it necessary upon returning home. Describing himself as a family man, Juan admits to a shift in behavior, having never consumed alcohol in front of his family until recently. The demanding nature of his job leaves him too fatigued to engage in meaningful conversations with his wife and children. Juan confesses to lose track of his off days due to his drinking habits. Recollecting times spent with his three daughters before his current profession, he acknowledges occasional yearning for those moments. Attempts to cut down on drinking during special occasions or lent result in irritability and increased cravings, leading to a return to previous drinking levels. Disputes with his wife arise over financial allocations for alcohol versus essential expenses, with Juan believing he can curb his spending with enough effort | 1. Explore the principles of substance abuse |
| 2. Identify and utilize symptoms linked to this syndrome in evaluating clients | |
| 3. Apply the nursing process by | |
| a. Formulating nursing diagnoses and treatment goals for individuals struggling with substance abuse | |
| b. Recognizing key topics for client and family education related to substance abuse | |
| c. Outlining appropriate nursing interventions for behaviors associated with this disorder | |
| d. Defining criteria for assessing the quality of nursing care provided to individuals dealing with substance abuse | |
| e. Examining diverse treatment strategies for substance abuse | |
| Week: 4 | |
| Scenario 3: bipolar disorder | Time: 45 min |
| Overview: | Scenario objectives: |
| Sarah, a 42-year-old woman, is married and has a history of depressive and hypomanic episodes. Diagnosed with major depression, borderline personality disorder, and most recently, bipolar disorder, her symptoms indicate multiple depressive episodes since her late teens, later developing clear hypomanic episodes. Experiencing heightened interpersonal conflicts and hypersexuality, coupled with alcohol use during hypomanic episodes, she received a temporary borderline diagnosis. However, considering her comprehensive history, bipolar disorder seems to be the most accurate diagnosis. Currently single with strained family relationships, sarah has been on mood stabilizers for a year, yet she still experiences mild depression. Despite discontinuing medication previously, she now expresses a desire for individual treatment, feeling weary of constant challenges in her life | 1. Explore the concepts surrounding bipolar disorders |
| 2. Recognize the symptoms associated with these disorders and apply this knowledge in client assessments | |
| 3. Nursing process | |
| a. Formulate nursing diagnoses and establish care outcomes for clients with bipolar disorders | |
| b. Identify topics related to bipolar disorders for patient and family education | |
| c. Define appropriate nursing interventions for behaviors associated with bipolar disorders | |
| d. Establish suitable criteria for evaluating the nursing care of clients with bipolar disorders | |
| 4. Discuss diverse treatment modalities for bipolar disorders | |
| 5. Identify nursing treatments appropriate for behaviors linked with bipolar disorder symptoms | |
| 6. Determine acceptable criteria for assessing the nursing care of individuals with bipolar disorders | |
| 7. Explore various treatment options available for bipolar disorders | |
| Week: 5 | |
| Scenario 4: panic disorder | Time: 45 min |
| Overview: | Scenario objectives: |
| Dave, a 41 year-old man, was referred to the ER by his primary care physician due to breathing problems. Despite thorough medical examinations, his doctor couldn’t identify a physiological cause for his symptoms, leaving him puzzled, stressed, and frustrated. Over the past 6 months, dave has been grappling with recurring episodes of intense fear, lasting only a few minutes each time. These episodes were accompanied by symptoms such as perspiration, heart palpitations, chest pain, discomfort, and shortness of breath, making him fear for his life. The constant worry about experiencing another attack has led dave to live in a perpetual state of fear. As a coping mechanism, he has started avoiding unfamiliar places and people, particularly those where obtaining help during a panic attack might be challenging. This anxiety-driven behavior has significantly impacted Dave’s life, causing him to decline social invitations, find reasons to stay home as much as possible, and rely on his wife to manage their children’s activities. Despite her initial acceptance, Dave’s wife is growing weary of what she perceives as his irrational fear of panic attacks. | 1. Explore the fundamentals of panic disorder |
| 2. Demonstrate the ability to identify and employ the symptoms linked to this condition during client assessment | |
| 3. Apply the nursing process effectively | |
| a. Formulate nursing diagnoses and design treatment plans for patients with panic disorder | |
| b. Identify topics related to panic disorder for educating both clients and their families | |
| c. Recognize appropriate nursing interventions for behaviors associated with this condition | |
| d. Develop suitable criteria for assessing the nursing care provided to patients with panic disorder | |
| e. Engage in discussion about various therapy options available for panic disorder | |
Each simulation day included structured phases: preskill training, prebriefing, the simulation exercise, and debriefing. During preskill training, students practiced essential skills; prebriefing outlined the objectives and roles within the simulation. Each student group participated as either an observer or a performer, depending on their assigned roles within the simulation. The HFS was conducted in a classroom setting, where the instructor, simulating the patient, controlled the manikin to guide the scenario from an adjacent room. A total of 235 students were divided into 11 groups, with each group consisting of approximately 20 students to manage the participant load efficiently. Students alternated between roles to ensure equal exposure to patient interactions.
The simulated patient was portrayed by either the instructor or a manikin, depending on the scenario. Following each 45 min simulation session, participants engaged in a structured 20 min debriefing with video-assisted review and self-assessment against learning objectives.
Data collection instruments encompassed a demographic questionnaire covering age, gender, and prior mental illness experience. In addition, the study employed The Empathy Toward the Mentally Ill Scale and the Self-Consciousness Scale: A Revised Version. The characteristics considered for analysis included the student’s code number, gender, age, home address, previous academic psychiatric experience, occupation, and interactions with mentally ill patients. Questionnaires were administered before and immediately after the intervention.
3. Measures
The Emotional Empathic Tendency Scale (EETS) has been updated to include The Empathy Toward the Mentally Ill. Mehrabian and Epstein [23] were the first to design EETS [24]. The original 33-item scale was used to evaluate participants’ empathy in interpersonal interactions. Later, Turner [25] modified the EETS to only include questions that are relevant to individuals with psychiatric disorders [23]. The Empathy Toward the Mentally Ill Scale is a 16-item questionnaire that uses a 5-point Likert scale to evaluate students’ empathy for patients with psychiatric disorders. A score of 16–48 indicates a low level of empathy, while a score of more than 48 indicates a high level of empathy. With Cronbach’s alpha of 0.71, the EETS was found to be valid and reliable [23].
The Self-Consciousness Scale: A Revised Version [26] was used to assess self-awareness. It includes a 22-item questionnaire with a 3-point Likert scale format (from 0: Not at all like me to 3: Very much like me) [25]. A higher score indicates greater self-awareness. As a result, we used the terms “self-awareness” and “self-consciousness” interchangeably in this study. In their analysis of Cronbach’s alpha, DaSilveira et al. [27] reported reliability coefficients ranging from 0.74 to 0.90, indicating strong reliability for the scale. This aligns with reliability standards established by Scheier and Carver [26].
3.1. Statistical Analyses
The data analysis was performed using SPSS for Windows (version 26.00; SPSS Inc., Chicago, IL, USA). Descriptive statistics, including mean and standard deviation for continuous variables and numbers and percentages for categorical categories, were employed to analyze the demographic data of the participants. A paired t-test was utilized to compare demographic data before and after the HFS intervention, aiming to assess changes in study variables. Statistical significance was determined at the 0.05 level.
3.2. Ethical Approval
The study received ethical approval from the University (23/139/2023, 22. 3. 2023), and data collection was conducted anonymously. The researchers provided a detailed explanation of the study’s purpose to the students, ensuring that they were aware of their right to withdraw from the course at any point without facing consequences regarding their course status or academic standing. Informed consent was obtained from students who chose to participate in the study. This research adhered to strict ethical standards, having obtained formal approval from the ethical review board at Al al-Bayt University. The anonymity of all participants was safeguarded throughout the data collection process. The students were comprehensively briefed on the study’s objectives, and it was explicitly communicated that they could withdraw from the course or discontinue their participation at any time without facing adverse consequences. In line with ethical protocols, informed consent was diligently obtained from students voluntarily choosing to partake in the research endeavor.
4. Results
Two hundred and thirty-five students completed this study. There were no outliers. The participants’ mean (SD) age was 20.71 (1.30). Around three-quarters of the participants (74%) were female, 64.3% had no contact with patients having a mental illness, and 60.4% had no prior academic experience or had worked in an academic setting. Table 2 shows the demographic characteristics of the students and their previous experience with psychiatric studies and work. The mean (SD) of empathy toward mental illness was 44.74 (10.24) before the HFS intervention, indicating a low level of empathy. In addition, the mean (SD) of self-awareness before the HFS intervention was 46.48 (8.48).
| Variable | Categories | n (%) |
|---|---|---|
| Gender | Male | 61 (26%) |
| Female | 174 (74%) | |
| Having contact with patients who have a mental illness | Yes | 84 (35.7%) |
| No | 151 (64.3%) | |
| Having prior academic experience or having worked in a psychiatric setting | Yes | 93 (39.6%) |
| No | 142 (60.4%) | |
| Mean age; SD | 20.71; 1.30 | |
| Age range | 18–24 | |
- Note: %, percentage.
- Abbreviations: n, number; SD, standard deviation.
Table 3 summarizes the differences between study variables before and after the HFS intervention. There was a significant difference in empathy (t234 = −26.90, p < 0.001) and self-awareness (t234 = −19.70, p < 0.001) after the HFS intervention. As a result of HFS, there was a statistically significant improvement in empathy and self-awareness (Table 3).
| Item | Preintervention M (SD) | Postintervention M (SD) | 95% CI | t value | p value |
|---|---|---|---|---|---|
| Empathy | 44.74 (10.24) | 69.20 (7.64) | −26.26–−22.68 | −26.90 | p < 0.001 |
| Self-awareness | 46.48 (8.48) | 56.47 (6.48) | −25.17–−21.18 | −19.70 | p < 0.001 |
- Abbreviations: CI, confidence interval; M, mean; SD, standard deviation.
- p value: significant at ≤ 0.05 level.
5. Discussion
This study marks the inaugural exploration into the impact of HFS on empathy toward mental illness and self-awareness perceptions among psychiatric nursing students. The initial assessment revealed a low baseline of empathy toward mental illness and self-awareness among participants. However, the intervention, delivered through four HFS group settings, remarkably enhanced nursing students’ empathy for patients with mental illness and their self-awareness.
The positive outcomes observed in this study may be attributed to the group nature of the interventions, particularly effective in societies with a collectivist orientation, such as those of Arab descent. This aligns with the notion that group activities in educational settings can significantly influence empathy development, especially in fields where understanding diverse perspectives is crucial.
The discourse on whether empathy is an inherent trait or a skill shaped by education and practice is ongoing [28]. Our findings suggest that empathy, as a skill, can be cultivated through activities such as HFS scenarios. The psychiatric nursing experience portrayed in these scenarios appears to be particularly effective in prompting students to navigate and appreciate differences, fostering heightened levels of empathy.
Contrary to earlier perspectives that empathy is an unalterable personality trait [29], our study challenges this notion by demonstrating significant improvements in empathy among nursing students’ post-HFS intervention. The findings diverge from the previous research suggesting that empathy levels either remain unaffected or decline after psychiatric education and training [23, 30]. This highlights the potential of targeted educational interventions, such as HFS, in positively influencing empathy levels among psychiatric nursing students.
The observed increase in empathy among Jordanian psychiatric nursing students, compared to pediatric nursing students from Palestine and Australian nursing students, highlights the effectiveness of the HFS intervention in enhancing empathy within our specific educational context. Notably, the majority of our participants possessed prior clinical experience, aligning with the existing research indicating that clinical exposure contributes to higher empathy levels among students [14].
In addition, the HFS intervention not only enhanced empathy but also contributed to a significant improvement in self-awareness among psychiatric nursing students. This aligns with similar studies in Italy, where nursing students’ self-awareness significantly increased after three HFS scenarios [31]. The positive correlation between self-awareness, empathy, and attitudes observed in other studies [24, 32] further emphasizes the potential of HFS in fostering holistic personal and professional development among nursing students.
In conclusion, this study contributes valuable insights into the malleability of empathy and self-awareness among psychiatric nursing students through HFS interventions. The implications extend to the realm of nursing education, advocating for the incorporation of targeted interventions to enhance students’ interpersonal skills, ultimately contributing to improved patient outcomes.
6. Limitations
This study has some limitations that should be addressed. Rather than a multisite study, this is a single-site study with a homogeneous sample. Because the sample consists of enrolled students in the psychiatric course, the results are based on a one-site study and a single course, using an accessible student. Also, students’ self-awareness and empathy were assessed through a single simulated experience, which may or may not accurately reflect real-world self-awareness and empathy. Furthermore, the results may have been muddled because we only used one group design and not all students took on the same roles. Finally, because the study was based on self-reported data, desirability bias could have influenced the findings. As a result, the study’s generalizability must be taken into account. There was no randomization or comparative cohort in this study, which used a pretest–posttest design.
7. Conclusion
Students’ learning outcomes were influenced by their judgments of empathy and self-awareness, according to the current study. The HFS and traditional didactic approaches may be able to help nursing students develop empathy and self-awareness in order to better serve patients. However, a multisite study involving nursing students is advised since the results are more generalizable and can affect nursing education and policies more effectively.
7.1. Relevance to Clinical Practice
The study underscores the practical application of HFS in nursing education. By enhancing empathy and self-awareness, the HFS prepares nursing students for real-world clinical settings where these skills are vital for effective patient care. The implementation of the HFS can address gaps in clinical training environments and improve the overall quality of nursing education, making it a valuable tool for nursing programs globally.
Conflicts of Interest
The author declares no conflicts of interest.
Funding
This research does not have any funding.
Acknowledgment
We would like to express our gratitude for the invaluable support from the undergraduate students who made significant contributions to this project.
Open Research
Data Availability Statement
The data utilized in this study to support its findings can be obtained from the corresponding author, subject to approval by the Princess Salama Faculty of Nursing at Al al-Bayt University.
