A junior-level nursing student confided in me during one of my clinical rounds on the first day of the clinical rotation that she felt uneasy handling a “difficult” patient. The patient talked to himself, was aggressive, suspicious of everyone, and suffered from schizophrenia. Schizophrenia is a “brain disorder that affects how people think, feel, and perceive. The hallmark symptom of schizophrenia is psychosis, such as experiencing auditory hallucinations (voices) and delusions (fixed false beliefs)” (Frankenburg 2024, para. 1). Schizophrenia creates significant disability that disrupts quality of life, especially impairing social relationships and cognitive skills (World Health Organization 2022). Based on research conducted by the Research Triangle Institute in 2023, it is projected that 3.7 million Americans aged 18 to 65 suffer from schizophrenia spectrum disorders. People in this group are often stigmatized, discriminated against, and branded as mad by society. First-year nursing students who are not yet familiar with the role of nurses and nursing practices are the level of students I teach. Since my inexperienced students work in a clinical setting with patients who have schizophrenia, it may be easier to explain the inconsistent behavior and maintain equity of care if they are aware of the challenges this demographic faces.
Auditory Hallucination Simulation
To help my students, I thus took part in a cultural immersion exercise to learn more about what it is like to live with schizophrenia. My objective was to become more skilled in facilitating learning in the area of providing care for a variety of populations; in this case, those with psychiatric symptoms. I ran an experiment with the auditory hallucination simulation that the senior, first semester nursing students in my department use during their Mental Health course.
Auditory hallucination simulation is an empathy-based training tool that allows a user to feel what it is like to be a schizophrenic who hears voices (STARR Coalition 2024). Students are given a headset that is connected to a device that mimics the auditory hallucinations of a person with schizophrenia for the duration of the simulation. Students listen to these voices while working on a variety of tasks for a suggested one to one and a half hours. They can remove the headset and stop the exercise if the voices become too loud for them to bear.
I ran through the simulation for my experiment. I went about my daily business at home while wearing a headset and listening to the voices. I cooked and cleaned the dishes. I tried to do more, but it was difficult to concentrate on my work because of the incessant flurry of shouting noises, spiteful comments, and whispers. A number of the voices were insulting and menacing. The most unnerving were the murmurs that were accompanied by a frightening laugh. It was so terrifying that I had trouble falling asleep that night. It was tiresome to hear taunts and mockery constantly. I found it incredibly daunting that I could only do the exercise for roughly 45 minutes. A person can be created or destroyed by words. Finding out how helpless someone with schizophrenia could feel was an eye-opening experience. This group deals not only with emotional fluctuations and cognitive limitations but also with stigmatization as a threat to society. Implicit judgments about individuals based only on their diagnosis of schizophrenia have become frequent in healthcare facilities, which inadvertently causes discrepancies in the quality of care.
Lessons Learned
The experience strengthened my capacity for empathic communication, increased my awareness of the reality of people’s experiences, and expanded my comprehension of the detrimental impacts on the suffering person. Understanding the distinctive qualities of a particular group allowed me to help students develop the essential nursing skills of compassion, inclusion, and advocacy. A systematic review examining the outcomes of voice-hearing simulations discovered enhanced empathy, improved knowledge, cognition, and attitudes, and higher confidence in the practices of experienced health professionals and those still undergoing training (Bradshaw et al. 2021). Although ignorance may undermine nursing students’ confidence in providing care to a population with psychiatric deficiencies, bias is not a deliberate part of their education. According to a qualitative study investigating the experiences of interdisciplinary healthcare professionals caring for patients experiencing auditory hallucinations, participants’ lack of comprehension was seen as a clinical concern, and they had low trust in their ability to provide this population with high-quality treatment (Kramarz et al. 2020). Health outcomes are improved when students feel more capable of providing care for a diverse group. Therefore, understanding a varied population’s experiences early in the program is imperative. Active learning techniques that improve psychiatric learning must be included and supported across all curriculum levels. Other instructional alternatives, such as employing unfolding case studies with role-playing and virtual psychiatric simulations, should be taken into consideration in addition to auditory hallucination simulation. It was discovered that using standardized patients in psychiatric simulation exercises was a successful teaching method for nursing undergraduates (Conway & Scoloveno 2024). Across nursing levels, there needs to be scaffolding involved in exposing students to the experiences of people with psychiatric problems to develop awareness. Students’ understanding of the experiences of those with psychiatric problems can be improved through the use of technology and social media platforms such as YouTube. As it often occurs after hearing shift reports at the beginning of the clinical rotation, junior-level nursing students would be well served to begin with mitigating stereotyping. Clinical faculty should urge students to keep an unbiased, open-minded mindset and to be conscious of the dangers of holding predetermined beliefs.
With more than 20 years of nursing experience, Mary Grace Yousef, an assistant clinical professor at Texas Woman’s University (TWU) in Dallas, specializes in nursing education, medical-surgical, critical care, and palliative nursing. She has experience as a clinical education specialist, palliative care nurse, and critical care nurse. Since 2015, she has overseen a clinical course for junior, second-semester undergraduate students. She co-chaired the curriculum development of the TWU Accelerated BS in Nursing (ABSN) program. She is currently the Dallas campus co-chair of the Interprofessional Education (IPE) committee. Her primary research interests focus on metacognitive awareness of junior-level nursing students and multimodal student engagement techniques to promote deeper learning in the classroom and clinical setting.
References
Bradshaw, Tim, Amy Blakemore, Ian Wilson, Mike Fitzsimmons, Kate Crawford, and Hilary Mairs. 2021. “A Systematic Review of the Outcomes of Using Voice Hearing Simulation in the Education of Health Care Professionals and Those in Training.” Nurse Education Today 96: 1-18. https://doi.org/10.1016/j.nedt.2020.104626
Conway, Kimberly and Scoloveno, Robert. 2024. “The Use of Standardized Patients as an Educational Strategy in Baccalaureate Psychiatric Nursing Simulation: A Mixed Method Pilot Study.” Journal of the American Psychiatric Nurses Association, 30(2): 414–417. https://doi.org/10.1177/10783903221101049
Frankenburg, Frances. 2024. “Schizophrenia.” Last modified April 12, 2024. https://emedicine.medscape.com/article/288259-overview.
Kramarz, Emilia, Sophie Lyles, Helen L. Fisher, and Simon Riches. 2020. “Staff Experience of Delivering Clinical Care on Acute Psychiatric Wards for Service Users Who Hear Voices: A Qualitative Study.” Psychosis 13 (1): 58–64. https://www.tandfonline.com/doi/full/10.1080/17522439.2020.1781234
Research Triangle Institute. 2023. “New Study Finds at Least Twice as Many US Adults Experience Schizophrenia Spectrum Disorders than Previously Thought.” Last modified June 26, 2023. https://www.rti.org/news/new-study-finds-least-twice-many-us-adults-experience-schizophrenia-spectrum-disorders
The STARR Coalition. 2024. “Auditory Hallucination Simulation.” Accessed June 19, 2024. https://thestarr.org/module/auditory-hallucination-simulation/
World Health Organization. 2022. “Schizophrenia.” Last modified January 10, 2022. https://www.who.int/news-room/fact-sheets/detail/schizophrenia
