Rhonda L. Wilson RN MHN, Lecturer Mental Health Nursing Email: rhonda.wilson@une.au

1. Mental Health Case-Based Simulation and Virtual Learning Environments (VLE) in Mental Health Pre-Registration Nursing Education Virtual Learning Environments (VLEs) have been widely adopted as a teaching and learning strategy for pre-registration nursing education in Australia. The transition from traditional models of learning, towards the utilization of Web 2.0 technologies in online nursing education, has required nurse academics to adapt their teaching methods. This paper will demonstrate how case-based simulations can be incorporated into the VLE, to achieve the learning outcome of applying basic nursing interventions in simulated and real environments, and, to embed components of the Core Values of the Framework for Mental Health in Pre-Registration Nursing (Mental Health Nurse Education Taskforce [MHNET], 2008) in an undergraduate mental health nursing unit of study. Learning Strategy Nursing students are required to undertake semester-long cased-based learning activities across two case studies, from a collection of four common mental health problem options (see Figure 1 & 2). Using a wiki tool, they enter into a role play scenario whereby each student assumes the role of Nurse in the first case study, and Client in the second case study (see Figure 3 & 4). Students build virtual clinical skills and consumer awareness in a wiki through an assessable portfolio and transfer these skills to the real clinical environment during a three week clinical practicum. The integration of virtual and real clinical skill development is complementary of the broader curriculum requirements and assists students in a seamless learning experience about this topic. Figure1. Nurse and Client role descriptions • Don Berryman is a 40 year old male with a medical diagnosis of chronic paranoid schizophrenia. He first presented in 2009 at the age of 39 when he was referred to your community mental health clinic after he had moved from Queensland with his family. You have been designated his case in your client load. Your role is to case manage this client and implement nursing management which is appropriate. The following information is included in his file and will assist you to develop further recovery care planning for Mr Berryman. • His weight is 150kg and height is 190cm. BMI =41 • Past Mental Health History • Diagnosed with schizophrenia at age 17 years during HSC. He has no history of substance abuse. However he experienced bullying at school and as a result he changed schools in year 9. During year 12 he remembered thinking that he could hear peoples’ thoughts and that he had ESP. He frequently refused to go to class. • Cognitive, social and occupational decline has been evident throughout this adult life. • He has had many admissions to hospital & has tried antipsychotic medications in past including Stelazine, Anatensol, Risperidone and Quetiapine.He remained unwell with persistent positive and negative symptoms and was eventually started on Clozapine in 2000, at which time he weighed less than 100kg. • Social and family history • Don is single and lives alone in a private rental apartment. He receives a disability support pension. He had previously worked part time in a factory for a short period, but his mental health problems combined with the sedating effects of the medication precluded him continuing this work. • His primary support is his Mother, who lives nearby. He is socially isolated, with no close friends. • Family mental health history includes his father’s cousin who has schizophrenia and his nephew has autism. • Medical History • Adenoidectomy (2000); Hernia repair (2005); Laparoscopic cholecystectomy (2008);Gastro-oesophageal reflux disorder (2008 ongoing). • Current Problems • Severe obesity, dyspnoea and fatigue, even on minimal exertion; obstructive sleep apnoea (declined to use CPAP machine.),chronic joint pain, particularly with activity; abnormal liver function tests (fatty liver); lack of motivation in general; difficulty with mobility; late night snacking. • Mental State Examination. Mental health online regular weekly appointment, 1400hrs, 5 July 2010. Present: R Wilson (MHN), S Jones (Student Nurse) and client – Don Berryman. • Appearance: Tall, obese man. Casually dressed, stooped over, drooling slightly, sedated. Short of breath, despite sitting in reception area for 20 minutes prior to his appointment. Mottled facial skin, cyanotic colouration to nose and lips. • Mood and Affect: He had a flattened affect however he described his mood as “OK”, but said he had “no energy”. • Speech: Softly spoken with monosyllabic answers. • Thought Form/Cognition: Mild thought disorder present. • Perceptions: He described a past history of auditory hallucinations but not bothering him at present. (He was aware they were “not real”.) • Insight and Judgment: Limited insight into his illness. He was aware he had a diagnosis of schizophrenia and that he needed to take medication. • Current medication: • Clozapine 100mg mane and 500mg nocte • Metformin XR 500mg • Case Conference with Mother (carer), Don and mental health team. • Discussion about Donald’s obesity. Agreed outcome: • Develop a nutrition and cooking program • Develop an exercise and lifestyle program • Commence Metformin XR 500mg Virtual Clinical Practice in the Wiki The wiki-based simulation is designed to replicate and simulate the real experience of providing nursing care, and receiving nursing care, in a mental health context. Web 2.0 tools provide an opportunity for undergraduate student nurses to work collaboratively with their peers, and to undertake simulated clinical skills development within a safe virtual environment. The simulated clinical environment provides the student with an opportunity to practice nursing interventions and nursing management of a mental health problem without the risk of harm to real clients. The wiki tool was selected because it is well suited to flexible and asynchronous collaborative online work. Within the wiki, students build individualized mental health nursing care plans which include MH-OAT assessment tools, evidence-based nursing intervention selection and their virtual implementation, and, virtual medication administration management. This learning activity culminates in the final submission of an assessable portfolio (virtual client record) that reports on the comprehensive mental health care provided to and received by the client. Figure 3. Screen shot example of VLE wiki homepage. Figure 4. Screen shot FAQ located in VLE. Figure 2. Sample case study example located in wiki. This case study represents a starting point for students to commence their simulated virtual clinical skill development learning journey. Real Clinical Practicum World Wide Web (www.) access in any geographical location, enables students to revise and continue to utilise the unique resources which they have individually developed in their virtual clinical practice, and whilst on clinical practicum. Students can review their skills in mental health examination developed with the virtual client within the VLE, prior to administering the examination on an actual client. Following the clinical interaction, the student can then return to the VLE and blog their learning reflections in regard to the clinical experience. In this way the clinical experience enriches the simulation role-plays and integrates their real and virtual clinical practice development meaningfully. Strengths & Limitations The learning activity described in this paper has been developed and delivered to three student cohorts over three years of implementation. Those cohorts have consistently demonstrated that they have the requisite Web2.0 literacy to enable them work productively within a VLE, and have indicated in their feedback that this learning activity has been useful and meaningful in terms of nursing practice development of mental health care. Unstable and unintuitive VLE’s, which are not user friendly, significantly limit the full use of innovative teaching, and the early adoption online pedagogy such as described in this paper. Academic nurses who deliver innovative learning activities, are limited in their capacity to do so, where they are not supported with late model computing and mobile device hardware and associated software. In addition, innovative VLE teaching requires the support of Educational Developers with high level computing skills and web literacy. Conclusion Case-based learning activities in the VLE has added a clinical and consumer-oriented richness to the curriculum. Simulating mental health nursing in a VLE is an innovative approach to nurse education programs. Further, it is well matched to the online learning modes utilised in an undergraduate Bachelor of Nursing program in the Australian University setting. Future Directions The flexibility of this online learning strategy may be also suited to Continuing Professional Education modules or Post graduate course development for nurses seeking Mental Health Nurse credentialing. This should be considered as a future direction for this learning activity. Rhonda L. Wilson RN MHN, Lecturer Mental Health Nursing Email: rhonda.wilson@une.edu.au Acknowledgments: Grateful thanks is given to nurse academic colleague Jackie Lea for the contribution to the review and feedback of this paper, and equally, to Educational Developer colleagues Mary Jarrott & Lisa King for assistance in developing and supporting the technical aspects of the VLE . The collegial support of the Nursing Course Team, School of Health, University of New England is also acknowledged.