Emotional coping of nursing students during mental health nursing simulation training

. The process of carrying out simulation training within mental health nursing is part of a teaching method used to increase a student’s understanding of mental illness, allowing them to develop the required empathic practices that will form part of their skillset. Simulation training has proven to be an effective teaching method within the nursing curriculum. Simulation training provides assistance in the alleviation of societal stigma and general fear and anxiety when communicating with patients who have mental health disorders. The aim of this research is to study student emotions and feelings that may have arisen within the context of mental health simulation training. The current research was conducted by making use of a cohort of undergraduate nursing students in the field of mental health who were undertaking mental health simulation training in a healthcare college. Student feedback was analysed using qualitative content analysis, based on a process of self-reflection by the students themselves. The analysis focused on emotions that had arisen during the study process, and emotional management processes that had been adopted by the students. The results of the research confirmed the supposition that the students had undergone emotional tension during mental health simulation training. Based on the results of the analysis, a model could be designed, which would provide the required emotional preparation and support during a mental health simulation training. This consists of a series of recommendations, which will assist in the emotional preparation of students who are undertaking simulation training.


INTRODUCTION
The number of patients across all healthcare disciplines who have mental health disorders in addition to other diagnoses is ever on the increase. As a product of uninformed media-based or social prejudices, many students also often possess preconceived myths or stereotypes when it comes to referring to psychiatric patients. The practical preparation of nurses in terms of their being able to successfully communicate with patients who have mental health disorders is therefore essential (Langham et al. 2017;Kuhanen et al. 2013, 13-21.). Nursing students have expressed a degree of fear that has been derived from internships they have served in psychiatric nursing care units. Students often feel helpless or incompetent due to their lack of knowledge, and insecurity due to a lack of detailed guidelines and gaps in their com muni cation skills (Furnes et al. 2018;Choi 2012). Safe learning environments provide them with opportunities to make mistakes, which allows them to create an under standing of their com petencies (Sanford 2010). Previous studies have demonstrated the fact that the professional confidence levels of the student tended to increase in response to simulation training (Schwindt and McNelis 2015;Doolen et al. 2014;Lang and Hahn 2013).
Students who participated in simulation training noted that their sense of competence and confidence tended to improve, as did their therapeutic communication skills, while their anxiety and fear decreased (Mulyadi et al 2021;Dougherty 2014, 15-16;Choi 2012). Simulation Proceedings of the Estonian Academy of Sciences, 2023, 72, 3, 212-219 training may dispel the fear and anxiety that students may possess when they encounter patients who have mental health problems (Brown 2008;Kameg et al. 2009). Unfortunately, the method used in simulation training is underutilised within the mental health field when it comes to nursing practices (Brown 2008(Brown , 2015Dougherty 2014). This aspect makes our research particularly novel and important.
There are gaps in mental health simulation research, and multiple opportunities exist for improving simulation training (Dougherty 2014) when conducting research on students who are coping with emotions and feelings that they have experienced during simulation training. Such a process would also serve to reduce anxiety and fear for students when they have to face a patient who has mental health disorders (McGough and Heslop 2021;Kärki et al. 2018;Doolen et al. 2014). There is strong evidence of simulation-based mental health care as an effective method of pedagogy (Saunders et al. 2021).
The aim of this research is to study student emotions and feelings that may have arisen within the context of mental health simulation training.
The following research questions formed the focus of this study: • Which emotions are elicited from nursing students during mental health simulation training? • How do nursing students cope in terms of their emotions when undertaking work in mental health simulation training where counselling of a patient with a mental health disorder is involved. • How could the lecturer better support emotional coping of students in relation to mental health simulation training? Understanding the feelings and emotions of students will help teachers to support students during the simulation training process.

MATERIALS AND METHODS
To achieve the best possible results, any simulation should consider the following elements: an assessment of student needs, measurable targets and learning outcomes, the format being used with the simulation, exercise or specific case, the use of a safe study environment, a studentcentred approach from the instructor, the theoretical preparation of the student, and a final discussion and assessment along with feedback from the students (Lioce et al. 2015). The lecturer should be competent and must consider all aspects of the study process such as the planning process, student preparation, the teaching plan, and the analysis process (Reese 2014, 101-112). Discussion, reflection, and debriefing are all extremely important parts of an effective simulation training pro -gramme. The structure of the final discussion, the feedback process, and the instructor's teaching attitude are important issues when it comes to establishing a safe learning environment. Any emotions that arise within students during the simulations should be included in the process of self-reflection (Kärki et al. 2018).
Simulation training within the mental health field was conducted amongst a segment of third-year nursing stu dents who were undertaking the mental health course as part of the overall nursing programme. Prior to conducting any simulation training, the students had already com pleted theoretical classes in mental health nursing involving face-to-face instruction on the topics of anxiety in general, anxiety symptoms, and evidencebased nursing interventions with patients who had anxiety disorders. The theoretical part of this was conducted in preparation for the specific topic that had been set out as part of the simulation training. A total of 125 students, divided into four study groups, were included as participants. Simu lation training was compulsory for all students in the mental health nursing course. 122 students out of 125 had answered the independent assignment self-reflection ques tions. The simulations were carried out in March 2019. After the simulation, the students had to write a free-form self-reflection as an independent task on the topic 'Describe the emotions that you experienced as a result of the simu lation training'. Self-reflection was required to be submitted one week after the simulation to the study environ ment Moodle.
To analyse the data, the authors used a qualitative content analysis method. The results from the content analyses of student self-reflections were categorized into subgroups for each of the emotions they experienced during the practical course: emotions that arose from within themselves, emotions that were experienced in response to patient problems, and emotions that were drawn out from the counselling exercise.

Ethics of the research
The students were informed that the results of their independent tasks within their simulation training and their feedback in regard to self-reflection would be used as information to feed the research process. The importance of their contributions towards the development of simulation training was explained to the students along with how this would help to develop better study and assessment processes. The students retained the right to refrain from providing their performance results as material for the research. Students provided their informed consent digitally so that it could be recorded by a camera during parts of the simulation training counselling process.

The simulation training exercise
The topic of the simulation training exercise involved nursing interventions while counselling an anxious patient during a nurse-based appointment. The aim of the si mulation training was to teach the students how to use targeted, evidence-based nursing interventions while counselling anxious patients. At the beginning of the simulation training practical class, prior information was shared with the students in the form of a briefing. Written material was shared with the students covering relevant theoretical basics, which served to support the simulation training exercise. The lecturer explained the goals behind the study process along with the intended learning outcomes, the course of the simulation, and the guidelines that had been laid out in regard to independent tasks. Two mental health nursing lecturers participated in the simulation process. In addition to the informative and the oretical components of the programme, the students were offered an opportunity to ask questions as a topic-focused discussion was formed. Following the conclusion of the briefing, participants were assigned roles in the simulation (in the form of role players and observers) and in relation to the tasks that had been handed out. Participation by the role players was voluntary. Figure 1 visualises the positions of the simulation training participants within the classrooms. The patient who was to be counselled during the sample case was a middle-aged woman. She was a hypochondriac who, despite repeated examinations, which yielded negative results for breast cancer, was still convinced that she was suffering from the disease. The case patient's mother had died from breast cancer. The patient was referred to an appointment with a nurse because no medical indicators existed for the patient's particular complaints. The lecturer prepared the participating role players and students in their staging of the exercise prior to its start. Written case descriptions were given to the role players along with oral information about the contents of the case.
The staging of the study between the 'patient' and a 'counselling nurse' was carried out in a simulation room, where both sound and video were broadcast into the debriefing room where the observers were seated. Lec turers were present in both study rooms and, if necessary, they counselled and supported the students. The lecturers had a chance to comment upon and direct the course of events throughout the entire process. Role-playing stu dents had the chance to reflect on their emotions and activities both during and after the exercise. The simu lation training was recorded so that it could be viewed repeatedly and so that duplicate analysis could be conducted if this proved necessary.
Students and observers were divided into three groups, with each group being given different assignments regarding the activity they were to observe and evaluate. Each group consisted of eight or nine students. The observer groups were designed to be able to carry out analysis of the various tasks and to offer constructive feedback. Members of these groups had to evaluate the counsellor's body language, their verbal communication skills, and the use of counselling techniques or nursing interventions along with the ability to express empathy and to form a trusting relationship with the patient. The pedagogical aim was to develop the critical thinking and analytical skills of the observers. Two students were voluntary role players. One of them acted as a patient who had a mental health disorder and who was attending an appointment with a mental health nurse while the second performed the role Proceedings of the Estonian Academy of Sciences, 2023, 72, 3, 212-219 214 4) ) ) ) ) ))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))4)(2*$./2/) ) !"#$%&$%#' ) #502/62/0) 7'$%2&$ 0) #502/62/0) 82&2/'() #502/62/0) ) ) ) ) ) )))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))4)(2*$. of a nurse-counsellor at the nurse's office. The patient had to emphasise their assumed symptoms of anxiety by expressing them both verbally (involving subjective symptoms of anxiety) and physically (involving objective symptoms of anxiety), based on prior theoretical material, which they had acquired. The aim behind the counsellor's role was to counsel and calm an anxious patient who was attending a nurse's appointment, and to use evidencebased nursing interventions, which had been taken from prior studies in regard to counselling an anxious patient in order to be able to alleviate their feelings of anxiety. The educational goal was to establish contact between the patient and the nurse, and to enact nursing interventions along with adding further progress to the development of student communication skills. All of this would also make it possible to evaluate the patient's anxiety levels on a scale of 1-10 at the beginning, middle, and end of the counselling session. To be able to evaluate the patient's needs and the contents of the conversation, the observers who were watching the patient had to assess the condition of that patient and any changes in their condition in response to the activities that were being undertaken by the nurse-counsellor. They further evaluated the initial needs in terms of nursing diagnoses for this particular patient. The task of the general observers was to evaluate the exercise as a whole along with the dynamics and nature of a nurse-patient relationship. This would make it possible to assess the effectiveness of the counselling itself, to highlight the strengths of the exercise, and to point out any aspects that may need some improvement. Simulations lasted for an average time of fifteen minutes. After that, the final discussion was carried out between the participants and the observers. Before the debriefing process got underway, the lecturers stated that simulation training was primarily a playful and staged study exercise, one which was intended to create a safe and supportive environment. It was explained to the students that the aim of simulation training was not to conduct a perfect performance but to create an opportunity for the participants to be able to learn from their experience. The lecturers aimed to create a safe, trusting atmosphere, with students being encouraged to share their thoughts and emotions with others. Although the observers were divided into groups and the exercise was carried out as a group, the purpose of the final discussion was, without exception, to allow the students to be able to individually express any comments they may have. After the role players had shared their experience, the experience of the observer group -along with their notes -was read out in the form of structured questions and assignments. After that, all of the participants could share their experience, ask questions, and reflect. This process was led by the lecturers. Feedback was given on independent assignments during a face-to-face seminar.

ANALYSIS BASED ON SELF-REFLECTION
The written self-reflections of those students who were involved in the simulation training were analysed using a qualitative content analysis method. Out of 122 selfreflections 94 contained sufficient information for the analysis. A prerequisite of the analysed material was a description of the student's own emotions. Student emotions were divided into three groups: emotions that arose due to the patient, emotions that were derived from the simulation training, and emotions that had been triggered within oneself. Emotions that had arisen due to the counselling exercise may also be linked to emotions that had been triggered within oneself, with these being based on personal preconceptions. Based on the categories listed above, the process of content analysis and text coding was carried out by basing them on the words that had been used to describe any emotions found during the content analysis process.

RESULTS
Three types of emotions emerged: 1) Emotions that had arisen within the student: analysis was carried out on those emotions that were highlighted in the student's own text. These emotions were based on the preconceptions and attitudes that each student had held prior to taking part in the exercise, or how the student personally associated with the concept of mental health simulation training, and any feelings that may have arisen within them due to their participation in the current exercise. 2) Emotions that had been derived from the patient's stated problems: analysis was carried out in regard to the student's emotions where these had arisen due to the patient being anxious, or in regard to the patient's emotions where they related to the student who was acting as a nurse. 3) Emotions that had been triggered by the simulation training exercise: analysis was carried out of the student's emotions regarding the counselling exercise itself, or any emotions which may have been triggered by the exercise while the student was acting as a nurse (including self-confidence, knowledge, and skills). The terms that were used to describe emotions were 'anger', 'fear', 'sadness', 'irritation', 'empathy', 'sympathy', and 'insecurity'. Students described the emotions that had emerged from within, where they had been triggered by the student's experience, such as anxiety and fear: 'I think that it was a bit scary for me… [regarding] patients like that who have mental disorders…'. The fact that the patient's behaviour and symptoms tended to irritate the role-playing students was highlighted, causing them to feel sadness, empathy, and sympathy: 'It made me somewhat sad that people could have such serious problems. I felt empathy towards the patient'. Participation in and observing the counselling situation resulted in somewhat controversial feelings -both positive and negative -such as fear, relief, irritability, and sadness: 'During the simulation training various ideas lodged themselves in my head, making me feel rather anxious, so much so that I am not sure whether, as a nurse, I could have remained quite so calm and self-confident in that situation'. Table 1 demonstrates emotions that were the most often described out of all the self-reflections included in the analysis.
The most common emotion experienced by students during the exercise was anxiety, followed by fear, irritability, sadness, empathy, and sympathy.

DISCUSSION
The nursing students provided a positive evaluation when it came to any beneficial factors that could be drawn from the simulation training, in accordance with the various areas of research literature previously mentioned by authors. Kärki et al (2018) and Bartlett (2017) noted that student attitudes tended to change in a positive direction. The students provided a positive evaluation for beneficial factors, despite experiencing negative emotions such as helplessness, anxiety, and fear during their mental health simulation training. The analysis also confirmed that the negative aspects of the experience contributed towards growth. The students found that their experience in the mental health training simulation had tended to differ from prior clinical simulation training. When addressing mental health procedures, the training focused primarily on communication while prior training had focused on manual and operational activities. The students appreciated their mental health simulation training, categorising it as a valuable experience. A potential cause of any negative emotions and attitudes may be a lack of knowledge in the students along with negative preconceptions, which may have been caused by external factors such as the influence of social behaviours or the media. Knowledge and appropriate information may positively change such preconceptions and attitudes. Education may serve to dispel the fears and anxieties that the students found themselves experiencing when encountering patients who had mental health problems. The simulation training model has been compiled as a result of the current research analysis (Fig. 2). The lecturers would be able to support the emotional states of the students by means of the informed planning that was employed during the exercise.
Mental health simulation training requires sufficient time, planning, and collaboration (Felton and Wright 2017). Therefore, the authors have found that out of the total volume of the study's process (the full 100%), the preparation phase could take up about 40%, the process of con ducting the simulation training 30%, and the post-simulation activities the remaining 30%. In the preparatory part of the simulation study (40% of the overall time), student prejudices are dispelled by means of sharing evidencebased information, with the impact of stigmas upon society being analysed individ ually. This is followed by theoretical preparation during which students are provided with evidence-based theor etical knowledge, which will help them to become aware of the various problems and emotional tensions that can arise when dealing with a patient who has a mental health disorder. Various illustrative study materials are used to reinforce the theory. A secure learning environ ment needs to be created, which facilitates the ability of a student to ask questions, express opinions, and be open to discussion.
Regarding performance levels when it comes to si mulation learning (covering 30% of the overall time), a full explanation is provided to students regarding learning outcomes, learning objectives, and the situation task to be staged. Students are divided into roles and are prepared for those roles. Each participant has a specific role and task. A staged situation is performed for the simulation training. The professionalism and pedagogical skills of the lecturer along with the provision of immediate feedback, serve to support the emotional security of all participants. The follow-up for the simulation (covering 30% of the overall time) consists of a final discussion (in the form of a debriefing) in which all of the participants can express the feelings they have experienced and analyse the situation as a whole. Students carry out independent work following the simulation training stage, consisting of self-reflection and an assessment of the learning process. A feedback seminar is held in which the lecturer provides feedback on the independent work the participants have carried out, and then a discussion takes place. Based on this study, the emotional support model will be imple mented as part of simulation training. There are im provements that will be needed for the preparation process in terms of practical simulation training, particularly in order to address the emotional needs of the students, thereby utilising relevant information gained through self-reflec tion by the students regarding how they feel about the experience they underwent during the simulation training study process.

CONCLUSIONS
The results from the qualitative content analysis for the current research have significantly supported the results that came from the theoretical background study for this work. The students highlighted the presence of fear, anxiety, empathy, sympathy, and also irritability while counselling the patient during the exercise. However, the students found the study to be useful, productive, and thoughtprovoking while also more effectively helping them to acquire the working theory. The students further noted an increase in their levels of confidence and em pathy towards patients who have mental health disorders, and a decrease in their levels of fear re garding this topic. Students valued the improvement in their communication skills despite finding the counselling process to be some what complicated and emotionally chal lenging. All the major points were considered important, including partici pation in the final discussion, support of the lecturers along with their professionalism, the process of collabo ra ting with other students as well as their support.
The research results revealed that the emotional preparation of the students for simulation exercises is of extreme importance. Care should be taken in terms of preparation in order to create an emotionally secure and safe learning environment for the students. The authors contributed to the development of simulation pedagogy. The model of conducting simulation training can help to future-proof the emotional preparedness of nurses, and assist them to develop and manage their attitudes and emotions in preparation for situations in which they must encounter patients who have mental health disorders so that they can better understand and treat them more Self-motivated questionnaire in Moodle (Canvas) Visual teaching aids (video, cases, etc.) effectively. Due to the fact that the current research has been based on mandatory feedback, the results may be biased. The students may have thought that the feedback would influence their final grade. This could be regarded as a limitation to the current research. Future research should be done in an independent atmosphere. Research should further be conducted in order to examine the beneficial aspects of simulation training and its impact on other disciplines of nursing, particularly those where nurses often encounter patients who have mental health needs such as primary and emergency healthcare.