Breaking the Stigma in Mental Health Nursing through High-Fidelity Simulation Training

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Interventions that target the reduction of mental health stigma among medical providers are scarce, despite their impact on individuals with mental health disorders. I was impressed by the design of the current study using clinical simulation training for nursing students and believe the findings have the potential to be generalized to other medical professionals. There are several ways that the manuscript could be strengthened. First, it is unclear if the results were only from participants who placed the patient with mental health case last (almost half) or were for all 39 participants. Also, as categories and sub-categories were presented, more information about how many participants described these categories is needed to understand the strength for each. For example, please include information about whether the majority or only some participants described “Not knowing”. Second, a few typos and unclear language may need to be revised. For example, the word “observed” was used several times throughout the Results section, and it was unclear whether the researchers observed the students acting in a certain way or if it was used to describe a finding described by participants. Lastly, a broader discussion about how this training methodology can be applied to other healthcare professionals would be helpful. Nurses are the first-line for patients, but also interact within a multidisciplinary team who may benefit from this training.

 Other more minor suggestions are provided below:

 Introduction:

·         Please include a definition of stigma.

 

Methods:

• Please clarify the choice of the patient with borderline personality disorder being male when most of those with this diagnosis are female.
• Please share if the authors considered asking about feelings and emotions in the post-clinical simulation phase. This information may have been helpful to know pre- and post-simulation.
• Please fix the typo on p. 4, third bullet. “sued” should be changed to “used”

 

Results:

• Please share why some students declined to participate in the current study (p.6, first paragraph of results).
• Please describe the race and ethnicity of students who participated in the study and any information about years of training.
• There are a few incidents when Menth Health and Health do not need to be capitalized. Please also review the documents for person-center language. For example, on page 10, please change “Mental Health patient” to “patient with mental health condition” outside of the quote.
• Please indicate that the patient in the simulation name was Juan so that readers are not confused on p. 7 when a participant uses the name Juan.

 

Discussion:

• Please share potential barriers of other institutions in obtaining the ability to provide high-fidelity clinical simulation training devices. I am unaware of how easy it would be for motivated training institutions to offer this type of training to their students. This information may impact the generalizability of this methodology in practice.
• The authors appropriately cited Carrara et al. regarding the need for contact with the stigmatized population for effective anti-stigma intervention but then stated that previous studies support education strategies with direct social contacts. It seems like clinical simulation, while not an actual patient, maybe a type of social contact with the population. Please consider this notation in this section.
• In the limitation section, the importance of a qualitative study at a greater scale was recommended. Please include consideration of quantitative methods to evaluation the effectiveness of this education intervention.

Comments on the Quality of English Language

Please see comments in my previous post.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors The text is very good, bringing aspects little discussed in the international literature on simulation in the thematic area of ​​mental health. And, it is in this theme the relevance of the study and its applications. The training centers should invest in preparing the teaching staff to carry out possibilities such as those on the walls of the University or even in the ongoing training of health professionals and/or health services. Comments on the Quality of English Language We suggest a grammatical review of the English language standard.

Author Response

Thank you for your suggestions and recommendations. We appreciate the effort that you have made in reviewing our study. we have included changes in the text.

 

Reviewer 3 Report

Comments and Suggestions for Authors

The value of this study is on its focus on mental health and clinical education for nursing students using simulation. This is an area less well studied than others in terms of simulation research. That said, the outcome of increased self-confidence is a very well-known outcome of simulation, lessening the impact of this study. Its strengths lie in the qualitative approach and the focus on experience that simulation offers. As a result, the authors should have included a theoretical framework relevant to that, i.e., Experiential Learning Theory using for example Lewin or Kolb. Structured around that, the manuscript could focus on design features put in place that exposed the student to an experience with a patient struggling with mental illness. Then explore through their qualitative statements/responses to the structured interview questions how that experience enhanced their ability to care for such patients. In both the pre and post CS interviews, there are references to "experience." Focus on and expand that aspect of the study findings. 

Alternatively the concept of stigma or bias toward a patient population could be used to frame the study. That is where most of the focus is in this manuscript but the concept is not well structured. Consider the following reference and framework for instance:

Stangl, A.L., Earnshaw, V.A., Logie, C.H. et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 17, 31 (2019). https://doi.org/10.1186/s12916-019-1271-3

Additional guidance can be found below. 

Page	Paragraph	Comment
1 (Abstract)	1	Incomplete sentence: To learn about nursing students' perceptions of providing care to patients with severe mental disorders before and after participating in a simulated student clinical case.
1	1	Consider clarifying  that simulation is being used for experiential learning. (Generally, simulation is used to enable students to apply what they have learned via other modalities like textbooks, lectures etc).
1	1	Suggest changing this sentence: “: The use of high-fidelity simulation lets nursing students become closer to mental health patients,…” to the following: “: The use of high-fidelity simulation lets nursing students better understand the needs of patients with mental health illness,
1	2	Under introduction, suggest this wording: …mental disorders and substance abuse rose by 13%...}  I also suggest going through the document and eliminating the use of “has been,” “have been,” and other passive writing components. Use an active voice instead.
1	2	Who is the mentally ill user? Are you referring to the patient? Clarify
2	3	Indent paragraph 3
2	3	Use of “However….” Is not needed in this sentence: “However, clinical simulation is an excellent medium for learning and evaluating skills…”
2	3	Spelling: “evaluation of competencies”
2	4	Indent paragraph 4
2	1-4	I do not see a theoretical framework discussed in the Introduction section and I strongly encourage the use of one. Consider Experiential Theory.
3	2	I am a little concerned that only volunteers were sought, as opposed to integrating the simulation into a course so that all the senior students would be exposed to it.
3	Table 1	You indicate in the case description that the patient was admitted to the “Therapeutic community of mental mealth” Spelling error (mealth). And is this a kind of outpatient clinic setting? More details needed for international readers.
4	2	What kind of simulation expertise did the two university profs have who carried out the sims? Ie #years for instance
4	4	More spelling errors- replace sued with used. Go through paper carefully to find and correct others.
4	4	What kind of reliability and validity was established for the structured interview guide? Was it Content validity, expert validity… Describe this section more- for instance, was the guide pilot tested?
5	Table 2	I like the fact the whole interview guide was included.
5	Table 2	Rather than the phrase “tend to…” consider “care for…”
8	4	Spelling: “…cataloguing them are strange individuals…”  Change “are” to “as”
9	5	An important point is made by one respondent who stated: “I lack the necessary experience to know how to address it correctly.”  This needs to be highlighted, along with the fact that simulation is experiential. This relationship should be a main focus of the paper.  In the POST CS statements, experience is again commented upon under Management of mental health patients. The literature is replete with studies that show simulation increases confidence. But less focused on is the use of simulation in mental health content in the nursing curriculum. This paper would gain credence and be more publishable by strengthening that relationship
12	3	Stay focused on just limitations here. You have future recommendations as well. Put that in the Conclusion or in a separate section.

Comments on the Quality of English Language

The writing style is fine, though passive and there are some sentence structure and spelling errors that need attention. 

Author Response

Thank you for your suggestions and recommendations. We appreciate the effort that you have made in reviewing our study. we have included changes in the text.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the revised manuscript. The authors did an excellent job addressing my comments. I have no further feedback.

Author Response

We appreciate the reviewer's suggestions, we send our response in the attached file.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The cover page does not address the specific comments that were provided and how they were addressed. Changes are evident in red type. The additions are helpful but I still do not see an identified social stigma theory, like Goffman or Durkheim cited. There is a new reference but no theorist is cited. I have a concern re the added information regarding the fact that the scenario used is based on an actual patient. While the authors indicate the name was changed, there is personal health information like age and gender that remain, and that might enable the individual to identify himself would he read this article.  

There are still some grammar/sentence structure issues remaining, including: 

 

 

Comments on the Quality of English Language

There are still some grammar/sentence structure issues remaining, including: 

Page	Paragraph	Comment
Abstract	1	This is an incomplete sentence. “  To learn about nursing students' perceptions of providing care to patients with severe mental disorders before and after participating in a simulated student clinical case.’
Abstract	1	Under discussion, grammar needs correction ie “…become closer to patientS with A mental health condition..”
Section 3 Results	4	This sentence needs revision. You indicate that people agreed to participate because they lacked interest, had no time etc. You need to reference the NON-participants.  “A total of fifty-six students in the last year of their nursing degree attended the high-fidelity clinical simulation sessions, of which thirty-nine accepted to participate in the study (response rate of 67.5%) due to disinterest or lack of time or other reasons.’

Author Response

We appreciate the reviewer's suggestions, we send our response in the attached file.

Author Response File: Author Response.pdf