“If I go to see someone about my eyes, my eyes are what I am, and the rest of me doesn’t matter. It’s the same with mental health. If I go to see someone for a mental health problem, I AM a mental health problem”

Mental health focus group participant  ¹

If you work in healthcare or have ever been a patient with multiple conditions, you may relate to the statement above. You may have been that clinician or that patient.

Why is this? Why do we, as healthcare professionals, tend to see one issue at a time?

Part of it is the time pressures we are under – we need to prioritize and focus on the most urgent issue first. Part of it is about competence – the skills and confidence to work outside our conventional role boundaries. Part of it is about attitudes – there is a tendency to treat physical health ahead of mental health.

And part, unfortunately, is our education. In classes, in clinicals and in simulation, we are taught to think of issues as discrete. A mental health simulation involves a mental health issue, and cardiac scenario is about chest pain, and so on.

Yet we know in the real world people aren’t that simple. We know that mental and physical health are inextricably linked, and it is detrimental to a person’s overall wellbeing to regard these as two separate entities. As such, shouldn’t we be designing simulation to teach just that?

At Oxford Medical Simulation we think so…

Holistic Simulation

We deliver clinical experiences on-demand, helping educators provide fully interactive and immersive simulation on-screen and in virtual reality. Our virtual patients reflect what we see in the real world, taking a holistic approach to managing mental and physical health.

Angry virtual patient

Each scenario of the OMS mental health library has been created to help learners hone their skills in mental health assessment, and – as in real life – contain physical health issues as well.

For example, Maria is an 80-year-old patient presenting with shortness of breath. Though she has a history of heart failure, her most prevalent issue is acute anxiety. The learner must balance these two issues to manage Maria successfully. This involves establishing rapport, elucidating a medical and mental health history, assessing acute anxiety, use of scoring systems, investigating coping mechanisms and sources of support, involving the relevant teams for further assessment, and documenting as needed.

As with all the OMS scenarios, all elements of care are possible: communication, examination, investigations, EMR, charting, and team interaction – just like in the real world. This breadth of possibilities, combined with adaptive scenarios that change depending on learner behaviors, ensures scenarios feel real, whilst scaffolded learning ensures they are appropriate for a wide range of learners.

The virtual patients are designed to look and behave like real patients, from low mood and poor eye contact to confusion and agitation.

After each scenario, detailed feedback, evidence-based blended learning and performance analytics allow the learner to repeat and improve their performance over time, and guided debrief allows them to reflect and document their performance.

Scenarios are objective and standardized and can run with or without faculty input. This allows instructors to focus on debriefing, synchronously or asynchronously, with OMS providing the clinical experience. Running on learners’ own computers, ensuring accessibility, or virtual reality, OMS scenarios are built to deliver simulation at scale for maximal immersion.

The mental health library contains a range of scenarios to cover the mental health syllabus. The growing OMS mental health library consists of scenarios that challenge learners across multiple areas: anxiety, self-harm, bulimia nervosa, alcohol dependence, chronic pain, dementia with difficult behavior, gender transition and suicidal ideation.

There is a lot to learn within each scenario. Our approach reflects the understanding that healthcare professionals don’t need to be experts in mental health to have a huge impact. Getting the basics right is the most important element in mental health care.2 Taking a ‘whole person’ perspective, focusing on communication and consultation skills, ensuring coordination of care, and encouraging self-management and peer support are common across all scenarios.

Mental Health in Context

Physical health problems significantly increase the risk of poor mental health, and vice versa.

Around 30% of all people with a long-term physical health condition also have a mental health problem,3 and mental health problems can seriously exacerbate physical illness, affecting outcomes and the cost of treatment.4

COVID-19 mental health impact

This is compounded as many of those with diagnosable mental health problems receive no formal treatment. As such, a presentation for medical care may be the first presentation with an underlying mental health issue.5

To appreciate just how important and timely these issues are, before COVID-19, one in five U.S. adults lived with a mental health issue.6 In 2020 this skyrocketed. Nine months into the pandemic, 42% of people surveyed by the US Census Bureau reported symptoms of anxiety or depression – an increase from 11% the previous year.

This is not surprising. Fear of contracting the virus, working from home, temporary unemployment, home-schooling, and lack of physical contact contribute. “I don’t think this is going to go back to baseline anytime soon,” says clinical psychologist Luana Marques, at Harvard Medical School in Boston, Massachusetts, who is monitoring the mental-health impacts of the crisis.7

COVID-19 anxiety and depression impact

And amongst the mental health casualties are healthcare workers. It was known from the SARS outbreak that clinicians were at high risk of developing anxiety, depression, stress during outbreaks.8 Sadly, this has been reflected across the healthcare spectrum during COVID-19, with nurses seeming to be most impacted by the consequences of the pandemic.9 Without healthcare workers, there is no healthcare system, so whilst we continue to strive to improve the care we provide our patients, we mustn’t forget about ourselves, and each other.

All this to say that as the urgency of the pandemic begins to recede, the focus will rightly turn to the mental health epidemic. We should be designing scenarios that reflect this. Blending learning objectives across mental health and physical health through simulation is one way to help us deliver the complex care required for our patients, and scenarios such as those we design are part of that picture.

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