Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/locate/nedt Simulation with standardized patients to prepare undergraduate nursing students for mental health clinical practice: An integrative literature review Anita Øgård-Repål a, ⁎ , Åsne Knutson De Presno b , Mariann Fossum b a Department of Health and Nursing Science, Faculty of Health and Sport Sciences, Centre for Caring Research, Southern Norway, University of Agder, P.O. Box 422, 4604 Kristiansand, Norway b Department of Health and Nursing Science, Faculty of Health and Sport Sciences, Centre for Caring Research, Southern Norway, University of Agder, Grimstad, Norway ARTICLE INFO Keywords: Clinical practice Education Nursing students Psychiatric nursing Simulation training Standardized patients ABSTRACT Objective: To evaluate the available evidence supporting the efficacy of using simulation with standardized patients to prepare nursing students for mental health clinical practice. Design: Integrative literature review. Data sources: A systematic search of the electronic databases CINAHL (EBSCOhost), Embase, MEDLINE, PsycINFO, and SveMed+ was conducted to identify empirical studies published until November 2016. Multiple search terms were used. Original empirical studies published in English and exploring undergraduate nursing students' experiences of simulation with standardized patients as preparation for mental health nursing practice were included. A search of reference lists and gray literature was also conducted. In total, 1677 studies were retrieved; the full texts of 78 were screened by 2 of the authors, and 6 studies reminded in the review. Review methods: The authors independently reviewed the studies in three stages by screening the titles, abstracts, and full texts, and the quality of the included studies was assessed in the final stage. Design-specific checklists were used for quality appraisal. The thematic synthesizing method was used to summarize the findings of the included studies. Results: The studies used four different research designs, both qualitative and quantitative. All studies scored fairly low in the quality appraisal. The five themes identified were enhanced confidence, clinical skills, anxiety regarding the unknown, demystification, and self-awareness. Conclusions: The findings of this study indicate that simulation with standardized patients could decrease stu- dents' anxiety level, shatter pre-assumptions, and increase self-confidence and self-awareness before entering clinical practice in mental health. More high-quality studies with larger sample sizes are required because of the limited evidence provided by the six studies in the present review. 1. Introduction Nursing students are expected to learn and practice complex skills, and the duration of time spent in clinical practice and content of clinical practice are crucial for the development of clinical confidence. Due to limited learning opportunities in clinical practice, other learning methods that focus on how to combine theoretical knowledge with practical skills are important; such methods include simulation, gami- fication, and online learning programs (Edward et al., 2007; Khalaila, 2014). Nursing students often experience increased anxiety before clinical practice in mental health nursing. Interaction with patients who have mental illnesses in a mental health setting is often an unknown situation associated with stigma and stereotypes (Lehr and Kaplan, 2013; Robinson-Smith et al., 2009; Stuart, 2013). The use of simulation in nursing education has increased in recent years, and nursing stu- dents' clinical confidence seems to increase with simulation experiences because of the opportunity to practice skills before they are expected to enter clinical practice (Dearmon et al., 2013; Khalaila, 2014). Simula- tion as a pedagogical method has become an integrated learning strategy in the mental health nursing curriculum and is described as a way of exposing students to real-life clinical scenarios before entering clinical practice (Brown, 2015; Foronda et al., 2013). Simulation training with standardized patients (SPs) in the nursing education provides nursing students with an opportunity to be exposed to these unknown situations. An SP is defined as “an individual who is trained to portray a real patient in order to simulate a set of symptoms or problems used for healthcare education, evaluation, and research” (Society for Simulation in Healthcare, 2016, p.36). SPs in mental health https://doi.org/10.1016/j.nedt.2018.04.018 Received 5 December 2017; Received in revised form 23 March 2018; Accepted 13 April 2018 ⁎ Corresponding author. E-mail addresses: anita.ogard-repal@uia.no (A. Øgård-Repål), asne.depresno@uia.no (Å.K. De Presno), mariann.fossum@uia.no (M. Fossum). Nurse Education Today 66 (2018) 149–157 0260-6917/ © 2018 Elsevier Ltd. All rights reserved. T