title: Development, implementation, and evaluation of a mental rehearsal strategy to improve clinical performance and reduce stress: A mixed methods study.
abstract: BACKGROUND
  Mental rehearsal is a form of mental training that has been used by physicians and nurses to improve performance of clinical skills, and as a vital component of stress management training. To help novice nurses deal with often stressful clinical events that require the processing of information essential to patient management, a mental rehearsal strategy was developed and implemented in a Year 3 nursing simulation program. Inherent to mental rehearsal is imagery, which facilitates cognitive and affective modification, and reduction of extraneous cognitive load. As such, it was expected that the mental rehearsal strategy would improve students' performance and reduce stress in managing deteriorating patients.
  
  
  METHODS
  The study used a mixed methods design. Eighteen Year 3 nursing students participated in the pre- and post-design study, which consisted of the development and implementation of a mental rehearsal strategy. The Rescuing A Patient In Deteriorating Situations (RAPIDS) tool was used to assess performance. Heart rates and systolic blood pressures were used to measure stress. The State-Trait Anxiety Inventory (STAI) was used as a psychological measure of stress/anxiety. Five participants were involved in a focus group discussion that evaluated the usefulness of the mental rehearsal strategy.
  
  
  RESULTS
  There was a significant improvement in performance (P<0.05). However, post-test heart rate and systolic blood pressure were not significantly different from pre-test measures. A comparison of STAI results did not show significant differences between pre- and post-test state anxiety and pre- and post-test trait anxiety. Three themes emerged from the focus group interview: managing stress, using a mental framework, and integrating realistic simulations with the mental rehearsal strategy.
  
  
  CONCLUSIONS
  The mental rehearsal strategy for deteriorating patient management can be valuable based on the findings on performance and based on the participants' feedback. Its role in reducing stress, however, needs further evaluation.
authors.affiliation: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. Electronic address: nurimjj@nus.edu.sg.
authors.forename: Jeanette
authors.initials: J
authors.lastname: Ignacio
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Electronic address: d.dolmans@maastrichtuniversity.nl.
authors.forename: Diana
authors.initials: D
authors.lastname: Dolmans
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Electronic address: a.scherpbier@maastrichtuniversity.nl.
authors.forename: Albert
authors.initials: A
authors.lastname: Scherpbier
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Electronic address: j.rethans@maastrichtuniversity.nl.
authors.forename: Jan-Joost
authors.initials: JJ
authors.lastname: Rethans
authors.affiliation: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. Electronic address: nurvl@nus.edu.sg.
authors.forename: Violeta
authors.initials: V
authors.lastname: Lopez
authors.affiliation: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. Electronic address: nurliaw@nus.edu.sg.
authors.forename: Sok Ying
authors.initials: SY
authors.lastname: Liaw
mesh_terms: D000223:Adaptation, Psychological; D002983:Clinical Competence; D004508:Education, Nursing, Baccalaureate; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D016544:Patient Simulation; D013315:Stress, Psychological / Q000523:psychology*; D013338:Students, Nursing / Q000523:psychology*; D013850:Thinking; D055815:Young Adult
keywords: Clinical performance; Mental rehearsal; Nursing education; Simulation; Stress management