Simulation on alcohol withdrawal syndrome as a teaching method in nursing

Abstract

Objective  To construct and validate a clinical simulation scenario on nursing care for individuals experiencing alcohol withdrawal syndrome (AWS).

Methods  This was a methodological study on the construction and validity of a script based on scientific recommendations regarding advanced life support and simulation-based teaching. The scenario was submitted to validity by specialists through self-administered instruments. In data analysis, the Content Validity Index (CVI) and Gwet’s first-order agreement coefficient were used. A minimum agreement of 0.80 was adopted.

Results  The proposed simulation scenario in AWS was developed to validate the clinical simulation script and the Objective Structured Clinical Examination (OSCE) guide, under assessment by seven specialists in chemical dependency, clinical simulation, and emergency medicine. The scenario script and the OSCE showed high CVI values in most items, proving to be adequate in providing the necessary conditions for fulfilling the learning objectives, obtaining an overall CVI value of 0.98. Furthermore, it showed a high coefficient of agreement among specialists (0.95).

Conclusion  This study provides a validated and free guide for teaching skills, attitudes, and competencies in nursing care for people with AWS, which can be used as a pedagogical strategy in undergraduate, graduate, and continuing education.

Keywords:
Alcohol abstinence; Mental health assistance; Simulation training; Educational technology; Nursing education

Resumo

Objetivo  Construir e validar um cenário de simulação clínica sobre a assistência de enfermagem à pessoa em síndrome de abstinência alcoólica (SAA).

Métodos  Estudo metodológico de construção e validação de roteiro que teve por base as recomendações científicas sobre SAA e ensino baseado em simulação. O cenário foi submetido à validação realizada por especialistas mediante autoaplicação de instrumentos. Na análise de dados, foram empregados o Índice de Validade de Conteúdo (IVC) e o coeficiente de concordância de Gwet: First-order Agreement Coefficient. Foi adotada para a concordância mínima de 0,80.

Resultados  O cenário proposto de simulação em SAA foi elaborado para validação do roteiro de simulação clínica e do guia Exame Clínico Objetivo Estruturado (ECOE), sob avaliação de sete especialistas das áreas da dependência química, simulação clínica, e urgência e emergência. O roteiro de cenário e o Guia ECOE apresentaram valores altos de IVC na maioria dos itens, provando-se adequados em propiciar as condições necessárias para cumprimento dos objetivos de aprendizagem, obtendo valor geral de IVC=0,98. Além disso, apresentou alto coeficiente de concordância entre os especialistas (0,95).

Conclusão  O presente estudo disponibiliza um roteiro validado e gratuito para ensino de habilidades, atitudes e competências na assistência de enfermagem à pessoas em SAA que pode ser utilizado como estratégia pedagógica no ensino da graduação, pós-graduação e educação permanente.

Descritores:
Abstinência de álcool; Assistência à saúde mental; Treinamento por simulação; Tecnologia educacional; Educação em enfermagem

Resumen

Objetivo  Elaborar y validar un escenario de simulación clínica sobre la asistencia de profesionales de enfermería a personas con síndrome de abstinencia alcohólica (SAA).

Métodos  Estudio metodológico de elaboración y validación de un guion basado en las recomendaciones científicas sobre el SAA y la enseñanza basada en la simulación. El escenario fue sometido a una validación realizada por especialistas mediante la autoaplicación de instrumentos. En el análisis de datos se utilizó el Índice de Validez de Contenido (IVC) y el coeficiente de concordancia de Gwet: First-order Agreement Coefficient. Se adoptó una concordancia mínima de 0,80.

Resultados  El escenario de simulación propuesto para el SAA se elaboró para validar el guion de simulación clínica y la guía de examen clínico objetivo estructurado (ECOE), bajo la evaluación de siete especialistas de las áreas de dependencia química, simulación clínica y urgencias y emergencias. El guion del escenario y la guía ECOE presentaron valores altos de IVC en la mayoría de los ítems, lo que demuestra que son adecuados para proporcionar las condiciones necesarias para el cumplimiento de los objetivos de aprendizaje, con un valor general de IVC = 0,98. Además, se obtuvo un alto coeficiente de concordancia entre los especialistas (0,95).

Conclusión  El presente estudio ofrece un guion validado y gratuito para la enseñanza de habilidades, actitudes y competencias en la asistencia de profesionales de enfermería a personas en SAA que puede utilizarse como estrategia pedagógica en la enseñanza de grado, posgrado y educación permanente.

Descriptores:
Abstinencia de alcohol; Atención a la salud mental; Entrenamiento simulado; Tecnología educacional; Educación en enfermería

Introduction

Alcohol use has been considered a public health problem for decades, presenting numerous challenges, from detection to specialized treatment, with a significant increase during the pandemic. The social and health problems are diverse, with high rates of morbidity and mortality, compounded by the current increase in psychoactive substance use among the population and the worsening psychosocial conditions generated by the pandemic.(¹-³)

At different levels of healthcare, especially in emergency departments, nursing professionals may treat individuals experiencing alcohol withdrawal syndrome (AWS) resulting from the cessation or reduction of alcohol use. This syndrome can vary in severity and requires specific care.(⁴,⁵)

However, a study of students’ attitudes and knowledge in a clinical simulation environment related to nursing care for alcohol users revealed fear of violence among alcoholic patients, revealing difficulties and a lack of preparation for providing care to these users. Therefore, efforts must be invested in teaching alcohol user care to prepare nurses to work at various levels of healthcare.(⁶)

The literature highlights several benefits, in addition to the importance of qualified nursing education that meets contemporary demands, with the increasing use of clinical simulation in mental health nursing education. This strategy has been shown to enhance mental health skills acquisition, which is associated with increased student knowledge, confidence, and security in mental healthcare, as well as increased satisfaction and self-efficacy with learning and the implementation of care.(⁷)

In view of national and international recommendations,(⁸,⁹) the literature on clinical simulation for teaching mental health skills in undergraduate nursing is incipient, despite demonstrating the relevance of this strategy as a pedagogical practice.(⁷-¹⁰)

However, the literature points to the need to increase the development of research that assesses clinical simulation as a teaching tool in mental health, with replicable and validated methodologies.(¹¹)

Thus, the present study is justified by the need to expand this strategy for teaching in mental health, with the objective of constructing and validating a clinical simulation scenario on nursing care for people in AWS.

Methods

This is a methodological study that describes the construction and validity of a scenario for clinical simulation on nursing care for people in AWS.

The simulation scenario was developed at a higher education institution in Ribeirão Preto, São Paulo state, based on two scripts: (a) Clinical simulation script “Care for people with alcohol withdrawal syndrome”; (b) Objective Structured Clinical Examination (OSCE) guide. Both were developed following national and international recommendations.(⁸,⁹) Two nursing professors, specialists in clinical simulation, mental health and chemical dependency, and an undergraduate student participated in the scenario construction.

The validity process with specialists took place between July and September 2023, through a digital platform (RedCap).

To select specialists, the criteria established by Jasper(¹²) and adapted for the present study were considered: a) teaching experience in the area/topic; b) participation in the supervision of academic works on the topic; c) holding a master’s or doctoral degree with work on the topic; d) authoring scientific articles on the topic, published in journals classified by the Coordination for the Improvement of Higher Education Personnel; e) being a guest speaker at a national or international scientific event on the area/topic. In the search for specialists’ CVs, through the Lattes Platform (Brazilian National Council for Scientific and Technological Development), at least one of the aforementioned eligibility criteria was observed.

Specialist selection involved individuals with expertise in emergency care, drug addiction, and health education focused on clinical simulation, including nurses and/or faculty. Specialists were invited by email. After acceptance, they also received the Informed Consent Form (ICF) and assessment materials via email, including: i) “Care for people with alcohol withdrawal syndrome” clinical simulation guide; ii) OSCE; iii) Access link to the REDcap platform to complete the assessment instrument.

The deadline for receiving a response to participation and sending the signed ICF was 30 days, with three reminder emails sent weekly after the first contact. Failure to respond within the specified timeframe was considered a refusal. Each participant/specialist had a maximum of 20 days to return the assessment material, with a reminder about the importance of responding 15 days after the link was sent.

A total of 39 candidates who met the study’s inclusion criteria were invited by email. Of these, 13 expressed interest in participating, but only nine completed the data collection instrument in full, making up the final study sample.

The data collection instrument inserted into the RedCap platform consisted of: (a) Sociodemographic information form; (b) Assessment script for the “Care for people with alcohol withdrawal syndrome” clinical simulation scenario, containing 14 items to be assessed using a Likert scale with scores from one to four (1 - Adequate, 2 - Fair, 3 - Slightly inadequate, 4 - Very inadequate), a description of what should be assessed and space for suggestions for adjustments for each item; (c) Assessment script for the OSCE guide: containing 15 items to be assessed using a Likert scale with scores from one to four (1 - Adequate, 2 - Fair, 3 - Slightly inadequate, 4 - Very inadequate), and space for suggestions for adjustments for each item.

The data obtained through the online form were transferred to the Microsoft Excel 10 program. Subsequently, the data were processed, coded and analyzed using the Statistical Package for the Social Sciences (SPSS) version 20.0, and subjected to descriptive analysis.

For content validity, the Content Validity Index (CVI) and Gwet’s test (first-order agreement coefficient) were used. A minimum agreement level of 0.80 was adopted for this study.(¹³)

The ethical assumptions of Resolution 466/2012(¹⁴) and the guidelines for procedures in research with any stage in a virtual environment(¹⁵) were followed in the development of this study, which was approved by the EERP-USP Research Ethics Committee, under Certificate of Presentation for Ethical Consideration 68889123.5.0000.5393 and Opinion 6,136,666.

Results

Specialist characterization

The nursing care scenario for alcohol users was validated by seven specialists, all female, mostly white, adults, with a mean age of 45 (SD 5.3), unmarried, and from the state of São Paulo. Concerning training, all were nurses: one with a master’s degree (14.3%), five with a doctoral degree (71.4%), and one with a postdoctoral degree (14.3%). In relation to professional activity, all worked in higher education teaching. They had expertise in chemical dependency (28.6%), emergency care (28.6%), and clinical simulation (42.9%). They had, on average, 13 years of experience in the field (SD 6.9), ranging from five to 25 years.

Validity of a scenario script entitled “Care for people with alcohol withdrawal syndrome” and the OSCE guide

The final validated version of the scenario script “Care for patients with alcohol withdrawal syndrome” and the OSCE guide are available as Appendix 1 of this manuscript. Considering the validity process by specialists, in relation to acceptance and agreement (CVI), an overall CVI = 0.98 was obtained, and all items in the scenario obtained values equal to or greater than 0.80, exceeding the minimum approval criterion (Table 1). For both analyses, the options of “yes” (adequate and regular) and “no” (somewhat inadequate and very inadequate) were used.

Table 1
Specialist assessment of the adequacy of the scenario script (R) and OSCE guide items

Item	Adequacy		CVI
	Yes	No	(%)
R1 - Scenario title R1 - Scenario title	7	-	100
R2 - General objective of the simulation	6	1	86
R3 - Primary and secondary learning objectives	7	-	100
R4 - Human resources	7	-	100
R5 - Physical and material resources	7	-	100
R6 - Preliminary study for participants	7	-	100
R7 - Duration, R8 - Pre-briefing - contracts and conduct	7	-	100
R8 - Pre-briefing - contracts and conduct	7	-	100
R9 - Pre-briefing - detailed presentation and guidelines for the simulated case	7	-	100
R10 - Instructions for the simulated patient - volunteer role-playing	7	-	100
R11 - Debriefing: initial guidelines	7	-	100
R12 - Debriefing - descriptive phase	7	-	100
R13 - Debriefing - analytical phase	7	-	100
R14 - Debriefing - application phase	7	-	100
OSCE 1	7	-	100
OSCE 2	7	-	100
OSCE 3	7	-	100
OSCE 4	7	-	100
OSCE 5	7	-	100
OSCE 6	7	-	100
OSCE 7	7	-	100
OSCE 8	7	-	100
OSCE 9	6	1	86
OSCE 10	6	1	86
OSCE 11	7	-	100
OSCE 12	7	-	100
OSCE 13	7	-	100
OSCE 14	7	-	100
OSCE 15	7	-	100

• CVI = Content Validity Index

In relation to reliability among specialists, the simulation scenario on user assistance with AWS symptoms presented results considered satisfactory, with values obtained in the overall analysis regarding the two instruments very close to one and standard error close to zero (AC1: 0.95; SE: 0.024; CI: 0.90-1) (Table 2).

Table 2
AC1 coefficient of Gwet AC1* of validity of the simulation scenario on user assistance in alcohol withdrawal syndrome with specialists

Items	AC1	SE	95%CI
Overall	0.953	0.024	0.904 – 1
Script	0.960	0.028	0.900 – 1
OSCE	0.946	0.040	0.860 – 1

• AC1 – Gwet’s first-order agreement coefficient; n - number of specialists; SE - standard error; 95% CI - 95% Confidence Interval.

Specialist suggestions and changes in the scenario

The main modifications to the clinical simulation script included: adapting the proposed general and learning objectives; including freely accessible content and references to support and prepare students theoretically; incorporating verbalizations and data to improve student engagement; providing a more detailed characterization of the simulated case; addressing stigma and discomfort in caring for this population; and problematizing the care provided to the role-playing instructor. The main modifications made to OSCE included: adapting the terms used; incorporating nursing diagnoses and interventions; detailing aspects related to verbal and nonverbal communication; symptoms assessed during physical examination, as well as materials to be used at this time; information collected during the mapping of users’ needs in AWS; and explaining the objectives of care.

Discussion

When considering clinical simulation as a teaching strategy, it is essential that the activity be carefully planned and structured, defining the learning objectives and the elements that will enable students to make decisions and solve problems, prioritizing positive experiences and active participation.(¹⁶)

All scenario items were assessed as adequate by over 80% of specialists, indicating that the first version of the scripts met the established methodological criteria. Even so, during the validity process, specialists’ suggestions enabled us to review and improve important elements of the scenario script and OSCE.

Item R2, referring to the general objective of the simulation outlined in the script, was the item with the lowest score (CVI=0.86), even though it obtained the minimum value adopted in this study. This item was reviewed and adapted considering its importance for conducting the simulated activity.

To improve the simulation scenario’s general objective, the difference between pre-simulation and pre-briefing, which have different definitions, was considered.(¹⁷) Pre-simulation involves providing students with study materials and providing them with the necessary skills to perform the simulation. Pre-briefing, on the other hand, involves interaction between facilitator and students, presenting general and learning objectives prior to the simulation.(¹⁷,¹⁸)

When the script was initially developed, the simulation’s general objective did not mention AWS, and one of the learning objectives was to identify this syndrome. However, specialists’ suggestions indicated the need to link the title to the learning objective, considering the context of the simulated scenario.

As for students’ theoretical preparation, Leigh and Steuben(¹⁸) state that simulation cannot occur in isolation, requiring prior knowledge or preparation. For simulation objectives to be achieved, theory and practice must be integrated. Practice emerges by demonstrating the content learned in the classroom through the integration of knowledge into professional practice. Therefore, pre-simulation provided updated materials and scientific evidence on the topic as well as training in the skills necessary for optimal performance.

In this context, some specialists’ suggestions indicated the need for greater clarity regarding the theoretical preparation phase. Therefore, some content recommendations were included in “moment 2” of the scenario’s outline, as well as freely accessible references, respecting the professor’s autonomy and freedom in choosing materials to support lesson planning.

The simulated patient’s performance reflects the degree of realism of the scenario. Therefore, the director must be adequately prepared to perform the clinical case.(¹⁹) Considering this fact, in “moment 1” of the scenario script, there is information to be used in the directors’ prior study on AWS and information about the case for contextualization and guidance on their role and possible verbalizations.

In this context, suggestions were made regarding the director’s instructions, which should provide students with clues to help them achieve their objectives. The need for detailing the physician’s role in the scenario, including contextualization and verbalizations, also stood out.

To effectively carry out the pre-briefing phase, good simulation practices involve: establishing collaborative contracts; respecting psychological safety and confidentiality; providing guidance on the learning environment, mannequins, and equipment/materials; and presenting the learning objectives, scenario, and debriefing.(¹⁷) This information was included in the script to help the facilitator guide students.

To reduce student stress and anxiety levels during the simulation, enabling them to perform at their best, learning objectives must be adequately defined.(²⁰) In this study, learning objectives received a satisfactory assessment from specialists, demonstrating that the scenario meets their objectives. However, the application of scales to measure AWS symptoms was suggested, with the Clinical Institute Withdrawal Assessment for Alcohol, Revised, a validated scale commonly used in clinical practice, being selected.(²¹) In order to avoid mechanizing the service and compromising the simulation, it was included as a content suggestion.

In relation to human resources, it is necessary to define the target audience, professors, instructors, the use of actors and possible collaborators.(¹⁹,²⁰) In item R4 - Human Resources, which also obtained a high CVI value, it was suggested to include an actor in the scene representing the nursing technician. In a consensus meeting, it was determined that including another professional would imply a significant change in the scenario’s dynamics, which could compromise the proposed learning objectives. Therefore, this suggestion was rejected.

Another suggestion that was not accepted concerned item R5 – Physical and material resources, with the inclusion of a fictitious medical prescription being suggested. Considering that the focus of the scenario in question prioritizes the development of communication skills, assessment of mental functions, and non-pharmacological management of users with mental disorders related to alcohol dependence, as nursing care, this change would be unnecessary.

As for the duration of the stages involved in the simulation, there is no consensus in the literature for debriefing;(⁸,¹⁹,²²) the initial itinerary stipulated 20 minutes. In this section, it was suggested that the stipulated time be increased. Considering specialists’ expertise, the recommendation was accepted, increasing the time to 30 minutes.

Debriefing, when appropriately structured, promotes the development of reasoning and judgment skills through the process of reflective learning, favoring the identification of potentialities and needs for improvement in a constructive and healthy manner, given the varied approaches to the same clinical context.(⁸,²²) To ensure the discussion is not focused solely on technical skills, the debriefing of this scenario was structured to assist in reflecting on the simulation carried out through a script with questions and transition phrases according to the “debriefing diamond” method.(²²,²³) Specialists’ assessments indicated that the content developed for this phase was highly appropriate. Among the suggestions, a question was included to address students’ attitudinal aspects regarding this user.

The literature emphasizes that the approach adopted by healthcare professionals can have a significant influence on the search for treatment or its adherence.(²⁴) In this regard, nurses’ attitude towards users can directly impact adherence to treatment, generating positive or negative effects.(²⁴,²⁵)

Regarding the adequacy of OSCE guide items, items OSCE9 and OSCE10 received the lowest CVI scores in specialists’ assessment. Regarding these items, to assess students’ communication skills, the term “psychoeducation” was used in the initial construction. According to Oliveira and Dias,(²⁶) psychoeducation involves not only educating patients and their families about the disease and treatment, but also making them active contributors to their recovery, and is more complex than simply transmitting information. In this context, as the scenario involves a limited timeframe and a psychiatric emergency with cognitive alterations, the use of this term was revised.

Therefore, as demonstrated, even for those items that obtained high CVI scores in the validity stage, the feedback process provided by specialists’ suggestions contributed profoundly to the improvement of the validated scenario, giving greater veracity to the experience and enabling its replication.

The main limitations of this study were related to specialists’ participation in the scenario assessment (which may be related to the low number of specialists in clinical simulation specifically for mental health) and the concentration of specialists in one region of the country (making it difficult to assess the scenario’s suitability in other regions). It is worth noting that the verbalizations and environments can be adapted, as long as the main objectives are maintained, considering the simulated patient’s level of AWS. Future studies are needed to assess the scenario’s practical implementation in different institutions.

Thus, it is believed that the results of this investigation contributed to the improvement of new teaching strategies for both undergraduate and graduate courses and continuing education, providing opportunities for scientific advancement in the development of new teaching practices for mental health skills, strengthening clinical simulation as a tool to support teaching on this topic.

Conclusion

This study presents the stages of development and validity of a scenario for teaching skills, competencies, and attitudes involved in assisting individuals with AWS, providing the fully validated scenario. The scenario scripts and the student assessment instrument (OSCE) achieved the expected reliability and can help build a repertoire of mental health teaching strategies, expanding and encouraging their use. This teaching strategy sought to incorporate promising elements to foster reflections on discriminatory attitudes and failures in care and support for these users, stemming from stigma, helping to minimize the barriers that prevent this population from accessing healthcare services. The validated scenario is expected to provide students with the integration of theory and practice, fostering meaningful learning in a safe environment and contributing to greater confidence in decision-making. The simulation is also expected to foster the enhancement of attitudinal skills, such as ethical, empathetic, and stigma-free behavior, and the development of learning consolidation through guided reflection during the debriefing, encouraging group learning by identifying potential and needs for expanding the repertoire on the topic.

Acknowledgments

Funding for Research and Innovation at the Universidade de São Paulo, Support Program for New Professors - 2023. USP Process 22.1.09345.01.2.

Annex 1

Validated script for the clinical simulation scenario “Care for people with alcohol withdrawal syndrome” and Objective Structured Clinical Examination, 2024

Validated clinical simulation scenario script: “Care for people with alcohol withdrawal syndrome”
MOMENT 1: Guidelines for role-playing or “simulated patients”
Preliminary study for directors:
To carry out the planned activity, the clinical simulation script “Care for people with alcohol withdrawal syndrome” will be made available in advance to the role-players who will represent the simulated patient and physician at least one week before the simulation. To assimilate the content, a discussion circle will be held, detailing information about the scenario, such as the most common complaints, symptoms, and behaviors related to the care of people with alcohol withdrawal syndrome, at different levels, also considering the possible interventions that will be carried out by students to ensure the realism of the scenario. At this point, all clinical case data and verbalizations that will be necessary for the performance will be reviewed and clarified together with the simulation facilitators; If, during the simulation, the directors are asked for information that was not provided in the conversation circle, the general instruction is that they use the following answers: “do not know for sure”, “do not remember” or simply “no”.
Contextualization of alcohol withdrawal syndrome
This section will present clinical data on alcohol withdrawal syndrome to be presented to the directors. Below, we will present the signs and symptoms of users experiencing alcohol withdrawal syndrome, classified by impairment level: Level I - When the impairment is mild/moderate and therefore presents a mild/moderate withdrawal syndrome, comprising the following aspects: •Biological: Mild psychomotor agitation; fine tremors of the extremities; slight facial sweating; episodes of headache; nausea without vomiting; visual sensitivity, without alteration of auditory or tactile perception. •Psychological: Contact with the healthcare professional is complete; patients are oriented temporally and spatially; critical judgment of reality is maintained; presents mild anxiety; no reported episodes of self- or other-directed violence. •Social: Lives with family or friends and this relationship is regular or good; productive activity is ongoing, even if currently unemployed/on leave; social network is maintained. •Comorbidities: No complications and/or serious clinical and/or psychiatric comorbidities detected during the general clinical-psychiatric examination. For patients classified as level I, the intervention should be psychoeducational and clinical. This means patients should be clearly informed about the diagnosis, receive guidance on alcohol dependence and withdrawal symptoms, and receive specific treatment for the acute withdrawal phase, i.e., a one-time situation that may last a few days. Referral will be for specialized outpatient treatment, with or without home detoxification. Level II - When the impairment is severe and therefore presents a severe withdrawal syndrome with the following aspects: •Biological: Intense psychomotor agitation; generalized tremors; profuse sweating; headache; nausea with vomiting; intense visual sensitivity; acute epileptiform symptoms (seizures) or reported in patients’ history. •Psychological: Impaired communication with healthcare professionals; patients are disoriented temporally and spatially; critical judgment of reality is impaired; intense anxiety; reports a history of self- or other-directed violence; discontinuous, rapid, and unpleasant, delusional thoughts; auditory, tactile, or visual hallucinations are observed. •Social: Poor relationships with family or friends; patients have been unemployed and has not engaged in any productive activity; a social support network is non-existent or limited to the ritual of alcohol use; and no family members are assisting with treatment. •Comorbidities: with complications and/or severe clinical and/or psychiatric comorbidities detected during the general examination. For users with level II conditions, clinical psychiatric emergency care is the best intervention, requiring immediate family or friends to be present to provide guidance on the severity of the condition. Users will be referred for specialized hospital treatment, and the family will receive concomitant psychoeducational intervention regarding the disorder. In the present scenario, the case to be simulated, the director will represent a user with severe alcohol use disorder (DSM-5 – APA, 2014) in alcohol withdrawal syndrome at level II (Laranjeira et al., 2000).
Contextualization of the simulated case to directors
In this section, it is important to highlight that the user’s gender, age and city may be changed according to the directors’ characteristics. Simulated patient •You will represent patient M., 50 years old. He lives in Ribeirão Preto, has no health checkups, and is unfamiliar with the healthcare system. He sought the Emergency Care Unit spontaneously because he wants to stop drinking alcohol. He drinks about five shots of cachaça (150 ml per day) during the day and two cans of beer (700 ml) at bedtime. He needs to drink alcohol upon waking because he feels shaky upon standing and has an intense craving. Drinking relieves the unbearable tremors and sweating. •He has been in the Emergency Care Unit for a day, presenting with generalized tremors, profuse sweating, headache, nausea with reports of vomiting, stomach pain, mild psychomotor agitation, anxiety, and verbalizing visual hallucinations (venomous animals everywhere in the observation room, especially on his bed and near his body) and tactile hallucinations (he feels the animals on his arm and chest). Sometimes he speaks unrelatedly to the questions students may ask, making it somewhat difficult to communicate with the student/healthcare professional. He has episodes of temporal-spatial disorientation, not knowing why he is in the Emergency Care Unit or when he arrived. He will not be able to pronounce his own name. He has cognitive impairment, mainly in attention, memory, and orientation. He is never aggressive. •The patient has a flushed face (using red lipstick to simulate facial flushing) and intense sweating (using a water spray bottle). The patient appears unhygienic, neglected, and wearing dirty-looking clothing. •The patient will be alone on the stretcher. Interprofessional support (simulated physician) •You are an inexperienced resident physician who may be contacted by phone, has the patient’s medical records, and has not reassessed the case. When contacted, you discuss the signs, symptoms, and aspects they assessed with students. You explain that patients are experiencing alcohol withdrawal syndrome and that you will discuss the case with your supervisor to write a prescription, and then leave the scene.
Family/patient information: -M. lives in Ribeirão Preto; -M. is a warehouse assistant; -He started drinking two years ago after a disabling accident; -He has no close family but lives with his mother; -He has no companion at the Emergency Care Unit.
Verbalizations of the director (simulated patient) during the simulation
Good morning! Who are you?! What do you want with me? Look, they’re everywhere... they want to climb my arm, look... these spiders won’t leave... (shows her trembling arm) Can you help me?? Please, I’m desperate!! I don’t know what I’m doing here, I just know I came to stop drinking... I can’t stand these animals anymore... I don’t know when I arrived; I just know I need help! Please! I think I’m going to die (shows fatigue and rapid breathing). I’m glad you came; I feel safer with you here! Thank you for helping me... (she calms down during the consultation).
Verbalizations of the director (physician) during the simulation
Hello, I’ve been asked to come see the patient in bed X. What’s the reason for the call? How is the patient doing? What symptoms have they been experiencing? I will discuss this with my supervisor and get back to you with the prescription.
MOMENT 2: Directed study
Lesson plan
Enable knowledge development during the simulation, it is important that students have prior exposure to the content related to psychiatric emergencies. In this context, educators who choose to use this scenario have the freedom to develop their lesson plans, considering their own methodology, the institution’s structure, and available materials. In this sense, we offer recommendations for important content and freely accessible materials that can enhance students’ teaching and learning process and contribute to the consolidation of knowledge gained through the simulation. Contents: •Nursing care in psychiatric emergencies - conceptualization of the topic; •Bioethical principles involving nursing practice in psychiatric emergencies; •Main clinical conditions (alcohol intoxication and withdrawal; mood, sensory perception, psychomotor agitation); •CIWA-Ar scale; •Organic conditions and delirium; •Importance of nurses’ role in coordinating and developing nursing care in situations of psychiatric emergency. Open access references: • LARANJEIRA, R. et al. Consenso sobre a Síndrome de Abstinência do Álcool (SAA) e o seu tratamento. Revista Brasileira de Psiquiatria. vol. 22 n. 2, 2000 •.VEDANA, K.G.G. Urgências e Emergências Psiquiátricas. 2020. • ORGANIZAÇÃO MUNDIAL DA SAÚDE. Classificação de transtornos mentais e de comportamento da CID 10. Porto Alegre: Artes Médicas, 1998. • QUEVEDO, J.; CARVALHO, A.F. (Orgs). Emergências psiquiátricas [recurso eletrônico]. 3a. ed. Dados eletrônicos. Porto Alegre: Artmed. 2014. o Chapter 1: Avaliação do paciente na emergência; Chapter 2: Emergências Clínicas; Chapter 7: Emergências associadas ao álcool e drogas de abuso. • TOWNSEND, M. C. MORGAN, K.I. Enfermagem psiquiátrica: conceitos de cuidados na prática baseada em evidências. 9ª edição. Rio de Janeiro: Guanabara Koogan. 2021. o Chapter 13: Intervenção em crise; Chapter 23: Transtornos Mentais e Comportamentais decorrentes do uso de substância psicoativa e outros tipos de dependência.
MOMENT 3: Simulated activity
Scenario title: “Care for people with alcohol withdrawal syndrome”
GENERAL OBJECTIVE OF THE SIMULATED ACTIVITY
Demonstrate and discuss basic skills, competencies, and attitudes for providing quality nursing care to a patient (“simulated patient”) experiencing alcohol withdrawal syndrome who is in the observation room of an Emergency Care Unit. Students are expected to be able to conduct the initial patient approach using communication, observation, and interview techniques learned on the topic to collect data about the patient and their condition, identify signs and symptoms of changes in the patient’s mental state, identify alcohol withdrawal syndrome, and initiate necessary nursing care, developing, together with the team, appropriate nursing actions/interventions according to the case’s priorities.
LEARNING OBJECTIVES
Primary learning objective: to experience a psychiatric emergency situation related to nursing care for a person with alcohol withdrawal syndrome in the context of emergency. Secondary learning objectives: Identify a psychiatric emergency related to alcohol use; Recognize and describe the signs, symptoms, and levels of alcohol withdrawal syndrome, relating the clinical conditions that influence the changes in mental status manifested in alcohol withdrawal syndrome; Perform an initial patient approach using communication, observation, and interview techniques to obtain essential data on the health-disease process; Be able to assess and communicate the clinical condition of patients with alcohol withdrawal syndrome and provide necessary nursing care, given this is an emergency situation; Develop and describe competencies, skills, and attitudes involving the role of nurses in nursing care/interventions for alcohol withdrawal syndrome.
Estimated time for the activity
Pre-briefing (10 minutes) – familiarization with the case and scenario; Simulation (15 minutes) – period of interaction between students and the simulated patient. Once the maximum time has been reached, the simulation will be concluded by the facilitators. Debriefing (30 minutes) – reflection on the simulated activity.
Human Resources
Participants: Two to three students (volunteers), two directors (one “patient” and one “physician”) and one to two professors/facilitators. Roles in simulation: -Volunteers to play nurses: two to three students; -Stage director -“patient”: a volunteer from outside the class to be implemented; - Stage director - “physician”: a volunteer from outside the class to be implemented or one of facilitating professors; Simulation location: Laboratory of the Nursing Practice Simulation Center of EERP-USP, reserved for the discipline. Target audience: Undergraduate nursing students.
PHYSICAL AND MATERIAL RESOURCES
Classroom – 1 Simulated practice laboratory (observation room) - 1 Side table - 1 • Chair - 2 Stretcher or hospital bed - 1 Workbench with sink - 1 Scale - 1 Sphygmomanometer - 1 Stethoscope - 1 Gloves - 1 box, size S or M • Syringe - 3 units of 10 ml Needles - 10 units, 1.20 x 40 mm and 10 units, 0.80 x 30 mm Lancets - 10 units Cotton - 1 Fictional medical record on paper for recording care - 1 Scissors to be positioned near the patient - 1 Stretcher or hospital bed with lowered rails - 1 • Flashlight – 1
GUIDELINES FOR PARTICIPANTS
In this section, the facilitator provides instructions to students who will care for the “patient” before beginning the clinical simulation. It is important that the facilitator sign a mutual respect and confidentiality agreement to ensure a humane and ethical learning environment.
CONTRACTS WITH STUDENTS
Professors’ verbalizations to students: •You will accompany your classmates, who volunteered to participate in the simulation representing nurses, in providing care for one of the most common types of psychiatric emergencies encountered in professional practice; •To ensure the simulation runs smoothly, it is important that everyone is present at the scheduled time and that delays are preferably avoided; •Mutual respect and confidentiality are required regarding the activities carried out by volunteers at this time to guarantee a humane and ethical learning space for everyone; •This activity is not evaluative, as the objective of this activity is to enable the expansion of knowledge and skills related to psychiatric nursing care in the context of emergency; •To maintain the realism of the simulation, it is important that, once started, the simulation is not interrupted in any way. I ask that you do not leave or enter the room during the simulated practice; •In this lab, there is no delineating boundary for the simulated space, but we will establish an imaginary line around it. This line delimits everything that is part of the simulation scenario. Everything within it can be used by student volunteers in the simulated service. •To the observing students and volunteers, I ask that you respect the boundaries of the space and do not cross that line; •The simulated activity will last 15 minutes. The facilitators will conclude the simulation with the phrase “simulation closed”. •At the end of the simulated activity, we will have a moment to analyze, discuss and reflect on the possibilities of application in professional practice, with questions and opinions being very valuable at this time.
Guidelines for starting the simulation
Professor/facilitator’s speech: You are on duty at an Emergency Care Unit in Ribeirão Preto and will be treating a patient in the observation room. Patients are experiencing changes in their mental functions and requires assessment. You need to assess this person’s mental status and prioritize the case. If you need to check vital signs, you can use the necessary equipment, and we will inform you of the fees. If you require a medical assessment, simply call us. An inexperienced medical resident will be available with the patient’s care record, as they have just assessed the patient and are discussing the medical course of action with the preceptor.
Shift change: The shift handover will be conducted by the simulation facilitator, representing the nurse from the previous shift, who has just admitted the patient and will be waiting for the students to enter the scenario. The vital signs measured at admission will be reported by the simulated nurse during the shift handover. Verbalizations: Patient M., 58 years old, in the observation room, arrived this morning at the Emergency Care Unit by ambulance. The patient was admitted with symptoms of hallucinations, psychomotor agitation, slurred speech, frequent complaints of stomach pain and nausea, and had recently vomited moderately. The patient was unaccompanied. The ambulance was called by their 80-year-old mother because she feared M. was having a heart attack. With no history in our unit, the social worker contacted the family, who stated that Mr./Ms. has no prior psychiatric history, is a smoker, and is a chronic alcohol user. M. is single, does not work, and receives sickness benefits due to a traffic accident three years ago. M. has been hospitalized several times in the last four years due to alcohol abuse in different places in the city. The mother reported that her child started using alcohol in bars near home because M. was very sad about not being able to work, due to their disability, and having been separated from their family, who felt exhausted by the constant hospitalizations. M. has been attending the Psychosocial Care Center for a year, but misses appointments frequently and is not taking medication. Their family member told the team that has no control over their drinking and cannot stay sober for long because he becomes very agitated and upset. M. stopped drinking a day ago after a fight with their brother, who threatened to kick them out of their mother’s house if they did not stop drinking. M. drinks about five shots of cachaça (each shot 30 ml = 150 ml per day) during the day and two cans of beer (350 ml = 700 ml) to sleep. M.’s mother notices that they need to drink in the morning to alleviate tremor symptoms. ADDITIONAL INFORMATION: Vital signs – heart rate: high (140 bpm); blood pressure: high (150x90 mmHg); respiratory rate: 28 mvp; Glucose: 88 mg/dl.
Expectations (student action):
Expectations: •Initial approach with appropriate posture and vocabulary: approach the patient on the bed in the observation room, introduce yourself and identify the team that will monitor their care; •Explain the reason for the care: provide guidance to the patient (regarding time, location, personnel, and procedures); •Establish empathetic interaction with clear communication and active listening: explain to the patient about alcohol withdrawal syndrome and its potential signs and symptoms, relating to the complaints expressed; •Gather information about the patient: investigate patterns of alcohol consumption, intoxication, and the context of withdrawal (abrupt cessation or reduction in intake and for how long, intentional or unintentional?); •Observe and ensure an environment with minimal auditory and visual stimuli: reduce risks involving the patient, the environment, and staff, increasing safety (e.g., maintain high railings, remove objects from the environment that encourage self-harm or aggression, monitor the patient); •Provide guidance to the user and carry out necessary interventions: -Assess the patient’s clinical condition through frequent monitoring, considering the signs and symptoms of alcohol withdrawal syndrome and/or the CIWA-Ar scale; -Identify the patient’s nutritional and hydration needs (encourage oral hydration, if possible, and advise on fasting, if necessary, due to the risk of aspiration and respiratory complications in cases of mental confusion); -Assess the need for multidisciplinary support (physician); -Communicate the patient’s clinical condition to the physician and discuss the need for a prescription; -Administer medication and assess the response; -Encourage the initiation of the treatment process by demonstrating the availability of support from a professional and the entire healthcare team, and highlight possibilities for follow-up within the care network (e.g., encourage the patient to seek longitudinal follow-up in specialized services or primary care).
MOMENT 4: Activities after the simulated activity
DEBRIEFING - GENERAL GUIDELINES
After the simulated activity is completed, students and director will be invited to be with the other students in a circle to begin reflections and discussions about the simulation, experiences, knowledge, feelings and learning involved in the simulated practice, highlighting aspects listed and assessed in the Objective Structured Clinical Examination guide items using the “debrief diamond” technique, composed of the following stages: description, analysis and application (Jaye; Thomas; Reedy, 2015), described below:
Debriefing - descriptive phase
At this stage, we sought to highlight perspectives on what occurred in the case, without judging participants’ performance during the simulation. Verbalizations: At this initial stage, we would like to thank volunteer students and directors for their participation, which was crucial to the development of this activity. In this first phase, we will discuss the activity, emphasizing the previously agreed-upon agreement of mutual respect and confidentiality. We will then begin the reflection/discussion process by asking a few questions: The following questions are directed to the scenario participants (volunteer students): •Does anyone remember how to approach a user experiencing alcohol withdrawal syndrome? How do we handle this situation? Is there a protocol? •Could you describe what happened during the simulation without judging your own or the group’s performance? Where did you start? What was the first stage? And after that, what was the procedure? •In everyone’s opinion, what do you think the group did appropriately during the simulation? The following questions are directed to the director: •How did you feel during the consultation? What was the consultation like for you? Phrase for transition to the analytical phase: This scenario was created for you to experience a nursing care situation for a person experiencing alcohol withdrawal syndrome to foster recognition of nurses’ role in addressing psychiatric emergency care needs. With this in mind... (start questions below).
Debriefing - analytical phase
At this stage, we sought to highlight perspectives on the non-technical skills involved in the simulation that were important for participants and observers. The following questions are directed at the scenario participants: •How did you feel during the simulation? Please comment. •How do you rate your performance in group work during the simulation? •At that moment, you took this action. Why was it important for you to take this action? What prompted you to do this? How did you prioritize this intervention? The following questions are directed to participants and observers: •In everyone’s opinion, what do you think the group did well during the simulation? What was the positive aspect of the service provided? Which interventions stood out to you? How important were these actions to you? Questions to address feelings in terms of stigmas and student discomfort in caring for this clientele: •Did you have any difficulty working with this user? Phrase for transition to the application phase: Considering all the aspects discussed in this scenario so far, in which an alcohol-dependent user was treated with alcohol withdrawal syndrome, what do we agree we could do given the needs of our user/“simulated patient”?
Debriefing - application phase
In this last phase of debriefing, we sought to highlight perspectives on how participants can apply the knowledge in their clinical practice. The following questions are directed at the scenario participants: •What would you do differently during a new experience providing nursing care to patients with alcohol withdrawal syndrome? How can these skills we have discussed help in future situations? The following questions are directed at participants and observers of the scenario: •What can you take from this simulation experience (list objective) into your professional practice? •Considering this scenario in reality, do you think alcohol users are treated similarly to how your colleagues treated them? What do you think is different? What should be similar? •After this simulation and reflection, how do you feel about the possibility of treating a person experiencing alcohol withdrawal syndrome? •How would you classify this patient’s risk when entering a healthcare facility? Based on this classification, what decisions can we make or suggest? (We suggest a discussion also involving healthcare institutions’ protocols for managing alcohol withdrawal syndrome, revisiting the CIWA-Ar scale and completing it with students. Use this moment to discuss the possibilities of clinical decision-making in this context and the importance of nurses’ role in this discussion - hospitalization, treatment, monitoring).
Objective Structured Clinical Examination guide
Assessment items	Assessment	Notes
OSCE1. Do you welcome patients cordially, introducing yourself as a nurse and calling them by name?	( ) Yes ( ) No ( ) Partially
OSCE2. Explain what the service will be like and how long it will take. The student must explain where patients are and what the immediate objectives of care will be (assessment and relief of existing symptoms, monitoring, and interventions to prevent worsening of the condition)	( ) Yes ( ) No ( ) Partially
OSCE3. Do you use clear, accessible, and understandable language for patients, being sensitive to users’ perception of communication?	( ) Yes ( ) No ( ) Partially
OSCE4. Can you identify relevant data from the user’s nonverbal communication - attention to expressions, gaze, arm and leg movements, gestures and body language?	( ) Yes ( ) No ( ) Partially
OSCE5. Can you conduct an initial approach with the user to collect data involving the current situation and history communicated during shift handover? Important data to be considered and discussed in the debriefing •What type of substance do you use? Do you use more than one substance? •How often and how much do you consume alcohol on a typical day? •When was your last drink? And how much? •What was the context of the cessation (was it planned? supervised? or involuntary)? •Is this your first time stopping consumption? •Do you have comorbidities and/or existing diseases?	( ) Yes ( ) No ( ) Partially
OSCE6. Do you use therapeutic communication techniques to understand the current situation, the social and family context?	( ) Yes ( ) No ( ) Partially
OSCE7. Can you identify signs and symptoms of changes in users’ mental functions - tactile and visual hallucinations, temporospatial disorientation - and communicate them appropriately to the simulated physician?	( ) Yes ( ) No ( ) Partially
OSCE8. Can you gather the materials needed to perform the physical examination and clinical interventions? Materials: •Sphygmomanometer, stethoscope, thermometer, flashlights, sterile and non-sterile procedure gloves; cup and medications Priorities in the physical examination: •Assessment of vital signs; observation of possible involuntary and repetitive eye movements; identification of malnutrition as a risk factor; palpation to assess hepatomegaly; •assessment of mental status exam questions (memory, attention, sensory perception, recall, and language).	( ) Yes ( ) No ( ) Partially
OSCE9. Do you identify aspects that facilitate and/or compromise the implementation of the initial approach?	( ) Yes ( ) No ( ) Partially
OSCE10 - Do you provide interventions/guidance to minimize distress regarding the professional approach, treatment/monitoring, including medication? Nursing interventions related to alcohol withdrawal syndrome: •Establish trust, identify altered perceptions, encourage positive affirmations; •Administer and promote medication adherence, provide emotional support and safety devices; •Monitor neurological status and confusion; •Implement safety precautions against possible suicidal ideation and aggression; •Manage anxiety, demonstrating relaxation techniques and counseling on medication-related fears and hallucinations; •Obtain data and provide guidance on: orientation, memory; alcohol withdrawal; acceptance of health condition; self-esteem; ability to perform care; fatigue, mood, depression, sadness; nausea, self-care needs; sleep, hygiene patterns; reality orientation therapy; diet and hygiene; management (control) of nausea and other withdrawal symptoms; home safety, driving, and sleep; •Ensure continuity of care by promoting health-seeking behavior.	( ) Yes ( ) No ( ) Partially
OSCE11. Are you able to initiate appropriate nursing care according to the case’s priorities?	( ) Yes ( ) No ( ) Partially
OSCE12. Does it identify the need for multidisciplinary interventions (e.g., medical intervention, social assistance, or psychology)?	( ) Yes ( ) No ( ) Partially
OSCE13. Can you identify alcohol withdrawal syndrome and appropriately communicate priority information about the case to other professionals, such as your physician? Main information: •Altered vital signs, intense psychomotor agitation, generalized tremors, profuse sweating, headache, nausea with vomiting, intense visual sensitivity, temporally and spatially disoriented, intense anxiety, hallucinations.	( ) Yes ( ) No ( ) Partially
OSCE14. Did you establish nursing diagnosis and implement nursing care accordingly? Possible nursing diagnoses related to the scenario: •Hallucination, suicidal ideation, anxiety, impaired memory, impaired self-care, nausea, low self-esteem, risk of seizure, isolating (or withdrawn, introverted) behavior, impaired sleep, confusion, tremor, sadness, disorientation, vomiting, depressed mood.	( ) Yes ( ) No ( ) Partially
OSCE15. Do you consider the need for referrals given the moment of the health-disease process experienced and patients’ biopsychosocial needs?	( ) Yes ( ) No ( ) Partially

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• Data availability:
  The authors did not make the data from this article available in repositories prior to submission.

Edited by

• Associate Editor:
  Thiago da Silva Domingos (https://orcid.org/0000-0002-1421-7468) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Data availability

The authors did not make the data from this article available in repositories prior to submission.

Publication Dates

• Publication in this collection
  20 Apr 2026
• Date of issue
  2026

History

• Received
  12 Feb 2025
• Accepted
  8 Oct 2025