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‘Distressing Voices’ echo in nursing students’ heads

Woman hearing voices.

The School of Nursing's “Distressing Voices” seminar aims to help students become more empathetic to patients suffering from conditions like schizophrenia that can cause them to hear disturbing and threatening voices.


Published March 16, 2023

“It was very debilitating, and after doing the seminar I have a much better understanding of what it’s like to experience distressing voices and auditory hallucinations. ”
Santo Caruana, junior
School of Nursing

Santo Caruana heard the voices. The junior in the School of Nursing who took part in the school’s “Distressing Voices” simulation remembers feeling “anxiety, frustration” from the difficulty he experienced concentrating on everyday tasks and real voices while his head was filled with simulated ones.

“I often found myself actually listening to the voices,” Caruana says. “For instance, when I was filling out a form as part of the seminar, the voices said, ‘Don’t look up, don’t look up,’ and I would sometimes follow that command. At times, the voices would be so loud I could barely hear anything else, and then times I hardly noticed they were there.

“The entire seminar I was very distressed and discombobulated because of these voices,” he recalls. “I had to concentrate harder and make efforts to ignore or work through the voices. It was very debilitating, and after doing the seminar I have a much better understanding of what it’s like to experience distressing voices and auditory hallucinations.”

Caruana was one of about 40 nursing students last semester who took part in the immersive experience that nursing faculty hope will help students better understand patients suffering from conditions that result in them hearing disturbing and threatening voices.

It was the latest example of how simulation is transforming nursing education, nursing administrators say. The Distressing Voices seminar has been heard loud and clear by university nursing students and faculty. The initial session last November was so popular and successful that the school plans to present another one in the fall 2023 semester.

“Exposure to people who suffer with distressing voices may be limited or poorly understood,” explains James Cozza, simulation coordinator and clinical instructor in the nursing school. “This program has been shown to increase empathy with this special population. This simulation offers an opportunity to challenge mental illness stereotypes and explore personal perceptions.”

Cozza strongly believe mental illness is pervasive in all health care specialties.  This “empathetic activity” should enhance the school’s mental illness education for its undergraduate nurses.

“Distressing Voices provides a unique, immersive mental health experience to illustrate the challenges of people living with schizophrenia,” says Cozza. “We have found it increases awareness and empathy to people suffering from distressing voices.”

Simulations common in nursing curriculum

Each session included a brief program introduction, program orientation with brief video lecture and mp3 player distribution. Students rotated between four workstations that offered activities like working mental puzzles, completing government forms, participating in a mental health examination in a psychiatric emergency department, and participating in a scavenger hunt throughout Wende Hall.           

Students could pause or turn off the recording any time they felt uncomfortable, Cozza notes.

Distressing Voices isn’t the first instance of the School of Nursing using simulations, which integrate classroom learning with interpersonal abilities and technical skills training. High fidelity mannequins, standardized patients (actors), augmented reality technology and virtual reality modalities are employed through the school’s Simulation Department. Undergraduate nursing students participate in various simulations throughout their nursing coursework. 

Cozza recognized Pat Deegan PhD & Associates and Cali Karpinski, a UB psychiatric mental health nurse practitioner (PMHNP) student and graduate assistant, who tailored the program to fit the School of Nursing’s needs. The core objectives of the simulation were to provide a unique, immersive mental health experience to illustrate the challenges of people living with schizophrenia and to increase awareness and empathy to people suffering from distressing voices.

All participants and volunteers underwent a debriefing session after the simulation to express their feelings and engage in a structured, learning discussion on the topic, according to Cozza.

A path to empathy

The simulation earned high praise from attendees. “I will look into my patients more as people living with a mental illness and really making the distinction that they are not the mental illness,” one participant wrote on an evaluation.

Junior nursing student Jasmine Edmunds called the simulation “extremely valuable.”

“Really, it was interesting to be able to get a semblance of what these people are going through,” she says “It helped me to gain empathy and how the world doesn’t accommodate these individuals.

“It was hard because I was trying to focus on tasks I was trying to do and the voices were telling you to do other things.

“I would absolutely recommend it,” she says of the simulation.