As educators, we have responsibilities to our students and patients alike. Our students trust and expect us to provide them with accurate information, opportunities to practice what they have learned in the classroom under supervision, and fair methods of evaluation. Our patients trust and expect us, as clinical practitioners, to use our cumulative knowledge and skills to provide them with the best care possible. What happens when students do not meet established objectives in the clinical environment? The possibility for error increases; frustration between students and clinical preceptors builds; the students’ stress levels escalate, while their confidence levels drop; and at some point, patient safety is jeopardized. How do we respond to this situation? Are traditional remediation methods the best course of action, or are we discouraging students with these methods? What alternatives are available? Can we, as educators, better fulfill the commitments we have made to both our students and our patients?
Traditionally, suboptimal student performance in the clinical environment generates poor evaluations from clinical preceptors. Instructors then communicate with both the students and clinical preceptors to devise a plan that addresses the students’ knowledge deficits. The students then return to the clinical environment under close supervision.
This approach has served the nursing profession well for generations. However, if we examine the elements of this approach closely, some questions arise. When students return to the clinical environment, are they performing under dysfunctional stress levels? Has their ability to successfully meet the specified objective been enhanced, or crippled? Are students confident in their own abilities? What is the likelihood that an error will occur when tense students, who have little confidence in their ability to complete an objective, find themselves repeating that objective under stressful circumstances and close scrutiny? In this context, the need for alternative strategies is unmistakably clear. Without some modification, we will discourage students right out of our profession.
Simulator use has become increasingly popular in highly complex working environments in which the consequences of error are costly. Simulation has been used for many years in the aviation and nuclear power industries. It is from these experts that the principles involved in training and teaching with simulators are borrowed. The human patient simulator is used in health care education because it is a high-fidelity instrument that provides both educators and students with a realistic clinical environment and an interactive “patient.”
Components of the human patient simulator (HPS) include a mannequin and computer hardware and software. The mannequin is housed in a site designed to mimic a health care setting (e.g., an operating room, intensive care unit, postanesthesia care unit). The HPS has characteristics expected in patients such as a pulse, heart and lung sounds, and blinking eyes with reactive pupils. The mannequin also supports invasive procedures, such as airway management, thoracentesis, pericardiocentesis, and catheterization of the urinary bladder. Invasive and non-invasive monitoring of physiological function may be performed with displays viewed on mobile, intensive care unit, or anesthesia monitors. Many HPS models include a drug recognition system in which bar-coded syringes are used to administer “drugs” to which the mannequin responds with appropriate physiological changes.
Human patient simulators have been used for a number of different educational purposes including the training of medical and nursing students, anesthesia providers, and emergency medical technicians. When the HPS has been used in the educational process to teach basic physiology, pharmacology, or crisis management skills, the benefits have been widely recognized. A study conducted by Good, Gravenstein, and Mahla (1992) revealed that anesthesia residents acquired certain clinical skills more rapidly after exposure to the HPS. Chopra et al. (1994) found that anesthetists who trained using a simulator responded more quickly, deviated from accepted guidelines less frequently, and performed better in crisis situations than those who did not train with a simulator. The HPS has also been shown to be an effective tool to teach conscious sedation and analgesia to nurses (Farnsworth, Egan, Johnson, & Westenskow, 2000). The instructor’s ability to identify weaknesses in individual student performance is what makes the simulator a valuable tool (Hammond, Bermann, Chen, & Kushins, 2002). The HPS permits students, whether beginners or practicing clinicians, to learn and practice a variety of technical skills and manage basic and complex clinical situations in a reproducible environment (Monti, Wren, Haas, & Lupien, 1998).
The HPS is an invaluable accompaniment when teaching invasive skills that pose risks to patients. Using the HPS to master such skills is quicker and safer than practicing on “real” clinical patients. Repeated or failed attempts are not painful and generally not harmful to the simulator. David Gaba, MD, a respected authority in the field of simulation, has stated that the most significant advantage to training with an HPS is that crisis scenarios can be presented with no risk to the patient. “Known events, whether catastrophic or benign, can be presented repeatedly so that trainees can become proficient at recognizing and treating them” (Gaba, 1992, p. 492). In addition to familiarizing trainees with known, frequently encountered events, the simulator offers an additional advantage in that infrequent events can also be practiced. Exposure to rare events on the simulator helps trainees provide appropriate actions to avoid disaster (Chopra et al., 1994).
The HPS can also be used to provide individualized instruction. The simulation experience can be repeated as many times as needed until learners achieve a desired level of proficiency. Learners and instructors are afforded a measure of comfort when simulation training is used because patients are not harmed if mistakes are made. Many anesthesia educators advocate simulation as a prerequisite to clinical patient encounters much the same way and for the same reasons that flight simulators are used in pilot training. As the stakes of “real-life” experience rise, the attraction to simulation increases.
Simulation Use for Remediation
Simulators have been valuable tools in the instruction of providers identified as needing remediation in the anesthesia field (Rosenblatt, & Abrams, 2002). As educators, we know that some students have difficulty transitioning from the classroom to the clinical environment. While they may excel in lecture, didactic, and pedagogic formats, some students will have difficulty integrating and applying that knowledge to clinical practice. The simulator can act as a bridge for learners who experience this type of difficulty. Although not widely researched as a tool for remediation of students experiencing difficulty in the clinical area, simulation technology is believed to improve students’ acquisition and retention of knowledge better than the traditional lecture format (Issenberg et al., 1999).
Usually, remediation strategies are one-on-one, faculty-student instruction sessions, with additional time spent in the clinical setting. However, there are disadvantages to teaching skills entirely in the clinical setting. In addition to those mentioned above, there is a generally low exposure to rare critical events, not all trainees will have the same clinical experiences, and there are few opportunities to practice new procedures due to the inherent risks to patients and the need for patient cooperation (Shimada, Nishiwaki, & Cooper, 1998). It has been recommended that multiple methods be incorporated into the remediation process. Students learn best when a variety of teaching techniques are used, and alternative educational techniques are necessary to provide the best learning environment for these students (Hanna, Premi, & Turnbull, 2000).
As noted above, there are rare references in the literature to the use of the HPS as a remediation tool, but we believe many institutions with simulators probably do use them for this purpose. The purpose of this article is to share our experience with colleagues and advocate this additional use of the HPS. Perhaps the most significant things we have learned through our experiences are:
- The clinical task or objective to be remediated must be one that is amenable to simulation.
- The goals of remedial simulation work must be clear, measurable, and defined.
- The students must have the desire and capacity to change.
In the absence of these conditions, simulation sessions are not only difficult to choreograph but also become an unproductive use of student, faculty, and simulator time.
Simulation Method of Remediation
We devised a plan that we believe meets the needs of students and clinical preceptors, while preserving patient safety. Although we gained experience using this method with graduate-level nurse anesthesia students, we believe it can be adapted for use with other advanced practice and undergraduate nursing students. We adapted the nursing process to facilitate the development of plans for remedial work with students, resulting in a clear, organized approach that serves as a guide for instructors.
When students are struggling in the clinical environment and receive poor performance evaluations from their clinical preceptors, instructors should review the evaluations and discuss a plan with the preceptors and students. After specific problem areas are identified, the instructors can schedule student sessions in the simulation center. The simulation center consists of a patient mannequin, computer control area, vital sign monitors, and appropriate clinical scenario props (e.g., indwelling catheters, intravenous fluids). There are also two-way mirrors to enable faculty and students to view and critique simulations in progress, and video cameras to document simulations for review with the students who are having difficulty or with the entire class at a later date.
In the simulation center, students can “redo” assigned clinical tasks and skills. High-fidelity patient simulators make it possible to recreate the clinical environment both physically and physiologically. There is a wide margin of safety inherent in this process. The simulator will not be harmed if an error is made. Therefore, the simulation center is a safe place for students to practice skills and behaviors until a specified level of proficiency is reached. In this secure environment, students gain back confidence in their abilities.
When students return to their clinical sites, specific objectives are designed to promote additional practice with the skills that were problematic. Preceptor evaluations are sought on a daily basis and are reviewed carefully for evidence of the students’ improvement in the identified skills. We have observed improved performance, reduced anxiety, and increased self-reported confidence levels among students using this method. It has been our experience that time spent in the simulation center, away from the clinical site, is a brief and effective remediation method.
The first step is identifying the students having difficulty in the clinical area. Ideally, students will be identified early in the clinical experience. Identification can be based on instructor observation of the student or on preceptor evaluations of student performance. In either case, instructors must determine that the students are not satisfactorily meeting the objectives of the clinical experience.
The next step is to candidly discuss the areas of weakness with the students and preceptors. A plan for repeating the experience in which identified weaknesses were observed should be formulated. Often, the situation can be resolved with only this intervention. However, there are situations in which instructors, preceptors, or students may not consider this a sufficient resolution. When that is the case, the particular difficulty students are having must be analyzed with care. Is the problem lack of preparation, inadequate didactic knowledge, or lack of professionalism? Those are not problems that are amenable to simulation remediation. Is the problem an inability to integrate didactic knowledge into clinical practice, an inability to perform a skill correctly, or difficulty implementing planned care in a prioritized, timely fashion? Those are all problems that can be remediated in a simulation setting. The final part of the assessment step is to determine whether the students have the desire and capacity to modify their behavior to meet the defined objectives of the clinical experience.
In this step, the instructors develop a lesson plan or case scenario that helps the students by repeating the skills or situations that were difficult. The identical clinical scenario can be repeated multiple times using an HPS until the desired degree of proficiency is reached. The plan should be discussed with the students, and the objectives for the experience should be determined and shared with the students prior to the simulation session. Students are expected to prepare for the session as they would for a typical clinical day. The instructors (and preceptors) will determine whether the students will benefit from time away from the clinical environment or whether simulation sessions will supplement ongoing clinical experience. Finally, time in the simulation center should be scheduled.
The simulation sessions comprise the implementation step. Students work one-on-one with their instructors in the simulation center, and the planned scenarios are performed in an environment designed to mimic the clinical setting. Instructors may replay the scenario, allowing students to practice by repetition to improve time management skills, or to change their responses to a physiological cue generated by the simulator. The scenario may also be suspended to permit discussion of choices to be made as part of a clinical decision-making tree. The scenario can then be resumed, and the consequences of each decision observed. Inevitably, students will begin to internalize what they see and experience as “real” in the simulation center. Learning occurs, and the acquired knowledge becomes part of the students’ experience bank, which can then be called on in the clinical environment.
No simulation experience is complete without a debriefing of the participants. Instructors should review the objectives and evaluate the students’ performance based on those objectives. Students are encouraged to describe both their own strengths and areas in which they think improvement is still needed. Based on the debriefing evaluation, instructors will decide whether additional simulation sessions are needed. Subsequent sessions become narrower in scope and focus intensely on those areas still needing improvement. It has been our experience that two to three sessions are sufficient to remediate most of the problems that arise among our clinical students.
The final aspect of evaluation is the follow up required in the clinical environment. Assignments that permit students to practice the remediated skills and demonstrate mastery of clinical objectives are designed. The instructors (or preceptors) must observe that improvement has occurred.
Disadvantages do exist when the HPS is used as a remediation tool. One such disadvantage is that the HPS and the simulator environment are not reality. Students are aware of the simulation experience and may not take it seriously. Conversely, students may aggressively tune into the possibility that something is about to happen and become overzealous in treating a situation. Therefore, their performance may vary from what would have been done in real life.
Other disadvantages include equipment cost and availability. Developing a remediation plan using the HPS should reflect individual students’ needs, which can prove to be very labor intensive. However, the time spent in early remediation will ultimately relieve instructors of future time investments that would occur if students were allowed to continue without individualized attention.
Although there is no definitive evidence showing that the HPS is the most reliable method of evaluating how students will perform in real life, it remains a valuable tool to remediate routine clinical performance, maintain clinical skills, acquire new skills, and manage crises. Instructors should be aware of this innovative use for an existing simulator in their educational institutions. By using the simulator in this novel way, student learning can be enhanced, which will ultimately optimize patient care and safety.
- Chopra, V., Gesink, B.J., De Jong, J., Bovill, J.G., Spierdijk, J. & Brand, R. (1994). Does training on an anesthesia simulator lead to improvement in performance?British Journal of Anesthesia, 73, 293–297. doi:10.1093/bja/73.3.293 [CrossRef]
- Farnsworth, S.T., Egan, T.D., Johnson, S.E. & Westenskow, D. (2000). Teaching sedation and analgesia with simulation. Journal of Clinical Monitoring and Computers, 16, 273–285. doi:10.1023/A:1011422826240 [CrossRef]
- Gaba, D.M. (1992). Improving anesthesiologists’ performance by simulating reality. Journal of Anesthesiology, 76, 491–494. doi:10.1097/00000542-199204000-00001 [CrossRef]
- Good, M.L., Gravenstein, J.S. & Mahla, M.E., (1992). Can simulation accelerate the learning of basic anesthesia skills by beginning anesthesia residents?Anesthesiology, 77, A1133. doi:10.1097/00000542-199209001-01133 [CrossRef]
- Hammond, J., Bermann, M., Chen, B. & Kushins, L. (2002). Incorporation of a computerized human patient simulator in critical care training: A preliminary report. The Journal of Trauma, 53, 1064–1067. doi:10.1097/00005373-200212000-00006 [CrossRef]
- Hanna, E., Premi, J. & Turnbull, J. (2000). Results of remedial continuing education in dyscompetent physicians. Academic Medicine, 75, 174–176. doi:10.1097/00001888-200002000-00017 [CrossRef]
- Issenberg, S.B., McGaghie, W.H., Hart, I.R., Mayer, J.W., Felner, J.M. & Petrusa, E.R. et al. (1999). Simulation technology for health care professional skills training and assessment. Journal of the American Medical Association, 282, 861–866. doi:10.1001/jama.282.9.861 [CrossRef]
- Monti, E.J., Wren, K., Haas, R. & Lupien, A.E. (1998). The use of an anesthesia simulator in graduate and undergraduate education. CRNA: The Clinical Forum for Nurse Anesthetists, 9(2), 59–66.
- Rosenblatt, M.A. & Abrams, K.J. (2002). The use of a human patient simulator in the evaluation of and development of a remedial prescription for an anesthesiologist with lapsed medical skills. Anesthesia and Analgesia, 94(1), 149–153.
- Shimada, Y., Nishiwaki, K. & Cooper, J.B. (1998). Use of medical simulators, subject of international study. Journal of Clinical Monitoring and Computing, 14, 499–503. doi:10.1023/A:1009916813252 [CrossRef]