Ms. Thompson is Clinical Instructor, School of Nursing, University of Missouri Kansas City, and Dr. Bonnel is Associate Professor, School of Nursing, University of Kansas, Kansas City, Missouri.
The authors thank Mary Lou Wieliczka, RN, for her assistance in programming the simulator before the simulation experiences, and for running the simulator during the simulation exercises and ensuring that the simulations ran smoothly for the student experiences.
Address correspondence to Teri L. Thompson, MSN, RN, CPNP, Clinical Instructor, School of Nursing, University of Missouri Kansas City, 5407 Health Science Building, 2464 Charlotte, Kansas City, MO 64108-2718; e-mail:firstname.lastname@example.org.
Students often have difficulty making connections between the content learned in class and its practical application in the clinical setting. Multiple forms of simulations have been used in health care education to mimic patient encounters. High-fidelity patient simulations are receiving increased interest in the health care arena as a way to better prepare students for safe clinical practice. Although pharmacology courses usually do not include a clinical component, high-fidelity patient simulations provide key opportunities to promote the safe and knowledgeable use of medications. This article discusses the purposes and benefits of high-fidelity patient simulations, as well as theory and best educational practices related to it; a pharmacology-based case scenario is provided.
Purposes and Benefits
The greatest societal advantage from simulations is increased safety for patients. Medical error results in death more frequently than do motor vehicle accidents, AIDS, or breast cancer (Committee on Quality of Health Care in America, Institute of Medicine, 2000). An estimated more than 400,000 adverse drug events occur in hospitals every year, costing tax payers approximately $3.5 billion annually (Committee on Identifying and Preventing Medication Errors, Institute of Medicine, 2007). Although the cause of adverse drug events is multifactorial, human knowledge deficits are considered a major cause. Simulations can reinforce theoretical knowledge and skills by allowing students to practice and then apply the knowledge and skill gained in a safe environment in which they can make mistakes without the cost of human life.
High-fidelity patient simulations are consistent with educational best practices (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005). In a review of high-fidelity simulations used as an educational intervention, this study found more than half of the 100 articles reviewed described simulations as using multiple learning strategies and being consistent with best medical education practices. The review noted repetitive practice of clinical skills as the greatest benefit of simulations. While allowing numerous clinical variations, simulations also allow students to “make, detect, and correct errors without adverse consequences” (Issenberg et al., 2005, p. 10). Simulators provide students with the ability to learn about real-life health care situations while practicing real-life health care skills that are critical to preventing errors. Simulations allow dynamic active learning experiences with defined educational outcomes that can be measured as clinical skill expertise.
According to Jeffries (2006) and Peters, Vissers, and van der Meer (1998), educational purposes supported by simulations include:
- To teach and reinforce theoretical and clinical knowledge.
- To ascertain the level of performance of certain clinical skills and interventions.
- To practice critical thinking skills for the purposes of clinical reasoning.
- To explore alternative clinical decisions in a safe environment.
- To integrate technology.
- To answer research questions.
There are multiple educational benefits that can be noted after implementation of a simulation. Johnson, Zerwic, and Theis (1999) reported that students felt more comfortable making clinical decisions and practicing clinical skills without the pressures of a “real” patient. Students reported increased confidence in their ability to critically think about and apply the theoretical knowledge of their discipline while making multiple clinical decisions within the patient scenario (Johnson et al., 1999). Critical thinking during a clinical scenario serves to reinforce the theoretical learning from the classroom.
Simulation Theoretical Framework and Processes
High-fidelity patient simulators, although relatively new to nursing, do have frameworks to help guide their use in nursing education. Jeffries (2005, 2006), developed a framework for designing, implementing, and evaluating simulations. Based on educational best practices (Chickering & Ehrmann, 1996), the model incorporates the best practice of frequent contact and interaction between faculty and students, sharing and collaboration among students, dynamic active learning techniques, students’ increased time investment in learning, diversity that students bring to the learning environment, and the expectation that students will strive for and obtain the highest academic standards.
Faculty-led debriefing that follows the simulation has been identified as essential to student learning (Chiodo & Flaim, 1993; Dismukes, Gaba, & Howard, 2006; Peters et al., 1998; Stafford, 2005). Debriefing is considered an active reflective process that is preplanned with the use of a debriefing model and the educational objectives of the simulation (Chiodo & Flaim, 1993; Dismukes et al., 2006; Peters et al., 1998; Stafford, 2005). During facilitated debriefing, a faculty member guides the students so the connections between theory and practice are made and critical thinking about the simulation occurs. Students are allowed to express their feelings regarding the experience, as well as their decision process throughout the simulation experiences (Dismukes et al., 2006; Hertel & Millis, 2002; Stafford, 2005).
The importance of applied activities to engage students in learning and to promote critical thinking has been described (Billings, 2005). The interaction between the faculty and students, as well as the sharing and collaboration between the students within dynamically active learning environments, promotes retention of the gained knowledge and skills (Issenberg et al., 2005).
Pharmacology and the Use of Simulation
Pharmacology content remains difficult for most nursing students to master. In pharmacology courses, most students perceive that they memorize large amounts of facts without any practical application; a large disconnect exists between the theoretical knowledge learned in the classroom and the application of such knowledge in clinical practice. King (2004) noted that nurses need to understand therapeutic uses, normal dosages, side effects, precautions, and contraindications when administering medications. Thinking-in-action in clinical settings brings a complex interplay of these factors. Simulations give students the opportunity to apply the knowledge they have learned in a safe environment.
The following case scenario was developed by course faculty and a technological support person to meet the needs of the learning objectives of an undergraduate pharmacology course. The scenario development and simulation process were guided by best practice concepts and noted frameworks. Simulation strategies included integration of technology to reinforce course content knowledge and ascertain the achievement of clinical skills regarding medication administration. METI-man by Medical Educational Technologies, Inc., was the high-fidelity simulator used for this case. METI-man is a highfidelity human patient simulator, a full-bodied interactive manikin that allows faculty to create the interactive simulations. Faculty can choose between using scenarios that come with the simulator or developing and programming their own scenarios.
Scenario objectives consistent with the course objectives served as the foundation for the pharmacologic simulation. Based on the model by Jeffries (2005), the simulation design and process encompassed a standardized patient case scenario, prescenario questions that helped the students prepare for the learning encounter, and a postscenario debriefing.
Pharmacologic Simulation Case Scenario
The following case was implemented with undergraduate students at the beginning of their clinical program. Students are currently in supervised clinicals, in which they have not experienced independent clinical decision making. The scenario in this case was used as a learning tool, with students receiving credit for participation. Seventy-two students completed the scenario. The simulation was completed 12 different times during two independent class periods with groups of 6 students. The scenario was implemented and followed by postscenario debriefing. A faculty member and technology support staff were involved in the simulation session. The faculty member led the debriefing.
Urolithiasis and Narcotic Overdose Case Scenario
The scenario for the simulation was based on narcotic agonist and antagonist content taught in class approximately 4 weeks prior to the simulation. Students were formally tested on the content using a multiple-choice test, which resulted in a high average test score. Students completed the high-fidelity patient simulations at a later date.
The simulation was scheduled during a regular class day. Students were taken into the simulation experience in groups of 6. When not participating in the simulation, students worked on a self-taught learning module. Prior to entering the simulation room, students were given the scenario information, a medication book, and a physician’s phone number. Roles were assigned and explained to the students prior to the start of the simulation. Two students were assigned to be nurses and were responsible for making all clinical decisions. Two students were assigned to be family members and were coached to act like concerned family members. In addition, two students were assigned to serve as observers and watch interactions among members of the simulation.
The students entered a scenario where the simulated patient was experiencing kidney stones and extreme pain. All students who were assigned to be nurses had initial reactions, as evidenced by nonverbal responses and comments, of not knowing what to do and panicking. The students who engaged in the role of family members challenged the nurses to interact with and assist them. While the students interacted with the simulated patient, the faculty sat at the end of the room and observed, without commenting, all of the interactions transpire.
As the scenario unfolded, the nursing students called the physician, who was enacted by the technology support staff member. The physician visited and wrote an order for an excessive dosage of Demerol (meperidine). Without any further questioning, the students administered the large dosage of Demerol every time the scenario was enacted. The simulated patient then began the descent into respiratory depression and bradycardia. Students had to decide to call the physician again, who then gave them a verbal order for Narcan (naloxone). The students administered the Narcan and the patient recovered. The simulation lasted between 20 and 30 minutes for each student group.
The students were then moved to another room, where debriefing occurred. The debriefing discussion for the pharmacology simulation focused on questions related to performance and applied knowledge. The 4-step debriefing model by Chiodo and Flaim (1993) guided the debriefings:
- Experience of the simulation.
- Student inferences.
- Case analysis.
- Comparisons to practice.
Questions in each phase were developed to elicit and identify the differences in learning and experiences from the different roles that the students portrayed. The average debriefing for each student group lasted between 40 and 50 minutes.
In reviewing the various scenario enactments, the greatest difference among the groups was in their ability to care for the patient, interact with family, and make decisions while participating in the scenario. Varying student skill levels were evident. The students also varied in their use of the available resources. Some of the students relied on their learned knowledge, whereas some students used the drug book throughout the scenario. Although unique interactions occurred during each simulation, several of the interactions were repetitive. The most surprising repetitive interaction for the faculty was that all student groups failed to check the Demerol dosage. As noted, these same students had all previously answered classroom test questions indicating knowledge regarding this topic. Another finding discovered during the debriefing was that all of the students felt high levels of anxiety specific to the overdose scenario; they also described relief when follow-up actions were successful. Student comments during the evaluation indicated that they thought they had learned a valuable lesson in a safe environment.
Evaluation of the Simulation
The final step of the simulation was to evaluate the learning process, which was performed using:
- Formal testing.
- Skills testing.
- Reflective writing.
Formal testing included a pretest and a posttest specific to the high-fidelity patient simulations. Although the average pretest score was 80%, the average posttest score increased to 96%. Clinical skills were evaluated through observation and a checklist completed by faculty during the simulation. As part of the posttest, reflective questions were incorporated to ascertain knowledge gain, as well as student satisfaction with the learning experience.
The challenges with implementing the scenario included:
- Simulation development.
- Consistency in implementation.
- Creation of clinical situations within a typical didactic course.
Although the use of prepackaged simulations eases the development time, cases are not available to cover all of the course objectives. A time commitment to developing new cases and supervising the simulation is necessary. In addition, after the initial implementation of the scenario, the potential exists for students to share what has occurred and to influence future scenarios so the simulation is no longer a pure interaction. Also, building a clinical experience into what is usually a didactic course takes creativity; faculty and students must see the value of the applied high-fidelity patient simulation learning experience.
Discussion and Conclusion
High-fidelity patient simulations are consistent with applied, active learning and can assist in developing safe practitioners in a safe setting. A pharmacology simulation provides a new opportunity to help students gain clinical skills in medication administration and to prevent future medication errors. When simulations are based on educational best practices, they use an active, dynamic, and reflective process through which the students learn theoretical and clinical skills (Jeffries, 2006). High-fidelity patient simulations allow students to practice learned knowledge and decide between multiple clinical alternatives during patient care. High-fidelity patient simulations promote opportunities for students to practice newly gained knowledge and can help promote future patient safety.
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