Ms. Hawkins and Ms. Todd are Instructors, and Ms. Manz is Assistant Professor, Creighton University School of Nursing, Omaha, Nebraska.
The authors thank Joan Norris, PhD, RN, FAAN, Mary Parsons, PhD, RN, and Maribeth Hercinger, PhD, RN, for their assistance with the simulation method. They also thank all of the faculty involved in simulation at Creighton School of Nursing and Dean Eleanor Howell, PhD, RN, for her continuous support. The article was presented as a poster at the National Skills Lab Conference, San Antonio, Texas, June 2007.
Address correspondence to Kim Hawkins, MS, APRN, Instructor, Creighton University School of Nursing, Criss II, Office #196C, 2500 California Plaza, Omaha, NE 68178; e-mail: KHawkins@Creighton.edu.
Nurse educators are constantly challenged to create new teaching approaches that foster students’ self-discovery and actively engage them in their own learning (Barr & Tagg, 1995). With the current paradigm shift to student-centered learning, the more traditional methods of teaching, such as lecturing and presentations, are less desirable. High-fidelity simulation offers nurse educators many opportunities to teach using active learning strategies. Traditionally, simulated clinical experiences have been used to demonstrate competence in skill acquisition and assessment techniques and to augment clinical experiences (Nehring & Lashley, 2004). These uses can be seen in a variety of disciplines and are not necessarily unique to nursing. At Creighton University School of Nursing, a process of teaching with simulation that provides students with a comprehensive nursing experience has evolved.
This method of teaching comprises five essential components:
- Case introduction.
- Care plan development.
After a brief case introduction in which all students participate, they are divided into two groups that follow one of two paths. Path A consists of care plan development and simulation. Path B consists of simulation and documentation. The students reconvene as a large group for reflection (Figure). Each path integrates the same components to complete the simulated clinical experience.
Figure. Pathway Through the Simulation Components.
This approach to a simulated learning experience can easily be incorporated into nursing curricula. Nurse educators can adapt it to their specific needs by first selecting a simulated experience. Options for experiences vary in their scope, level of difficulty, and complexity. The best experience is determined by the level of the students, desired outcomes of the experience, and course content. Beginning-level experiences may focus on appropriate assessment and skill techniques, whereas advanced-level experiences may focus more on critical thinking, prioritization of care, and the ability to anticipate patient needs. Regardless of the level of the students or the complexity of the scenario, the amount of time dedicated to the simulated learning experience does not change. Although beginner-level scenarios are less complex, the same amount of time is provided for novice students to complete the components of the simulation. Advanced students, who are more adept with assessment and technical skills, are given the same amount of time to complete the more complex scenario.
All students in the clinical group were provided with an introduction to the specific simulation. This was accomplished in a variety of ways, ranging from minimal information being provided to detailed required readings and focused preparatory questions. If minimal information was desired, the introduction was provided immediately on arrival at the simulation laboratory. In this case, the students did not have a chance to prepare for the content or the skills that were incorporated into the experience. On the other hand, if extensive preparation was desired, case-specific objectives, required readings, and focused critical thinking questions were provided for the students, with enough time for student preparation. Faculty decides which approach was most appropriate on the basis of student level and the learning objectives of the simulation.
Another aspect of case introduction was orienting students to the simulator. If this was the student’s first experience, the orientation may have included information about the location of pulses, the patient’s voice, and the location of supplies. Faculty also provided a brief introduction about the expectations and assumptions of simulation as a learning strategy to facilitate student buy-in (Joyce & Weil, 1996). Buy-in fosters realism, an essential component of critical thinking. When students believed that the simulation mimics a true clinical experience, they assigned worth to it, and therefore were more invested in the learning experience. After the case introduction component was completed, the students were assigned to one of two groups. Students in Path A began with the care plan development, whereas students in Path B moved directly into simulation.
Care Plan Development
In this component, students established expected outcomes on the basis of the provided scenario. Appropriate nursing diagnoses were then developed and prioritized. Stemming from the nursing diagnoses, critical assessments, essential interventions, and appropriate teaching strategies were incorporated into the care plan. Students were encouraged to use the available resources, including textbooks, drug and laboratory resources, and care planning manuals. Later in the experience, the nursing care plan was evaluated and revised.
Students were assigned to specific roles for the simulated clinical experience. These roles included nurse, patient, and family member. As a family member, the student was expected to stimulate critical thinking by asking appropriate questions of those in the role of nurse. The students were also expected to demonstrate an emotional connection and relationship with the patient to enhance realism. As a patient, the student sat in the control room with the instructor, speaking through the voice microphone of the simulator and watching the scenario unfold behind the one-way mirror. The patient was expected to display the appropriate symptoms through answering questions from the nurses, thus indicating their comprehension of the disease process and clinical manifestations involved in the scenario. Usually, two students were assigned as nurses. These students were provided with a brief report and the chart, which included a set of provider’s orders. The nurses are given a brief amount of time to review the chart and discuss their approach to care.
During the enactment of the scenario, students performed assessments and interventions using appropriate techniques and adhering to principles of safety. This adherence was demonstrated through the use of patient identifiers, reading back orders, and standardizing communication using techniques such as SBAR (Situation, Background, Assessment, Recommendations) (Haig, Sutton, & Whittington, 2006). Students were expected to coordinate care with members of the interdisciplinary team through use of professional communication. To facilitate development of a therapeutic relationship with the patient and family members, students demonstrated empathy and use lay terminology in their interactions.
During the experience, faculty played several roles, such as health care provider and respiratory therapy, laboratory, and radiology personnel. Students could call on whichever role was applicable to the situation. These roles were often performed via telephone conversations.
Just as students were required to remain in their assigned roles, it was essential that the faculty remained in their specific roles. If the faculty stepped out of character and interrupted the scenario, student learning was stifled. According to the simulation model of teaching by Joyce and Weil (1996), students learned more from their own experiences than from verbal instruction. This required faculty to allow students to make mistakes and learn from the natural consequences of their actions. Because situations were bound to arise during the scenario in which students needed guidance and clarification, faculty functioned in the role of the charge nurse, mimicking how charge nurses are resources for floor nurses. When a student called the charge nurse, the faculty entered the simulation room in that role and acted accordingly. The goal of the charge nurse was to foster student learning by facilitating critical thinking appropriate to the situation. The student should not have been rescued and given the answer to the problem. After students in Path B completed the scenario, they progressed to documentation. Students in Path A, who were in care plan development, now proceeded to simulation.
During the documentation component, various methods were used to fulfill multiple objectives. Students practiced documenting assessments and interventions. This was accomplished in a variety of ways, such as narrative notes, preprinted flow-sheets, or computer charting. Another objective was for students to learn how to give a thorough, accurate, and succinct report. Therefore, students were encouraged to write and verbalize an end-of-shift summary. Principles of safety were again emphasized through the use of accurate documentation of verbal orders obtained during the scenario. Finally, students were required to critique and modify the care plan developed by the students in Path A during the care plan development. This was done through evaluating assessments, interventions, and patient outcomes. If outcomes were not met, the care plan was modified accordingly. After this step, students in both Path A and Path B reconvened as a group to reflect on the simulated clinical experience.
Reflection has been identified as a critical element of simulated clinical experiences (Bremner, Aduddell, Bennett, & VanGeest, 2006). Reflection must be a student-centered group discussion with active participation from each member. One of the primary goals of reflection was identification of strengths and areas for improvement. For example, the group was asked questions such as: “What went well?” or “What could have been done differently?” to stimulate discussion. Another focus of discussion involved examination and critical review of the pathophysiology, nursing care, and therapeutic effects of medications administered during the simulation. Through the use of prompts, faculty guided the students through this process. Emotions experienced throughout the simulation were reflected on and also examined to incorporate affective learning. Finally, students were encouraged to compare the simulation to real-world experiences.
The faculty’s method of teaching simulation provided an opportunity for a comprehensive learning experience through the components of case introduction, care plan development, simulation, documentation, and reflection. This model maximized available time and resources. It also allowed for continuity by maintaining student groups with their same clinical faculty for the simulation. Faculty were able to observe and critically analyze student understanding and performance simultaneously; whereas in the clinical experience, time with individual students was often limited. Also, in this model of teaching simulation, no moment was idle. Each moment was filled with learning activities that emphasized different objectives; therefore, student learning was dynamic and continuous. With the many challenges nurse educators face today, this method provided an innovative approach to teaching simulation that can be easily adapted into nursing curricula.
The majority of faculty responded positively to the implementation of this teaching strategy. One of the greatest benefits was that this method provided a framework for developing and implementing simulated learning experiences. Faculty who are new to simulation have found it especially helpful as they face the challenges inherent to implementing a new teaching strategy. Even experienced faculty commented on the richness that this method brings to simulation. Rather than an isolated simulation followed by a debriefing, this experience allowed faculty to incorporate a more thorough approach to patient care.
Throughout the development and use of this method of teaching with simulation, several lessons were learned. First, thorough planning by faculty was essential to a successful experience. Thorough planning involved structuring the simulation, anticipating questions and caveats, and orienting new or contracted faculty to the simulation. Time invested in initial planning resulted in a richer learning experience, and subsequent experiences were less time intensive for faculty. Second, buy-in by both students and faculty was a critical component to make the experience more meaningful. Strategies for faculty to increase student buy-in included comprehensive and thorough planning, role modeling, and inclusion of the student’s performance into their clinical evaluation. Strategies to improve faculty buy-in included orientation to this teaching-learning strategy and hands-on experience with the simulator. Third, there was a level of comfort that had to be established to use high-fidelity simulation. As faculty became more familiar with this teaching method, comfort levels increased. Similarly, as students had repeated experience with the simulator throughout their nursing education, they also established a higher level of comfort. Finally, the importance of an assistant who could prepare the simulation room and run the simulation from a technological standpoint could not be understated. This allowed faculty the freedom to truly evaluate and teach students.
One of the goals in developing this method of teaching with simulation was to have students follow one of two paths through the simulated clinical experience and still achieve the same outcomes. Future efforts will be directed toward evaluating whether the same outcomes are achieved and whether the order of the path that the students take affects the outcomes, as well as the students’ perception of the learning experience as a whole.
Nurse educators face many challenges in today’s educational and health care environment. This simulation pedagogy provides an innovative method for teaching with high-fidelity simulation, while maximizing the use of available resources. This unique method of teaching through simulation and reflection goes beyond skill acquisition to a more holistic nursing experience.
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