Ms. Curtin is Clinical Coordinator for Nursing, Baker College of Flint, and Ms. Dupuis is Adjunct Faculty, University of Michigan, and Partner, Dupuis and Whaite Nursing Education Consultants, LLC, Flint, Michigan.
The authors thank Baker College of Flint for its steadfast support in developing the authors’ simulation program. They also thank the Jewell Education Fund.
Address correspondence to Michelle M. Curtin, BSN, RN, Clinical Coordinator for Nursing, Baker College of Flint, 5377 Apple-hill Court, Flushing, MI 48433; or Michelle Denise Dupuis, MS, RN, 10090 Chestnut Ridge, Holly, MI 48442; e-mail: Michelle.email@example.com or firstname.lastname@example.org.
Simulation in nursing education is gaining momentum (Childs & Sepples, 2006; Jeffries, 2005; Larew, Lessans, Spunt, Foster, & Covington, 2006; Medley & Horne, 2005; Nehring, Lashley, & Ellis, 2002). Nursing programs are turning to the technology of human patient simulation (HPS) to engage students in creative learning, while providing a safe environment for students to learn and make mistakes (Jeffries, 2007). Simulation can be used to acquire new knowledge and provide an opportunity to apply knowledge in a variety of situations (Jeffries, 2007). According to Jeffries (2005), simulation can increase students’ critical thinking, decision making, and problem solving skills. Simulation can also provide students with an opportunity to work through situations they may not experience during their clinical rotations. It can be used to prepare students for intensive care units and emergency department experiences (Spunt, Foster, & Adams, 2004). In addition, according to Jeffries (2007), when students participate in simulation, they benefit from four learning styles: visual, auditory, tactile, and kinesthetic. Simulation brings theory to life.
To develop a simulation program, quality scenarios must be designed and integrated into the curriculum. Nursing research has recently provided evidence-based models for implementation of high technology simulation (Seropian, Brown, Gavilanes, & Drigger, 2004). Although models for implementation exist, limited information is available about adopting high-technology simulation when cost and resources are significant barriers. This article describes how a nursing program, faced with these challenges, successfully purchased and integrated simulation into the curriculum.
For this program, the cost of a high-fidelity simulator with accessories, renovations to an existing nursing laboratory, and special training for nursing faculty was prohibitive. Fortunately, that fall, the college awarded grants of up to $20,000 for the implementation of innovative teaching projects out of the scope of the standard budget. The challenge was to develop quality simulation for less than $20,000.
The Laerdal Nursing Anne Vital-Sim™ Advanced, a demonstration model with an extended warranty, proved to be affordable. In addition, the Nursing Anne VitalSim unit and the remote control can be stored on a small shelf at the bedside; a separate room and added security is not needed. Further cost-reduction strategies included the use of an existing bed in the laboratory for the simulation unit and installation of a fully functional training headwall to simulate the look of a critical care area. A refurbished, triple-channel pump was purchased and a red tool chest was equipped with donated emergency medications. Miscellaneous supplies required for simulation were available in the laboratory, including intravenous and blood solutions, a cardiac monitor, and basic emergency supplies.
According to Nehring and Lashley (2004), the fear of complicated technology is a common factor in resistance to the use of simulation as a teaching method. A medium-fidelity HPS can eliminate this problem. The Laerdal manager for health care and medical education visited the college and taught faculty how to use and maintain the simulator. After a brief orientation, the faculty thought they were acclimated to the simulator, resulting in frequent use. The Nursing Anne VitalSim unit is used in simulation laboratories to teach everything from basic assessment to advanced critical thinking. In addition, a small group of faculty was taught to program scenarios. This service is provided by Laerdal with the purchase of the simulator. Three faculty members interested in simulation and who have current clinical experience continue to develop scenarios and support the use of the simulator. This support is an important component for success and longevity (Medley & Horne, 2005).
The use of low-fidelity manikins in the program made progression to a medium-fidelity simulation manikin a natural transition. Multiple simulations were designed to apply advanced medical-surgical theory to a complex scenario. According to the literature, the complexity of simulation should be suited to the students’ level of knowledge (Jeffries, 2007). Students in an advanced medical-surgical rotation collected and analyzed data and established priorities for patients with rapidly changing conditions. Students were also expected to select, implement, and evaluate appropriate interventions.
Implementation of simulation using a medium-fidelity manikin requires a certain level of ingenuity. Four students attended the laboratory and participated in two scenarios. The 3-hour simulation laboratory accounted for some advanced medical-surgical clinical time. When students arrived at the simulation laboratory, they were oriented to the setting, equipment, and simulation objectives. Students were already familiar with the simulation manikin. Every attempt was made to make the students feel relaxed and to create an atmosphere conducive to learning. In addition, collaboration was strongly encouraged. The simulation was not graded.
Two nurse educators facilitated the simulation. The first disseminated data from the simulation template (chart) regarding the patient, family, and other members of the interdisciplinary team. Students had to ask for relevant information. The second educator controlled the simulator and modified the settings to reflect changes in the patient condition. This improvisation method provided the freedom to change the direction of the scenario (Jeffries, 2007). A poster board was used as an interactive tool to display data such as laboratory results and physician orders. A dry erase board was used for recording data and allowed all of the students to visualize the data used to prioritize and problem solve during the simulation.
Each simulation scenario was designed using three levels, each representing a decline in the patient’s condition. At each level, principles of guided reflection were used. Clinical reasoning skills were developed through focused questioning and thinking out loud. The scenario was paused while the students collaborated and developed an appropriate plan. This technique was referred to as reflection-in-action (Jeffries, 2007). The momentum of the simulation varied depending on how quickly students met the required competencies. After the scenario was completed, the group engaged in reflection-on-action, a form of debriefing, using scripted questions adapted from Jeffries (2007).
Implementation of this simulation method has resulted in positive feedback from students. Students reported that the simulation modeled real experiences in the clinical setting. Later, when asked to perform a mock emergency during employment orientation, students felt they performed better than other novice nurses. In addition, students felt better prepared to identify changes in a patient’s condition. They also identified an increase in confidence, which eased their transition into the workforce. Students also reported that they thoroughly enjoyed the simulation experience. Comments such as “love it,” “learned a ton,” “had fun learning,” and “felt real” indicated that satisfaction with this teaching method is an important component to learning.
This article describes creative ways to remove barriers and develop quality simulation on a small budget. Both faculty and students continue to enjoy learning through simulation. Simulation is an innovative way to teach and learn. A small investment resulted in a big return. Be innovative, use the resources already available, and become a champion for simulation. It is worth the effort.
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