Dr. McKeon is Assistant Professor, Dr. Norris is Professional Entry Program Director, and Ms. Britt is Director of Learning Lab, Tennessee Health Science Center, University of Tennessee Health Science Center, College of Nursing, and Ms. Cardell is Clinical Director, Methodist LeBonheur Children’s Medical Center, Memphis, Tennessee.
This project was supported through a subcontract under a grant from the Robert Wood Johnson Foundation (Grant I.D. #59182).
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Leslie M. McKeon, PhD, Assistant Professor, University of Tennessee Health Science Center, College of Nursing, 877 Madison Avenue, Room 617, Memphis, TN 38163; e-mail: firstname.lastname@example.org.
Improvement in health care of the magnitude to transform practice requires a fundamental change in how health professionals are taught quality improvement and patient safety. Creative teaching approaches coupled with academic and practice partnerships are paramount to bridging gaps in the preparation of nurses and achievement of excellence in the service setting (Herrin, et al., 2006).
The Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007) and The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008) include specific quality and patient safety outcomes that are required of nurse graduates to practice safely and effectively in complex health care systems. Recommended learning strategies to achieve these outcomes include unfolding case scenarios and simulation (AACN, 2009).
This article describes the development of simulations by faculty of the University of Tennessee Health Science Center and nurse leaders at Methodist LeBonheur Healthcare to teach patient-centered care competencies to baccalaureate nursing students through unfolding case scenarios. Pilot results comparing resource efficiency for computer-based simulation and traditional patient simulator training are included.
Health Care Quality and Education
In 1996, the Institute of Medicine (IOM) launched a concerted, ongoing effort focused on assessing and improving the nation’s quality of health care. The first report, To Err Is Human: Building a Safer Health System, concluded the majority of health care errors are caused by faulty systems, processes, and conditions that lead individuals to make or fail to prevent mistakes (IOM, 2000).
The second report, Crossing the Quality Chasm: A New Health System for the 21st Century, concluded the gaps between new technologies and the translation of that knowledge into practice have led to an inability to apply these new technologies safely and effectively (IOM, 2001). Subsequently, policy makers, clinicians, administrators, governing agencies, and consumers were challenged to reform the failing health care system to ensure services met six quality aims: care that is safe, timely, efficient, effective, equitable, and patient-centered.
A third IOM report, Health Professions Education: A Bridge to Quality, found clinicians were not adequately prepared in either academic or continuing education venues to address the complex needs of the nation’s patient population (Greiner & Knebel, 2003). A new vision for clinical education was proposed that encompassed the IOM quality aims so that all health care professionals would be prepared to deliver patient-centered care as members of an interdisciplinary team—emphasizing evidence-based practice, quality improvement approaches, and informatics.
Nursing education responded to the IOM challenge by creating a new set of competency standards developed by nurse academic and practice faculty through an initiative called Quality and Safety Education for Nurses (QSEN). The purpose of this initiative, funded by the Robert Wood Johnson Foundation, is to develop specific quality and safety competencies for nurses in the domains of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007).
In Phase I, QSEN faculty developed standardized definitions for six competencies and proposed statements of the knowledge, skills, and attitudes for each competency that should be developed during prelicensure education. In Phase II, academic-practice partners from 15 pilot schools were charged with formulating strategies for teaching and evaluating these competencies. Similar to QSEN, the American Association of Colleges of Nursing (2008) formed the Essential Patient Safety Competencies for Professional Nursing Care task force to augment The Essentials of Baccalaureate Education for Professional Nursing Practice. One of the nine learning outcomes includes “Basic Organizational and Systems Leadership for Quality Care and Patient Safety” (AACN, 2009, p. 4).
Simulation training is a recommended strategy to teach safe clinical practice, in part because initial learning for health care professionals in a real patient setting is hindered by changes in resources, such as shorter length of patient stay, higher patient acuity, nursing staff shortages, and a greater emphasis on medical errors (Medley & Horne, 2005). In nursing education, simulation is a mainstay for clinical learning (Tanner, 2006), particularly in the areas of safety, problem solving, communication, and team building (Durham & Alden, 2008).
According to Jefferies (2005), successful learning using simulation requires alignment of the design, teaching activities, competencies, and learning outcomes. The case scenario, including simulations of actual clinical problems, provides an interactive learning environment, engaging students in the learning process and encouraging them to make connections between and among concepts. Environmental interactivity and feedback typically is achieved through the use of a high-fidelity patient simulator supplemented with role-play techniques (Good, 2003).
Equipment costs, space availability, and faculty training are primary barriers to using human simulators in clinical education (McCausland, Curran, & Cataldi, 2004; Peteani, 2004; Ravert, 2008). Another barrier is that few students can use this technology simultaneously for effective learning (Nehring & Lashley, 2004). However, even though the use of a high-fidelity patient simulator is not critical for teaching nontechnical quality skills (Finkelman & Kenner, 2007), faculty informally report using human simulators to reinforce these competencies. For nontechnical skill acquisition, such as competencies for patient-centered care, computer-based simulations can be an effective and resource efficient alternative to human simulator scenarios due to their real-world application (Jeffries, 2005) and capability for an unlimited number of students at relatively low cost through online learning experiences (Loving & Siow, 2005).
Computer-based nontechnical skills simulation, known as social simulation, interacts with characters, documents, or images to make decisions that determine what students see next; training occurs through decisions, feedback, coaching, and performance reporting (NexLearn, 2007). Social simulation improves knowledge retention and critical-thinking skills and is tailored to the generation of workers raised as gamers (Decker, Sportsman, Puetz, & Billings, 2008). Current software allows faculty to develop customized simulation without the expertise of an instructional designer, graphic artist, or sophisticated programmer. Software examples include SimWriter, Adobe Captivate (ver. 2.0), and Quandry (ver. 2.3).
The primary aim of this study was to compare the effectiveness and efficiency of computer-based versus traditional manikin-based simulation to facilitate student learning in patient-centered care. If computer-based simulation is found as effective as traditional simulation for teaching nontechnical quality and safety skills, then opportunity exists to enhance achievement of student competencies while reducing financial and workload resources associated with simulation education.
The University of Tennessee Health Science Center-Methodist LeBonheur Healthcare partners were among 15 academic-practice partners selected to participate in phase II of the QSEN project. A pretest-posttest case study design was used to compare simulation learning methods for achievement of six QSEN patient-centered care competencies among baccalaureate nursing students (Table 1). Because the aim of the study was to compare the efficiency and effectiveness of two simulation methods, a control group was not included in the study design.
Table 1: Patient-Centered Care Competencies
The pretest, posttest, and computer-based simulation intervention were created using SimWriter simulation software. For this study, 6 of the 28 patient-centered care competencies were tested. Both the pretest and posttest were 10-minute simulated case studies; specific attributes are described in Table 2 using the 11 dimensions for simulation training defined by Gaba (2004).
Table 2: Patient-Centered Care Simulation Attributes
The pretest centered on a pediatric Hispanic patient in sickle cell crisis; no feedback regarding answer choice was provided to students. The post-test involved an adult intensive care unit patient with a severe closed head injury; feedback with rationale was included in the design.
The pediatric case study served as both the pretest and the structure for the simulation intervention. For the computer-based simulation intervention, Web-based learning resources were embedded in the case study after the decision points. For example, after the scenario on informed consent, information was provided on the hospital-specific policy for obtaining consent for minors, Spanish language consent form, interpretation phone, and Web-based resources for multilingual consent forms for various clinical procedures. For the traditional simulation intervention, similar learning resources were made available in a discrete or oral format.
The case studies were developed using a montage of actual patient events and outcomes. Both case studies started at patient admission and ended at discharge. The case studies included six unfolding scenarios commonly encountered by nurses. The primary interaction was between the clinical director and staff nurse.
Following each scenario was a four-item decision point that tested knowledge related to patient-centered care. Students were instructed to choose the best approach for the situation; the correct (1) and incorrect (3) items were assigned values of 1 and 0, respectively.
Simple character dialogues were used to transition students from one decision point to the next. Events emerged through dialogue, and specific questions were written to assess students’ understanding of patient-centered care and their ability to take appropriate action to ensure optimal patient outcomes.
For example, in one scenario, a hospitalized minor in sickle cell crisis wanted her boyfriend to visit with her until the end of visiting hours, whereas her mother, who did not condone the relationship, wanted the boyfriend barred from visiting unless she was present. Students were challenged to identify the best approach to resolve the conflict given that the patient’s comfort was enhanced by the presence of her boyfriend.
Content validity was established through review by experts in pediatrics, adult acute care, and quality and safety. Test construction experts completed a review of both the pretest and posttest. Revisions were made based on expert recommendations.
A series of design components were applied to “breathe life” into the case studies. Photographs were obtained of existing microsystems to use as a background. Clinical staff were photographed to use as character images displayed throughout the case studies. The script was recorded and converted to MP3 format. Images and audio files were linked to storyboard stages, and simulation intervention materials were embedded into the pediatric case study.
The case studies were tested by faculty and graduate student volunteers; revisions were made to assure clinical fidelity and maximum functionality. Operational details for administering the tests and intervention were finalized, and approval was obtained from the university’s institutional review board.
The study was conducted in 2008; all nursing students were asked to participate in the study. The pretest and simulation intervention was scheduled during the second term of students’ three-term program. The pretest was administered in the pediatric course prior to didactic or clinical coursework, and the simulation intervention was administered near the course end. The posttest was scheduled in the third term in the middle of the acute care course.
The pretest, posttest, and computer-based simulation intervention were scheduled in the computer laboratory to control the learning environment. Students were randomly assigned to a simulation intervention.
The traditional simulation intervention was conducted in the skills laboratory by the nursing laboratory director the same week that computer-based intervention was scheduled. Simulation activities developed by the study team matched the pediatric case study scenarios.
Students were scheduled in groups of eight; all students played the role of the clinical director or staff nurse in one of the six unfolding scenarios. The nursing laboratory director used the scripted scenario to guide interaction between the student actors, human simulator, and other characters identified in the case study. Instructional resources similar to the computer-based simulation, such as the blue interpreter phone, were available to facilitate student learning. Student debriefing occurred immediately after completion of each scenario to discuss decision making related to patient-centered care.
The pretest was completed by all 65 nursing students enrolled in the pediatric course. Thirty-four students completed the computer-based simulation intervention, and 31 students completed the traditional simulation. The posttest was completed by all students in the adult care course; 53 students completed both tests and a simulation. The pretest and computer-based simulation intervention were conducted in the computer laboratory; the posttest was conducted in a student-selected learning environment due to the distracting audio background in the computer laboratory.
There was a significant improvement (p < 0.001) in the overall patient-centered care competency score for all students; no differences in scores were found by simulation intervention (p = 0.972). Table 3 shows the results of student pretest and posttest scores by simulation intervention. Student scores for patient-centered care competencies are shown in the Figure.
Table 3: Student Pretest and Posttest Scores by Simulation Intervention
Figure 1. Nursing Student Scores for PCC Competencies (N = 53).Note. TX = Treatment.
Students reported the computer-based pretest and posttest were a welcome change to written case studies. Students indicated the scenarios were realistic and plausible given what they had experienced in the clinical setting. Several students in the computer-based simulation intervention group complained the dialogue slowed them down and requested that a written script be embedded in the frames for use if desired.
The majority of the study’s development time was spent writing the two case scenarios and respective test questions, and building the simulation. The time administering the computer-based intervention was nominal; embedding the learning resources in the simulation took less than 4 hours. In contrast, the time administering the traditional simulation intervention required 26 faculty hours; the skills laboratory director spent 10 hours to prepare, and the skills laboratory director and another faculty member spent 2 hours teaching for each of the four groups of seven to eight students.
Findings of this pilot study suggest students in both intervention groups achieved similar competencies in patient-centered care. These findings support the assertion that regardless of the simulation method used, the success of a simulation ultimately depends on the ability of faculty to design scenarios that are relevant to the learning outcomes (Comer, 2005) and realistic with multiple learning points (Kyrkjebo, Brattebo, & Smith-Strom, 2006). However, as expected, the computer-based simulation intervention was found to be more resource efficient than the traditional manikin-based method.
Although case scenario and test question development consumed the most faculty time, this time is required regardless of the simulation method and therefore is considered fixed. In addition, building the first patient simulation required a sizable learning curve; however, after the template was developed, the time to build the second case study was approximately 8 hours.
Resources to administer the simulation differed significantly by method. The computer-based intervention required little time to embed electronic learning resources and could be easily added to an electronic learning system for ongoing use. In contrast, administration of the traditional manikin-based simulation required 26 faculty hours and 8 hours of simulation laboratory time for a cohort of 60 students. Moreover, the advantages of computer-based simulation for teaching nontechnical patient safety skills are further enhanced when considering class sizes of 100 or more.
Limitations of this pilot study include a small sample size and a partial analysis of resource consumption for the two simulation interventions. Recommendations include conducting more detailed financial and workload analyses to comparing the efficiency of both interventions. In addition, because of the lag time between the pretest and posttest, other factors contributing to improvement in student patient-centered care scores are unknown. Consequently, inclusion of a control group is recommended to test the efficacy of the intervention in achieving patient-centered care competencies.
Reinventing nursing quality and safety education requires creating a learning system and conditions similar to the clinical microsystem where students can learn and discover, test out new ideas, and attempt to innovate (Batalden, Nelson, Edwards, Godfrey, & Mohr, 2003). To transform care, quality and safety education must be the cornerstone of every clinical course and include opportunities to examine and improve real-life practice problems so nurses are prepared to do their work and to improve it (Batalden & Davidoff, 2007).
Nurse educators in collaboration with clinical leaders can create reliable virtual clinical microsystems through simulation, where students learn essential quality and safety competencies. Computer-based simulation offers great promise as an effective and efficient method for nurses to develop and sustain quality and safety competency for better patient outcomes.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved December 1, 2008, from http://www.aacn.nche.edu/Education/pdf/BaccEssentials08.pdf
- American Association of Colleges of Nursing. (2009). Nurse faculty tool kit for the implementation of the baccalaureate essentials. Retrieved June 13, 2009, from http://www.aacn.nche.edu/Education/pdf/BacEssToolkit.pdf
- Batalden, P. & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare?Quality & Safety in Health Care, 16, 2–3. doi:10.1136/qshc.2006.022046 [CrossRef]
- Batalden, P.B., Nelson, E.C., Edwards, W.H., Godfrey, M.M. & Mohr, J.J. (2003). Microsystems in health care: Part 9: Developing small clinical units to attain peak performance. Joint Commission Journal on Quality and Safety, 29, 575–585.
- Comer, S.K. (2005). Patient care simulations: Role playing to enhance clinical understanding. Nursing Education Perspectives, 26, 357–361.
- Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J. & Mitchell, P. et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
- Decker, S., Sportsman, S., Puetz, L. & Billings, L. (2008). The evolution of simulation and its contribution to competency. The Journal of Continuing Education in Nursing, 39, 74–80. doi:10.3928/00220124-20080201-06 [CrossRef]
- Durham, C.F. & Alden, K.R. (2008). Enhancing patient safety in nursing education through patient simulation. In Hughes, R. (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 3, pp. 221–260). Rockville, MD: Agency for Healthcare Research and Quality.
- Finkelman, A. & Kenner, C. (2007). Teaching IOM: Implications of the IOM reports for nursing education. Silver Spring, MD: American Nurses Association.
- Gaba, D.M. (2004). The future vision of simulation in health care. Quality & Safety in Health Care, 13(Suppl. 1), i2–10. doi:10.1136/qshc.2004.009878 [CrossRef]
- Good, M.L. (2003). Patient simulation for training basic and advanced clinical skills. Medical Education, 37(Suppl. 1), 14–21. doi:10.1046/j.1365-2923.37.s1.6.x [CrossRef]
- Greiner, A.C. & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
- Herrin, D., Hathaway, D., Jacob, S., McKeon, L., Norris, T. & Spears, P. et al. (2006). A model academic-practice partnership. The Journal of Nursing Administration, 36, 547–550. doi:10.1097/00005110-200612000-00002 [CrossRef]
- Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
- Jeffries, P.R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26, 96–103.
- Kyrkjebo, J.M., Brattebo, G. & Smith-Strom, H. (2006). Improving patient safety by using interprofessional simulation training in health professional education. Journal of Interprofessional Care, 20, 507–516. doi:10.1080/13561820600918200 [CrossRef]
- Loving, G.L. & Siow, P. (2005). Use of an online case study template in nursing education. Journal of Nursing Education, 44, 387–388.
- McCausland, L.L., Curran, C.C. & Cataldi, P. (2004). Use of a human simulator for undergraduate nurse education. International Journal of Nursing Education Scholarship, 1(1), Article 23. doi:10.2202/1548-923X.1035 [CrossRef]
- Medley, C.F. & Horne, C. (2005). Using simulation technology for undergraduate nursing education. Journal of Nursing Education, 44, 31–34.
- Nehring, W.M. & Lashley, F.R. (2004). Current use and opinions regarding human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25, 244–248.
- NexLearn. (2007). SimWriter User Guide (Version 2.0). [Computer software manual]. Wichita, KS: Author.
- Peteani, L.A. (2004). Enhancing clinical practice and education with high-fidelity human patient simulators. Nurse Educator, 29, 25–30. doi:10.1097/00006223-200401000-00008 [CrossRef]
- Ravert, P. (2008). Patient simulator sessions and critical thinking. Journal of Nursing Education, 47, 557–562. doi:10.3928/01484834-20081201-06 [CrossRef]
- Tanner, C.A. (2006). The next transformation: Clinical education. Journal of Nursing Education, 45, 99–100.
Patient-Centered Care Competencies
|Elicit patient values and preferences to assess, plan, and evaluate care|
|Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs|
|Assess level of patient’s decisional conflict and provide access to resources|
|Recognize the boundaries of therapeutic relationships|
|Facilitate informed patient consent for care|
|Participate in resolving conflict and building consensus|
Patient-Centered Care Simulation Attributes
|Aim: performance assessment and training|
|Experience level: prelicensure, intermediate level|
|Health care domain: in-hospital|
|Health care discipline: nursing|
|KSAs: patient-centered care|
|Patient age: adolescent or young adult|
|Technology: computer-based case scenario|
|Site: self-selected learning environment|
|Extent of participation: remote viewing with debriefing|
|Feedback: automatic critique|
Student Pretest and Posttest Scores by Simulation Intervention
|Sample Size||Pretest Score||Posttest Score||p|
|All students||53||3.3 (1.2)||4.2 (1.3)||< 0.001|
|Computer-based simulation||29||3.3 (1.3)||4.2 (1.4)||< 0.001|
|Traditional simulation||24||3.4 (1.0)||4.3 (1.3)||< 0.001|