Dr. Parsh is Assistant Professor, Division of Nursing, California State University, Sacramento, Sacramento, California.
The author has no financial or proprietary interest in the materials presented herein.
The author thanks the University of San Francisco and Susan Evans, EdD.
Address correspondence to Bridget Parsh, EdD, RN, Assistant Professor, Division of Nursing, California State University, Sacramento, 6000 J Street, Sacramento, CA 95819-6096; e-mail: email@example.com.
With improvements in technology, and the shortages of clinical placements, many universities have begun using the simulated clinical experience (SCE) as an adjunct or substitute to the clinical practicum (Alinier, Hunt, Gordon, & Harwood, 2006; Lusk, Winne, & DeLeskey, 2007). The SCE mimics the reality of a clinical environment to demonstrate procedures, facilitate decision making, and encourage critical thinking (Jeffries, 2005). Using a high-fidelity patient simulator, or human patient simulator, the SCE allows students to practice real-life nursing care in a simulated clinical environment. Recent research reports that the SCE helps students learn and builds their self-confidence (Bremner, Aduddell, & Amason, 2008; Feingold, Calaluce, & Kallen, 2004; Rhodes & Curran, 2005).
Currently, 63% of California nursing programs use an SCE and 75% plan to expand their use (Waneka & Spetz, 2006). The majority of these programs use the SCE to check clinical competencies and provide clinical experiences not available in a traditional clinical setting. Within the next few years, it is expected that increasing numbers of nursing programs will use this technology (Jeffries, 2006; National Council of State Boards of Nursing, 2005; Nehring, Ellis, & Lashley, 2001).
Although nursing clinical faculty play a pivotal role in supporting students during clinical practicum (Gillespie, 2002; Poorman, Webb, & Mastorovich, 2002; Tsai & Tsai, 2004), the characteristics of effective instructors in the SCE have not been investigated. Research suggests clinical nursing instructors have a great influence on the nursing students under their charge (Knox & Mogan, 1985; Medley & Horne, 2005; Poorman et al., 2002). In the SCE, students are actively involved in using previous knowledge to provide the best care possible to the patient in the simulation. Instructors play an essential role in facilitating these simulations, supporting the learning activities, and assisting students to process their learning in debrief sessions (Johnson, Zerwic, & Theis, 1999). Poorly planned and badly executed simulations without proper equipment or instructions are not effective (Prion, 2008). For these reasons, it is essential to identify the characteristics of effective clinical instructors in the SCE in advancing nursing education (Mogan & Knox, 1987; Stafford & Graves, 1978).
Recent research reports that the SCE helps students learn and builds their self-confidence (Bremner et al., 2008; Feingold et al., 2004; Rhodes & Curran, 2005). Using the SCE, students can get hands-on learning in a risk-free environment, without requiring a clinical placement site. Maximizing the effectiveness of the SCE is essential for nursing education.
Although nursing clinical faculty play a pivotal role in supporting students during clinical practicum (Gillespie, 2002; Poorman et al., 2002; Tsai & Tsai, 2004), the characteristics of effective instructors in the SCE have not been investigated. The purpose of this case study was to investigate nursing student and clinical instructor perceptions of effective clinical instructors in the SCE.
In brief interviews, nursing students (N = 8) and SCE instructors (N = 3) from two Northern California universities were asked three open-ended questions by the researcher about the characteristics of effective clinical instructors in the SCE. Participants were given the option of face-to-face, telephone, or e-mail interviews. Anonymity was assured by the researcher. The following questions were asked:
- Are there characteristics of effective instructors that are similar between the simulated clinical experience and the traditional clinical practicum?
- Are there characteristics of effective instructors that are different between simulated clinical experience and the traditional clinical practicum?
- Is there anything you would like to add about the role of instructors in the SCE compared with traditional clinical practicum?
Eight students and three SCE instructors participated in the interviews. Telephone and face-to-face interviews were recorded, transcribed, and content analyzed by the researcher. The interview findings will be discussed by themes, which emerged during the interviews.
According to the students who participated in the follow-up interviews, characteristics in the Personality category, such as patience, respect, and support, were important, especially when covering unfamiliar topics. Students described effective instructors as “understanding that students are new to the profession” and “having patience as they try to grasp new concepts and gain proficiency in complicated skills.” Several students indicated that effective instructors in the SCE “listen to students,” “demonstrate understanding,” and “have a love of teaching.” One student described the instructor-student relationship in this way:
The teachers I have found that are successful as SCE instructors are more positive, have less of an egocentric attitude, [and] do not treat students as ‘their students.’ These instructors are more like participants in the students’ success.
Another student stated effective SCE instructors:
give more of themselves, engage the students, care more for the students and their struggles, and make students feel as if our presence is beneficial to them.
Several students mentioned that effective SCE instructors share their time, experiences, and enthusiasm.
“Being able to guide students during patient care” was mentioned by students as important in both the SCE and the clinical setting. One student said:
Both groups of instructors must be able to explain anatomy, physiology and the pathophysiology of a disease at a level that is not overwhelming for the student. This way the explanations and outcomes are easier to remember.
SCE instructors are effective if they:
can gently guide the student towards the next step without giving out the answers or taking over tasks when the student is in doubt of what to do.
In describing the differences between the traditional clinical instructor and the SCE instructor, one student stated:
In clinical, the instructor is not always with the student. They may walk a student through a procedure the first time, but not the second time.
Another student said, “In clinical, we are on our own a lot, which leaves us kind of stuck.” In another interview, a student stated:
Clinical instructors have lots of other students to work with and do not always know what students are thinking since they are not always there.
Because the SCE is meant to be similar to an actual scenario, one student said:
The same characteristics that make for an effective clinical instructor are equal to those that make for an effective SCE instructor.
Several interview participants described the SCE as more of a “learning ground” for basic questions and experimentation, whereas the clinical area is a place to perform and to be evaluated. Students felt that the instructor is valuable in both learning environments. One student said:
In both settings, instructors help us build a foundation of knowledge for when we enter the real world of nursing. They are highly important for our learning and, when effective, contribute greatly to our success.
Critical thinking development is essential in both the SCE and the clinical practicum, so providing a supportive, positive environment can facilitate learning in both areas (Dunn & Hansford, 1997; O’Connor, 2001; Poorman et al., 2002). Student success was a common theme among the interviews. One student stated:
Good SCE instructors give positive, direct, and energetic responses to students participation, and seem to truly want the students to succeed.
Several students discussed the differences between the nursing setting of the traditional clinical practicum and the SCE. One student stated:
In clinical, there are more variables to consider. We can’t just talk anywhere. We need to consider the location, the patient, the patients’ feelings, [and] the surroundings. Are we talking in front of the patient? In the [laboratory], we don’t have to consider the patients’ feelings. It’s very straightforward.
Another student stated:
In the SCE, the instructors can slow down and take time to explain more in front of the ‘patient’. In clinical, it seems the instructors are there to keep students safe and answer questions as they arise during the shift.
Another common topic mentioned by students was that “instructors need to adapt” to unexpected events in the traditional clinical practicum. One student said:
I think that the instructors of the traditional clinical practicum are forced to think on their feet more. In the clinical experience every patient is different and both the student and instructor may see and/or hear things that they haven’t experienced before.
Students discussed the relationship differences between the instructor and students in the SCE and traditional clinical setting. In contrast to the traditional clinical practicum, the SCE instructor “has developed the scenario and knows where they are leading the students.” Effective SCE instructors:
engage the whole group of students in formulating decisions. This helps students feel more confident in clinical situations, engages students in critical thinking more effectively, and makes instructors and students feel as if they are part of a team rather than just a student who is striving to succeed all alone.
Effective SCE instructors also:
give more thorough explanations, discuss pathophysiology, and are looking for more technical answers from students.
One student said:
To me, a good analogy would be a supervisor (the practicum instructor) who oversees your work with less engagement compared to a sports coach (SCE instructor) who engages all of its members and wants the whole team to succeed.
Students mentioned the realism of SCE as both a positive and a negative feature. One student commented:
In the hospital, we can truly see the patient decompensate. In the SCE, we can only hear the lung sounds getting worse, or see the numbers dropping on the monitor. In the hospital, there is more environmental information to help us put things together.
Another student said:
I thoroughly enjoyed all of the SCE experiences that I’ve been a part of over the semesters. However, I feel that nothing surpasses the learning experience of working with real patients and all of the variances that entails.
SCE Instructor Interviews
All three SCE instructors emphasized the need for constructive student Evaluation during the SCE. One instructor said:
The SCE instructors must be trained in giving specific detailed feedback on skills and critical thinking.
Another instructor stated:
Giving feedback is crucial. Going back and redoing a simulation in which the student has made a big error is crucial so that the student learns to interpret the data and to respond correctly, but also so they leave feeling that they can do it right!
The instructors agreed that both the traditional clinical and the SCE require instructors with high standards who need to communicate their expectations clearly. Instructors felt it important to hold students accountable for their actions and give immediate feedback in both the SCE and the traditional clinical practicum.
Instructors mentioned that clinical instructors in both settings must be current on practice skills, have an expertise in bedside nursing, and have a foundational base of critical thinking. One instructor said:
Like in the traditional clinical setting, an unprepared instructor in a simulation setting can be deadly. It may be a different kind of deadly, but if students don’t learn nursing skills correctly, it can have an effect on real patients in the hospital.
Only one instructor identified the importance of instructor Personality in the SCE. The instructor stated:
I think the simulation instructor must have a sense of humor, make the learning fun, and engage the student.
Although only one instructor mentioned this category, the importance of Personality has been identified by previous research (Allison-Jones & Hirt, 2004
; Mogan & Knox, 1983
The instructors identified the need for SCE instructors to allow students to make independent decisions without taking over to correct any “would-be” errors. SCE instructors must have the skills to assess the learning needs of students. One instructor said:
SCE instructors must have skills in being quiet and letting students work through their own problems.
At the end of the scenario, the SCE instructor debriefs students about their actions to “move students to higher order thinking and skill.”
SCE instructors identified an ability to work with technology to design and run the scenarios as important. Because this study is the first to use the Nursing Clinical Teaching Effectiveness Inventory with students and instructors in the SCE, technology is a unique category, previously unidentified as important for effective clinical instructors. All of the instructors interviewed discussed the need for Technological Skills. One instructor said:
In the hospital setting today, nurses must feel comfortable with computers to do charting. In the SCE, instructors have to understand computers in order to set up the programs.
Training in how to run simulations was deemed important for effective instructors in the SCE. Another instructor stated:
I do believe the work in the SCE is comparable to the clinical setting if it has been orchestrated well.
This finding has implications for future research regarding effective instructors in the SCE.
Students discussed six areas in the open-ended interviews: Personality, Teaching Ability, Evaluation, Nursing Competence, Interpersonal Relationships, and Realism. The students addressed the issue of Realism as a difference between the traditional clinical area and the SCE. Previous studies have suggested that the SCE learning environment can have a powerful effect on self-confidence, self-efficacy, and satisfaction with learning (Bremner et al., 2008; Feingold et al., 2004; Foster, Sheriff, & Cheney, 2008). The results of the current study support these findings. Interviews suggest that students would like SCE instructors to be partners with them in the learning process while providing support through their decision making. Student interview participants appreciate the combination of instructor guidance and student independence in the SCE.
During the open-ended interview, instructors discussed characteristics of effective and ineffective faculty in the SCE. Faculty discussed five areas during the interviews: Evaluation, Nursing Competence, Personality, Teaching Ability, and Technological Skills. Technological Skills includes such characteristics as computer skills, designing scenarios, and manipulating equipment. A study by Rhodes and Curran (2005) suggested that the SCE may increase the time and workload of faculty members to design the scenario and to provide content validity. Interviews with instructors support the belief that SCE instruction requires some expertise in technology to work with the equipment, design the scenarios, and coordinate the experience for the students.
The SCE provides a realistic environment for students, fosters improved learning of nursing procedures, and increases student confidence and satisfaction (Alinier et al., 2006; Foster, Sheriff, & Cheney, 2008; Grady, Kehrer, Trusty, Entin, Entin, & Brunye, 2008; Schoening, Sittner, & Todd, 2006). Led by an effective instructor, student knowledge acquisition and clinical judgment skills can be developed. Although these findings should be viewed with caution, the need to prepare instructors to teach in this new nursing education environment, the SCE, is apparent. Continued research to maximize this resource for future nurses is essential.
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