Journal of Nursing Education

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Major Articles 

Expanding Simulation to Teach Family Nursing

Sandra K. Eggenberger, PhD, RN; Mary Regan, PhD, RN

Abstract

Caring for families during an illness experience is increasingly recognized as a core of nursing practice. Yet research reports deficiencies in the current state of family nursing care. It is possible that these deficiencies are rooted in a lack of integrating family care throughout nursing education and a focus on the biomedical science paradigm. As a relational skill, family care requires different pedagogical approaches to effectively teach family nursing. Simulation is one such approach. Even though simulation is rapidly moving into nursing education, the primary focus is teaching psychomotor nursing skills, rather than caring and family nursing.

Abstract

Caring for families during an illness experience is increasingly recognized as a core of nursing practice. Yet research reports deficiencies in the current state of family nursing care. It is possible that these deficiencies are rooted in a lack of integrating family care throughout nursing education and a focus on the biomedical science paradigm. As a relational skill, family care requires different pedagogical approaches to effectively teach family nursing. Simulation is one such approach. Even though simulation is rapidly moving into nursing education, the primary focus is teaching psychomotor nursing skills, rather than caring and family nursing.

Dr. Eggenberger is Professor and Director of Glen Taylor Nursing Institute for Family and Society, School of Nursing, Minnesota State University Mankato, Mankato, Minnesota; and Dr. Regan is Assistant Professor, University of Maryland’s School of Nursing, Baltimore, Maryland.

This project was supported by funds from Minnesota State Colleges & Universities, under the Academic Innovations RFP 5 Grant mechanism. The information and conclusions are those of the authors and should not be construed as the official position or policy of Minnesota State Colleges and Universities.

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank the graduate students enrolled in the nurse educator program at Minnesota State University, Mankato, who participated in the design, implementation, and evaluation of the simulation experiences.

Address correspondence to Sandra Eggenberger, PhD, RN, Professor and Director of Glen Taylor Nursing Institute for Family and Society, 360 Wissink Hall, Minnesota State University Mankato, Mankato, MN 56001; e-mail: sandra.eggenberger@mnsu.edu.

Received: December 21, 2009
Accepted: February 10, 2010
Posted Online: June 30, 2010

Caring for families during an illness experience is a vital aspect of nursing practice (Denham, 2003; Wright & Bell, 2009; Wright & Leahey, 2009). There is a growing awareness that nurses need to be competent in developing collaborative nurse-family relationships (Astedt-Kurki, Paavilainen, Tammentie, & Paunonen-Il-monen, 2001a, 2001b; Hupcey, 1998; Soderstrom, Benzein, & Saveman, 2003; Wright & Leahey, 2009). Family scholars call for a commitment to family care (Wright & Leahey, 2009) in response to research findings that highlight the significance of the family to the health and well-being of individual members, as well as the influence of a family member’s illness on the family (Paavilainen, Seppanen, & Astedt-Kurki, 2001; Weihs, Fisher, & Baird, 2002). Despite increasing knowledge of the importance of family nursing, research continues to report deficiencies in the current state of family nursing practice (Chesla & Stannard, 1997; Engstrom & Soderberg, 2007; Hupcey, 1998; Soderstrom et al., 2003). It is possible that these deficiencies are rooted in a lack of formal education about family nursing in curricula. This is further compounded because teaching family nursing demands pedagogical approaches that endorse the principles of family caring in health care settings.

A pedagogy is a particular approach to education that addresses the art and science of teaching learning (Bastable, 2008; Diekelmann, 2003; Young & Paterson, 2007). Examples of pedagogies include Freire’s Critical Pedagogy, feminist pedagogy, and narrative pedagogies (Billings & Halstead, 2009) that emerge from divergent premises. Pedagogies encompass a set of synergistic teaching strategies that lead the learner to a specified endpoint in thinking or acquisition of knowledge (Billings & Halstead, 2009). In nursing, that endpoint is often called clinical competence (Klein, 2006; Klein & Fowles, 2009), even though the conceptualization and measurement of competence in nursing practice remains somewhat elusive (Gaberson & Oermann, 2007).

Competency is frequently viewed from a behaviorist paradigm that focuses on performance in the domain of a task (Billings & Halstead, 2009; Klein, 2006). Yet competence in nursing is greater than the ability to fluidly perform tasks; it is about being able to “do that” (Benner, 1983, p. 38) while simultaneously “engaging with [people] and living the knowledge” (Brown & Hartrick Doane, 2008, pp. 99–100) in “relational practices” (Doane, 2002, p. 400; Tapp, 2000). This duality of nursing practice has given rise to renewed interest in caring approaches such as family care. Family care has gained recognition in recent decades because it represents a core of nursing practice that has not received equal time to the biomedical science paradigm within the educational process (Lewis, Rogers, & Naef, 2006). Furthermore, research has demonstrated that the caring aspect of nursing, when done well, has a profound effect on health outcomes (Benner & Wrubel, 1989; Benner, Tanner, & Chesla, 1998). Therefore, if nursing is equally about caring and relationships as it is the tasks, then our educational approaches must reflect the teaching of caring processes of family nursing.

As a relational skill, family care requires different pedagogical approaches to effectively teach family nursing. Simulation is one such approach. Although simulation is rapidly being moved into nursing education (Billings & Halstead, 2009; Jeffries, 2007; Rothgeb, 2008), the primary focus of this approach has been to teach psychomotor nursing skills, rather than caring actions (Eggenberger & Keller, 2008) and family nursing. However, simulation is a pedagogical approach that has potential for educating nurses about this type of practice. Simulation provides a safe environment where students may experience the influence that family care can have on ill clients and their families. It also allows an opportunity to critique their ability to initiate family-nurse relationships and implement actions that support a family. Given the evolving body of knowledge advancing the nursing care of families during the illness experience, the question arises of how nurse educators can capitalize on the potential that simulation offers to teach family care.

This article describes a pedagogical approach focused on teaching family care. This approach recognized simulation as a successful technique for teaching psychomotor skills and expanded it to teaching integrated clinical reasoning with high-fidelity simulations that blended psychomotor skills and family nursing care with a critique of practice. It is presented here as a means to provide a systematic approach that develops relational competency central to family care. The strength of this approach lies in its expansion of simulation beyond the current state of emphasizing psychomotor skills to embrace caring—the vital core of nursing. This approach to simulation can bridge the worlds of technology and caring (Locsin, 2008) by placing a family in the center of a hospitalized individual’s illness experience with needs for nursing care.

Literature Review

Teaching Family Nursing

Family research identifies the need for nursing care to support a family coping with an illness and navigating the complexities of the health care setting (Chesla, 2005; Meiers & Tomlinson, 2003; Paul & Rattray, 2008; Vandall-Walker, Jensen, & Oberle, 2007). Families seek to partner with a nurse who includes them in the care of their loved one (Eggenberger & Nelms, 2007) and creates a nurse-family connection to begin therapeutic conversations (Wright & Bell, 2009; Wright & Leahey, 2009). However, research reveals deficiencies in family nursing care, as nurses often fail to support and interact with families during illness experiences (Engstrom & Soderberg, 2008; Soderstrom et al., 2003; Stayt, 2007). Despite the awareness of concerns related to family nursing practice, only limited literature exists regarding feasible and effective teaching approaches that could advance family nursing. Literature that focuses on strategies to teach family nursing in undergraduate nursing courses becomes increasingly sparse when one searches for educational approaches to teaching family nursing using simulation.

In recent decades, some family scholars have explored the core knowledge needed to effectively teach family nursing. Bell (1997) described the what, when, and where related to teaching family nursing theory, skills, and knowledge in undergraduate curricula. In her work, she emphasized a need to focus on the relationship between nursing and family in a variety of contexts during the fourth year of an undergraduate curriculum. Therapeutic conversations with families experiencing an illness were also identified as an essential practice in nursing courses. Family interventions of commending the family, offering information, validating responses, and encouraging the telling of illness narrative have been described in the Calgary Family Intervention Model (Wright & Leahey, 2009).

Developing these relational practices in nursing students creates a context for providing family nursing care (Wright & Bell, 2009). Development of family nursing skills in an undergraduate curriculum has been described in the nursing literature (Tapp, Moules, Bell, & Wright, 1997). A family skills laboratory was created as a setting where students could practice family interview skills, conduct family assessments, and engage in family conversations through role-playing. Student evaluation of the laboratory experience was positive and highlighted their increased confidence, knowledge, and skills of aspects related to family nursing. Moules and Tapp (2003) further described innovations in a family skills laboratory experience that created more experiential and interactive learning strategies in nature. Actual families participated in a clinical laboratory experience designed to teach graduate students the family nursing skills of interviewing and intervening. This study found the family nursing clinical laboratory to be a safe learning environment that increased students’ confidence in family interviewing and intervening (Flowers, St. John, & Bell, 2008).

Supervision of nursing students has been identified as an important element in developing competence in family nursing (Wright, 1994). However, supervision within the context of nursing education has been used predominantly for the acquisition of psychomotor skills and clinical judgment skills (Hodson-Carlton, 2009; Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008; Roberts, Vignato, Moore, & Madden, 2009). Nurse educators have devoted countless hours to supervising nursing students as they practice dressing changes, catheter insertions, and vital sign monitoring, among other skills. Extensive literature (Billings & Halstead, 2009; Gaberson & Oermann, 2007) describes teaching strategies related to psychomotor skills; however, the lack of literature devoted to family nursing skills suggests it is seldom a core part of nursing curricula. This is indicated by relatively infrequent observation of family nursing skills.

Teaching Family Nursing in Health Care Settings

Despite the recognition by nurse educators of a need to provide learning experiences in the work of family care, the realities of the current clinical setting and educational barriers often halt the charge. Safety of the acutely ill patient must remain a priority of the student and the faculty (Gaberson & Oermann, 2007), which often makes attention to family skills a lesser priority. Not only are clients acutely ill in the hospital setting, nursing practice in the hospital setting often views the family contextual to the ill patient (Gilliss, 1991; Harmon-Hanson, Gedaly-Duff, & Kaakinen, 2005), and faculty cannot always create a family experience during a student’s assigned clinical hours (Oermann & Gaberson, 2009). Furthermore, one clinical educator is supervising 8 to 10 students (Billings & Halstead, 2009), which often constrains the ability to observe a family-nurse interaction, however limited it may be. There may also be a shortage of nurses to offer additional support to faculty or students (Gaberson & Oermann, 2007). Student anxiety in the current context of a demanding hospital setting can make it even more difficult for a faculty member and student to focus on learning, much less on family nursing care (Gaberson & Oermann, 2007).

In response to these limitations, simulation has rapidly emerged on the forefront of nursing education as a pedagogical strategy to address clinical education (Campbell, 2007; Jeffries, 2005; Nehring & Lashley, 2004). Simulation has been described as an event or situation constructed to reflect the clinical environment to teach clinical procedures and critical thinking (Jeffries, 2005). Students actively engage in clinical situations within the confines of a laboratory setting for experiential learning that allows students to practice skills, make decisions, take actions, and observe outcomes (Billings & Halstead, 2009; Brannan, White, & Bezanson, 2008; Rothgeb, 2008). Simulation provides a level of realism, but it also provides the opportunity to allow students to make mistakes in a safe environment. It can be used to demonstrate, practice, and evaluate nursing practices (Rothgeb, 2008). High-fidelity simulations use a human patient simulator programmed to emulate a realistic depiction of a body that can speak and respond physiologically to the provided care (Brannan et al., 2008; Rothgeb, 2008; Seropian, Brown, Gavilanes, & Driggers, 2004).

Despite the obvious benefits that simulation provides to teach family nursing, there is scant literature to suggest that it is being used in the educational setting or that it has been systematically tested in regard to family and caring. In a discussion of her model for simulation, Jeffries (2005) mentioned humanism and sociocultural factors, but no direction is provided. One author (Campbell, 2007) introduced the idea of adding challenging family situations to scenarios; however, the focus was on a “hard to handle” (p. 132) family member, which continues to perpetuate a negative image of families and has been identified by Chesla (1996) as a barrier to optimal family caring.

Family Nursing Care in Simulations

One innovative educational approach of grounding nursing simulations in humanism and caring was proposed by Eggenberger and Keller (2008). They called attention to the concern that simulation seldom recognizes the interconnections of others in the environment and the nurse-patient relationship, and they called for a need for simulation to go beyond the physiological parameters and ground practice knowledge in caring (Eggenberger & Keller, 2008). Their simulation scenarios include the recognition of family in the whole of a practice situation. Locsin (2008) supported their approach to simulation because it took one step toward bridging technological knowing and caring.

With caring as a central aspect of nursing practice, it is surprising and troubling that only one publication devoted to caring and simulation could be identified in the literature (Eggenberger & Keller, 2008; Locsin, 2008). Simulation provides nurse educators the opportunity to teach family nursing within the context of the illness experience, which is often technologically and biomedically oriented in the current hospital settings; however, to date the lack of literature reporting the use of the strategy for this purpose would suggest that it is not being fully realized in the human science paradigm.

Simulation Framework

The model that was used for this project’s simulation extends the concepts of Nursing Education Simulation Framework articulated by Jeffries (2005). The elements in this simulation, known as the KAR Model, are designed to promote three core abilities: Knowledge (attainment and interpretation), Action (clinical), and Reflection (in and on action). The model presents both task-based skills and relational care with a specific focus on families as a framework for relational care. This approach was thought to be an important element in the educational process because there is a diminished focus on relational care in contemporary nursing education (Doane, 2002), yet this type of care is essential for nurses to understand “the complexities of the human dynamics and multiple meanings and relations in forming the process [of care] for patients and practitioners” (Watson, 2005, p. 304). Providing family care was viewed as central to relational care because it purposefully includes the most important social network of the patient (Harmon-Hanson et al., 2005) and directs nurse attention to a wider focus of care beyond the “caring for” to the “caring about” (Cronqvist, Theorell, Burns, & Lutzen, 2004, p. 68; Noddings, 1984). The realities of practice demand that nurses learn how to work with families and build connecting relationships with families to support positive outcomes for the patient and family.

Simulation Design

The simulation design for this project incorporated three distinct phases. The first phase was aimed at promoting the students’ attainment and interpretation of data. Students worked in small groups to analyze and evaluate data common to clinical practice. Data were gleaned from the electronic health record, which included relevant detail of physician notes and nurse notes infused with relevant family information. Students were asked to complete a clinical reasoning worksheet based on Tanner’s clinical judgment model (Tanner, 2006). The students documented evidence for their course of actions using the worksheet. Students collected information from the Internet, library, or textbooks to support their thinking and prepare for their participation in the simulation scenario. During the simulation, data also included an oral report from a nurse that described pertinent patient and family information.

The next phase was a high-fidelity multistage simulation. Approximately 50 students participated in the simulation day, which was part of their synthesis culminating clinical course. Students were divided into groups of approximately 10 students who would participate in a simulation scenario designed to guide them in conducting psychomotor and relational skills in a health care setting. The simulation was focused on providing nursing care to a hospitalized patient with supportive family members. Two students assumed the roles of nurses who directed the nursing care (assessment, intervention, and evaluation) during a scenario. They could use each other in a partnering experience to support their thinking and acting. Two additional students acted as observers who used a prepared form to evaluate nursing actions and environment. These forms contained a family element where students noted nursing students’ actions with family members. For example, these students noted whether the nurse-students engaged in family care, such as inviting the family into the room, seeking information from the family, or acknowledging the family’s presence and emotional experience. Four students observed a videotaped simulation in another room and noted general impressions.

The roles of family members were assumed by two additional students who were given a script with cues to portray family behaviors that commonly occur with an illness and hospitalization. The cues also prompted them to take a course of action if the nurses did not attend to their needs or use them to seek information. For example, the role-playing family members were instructed to become more anxious and agitated if the nurses did not answer their questions or include them. They were also told they could offer information that was pertinent to the patient’s care if the nurses did not seek data from them. In addition, the manikin’s physiologic parameters also responded to the family care, such as a heart rate increase if the family was forced to leave the room or nurse failed to answer questions. The manikin also prompted students to think about his or her family by a statement such as, “Why don’t you ask my wife? I think she knows the answer to that question.”

The third phase was a structured reflection on high-fidelity simulation with a particular focus on how patient and family needs were addressed and how students demonstrated family caring. Debriefing was specifically directed to critique their clinical action in relation to the context of the situation. Reflection is critical for the development of clinical reasoning (Tanner, 2006). This reflection was thought to advance thinking (Green, 1997; Tanner, 2006) related to family care by purposively addressing student responses to family during the illness situation.

Family Nursing Skills in Simulation Design

Simulation design was founded on the premise that assuring nursing practice cares for the family requires teaching strategies to include the family. Therefore, simulation scenarios were developed with a family component. Each scenario included critical elements of practicing family nursing skills with family members while meeting the patient needs and implementing psychomotor skills. Students were expected to provide nursing care that required nursing actions of psychomotor skills and family care with use of technology, such as monitoring equipment and intravenous therapy. The authors’ assertion was that integrating family caring with psychomotor skills and technological knowledge could advance the teaching of family nursing practices.

Replicating the realities of clinical practice demands the simulation model include a family with all of its vulnerabilities, needs, and experiences. Doing the nursing work of family care requires nurses to build a nurse-family connection by understanding the family illness experience, knowing nursing actions that support and connect with family members, and acquiring the confidence to implement these nursing actions. The Table identifies those family caring actions that were expected during the simulation. These elements of family nursing care were developed from an extensive review of family nursing literature (Denham, 2003; Wright & Bell, 2009; Wright & Leahey, 2009).

Nursing Actions to Support Family Caring

Table: Nursing Actions to Support Family Caring

Method

Simulation scenarios were constructed that focused on nursing care in a pediatric setting, medical adult health setting, emergency department, and critical care setting. Students were assigned a particular scenario based on the setting of their clinical course. On the day of the simulation activities, students were assigned their roles in the simulation. Groups of students were then given time to analyze and interpret the health record. Next, students were oriented to the simulation room before the simulation scenario began. Simulation scenarios were videorecorded to allow for strategies of discussion and reflection during debriefing. Two faculty members later viewed each of the video-recordings and field notes from the simulation day for family skills and competencies in family nursing care.

Results

Findings of Family Nursing Care Simulation Using the KAR Model

Students exhibited varying levels of competence in providing family nursing care with deliberate intentional connections to a family. Their ability to acknowledge the family and their level of distress, as well as provide information, also differed. Some students recognized the central nature of the family in this illness experience, whereas others continued to pay no attention to the family despite an increase in prompting cues by simulator or role-players. Throughout the simulation preparation, implementation, and evaluation, it became evident to the faculty members involved that a simulation scenario provides promise for teaching family nursing skills.

Students Begin Connecting with Families

Some students immediately initiated actions to begin connecting with families, whereas others failed to begin any relationship with a family member. A nurse’s introduction of himself or herself has been described as an essential ingredient of relational family nursing practice (Wright & Leahey, 2009). Some students promptly introduced themselves to the family members, whereas other students avoided eye contact and ignored the family member sitting crying in the corner. For example, a student participating in a pediatric scenario readily invited the family to the bedside and gathered data from the family. The student stated, “You can come closer to the bed and touch her if you want.” Family scholars suggest that the lack of a basic social act such as introductions depersonalizes the patient and family, which limits possibilities of therapeutic conversations and potential of trusting health care provider relationships (Lynn-McHale & Deatrick, 2000; Wright & Leahey, 2009).

The nursing practice of noticing family strengths and resources has also been identified as an important aspect of caring for families (Limacher & Wright, 2006; Wright & Bell, 2009; Wright & Leahey, 2009). Some students found ways to comment on the abilities of the families. For example, a student commended a family who had been providing care in their home for a chronically ill family member who was now hospitalized with an acute exacerbation: “Your family has worked hard to provide just the care he needed for all of these years.” Another student stated to the mother of an ill infant, “Bringing her to the clinic after you worked to keep her temperature down was a good action to take. You were able to get the help she needed.” A limited number of students directed these type of therapeutic statements to family members, even though commendations can have a profound impact on families (Wright & Bell, 2009; Wright & Leahey, 2009).

It was also shown in these scenarios students had divergent viewpoints of the role of a family in assessment and teaching interventions, despite these elements being frequently emphasized in nursing literature (Harmon-Hanson et al., 2005). In some situations, students volunteered information to a family, whereas other students appeared to disregard family requests for information. For example, a student stated, “We are checking your husband’s blood sugar and electrolytes, and then we are going to give him the medicine to help with his blood pressure.” In contrast, another student continued a psychomotor skill performance while pretending not to hear the wife’s questions. At times, questioning techniques were used to gather data from the family, such as “When did your baby last have a bottle?” However, the family who had pertinent information to offer in the adult medical setting was consistently ignored by the nursing student. Although the patient was unable to answer questions about the time of a fall, the student ignored the family’s statements and the manikin’s cues to ask the patient’s family. These nursing actions of neglecting families are consistent with findings revealed in nursing practice research (Chesla & Stannard, 1997; Soderstrom et al., 2003), which suggests new strategies are needed in nursing education.

Observation and review of recordings showed that the practice of some students was grounded in a focus on performing psychomotor tasks and the disease of a behavioristic medical model. Many students ignored comments by a family member that would provide an opening for further dialogue or failed to take the opportunity to initiate a conversation with the family members. This finding is similar to the research of actual nursing practice with families that suggests families often feel the need to begin the interaction with a nurse (Astedt-Kurki et al., 2001a), but research findings suggest that families want the nurse to make the first move to connect because of the families own sense of uncertainty and vulnerability in the foreign hospital environment (Eggenberger & Nelms, 2007). A few students promptly initiated conversation with family member with statements such as, “Come to the bedside and I will show you” or “you have done so much to help your husband at home.”

When students were able to reflect on their actions with the help of reviewing the videorecording or feedback from observers, they were able to identify the need to further develop their relational family care. Students’ statements provide a convincing argument for the use of simulation scenarios with observers and videorecordings to encourage reflection. Statements included: “Before today, I thought I was a good communicator and worked well with families, but now I see I still have much to improve” and “This helped me really see the family needs and concerns.”

Students Developed an Understanding of the Family Experience

Asking students to role-play family members and their experience with illness produced an unexpected finding. Despite being given only a brief synopsis of the family role and emotion they were to portray, they were readily able to depict emotions and family distress with an illness experience that proved to be a powerful learning tool. As one student who played the wife of a patient stated, “I was surprised how anxious I was about a mannequin who was supposed to be my husband. I knew the scenario, but I was still feeling the uncertainty and doubts of the illness.” Simulation experience provided possibilities for an emotional connection to the family distress of a family experience during illness. During debriefing, students who observed the scenarios made statements such as, “I could feel the family member’s anxiety when the nurse did not listen.” One example of a reflective statement by a student who role-played the family member is “I actually was getting upset when the nurse started doing things without telling me what she was doing.”

Each simulation debriefing included a spontaneous dialogue about family care without faculty prompting, although faculty had planned for this particular focus. Some students easily identified with distress and needs of a family, whereas others had a limited understanding of the family experience. Conversations and reflections pointed out how some students wanted to totally focus on the patient, whereas few others recognized the significance of the family in the situation. Although all students recognized the priority of physical status of a patient, many were able to identify the interrelationship of patient and family to the health outcomes. However, regardless of the flow of the de-briefing dialogue, all groups explored the family nursing actions and concerns with providing family care.

Faculty Envisioned Possibilities of Simulation for Teaching Caring

These patient-family illness scenarios provided a realistic clinical situation to help the faculty better understand ways to support student learning in the future. A faculty member stated, “That family situation of anxiety and distress was realistic. Families act just like that scenario. I think I can help students learn how to address the patient and the family when the condition changes in clinical situations.” Faculty members were readily able to identify actions and abilities in family competence and skills needed for students to provide family nursing care. Student actions that indicated family caring were visible to faculty members. Faculty members indicated this simulation experience might assist students to “think family” (Green, 1997, p. 230), develop skills needed to develop collaborative working relationships with families, and increase nursing students’ competencies in the care of families.

One faculty member stated, “Even though these simulations were short, students could realize the impact of even a brief nurse-family interaction.” As Wright and Leahey (1999) stated, “No conversation that a nurse has with a patient or family member is trivial” (p. 263). Another faculty member stated when responding to a scenario where a student briskly forced a family to leave the room during assessment even though patient and family expressed distress with the action, “I had no idea a student would talk to a family member that way.” Family research indicates that a family often feels a sense of mistrust and distress when they are excluded from the room of their loved one (Eggenberger & Nelms, 2007; Hupcey, 1998). Through this project, it became visible to students and faculty that therapeutic conversations between nurses and families have significant potential for healing and softening their suffering (Wright & Bell, 2009).

Faculty and students appeared to grasp the central nature of a family to an individual’s health outcomes in a hospital setting through the simulations. Simulation provided the chance for faculty members to help students learn skills of family questioning, which are key elements of family nursing practice (Wright & Leahey, 2009). Faculty member statements such as “If the student had just asked the family member everything would have turned out differently” were heard. Scenario design allows the faculty member to construct a situation that requires a purposeful interaction designed to encourage the students to develop family nursing practices such as asking questions, exploring the illness story, and inviting reflections. This simulation design provided the faculty member with the opportunity to create scenarios that encourage students to adopt the relational stance of family as partner, rather than nurse as expert and family as obstacle (Tapp, 2000).

Discussion

The nursing curriculum where this simulation was developed includes family knowledge and content incorporated in several didactic and clinical courses. Courses include objectives related to nursing process and family with aspects of family theory, the philosophy of family-centered care, communication techniques, and family concerns with health conditions. However, with all of this attention to family in a nursing curriculum, many students showed a limited ability to demonstrate family nursing competencies in the simulation. This would suggest that the current approach does not offer the students the full potential to implement family caring actions and that students need multiple opportunities to develop and practice family nursing competencies. Simulation possibly could bridge this gap and help students practice family care and evaluate family practices. Simulation makes it possible for a nursing curriculum to provide that element of live supervision of nursing students, which is critical in nurturing family competent students (Wright, 1994).

The students and faculty response to integrating family nursing care with psychomotor skills creates a compelling case for the learning possibilities with simulation. Nursing actions during simulation highlighted for the student the significance of family care in illness situations while calling forth for faculty members the need for more student practice to develop family nursing actions that exhibit caring. Simulation is a productive tool to teach family nursing and improve competency in family clinical practice. Simulation allowed students to enter the world of a patient and family, with all their fears, anxieties, and distress, which may produce a new approach to effective learning. It is possible that experiencing these realistic emotions during a simulation may move these students to care for a family in a new way during actual clinical practice. The nursing education literature suggests that reflection on an experience during illness has potential to facilitate learning (Tanner, 2006).

At first glance, the notion of reaching competence in family nursing practices at the undergraduate level may seem idealistic to some, yet being able to evaluate behaviors of moving toward competence is a realistic endeavor. Now would be the time to embed family nursing skills into simulation design because numerous nursing curricula are designing and evaluating their simulation laboratories. The work of Tapp et al. (1997) describing the creation of a family skills laboratory experience in the traditional laboratory setting can be used to focus simulation strategies on caring for families. It is a critical time for nursing education to focus on blending caring and psychomotor skills. A focus on family may provide that impetus. Introducing beginning family nursing skills early in a curriculum, such as introducing oneself and interacting with a family, can be easily integrated into a psychomotor skills laboratory experience. Later, as psychomotor skills advance, the family skills could move to evaluating family nursing competencies such as conducting a family assessment and a therapeutic conversation (Wright & Bell, 2009; Wright & Leahey, 2009). This approach provides nursing education with the possibilities of extending simulation beyond the current state and advancing family caring skills.

Conclusion

A simulation that is grounded in the human science of family caring can advance family nursing practice. This pedagogy can support students’ acquisition of family nursing knowledge and skills because the faculty can limit the students’ performance anxiety focused on working with families, provide a safer environment to practice family care actions, and allow ample opportunity to critique and reflect on behaviors that support optimal family-nurse relationships. If caring is central to the nursing discipline (Boykin & Schoenhofer, 2001; Newman, Sime, & Corcoran-Perry, 1991), then caring needs to be embedded in teaching pedagogies.

Simulation is a pedagogical approach capable of teaching family nursing and evaluating family caring practices of students. Nurse educators can design simulations that portray family needs, concerns, and issues while teaching psychomotor skills and nursing knowledge. It is possible that the use of debriefing and reflection during family scenarios will increase students’ awareness of family needs during hospitalization and health concerns. Reflections offered the opportunity to become aware of the deficiencies in providing family care, actions that were not built on family nursing research, and missed opportunities to provide family nursing skills. This recognition may result in a shift in attitudes—from the family as a bothersome obstacle to a source of data and a recipient of care.

With more nursing programs exploring the usefulness of simulation in facilitating student learning (Campbell, 2007; Jeffries, 2005), now is the time to reevaluate its use in nursing education and anchor simulation pedagogies in family caring. The full potential of the pedagogy can be realized if nursing education begins to move toward teaching not only psychomotor skills, but also relational care through simulation. If we want nursing students to care, then we should give them the opportunities to practice from a stance of family caring.

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Nursing Actions to Support Family Caring

Student Demonstrates the Ability to Simultaneously Care for Patient and Family Members by the Following Actions:
Begins developing a connecting relationship with family members
  Introduces self
  Makes eye contact
Acknowledges family members’ illness experience
  Expresses empathy of patient and family
  Offers verbal statements recognizing this is a difficult family experience
  Uses therapeutic statements recognizing the family suffering with the illness experience
Reassures family that health care team is caring for their loved ones
Invites family members to stay in the presence of ill family member in the room or at the bedside with instructions such as where to stand, what to do, or how to stay involved
Creates an environment of including the family, rather than excluding the family
  Develops a purpose for the family members
  Seeks information/history data from family members
  Gives family members’ information
  Elicits data from family members using efficient interviewing techniques
  Seeks history or pertinent information from family members
Provides information to the family members
  Explains purposes of nursing action
  Provides assurance of care for loved one
  Gives accurate and realistic information, while maintaining hope
Commends the family strengths, resources, or actions
Provides supportive statements for both patient and family members
Advocates for family members
Initiates therapeutic conversation with both patient and family members
Develops family nursing interventions based on assessment
Plans a family interview and family meeting
Authors

Dr. Eggenberger is Professor and Director of Glen Taylor Nursing Institute for Family and Society, School of Nursing, Minnesota State University Mankato, Mankato, Minnesota; and Dr. Regan is Assistant Professor, University of Maryland’s School of Nursing, Baltimore, Maryland.

This project was supported by funds from Minnesota State Colleges & Universities, under the Academic Innovations RFP 5 Grant mechanism. The information and conclusions are those of the authors and should not be construed as the official position or policy of Minnesota State Colleges and Universities.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Sandra Eggenberger, PhD, RN, Professor and Director of Glen Taylor Nursing Institute for Family and Society, 360 Wissink Hall, Minnesota State University Mankato, Mankato, MN 56001; e-mail: .sandra.eggenberger@mnsu.edu

10.3928/01484834-20100630-01

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