Currently, nursing education is faced with many challenges, including preparing nursing students to competently care for the increasing number of older and chronically ill adults. Baby Boomers began to turn age 65 in 2011. It is anticipated that by 2030, 71 million Americans will be older than age 65. Older adults account for 52.7% of all hospital stays (Centers for Disease Control and Prevention [CDC], National Center for Health Statistics, 2009a) and 263.6 million ambulatory adult care visits (Schappert & Rechtsteiner, 2008). In addition, 184.3 individuals over age 65 per 1,000 were living in nursing homes in 2004 (CDC, National Center for Health Statistics, 2009b). Approximately 50% of adults over age 65 have two or more chronic conditions (U.S. Census Bureau, 2005) and require educated, clinically competent nurses who understand their special needs (Gebhardt, Sims, & Bates, 2009; Palmer et al., 2008). In addition, family caregiving concerns escalate with older adults and communication between family caregivers becomes even more important (American Association of Colleges of Nursing & the John A. Hartford Foundation Institute for Geriatric Nursing, 2000). The California Board of Registered Nurses mandates that care of older adults be part of the curricula for nursing education; therefore, communication with older adults and their families is essential as part of the nursing educational foundation (California Department of Consumer Affairs, 2010).
Nursing is a complex profession and the students are diverse; therefore, the learning opportunities provided for students require that faculty be creative and attentive to students’ needs and provide multiple ways of learning (Allan & Aldebron, 2008). Student learning is enhanced using active learning strategies such as simulation (Childs & Sepples, 2006; Kardong-Edgren, Starkweather, & Ward, 2008; Palmer et al., 2008). According to Decuyper, Dochy, and Van den Bossche (2010), students learn more through group interaction than through passive learning. Knowledge and ability increase as students combine the activities of hearing, seeing, saying, doing, and teaching (Bastable, 2008); further, adult learners need concrete experiences they can apply to their clinical settings (North Central Regional Educational Laboratory, n.d.). Johnson and Johnson (2002) suggested that active group learning promotes superior student outcomes and facilitates student achievement, retention, and accountability; it allows formative feedback, promotes better productivity and critical thinking, and reduces student anxiety (Cortright, Collins, Rodenbaugh, & DiCarlo, 2003; Slusser & Erickson, 2006), whereas passive learning requires a lower level of cognitive involvement (Billings & Halstead, 2009).
Various simulation techniques have been used to augment and teach nursing skills such as standardized patients, role-playing, and models (Childs & Sepples, 2006; Kardong-Edgren et al., 2008; Zavertnik, Huff, & Munro, 2010). When used in simulated hospital settings, high-fidelity simulation techniques allow students to experience the importance of context that cannot be replicated in a didactic setting (Harder, 2010). Allan and Aldebron (2008) proposed that the use of high-fidelity simulation helps students to develop “psycho-motor skill competency and better prepare(s) them to assume patient care responsibilities” (p. 292). Others suggest that high-fidelity simulation is an approach that will support learning of core competencies among baccalaureate nursing students (Curl, Smith, Chisholm, Hamilton, & McGee, 2007).
High-fidelity simulation along with active learning in the form of the Geri Sim Fair (GSF) is a valuable educational strategy that recognizes the need for student hands-on and group learning approaches. This article describes a successful clinical active learning educational innovation at one Pacific Coast university and discusses the benefits and future potential for using the framework in other courses and in practice settings.
Second-semester sophomore Bachelor of Science in Nursing (BSN) students were introduced to the hypothetical Mr. and Mrs. Wagner on the first day of class. The case-based course features the 90-year-old and 85-year-old community-dwelling older adults, Mr. and Mrs. Wagner, and forms the basis of learning about older adults and all aspects of their lives. Through active learning activities and in-class group work, students began to understand the multiple age-related and disease-specific challenges this couple faced, as well as issues of chronic disease management, functional decline, social isolation, and eventually the hospitalization of Mr. Wagner for aspiration pneumonia and dehydration. During the 10th week of a 15-week course, students were introduced, in the form of the GSF, to the hospital setting (simulation laboratory) where Mr. Wagner had been hospitalized. Prior to this clinical experience, students had an orientation tour of the simulation laboratory but no other high-fidelity simulation experience.
The day-long clinical GSF was developed to capture the many aspects of Mr. Wagner’s hospitalization. This educational model incorporated multiple learning stations. The 56 students rotated through the seven learning stations eight students at a time.
In a scenario using the Laerdal Sim-Man® as Mr. Wagner, student experiences in Station 1 included learning basic patient assessment skills for an older “hospitalized patient” and communication with anxious family members. Four students participated in the scenario and the roles included two nursing students, two family members, and one faculty role as a clinical instructor. After the 10-minute scenario, the action was stopped and students switched with the four observers, who were other students in the clinical group watching the scenario from another room. The progressive scenario was then continued with the new students. As recommended in Jefferies’ (2007) Nursing Education Simulation Framework, unanticipated events were built into the scenario that the nursing students had to address that were not part of their report prior to entering the room, which included:
- Group one: a crimped Foley catheter causing lower abdominal pain.
- Group two: dyspnea caused by a nasal cannula being under the covers rather than in place in the nostrils.
A 10-minute debriefing of both groups took place at the end of the scenarios. The total time in the simulation laboratory was 30 minutes.
The six active learning stations with varying degrees of simulation supported the main high-fidelity simulation scenario in Station 1. The student clinical groups of eight rotated every 30 minutes to the different learning stations, where they would stop, listen, participate, and learn different aspects of providing care for Mr. Wagner (Figure). In Station 2, students performed the Mini Cog and CAM cognitive assessments from the Try This® series on each other. Station 3 included communicating with an anxious family in a role-play. In Station 4, students listened to and assessed heart and lung sounds with a mid-fidelity mannequin. Station 5 included practice on how to provide therapeutic massage for older adults, and students practiced on each other while they had snacks and a break. In Station 6, they contacted the physician by telephone using SBAR (Situation-Background-Assessment-Recommendation) methodology, and in Station 7, students planned Mr. Wagner’s transition from the hospital in an interdisciplinary team meeting role-play.
Figure. Conceptual model of the Geri Sim Fair.
The clinical instructors facilitated each station and were given the chance to create the station themselves, offering opportunities for personal ingenuity and resourcefulness. For instance, the clinical instructor for Station 2, the Cognition Assessment station, decided to use the Mini Cog and the CAM as examples of assessment of memory loss and delirium, and then created an activity for students to practice on each other. Two workshops for faculty provided for coordination and planning, which were central to the success and support of the project.
Following the GSF, an assessment technique using green, pink, and yellow index cards was used to evaluate the success of the GSF. Students were asked to anonymously write on the cards their comments about the day: green for anything positive, pink for anything that needed more work, and yellow for any suggestions they might have for improvement. The evaluation process evolved into Station 8. The index card assessment was an expeditious way of gaining a quick initial evaluation of the GSF. All student suggestions were incorporated in the subsequent GSF as faculty attempted to improve all stations so they met the learning needs of the students. To more accurately assess student satisfaction with the learning process, and after institutional review board approval was attained, three National League for Nursing (NLN) surveys were used to assess the more intricate details of the program (NLN, 2006). Content validity of the NLN Simulation Design Scale was determined by 10 experts in testing and simulation development. Reliability was tested using Cronbach’s alpha in which the Simulation Design Scale (SDS) was reliable at alpha = 0.92 for presence of features and alpha = 0.96 for importance of features. The Educational Practices Questionnaire (EPQ) was valid at alpha = 0.86 for presence of specific practices and alpha = 0.91 for importance of specific practices. Reliability for the Student Satisfaction and Self-Confidence in Learning (SSSCL) was alpha = 0.96 for satisfaction and alpha = 0.87 for self-confidence (Chickering & Gamson, 1987).
The SDS (Student Version) rated simulation design elements, as well as how important the element was to the student. The EPQ was designed to measure educational best practices; and the SSSCL tool is a 13-item, 5-point Likert scale that measured satisfaction with simulation and self-confidence in obtaining the instruction needed for the simulation experience. The SDS survey results were mean = 4.52, SD = 0.37; EPQ results were mean = 4.93, SD = 0.46; and the SSSCL results were mean = 4.37, SD = 0.39. Student reflective journals were positive regarding the educational experience. A faculty feedback form was designed by the researcher to evaluate the educational pedagogy, the 2-day workshop as preparation for teaching each station, and the perceived autonomy to develop their station, as well as to elicit suggestions to improve both teaching and learning aspects of the GSF. Faculty responses to the feedback form reflected their overall enthusiasm about their role in the GSF.
The design of the GSF is not unique to gerontological nursing. The pedagogy is easily adaptable to other courses. One example is obstetrical nursing, in which the main scenario might be an obstetrical assessment topic, such as a “Peri Fair,” with each station a pertinent assessment specific to the situation or group of situations common to a birthing mother using the obstetrical high-fidelity mannequin and creating corresponding learning stations. Another example is pediatric nursing, in which the main scenario might be a hospitalized child with acute asthma; each station would include assessments, as well as pertinent interactions with parents and education for discharge. In addition, any level of medical-surgical nursing could be adapted to this learning innovation.
The GSF framework could be useful in community health nursing, in which students become involved in an epidemiological study as the main scenario and rotate from station to station learning how to gather evidence and formulate a conclusion. A mock community assessment could be simulated, with students visiting different parts of neighborhoods and agencies instead of stations. The education framework could be useful in nursing practice for staff development offerings and in-service education, for annual competency testing, or a quick way to introduce a complex system of treatments. The versatile teaching–learning method engages students, satisfies their need for participation in their learning, and offers a quick-paced approach to acquire necessary skills for the care and management of patients.
The GSF was established for beginning nursing students enrolled in a Foundations of Gerontological Nursing course to provide an active learning method for the acquisition of skills to care specifically for older adults. The creative approach was student centered and active learning based. Students expressed great satisfaction with the learning method, and faculty expressed equal satisfaction with their roles as facilitators of the learning stations. It has been a win–win endeavor as students continue to suggest their hope that more of their courses would include this approach to teaching nursing assessments and skills. Future research should measure GSF student learning outcomes and implementation of the learned assessments and skills in the actual clinical setting to ascertain whether the new knowledge is transferable.
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