When the authors first began planning to integrate simulation into the nurse practitioner (NP) program, creativity was essential due to several challenges. These challenges also appeared commonly in the simulation literature, including large class sizes, limited faculty, and time and budget constraints (Hovancsek, 2007; Jansen, Johnson, Larson, Berry, & Brenner, 2009; Nehring & Lashley, 2004). The NP clinical courses had 28 to 30 students, with only three faculty teaching in the graduate NP program with no course release time or funding for simulation and no dedicated simulation facility or staff. The authors recognized that it was impossible to rotate 30 students through a simulation experience, either individually or in small groups with various roles, as was described in the literature (Jeffries, 2007; Rauen, 2001).
This article describes the development and evolution of an innovative design based on a caring philosophy (Boykin & Schoenhofer, 2001) used to engage large groups of NP students in simulated clinical experiences (SCEs) simultaneously. The inspiration for the large-group design came from a popular television game show that used a “phone-a-friend” or “lifeline” concept to provide back-up support for contestants (Davies, 1999–2002). This foundational teamwork model allowed twice as many students to participate in the simulation and provided a built-in safety net, or buddy system, for each student. The subsequent addition of live video-streaming capability 2 years later essentially doubled the number of potential students able to interact in a given scenario, with half participating and the other half observing. In an NP program, it seemed logical that the roles students played were the components of the primary care patient encounter in a SOAP (Subjective, Objective, Assessment, and Plan) format: collecting subjective data and objective data, making assessments, and developing management plans. Progressive enhancements to this observer–participant design included pairing two cohorts of students in SCEs as mentors–mentees, as well as in scenarios of initial and follow-up visits on the same simulated patient. A simulation program designed to engage large groups of NP students in full-day simulated clinical experiences offered twice per semester evolved from this early foundation.
The use and value of simulation in baccalaureate nursing education has been extensively described in the literature (Cant & Cooper, 2010; Jeffries, 2007; Nehring & Lashley, 2004; Seropian, Brown, Gavilanes, & Driggers, 2004; Weaver, 2011). Less has been written about the use of simulation in advanced practice nursing (APN programs), and in particular, the use of high-fidelity simulation rather than standardized patients. Only recently has the use of simulation in primary care NP programs been described (Pittman, 2012). Further, information describing high-fidelity simulation with large groups of students simultaneously, which is the focus of this article, is scarce. In this literature review, current articles were included that describe ways that high-fidelity simulation has been used to engage large groups of APN students, as that is the goal of the simulation program.
Simulation in APN Programs
Using the keywords advanced practice nursing education, nurse practitioner education, simulation, and high-fidelity simulation, literature searches conducted in CINAHL® and PubMed® revealed a broad range of applications of human patient simulation in a variety of APN specialty programs or to teach specialized content. The applications include the use of human patient simulation to train nurse anesthesia students in advanced cardiovascular life support emergencies (Gonzalez et al., 2008), to train nurse midwife students in obstetric emergency management (Andrighetti, Knestrick, Marowitz, Martin, & Engstrom, 2012), and in clinical decision making (Cioffi, Purcal, & Arundell, 2005). Human patient simulation has been used to improve cardiovascular assessments by primary care, acute care, and nurse anesthesia students (Jeffries et al., 2011), as a tool to strengthen teaching complex cardiovascular management to APN students (Hravnak, Beach, & Tuite, 2007) and in conducting a pediatric mock code with emergency NP students (Kaplan, Holmes, Mott, & Attalah, 2011). Beauchesne and Douglas (2011) developed a high-fidelity simulation program for primary care and acute care pediatric NP students. In another approach, simulation was compared with a case study presentation on the knowledge and confidence of adult and acute care NP students in the management of a cardiac arrhythmia (Scherer, Bruce, & Runkawatt, 2007) and to online learning in teaching mechanical ventilation to APN students (Corbridge, Robinson, Tiffen, & Corbridge, 2010.) In acute care NP programs, simulation has been used to teach the management of respiratory failure (Scherer, Bruce, Graves, & Erdley, 2003), for invasive procedure training (Hravnak, Tuite, & Baldesseri, 2005), and as a tool in teaching complex cardiovascular management (Hravnak et al., 2007). Human patient simulation has also been used as a strategy to assess student NP preparedness for clinical experiences (Reinisch & Kwong, 2014). Although those studies provide helpful information, none address the use of simulation for large groups of students in a primary care setting.
Simulation in Primary Care NP Programs
Little has been written until recently about the use of high-fidelity human patient simulation to teach primary care management to NP students (Bryant, 2013; Campbell & LoGiudice, 2013; Elliott, DeCristofaro, & Carpenter, 2012; Mompoint-Williams, Brooks, Lee, Watts, & Moss, 2014; Walton-Moss, O’Neill, Holland, Hull, & Marineau, 2012). Several authors described how to use simulation with small groups of NP students simultaneously by having students work in teams (Bryant, 2013; Mompoint-Williams et al., 2014) or by assigning multiple roles (Campbell & LoGiudice, 2013; Walton-Moss et al. 2012), and by broadcasting to another classroom or using direct observation (Campbell & LoGiudice, 2013; Elliott et al. 2012; Walton-Moss et al. 2012). However, information about how to provide a simulation experience to large groups of NP students simultaneously is lacking.
Mompoint-Williams et al. (2014) developed two simulation scenarios to build confidence and knowledge prior to Objective Structured Clinical Examinations in an APN program for 85 students. Walton-Moss et al. (2012) discussed a pilot test of a scenario in which three students participated by playing the roles of NP, family member, and observer, while three other students observed from an adjacent room. In another approach, Bryant (2013) rotated three to four NP students every 15 minutes through five stations representing components of the primary care visit. Multiple repetitions were required to accommodate 110 students in a 1-day session.
Using another strategy, Elliott et al. (2012) incorporated personal digital assistants and high-fidelity simulation in scenarios for 12 family NP students in an advanced health assessment course. Half of the students played the roles of NP, physician, patient’s wife, and observer or recorder, while the other half observed. At the midpoint, the six students observing became the participants.
Campbell and LoGiudice (2013) described a scenario in which NP students played the roles of NPs, the patient care assistant, and the RN. Students not participating observed the SCE with live video and joined in the debriefing. Campbell and LoGiudice uniquely described the use of simulation with a few active participants and simultaneously to a potentially large group of observers through live broadcasts to classrooms with capacities of 35 to more than 120 students. Although the articles mentioned provided insight about providing SCEs for large groups, none were feasible for the authors’ program due to limited resources.
Simulation With Large Groups of Baccalaureate Students
Several authors have addressed the challenge of exposing large groups of baccalaureate students to simulation. Kaplan, Abraham, and Gary (2012) used participant and observer groups to accommodate six to seven students. Ninety-two students rotated through this simulation experience. Using another strategy, Norman, Thompson, and Missildine (2013) took the simulator to a classroom with 52 students, utilizing 2-minute drills with four students assigned to each team. Nonparticipating students observed the simulation with video projection. Rochester et al. (2012) described a simulation experience for 375 students, in which groups of 10 students participated at a time—half in a pre-operative activity and half in a postoperative activity on the same patient. When not participating, students observed the simulation, and all students debriefed together. All of those authors described creative SCEs in nursing programs, each with their own merits. However, none addressed the goal of the current study, which was to provide simulated experiences to large groups of students simultaneously, with hands-on participation for all students and greater interactions between them.
Large-Group Design: The Evolution
The initial simulation program began with a game show design to accommodate a large group of students, using student pairs in randomly assigned roles. Student participants were in either the family or adult NP track during their first clinical semester and all had taken “the 3 Ps” (Pathophysiology, Pharmacology, and Physical assessment). The faculty divided the components of a primary care patient encounter in a SOAP format for the student roles (Table 1). They also developed a “caring advocate” role to ground themselves in a caring philosophy as espoused by the college of nursing. The students learn caring competencies throughout the caring-based nursing curriculum. The caring advocate observed caring behaviors and discussed them during the debriefing. Depending on class size, additional roles included an NP preceptor and a recorder. This design accommodated up to 19 students in one scenario while the other half of the class participated in another activity, such as a suture workshop. The SCE and additional activity were then repeated.
Potential Student Roles Based on Components of Primary Care Encounter
Advantages of this model include the opportunity to use simulation with large classes and engage all students in various components of the primary care visit. Disadvantages include the need to repeat the scenario to accommodate everyone and to plan an alternate activity. In addition, dividing the history and physical assessment into pieces to accommodate more students in the simulation can be distracting to the students, whereas in the real world one provider obtains the history, conducts the physical assessment, and plans for the management of the problem, with the components often overlapping.
Observer–Participant Group Design
With the acquisition of live video-streaming capability between two classrooms, the authors were able to augment the game show concept and again double the number of students involved in each SCE by creating observer and participant groups. Television or video-streaming broadcast from the simulation laboratory to another classroom is described in the literature as a method to “engage all students while a few are involved in simulations” (Jansen et al., 2009, p. E12). Campbell and LoGiudice (2013) described a participant and observer model in which two to four students participated in the SCE while their classmates observed through closed-circuit broadcast. All of their students debriefed together.
The authors’ unique design uses two scenarios so that all students can participate in one scenario and observe the other. In this model, half the class participates while the other half observes, then the groups alternate. The advantages of this model include exposure to twice as many scenarios and opportunities to debrief together after both groups finish the SCEs. One disadvantage to this model is the requirement of either two rooms large enough to accommodate the entire class or live video-streaming or closed-circuit television between the two rooms. Setting up two distinct scenarios is also labor intensive, which led to the next design strategy.
Initial and Follow-Up Patient Visit Design
In the progressive evolution of the large-group design, the faculty enhanced the observer–participant model with the addition of an initial and follow-up clinic visit on the same simulated patient. In this model, the first student group conducted the initial clinic visit with a simulated patient, while the other group observed through live video-stream in another classroom. Then the groups alternated roles and the second group provided care to the simulated patient during a time-lapse follow-up visit where they reevaluated the patient based on the management plan recommended by the first group. During the initial visit, the observer group had to pay close attention to the assessment and treatment plan that their colleagues developed to conduct the follow-up visit. At the conclusion, all students debriefed together.
Similarly, Pittman (2012) described an initial and follow-up visit model in a family NP program, using two patient office visits. The first visit was for the initiation of insulin therapy, with a follow-up visit at a later date to reevaluate the patient’s response to treatment. One advantage of the initial and follow-up visit design was that the first observer group was more engaged in watching the initial visit, as they were responsible for the follow-up visit. Another advantage was the opportunity for students to participate in four scenarios in an 8-hour day. An unanticipated outcome was that students who observed the initial visit and participated in the follow-up visit evaluated the experience more positively, emphasizing the importance of ensuring that students alternate these roles. Their comments indicated an increased comfort level when they observed first, and then conducted a follow-up visit, and that they learned from each other. Faculty noticed that keeping students who participated in the initial visit engaged while they observed the follow-up visit was challenging. Assignments, such as documenting observations or writing SOAP notes during the SCE, have since been added to help keep those who are observing engaged.
The most recent enhancement of the large-group design is the mentor–mentee variation. Similar to the game show format, this is another type of buddy system that allows double the number of participants in SCEs. The nursing faculty felt this model provided a unique and interesting way to encourage a bonding experience between two cohorts of students who otherwise have limited interaction. The mentor group is 1 year ahead of the mentee group and thus are more experienced. Wagner and Seymour (2007) described a mentoring model in nursing based on a caring philosophy, which is complementary to a caring philosophy. In the caring literature, Mayeroff (1971) described caring as “helping the other grow” (p. 7).
For the mentor–mentee model, students in the first clinical course (mentees) were randomly paired with students in the final clinical course (mentors). Wagner and Seymour’s (2007) article was posted on Blackboard™ 1 week prior to the SCE to acquaint the students with the mentoring concept. It was assumed that most, if not all, of the students had been either mentees or mentors at some point in their nursing careers and would value this opportunity.
The primary advantage to this model is that instead of a lifeline, the first-year students (mentees) have a second-year, and therefore presumably more experienced and program-savvy, mentor. The disadvantage is that the group size (54 to 62 students) requires alternating the SCE with another activity and repeating the initial visit and follow-up visit with observer and participant groups in the morning and afternoon. This was labor intensive for faculty and for the volunteer participant acting as the voice of the patient.
SCE Implementation Process and Applications in the Curriculum
The process of implementing simulated clinical experiences for large groups of nurse practitioner students can best be visualized with a flow diagram (Figure). Adult and family nurse practitioner students are introduced to human patient simulation in their advanced physical assessment course. The following semester, in their first primary care clinical course, the students are oriented to SCEs on the first day of class. SCEs are integrated into the curriculum in all the clinical courses to teach high-risk, low-frequency problems, as well as common and significant diagnoses in primary care. The current SCE applications in our primary care curriculum are highlighted in Table 2.
Process of simulated clinical experience (SCE) implementation. VS = vital signs; EKG = electrocardiogram; H & P = history and physical examination.
Primary Care High-Fidelity Simulation Program Applications
Evaluation and Future Recommendations
When the SCE is finished, all students, faculty members, and community volunteers participate in the debriefing, or guided reflection. Following the debriefing, students evaluate the experience using the Program for Nursing Curriculum Integration (PNCI™) Simulation Effectiveness Tool (2012 and an SCE Caring Evaluation tool© based on Roach’s (2002) 6 Cs of caring: Compassion, Competence, Confidence, Conscience, Commitment, and Comportment. This tool was developed by faculty in the college for the undergraduate program and revised for the graduate program (Winland-Brown, Garnett, Weiss, & Newman, 2013). In addition to evaluating caring behaviors, two questions were added to the SCE Caring Evaluation Tool to assess the perceived value of the simulated clinical experience, compared with the same amount of time at the clinical site and to evaluate the mentor–mentee experience. Over six semesters, 64% to 83% of students rated the SCEs as about the same, more valuable, or much more valuable as the same amount of time at their clinical sites.
In addition to the positive rating scales on the evaluation tools, students often add written comments about the simulation experience. Some students appreciated the additional time that the SCEs provided for problem solving, indicating, “It allows [us] to spend more time analyzing and preparing our diagnoses/plan, etc.”, whereas others found it helpful to be able to discuss cases with their classmates, stating, “It’s good to have an opportunity to talk about why each student feels certain tests [or] procedures should be done.” Students often commented that they found the SCEs to be helpful in increasing confidence while decreasing anxiety, stating, “This simulation helped decrease my anxiety about my first clinical day.” Another stated, “It’s nice to have a patient experience without the fear of making a mistake.”
Some students mentioned that the SCEs were helpful in strengthening skills, such as, “I feel more confident in my skills after this simulation.” Other students acknowledged the benefits of having exposure to patients with diagnoses they had not encountered in their clinical practicums, indicating, “Autism is always spoken about but I have not encountered this before.” Another stated, “[I] learned much as I had no patients in ped[iatrics] with diabetes or hypertension.”
Students who rated the SCE as being less valuable than the same amount of time spent at their clinical sites shared more critical comments. Some did not appreciate the slow pace of the SCEs, stating, “In 6 hours at a clinical site, I would have seen around 10 patients and been exposed to many various patient conditions.” A few others felt increased anxiety during the SCEs, stating, “[Being] in front of a group is much more anxiety creating, 1:1 with our preceptors is better.”
Comments following the mentee–mentor SCEs were predominantly positive. Mentees, in their first primary care course, especially appreciated these experiences. One mentee said, “My mentor shared valuable suggestions on treating patients. She also supported me in my simulation task.” Another student stated, “Very enjoyable to have a student graduating soon. She answered so many questions for me and gave me much encouragement and incentive.” The authors were encouraged to continue this format due to comments such as these: “Thank you for such a wonderful experience….”; “My mentor…was fantastic. She was friendly, supportive, encouraging, and provided insight into organizing patient care and the use of iPad™ tools for clinical practice….”; and “We had a blast!”
The mentors (third primary care course students) also commented positively on the shared simulation experience, stating, “I think it gave us a chance to look back to where we were from where we are now!” Another stated, “Good to have feedback and bounce ideas off each other, relate experiences and compare/learn from each other.”
In student evaluations of the mentor–mentee design over two spring semesters, 83% to 84% of students rated the experience as very to extremely effective; however, the mentors reported less satisfaction with the design than the mentees. The authors acknowledge the need to continue to develop this program in various ways, such as more thoroughly preparing mentors for the roles and responsibilities of mentorship to enhance their satisfaction with the experience, as well as designing more opportunities for the two cohorts to interface and build relationships throughout their year together. The primary care scenarios in this program have been successfully grounded in a caring philosophy through the role of the caring advocate in the SCEs and with the debriefing and guided reflection process. The program continues to evolve in this effort.
This article describes how the faculty of a nurse practitioner program were able to overcome many common challenges to using simulation with an innovative large-group design to augment primary care management. The faculty’s commitment to providing high-risk, low-frequency simulated clinical experiences for all students was reinforced by student comments that they had not experienced patients presented in some of these scenarios in their clinical practice settings. The goals in sharing these experiences are to inform faculties with similar challenges and, hopefully, to inspire them to replicate, adapt, and improve these models to engage their students with clinical simulation.
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Potential Student Roles Based on Components of Primary Care Encounter
|Subjective data collection|
| #1 nurse practitioner (NP) student and lifeline||History of present illness—seven variables of symptoms: location, quality, quantity/severity, timing, setting, remitting or exacerbating factors, associated manifestations|
|Past medical and surgical history; social and family history|
| #2 NP student and lifeline||Review of systems|
|Objective data collection|
| #3 NP student and lifeline||Focused physical examination|
| #4 NP student and lifeline||Diagnostic studies results and interpretation|
| #5 NP student and lifeline||Primary and differential diagnosis|
| #6 NP student and lifeline||Management plan—pharmacologic|
| #7 NP student and lifeline||Management plan—nonpharmacologic|
| #8 NP student and lifeline||Patient and family education and counseling|
| #9 Caring advocate||Record caring interactions|
| #10 Recorder, if needed|
Primary Care High-Fidelity Simulation Program Applications
|Semester||Course Details||Simulation Design||Simulation Description|
|Spring||First primary care clinical course. First week of classes prior to beginning clinical rotations (N = 25 to 35 students)||Initial and follow-up visit design. Faculty role-play of initial visit, in roles of nurse practitioner (NP) student and preceptor. Student volunteers assume roles during follow-up visit (half-day alternate activity-workshop).||Introduction to simulation: PowerPoint® presentation, photo/video, and research consents signed, Professional Integrity Contracta; simulated clinical experience (SCE): 60-year-old Caucasian male; diagnoses: hypertension, hyperlipidemia, diabetes mellitus type 2, peripheral vascular disease, posttraumatic stress disorder, tinea pedis, erectile dysfunction; focus: preparation for clinical experiences; how to approach patients and families; how to present findings to preceptor, how to write concise SOAP notes; how to use eLogs™; debriefing and evaluation|
|Spring||First and third primary care clinical courses combined (N = 54 to 62 students)||Mentor–mentee design + initial and follow-up visit ; student distribution: 25% participants, 25% observer, 50% in alternate activity, with groups alternating AM and PM visits||SCE: Adult respiratory scenario, 50-year-old Caucasian male; diagnoses: COPD, pneumonia; debriefing and evaluation|
|Fall||Second primary care clinical course: Women’s health/pediatrics (N = 25 to 35 students)||Observer–participant design + initial and follow-up visits; two patients. SCEs set up in two different rooms with video streaming in-between. Groups alternate rooms AM and PM—if students participate in initial pediatric scenario, they observe the follow-up visit; if students participate in initial women’s health visit, they observe the follow-up visit.||SCEb: am—initial pediatric visit (Room A), 7-year-old Caucasian male; diagnoses: autism and acute asthma; initial women’s health visit (Room B), 36-year-old Hispanic female; diagnoses: gestational diabetes and hypertension; pm—follow-up visit pediatric patient, follow-up visit women’s health patient; debriefing and evaluation|