Journal of Nursing Education

Research Briefs 

Using Simulation to Evaluate Clinical Performance and Reasoning in Adult-Geriatric Acute Care Nurse Practitioner Students

Megan M. Keiser, DNP, RN, CNRN, SCRN, CHSE, ACNS-BC, NP-C; Carman Turkelson, DNP, RN, CCRN, CHSE

Abstract

Background:

The use of simulation-based learning experiences (SBLE) with nurse practitioner (NP) students is largely unexplored. The purpose of this pilot project was to develop, implement, and evaluate a simulated patient (SP)-SBLE to improve confidence and evaluate clinical performance and reasoning in Adult-Geriatric Acute Care NP (AG-ACNP) students.

Method:

A mixed-methods design was used to evaluate an SP-SBLE on AG-ACNP student clinical performance and reasoning.

Results:

Self-confidence scores and themes from reflections indicated that students perceived this as a valuable experience that enhanced learning and confidence.

Conclusion:

Results supported the use of SP-SBLEs to improve confidence in clinical performance and reasoning with AG-ACNP students. [J Nurs Educ. 2019;58(10):599–603.]

Abstract

Background:

The use of simulation-based learning experiences (SBLE) with nurse practitioner (NP) students is largely unexplored. The purpose of this pilot project was to develop, implement, and evaluate a simulated patient (SP)-SBLE to improve confidence and evaluate clinical performance and reasoning in Adult-Geriatric Acute Care NP (AG-ACNP) students.

Method:

A mixed-methods design was used to evaluate an SP-SBLE on AG-ACNP student clinical performance and reasoning.

Results:

Self-confidence scores and themes from reflections indicated that students perceived this as a valuable experience that enhanced learning and confidence.

Conclusion:

Results supported the use of SP-SBLEs to improve confidence in clinical performance and reasoning with AG-ACNP students. [J Nurs Educ. 2019;58(10):599–603.]

Simulation-based learning experiences (SBLEs) have been used with increasing frequency in baccalaureate nursing programs. SBLEs create a realistic low-risk setting where learners are able to assess and respond to clinical problems developing technical, clinical reasoning, communication, and collaboration skills (McGaghie, Issenberg, Petrusa, & Scalese, 2010). As a result, SBLEs as a pedagogical approach have continued to gain widespread use in both academic and health care settings for training students and health care providers (Kalisch, Aebersold, McLaughlin, Tschannen, & Lane, 2015). SBLEs in these settings have been shown to improve self-confidence, skill development, and knowledge transfer from the simulated environment to the clinical environment (Bambini, Washburn, & Perkins, 2009; Blum, Borglund, & Parcells, 2010; Cant & Cooper, 2010; Decker, Sportsman, Puetz, & Billings, 2008; Kalisch et al., 2015).

As it relates to nurse practitioner (NP) education, there is support, albeit limited, for the inclusion of simulation in NP programs. Recent studies have demonstrated the effectiveness of simulation to teach specific skills to NP students, such as physical assessment (Loomis, 2016), mechanical ventilation (Corbridge, Robinson, Tiffen, & Corbridge, 2010), heart and lung assessment (Tiffen, Corbridge, Shen, & Robinson, 2011), and patient communication (Rosenzweig et al., 2008). Support also exists for the efficacy of SBLEs to teach the management of several high-risk clinical conditions, including adult cardiac arrest (Bruce et al., 2009), acute asthma exacerbation (Pittman, 2012), and sepsis in infants (Haut, Fey, Akintade, & Klepper, 2014).

At the same time, support is limited related to the use of simulation for summative evaluation with acute care nurse practitioner (ACNP) students (Clark, 2015; Scherer, Bruce, Graves, & Erdley, 2003). Corbridge et al. (2008) developed a 2.5-hour SBLE to determine the effect of simulation on knowledge acquisition and confidence in senior ACNP students. Their results indicated that a single critical care SBLE did increase knowledge acquisition and confidence (Corbridge et al., 2008). Rutherford-Hemming and Jennrich (2013) developed a 3-hour SBLE, which was limited to first-semester ACNP students in an attempt prepare them for the clinical setting. They concluded that an SBLE can enhance knowledge, skills, and attitudes necessary for ACNP students in the clinical setting.

Although research into the use of SBLEs in NP education is slowly increasing, a systematic review of the effectiveness of simulation-based education on satisfaction and learning outcomes in NP programs concluded that there is limited evidence supporting the use of high-fidelity simulation in NP education (Warren, Luctkar-Flude, Godfrey, & Lukewich, 2016). As a result, the authors recommended future research to explore knowledge retention, transferability to real patient situations, and the impact of simulation on patient outcomes (Warren et al., 2016). A gap in the literature also exists related to the use of SBLEs, specifically in Adult-Geriatric Acute Care Nurse Practitioner (AG-ACNP) programs. To address this knowledge gap, the purpose of this project was to develop, implement, and evaluate an innovative simulated patient (SP)-SBLE in an emergency center setting to evaluate clinical performance and reasoning in AG-ACNP students.

Sample

A convenience sample of 10 students in the AG-ACNP Doctor of Nursing Practice program was the proposed target population for this project. Institutional review board approval was obtained prior to initiation of the project and the project was deemed “not regulated.” Participation in the SP-SBLEs and the reflective writing assignment were requirements for all students as part of their coursework in the final clinical semester of their AG-ACNP program; however, all surveys were voluntary.

Method

A prospective, mixed-methods design was used to examine the effects of a single SP-SBLE on AG-ACNP student clinical decision making, diagnostic reasoning, and treatment planning, as well as on their self-confidence in the role of medical care provider.

Development of Simulation Scenarios

The SP-SBLE was created to support attainment of core AG-ACNP student objectives for the final clinical semester in the Doctor of Nursing Practice program. Primary objectives for the experience included conducting a thorough history and physical examination, identification of differential diagnoses, determination of appropriate diagnostics to support identification of the patient problem, accurate identification of the patient diagnosis, and development of a comprehensive patient-centered plan of care for an emergency center patient. All scenarios and objectives were mapped to clinical competencies for AG-ACNP students as defined by the National Organization of Nurse Practitioner Faculty and the American Association of Colleges of Nursing (2016). The simulation objectives and scenarios were developed by the lead faculty member for the AG-ACNP track, who has been an ACNP for the past 28 years and is a Certified Healthcare Simulation Educator (International Nursing Association for Clinical Simulation in Learning [INACSL], 2016). One content expert and one simulation expert reviewed the scenarios—as well as the evaluation rubric to determine the completeness, suitability, and fidelity—and their ability to meet the objectives of the SP-SBLE. All simulation scenarios were developed following the INACSL Standards of Best PracticeSM. The lead faculty member served as the SBLE facilitator, the evaluator, and the lead debriefer during this project. Further details regarding the scenarios will be provided on request as the scenarios continue to be used in the AG-ACNP track at the school of nursing where this project took place and therefore cannot be published.

Six trained SPs portrayed six patients, all with different presenting chief complaints (e.g., abdominal pain, chest pain, dyspnea, headache, low back pain, mental status change). All SPs were provided with the scenario objectives, learner information, and a patient/actor script 2 weeks prior to participation in the SP-SBLE following the Association of Standardized Patient Educators Standards of Best Practice and the INACSL Standards of Best Practice Practice SM (INACSL, 2016; Kameg, Szpak, Cline, & Mcdermott, 2014; Lewis et al., 2017; Liao, Kao, Liang, & Hsieh, 2015; Lopreiato, 2016). Practice sessions were also scheduled for the SPs with the lead faculty member and the Simulation Center faculty (Lewis et al., 2017). During the practice sessions, the SPs had an opportunity to receive feedback about their performance, as well as the opportunity to ask questions and clarify case questions (Kameg et al., 2014; Keiser & Turkelson, 2017; Lewis et al., 2017).

Presimulation Work

Two weeks prior to the SP-SBLE, all AG-ACNP students received a list of six potential chief complaints they may encounter during the SP-SBLE. Students were encouraged to review the appropriate work-up and treatment plan for diagnoses associated with each potential chief complaint. The students were informed that they could use any electronic or print resource during the SP-SBLE and could also collaborate with each other. Students were also aware of the objectives for the SP-SBLE and understood that this was a pass-or-fail high-stakes summative experience, during which they would be required to perform a complete history and physical examination, diagnostic work-up, and plan of care for their assigned patient. Students were additionally informed that this learning experience would include a structured debriefing immediately following the simulation and that they would complete a reflective writing assignment (Table A; available in the online version of this article). The evaluation rubric was provided to the students in advance. Students were also informed that remediation would involve another SP-SBLE where they would be required to work up another patient until they were able to successfully meet minimum performance standards outlined on the evaluation rubric (Table B; available in the online version of this article).

Reflective Writing Assignment

Table A:

Reflective Writing Assignment

Evaluation Rubric for Adult-Gerontology Acute Care Nurse Practitioner Summative Simulation

Table B:

Evaluation Rubric for Adult-Gerontology Acute Care Nurse Practitioner Summative Simulation

Simulation Activity

Upon arrival to the simulation center, the AG-ACNP students were led to a small conference room that served as a work room throughout the SP-SBLE. Students were able to access any print or electronic resources and could collaborate with each other during the SP-SBLE. Each student drew a slip of paper from a hat that identified which SP they would be evaluating. The students were then introduced to their patient by the facilitator and were provided with only the patient's name and chief complaint. The students were then asked to perform a thorough history and physical examination and present their findings to the facilitator who was portraying the role of an attending physician in the emergency center. After presenting their patient's history and physical examination, as well as a list of differential diagnoses, the students discussed their plans for a diagnostic work-up with the facilitator. The AG-ACNP students were given the results for all laboratory and radiographic tests they ordered. They were then required to interpret the results of their diagnostic work-up and formulate a comprehensive plan of care to appropriately manage the patient's most likely diagnosis. They discussed their plan of care with the facilitator and then they presented it to the patient. The facilitator did not intervene during the students' interactions with their assigned patient and provided minimal prompting through the use of guided questions (e.g., inquiring what assessment findings supported the diagnosis and/or requested diagnostics) during the discussion of the patient's differential diagnosis and diagnostic work up. The SP-SBLE session for the AG-ACNP students lasted approximately 2.5 hours. The AG-ACNP students were allowed up to 90 minutes to interact with the SP before finalizing their comprehensive plan of care with the facilitator and the patient.

Upon completion of the SP-SBLE, students were first debriefed with the SPs for approximately 15 minutes, guided by the facilitator who only provided feedback and insight on their communication and demeanor. Immediately after, a structured debriefing was conducted by the facilitator for approximately 45 minutes using the Debriefing for Meaningful Learning framework. This model of debriefing was developed to actively teach students clinical reasoning skills that would translate into practice (Dreifuerst, 2012) and has been used successfully with graduate nursing students with positive learning outcomes (Dreifuerst, 2015). During the debriefing, each student presented their patient to the group and received feedback from the facilitator, as well as from fellow AG-ACNP students. At the conclusion of the debriefing, each student was asked to complete the National League for Nursing (NLN) Student Satisfaction and Self-Confidence in Learning Scale (SSSCL) and the NLN Simulation Design Scale (student version) (SDSsv). The surveys were voluntary, but all students completed them. Each student was also required to write a one- to two-page reflection with guiding questions (Table A) regarding their SP-SBLE experience.

Quantitative Evaluation Measures

National League for Nursing Student Satisfaction and Self-Confidence in Learning Scale (NLN-SSSCL). The NLN-SSSCL is a 13-item instrument using a 5-point Likert rating scale (1 = strongly disagree to 5 = strongly agree) to measure student satisfaction with instruction (five items) and self-confidence in learning (eight items) (Adamson, Kardong-Edgren, & Willhuas, 2013; Kardong-Edgren, Adamson, & Fitzgerald, 2010). The reliability of this tool has previously been established with the satisfaction scale achieving a Cronbach's alpha of .94 and the self-confidence scale achieving a Cronbach's alpha of .85 (Adamson et al., 2013; Kardong-Edgren et al., 2010).

The Simulation Design Scale (student version) (SDSsv). The SDSsv is a 20-item instrument using a 5-point Likert scale and was designed to evaluate the five design features of instructor-developed simulations: (a) objectives/information; (b) support; (c) problem solving; (d) feedback; and (e) fidelity (Adamson et al., 2013; Kardong-Edgren et al., 2010). The instrument has two parts: one asks about the presence of specific features in the simulation and the other asks about the importance of those features to the learner (Adamson et al., 2013; Kardong-Edgren et al., 2010). Content validity was established by 10 content experts in simulation development and testing (Adamson et al., 2013; Kardong-Edgren et al., 2010). The instrument's reliability was tested using Cronbach's alpha, which was found to be .92 for presence of features and .96 for the importance of features (Adamson et al., 2013; Kardong-Edgren et al., 2010).

Qualitative Evaluation Measures

All students were required to complete a one- to two-page self-reflection on completion of the SP-SBLE. Students were provided with guiding questions but were encouraged to reflect on their personal thoughts and feelings during and after the SP-SBLE (Table A).

Results and Discussion

Sample Characteristics

The students (N = 10) who participated in this summative SP-SBLE were fairly homogeneous in gender (one man, nine women) and ethnicity (two African American and eight Caucasian). The students had an average of 8.16 years in nursing practice (range = 4 to 20 years) and an average of 4.83 years in critical care (range = 1.5 to 10 years). All but one student had some experience in the emergency center either through employment or during an AG-ACNP clinical rotation.

Quantitative Results: NLN-SSSCL and SDSsv

The NLN-SSSCL subscale mean scores (Table 1) indicated a high level of satisfaction with the SP-SBLE. The mean scores for student satisfaction were 4.86 (range = 4.0 to 5.0) and the mean score for self-confidence in learning was 4.73 (range = 4.375 to 5.0). The SDSsv mean scores (Table 2) indicated that students perceived that they had enough information (M = 5), a high level of support (M = 4.75), fidelity (M = 4.8), problem solving (M = 4.5), and feedback (M = 4.75) during the SP-SBLE.

National League for Nursing (NLN) Student Satisfaction and Self-Confidence in Learning Scale (SSSCL)—Participant Self-Confidence and Satisfaction with Learning (N = 10)

Table 1:

National League for Nursing (NLN) Student Satisfaction and Self-Confidence in Learning Scale (SSSCL)—Participant Self-Confidence and Satisfaction with Learning (N = 10)

National League for Nursing (NLN) Simulation Design Scale (N = 10)a

Table 2:

National League for Nursing (NLN) Simulation Design Scale (N = 10)

Evaluation by Faculty

During the SP-SBLE, the simulation facilitator (faculty) used a rubric (Table B) to score each student as they presented the elements of their patient case. The students were scored using a dichotomous scale that was either satisfactory or unsatisfactory. All students (N = 10) were deemed satisfactory on their first case and no remediation was necessary for any student.

Qualitative Results: Reflective Essay

The review of the reflective essays yielded the following three main themes: Realism, Value, and Support.

The fidelity of the simulation was perceived as very realistic:

  • The moment I introduced myself to the patient, I felt like I was interacting with a normal patient.
  • I was able to suspend disbelief easily and treat the patient just as I would a real patient.

The students thought that the SP-SBLE was a valuable learning experience:

  • I think that performing simulations in acute care is valuable to my learning because it allows us to show what we do or do not know and learn from it in a safe environment.
  • Simulation experiences are extremely important in the acute care learning process. You can only learn so much reading a book—actually going through the motions and being in the moment reinforces concepts that are learned in the classroom.

The students were thankful for the support of each other and the facilitator:

  • The ability to use resources and be able to run things by my faculty and fellow students allowed me to feel more comfortable with my management decisions.
  • Having a work room with the ability to look things up and discuss my case with the other students felt like the way it would be in a real emergency center and improved my comfort level all the way around.

This qualitative data supports the value of both the simulation design, as well as the experience and provides support for the use of this SP-SBLE with future cohorts of AG-ACNP students as a method of summative evaluation.

Limitations

First, use of a small convenience sample of highly specialized AG-ACNP students at a single school of nursing may limit its application to other settings. The study's small sample size limited the ability to assess for statistical significance with the quantitative measures. Additionally, all observations and evaluations were completed by a single researcher who developed and facilitated the SP-SBLEs, as well as conducted the student evaluations. This may have created bias in the eyes of the observer representing another potential limitation of this project. Due to the fact that there was only a single observer, the opportunity for interrater reliability was not available. Also, due to the unique nature of this prototype project, use of an established evaluation tool was not possible. Further exploration of the validity and reliability of the evaluation rubric is necessary. Future studies on simulation for graduate-level NP students should include a larger number of NP students and additional sites to further advance the science supporting simulation as a valuable pedagogical strategy for graduate-level NP students.

Conclusion

In this project, the use of an innovative SP-SBLE demonstrated potential as an effective methodology to improve self-confidence and enhance clinical reasoning in AG-ACNP students. The debriefing sessions and reflective writing assignment demonstrated promise in improving the confidence and clinical reasoning abilities of AG-ACNP students. Finally, findings from this small prototype project support the need for further exploration and expansion of simulation as a frontline strategy to educate and evaluate NP students in all specialty areas. Expanding simulation beyond skill development, knowledge acquisition, satisfaction, and confidence to examine transfer into practice and impact on patient outcomes is also critical not only to demonstrate the value of SBLEs but also to enhance quality and safety for patients.

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National League for Nursing (NLN) Student Satisfaction and Self-Confidence in Learning Scale (SSSCL)—Participant Self-Confidence and Satisfaction with Learning (N = 10)

SubscaleMeanActual Rangea
Satisfaction with learning4.864.0 to 5.0
Self-confidence in learning4.734.37 to 5.0

National League for Nursing (NLN) Simulation Design Scale (N = 10)a

SubscaleRating of Design Elements (Mean)Importance of Item (Mean)
Objectives and information54.9
Support4.755
Problem solving4.54.5
Feedback and reflection4.754.5
Fidelity/realism4.84.75

Reflective Writing Assignment

Following your simulation experience on campus, I would like you to write a 1–2 page reflection using the following guiding questions in paragraph/essay format:

Were you able to “suspend disbelief” and treat the simulated patient as if they were a real patient you were treating? If not, why not?

How do you think you performed during the simulation?

Do you think that performing simulations in acute care is valuable to your learning? Why or why not?

Did you feel that you were able to properly evaluate and treat your patient(s)? Why or why not?

These are just guiding questions - you can write your reflection as you see fit. Be honest - I am interested in how your education was impacted by this simulation. I look forward to reading your reflections.

Evaluation Rubric for Adult-Gerontology Acute Care Nurse Practitioner Summative Simulation

Student Name: ______________________________Chief Complaint: ________________________
ItemSUComments
Performs through history and physical examination

□ Review of Systems

□ History: present illness, past surgery, past medical, family, social, medications, allergies

□ Complete Physical Exam

□ Able to present logically to facilitator

Complete list of differential diagnoses presented to facilitator – able to explain why each diagnosis is on their list.
Appropriate diagnostic tests are ordered and can explain why each test is being ordered.
Ability to properly interpret results of diagnostic tests.
Arrives at correct diagnosis (definitive or most likely) based on history and physical and diagnostic work-up.
Formulates appropriate, comprehensive plan of care (POC) for the diagnosis. Includes issues related to pharmacologic and nonpharmacologic interventions.
Presents POC to patient with thorough explanation and answers all questions appropriately.
Miscellaneous:

□ Properly communicates with emergency center staff

□ Properly communicates with patient

□ Utilizes available resources to develop POC

Authors

Dr. Keiser is Director of Undergraduate Nursing Affairs and Associate Professor of Nursing, and Dr. Turkelson is Director of the Simulation Center and Associate Professor of Nursing, University of Michigan-Flint, School of Nursing, Flint, Michigan.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Megan M. Keiser, DNP, RN, CNRN, SCRN, CHSE, ACNS-BC, NP-C, Director of Undergraduate Nursing Affairs and Assistant Professor of Nursing, University of Michigan-Flint, School of Nursing, 2180 William S. White Building, 303 E. Kearsley Street, Flint, MI 48502-1950; e-mail: keiserm@umflint.edu.

Received: December 27, 2018
Accepted: July 17, 2019

10.3928/01484834-20190923-08

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