Traditionally, pediatric clinical rotations for undergraduate nursing students have been conducted in outpatient settings such as schools and clinics and inpatient settings. However, the large demand for nursing student placements within facilities in a given area can limit the availability of clinical placements that enable students to experience variations in patient types and disease processes. A student may spend the majority of rotations in a respiratory unit, with no opportunity to care for patients who have gastrointestinal, surgical, or neurologic diseases. The seasonal variability of infectious diseases in pediatric patients such as respiratory syncytial virus and influenza also affects numbers and types of patients, so that pediatric students' exposure to common childhood diseases may be inconsistent. Clinical shifts are also frequently limited to 6 to 8 hours to accommodate oncoming groups of students, which makes it difficult for students to witness the full progression of a treatment plan or disease process within their allotted time frame. With these limitations in mind, faculty worked to develop unfolding simulation scenarios that would serve as an adequate replacement for a portion of clinical rotations in undergraduate pediatrics. The simulation development process and logistics of implementation are discussed. Outcome measures were designed to evaluate the overall shift in percentage of clinical time spent in simulation while maintaining simulation quality and thus improving overall clinical readiness.
Literature searches were conducted in the CINAHL®, PubMed®, and Cochrane Library databases, using combinations of subject headings and keywords that included pediatrics, nursing, simulation, and unfolding. Although there is much research on the need, efficacy, and benefits of implementing simulations for pediatric nursing students (Arslan et al., 2018; Bowling, 2015; Eade & Winter, 2017; Filer, Champlin, & Hunt, 2012; Gamble, 2017; Hogewood, Smith, Etheridge, & Britt, 2015; Lubbers & Rossman, 2016; Megel et al., 2012; Shin, Shim, & Lee, 2013) and on unfolding case studies in pediatrics (Flood & Commendador, 2016; Jones & Sheridan, 1999), sparse literature discusses the implementation of an unfolding or progressive simulation scenario in pediatric nursing education. Only one article was found that described the use of unfolding simulation in maternity and pediatric nursing education. In that article, Edwards, Boothby, Succheralli, and Gropelli (2018) discussed the need to develop unfolding simulations for maternity and pediatric students, owing to barriers of clinical placement and exposures. Their intervention involved several simulations with different family members at differing time intervals throughout pregnancy and delivery. They concluded that their unfolding case with fidelity provided students with meaningful clinical experiences that would have been limited in traditional clinical learning situations.
Witt, Weiss, and Elixhauser (2014) used data from the Healthcare Cost and Utilization Project and the Kids' Inpatient Database to determine the most common principal diagnoses for hospital inpatient stays among children ages 0 to 17 years. The most prevalent diagnostic-related groups for this population were pneumonia, acute bronchitis, and asthma. All were the top respiratory-related admissions for nonneonatal and nonmaternal disorders. Mood disorders, appendicitis, epilepsy, skin and tissue infections, fluid and electrolyte disorders, chemotherapy, and urinary tract infections were also among the top 10 reasons for pediatric admissions. For the current project, these data provided a guide in discussions with faculty from our undergraduate nursing program, who reviewed the data to examine gaps between prevalent diagnoses and current clinical experiences in both inpatient and outpatient settings. The faculty determined that exposure to pediatric patients with pneumonia, bronchitis, and asthma was adequate, but that students often were not allowed to participate fully in the care of those patients. The faculty felt that current clinical placements provided adequate exposure to gastrointestinal disorders such as appendicitis, as well as skin and subcutaneous infections, but the overlap between content areas such as fluid and electrolyte disorders and urinary and renal conditions could be explored through simulation. The faculty therefore decided on a model in which individual scenarios would have three phases that progressed in response to nursing interventions or through anticipated changes in patient conditions and likely complications of disease processes. Faculty teams were formed to develop each unfolding scenario based on their areas of clinical expertise. Our pediatric clinical facilitator served as the lead faculty and simulation liaison between pediatric clinical faculty and our simulation center to ensure that scenario development was realistic with an appropriate level of fidelity.
After initial drafts of scenarios were completed by the faculty teams, peer review was conducted by an alternate member of the pediatric clinical faculty. Meetings were conducted to discuss clinical guidelines and practice standards for each scenario, keeping in mind the level of fidelity and time required to complete interventions within the simulation center.
Needs analysis was conducted using the scenario drafts to determine simulation requirements. It was determined that additional infant and pediatric simulators and pediatric-specific equipment were needed, which were purchased with Nursing Innovation Grant program funds from the Texas Higher Education Coordinating Board. The goal was to provide a realistic pediatric hospital environment or outpatient setting. Table 1 demonstrates the scenarios developed, along with the skills integrated and the progression across settings and times that allowed equipment and settings to provide a sense of realistic replacement for actual clinical settings.
Simulation Scenario Progression and Skills
When planning the simulation schedule each semester, consideration was given to the number of clinical groups in the pediatrics course, the simulation expertise of the faculty, teaching assistants in the course, and demands on the simulation center by other clinical simulations. The number of students in the course varied between 60 and 72 each semester. Each semester, students register for clinical sections of nine to 12 students each under a primary faculty and clinical teaching assistant. The faculty member accompanied students to all clinical settings, including simulation. Therefore, all clinical faculty underwent yearly training in simulation pedagogy. Clinical teaching assistants, who typically provide support only during inpatient rotations, were also trained to provide simulation instruction and evaluation. To increase the efficient use of faculty, teaching assistants, and simulation center staff, two sections participated in alternating morning and afternoon simulation sessions on a scheduled simulation day. The result is two faculty and two clinical teaching assistants capable of running four simultaneous simulations throughout the day. For example, one faculty and one teaching assistant pair implemented parallel asthma scenarios while the other faculty and teaching assistant pair implemented parallel pneumonia scenarios. Simulation days were spread throughout the semester, with more complex scenarios toward the end of the rotation.
Students were assigned presimulation modules that included textbook reading, video vignettes, and a list of possible medications. The students were responsible for completing a prescenario quiz and submitting medication cards for assigned medications. On presentation to the simulation center, students were prebriefed in groups of nine to 12 and then divided into groups of three. Ground rules for the simulation setting were outlined, including treating all simulators as real patients, instructions for completing procedures on the simulator, and using equipment appropriate to the setting (i.e., no oxygen available in a school health clinic, programming of intravenous pumps and medication devices appropriately, and confidentiality of patient, student, and scenario information within the simulation center). Students had previously signed consent regarding the use of video monitoring within the simulation center.
Each small group of three students was escorted to a room, oriented to the equipment and surroundings, and provided with a prebrief of the scenario. The students were then assigned individual roles of primary nurse, secondary or support nurse, and family member. The family member role was scripted so that the student could respond appropriately and ask questions at certain junctures during the scenario to ascertain the primary and secondary nurse's knowledge. Students were given a 10-minute planning session prior to beginning the simulation. Faculty monitored the situation from the control booth via remote video, as well as provided the patient's voice. Remote monitoring allowed faculty to control simulator responses such as vital signs in response to nursing student interventions or lack thereof. After 20 minutes, faculty provided a reset to rotate student roles and further the scenario. Students were given cues such as “It is now 1 hour later, and the patient has been moved from the emergency room to the floor, you are admitting the patient,” or “It is now 24 hours of time elapsed and you are returning for your shift with the same patient assignment.” Three 20-minute segments in each scenario allowed all students to assume the role of primary, secondary, and family member within the same patient scenario. Ninety minutes were allotted for each simulation to allow three 20-minute segments and 10 minutes of instruction in between. Following completion of the full scenario, faculty led a 15-minute just-in-time debrief in the simulated hospital room, which focused on learning outcomes of knowledge, skills, and attitudes, as well as the reaction outcome of self-confidence. The Jeffries simulation theory provided the framework for this debrief (Jeffries, Rogers, & Adamson, 2015). The same group of students then progressed to the second simulation scenario so that they could complete the same design within a different patient situation.
Following completion of two unfolding scenarios, small groups of three students each rejoined into a larger group debriefing session led by the two pediatric faculty. The scope of this debrief included participant and patient outcomes, which included additional discussion of learning, reactions, and behaviors (Jeffries et al., 2015). In the larger group, students were able to share experiences, insights, knowledge acquisition, learner satisfaction, critical thinking, and self-confidence. Because there was room for some variation in patient responses based on students' intervention performed during the individual scenarios, the smaller groups had slightly different experiences to share. The sharing of successes and learning opportunities was facilitated in a nonthreatening manner with emphasis on how outcomes translate to behavior changes in other clinical settings. Students then selected one of the patient case scenarios to develop a graded concept map to comprehensively link the disease process, diagnostic studies, and assessment findings and interventions.
The initial goals of this project were to shift pediatric clinical hours from inpatient and outpatient settings into simulation while increasing student clinical readiness. The goal for year 1 of implementation was a shift to 25%, or an additional 8 hours of simulation time per student. The goal for year 2 was to increase that shift to 33% of clinical time, or an additional 16 hours. Due to logistics and time needed for faculty training, the full goal was not realized in the first year. The shift in clinical hours is outlined in Table 2.
Shift in Clinical Hours to Simulation
Clinical readiness was measured via a standard simulation effectiveness survey administered electronically to all students at the conclusion of the simulation day. The percentage of students who answered strongly agree is provided below for the first semester of implementation (S1), the second semester of implementation (S2), and during the second full year of implementation (Y2). In response to the prompt “I feel better prepared to care for real patients,” there was an increase of 46.5% over the 2-year period (S1 = 46.2%; S2 = 71.3%; Y2 = 89.7%). For the statement “I am able to better predict what changes may occur with my real patients,” there was a 35% increase (S1 = 53.9%; S2 = 71.6%; Y2 = 88.9%). Understanding of medications demonstrated 30.7% increase (S1 = 53.9%; S2 = 76.3%; Y2 = 84.6%). Confidence in patient assessment noted a 38.5% increase (S1 = 46.2%; S2 = 67.5%; Y2 = 84.7%). Confidence in decision-making skills demonstrated a 27.3% increase (S1 = 61.5%; S2 = 85.8%; Y2 = 88.8%). Students also indicated that the debriefing and group discussions were valuable (S1 = 69.2%; S2 = 80.4%; Y2 = 94%). This information is represented in Figure 1.
Clinical readiness indicators.
Student comments on the survey included feeling that the scenarios were well organized and balanced in regard to skills, assessments, and interactions with the patient and family member. The students noted that the unfolding case study provided them with the opportunity to think critically and apply nursing judgment in a way that they had been unable to do both in clinical settings and in prior simulations. The students also stated that exposure to the family member's role was a valuable learning opportunity that opened their eyes to the stressors of family members of pediatric patients.
Because of the complexity of these unfolding case studies, several rounds of revisions have taken place over many semesters; these revisions were made by faculty based on feedback from students, faculty, simulation laboratory staff, and clinical teaching assistants. The length of these simulations and the three-phase layout requires strict adherence to a time schedule, so many of the revisions have been made with regard to the balance of skills, assessments, and treatments required within each phase. Additionally, revisions have been made to both the simulator settings and electronic health record system to more adequately and accurately mimic a true clinical experience.
Simulation as a replacement for clinical hours must provide students with equal or enhanced opportunities to develop in skills and critical thinking, compared with the traditional clinical setting. Through the unfolding simulations, students experienced a variety of conditions that would not have been consistently available in the clinical setting. The changes in patient condition and responses to nursing interventions allowed students to gain nursing judgment. Clinical hours may be shifted into simulation with appropriate planning, implementation and faculty commitment.
- Arslan, F.T., Türkmen, A.S., Çelen, R., Özkan, S., Altiparmak, D. & Sahin, A. (2018). Comparing traditional and simulation-based experiences in pediatrics with undergraduate nursing students in Turkey. Clinical Simulation in Nursing, 16, 62–69.
- Bowling, A.M. (2015). The effect of simulation on skill performance: A need for change in pediatric nursing education. Journal of Pediatric Nursing, 30(3), 439–446.
- Eade, A.C. & Winter, C. (2017). Using simulated practice in pre-registration education to explore mental health issues. British Journal of Nursing, 26(12), 690–694. doi:10.12968/bjon.2017.26.12.690 [CrossRef]
- Edwards, T., Boothby, J.E., Succheralli, L. & Gropelli, T. (2018). Using an unfolding simulation with maternity and pediatric nursing students. Teaching and Learning in Nursing, 13, 122–124. doi:10.1016/j.teln.2017.10.003 [CrossRef]
- Filer, D.A., Champlin, B. & Hunt, R. (2012). Creating and implementing an unfolding, multisetting simulation in a postbaccalaureate nursing program. Clinical Simulation in Nursing, 8(5), e181–e186. doi:10.1016/j.ecns.2010.09.003 [CrossRef]
- Flood, J.L. & Commendador, K. (2016). Avatar case studies: A learning activity to bridge the gap between classroom and clinical practice in nursing education. Nurse Educator, 41, 3–4. doi:10.1097/NNE.0000000000000195 [CrossRef]
- Gamble, A.S. (2017). Simulation in undergraduate paediatric nursing curriculum: Evaluation of a complex ‘ward for a day’ education program. Nurse Education in Practice, 23, 40–47. doi:10.1016/j.nepr.2017.02.001 [CrossRef]
- Hogewood, C., Smith, T., Etheridge, S. & Britt, S. (2015). Clinical boot camp: An innovative simulation experience to prepare nursing students for obstetric and pediatric clinicals. Nursing Education Perspectives, 36(6), 410–411. doi:10.5480/15-1677 [CrossRef]
- Jeffries, P.R., Rodgers, B. & Adamson, K.A. (2015). NLN Jeffries simulation theory: Brief narrative description. In Jeffries, P.R. (Ed.),The NLN Jeffries simulation theory (pp. 39–42). Philadelphia, PA: Wolters Kluwer.
- Jones, D.C. & Sheridan, M.E. (1999). A case study approach: Developing critical thinking skills in novice pediatric nurses. The Journal of Continuing Education in Nursing, 30(2), 75–78. doi:10.3928/0022-0124-19990301-09 [CrossRef]
- Lubbers, J. & Rossman, C. (2016). The effects of pediatric community simulation experience on the self-confidence and satisfaction of baccalaureate nursing students: A quasi-experimental study. Nurse Education Today, 39, 93–98.
- Megel, M.E., Black, J., Clark, L., Carstens, P., Jenkins, L.D., Promes, J. & Goodman, T. (2012). Effect of high-fidelity simulation on pediatric nursing students' anxiety. Clinical Simulation in Nursing, 8(9), e419–e428. doi:10.1016/j.ecns.2011.03.006 [CrossRef]
- Shin, H.S., Shim, K.K. & Lee, Y.N. (2013). Nursing activities identified through pediatric nursing simulation. Child Health Nursing Research, 19, 111–119.
- Witt, W.P., Weiss, A.J. & Elixhauser, A. (2014). Overview of hospital stays for children in the United States, 2012 (Statistical Brief No. 187). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.jsp
Simulation Scenario Progression and Skills
|Fever/sepsis workup (neonate)||Emergency department progressing to inpatient admission||Time from triage presentation in the emergency department through admission to the floor||Specimen collection, IV insertion, maintenance fluid calculation, antibiotic administration, specimen handling, in and out catheterization, and neonatal assessment|
|Asthma exacerbation (school age)||School nurse clinic to emergency department to inpatient admission||School nurse assessment and recommendation for emergency treatment progressing to 24 hours after stabilization and admission to the floor||Focused pediatric respiratory assessment, peak flow readings, administration of metered-dose inhaler and nebulizer, IV insertion, IV push medications, and asthma education|
|Pneumonia (adolescent)||Inpatient setting 12 hours postadmission||Stable patient with routine antibiotics progresses to pneumothorax complication of pneumonia||Head to toe adolescent assessment, administration of IV antibiotics, maintenance of IV fluids, oxygen administration through various devices, maintenance of sterile field, and chest tube care|
|HSP (Henoch-Schonlein purpura) (early school-age)||Inpatient setting 24 hours after admission||From initial disease presentation through development of renal failure complications||Head to toe pediatric assessment, pediatric pain assessment and management, specimen collection, laboratory interpretation, and fluid and electrolyte management|
|Accidental ingestion (toddler)||Emergency department through inpatient admission||Emergency management of accidental ingestion progressing to hypoglycemia episode with patient management and family teaching on safety||Head to toe pediatric assessment, focused neurological assessment, control of nausea and emesis, evaluation and management of hypoglycemia, fluid and electrolyte management|
Shift in Clinical Hours to Simulation
|Time Frame||Total Clinical Hours||No. of Simulation Hours||Increase in Simulation|
|Prior to implementation||120||8 (7%)||–|
|Year 1||120||24 (20%)||200%|
|Year 2||120||40 (36.5%)||475%|