Demand for nursing care is shifting from acute care to community health settings due to growth in the elder population and changes to health care policies (Gray, Grist, & Race, 2016). As health care expands beyond the acute care setting, nurses must be equipped to meet patient needs in the community (Molloy et al., 2018). Nurse educators must prepare students for safe practice in community and home care environments (Gibbs, Trotta, & Overbeck, 2014). Providing community clinical experiences for the baccalaureate student is an essential part of the curriculum; however, large cohort student placement for home health care clinicals can be challenging (Molloy et al., 2018). The purpose of this project was to evaluate the implementation of a simulated home environment to increase nursing students' experience in home health care in response to increasing student numbers and decreasing clinical placements.
Often, multiple teaching strategies are used in the curriculum to prepare students for practice in various health care environments. Investigators aimed to use simulated home visits as a teaching strategy to better prepare students for follow-up home health nursing visits. Simulation is an alternative teaching method to introduce patient-centered concepts (Hartman, 2018). Simulation stimulates critical thinking, promotes knowledge transfer to the clinical setting, and allows time for meaningful reflection (Gibbs et al., 2014; Yeun, Bang, Ryoo, & Ha, 2014). As simulation is integrated within the curriculum, learning outcomes are achieved (Masters, 2014). In a study by Gibbs et al. (2014), simulation provided opportunities for students to “think” and “do” and was a beneficial teaching strategy for commonly occurring health conditions, not only high-risk, low-volume disease occurrences.
Benner's novice to expert model (Benner, 1984) provided a foundation to explore nursing students' acquisition of knowledge and skill development to care for patients in the home environment. Benner's model posits that nursing skills and patient care develop over time from a combination of foundational educational principles and personal experiences. Benner's model describes five stages of clinical skills acquisition: novice, advanced beginner, competent, proficient, and expert. Advancement through these five stages indicates changes in three aspects of skill performance, including moving from relying on abstract principles to using past experiences to guide practice, viewing situations holistically rather than as separate pieces, and actively engaging in situations rather than observing. The students participating in this home health simulation experience were in the second semester of a five-semester program. They completed clinical experiences in the first and second semesters, but none in the home environment. Faculty expected the majority of second-semester students would fall into the novice stage and some into the advanced beginner stage. Nursing student progression from novice to advanced beginner may occur throughout the program as students experience a variety of clinical experiences. The theoretical underpinning for this experience, based on Benner's model, is that nursing students will have increasing knowledge and skills to care for patients in the home environment with repeated exposure and various clinical experiences throughout the program.
A pilot study was conducted to evaluate implementation of a simulated home environment to increase nursing students' experience in home health care. The setting was a baccalaureate school of nursing program located within a public university in the southeastern United States. The home health simulation was offered during the second-semester medical–surgical course, which includes inpatient and community health clinical hours.
Institutional review board approval was obtained. All students enrolled in the second-semester medical–surgical course were required to complete the simulation, but data were recorded only for those who consented to the study. Course faculty were not aware of which students chose to participate in the study.
The simulation took place in the home health simulation suite and used a low-fidelity manikin. Students completed the simulation in pairs. The simulation was recorded for education purposes per school of nursing protocol.
The scenario for the simulation involved a home visit with a patient diagnosed with congestive heart failure (CHF). Faculty chose the CHF diagnosis because this is a topic discussed in the second-semester medical–surgical course and students frequently care for patients with CHF in the clinical setting but do not get to see the impact of the condition on patients' day-to-day life. According to Benner's model, second-semester students with limited clinical experience are at the novice to advanced beginner stages. Objectives for the simulation that were appropriate for this level of student were developed.
The simulation consisted of a 10-minute prebrief, 20-minute simulation, and 30-minute debrief. Students were provided with background information through an audio recording of the patient which included an introduction, the patient's description of his experience in the hospital, and the patient's understanding of the role of the home health nurse. Students take this report and develop a plan of care prior to the simulation experience as a part of the simulation prework. Students were also required to complete presimulation activities, including review of patient's health condition and medications and identification of community resources the patient can use to assist in disease management. The students used information from the presimulation activities to guide patient teaching during the simulation.
During the 20-minute simulation, students focused on three objectives:
- Evaluate the patient for signs and symptoms of CHF by conducting a focused cardiovascular and respiratory assessment.
- Educate the patient to recognize at least two signs and symptoms of CHF exacerbation using the teach-back method.
- Discuss three potential environmental hazards in the home setting with the patient.
Faculty who observed the simulation conducted a 30-minute debrief using the International Nursing Association for Clinical Simulation and Learning (2016) best practice standards for conducting debriefing.
The Simulation Effectiveness Tool-Modified (SET-M; Leighton, Ravert, Mudra, & Macintosh, 2015) was used to assess effectiveness of the simulated learning experience in meeting student learning needs. This 19-item self-report tool measures confidence, empowerment, and understanding in prebriefing, simulation, and debriefing using a scale of 1 (do not agree) to 3 (strongly agree). A high overall internal consistency reliability score (α = .936) was previously reported for this tool (Leighton et al., 2015).
Student performance was evaluated using the Quint Leveled Clinical Competency Tool (QLCCT; Prion, Gilbert, Adamson, Kardong-Edgren, & Quint, 2017). This tool allows rating of observed learner performance for 10 competencies using a scale of 1 (novice) to 4 (graduate nurse). Investigators eliminated the last section, self-reflection and improvement, because the debriefing was not recorded and thus could not be evaluated. As a result, the total possible score ranged from 9 to 36. Given the nine categories, a score of 1 in all nine categories would receive an overall score of 9 and a score of 2 in all categories would receive an overall score of 18. Students who are new to the nursing program (in their first and second semesters) are expected to score mostly 1s and 2s. Overall internal consistency was previously reported to be α = .83 for this instrument (Prion et al., 2017).
Prior to prebrief, students were assigned a number and the number was displayed on their scrub top, easily viewable on the video recording. Following the debriefing portion of the simulation, the study was explained to the students by the simulation coordinator who was not responsible for assigning grades in the course. Students were provided an information letter and offered the opportunity to ask questions about the study. Completion of the SET-M indicated consent to participate in the study. Students who chose to participate wrote their assigned number on the tool to maintain confidentiality.
At the completion of the semester, a list of student numbers who consented to participate was provided to a graduate research assistant who had been trained in the use of the QLCCT. The graduate research assistant used the assigned student number list and rated the students' performance using the QLCCT by watching video recordings of the scenario. The anonymous data from the QLCCT and SET-M instrument scores were provided to the principal investigators by the assistant.
Of the 94 second-semester students who completed the home health simulation, 70 (74%) agreed to participate in the study. This cohort of students was 95% female and 5% male. The total mean score for the SET-M was 2.7 (SD = 0.34; range = 1 to 3). Reliability for the SET-M measured by Cronbach's alpha was .85. The overall mean score for the QLCCT was 16.78 (SD = 0.24; range = 9 to 36). Only 58 of the 70 participants were scored using the QLCCT due to a technical issue with the recording of six student groups. Reliability of the QLCCT measured by Cronbach's alpha was .62. Spearman's rho analysis was conducted to determine whether there was an association between the SET-M and QLCCT scores. A medium statistically significant correlation existed between the two variables (rs = .35; p = .01).
Investigators aimed to provide a simulation to better prepare junior-level nursing students for home care in light of limited clinical placements. Literature indicates that preparation work and a safe simulated environment allow students to gain confidence in patient communication skills, patient monitoring, and assessment (Ellis, Meakim, Prieto, & O'Connor, 2018; Molloy et al., 2018). Students in this study completed a simulation that provided experience with patient communication, monitoring, and assessment. Students met the simulation objectives by satisfactorily assessing the patient with CHF, educating the patient about signs and symptoms of an exacerbation, and discussing environmental hazards in the home setting. Study results indicated that the home health simulation was an effective teaching strategy to introduce second-semester students to care for a patient in the home environment.
Students perceived the simulation to be an effective clinical experience as indicated by the high overall mean score (2.7 of 3) on the SET-M. The setting for the simulation was a customized home health room within the simulation suite, which provided a realistic home environment. Having a dedicated space for home health to enhance learning needs for the community course objectives provides more positive and effective simulation experiences (Hartman, 2018). Qualitative comments on the SET-M indicated that students found the simulation to be a meaningful learning experience. Comments included “This was the most useful simulation experience I have had yet. I felt confident about patient education and communication.” and “Very helpful for home health clinicals we have in the future!”
Prior to the simulation, students participated in a class where cardiovascular content was covered, completed readings, and listened to a prerecorded audio clip of the patient where the health history, medications, and psychosocial information were shared. During the prebriefing, simulation objectives and patient report were reviewed. The information provided to students prior to the simulation likely contributed to the 2.69 prebriefing mean score on the SET-M. The mean score on SET-M for the simulation was 2.61. Students commented that they felt much more confident in their skills, assessment, patient education, communication, and overall home health knowledge. The mean score for debriefing questions was 2.94, indicating that the students' perception is that debriefing strengthens their learning, confidence, and clinical judgment. Several students qualitatively reported that debriefing gave them a chance to discuss and reevaluate the situation and gave them a better understanding of care of the patient in the home versus hospital setting.
The mean score for the QLCCT was 16.78 (range = 9 to 36), which is low but at the expected level for second-semester students, and aligns with Benner's novice to expert model (Benner, 1984). Students primarily received scores of 1 or 2 in each category. The highest category score was for nursing skills (mean = 2.02) and the focused observation and information-seeking category was also high at 1.91. The simulation required students to obtain vital signs, conduct a focused cardiovascular and respiratory assessment, and perform a home safety check. Faculty believe these two category scores were high because of the emphasis placed on health assessment in first semester and reinforced in second semester with an assessment check off. Additionally, this simulation occurred at the midpoint of second semester after students completed several days of acute care clinical experiences. The prioritizing mean QLCCT score was also high at 2.0 (progressing stage). The criteria for progressing includes ability to prioritize pertinent data for the development of a basic diagnosis in simple situations, prioritize client care in a sufficient time frame for routine types of care in simple situations, and develop and explain the basis of interventions in routine situations. Faculty believe this category score was high because of the presimulation information the students received. According to this school's simulation pedagogy, early learners get more information, and as students progress through the program, less specific information is provided to assess clinical judgment. This also aligns with Benner's model, which describes growth from novice to expert—as students move across the spectrum and develop in their role, they require less presimulation information because they are able to assess situations and draw on previous experiences. The scenario for the home health simulation was set up to be appropriate for the learner; thus, information was provided to students, which may have contributed to the higher scores on the prioritizing category.
The correlation between the SET-M and QLCCT was statistically significant. Students' perception of clinical performance and knowledge gained from the experience aligned with QLCCT scores. Students perceived they were performing at the expected level. The correlation between student and faculty evaluations confirmed their perceptions.
A small convenience sample of second-semester students, predominately female, was used for data collection, which limits generalizability. Due to a technical glitch, six groups were not videoed during the simulation, which left a smaller sample size for the QLCCT data. The simulation itself was not free from limitations. Students reported feeling rushed during the scenario and that the manikin appeared too healthy for the symptoms he was exhibiting. These limitations may have affected student performance during the simulation and thus outcomes on the QLCCT and SET-M. In future home health simulations, faculty plan to extend time of the scenario and use standardized patients to increase believability of the experience.
A home health simulation can augment clinical education by offering experience in a controlled environment. The results of this study indicate that simulation is a viable alternative to meet learning objectives for acute or commonly occurring medical–surgical conditions treated in a home health environment. Providing community health experiences for the baccalaureate student is an essential part of the curricula. In light of limited availability of clinical sites, nurse educators can use simulation to equip students with clinical judgment skills to meet the needs of an increasing home health care population.
- Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
- Ellis, D.M., Meakim, C., Prieto, P. & O'Connor, M. (2018). Transitional care experience in home health: Exposing students to care transitions through scenarios and simulation. Nursing Education Perspectives, 39, 48–50.
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