CHAPTER 15

The New Skills Laboratory:

Application of Theory, Teaching,

and Technology

Deborah Tapler and Judy Johnson-Russell

INTRODUCTION

Creating an effective skills laboratory can energize students and facilitate the transition from practice of required skills to delivery of direct care to clients. The skills laboratory, using multiple modes of teaching and learning, provides an atmosphere for students to acquire new skill knowledge and implement those new skills. With emerging restrictions of clinical placement of health-related students, the skills lab can be used as a learning environment without the presence of clients (Duffin, 2004).

Nursing programs are debating proposals that would allow students to spend much more clinical time in practice labs instead of in actual hospital units. With unlimited hours of operation, the lab can provide needed opportunities to practice procedures, evaluate learning outcomes, and reinforce critical thinking objectives. As technology increases in complexity through the use of advanced human patient simulators, the skills laboratory can now provide almost true-to-life clinical situations.

DEFINITIONS AND PURPOSES

Acquisition of new knowledge and skills is an important component of the educational curriculum for healthcare professionals. Nurses must be able to perform procedures such as wound care, intravenous therapy, and endotracheal suctioning. Through the use of a skills laboratory, these and other integral patient care skills are learned and practiced before implementation on patients. The instructor educating students about skills uses several sources for instruction.

The roles and responsibilities of the skills lab have changed with time and advances in learning technology. The skills lab takes on various labels based on its broad offering of services or purposes (Childs, 2002). Schools of nursing across the country suggest the following names: Clinical Skills Laboratory, Clinical Resource Center, Learning Resource Center, Clinical Competencies Learning Laboratory, or, simply, Nursing Laboratory. Current laboratory facilities 227

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offer assessment labs, bed labs, static mannequins, simulation, training devices such as intravenous insertion simulators, video libraries, and computer services.

Some universities support patient clinics associated with the skills lab for student experiences with actual patients. The skills lab offers a continuum of services depending on the school’s interests, specific curriculum needs, and financial capability.

Theory-based practice guides the educator when preparing to teach new skills.

Theory has a direct link to practice. Educational theories relate the instructor to students through the development of effective learning strategies appropriate for selected students. Theory also influences practice through theory-driven research that impacts patient care. For example, germ theory dictates the procedure of successful hand washing, which is a skill that every student must master to prevent infection. When learning in the skills lab, the student must progress beyond the

“how” of a procedure to the more complex level of thinking to ask “why.”

Evidence-based practice must also be used in the skills laboratory. Evidence-based practice is a systematic approach to problem solving that can be applied to patient care delivery as well as education (Pravikoff, Tanner, & Pierce, 2005).

Teaching skills that are based on valid research provide students with state-of-the-art information for safe implementation of skills in actual clinical experiences.

It is imperative to educate students about the process of accessing research evidence as part of a lifelong learning goal. Inviting students to participate in the evidence-based process is an important teaching opportunity to allow students to discover best practices regarding content reviewed in the skills lab. For example, students are assigned a particular topic, such as blood pressure monitoring or safe medication administration, to seek reputable best practice standards regarding the psychomotor skill. Elements of procedures and relevancy of skills change as knowledge and technology grow. The skills laboratory must reflect the most current information when educating nurses for the future.

The purpose of this chapter is to explore the roles, diverse uses, and effectiveness of a skills laboratory. Based on current theory, valuable teaching modalities, and advanced technology, the skills laboratory can be an effective tool of education for a wide range of health-related disciplines.

THEORETICAL RATIONALE

Knowles’ theory of adult learning has shaped the way that educators present information to adult learners (Knowles, 1989). Adults approach a learning situation differently than children. With life experiences to color the acquisition of new knowledge and skills, adults thrive in a learning environment that is open to creativity, values personal knowledge, and is relevant to immediate learning Conditions 229

goals. Adult learners desire to make individual choices and decisions. Education in the skills laboratory is hands-on and relevant to direct patient care. Students are allowed and encouraged to self-evaluate their competence prior to clinical placement (Clarke, Davies, & McNee, 2002). They develop self-confidence as they learn psychomotor skills without fear of failure. After the students attend traditional learning presentations, such as lecture, the adult learners are motivated to learn those things in the skills lab that they know will be necessary to accomplish course objectives. Practice in the skills lab allows the students to cope effectively with future patient interactions. The skills lab can also provide academic assistance when a student has difficulty integrating knowledge regarding a psychomotor skill.

Benner’s theory of skill acquisition plays an important part in the nursing education curriculum (Benner, 2001). Benner proposed a model for the nursing profession based on the Dreyfus model explaining that nurses function at various levels of skill from novice to expert. The novice level is characterized by a lack of experience of the situations in which the person is involved and is expected to perform. The beginning nursing student functions at the novice level. The nursing curriculum gives students entry to nursing situations and allows them to gain the experience through skills development. The skills lab acts as an instrument to transfer knowledge and skills to novice nursing students so that they may progress to increasingly more complex levels of understanding. The skills lab can be used to teach about situations in terms of “objective attributes” such as intake and output, blood pressure, and temperature (Benner, 2001, p. 20). These features of the task world of nursing have to be learned before actual situational experiences with patients. The behavior of the novice is rule-governed and very limited and inflexible. Faculty members impart rules to guide performance before the information makes sense to students. Practice and rehearsal of new behaviors allow the students to gain confidence in their abilities despite little understanding of the contextual meanings of recently learned nursing concepts. Thus, the skills lab plays an important role in the learning process of new students who have no contextual cues. As the nursing student progresses through the nursing curriculum to graduation, the role of the skills lab can evolve and change to meet the expectations for learning dictated by the faculty and content objectives. According to Benner, students may progress from novice to advanced beginner then to the competent, proficient, and expert levels of nursing ability over the lifetime of a career.

CONDITIONS

The skills laboratory can be used effectively throughout the curriculum. According to Infante (1985), the purpose of a skills laboratory is to offer students the 230 Chapter 15 • the New SkillS laboratory

appearance of reality in an artificial environment where the setting is controlled and offers practical application. The students are encouraged to achieve a pre-defined level of skill competence (Clarke et al., 2002). As skills move from simple (such as bathing) to complex (such as suctioning), the skills lab can be a learning experience that provides for advancing levels of knowledge and abilities.

Faculty involved in undergraduate curricula should identify skills associated with each level of progression to ensure that all necessary content is reflected in the educational goals of the laboratory. In addition, identified skills should be appropriate to the skill level of the student. Typically, nursing education has utilized the skills lab to provide psychomotor skill acquisition at the beginning of the curriculum. However, with technologies used in the lab, such as computer-based interactive case studies and human-patient simulators, new modalities have provided unlimited opportunities for knowledge as well as skill development. Critical thinking scenarios are appropriate and can be facilitated by skills lab experiences.

Faculty members using the skills lab should strive to teach a diversity of skills to students. Even though the skills lab typically provides an environment that lends itself to the training of psychomotor skills, other cognitive and affective domain skills can be developed by students. Students learn therapeutic communication and interpersonal skills through staged interactions with mannequins.

Collaboration is instilled when students work in groups to deliver patient care through participation in simulation. Faculty-developed case studies used in the lab should be structured with a communication component to include telephoning the physician to clarify an order or suggesting strategies to interact with a distressed family member.

Learning situations can be enhanced by the contained setting of the skills laboratory. With close supervision and responsive interactions between students and faculty, the students learn in an environment of collaboration and inquiry.

Questions about new procedures or concepts can be answered and discussed promptly without the constraints of a fast-paced patient care area. Faculty members act as facilitators and have opportunities to present information regarding advances in evidence-based practice. Students feel confident to try new skills in a low risk situation without fear of harming patients. Mistakes are excellent sources of learning and do not have to possess penalizing consequences. However, if the skills laboratory is used for mastery performance evaluation of student abilities, the results can be recorded as a component of a course grade or used for remedial identification. Students who have weaknesses in psychomotor or critical thinking skills can use the environment of the skills laboratory for tutoring assistance from faculty. Through one-on-one interaction, the weak student can practice and receive immediate feedback from a qualified evaluator to gain knowledge and confidence.

Types of Learners 231

TYPES OF LEARNERS

Undergraduate nursing students possess various learning styles. The skills laboratory can provide a rich learning experience for all types of learners. Whether the student learner is self-directed or takes a more dependent approach, the faculty can individualize instruction based on each student’s abilities and learning style. (See Chapter 1 for an overview of cognitive styles, learning styles, and learning preferences.) Kolb’s theory of experiential learning proposes cycles of learning along a continuum from concrete experience to abstract conceptualization of knowledge (Dobbin, 2001). Nursing students possess a more concrete, active pattern learning style characterized by the need for dynamic involvement when learning new concepts and skills (Schroeder, 2004). According to Dobbin (2001), “learners also can have a preference for reflective observation (watching to learn) or active experimentation (learning by doing)” (p. 5). For example, tactile exploration by touching and manipulating syringes and needles is essential for the concrete learner. Lecturing has only limited ability to educate in regards to psychomotor skill acquisition. As the student learns new skills in the lab, questions arise and “what ifs” are posed to enhance the learning experience. The use of return demonstration strengthens mastery and confidence.

Faculty must ensure that instruction in the skills laboratory is directed to students with a wide range of learning styles. Students may possess any one or a combination of the following learning styles: visual (spatial), aural (auditory-musical), verbal (linguistic), physical (kinesthetic), logical (mathematical), social (interpersonal), or solitary (intrapersonal) (Schroeder, 2004). Through the use of simulators, audiovisual software, graphs and diagrams, charts, pictures, demonstrations, practice, discussion, or even music, the skills laboratory can address the needs of all students when acquiring new nursing knowledge. The key to effective teaching in the lab is dependent on the faculty use of a varied and innovative approach to education.

Generational differences among students are addressed by the variety of teaching strategies that are offered by faculty in the skills lab. Whether a Generation X, Millennial, or Baby Boomer, each student approaches the learning environment with different characteristics and learning needs (Billings & Halstead, 2005). The skills lab offers an array of options to capture the attention of students in today’s society. For example, the Millennial student prefers to work with a team and be socially involved. According to Godson, Wilson, and Goodman (2007), third year students working with first year students in a nursing program proved very effective. The third year students were asked to teach a psychomotor skill related to patient care to the first year students. The first year students then practiced the skill that they had learned from their fellow nursing students. The mentors’ support helped to comfort and ease the anxiety of learning a new skill experienced by the beginning nursing students. Each group described benefits 232 Chapter 15 • the New SkillS laboratory

of working together as a team. (See Chapter 5 for an in depth exploration in the generations of learners).

CONDITIONS FOR LEARNING AND RESOURCES

Opportunities for learning skills in the clinical environment continue to dwin-dle due to fewer clinical placements available in healthcare institutions. With often fierce competition among educational programs for optimal student assignments in hospital and community resources, the skills lab takes on an increased importance for all clinical courses in the curriculum. Skills, which were once discussed and practiced briefly in the lab and then performed on clients, may no longer be practiced in the clinical area due to patient availability and legal ramifications. Practice in the skills lab may be the only opportunity for learning many basic as well as complex skills needed after graduation. Therefore, skills taught in each course must be identified and additional time and supplies allotted for practice in the lab. Skills will not only be taught in isolation with low-fidelity simulators such as static mannequins, but can also become a part of scenarios with high-fidelity human patient simulators. These scenarios offer the students opportunities to interact with simulators with specific problems, and the skills learned are carried out as interventions become necessary, rather than in isolation. Thus, scenarios based on learning objectives for each course throughout the curriculum and imbedded with increasingly complex skills become an important avenue for assisting the student in progressing from novice to higher levels of ability. Skills performed within scenarios also allow for the adult learner to apply knowledge and psychomotor ability to immediate learning goals.

Skills labs must take on a new look that parallels the hospital environment as simulators become patients and assist the student is the suspension of disbelief while practicing necessary skills. This environment includes not only sights, but also the sounds that are inherent in a busy clinical area. Labs must include the equipment, technology, and resources that are currently found in the clinical environment. The skills laboratory includes not only typical equipment, such as intravenous pumps, but also computers and personal digital assistants (PDAs) with evidenced-based resources that will be needed to assist students with problem solving and critical thinking as they work through scenarios. Informatics should be accessible as students must learn to work with databases and documentation software. Labs will need to be designed to provide rooms/bays that are essentially self-contained hospital units for scenarios to be carried out. Although the rooms may be used for a variety of scenarios, different rooms may need to be designed and equipped for areas such as obstetrics, emergency care, acute care, home care, pediatrics, and intensive care units in addition to ancillary units. As the Using the Method 233

hospital environment changes and innovations, such as telenursing and eICUs become commonplace, skill labs require design elements that provide multiple screen workstations connected to multiple simulators.

USING THE METHOD

Teaching within the new skills lab combines the best of the traditional methods of instructions with the new technological advances. Regardless of the complexity of the skill, acquisition begins with didactic instruction and practice in the lab on low-fidelity mannequins. Additionally, students may be provided with kits of equipment and supplies to continue practicing skills at home. These include such things as mock wounds for dressing changes and styrofoam wig heads with tracheostomy tubes for practicing tracheostomy care. As mentioned previously, performance of skills at this time is rule-governed and inflexible. These skills can then be imbedded within a scenario accompanied by the complexity of care based on the course objectives. Three to five students can work through the scenario on a high-fidelity human patient simulator, identifying indicators for various skills, perhaps obtaining orders for the skill, collecting supplies needed, performing the skills, observing the effects, and documenting and reporting the procedure and effects. Although only one student actually performs any one skill, other students actively participate in the skill through discussion and support. The importance of the skill takes on a new meaning as it becomes a part of patient care for an illness and a patient with specific needs and responses. Communication and professionalism is fostered with other team members, such as healthcare providers, and among other members of the student’s peer group. Debriefing following the completion of the scenario should be considered integral to the process. Discussions with the faculty as facilitators can assist the student in applying theory to practice, correcting mistakes, answering questions, identifying learning needs, and making connections to the real world.

The use of appropriate scenarios and all levels of human patient simulators and mannequins are invaluable for teaching skills in a safe environment where patient cooperation is not needed, where repetition is essential, and especially where skills could potentially cause harm to the patient. Critical thinking and problem solving, obtaining appropriate supplies, manipulating equipment, looking up resources, performing procedures accurately and safely, and communicating verbally and in writing are all activities that require considerable amounts of practice by the novice learner. In the fast-paced clinical environment, time is of the essence and students are often expected to perform beyond the level of novice learner.

Students can move beyond the novice level with the use of credible scenarios and simulated patients in the realistic, transferable environment of the skills lab.

234 Chapter 15 • the New SkillS laboratory

Skill labs may include evaluation of specific skills as a part of outcome measurements at the end of the semester. Students are often evaluated performing a specific skill or skills as the faculty observe and record their performance. Return demonstration to determine mastery of specified skills is an effective method to determine the safety of transition to patient care in the clinical setting. If students demonstrate a poor performance when evaluated, immediate remedial action can be taken to correct deficiencies before exposure to patients. Patient safety must be the overriding consideration when documenting student abilities. For example, if during a lab check-off, a student draws up 10 ml of a medication instead of the required 3 ml dose, the faculty can reeducate the student immediately, validate that accurate knowledge is mastered, and avert a potential patient injury in subsequent clinical encounters.

Simulated patients also are used in effectively evaluating skills. The required skills are developed in a short scenario. Three to five students care for the patient and perform the skills as the intervention becomes necessary in the scenario. Students should be aware of the criteria and expected behaviors, having practiced all the skills to be evaluated previously. At the beginning of the scenario, students can draw for the skills they are to perform during the scenario. As the scenario progresses, students care for the patient together, except when a specific skill is needed.

Peers then become observers as the student who was assigned a skill performs according to the criteria outlined, and is evaluated by the instructor. Peer observers become active learners as they mentally rehearse and evaluate the skills as they are being performed. Once the skill has been completed, the scenario resumes until another skill is needed. The process is repeated throughout the scenario until all students have demonstrated their selected skills. Verbal and/or written feedback can be given to the students individually by the instructor following the scenario.

Students may also give their peers feedback about their performance.

Video recording may be used as an adjunct to learning or evaluation of skills.

This method of assessment offers findings that are very objective when used for grading purposes. Students can learn by video recording and critiquing their own performance or viewing the video and discussing their performance with a faculty member. They can also video record and submit their video for evaluation and feedback by a faculty member. In a study by Brimble (2008), skills assessment using video analysis in a simulated environment was an effective evaluation tool. The nursing students completed a questionnaire before, during, and after video taping a simulation in the skills lab. The most common, positive theme that students expressed was the ability to learn from their mistakes by watching the reenactment of their performance on video. Subjects indicated that the visual feedback that they received from viewing their actual performance complemented the verbal critique offered by their faculty member. Negative themes included feelings for anxiety, being judged by others, and being embarrassed.

Potential Problems 235

However, Miller, Nichols, and Beeken (2000) found that students prefer faculty member presence during skill demonstrations and immediate feedback rather than video recording and delayed feedback.

POTENTIAL PROBLEMS

Major problems inherent in the development of the modern skills laboratory are the cost to provide the needed technology, supplies, and the physical space to house them. In order for students to practice with the equipment used in the profession, it must be purchased from medical vendors. Supplies are very expensive, especially when they are the most recent equipment used by the clinical agencies. Needles with integral safety devices are often more costly than traditional needle systems.

Students must see and practice with the tools that they will use in their clinical experiences, which requires frequent equipment revision in the laboratory. As enrollment in schools of nursing increases due to shortage mandates, the skills lab provides space that is available from early morning to late in the evening for student use.

Skills labs have typically been large rooms with multiple beds and static mannequins. Large numbers of students often practice the same skill at the same time.

Although this type of space and instruction are a beginning, additional smaller simulation rooms are needed for the more costly high-fidelity human patient simulators with all of the equipment, technology, and added supplies needed for implementing simulations. In addition, some labs have a small control room with a one-way mirror attached to each simulation room.

Other problems include lack of faculty willingness to embrace new technology and other services offered by the skills lab. Implementation of high-fidelity simulation, evidence-based case scenarios, and the additional time it takes to have students, three to five at a time, complete the skills within the case scenarios requires dedicated faculty participation. Learning new simulation teaching strategies and management of the simulators requires additional faculty time and energy.

Writing evidence-based scenarios that contain the necessary skills is another time-intensive faculty activity, unless these are purchased. According to Childs (2002), faculty and students must be interested and motivated to use the skills lab for the multiple teaching opportunities that are possible. Often, a core group of faculty members use the services of the skills lab on a routine basis, but all instructors should be informed about the applicability of skills lab services to augment the delivery of the curriculum content. In return, the skills lab must be responsive to the faculty and their needs to maximize the use of available technology.

Communication with faculty and students about the skills lab services is a critical element of an effectively functioning lab. This challenge is often addressed through the use of Web-based software. Currently, most colleges and universities 236 Chapter 15 • the New SkillS laboratory

support a Web-based framework such as Blackboard or WebCT. The skills lab should offer a Web site directed to students and faculty where policies and procedures, calendar events, and contact information for lab personnel are posted. A schedule of open lab times and remedial sessions should be easily accessible for students who need those services. Communication is an essential key to allow users to take full advantage of all the services offered by a well-equipped skills lab.

Every skills laboratory must be a safe environment for faculty, students, and staff. Skills labs are required to follow strict safety procedures to protect personnel and students in the lab from injury or spills. Needles, sutures, and performance of certain procedures pose daily threats. The expense to adhere to federal and local government regulations may prove costly but are a necessary component of a safe and effective skills lab.

CONCLUSION

The skills laboratory provides an enriched teaching and learning atmosphere that encourages active and involved exploration and mastery of new knowledge and skills to develop competent graduate nurses. Theory is applied to practice and validated in the skills lab through teaching and technology. The faculty member can use unlimited strategies to educate students who have a spectrum of learning needs in order to foster critical thinking. In the protected environment of the skills lab, students learn, make mistakes, question conceptual ideas, practice psychomotor skills, and expand knowledge to a new level of understanding. Students learn by doing through experimentation that would be impossible and dangerous in direct patient care situations. Faculty members have direct observation and supervision of all student activities which is often difficult in a busy clinical agency.

Transition to the role of graduate nurse is enhanced by effective and innovative use of the new skills laboratory.

APPLIED EXAMPLES

Comprehensive Nursing Skills Experiences

In a fundamental skil s course offered by various disciplines, skil s are a primary focus requiring didactic instruction and demonstrations first given in lecture and then reinforced in the skills lab.

Skills that are appropriate for beginning nursing students include the complex task of medication administration: obtaining or understanding healthcare provider orders, learning the appropriate dosages and where to research information about the drug, calculating dosages from the correct amount of drug available, safely and competently handling the syringe during drawing up of medication, administration, disposal of the syringe, recognizing appropriate sites for administration Conclusion 237

(subcutaneous or intramuscular), performing the five rights prior to administration, and recording the medication in the permanent patient record. All these basic skills must be understood and practiced repeatedly by the student. To meet the wide range of learning styles, instruction should include verbal and written material as wel as audio-visual demonstrations and one-on-one interactions and demonstrations with the students. Kinesthetic learning is provided by the use of different types of syringes, vials, and pills; and solitary practice is combined with discussion, reflective observation, and active experimentation.

Administering insulin and digoxin can be used as examples for student practice. Sliding scale insulin orders could be written in a mock chart, and students could be given various blood glucose results so that different amounts of insulin would need to be drawn up. In the lab, students practice drawing up insulin, selecting an appropriate site, administering the medication on a manikin, discarding the syringe, and documenting on the mock chart. They should also practice giving oral medications such as digoxin correctly, which would include auscultation of the apical pulse. Not only must they be able to perform the skil of giving the medication correctly, but they would also need to recognize that an apical pulse rate must be taken before administration, under which circumstances the medication should be withheld based on current literature, and when the healthcare provider must be notified for future actions.

Once the skills have been practiced, three or four students are introduced to the high-fidelity simulator. They are presented with the history and physical findings of a patient who is hospitalized with selected clinical problems. A mock chart is available with healthcare provider orders, which include treatment and medication orders. Medications are noted on the medication administration record, including insulin sliding scale, oral medication, and prn medication orders. The students are made aware of the time of day and results of lab studies such as blood glucose readings. Students at this point are assigned selected skills to perform, such as wound dressing change, urinary catheterization, administration of pain medication via the intramuscular route, application of bandages, or performance of a basic head-to-toe assessment. The skills are embedded in the scenario and must be performed according to patient need and healthcare provider orders. The students must prioritize their actions based on the dynamic events unfolding in the patient scenario. This complex situation fosters critical thinking and problem solving to meet patient demands. The faculty member acts as facilitator to encourage competent participation by individual students and provides immediate feedback to correct problems in cognition and performance of skil s. As the student progresses in level of learning ability across the curriculum, the faculty member offers less prompting to increase the independence exhibited by the student. By applying adult learning principles, the student is allowed to demonstrate more creativity in a learning environment that supports personal knowledge and meets immediate learning goals.

Evaluation of required skil s is an important function of the skil s lab. The lab provides unlimited opportunities for faculty to observe and test acquisition of psychomotor skil s as wel as cognitive processing. For example, the evaluation process in the form of a formalized checkoff can be implemented at the end of a semester to determine mastery of required skills. Before the checkoff is completed, students receive detailed procedural (step-by-step) information or criteria regarding the skills that they must master. By knowing the exact expectation before the evaluation, the anxiety level experienced by the students is decreased, and the faculty member can more easily determine the skil level of an individual student unclouded by psychological barriers. Practice opportunities are provided to reinforce skills the week before checkoff. The lab is arranged to represent the hospital setting with a patient in bed, a medication room, and a supply area. The student receives an assigned skill, reviews 238 Chapter 15 • the New SkillS laboratory

the patient’s mock chart, assembles the necessary equipment to perform the skill, and prepares the patient for the procedure. The interaction with the manikin should appear as authentic as possible.

This situation can be achieved by encouraging the student to communicate with the patient in a normal manner. The faculty member observes the performance of the skil based on the criteria previously provided to the student. A checkoff form is used to document and evaluate the student’s actions in relation to the criteria. The faculty member does not interact with or prompt the student in any manner. If the student fails to fol ow the criteria, points are deducted, affecting the final score.

The criteria contains selected critical behaviors that must be accomplished successfully to pass the evaluation. Examples of critical behaviors are contamination of a sterile field or recapping a used needle. If the student fails to acquire sufficient points or neglects to perform critical behaviors, the student fails the checkoff and is provided the opportunity for remediation and a repeated attempt.

Failure of the course is possible if the student is unable to successfully master the performance of the skill. The skills lab is an excellent venue to assess competency and determine learning needs. By utilizing theory combined with innovative teaching approaches and technological advances in the skills laboratory, faculty members optimize learning opportunities.

REFERENCES

Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice-Hall.

Billings, D. M., & Halstead, J. A. (2005). Teaching in nursing: A guide for faculty. St. Louis, MO: Elsevier Saunders.

Brimble, M. (2008). Skills assessment using video analysis in a simulated environment: An evaluation.

Pediatric Nursing, 20(7), 26–31.

Childs, J. C. (2002). Clinical resource centers in nursing programs. Nurse Educator, 27(5), 232–235.

Clarke, D., Davies, J., & McNee, P. (2002). The case for a children’s nursing skills laboratory. Pediatric Nursing, 14(7), 36–39.

Dobbin, K. R. (2001). Applying learning theories to develop teaching strategies for the critical care nurse: Don’t limit yourself to the formal classroom lecture. Critical Care Nursing Clinics of North America, 13(1), 1–11.

Duffin, C. (2004). Simulated ‘skills labs’ to ease pressure on training. Nursing Standard, 18(39), 7.

Godson, N. R., Wilson, A., & Goodman, M. (2007). Evaluating student nurse learning in the clinical skills laboratory. British Journal of Nursing, 16(15), 942–945.

Infante, M. S. (1985). The clinical laboratory. New York: John Wiley.

Knowles, M. (1989). The making of an adult education: An autobiographical journey. San Francisco: Jossey-Bass.

Miller, H., Nichols, E., & Beeken, J. (2000). Comparing video-taped and faculty-present return demonstrations of clinical skills. Journal of Nursing Education, 39, 237–239.

Pravikoff, D. S., Tanner., A. B., & Pierce, S.T. (2005). Readiness for US nurses for evidence-based practice. American Journal of Nursing, 105(9), 40–52.

Schroeder, C. C. (2004). New students – New learning styles. Retrieved March 19, 2006, from http://

www.virtualschool.edu/mon/Academia/KierseyLearningStyles.html

CHAPTER 16

Innovations in Facilitating Learning

Using Simulation

Kimberly Leighton and Judy Johnson-Russell

INTRODUCTION

A new world of teaching opportunities has opened up to faculty in the healthcare industry in the last few years, and continues to grow in sophistication. These opportunities come at a time when educators are struggling with the realization that they are unable to prepare students adequately to assume the role of the healthcare provider. The vast amount of content, technical and interpersonal skills, and professional role expectations coupled with the increased number of incoming students and decreased availability of clinical placements (Nehring, 2010) have created a frustrating and sometimes dangerous situation. Clinical sites, which once were the primary place of learning, now restrict student activities leading to suboptimal experiences for content integration and mastery. Observational experiences and mentor–apprenticeship are not always beneficial as preceptors are frequently preoc-cupied with pressing patient problems and are not as invested in student learning.

The use of high-fidelity simulators creates a learning environment that closely resembles the clinical setting and can present learners with almost any situation they might find in a patient care setting. Although the technology still intimidates many, the techniques of facilitating learning are at the essence of this pedagogy.

For those who embrace this pedagogy, teaching with high-fidelity simulators using realistic scenarios is exciting and rewarding. This methodology provides a safe environment for educating students without risk to human life and helps learners transfer knowledge and skills into actual clinical practice (Morgan, Cleave-Hogg, Desousa, & Lam-McCulloch, 2006). This chapter is intended to present innovative ways of utilizing simulation.

DEFINITIONS AND PURPOSES

Simulation and patient simulators are commonly referred to as low, medium, and high fidelity; however, there is no accepted classification that differentiates 239

240 CHAPTER 16 • INNOVATIONS IN FACILITATING LEARNING USING SIMULATION

each from the other (Gaba, 2004). Fidelity of simulation follows a continuum beginning with low-fidelity simulation experiences, such as use of role play, or may incorporate a static mannequin that does not respond to intervention. Medium-fidelity simulations build on the degree of realism presented and may involve task trainers or moderate-fidelity simulators that provide a degree of feedback to the participant. At the upper range of the continuum lie high-fidelity simulations that provide for more immersive simulated clinical experiences (SCEs), using realistic and sophisticated computer technology to enhance the abilities of the patient simulator to provide feedback to learners (Decker, Sportsman, Puetz, & Billings, 2008; Hovancsek, 2007; Jeffries & Rogers, 2007a; Nehring, 2010). For an overview on background and use of the high-fidelity patient simulator, please see Chapter 14.

The purpose of integrating simulation into any curriculum is to provide students with beneficial learning experiences that will assist in meeting course and program objectives, while promoting safe patient care. The focus of the simulated patient experience is on the needs of the learner, rather than being on the needs of the patient, as it must be in the hospital or other clinical environment. Carefully chosen SCE provide the opportunity for multiple objectives to be met by multiple learners at the same time.

Task trainers or low-fidelity trainers and mannequins provide for repeated skill practice, such as catheter insertion. The catheter is inserted and removed according to a defined order of skill demonstration. Higher-fidelity simulators, sometimes referred to as human patient simulators, challenge students to reach higher level objectives by prioritizing care and promoting critical thinking. Students must critically think about why the catheter is important to the patient’s care, its correlation to the illness or disease process, expected outcomes, and plan for additional care and safety needs of the patient as the scenario proceeds. The communication component is added as the patient simulator or the patient’s family may question the student, asking for explanation of the procedure. Although the skill of catheterization is the same, it has not occurred in isolation, but in context as a part of the total care of the patient. As the simulation continues, students see the results of their interventions and the impact on the patient’s condition (Leigh

& Hurst, 2008).

An advantage to simulation is that an SCE can cover any desired time span to demonstrate the changes in the patient’s condition. Students may take care of the patient upon admission to the emergency department, continue several hours later during admission to the patient care unit, as the patient’s condition improves with intervention over time, and culminate with discharge planning and teaching. The time span of an SCE may cover anywhere from a few hours to days. Students experience the physiologic changes in the patient’s condition over time, an advantage that is rarely available in the traditional clinical environment.

Definitions and Purposes 241

Faculty control the progression of the SCE by moving from state to state as objectives are met or appropriate student behaviors are demonstrated. Students benefit from being able to experience and participate in the whole process of managing the patient’s illness or condition.

When sufficient time is provided for simulation, students in nursing have the opportunity to work through the process of completing assessments, analyzing data, planning appropriate care, prioritizing care, providing interventions, and evaluating the responses to their interventions. Rarely is there time in clinical to proceed purposefully at this slower pace.

Another purpose of simulation is to enhance communication. Communication in the simulation laboratory can occur face-to-face, via the phone, or via written documentation, which will be discussed later in this chapter. Students can be provided opportunities to communicate face-to-face with the off-going nurse (role played by faculty) during shift report, while being encouraged to ask questions or seek out additional patient information. Students communicate with each other as they determine priorities for care and problem solve situations that arise.

Communication with the patient and any present family members provides for experiences that may not occur in the traditional clinical environment and can be tailored by faculty to present specific concepts. For example, while receiving discharge instructions, the simulated patient may state that they do not have money to purchase their prescriptions. Perhaps as a simulated patient deteriorates, the student decides to call and notify the patient’s family. It is at that point that the student learns that the phone has been disconnected because the bill has not been paid.

The simulation laboratory is also a safe place to practice communication with other healthcare providers, including physicians. Many, if not most, new nursing graduates have never been allowed to place a phone call to a healthcare provider while on the traditional clinical unit. Therefore, it is vital that this opportunity be included in simulated experiences. This communication may occur face-to-face with a faculty person role playing the provider or via phone. If the students place a call about early findings and the faculty wish to encourage further critical thinking, the caller can be told that the provider is not available because their cell phone is out of service range, they are busy in the operating room, or in a patient room at their office. Students should also practice communication with other healthcare providers by calling the laboratory, radiology, or other ancillary departments for test results.

It is important to make these exchanges as realistic as possible; however, it is equally important to not perpetuate stereotypes. For students who are novice at this type of communication, provide guidance and ask questions to promote critical thinking and organization. Using organizational tools, such as situation-background-assessment-recommendation (SBAR), will help to arrange thoughts 242 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon prior to initiating communication. As students progress through the program and become more proficient, the realism of the verbal exchange should increase accordingly.

SCEs provide numerous opportunities for faculty to observe intrapersonal, interpersonal, and communication among small groups of students, as well as other professionals. It is often difficult to observe communication in the traditional clinical environment as clinical faculty attempt to meet the needs of all students.

In the simulation laboratory, faculty can observe communication skills and provide immediate feedback (Pagano & Greiner, 2009).

The five core competencies for integrating safety and quality into nursing education developed by the Institute of Medicine (IOM) can be addressed in the simulation laboratory. The competencies are: (1) provide patient-centered care, (2) work in interdisciplinary teams, (3) employ evidence-based practice, (4) apply quality improvement, and (5) utilize information (IOM, 2003). Patient-centered care could include patient education and support interventions as patients learn to manage their health problems. Interdisciplinary teams can be formed with students working together to meet the scenario objectives. Nursing schools often collaborate with respiratory, pharmacy, social work, seminary, and medical students and together plan and carry out patient care. Evidence-based guidelines should be utilized to develop the SCE and to define interventions to be completed during the SCE. All SCEs can contain a safety issue so that students are able to identify hazards and take steps to prevent errors and accidents. Computers and personal digital assistants (PDAs) can be utilized in the simulation laboratory so that students experience working with computerized documentation systems and clinical decision support systems.

Policies and procedures from the traditional clinical environments should be available during the SCE, along with additional resources for students to reference prior to and during care provision. Students need to become expert seekers and processors of information in this ever expanding healthcare environment. Having appropriate resources and references, as well as the time to utilize them, during the SCE will assist graduates to know where and how to find needed information.

A real advantage to simulation is that it assists students in learning their role in emergency situations. When an emergency occurs in the hospital, generally students are not allowed to participate. However, in the simulation laboratory they can practice their role repeatedly without fear of harm to a patient. In addition, when incorrect decisions or interventions are completed in the simulation laboratory and the patient has a poor outcome, the opportunity exists to redo the SCE after debriefing occurs and correct patient management has been discussed.

This allows the learner to see a better outcome and add experience.

Faculty often comment that participating with their clinical students in simulation provides them with knowledge of each student’s strengths and limitations. This assists in individualizing clinical experiences and provides focus for remediation Designing the Simulated Clinical Experience 243

and assignments. It is particularly helpful if an SCE is in the beginning weeks of the rotation. It is also possible to see growth and changes in behavior when an SCE is conducted some weeks later.

DESIGNING THE SIMULATED CLINICAL EXPERIENCE

Deciding How to Integrate SCEs into the Curriculum

Deciding on appropriate SCEs to include into any curriculum takes careful thought and planning. All clinical courses and some didactic classes, such as pathophysiology, pharmacology, and cultural issues, can incorporate simulation.

A review of the program’s specific strengths and limitations will assist in choosing SCEs that will best meet student needs. Concepts that seem hard for students to grasp or that are difficult to teach are excellent choices for SCEs. Test scores such as from the National Council Licensure Examination-Registered Nurse or Practical Nurse (NCLEX-RN; NCLEX-PN), Assessment Technologies Institute (ATI), Health Education Systems, Inc. (HESI), or faculty developed tests for specific courses give indications of content and concepts that students are not comprehending. SCEs that address these areas should be chosen to facilitate learning in weak areas.

When choosing SCEs, patients with conditions or illnesses that are not readily available in the clinical agencies are beneficial, as all students then have the opportunity to care for that type of patient. SCEs that prepare students for specific clinical experiences, for high-risk situations, or for complex patients are also excellent choices. The timing of the simulation is another important consideration. Some schools incorporate simulation at the beginning of each course to assist with preparation for entering a new clinical rotation and again at the end of the rotation as a capstone experience. Another factor to consider is participation in the SCE in correlation to the presentation of didactic content. Most faculty utilize simulation after the content has been assigned or presented. Test scores after simulation may reflect a deeper understanding of the content than before simulation. Each course within a program will have its own needs and objectives that can be addressed through carefully planned SCEs.

Scheduling Students in the Simulation Laboratory

Scheduling of SCEs is often a major hurdle for faculty to overcome. For most educational institutions, class scheduling is part of a complex process that includes many departments, faculty, resources, and buildings. Making one change can be very disruptive. Therefore, it is valuable to consider a variety of options 244 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon when integrating simulation into the curriculum, beginning with a critical look at current teaching methods and clinical experiences.

Often, nursing schools have been challenged to increase enrollment but have limited clinical resources. As a result, clinical experiences may have been added to the curricula that do not provide the best opportunity to meet learning objectives for the student. The site’s experiences may be too complex, or too easy, for a given level of learner. Available hours may not fit easily into the course schedule.

Occasionally, professional behaviors of the clinical site do not mesh with those of the nursing program. Faculty are encouraged to critically review all clinical placement sites to determine if needs are being well met in that environment. If not, consideration should be made for moving the experience to the simulation lab.

The question is often raised about the number of hours that can be provided in the simulation lab. This is dependent on the state Board of Nursing regulations in each state and may be prescriptive as to the number of hours or percentage of hours. Other states leave discretion to the faculty as long as program outcomes continue to be met. A more difficult question is, “How many hours of simulation are needed to replace the same number of clinical hours?” This question is much more challenging to answer and the answer needs to be supported by research.

Scheduling simulation throughout the curriculum is best achieved by using a variety of scheduling methods. This allows for increased simulation use with less disruption to the course schedule. Several methods can be utilized: stations in a lab, set blocks of time, postconference, entire day, and class time. It is important to remember that the students will always take longer to make decisions and perform skills than faculty expect, as this is part of their learning process.

To decrease frustration and “catching up” during the day, allow more time than thought necessary to schedule SCEs.

Stations

This method works well for integrating SCEs into assessment and fundamental skills courses. These courses are often designed so that students work in pairs and small groups to practice psychomotor skills, communication techniques, and critical thinking. Students often rotate through different learning activities during lab time. A short SCE can be added that allows students to apply what they have learned in context of a patient situation. Using this method may result in adding time to the existing lab, but more often, another learning station is deleted.

Blocks of Time

This method creates a set period of time for self-determined groups or faculty-assigned groups to participate in an SCE. All blocks of time might be together Designing the Simulated Clinical Experience 245

during a specific week of the course, or the blocks of time could be distributed throughout the semester until everyone has completed their time. Blocks of time must be long enough and filled with enough activity to make it worth the students’ time to come to campus for the experience. For programs with set amounts of student contact hours, some faculty have decreased their clinical time by 10 minutes/week over a 15-week semester, resulting in the ability to reassign that time (150 minutes) to simulation.

Postconference

This scheduling method can be planned in advance or done impromptu based on activities of the clinical day. Typically, postconferences last approximately 1 hour and occur at the end of the clinical day. They are designed to serve as a time to reflect on the day’s activities, but are often used for various other activities such as topical review of difficult theoretical concepts, review prior to exams, or even as time to remain on the clinical unit to observe an unusual activity. This time frame is included in the schedule of the clinical day and some faculty facilitators have found that SCEs designed to include concepts unique to their clinical unit, are a valuable use of this time. For example, a postoperative unit may have several patients with chest tubes but not every student has the opportunity to care for those patients. Managing a chest tube patient in the simulation laboratory provides an opportunity for every student to care for that type of patient.

Entire Day

In this scheduling method, a clinical group participates in various SCEs over an entire day. Rather than attending a hospital unit or clinical agency for clinical, the students report to the simulation laboratory. The simulation laboratory is placed on the clinical schedule rotation instead of an agency site. A typical day’s schedule should begin and end at the usual clinical times. Students can provide care for a variety of patient types, depending on the length of the scenarios. It is helpful to assign rotating roles to keep students engaged. Expectations for preparation, care, resource use, and documentation should be the same as on the clinical unit.

During Class

Simulators can be used during class time by either moving a portable simulator to the classroom or using video to transmit from the simulation laboratory to the classroom. Portable simulators are designed for ease of movement and 246 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon can be placed in the front of the classroom to demonstrate various concepts.

Students can be chosen to participate in caring for the simulated patient either randomly, based on skill level, or based on identified learning needs. Students remaining in the audience can participate in directing the care, prioritizing care, or observing for various aspects of care, such as communication techniques. Using video, especially two-way interactive video, provides the same in-class learning advantage without moving the simulator. Another learning opportunity is provided when both an adult and pediatric simulator is moved into the classroom, setting the stage for comparing and contrasting between the care of an adult patient and pediatric patient with the same illness or disease process.

An additional in-class learning opportunity exists through use of the simulation software. The computer running the simulation software can be connected to the classroom projector, allowing all students to see the patient parameters.

After orienting students to the various parameters, the faculty member can demonstrate the hemodynamic changes that occur with hypervolemia, hypovolemia, pneumothorax, pericardial tamponade, different cardiac rhythms, and numerous medications. The simulator does not have to be connected to this computer in order to demonstrate these features. Further discussion of classroom use of simulation is provided later in this chapter.

Fidelity of the Simulated Clinical Experience

Realism of the SCE is commonly referred to as fidelity. There is no consensus as to how much fidelity is necessary for learning to occur, but many believe that the closer to real a scenario is, the more engaged students become and the opportunities for learning to occur increase. Medley and Horne (2005) recommend that in a high-fidelity SCE, the real-life situation be recreated in as realistic manner as possible. Cantrell, Meakim, and Cash (2008) identified the theme “the more real the simulation, the better the learning” when analyzing the qualitative portion of their study of student evaluations of a simulation experience. In a small pilot study, researchers found no statistically significant difference in pretest/post-test scores of a group learning with low-fidelity simulation and a group learning with high-fidelity simulation (Kardong-Edgren, Anderson, & Michaels, 2007). It is important to match the level of fidelity to the desired learning outcomes, as some SCEs require higher levels of fidelity than others (Gaba, 2004).

The learning can be positive or negative and, while it is hoped that only positive learning is transferred to real patient care, the potential for negative transfer of learning also exists. Therefore, it is important that processes and procedures in Designing the Simulated Clinical Experience 247

the simulation laboratory as closely mimic reality as possible. Four major areas of fidelity should be considered when creating the SCE: the simulator, the physical patient, holistic aspects of the patient, and the environment. Simulator fidelity was addressed previously in this chapter.

Physical Patient

Fidelity of the simulated patient’s physical condition should impact as many of the student’s senses as possible: sight, smell, touch, and hearing. This involves significant creativity on the part of the faculty member but can often be accomplished at little cost. Creating this type of fidelity is often referred to as moulage, a word often associated with the military. Examples of low-cost solutions to create physical conditions are provided in Table 16-1. Always test new moulage in an inconspicuous area if there is a risk for staining to occur.

Table 16-1 Physical Fidelity of the Simulated Patient

Sense

Physical Condition or Disease

Moulage

Sight

Vomit

Egg white whisked with fork; streak

yellow food coloring with toothpick tip

Blood clots

Cherry pie filling; thick lumpy tapioca

with red food coloring

Smell

Incontinence

Water with yellow food coloring and

ammonia

Vomit

Add grated parmesan cheese to vomit

Touch

Edema

Memory foam covered with ace wrap

or antiembolism stockings

Clammy skin

Spray with water bottle

Hearing

Hospital sounds

Loop a recording and play back

Hospital pages

Announce random overhead pages via

microphone

248 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon

Holistic Aspects of the Patient

Nursing care of the patient involves not only physical care, but developmental, cultural, psychosocial, and spiritual care as well. These important aspects are often left out of the SCE. Undergraduate nursing students were asked their perceptions of how well their learning needs were met in the traditional clinical environment and in the simulated clinical environment (Leighton, 2007). Learning needs related to holistic patient care were better met in the traditional clinical environment ( P  .000).

Positively impacting these learning needs is easy to do in the simulation lab and costs little or no money to do so. In most cases, adding more information to the patient’s story or health history can add this dimension.

Table 16-2 outlines several ways in which holistic patient care can be added to the SCE.

A variety of props can be added to the simulated patient’s room to help prompt students to address holistic aspects of care. A picture frame with a family picture including several children might be placed at the bedside to see if students address the patient’s role in the family. A Bible, Koran, or other religious book or icon can be placed at the bedside to shift the focus to spiritual aspects of care. It is helpful to have resources available to students to look up information about different cultural and religious beliefs while caring for the simulated patient.

Environment

Simulation centers or laboratories come in all shapes and sizes, from the corner of a skills lab to a large, free-standing space with individualized and very realistic patient rooms. No matter the space, it is important to make it appear as realistic as possible to the intended clinical environment. While this is typically a patient’s hospital room, many SCEs can occur in a patient’s home, an outpatient setting, or in the recovery room. Having the equipment and props characteristic of the desired environment will help learners to be engaged and learn use of appropriate equipment and supplies.

Obtaining supplies and equipment can be a costly endeavor. Consider discussing simulation needs with clinical nurse managers who may be able to divert opened sterile kits to the simulation laboratory if they cannot be used with human patients. Many hospitals have warehouses where unused or overstocked equipment is stored. Simulation laboratories are often able to purchase at discount or borrow equipment. Many pharmacies now return expired medications for account credit; however, simulation personnel may be able to obtain these medication vials or ampoules. Different regions of the Designing the Simulated Clinical Experience 249

Table 16-2 Holistic Care of the Simulated Patient

Aspect

Patient

Concern

Developmental

45-year-old male with heart

He and wife have five children

attack

and he is unable to return to

construction job

14-year-old with abdominal

Sexually active and has

pain

contracted a sexually

transmitted infection

Cultural

26-year-old female speaks

Only available person who

only Vietnamese

knows Vietnamese is the

hospital’s maintenance man

88-year-old Native American

Prefers to wait for medicine

patient who urgently needs

elder

medication

Psychosocial

8-year-old boy requires

Parents recently moved to area

appendectomy

and father’s health insurance

has not yet taken effect

72-year old patient with

Unable to afford medications

chronic obstructive

with current finances

pulmonary disease requiring

several medications

Spiritual

52-year-old female requires

Refuses to remove jewelry with

abdominal surgery

religious icons

66-year-old patient who was

Refuses treatment because

just diagnosed with cancer

believes the illness is a result of

past sins

country have differing rules and regulations as to disposal of expired items.

Some simulation laboratories have reported obtaining syringes and expired intravenous fluids from veterinarians and from patients who no longer require home care services. Be creative in seeking out solutions to supply and equipment needs.

250 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon Student Preparation/Professional Expectations

In the previously mentioned survey of undergraduate nursing students (Leighton, 2007), it was reported that students did not prepare to the same level for simulated experiences (0–1 hour) as they did for human patients (2–4 hours). Many reasons exist for this difference, such as the student may have already experienced caring for the type of simulated patient and therefore need less preparation time, personal or social obligations limit preparation, or the student may perceive the simulated experience as less stressful and without consequence if performance is poor.

It is recommended that students prepare for SCEs in the same manner and to the same degree as they do for traditional clinical experiences. Providing the student with focused preparation activities is also more efficient than the time spent seeking out information from the chart, the patient, the family, and other caregivers. Preparation activities contribute to learning and allow the simulation facilitator to answer questions, clarify misconceptions, enhance the knowledge base, and facilitate learning rather than teach. Time in the simulation lab is therefore more likely to be focused and intense.

Professional behavior and dress is important to the learning experience in the simulation laboratory. In fact, observations have been made that students behave more professionally when in uniform than when in street clothes (Ravert, 2010).

While learning to manage a variety of patient types and conditions, nursing students are also learning professional behaviors and communication techniques.

Providing an environment in which professional behaviors are modeled and practiced will likely enhance professionalism. At the same time, state boards of nursing are often being asked to consider patient simulation as a replacement for traditional clinical experiences. If this is to occur, then efforts should be made to ensure that the experiences in the simulation laboratory are as realistic as possible.

IMPLEMENTING THE SIMULATED CLINICAL EXPERIENCE

Faculty Roles

Faculty roles during simulation are primarily facilitative. Rather than the sage on the stage, faculty become the guide on the side (Kardong-Edgren, Starkweather,

& Ward, 2008). Although the role varies somewhat depending on the level of the students, the faculty may provide the learner with prompts and cues. These are most often in the form of carefully asked questions that stimulate critical thinking and problem solving and assist the student in taking necessary actions with appropriate interventions. As students progress through the program, fewer prompts and cues are required or are given.

Implementing the Simulated Clinical Experience 251

Critical thinking, problem solving, and planning care are aided in simulation when a large flip chart with removable paper is utilized. One person is assigned to be the documenter/recorder for the simulation. Beginning with report, the documenter writes down pertinent information and continues to record as assessments, new data, and interventions occur. The information can then be easily viewed by all participants and is referred to constantly. This documentation can be utilized as the student calls the healthcare provider, as the faculty asks questions about the meaning of newly acquired lab data, or as students plan care based on new orders. The paper can easily be removed and taken to debriefing for further evaluation and discussion of care.

Alternatively, a whiteboard may be used for data gathering documentation.

The Dreyfus and Dreyfus’ model of skill acquisition, adapted for use with nursing by Benner (1984), supports learning on a continuum beginning with novice and progressing through advanced beginner, competent, proficient, and expert stages. This model has implications for faculty who facilitate in the simulation laboratory. Learning the skill of facilitation is a new challenge for most faculty and they begin at a novice level. It is important for faculty to recognize this and to not attempt a SCE that is overly complex and detailed for their first effort. Begin with simple scenarios as they can often have as much impact as those that are complex. As the level of comfort with facilitation grows, so will creativity and willingness to attempt more complex scenarios. Trying to do too much at the beginning will only frustrate the facilitator and the students, making the next attempt at simulation more of a challenge.

The novice-to-expert approach has also been used to help determine the role of facilitators when interacting with students in the simulation laboratory. Novice students may experience increased stress or anxiety when placed in an unfamiliar environment and given new expectations to care for a simulated patient. They have little to no experience to draw from and it may be of value for the faculty to be present at the bedside, assist in proper assessment techniques, and respond to questions immediately.

As the students progress to advanced beginner, the facilitator can play the role of a family member. Continued presence in the room provides a level of comfort and reportedly decreases anxiety among students. The facilitator asks questions of students while in the family member role and is able to determine if students understand the care they are providing and can provide appropriate education and responses to the patient and family.

When learners reach the proficient stage, facilitators become further removed, although depending on the laboratory set up, they might remain in the room with the students. However, at this point, they only observe unless it is essential to intervene and redirect the students. At the expert stage, the facilitator is completely removed from the simulated patient room and observes through a one-way window or via technology such as Skype.

252 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon Student Roles

One of the biggest challenges facing faculty in the simulation laboratory is that of group size. Defining roles for each individual student brings focus to the experience and decreases confusion. A variety of roles can be utilized, depending on the SCE. Roles can be assigned or chosen at random, or purposefully assigned based on identified student weaknesses. Suggestions of roles and responsibilities utilized by many simulation laboratories are provided in Table 16-3.

Facilitators are encouraged to utilize roles that are nurse specific as outlined in Table 16-3. Assigning roles of other healthcare providers, such as laboratory technician, respiratory therapist, or physician, are often troublesome, as the students do not have the background to know the roles of those providers. It is also challenging to have students play the role of the family member, again because most lack that Table 16-3 Roles for Students in the Simulation Laboratory Role

Responsibilities

Primary nurse

Assessment; final decision

Consider two primary nurses so one student is not responsible alone if a poor outcome is experienced

Secondary nurse

Backs up primary nurse if two primary system not used

Assists the primary nurse in assessment and decision making Medication nurse

Administers medications safely according to orders

Documentation

Documents on paper or electronically to maintain a patient nurse

record

Documents on flip chart or whiteboard to keep all informed of assessment findings and care provided

Healthcare

Provides information to healthcare provider in person or via communicator

phone calls; contacts ancillary departments for test results Observer

Provides focused role for observer such as observing for

communication between nurse and patient; identification

of cultural care; patient education provided by nurse;

recognition of psychosocial care; overall management of care Implementing the Simulated Clinical Experience 253

type of experience, but also because they have to perform in front of their peers.

Those who are shy or introverted tend to struggle in these types of roles.

There is often concern expressed by facilitators that the students in the observation role will not learn as much as those actively caring for the simulated patient. In Phase III of the NLN/Laerdal project, Designing and Implementing Models for the Innovative Use of Simulation to Teach Nursing Care of Ill Adults and Children: A National, Multi-Site, Multi-Method Study, researchers reported that there were no significant differences in knowledge gain, satisfaction, or self confidence based on the role of the student (Jeffries & Rizzolo, 2006).

Use of Resources in the Simulation Lab

PDAs are beginning to be incorporated into simulation experiences. During the SCE, students can immediately access textbook information and can look up diseases, care plans, drug and laboratory guides, medical dictionaries, procedural guidelines, and literature databases. It is important in today’s constantly changing healthcare environment that students learn where to access needed information rather than expecting to always rely on memory. Nurses need to be able to rely on the latest evidence-based information to make decisions and to have it available when needed at the point of care. PDAs are invaluable as students move from performing skills to making decisions about care based on the latest knowledge available. Clinical calculators are also utilized in simulation laboratories to more safely determine drug dosing, intravenous drip rates, and for other physiological calculations.

The Joint Commission (TJC) identified the leading root cause of sentinel events in the United States between 1995 and 2006 as a breakdown in hand-off communication (WHO, 2007). These sentinel events resulted in unintended harm to patients and prompted TJC to recommend that hospitals standardize hand-off communications.

SBAR is being used by hospitals across the country to improve communication.

During the SCE, students can have valuable practice in communication skills by giving hand-off reports, by calling healthcare providers, and by interacting with the interdisciplinary team utilizing the SBAR format. Use of the format assists students to become more organized and confident in their thinking and reporting.

Charting

Charts and forms, if not on the lab’s computer, should be constructed for each SCE. Documentation forms should be as similar as possible to those the students 254 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon utilize in their clinical areas. Additional forms that might be appropriate for the SCE, such as emergency department records, blood transfusion and blood bank forms, and incident reports, for example, should also be available Various methods are utilized in simulation laboratories to create documentation opportunities for students. It is helpful to utilize a system as close to what students see on the traditional clinical unit as possible; however, many simulation laboratories do not have the resources to do this. There are several existing commercial products available, but many simulation facilitators create their own system.

Types of documentation can range from paper charting, using blank forms obtained from a local facility or creating one’s own, to electronic charting similar to an electronic health record. The level of complexity in the design of these documentation systems is up to the faculty. Some faculty created realistic systems using Microsoft office products such as Word and Excel. There is no known research pointing to whether one method is better than another. The underlying principles and concepts of documentation are the important focus.

Multidisciplinary/Interdisciplinary Team Simulations

As nursing faculty become more comfortable with simulation, they are beginning to incorporate SCEs that foster an interdisciplinary team approach with other healthcare students. The IOM has said that “all health professionals should be educated to deliver patient-centered care as member of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” (IOM, 2003, p. 3). As the population ages and lives with multiple comor-bidities and chronic health needs, their care requires the collaboration of multiple healthcare professionals. Therefore, simulation provides the perfect opportunity for students to work together on complex patient care problems. Pharmacy, respiratory therapy, social work, seminary, and medical practitioners or students have all collaborated with nursing students during SCEs. Students learn the knowledge, roles, responsibilities, and frame of reference each brings to the patient situation.

They learn to work together as a team, to share the information they have about the patient, and to communicate and resolve differences related to care.

Many hospitals and schools of nursing are utilizing the TeamSTEPPS program developed by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. This program provides materials and a training curriculum for an evidence-based teamwork system to improve communication and teamwork skills. Information about this program may be obtained by going to http://teamstepps.ahrq.gov/. The goal of TeamSTEPPS, and all intradisciplinary training, is to assist in providing higher Implementing the Simulated Clinical Experience 255

quality, safer patient care through more effective communication among health professionals.

Classroom Use of Simulation

Most faculty think of a laboratory space when envisioning the use of patient simulation in their courses; however, simulation can be added to the classroom experience as well. Three common methods of integrating simulation into classroom teaching follow.

Simulator in Classroom

Many patient simulators are portable and can be moved easily into a classroom. While this may seem overwhelming the first one or two times, it is not difficult to learn with repetition and can be accomplished in only a few minutes.

Once in the classroom, place it at the front of the class and invite two or three students to care for the patient, who should be designed to facilitate learning of concepts currently being taught. Students often hesitate to volunteer for this role and may have to be assigned.

The simulated patient’s condition or illness may be cared for to resolution during one time frame of the class or the care can be divided into sections corresponding to the didactic material as it is presented. Another option is to simulate two different but similar conditions, such as heart failure and chronic obstructive pulmonary disease. Selected students care for each patient and the subsequent patient management is subjected to contrast and comparison analysis.

Simulation via Two-Way Interactive Video

Some simulators and their environs are not designed for easy transport and cannot be removed from the laboratory. The simulated patient remains in the laboratory and the designated number of students leave the classroom to care for the patient there. This interaction is broadcast to the classroom using existing interactive video capabilities. Many schools do not have the resources for this type of equipment but there are now many free or low-cost options, such as Skype, now available via the Internet.

Simulation Software

The laptops that run the simulation software can be connected to an overhead projector in the classroom in the same manner that a computer is connected to project PowerPoint presentations. Once connected, the students are oriented to 256 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon the instructor view and instructed on which visible parameters to monitor. Simple to complex material can be visually presented using the following examples:

• Administer the same medication and dose to a young healthy simulated patient and to a simulated patient with cardiovascular disease. Observe changes in blood pressure and heart rate (novice students) or mean arterial pressure and central venous pressure (advanced students).

• Provoke a pneumothorax through the software and have learners monitor the respiratory rate and oxygen saturation levels for changes.

• Create a pericardial tamponade through the software and have learners monitor hemodynamic changes with various amounts of fluid.

• Remove 2 to 3 liters of blood through the software and have students monitor hemodynamic changes. Conversely, administer 2 to 3 liters of crystalloids and monitor the same hemodynamics.

POSTSIMULATED CLINICAL EXPERIENCE

Debriefing

Debriefing is essential to the simulation experience. It is during this time when students have the opportunity to reflect on the experience that much of the learning occurs. Faculty function as facilitators in the debriefing by stimulating students to consider what they were thinking during the simulation, how they were feeling, what they did, what occurred as a result, and how they can apply what they have learned to their care with real patients. It is important for students to be able to follow the fast-paced simulation with a quiet time away from the simulator where they can cognitively process and reflect on what occurred. Video clips may also aid in the understanding of what transpired (Fanning & Gaba, 2007).

There are four parts to the verbal debriefing: the introduction, sharing of personal reactions, discussion of events, and the wrap-up (Johnson-Russell & Bailey, 2010). Although the first three are sometimes discussed simultaneously, all should be covered at some point in the debriefing.

The introduction sets the stage for the debriefing by letting students know that this is a safe place to discuss what went on and that what they share about their feelings and behavior will not be discussed outside the room. Many faculty have students sign a confidentiality statement at this time. Students appreciate when faculty also sign this statement so that they know that what went on in the SCE

will not affect their future in school. At this time, the faculty inform students about their expectations for the debriefing. They remind them that the expectation is that all students will contribute to the discussions by analyzing the simulation and what transpired in depth. Students are also expected to look at not just what Postsimulated Clinical Experience 257

went on with the patient, but also at their own behavior as well as how they functioned as a team.

In the immediate postsimulation period, there is often excitement and/or anxiety from the tension built up during the simulation. Expressing these feelings or sharing of personal reactions is often necessary before students can cognitively process other aspects of the SCE. Assisting students to delve deeper into the events that led to these feelings may provide a new awareness of their functioning and thought processes.

The discussion of events focuses more on the patient, the condition, the interventions, and the outcomes. The facilitator can segue into this part of the discussion using comments the students have previously just expressed, or ask specific questions about their knowledge of the patient and their condition, what they anticipated the outcome would be, how the SCE unfolded, how they prioritized and instituted a plan to manage care, and what they might have done differently.

Asking about what resources were utilized and others that were available but not used may be appropriate. Additionally, it is important to have students look at safety needs of the patient and if any of these were overlooked and the possible problems as a result of the oversight. Questions about their individual functioning, difficulties in performing care, and what each student needs to do to remedy their deficiencies should be asked.

Team functioning is important to discuss, especially in relation to communication with team members. Communication with family members and the patient may also need to be addressed. Debriefing is an excellent time to have students role play and practice more effective communication. Students frequently have difficulty relating the events of the SCE to the real world because their experience is limited. It is often valuable, therefore, to spend time discussing how the SCE applies to the clinical setting and to patients they may encounter in the future.

Video clips may provide additional stimulation for discussions. They should be used as an adjunct in the debriefing to assist students in understanding those things that they might have missed or when there have been procedural problems, missed cues, or poor decision making. Viewing the videotape is an excellent way of helping learners understand the events that transpired in the SCE and their participation in them. Viewing segments where they performed well is also important in reinforcing appropriate behaviors and instilling confidence.

The summary or wrap-up can be accomplished by the faculty using statements the students have verbalized about what they felt went well and what did not. Faculty can also remind students of areas that need improvement. Some faculty prefer to have the students summarize the session by verbalizing what they learned from the SCE. Students appreciate hearing positive comments from the faculty about their performance or the improvements in their functioning that were observed.

258 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon Additionally, some faculty post questions on their intranet, have the student reflect on the experience, and answer the questions within 24 hours of the SCE.

Students should complete an evaluation at the end of the debriefing. These can give the faculty valuable information about what was most helpful to the students and what might be changed to make the SCE an even better learning experience.

Faculty may want to utilize the debriefing assessment for simulation in healthcare (DASH) from the Center for Medical Simulation to evaluate and develop their debriefing skills. Information about the rating forms can be found at the DASH Web site (http://harvardmedsim.org/cms/dash.html).

Postsimulated Patient Death

Many simulation facilitators are fearful that simulated death experiences will cause the student to believe they killed the simulated patient or are responsible for its death, leading to feelings of guilt. There is also concern that buried feelings may rise to the surface leading to psychological trauma. There is no literature to support these assumptions; however, the facilitator is charged with recognizing and managing psychological stress of participants (Leighton, 2009a).

The debriefing process is vital to managing this psychological stress as students are given the opportunity to talk about their feelings and explore the events that occurred during the SCE in a safe, nonjudgmental environment. The facilitator may consider involving a chaplain or mental health practitioner in the scenario or during the debriefing. In some cases, the facilitator may need to refer the student for further psychological assistance (Leighton, 2009a).

Evaluation/Testing/Assessment

Considerable discussion occurs at simulation conferences and informal meetings about evaluating students in the simulation laboratory. Several schools have developed rubrics to use for this process, while formal research protocols have created other methods to evaluate learning, critical thinking, or components of critical judgment (Lasater, 2007). At this time, more nursing schools use simulation as a teaching strategy than do those who use simulation as an evaluation tool (Hovancsek, 2007).

It is imperative that nursing programs identify their philosophy related to evaluation or assessment in the simulation laboratory. To begin, definitions must be determined. During meeting discussions, participants use a variety of different terminology to describe evaluation, assessment, and testing. It is clear that many of these conversations are attempting the compare apples to oranges.

Postsimulated Clinical Experience 259

Questions that should be considered during discussions about evaluation, testing, and assessment could include:

• Is the simulation lab better suited for facilitating learning or for evaluating students? Is it possible to do both?

• Is it fair to test students if they have not had significant exposure to simulated clinical experiences?

• Are faculty all competent in their roles? How is this variable controlled for evaluation purposes?

• How do we account for the variety of student responses and interventions that are inherent in simulations?

• Are we sending mixed messages when we tell students that simulation is a safe environment to learn in and then use that same environment for evaluation?

• Do we test students in the traditional clinical environment? Is it then fair to test in the simulation lab?

• If the focus is on testing, will the experience become an experience about performing rather than about learning?

• What can you learn about your students in the simulation environment without formal evaluation or testing?

• If we say that most of the learning occurs in debriefing, can we fairly evaluate students before that debriefing occurs? (Leighton, 2009b, p. e57).

If the decision is made to evaluate simulations, the faculty must determine the purpose of the evaluation, decide when to evaluate, create an evaluation plan, utilize instruments to collect the data, and interpret the data (Jeffries & Rogers, 2007b). Various instruments can be found in the education and simulation literature; however, the facilitator must consider the reliability and validity of the tool to be used.

No matter what decision is made regarding evaluation or assessment of learning in the simulation laboratory, the SCE itself must be evaluated. Obtaining information about the design of the simulation, availability of resources, effectiveness of the facilitator, perception of learning outcomes, and suggestions for future SCEs provides valuable insight to the facilitator (Horn & Carter, 2007).

This information should be trended and adjustments to the scenario made as necessary.

Research Opportunities

It should be clear to the reader of this chapter that a wide variety of research opportunities exist for the users of simulation. While simulation has been used 260 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon in healthcare education for years, the use of high-fidelity patient simulation is still in its infancy in nursing education. While it is often bemoaned that there is little research pointing to the efficacy of this teaching strategy, the research base is growing as facilitators become more comfortable in their role.

Conducting research in the simulation laboratory has several advantages over research in the traditional clinical environment; namely, that there is no risk to patients. Facilitators are also able to control the scenario, patient responses, communication with healthcare providers, and what equipment is available. However, those same faculty are also as difficult to control as a variable. Faculty have different levels of education regarding the role of facilitator, respond variably to students’ efforts to communicate, and often need to step outside of the planned script to respond to unpredictable student actions (Alinier, 2008).

There have been many obstacles to using research data to support increased use of patient simulation or to justify the expense and time required to learn.

A systematic research review, over a 34-year period of time ending in 2003, revealed wide variety in research design, methods of measuring outcomes, journal report structure, as well as use of small sample sizes (McGahie, Pugh,

& Wayne, 2008).

It is a responsibility of each of us as simulation facilitators and proponents to help move the field forward through well-designed research studies and documentation of best practice and standards of excellence. It is no longer enough to document that students like simulation or that they prefer this method to another. The time has come to document that learning occurs and that it is equal to or better than our traditional teaching methods. As the competition for clinical sites continues to build, simulation will take a vital role in the future of nursing education.

CONCLUSION

This chapter has provided information intended to help those who take on the challenge of facilitating learning in the simulation laboratory. While many nursing programs have managed to obtain funding for simulation equipment, there has often been little forethought into how faculty will manage to learn this type of teaching strategy and where the time will come from for that purpose (Kardong-Edgren & Oermann, 2009). This chapter was intended to help aide the process of faculty development by providing realistic ideas that can be easily implemented by facilitators of learning in simulation laboratories. The simulator and its features have little value if the faculty does not know how to effectively teach with the technology.

Conclusion 261

APPLIED EXAMPLE

Strategy

Incorporation of fidelity, role of faculty, and holistic aspects of patient care for a beginning assessment course SCe. Participants in the simulation laboratory include the course faculty member and up to eight students.

Expectations

the students are expected to obtain subjective and objective assessment data and inform the healthcare provider of their findings. Prerequisite knowledge should include anatomy and physiology of the cardiovascular system and corresponding assessment techniques. this is a young morbidly obese female patient whose symptoms are precipitated by a systolic heart murmur.

Setting

the simulator is lying on a bed or stretcher and has not been seen by a healthcare provider. Place two individual breast models (often used to teach palpation for lumps) on the chest of the simulator. the patient’s obesity can be simulated by placing a pillow over the abdomen and securing it with an ace wrap or gauze roll. Put female clothes appropriate for the weather on the simulator (it is easiest to cut the shirt up the back leaving the col ar intact; cut the pants along the back to the inseam to al ow ease of application). apply a female wig. Makeup can be applied to the simulator after it is tested in a nonvisible place for staining. Personal effects such as magazine, cell phone, and purse can be placed on the bedside table next to a bottle of sugared carbonated beverage.

Simulator Settings

Set systolic murmur (or other preferred abnormal heart sound). all other settings are normal.

Faculty Role

this is the first SCe for students and, therefore, they are at a novice level and will need faculty assistance. It is preferable to orient students to the simulator and its features prior to starting the scenario. Only tel students what they need to know to care for this patient, as providing information on intravenous (IV) sites, defibril ation, or monitoring is above their knowledge level and wil be extraneous information.

Begin outside of the simulator’s room and brief students on the patient who has just arrived to the healthcare provider’s office. report is as follows:

“this is a 38-year-old female with complaints of fatigue, orthopnea, and palpitations. She is 5’2” tall and weighs 100 kg.”

Student Expectations

O Knock on the door and announce entry

O Introduce self and role to patient

O Wash hands

O ask subjective questions to obtain more information from the patient, such as:

o How long ago did you symptoms start? (6 months ago; gradually worsening)

o any associated symptoms? (no dyspnea or chest pain)

o What makes the symptoms worse? (walking and exercise) 262 Chapter 16 • InnovatIons In FaCIlItatIng learnIng UsIng sImUlatIon

o What makes the symptoms go away? (rest)

o How many pillows do you use at night? (three)

o Do you have any history of medical problems? (no)

o Do you have any family history of medical problems? (no cardiac disease)

o Do you smoke, drink alcohol, or use drugs not prescribed for you? (no)

o How much do you exercise in a week? (none)

o Has there been any change in your weight recently? (gained 40 pounds past 4 months)

o What is you typical diet? (fast food, soda)

o Do you take any medications? (ibuprofen as needed for back pain)

o When was the last time you saw a healthcare provider?

Questioning may continue until the facilitator believes that enough data has been col ected. the facilitator then prompts the beginning of the physical assessment.

Student Expectations

O Wash hands

O explain what will be done to patient

O Conduct general survey

O Provide for privacy

O Head-to-toe physical assessment with emphasis on cardiovascular system

O Wash hands

O Make sure personal items are in reach

O ensure safe environment

During the physical assessment, the students wil discover an abnormality in the heart sounds.

although it may be beyond their scope to recognize and define a heart murmur, they should be able to identify that an abnormality exists. all other findings, including vital signs are normal.

Holistic Aspects (one or more may be included):

O Psychosocial: Patient does not have health insurance and voices concern about how to pay for office visit, follow-up tests, or prescriptions.

O Spiritual: Patient may be anxious and ask student to pray with her.

O Cultural: Patient may be from a culture other than that of most of the students.

O Developmental: Patient may blame weight gain on a recent life experience, such as a divorce.

antICIPateD anD UnantICIPateD eVentS anD COnSeQUenCeS

Nervousness

as this is often the first SCe for the students, they are prone to nervousness and have trouble getting started. the facilitator may need to go around the bed, student by student, and ask them to pose a subjective question to the patient. the person responding as the patient should be patient and al ow time for questions to be formulated, not rushing the students.

Scattered Thought Processes

novice students tend to randomly ask subjective questions without organization. Fol owing subjective questioning, the facilitator can help them to prioritize their completed assessment questions and findings.

References 263

Incorrect Assessment Techniques

the facilitator is at the bedside with this novice group and can correct technique as problems occur.

Unless the SCe is recorded, this level of learner may not recall what they did right or wrong by the time debriefing occurs.

Failure to Recognize Abnormality

this may occur in the novice student due to lack of experience. If this is the case, the facilitator should point it out and have al students listen to the heart sounds. the respiratory rate may be lowered on the simulator and the heart sound volume increased to facilitate hearing of abnormal heart sounds.

eValUatIOn OF learner attaInMent

the intent of this SCe is to provide an introductory level experience for the student who has not yet interacted with a real patient and is just beginning to learn physical assessment techniques and concepts. the facilitator wil often be surprised by the learner’s inability to formulate subjective questions and conduct a basic physical assessment. remembering that novice learners have no experiences to draw on will keep expectations in perspective. learners should be able to demonstrate physical assessment techniques learned in class; however, they often need help finessing their technique and need reassurance that they are doing the assessment correctly.

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