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Simulation in Community Health Nursing: A Conceptual Approach
Clinical Simulation in Nursing (2013) 9, e445-e451
www.elsevier.com/locate/ecsn
Featured Article
Simulation in Community Health Nursing: A Conceptual Approach Karen S. Distelhorst, MSN, GCNS-BC, RN, Lora L. Wyss, PhD, CNS, Certified School Nurse, RN* Malone University, Canton, OH 44709, USA KEYWORDS aggregates in the community; community-based nursing education; community health; home visit simulation; simulation; vulnerable populations in the community
Abstract: Simulation activities have proven to be a valuable resource for nursing education, providing students with the opportunity to practice physical assessment and technical skills. Most published simulation scenarios have focused on traditional medical specialties. However, there is a recent trend in which entry-level nurses are increasingly engaged outside the traditional acute care setting. To prepare student nurses for practice in a wide range of community-based environments, nursing programs might consider the use of simulated clinical experiences that focus on community health concepts. The proposed community health nursing simulation curriculum is organized through its relationship to community health themes: (a) care of individuals in the community; (b) care of aggregates in the community; (c) care of vulnerable populations in the community; and (d) health of communities. Within these themes, the clinical scenarios are based in typical community health settings, such as home health care, public health clinics, school health, occupational health, free or migrant clinics, and the community at large. Examples of scenarios for each theme are discussed, including proposed settings, skills, and concepts for each. Cite this article: Distelhorst, K. S., & Wyss, L. L. (2013, October). Simulation in community health nursing: A conceptual approach. Clinical Simulation in Nursing, 9(10), e445-e451. http://dx.doi.org/10.1016/ j.ecns.2012.07.208. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Simulation activities have proven to be a valuable resource for nursing education, providing students with the opportunity to practice physical assessment and psychomotor skills. These students report higher levels of selfconfidence for nursing practice through the use of simulation as a method of teaching and learning (Sinclair & Ferguson, 2009). Most published simulation scenarios have focused on traditional medical specialties, such as maternalechild, pediatric, and medicalesurgical nursing. However, entrylevel nurses are increasingly engaged in practice outside * Corresponding author: [email protected] (L. L. Wyss).
the traditional acute care setting, such as home health, health departments, schools, free clinics, and other outpatient venues. To prepare student nurses for these nontraditional roles, nursing programs might consider the use of simulation scenarios that focus on community health concepts.
The Future of Community Health Nursing Education In baccalaureate programs, community health nursing may be taught as a stand-alone course or threaded throughout
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2012.07.208
Simulation in Community Health Nursing
e446
the curriculum. The content of the community health nursing course has always provided important preparation for the graduate nurse. It is an expectation that baccalaureate nursing educators prepare students to eventually work with individuals, families, groups, and communities across the continuum of health care environments (American Key Points Association of Colleges of There is an increased Nursing, 2008). In spite of emphasis on nursing this expectation, community education in the comhealth nursing content may munity and public be undervalued as the majorhealth settings as ity of registered nurses have nursing employment been reported to be working trends shift. within the hospital setting Simulation activities (U.S. Department of Health can be used to suppleand Human Services, ment the community 2010). This trend is changhealth nursing clinical ing, however; with nursing experience and proshortages and economic vide opportunities for constraints within hospitals, learning that might more new registered nurses otherwise be missed. are working in community Students report that based health care environsimulation activities ments than ever before. The increase their confilarge uninsured population dence when approach(4.9 million people in 2010) ing independent adds to this trend as many community health uninsured patients avoid nursing clinical work. hospitals and depend on free clinics for a wide range of services (U.S. Department of Health and Human Services, 2011). Changes in the National Council Licensure Examination (NCLEX) have reflected this trend with an increased emphasis on community-based concepts such as emergency response plans, health promotion and maintenance, lifestyle choices, and chronic illness management (Longo, 2011). Within the current environment of health care reform, nurses are expected to be leaders in addressing the health care needs of the nation, and community health nurses have the opportunity to contribute significantly to this charge. The Institute of Medicine report ‘‘The Future of Nursing: Leading Change, Advancing Health’’ (Institute of Medicine, 2011) addresses the need for nursing education to prepare students to work in the community health arena. ‘‘Entry-level nurses . need to be able to transition smoothly from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings’’ (Institute of Medicine, 2011, p. 164). According to the U.S. Department of Health and Human Services, Health Resources and Services Administration (2010), 62% of nurses are employed in acute care, while nearly 25% are working in home health, ambulatory care, and public or community health. These trends are depicted in Figure 1. The U.S. Department of Health and Human Services defines
Other 3.90% 0 Ambulatory care 10.50%
Public/community health 7.80%
Home health 6.40%
Academic education 3.80%
Hospital 62.20%
Nursing home/extended care 3.20%
Figure 1 Employment settings of registered nurses. Public/ community health includes school and occupational health. Ambulatory care includes medical ands physician practices, health centers and clinics, and other types of nonhospital clinical settings. Other includes insurance, benefits, and use review. Percentages may not add to 100 because of the effect of rounding. Adapted from U.S. Department of Health and Human Services, Health Resources and Services Administration (2010).
ambulatory care to include primary care practices, health centers and clinics, and other types of nonhospital clinical settings; public or community health also includes school and occupational health. Not only are entry-level nurses working in these community settings, but the care provided in them requires a higher level of clinical reasoning (which is difficult to teach in a classroom environment) because of the intermittent and independent nature of the work (Weis & Guyton-Simmons, 1998). Community health nursing clinical experiences should also have a positive impact on NCLEX scores since critical thinking skills are necessary for high achievement on the NCLEX. Clinical learning is extremely important to help students develop and refine the knowledge and skills necessary to transition to community practice (American Association of Colleges of Nursing, 2008). Unfortunately, community experiences are limited because they often involve small facilities with few patients. Traditionally, these clinical agencies may accommodate only one or two students at a time, limiting students’ experiences. Further complicating the issue, free and charitable clinics are valuable sites, but limited funding makes staffing unpredictable since many rely on donations and volunteers (National Association of Free & Charitable Clinics, 2011). In order for students to have exposure to all the different community health care settings, simulation activities can be used to complement the clinical experience and provide opportunities for learning that might otherwise be missed.
A Curriculum for Community Nursing Simulation Our proposed community nursing simulation curriculum is organized according to its relationship to community health
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themes: (a) care of individuals in the community, (b) care of aggregates in the community, (c) care of vulnerable populations in the community, and (d) health of communities. The themes should coordinate easily with most community and public health nursing textbooks. Within these themes, the scenarios are based in typical community health settings, such as home health care, public health clinics, free clinics, school health, correctional facilities, and occupational health. For nursing students to believe that the simulation is worthwhile, it is important for students to perform some technical skills as they explore important community health concepts. Examples of the settings, skills, and concepts are provided in Table 1. Largescale simulation scenarios could combine the use of simulation equipment and group role play to represent community-wide interventions, such as disaster management or mass immunization during a pandemic. By using this overall framework of content, nursing faculty can provide the student with a more comprehensive view of the health care needs of a community.
and a brief background report. Prebriefing allows for an orientation to set the stage for the scenario and assist participants in achieving scenario objectives (International Nursing Association for Clinical Simulation and Learning, 2011). Home health nurses frequently have little information when first entering the home. The students must accurately identify that the patient is in respiratory distress and use the resources available to them to appropriately treat the patient: home oxygen, prescribed albuterol, positioning, and communication with the primary care provider. Participant objectives are to prioritize care, communicate effectively with providers and family, and identify infection control and safety concerns. An embedded faculty member or actor portraying a caregiver can regulate the visit by being cooperative, difficult, or even threatening. At the end of the scenario, a salient point that can be discussed in debriefing is the unpredictable nature of home visits.
Care of Individuals in the Community
Community health nurses use a population-focused approach to health care when working with aggregates across the lifespan. Clinical sites that reflect the care of aggregates in the community include health department clinics (e.g., well-child; women’s health; women, infants, and children; and prenatal), school nurse programs, occupational health clinics, and adult day care facilities. While nurses working in these areas usually deliver direct care at the individual level, they are continually assessing for trends and issues that are common to the group as a whole. Nurses use statistical and epidemiological data to support the need for targeted programs and develop interventions at the aggregate level. Simulated clinical experiences may include aggregatespecific health issues, such as teenage pregnancy, lead exposure in children, work-related injury, or even chronicillness management. The simulation begins at the individual level; for example, a school nurse assesses an overweight child with type 2 diabetes. The participant objectives are to (a) assess the child during a suspected hypoglycemic reaction; (b) perform a finger stick to test blood glucose; (c) provide the proper treatment for a hypoglycemic reaction; and (d) communicate effectively with the student, school, and parents in order to initiate follow-up care. Students are then provided the opportunity to investigate the problem at the aggregate level. Epidemiological data is provided along with the core case, and a group activity uses the nursing process to plan a targeted intervention. In this instance, the school nurse may identify an increased incidence of type 2 diabetes among the children in the district and a higher prevalence compared with other school districts in the state. The student nurse also evaluates the results of the most recent schoolwide health screening, noting that a large number of children are categorized as overweight. The student nurses use this analysis to
Activities such as creating a home environment in the nursing school laboratory and using human patient simulators for simulated home visits have been documented as effective strategies to decrease the anxiety of students regarding home care experiences (Simones, 2008; Yeager & Gotwals, 2010). Much more could be achieved with students practicing in a simulated home-based setting. The value of using simulation in community health is that it can provide an opportunity for complex decision-making environments with high levels of uncertainty and low levels of information (Jeffries, 2005). Nurses practicing in the community often have access to few resources and limited information. In acute care, nursing activities take place continuously, and patient information is readily available from many sources. In the community, care is provided on an intermittent basis, and nurses must assess for critical changes between episodes of care. Purposeful questioning regarding physical, environmental, and social issues must be efficient and the responses analyzed quickly to identify problems. Once problems are identified, nurses must use appropriate clinical reasoning to obtain the necessary resources for patients. An example of a home visit simulation scenario presents a patient with chronic obstructive pulmonary disease who is in moderate to severe respiratory distress. The student is expected to (a) provide the standard of care related to patient safety and infection control; (b) initiate a focused respiratory assessment; (c) communicate effectively with the patient, caregiver, and physician; and (d) provide appropriate interventions in the home setting. In prebriefing, the students are given information on the patient that consists only of the physician orders and plan of care (including medication list, medical diagnoses, and orders)
Care of Aggregates in the Community
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Simulation in Community Health Nursing Table 1
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Community Health Nursing Simulation
Community Health Theme
Environmental Conditions
Community Health Concepts
Skill Acquisition
Care of individuals in the community
Home health care Home visits
Chronic illness management Interdisciplinary collaboration
Care of aggregates in the community
School health Health department Occupational health
Population-focused care Health promotion Interagency collaboration
Care of vulnerable populations in the community
Migrant clinic Free clinic Correctional facility
Cultural competency Social justice
Health of communities
Bioterrorist attack Pandemic Mass casualty (Large-scale simulation)
Emergency preparedness Upstream thinking Epidemiology
Physical assessment Administration of oxygen Administration of MDI, aerosol treatment Report to physician Assessment of DM Blood glucose check Treatment of hypoglycemia Communication with family Injections (immunizations) Administering, reading TB test Sputum collection for TB Use of interpreter Neurologic assessment Various first aid procedures Color-coded disaster triage Starting intravenous fluids
Note. The table is intended to provide examples for settings and skills; it is not an exhaustive list. Community simulation scenarios should integrate individual-focused care (through hands-on procedures) with population-focused care (through group activities and debriefing). It is important to allocate time before and after the simulation for group preparation and activities. DM ¼ diabetes mellitus; MDI ¼ metered dose inhaler; TB ¼ tuberculosis.
determine a plan of action to address nutrition and obesity within the school district. In this type of scenario, the facilitator assists the students to move from an individual focus of care to an aggregate level of care. According to Jeffries, ‘‘a debriefing activity reinforces the positive aspects of the experience and encourages reflective learning, which allows the participant to link theory to practice and research, think critically, and discuss how to intervene professionally in very complex situations’’ (2005, p. 101). This activity helps the students to develop a plan at a community level, not just an individual level.
Care of Vulnerable Populations in the Community The concept of social justice is central to community and public health nursing. Clinical experiences with vulnerable populations provide a context for students to understand this concept. Free clinics, correctional facilities, and migrant clinics are a few examples of clinical sites that address the needs of vulnerable populations. Simulating these types of environments is valuable for several reasons. First, many of the agencies that provide care to the vulnerable have limited resources and may be able to accommodate only a few students. Simulation activities can supplement clinical learning and also boost students’ selfconfidence prior to the actual experience (Simones, 2008). Students can also develop cultural competence as they prepare to interact with diverse populations and consider the health disparities that exist. The simulation scenario for this theme is similar to that of the care of aggregates in the community. Care begins at
the individual level; then the nurse must expand the focus to the family and finally to the vulnerable group as a whole. In addition, the nurse must be aware of the health disparities that exist for the group of focus. For example, a scenario involving a migrant health clinic (a clinic that treats primarily Latino migrant farm laborers) can provide challenges for students in terms of cultural and linguistic competence, family dynamics, and interdisciplinary coordination. In a scenario in which the nurse must provide care to a migrant worker with latent tuberculosis, the student will need to (a) perform a focused assessment on the simulator patient, (b) use infection control measures, (c) obtain a blood specimen, and (d) administer medication. The student, recognizing that many migrant children are unimmunized, will also interact with the families. Students will administer injections (subcutaneous, intramuscular, and intradermal), evaluate immunization schedules, and provide education to families. Next, the students can plan interventions for the overall migrant population in order to prevent the spread of tuberculosis, as 5% to 10% of those diagnosed with latent tuberculosis convert to active status (Jensen, Lambert, Iademarco, & Ridzon, 2005). With the use of prerecorded scripts and faculty guidance, students can practice communicating with patients through an interpreter.
Care of the Community Education regarding disaster preparedness is an important aspect of community health courses in baccalaureate nursing programs. The 2010 NCLEX has expanded the
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content on disaster planning into a more comprehensive section titled Emergency Response Plan (Longo, 2011). The International Nursing Coalition for Mass Casualty Education has identified basic competencies for all nurses in order to be prepared to respond to a mass casualty incident (MCI), most of which are basic to nursing practice and included in all nursing education programs (International Nursing Coalition for Mass Casualty Education, 2003). A clinical experience in disaster preparedness allows students to draw on previous learning in order to develop basic proficiency for an MCI response. Students should be able to (a) develop sufficient knowledge and skills to recognize the potential for a MCI, (b) identify when such an event may have occurred, (c) know how to protect themselves, (d) know how to provide immediate care for those individuals involved, (e) recognize their own role and limitations, and (f) know where to seek additional information and resources (International Nursing Coalition for Mass Casualty Education, p. 5). Clinical simulations for this content can be very effective and can actively involve large groups of students in a variety of ways. Potential simulated MCI scenarios for community health nursing students include a natural disaster resulting in a mass casualty, a bioterrorism attack, or a mass immunization in response to a pandemic. Some bioterrorism simulation exercises have been reported in the literature (Carter & Gaskins, 2010; Doran & Mulhall, 2007), with a single human simulation patient and teams of students to provide treatment. Morrison and Catanzaro (2010) have described using a combination of high-fidelity simulation and role-playing to provide students with an exercise in emergency preparedness, specifically, an infectious disease outbreak. Large-scale simulations could easily involve students and faculty as both casualties and responders. These simulations can begin with a single human simulator, who first presents with injuries or symptoms of exposure to an infectious agent, such as smallpox. Using role play for additional casualties and including multiple responders would give students the opportunity to practice basic nursing skills, disaster triage, and interdisciplinary collaboration. In this type of scenario, educators need to allow adequate time for prebriefing and debriefing (Morrison & Catanzaro, 2010). This time on task, as described by Jeffries (2005), can be increased with clear and realistic time frames, as well as clear and focused objectives. It is best if only a few key concepts are taught and reinforced in each lab setting.
Implementation We are from a baccalaureate nursing program in small private university in the Midwest. Together we have a combined 20 years of experience in community health nursing education. One of us has extensive clinical experience in home health care; the other researches and has
worked directly with the Hispanic migrant population for more than 12 years. When the school of nursing obtained high-fidelity simulators, the faculty quickly realized that there were at that time no programs available specific to community health concepts. During a 3-year period, we have implemented the simulated clinical experiences described in this article, with the exception of the school nurse scenario, which is currently in the planning stage. The faculty had limited training on the equipment from the simulator manufacturer and relied mostly on evidence from simulation journals for direction on development of the simulated clinical experiences. The simulation experiences are implemented in the 4th year of the baccalaureate program within the community health nursing course. The average age of the students is 25 years; approximately 10% are men, and 7% are nontraditional students. Early in the course, the home visit simulation experience uses a facilitator-prompted methodology with the use of a high-fidelity simulator. Prompting is used to assist the participants in prioritizing assessment, data collection, implementation, and evaluation (Nehring & Lashley, 2010) in the home setting. Each clinical group was allowed 2 hours for the simulation experience, which included prebriefing, the clinical scenario, and debriefing. Students were expected to prepare for the experience through a guided reading assignment. Two students actively participated in the simulation, while the rest of the clinical group observed and offered a summative evaluation of their peers’ achievement of outcome criteria. Although all students were required to engage in the activity, as either a scenario role player or an evaluator, there was no high-stakes evaluation with passefail implications. During the debriefing period, guided reflection was used, and students reported they were surprised at the complexity of a typical home visit. Students have reported in course evaluations that the simulation helped to prepare them for their community clinical assignments. Midway through the course, a simulated migrant immunization clinic provides students with the opportunity to develop competence in clinical reasoning and psychomotor skills in a safe environment. Students are given actual immunization records of migrants (identifying information removed); they are also provided with current Centers for Disease Control and Prevention immunization guidelines and must determine the appropriate course of action. A facilitator is present to help the participants understand and achieve the objectives. At the end of the learning period, guided reflection is used to allow the participants to assimilate the theory, the immunization practice, and the provided standards in order to meet the objectives. Students discover that actual immunization records do not support the popular belief that migrants are underimmunized but may actually have had repeated immunizations because of issues involving record keeping and mobility. In evaluation of the experience, students feel more prepared when they participate in actual immunization clinics.
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Near the completion of the course, students participate in a simulated MCI experience. This is a large-group activity that includes many standardized patients and scenario role players. Time on task for this experience is approximately 4 hours, which includes extended prebriefing (review of Simple Triage and Rapid Treatment triage system, discussion of disaster), the disaster simulation itself, and debriefing. Within the activity, the student has the opportunity to practice basic nursing skills and disaster triage and to experience interdisciplinary collaboration with the local Red Cross staff and local hospital trauma coordinator. After assessing evaluations from students, faculty, and community collaborators, we are initiating plans for a potential campus-wide mass casualty disaster simulation, providing an expanded opportunity for interdisciplinary collaboration. In all the simulation clinical experiences, diverse learning styles of the students were addressed. Examples of principles of good practice in undergraduate education, as described by Chickering and Gamson (1987, 1999), include providing studentefaculty contact, encouraging cooperation and active learning, giving prompt feedback while emphasizing time on task, and communicating high expectations while respecting diverse talents. Moving the simulation scenarios from simple to complex during the course allows for students to build their clinical reasoning skills through collaboration practices. Students and faculty working in groups together, through role-playing and debriefing, strengthens the learning process. Students are encouraged to use their diverse strengths in the group dynamic of the simulation. Some students are better at the ‘‘hands-on,’’ or psychomotor, aspects of the simulation while others bring a deeper understanding of the theory behind the content. Facilitators of the simulation experience need to move among the groups and shape the environment so that student-to-student learning can be maximized.
Conclusion Community health is an expansive topic encompassing many diverse settings and populations. Simulation can be used in any RN curriculum to assist with a more in-depth understanding of community health clients and the concept of population-focused care. It is intended to supplement the clinical experience in community-based courses. Each student is expected to gain proficiency in intermediate-level assessment and clinical reasoning skills. Students report that the simulations also increase their confidence when they are approaching independent work in their actual community clinical experience. Community healtherelated simulations can be taught at the intermediate or advanced level and can be used with low-fidelity or high-definition simulation equipment. Because community health nursing uses a macroscopic, population-focused approach, the activities surrounding the simulation must provide the opportunity for students to plan, implement, and evaluate care beyond the individual client. Some examples provided were implemented in our school
of nursing, some are in the process of development, and others are suggestions based on our community health clinical expertise. Research is needed to determine the most effective way to deliver these community-based simulation activities, including the role of debriefing and post-simulation exercises.
References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved August 2, 2012, from http://www.aacn.nche.edu/education-resources/ BaccEssentials08.pdf. Carter, M. R., & Gaskins, S. T. (2010). Incorporating bioterrorism content in the nursing curriculum: A creative approach. Journal of Nursing Education, 49(7), 406-409. http://dx.doi.org/10.3928/0148483420100217-08. Chickering, A. W., & Gamson, Z. F. (1987). Seven principles for good practice in undergraduate education. AAHE Bulletin, 39(7), 3-7. Chickering, A. W., & Gamson, Z. F. (1999). Development and adaptation of the seven principles for good practice in undergraduate education. In M. D. Svinicki (Ed.), Teaching and learning on the edge of the millennium: Building on what we have learned: New directions for teaching and learning, no. 80 (Chapter 6). San Francisco, CA: Jossey-Bass. Doran, A. J., & Mulhall, M. (2007). Bioterrorism in the simulation laboratory: Preparing students for the unexpected. Journal of Nursing Education, 46(6), 292. http://dx.doi.org/10.1016/j.cnur.2008.06.009. International Nursing Association for Clinical Simulation and Learning Board of Directors. (2011). Standard I: Terminology. Clinical Simulation in Nursing, 7(Suppl 4), s3-s7. http://dx.doi.org/10.1016/j.ecns.211.05.005. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Retrieved August 2, 2012, from http://books.nap.edu/ openbook.php?record_id¼12956. International Nursing Coalition for Mass Casualty Education, Competency Committee. (2003). Education competencies for registered nurses responding to mass casualty incidents. Retrieved August 2, 2012, from http:// www.aacn.nche.edu/leading-initiatives/education-resources/INCMCE Competencies.pdf. Jeffries, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-104. http://dx.doi.org/10.1043/15365026(2005)026<0096:AFWFDI>2.0.CO;2. Jensen, P. J., Lambert, L. A., Iademarco, M. J., & Ridzon, R. (2005). Guidelines for preventing the transmission of mycobacterium tuberculosis in the health-care settings. MMWR, 54(RR17), 1-141. Longo, B. (2011, March). NCLEX 2010: What’s new? Presentation at the Forum for Innovations in Nursing Education, Cleveland, OH. Morrison, A. M., & Catanzaro, A. M. (2010). High-fidelity simulation and emergency preparedness. Public Health Nursing, 27(2), 164-173. http:// dx.doi.org/10.111/j.1525-1446.2010.00838.x. National Association of Free & Charitable Clinics. (2011). Comparison of free and charitable clinics to federally funded clinics. Retrieved August 2, 2012, from http://www.nafcclinics.org. Nehring, W. M., & Lashley, F. R. (2010). High-fidelity patient simulation in nursing education. Boston, MA: Jones & Bartlett. Simones, J. (2008). Creating a home care simulation laboratory. Journal of Nursing Education, 47(3), 132-133. http://dx.doi.org/10.3928/0148483420080301-08. Sinclair, B., & Ferguson, K. (2009). Integrating simulated teaching/learning strategies in undergraduate nursing education. International Journal of Nursing Education Scholarship, 6(1), Article 7. http://dx.doi.org/ 1002202/1548-923X1676. U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses.
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Retrieved August 2, 2012, from http://bhpr.hrsa.gov/healthworkforce/ rnsurveys/rnsurveyfinal.pdf. U.S. Department of Health and Human Services. (2011). Overview of the uninsured in the United States: A summary of the 2011 Current Population Survey. Retrieved August 2, 2012, from http://aspe.hhs.gov/health/ reports/2011/CPSHealthins2011/ib.shtml.
Weis, P., & Guyton-Simmons, J. (1998). A computer simulation for teaching critical thinking skills. Nurse Educator, 23(2), 30-33. Yeager, S. T., & Gotwals, B. (2010). Incorporating high-fidelity simulation technology into community health nursing education. Clinical Simulation in Nursing, 6(2), e53-e59. http://dx.doi.org/10.1037/02786133.24.2.225.
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Featured Article
Simulation in Community Health Nursing: A Conceptual Approach Karen S. Distelhorst, MSN, GCNS-BC, RN, Lora L. Wyss, PhD, CNS, Certified School Nurse, RN* Malone University, Canton, OH 44709, USA KEYWORDS aggregates in the community; community-based nursing education; community health; home visit simulation; simulation; vulnerable populations in the community
Abstract: Simulation activities have proven to be a valuable resource for nursing education, providing students with the opportunity to practice physical assessment and technical skills. Most published simulation scenarios have focused on traditional medical specialties. However, there is a recent trend in which entry-level nurses are increasingly engaged outside the traditional acute care setting. To prepare student nurses for practice in a wide range of community-based environments, nursing programs might consider the use of simulated clinical experiences that focus on community health concepts. The proposed community health nursing simulation curriculum is organized through its relationship to community health themes: (a) care of individuals in the community; (b) care of aggregates in the community; (c) care of vulnerable populations in the community; and (d) health of communities. Within these themes, the clinical scenarios are based in typical community health settings, such as home health care, public health clinics, school health, occupational health, free or migrant clinics, and the community at large. Examples of scenarios for each theme are discussed, including proposed settings, skills, and concepts for each. Cite this article: Distelhorst, K. S., & Wyss, L. L. (2013, October). Simulation in community health nursing: A conceptual approach. Clinical Simulation in Nursing, 9(10), e445-e451. http://dx.doi.org/10.1016/ j.ecns.2012.07.208. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Simulation activities have proven to be a valuable resource for nursing education, providing students with the opportunity to practice physical assessment and psychomotor skills. These students report higher levels of selfconfidence for nursing practice through the use of simulation as a method of teaching and learning (Sinclair & Ferguson, 2009). Most published simulation scenarios have focused on traditional medical specialties, such as maternalechild, pediatric, and medicalesurgical nursing. However, entrylevel nurses are increasingly engaged in practice outside * Corresponding author: [email protected] (L. L. Wyss).
the traditional acute care setting, such as home health, health departments, schools, free clinics, and other outpatient venues. To prepare student nurses for these nontraditional roles, nursing programs might consider the use of simulation scenarios that focus on community health concepts.
The Future of Community Health Nursing Education In baccalaureate programs, community health nursing may be taught as a stand-alone course or threaded throughout
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2012.07.208
Simulation in Community Health Nursing
e446
the curriculum. The content of the community health nursing course has always provided important preparation for the graduate nurse. It is an expectation that baccalaureate nursing educators prepare students to eventually work with individuals, families, groups, and communities across the continuum of health care environments (American Key Points Association of Colleges of There is an increased Nursing, 2008). In spite of emphasis on nursing this expectation, community education in the comhealth nursing content may munity and public be undervalued as the majorhealth settings as ity of registered nurses have nursing employment been reported to be working trends shift. within the hospital setting Simulation activities (U.S. Department of Health can be used to suppleand Human Services, ment the community 2010). This trend is changhealth nursing clinical ing, however; with nursing experience and proshortages and economic vide opportunities for constraints within hospitals, learning that might more new registered nurses otherwise be missed. are working in community Students report that based health care environsimulation activities ments than ever before. The increase their confilarge uninsured population dence when approach(4.9 million people in 2010) ing independent adds to this trend as many community health uninsured patients avoid nursing clinical work. hospitals and depend on free clinics for a wide range of services (U.S. Department of Health and Human Services, 2011). Changes in the National Council Licensure Examination (NCLEX) have reflected this trend with an increased emphasis on community-based concepts such as emergency response plans, health promotion and maintenance, lifestyle choices, and chronic illness management (Longo, 2011). Within the current environment of health care reform, nurses are expected to be leaders in addressing the health care needs of the nation, and community health nurses have the opportunity to contribute significantly to this charge. The Institute of Medicine report ‘‘The Future of Nursing: Leading Change, Advancing Health’’ (Institute of Medicine, 2011) addresses the need for nursing education to prepare students to work in the community health arena. ‘‘Entry-level nurses . need to be able to transition smoothly from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings’’ (Institute of Medicine, 2011, p. 164). According to the U.S. Department of Health and Human Services, Health Resources and Services Administration (2010), 62% of nurses are employed in acute care, while nearly 25% are working in home health, ambulatory care, and public or community health. These trends are depicted in Figure 1. The U.S. Department of Health and Human Services defines
Other 3.90% 0 Ambulatory care 10.50%
Public/community health 7.80%
Home health 6.40%
Academic education 3.80%
Hospital 62.20%
Nursing home/extended care 3.20%
Figure 1 Employment settings of registered nurses. Public/ community health includes school and occupational health. Ambulatory care includes medical ands physician practices, health centers and clinics, and other types of nonhospital clinical settings. Other includes insurance, benefits, and use review. Percentages may not add to 100 because of the effect of rounding. Adapted from U.S. Department of Health and Human Services, Health Resources and Services Administration (2010).
ambulatory care to include primary care practices, health centers and clinics, and other types of nonhospital clinical settings; public or community health also includes school and occupational health. Not only are entry-level nurses working in these community settings, but the care provided in them requires a higher level of clinical reasoning (which is difficult to teach in a classroom environment) because of the intermittent and independent nature of the work (Weis & Guyton-Simmons, 1998). Community health nursing clinical experiences should also have a positive impact on NCLEX scores since critical thinking skills are necessary for high achievement on the NCLEX. Clinical learning is extremely important to help students develop and refine the knowledge and skills necessary to transition to community practice (American Association of Colleges of Nursing, 2008). Unfortunately, community experiences are limited because they often involve small facilities with few patients. Traditionally, these clinical agencies may accommodate only one or two students at a time, limiting students’ experiences. Further complicating the issue, free and charitable clinics are valuable sites, but limited funding makes staffing unpredictable since many rely on donations and volunteers (National Association of Free & Charitable Clinics, 2011). In order for students to have exposure to all the different community health care settings, simulation activities can be used to complement the clinical experience and provide opportunities for learning that might otherwise be missed.
A Curriculum for Community Nursing Simulation Our proposed community nursing simulation curriculum is organized according to its relationship to community health
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themes: (a) care of individuals in the community, (b) care of aggregates in the community, (c) care of vulnerable populations in the community, and (d) health of communities. The themes should coordinate easily with most community and public health nursing textbooks. Within these themes, the scenarios are based in typical community health settings, such as home health care, public health clinics, free clinics, school health, correctional facilities, and occupational health. For nursing students to believe that the simulation is worthwhile, it is important for students to perform some technical skills as they explore important community health concepts. Examples of the settings, skills, and concepts are provided in Table 1. Largescale simulation scenarios could combine the use of simulation equipment and group role play to represent community-wide interventions, such as disaster management or mass immunization during a pandemic. By using this overall framework of content, nursing faculty can provide the student with a more comprehensive view of the health care needs of a community.
and a brief background report. Prebriefing allows for an orientation to set the stage for the scenario and assist participants in achieving scenario objectives (International Nursing Association for Clinical Simulation and Learning, 2011). Home health nurses frequently have little information when first entering the home. The students must accurately identify that the patient is in respiratory distress and use the resources available to them to appropriately treat the patient: home oxygen, prescribed albuterol, positioning, and communication with the primary care provider. Participant objectives are to prioritize care, communicate effectively with providers and family, and identify infection control and safety concerns. An embedded faculty member or actor portraying a caregiver can regulate the visit by being cooperative, difficult, or even threatening. At the end of the scenario, a salient point that can be discussed in debriefing is the unpredictable nature of home visits.
Care of Individuals in the Community
Community health nurses use a population-focused approach to health care when working with aggregates across the lifespan. Clinical sites that reflect the care of aggregates in the community include health department clinics (e.g., well-child; women’s health; women, infants, and children; and prenatal), school nurse programs, occupational health clinics, and adult day care facilities. While nurses working in these areas usually deliver direct care at the individual level, they are continually assessing for trends and issues that are common to the group as a whole. Nurses use statistical and epidemiological data to support the need for targeted programs and develop interventions at the aggregate level. Simulated clinical experiences may include aggregatespecific health issues, such as teenage pregnancy, lead exposure in children, work-related injury, or even chronicillness management. The simulation begins at the individual level; for example, a school nurse assesses an overweight child with type 2 diabetes. The participant objectives are to (a) assess the child during a suspected hypoglycemic reaction; (b) perform a finger stick to test blood glucose; (c) provide the proper treatment for a hypoglycemic reaction; and (d) communicate effectively with the student, school, and parents in order to initiate follow-up care. Students are then provided the opportunity to investigate the problem at the aggregate level. Epidemiological data is provided along with the core case, and a group activity uses the nursing process to plan a targeted intervention. In this instance, the school nurse may identify an increased incidence of type 2 diabetes among the children in the district and a higher prevalence compared with other school districts in the state. The student nurse also evaluates the results of the most recent schoolwide health screening, noting that a large number of children are categorized as overweight. The student nurses use this analysis to
Activities such as creating a home environment in the nursing school laboratory and using human patient simulators for simulated home visits have been documented as effective strategies to decrease the anxiety of students regarding home care experiences (Simones, 2008; Yeager & Gotwals, 2010). Much more could be achieved with students practicing in a simulated home-based setting. The value of using simulation in community health is that it can provide an opportunity for complex decision-making environments with high levels of uncertainty and low levels of information (Jeffries, 2005). Nurses practicing in the community often have access to few resources and limited information. In acute care, nursing activities take place continuously, and patient information is readily available from many sources. In the community, care is provided on an intermittent basis, and nurses must assess for critical changes between episodes of care. Purposeful questioning regarding physical, environmental, and social issues must be efficient and the responses analyzed quickly to identify problems. Once problems are identified, nurses must use appropriate clinical reasoning to obtain the necessary resources for patients. An example of a home visit simulation scenario presents a patient with chronic obstructive pulmonary disease who is in moderate to severe respiratory distress. The student is expected to (a) provide the standard of care related to patient safety and infection control; (b) initiate a focused respiratory assessment; (c) communicate effectively with the patient, caregiver, and physician; and (d) provide appropriate interventions in the home setting. In prebriefing, the students are given information on the patient that consists only of the physician orders and plan of care (including medication list, medical diagnoses, and orders)
Care of Aggregates in the Community
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Community Health Nursing Simulation
Community Health Theme
Environmental Conditions
Community Health Concepts
Skill Acquisition
Care of individuals in the community
Home health care Home visits
Chronic illness management Interdisciplinary collaboration
Care of aggregates in the community
School health Health department Occupational health
Population-focused care Health promotion Interagency collaboration
Care of vulnerable populations in the community
Migrant clinic Free clinic Correctional facility
Cultural competency Social justice
Health of communities
Bioterrorist attack Pandemic Mass casualty (Large-scale simulation)
Emergency preparedness Upstream thinking Epidemiology
Physical assessment Administration of oxygen Administration of MDI, aerosol treatment Report to physician Assessment of DM Blood glucose check Treatment of hypoglycemia Communication with family Injections (immunizations) Administering, reading TB test Sputum collection for TB Use of interpreter Neurologic assessment Various first aid procedures Color-coded disaster triage Starting intravenous fluids
Note. The table is intended to provide examples for settings and skills; it is not an exhaustive list. Community simulation scenarios should integrate individual-focused care (through hands-on procedures) with population-focused care (through group activities and debriefing). It is important to allocate time before and after the simulation for group preparation and activities. DM ¼ diabetes mellitus; MDI ¼ metered dose inhaler; TB ¼ tuberculosis.
determine a plan of action to address nutrition and obesity within the school district. In this type of scenario, the facilitator assists the students to move from an individual focus of care to an aggregate level of care. According to Jeffries, ‘‘a debriefing activity reinforces the positive aspects of the experience and encourages reflective learning, which allows the participant to link theory to practice and research, think critically, and discuss how to intervene professionally in very complex situations’’ (2005, p. 101). This activity helps the students to develop a plan at a community level, not just an individual level.
Care of Vulnerable Populations in the Community The concept of social justice is central to community and public health nursing. Clinical experiences with vulnerable populations provide a context for students to understand this concept. Free clinics, correctional facilities, and migrant clinics are a few examples of clinical sites that address the needs of vulnerable populations. Simulating these types of environments is valuable for several reasons. First, many of the agencies that provide care to the vulnerable have limited resources and may be able to accommodate only a few students. Simulation activities can supplement clinical learning and also boost students’ selfconfidence prior to the actual experience (Simones, 2008). Students can also develop cultural competence as they prepare to interact with diverse populations and consider the health disparities that exist. The simulation scenario for this theme is similar to that of the care of aggregates in the community. Care begins at
the individual level; then the nurse must expand the focus to the family and finally to the vulnerable group as a whole. In addition, the nurse must be aware of the health disparities that exist for the group of focus. For example, a scenario involving a migrant health clinic (a clinic that treats primarily Latino migrant farm laborers) can provide challenges for students in terms of cultural and linguistic competence, family dynamics, and interdisciplinary coordination. In a scenario in which the nurse must provide care to a migrant worker with latent tuberculosis, the student will need to (a) perform a focused assessment on the simulator patient, (b) use infection control measures, (c) obtain a blood specimen, and (d) administer medication. The student, recognizing that many migrant children are unimmunized, will also interact with the families. Students will administer injections (subcutaneous, intramuscular, and intradermal), evaluate immunization schedules, and provide education to families. Next, the students can plan interventions for the overall migrant population in order to prevent the spread of tuberculosis, as 5% to 10% of those diagnosed with latent tuberculosis convert to active status (Jensen, Lambert, Iademarco, & Ridzon, 2005). With the use of prerecorded scripts and faculty guidance, students can practice communicating with patients through an interpreter.
Care of the Community Education regarding disaster preparedness is an important aspect of community health courses in baccalaureate nursing programs. The 2010 NCLEX has expanded the
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content on disaster planning into a more comprehensive section titled Emergency Response Plan (Longo, 2011). The International Nursing Coalition for Mass Casualty Education has identified basic competencies for all nurses in order to be prepared to respond to a mass casualty incident (MCI), most of which are basic to nursing practice and included in all nursing education programs (International Nursing Coalition for Mass Casualty Education, 2003). A clinical experience in disaster preparedness allows students to draw on previous learning in order to develop basic proficiency for an MCI response. Students should be able to (a) develop sufficient knowledge and skills to recognize the potential for a MCI, (b) identify when such an event may have occurred, (c) know how to protect themselves, (d) know how to provide immediate care for those individuals involved, (e) recognize their own role and limitations, and (f) know where to seek additional information and resources (International Nursing Coalition for Mass Casualty Education, p. 5). Clinical simulations for this content can be very effective and can actively involve large groups of students in a variety of ways. Potential simulated MCI scenarios for community health nursing students include a natural disaster resulting in a mass casualty, a bioterrorism attack, or a mass immunization in response to a pandemic. Some bioterrorism simulation exercises have been reported in the literature (Carter & Gaskins, 2010; Doran & Mulhall, 2007), with a single human simulation patient and teams of students to provide treatment. Morrison and Catanzaro (2010) have described using a combination of high-fidelity simulation and role-playing to provide students with an exercise in emergency preparedness, specifically, an infectious disease outbreak. Large-scale simulations could easily involve students and faculty as both casualties and responders. These simulations can begin with a single human simulator, who first presents with injuries or symptoms of exposure to an infectious agent, such as smallpox. Using role play for additional casualties and including multiple responders would give students the opportunity to practice basic nursing skills, disaster triage, and interdisciplinary collaboration. In this type of scenario, educators need to allow adequate time for prebriefing and debriefing (Morrison & Catanzaro, 2010). This time on task, as described by Jeffries (2005), can be increased with clear and realistic time frames, as well as clear and focused objectives. It is best if only a few key concepts are taught and reinforced in each lab setting.
Implementation We are from a baccalaureate nursing program in small private university in the Midwest. Together we have a combined 20 years of experience in community health nursing education. One of us has extensive clinical experience in home health care; the other researches and has
worked directly with the Hispanic migrant population for more than 12 years. When the school of nursing obtained high-fidelity simulators, the faculty quickly realized that there were at that time no programs available specific to community health concepts. During a 3-year period, we have implemented the simulated clinical experiences described in this article, with the exception of the school nurse scenario, which is currently in the planning stage. The faculty had limited training on the equipment from the simulator manufacturer and relied mostly on evidence from simulation journals for direction on development of the simulated clinical experiences. The simulation experiences are implemented in the 4th year of the baccalaureate program within the community health nursing course. The average age of the students is 25 years; approximately 10% are men, and 7% are nontraditional students. Early in the course, the home visit simulation experience uses a facilitator-prompted methodology with the use of a high-fidelity simulator. Prompting is used to assist the participants in prioritizing assessment, data collection, implementation, and evaluation (Nehring & Lashley, 2010) in the home setting. Each clinical group was allowed 2 hours for the simulation experience, which included prebriefing, the clinical scenario, and debriefing. Students were expected to prepare for the experience through a guided reading assignment. Two students actively participated in the simulation, while the rest of the clinical group observed and offered a summative evaluation of their peers’ achievement of outcome criteria. Although all students were required to engage in the activity, as either a scenario role player or an evaluator, there was no high-stakes evaluation with passefail implications. During the debriefing period, guided reflection was used, and students reported they were surprised at the complexity of a typical home visit. Students have reported in course evaluations that the simulation helped to prepare them for their community clinical assignments. Midway through the course, a simulated migrant immunization clinic provides students with the opportunity to develop competence in clinical reasoning and psychomotor skills in a safe environment. Students are given actual immunization records of migrants (identifying information removed); they are also provided with current Centers for Disease Control and Prevention immunization guidelines and must determine the appropriate course of action. A facilitator is present to help the participants understand and achieve the objectives. At the end of the learning period, guided reflection is used to allow the participants to assimilate the theory, the immunization practice, and the provided standards in order to meet the objectives. Students discover that actual immunization records do not support the popular belief that migrants are underimmunized but may actually have had repeated immunizations because of issues involving record keeping and mobility. In evaluation of the experience, students feel more prepared when they participate in actual immunization clinics.
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Near the completion of the course, students participate in a simulated MCI experience. This is a large-group activity that includes many standardized patients and scenario role players. Time on task for this experience is approximately 4 hours, which includes extended prebriefing (review of Simple Triage and Rapid Treatment triage system, discussion of disaster), the disaster simulation itself, and debriefing. Within the activity, the student has the opportunity to practice basic nursing skills and disaster triage and to experience interdisciplinary collaboration with the local Red Cross staff and local hospital trauma coordinator. After assessing evaluations from students, faculty, and community collaborators, we are initiating plans for a potential campus-wide mass casualty disaster simulation, providing an expanded opportunity for interdisciplinary collaboration. In all the simulation clinical experiences, diverse learning styles of the students were addressed. Examples of principles of good practice in undergraduate education, as described by Chickering and Gamson (1987, 1999), include providing studentefaculty contact, encouraging cooperation and active learning, giving prompt feedback while emphasizing time on task, and communicating high expectations while respecting diverse talents. Moving the simulation scenarios from simple to complex during the course allows for students to build their clinical reasoning skills through collaboration practices. Students and faculty working in groups together, through role-playing and debriefing, strengthens the learning process. Students are encouraged to use their diverse strengths in the group dynamic of the simulation. Some students are better at the ‘‘hands-on,’’ or psychomotor, aspects of the simulation while others bring a deeper understanding of the theory behind the content. Facilitators of the simulation experience need to move among the groups and shape the environment so that student-to-student learning can be maximized.
Conclusion Community health is an expansive topic encompassing many diverse settings and populations. Simulation can be used in any RN curriculum to assist with a more in-depth understanding of community health clients and the concept of population-focused care. It is intended to supplement the clinical experience in community-based courses. Each student is expected to gain proficiency in intermediate-level assessment and clinical reasoning skills. Students report that the simulations also increase their confidence when they are approaching independent work in their actual community clinical experience. Community healtherelated simulations can be taught at the intermediate or advanced level and can be used with low-fidelity or high-definition simulation equipment. Because community health nursing uses a macroscopic, population-focused approach, the activities surrounding the simulation must provide the opportunity for students to plan, implement, and evaluate care beyond the individual client. Some examples provided were implemented in our school
of nursing, some are in the process of development, and others are suggestions based on our community health clinical expertise. Research is needed to determine the most effective way to deliver these community-based simulation activities, including the role of debriefing and post-simulation exercises.
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