- Email: [email protected]
A simulation case study from an instructional design framework
Teaching and Learning in Nursing (2010) 5, 73–77
www.jtln.org
A simulation case study from an instructional design framework Patricia M. Burke RNC, MSN⁎ Queensborough Community College, Basyside, NY 11364, USA KEYWORDS: Instructional design; Simulation program; Entry-level nursing students
Abstract This study applies the principles of instructional design to the development and evaluation of simulation instruction for entry-level nursing students. The first scenario was unveiled in the fall of 2006 with a group of evening students in the final week of nursing fundamentals. Throughout the next two semesters, the simulation scenario was continuously evaluated and adapted to meet the needs of the students. Instructional design focused on the application of basic skills, patient safety, and student-topatient communication. © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction Instructional design (ID) is a model that is used as a guide for developing and evaluating effective methods of instruction (Morrison, Ross, & Kemp, 2007). Often, an expert in ID acts as a consultant to the subject-matter expert (SME) to develop a “well-organized, easy-to-follow, consistent framework” (Barker, 2002, p. 183). In this report, the instructor is both the SME and the instructional designer. Morrison et al. (2007) described the components of ADDIE (analysis, design, development, implementation, and evaluation), with reference to different theories of ID and the importance of viewing ID as a process that is continuously evolving. Barker (2002, p. 184) stated that the main objective of the ID consultant is to ensure that “expectations for tasks and timing are clear and understandable.” This study demonstrates how ADDIE applies to developing a simulation program for nursing students to be offered at the completion of the Fundamentals of Nursing course. * Corresponding author. E-mail address: [email protected]
According to Waldner and Olson (2007), three types of simulation are used in nursing: task and skill trainers, computer-based simulation, and simulation that replicates the clinical environment. This case study presents details of both task trainers and human patient simulators (HPS). These simulators are full-body manikins that can produce changes in vital signs to mimic that of a clinical scenario. Initially, the college purchased four VitalSim (Laerdal) manikins, with the addition of a microphone unit to allow the HPS to “speak.” The manikins were placed in a room with headwalls that simulated oxygen and suction. The room contained a chart rack, medication cart, narcotics cabinet, and emergency equipment. This room was officially opened as the Virtual Hospital on May 2007. The VitalSim manikins are considered low or medium fidelity, as opposed to the high-fidelity SimMan that exhibits more human responses. Kardong-Edgren, Anderson, and Michaels (2007) discussed the use of low-fidelity simulation in comparison with the more expensive highfidelity manikins. Comer (2005) and Kardong-Edgren et al. identified cost as one of the barriers to implementing simulation. With the use of ID, scenarios using the low-
1557-3087/$ – see front matter © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2010.01.003
74
P.M. Burke
fidelity manikin can be developed to meet a wide variety of learners' needs and skill levels (Fig. 1).
2. Analysis phase In the analysis phase, the characteristics of the learners are identified, delivery options are examined, and a timeline is projected. The learners are students in an associate degree nursing program at a community college located in a borough of New York City. The college has one of the most diverse student populations in the nation. A majority of the students are nontraditional and older, many are immigrants, and English is a second language (ESL). Because there is much competition to obtain a place in the nursing program, most students enter the program with a grade point average of 3.0 or higher. Students who are in the Fundamentals of Nursing course have completed their prerequisites. Prior to the simulation case study, students must pass four critical elements or skills. Students are tested by an individual instructor in the following areas: vital signs, medication administration, physical assessment, and intravenous (IV) infusion administration. Most students work more than 20 hours per week, in addition to their coursework. Students are motivated and competitive, and they utilize the nursing skills practice laboratory on weekends and evenings. Study groups and mentoring begin early in the nursing program. Students who work well together try to stay within the same clinical rotation as this is where the bulk of their time is spent. Groups are formed based on the clinical rotation rather than on culture. For instance, if students live or work close to one hospital, they opt to go there, and their study group is formed. This makes for a diversity of learning
styles and a diversity of cultures. Because of the large number of ESL students in the nursing program, the design of the simulation case study must take into account communication. The Joint Commission (2008) identified communication as the second goal of the National Patient Safety standards. The Joint Commission (2008) stated that, “Ineffective communication is the most frequently cited root cause for sentinel events.”
2.1. Delivery strategies Simulation scenarios provide an innovative teaching strategy that addresses patient safety issues without putting the patient at risk. Waldner and Olson (2007, p. 1) stated that the focus of simulation with entry-level students “is the development of those physical assessment and intervention skills as alternative strategies to help nursing students achieve practice competencies.” With simulation, all students gain from the clinical experience. For example, when administering pain medication, not every student will have to make a decision regarding the route of administration. With the scenario, all students participate in the postscenario reflection and are exposed to the critical-thinking decisionmaking process that is necessary when choosing the right route for medication administration. For students at this level, basic decisions, based on their assessment of the patient, can be difficult. This is consistent with Benner's (1984) theory of the novice nurse.
2.2. Timeline It is imperative that all the faculty work to schedule the scenario after the student has completed all of the critical and skill competencies and the theory related to postoperative assessment. Clark (2001) stressed the importance of focusing on the learners' needs rather than the medium of instruction. He cautions that “trainers become enamored with the latest technology and use it without considering the learner's needs.” If the scenario is scheduled before the students have practiced and are proficient with the skills needed, they will not be confident performing the scenario. It is important that students have adequate time to “get to know” the HPS. Students need to be familiar with assessing the HPS as there are variations. For example, lungs can only be auscultated anteriorly on the manikin.
3. Design phase
Fig. 1
Virtual hospital.
The design phase deals with setting the learning objectives, assessing strategies and content, and selecting the delivery method. Learning objectives are developed to match the theoretical content of the curriculum. Cognitive objectives can be written at different levels of complexity (Billings & Halstead, 2005). Billings and Halstead (2005)
Instructional design simulation
75
stated that objectives are important to provide focus on the necessary course content and as a guide in developing evaluation tools. Objectives, outcomes, and competencies are derived from the curriculum. Morrison et al. (2007) described objectives that deal with the cognitive domain as relating to information or knowledge. A behavioral objective is a precise statement that answers the question of how learners indicate that they have mastered the necessary skills (Morrison et al., 2007). For this case study, the objectives were developed from a scenario provided by the National League for Nursing (NLN). The objectives were then adapted to meet the curriculum content of the fundamentals course. The assessment of the scenario consisted of informal input from the instructors, written documentation of student observation, and analysis of time spent for each objective (Table 1). The decision was made to use the “postoperative pain management” scenario presented at the NLN technology conference (Jeffries, 2006). The NLN provided sample worksheets and doctor's orders. A consideration when using simulation is that it is labor intensive, with one faculty member to 4 or 5 students. Within the group, each student was given a role: family member, two student nurses, observer, or staff nurse. With the initial group of 40 evening students, the remaining 35 students were assigned on a rotation basis to “skill” stations. This allowed students to practice their skills when not participating in the actual scenario. A reflection session took place with the faculty and students after all the scenarios were completed.
4. Development phase Morrison et al. (2007) stated that the primary goal of instructional strategies is to provide a method of instruction Table 1
based on the content. According to Morrison et al., a powerful instructional strategy “motivates the learner to actively make these connections between what the learner already knows and the new information” (p. 146). In nursing, some of the instructional strategies used for students to problem solve are simulation and case studies (Daley, 1996). Dabbagh (n.d.) listed various instructional strategies that can be adapted to content so as to meet the needs of diverse learners. With each of the instructional strategies listed, the emphasis is on applying theory to practice. From the exhaustive list provided, it was determined to focus on five areas that relate to simulation in nursing. The five areas are as follows: 1. 2. 3. 4. 5.
drill and practice, advance organizers, problem-solving activities, case-based reasoning, and collaborative groups.
Dabbagh (n.d.) described drill and practice as using “repeated exercises and individual feedback to master a specified learning objective.” Prior to the simulation, students will practice their skills using the manikins. This combination of drill and practice provides a foundation for the basic skills that are needed at this level. The strategy of advance organizers (Ausubel et al., as cited by Dabbagh, n.d.) will be applied to the simulation scenario. This method builds on what the learner already knows and can be used for learners at different levels. According to Dabbagh (n.d.), “problem-solving activities place more emphasis on learning how to learn, rather than specific content.” Learners focus on problem solving, applying knowledge to the case study (simulation). Problem solving
Objectives and evaluation
Objectives
Evaluation Time started__________
• Provide patient safety • Identify patient using 2 identifiers • Identify self to patient • Assess vital signs • Assess IV administration & site • Perform basic post-op assessment • Evaluate pain: severity • Assess medication record • Administer pain medication as ordered Administer correct choice for a patient who is NPO • Do not give anything to the patient to drink • Offer emotional support to pt & family member • Document assessment & interventions • Reassess pain: severity, location, cause
□ Provide pt safety □ Identify pt using 2 identifiers □ Identify self to pt □ Assess vital signs □ Assess IV administration & site □ Perform basic post-op assessment □ Evaluate pain: severity, location, cause □ Assess medication record, decide re pain relief □ Administer pain medication as ordered (Administer correct choice for a patient who is NPO) □ □ □ □
Do not give anything to the patient to drink Offer emotional support to pt & family member Document assessment & interventions Evaluate pain
Time ended__________ Debriefing: First, student observer will give his/her evaluation. Then instructor will guide debriefing and indicate whether goals were met and if they were timely.
76 is also evident in the postscenario reflection, where students discuss their observations and describe what they have learned. The strategy of multiple perspectives, utilizing both problem-solving activities and case-based reasoning, will be used to reflect on the simulation. The worksheet with objectives (Table 1) is used to guide the instructor during the reflection phase. Discussion during the reflection phase is related to each of the objectives. Students gave feedback regarding whether or not the objectives were met. Having the students work together in collaborative groups promotes teamwork, and according to Dabbagh (n.d.), this provides “a sense of community, and emphasizes approaching the problem from different directions and different perspectives.” As content is evaluated and developed, the instructional strategies must be evaluated to ensure that they support the objectives. Likewise, as the learners change, the instructional strategies must be evaluated to ensure that the learners' needs are met.
5. Implementation phase The scenario was developed and refined over three semesters with three groups of students. Time management was one of the first issues addressed. Initially, the time allowed for “getting to know” the manikin was not sufficient. In subsequent semesters, students were exposed to the HPS early in the course; the HPS were used for taking vital signs and performing assessment skills. Prior to engaging in the scenario, the first hour was assigned to practicing skills with the manikin and becoming familiar with the layout of the Virtual Hospital. Initially, students were given the role of the staff nurse who reported to the incoming students. However, the students were not at the proficiency level to give a concise, timely report, and in subsequent scenarios, faculty gave the report. Another alternative is to provide a taped report as demonstrated by Jeffries (2006). Ongoing evaluation provided insight into how students synthesized the information given in the report. Some took notes; some wrote down incorrect information. Few students felt comfortable questioning or clarifying the information. The role of staff nurse was changed to that of recorder. Previously, the observer had recorded times, interventions, and observations, but some students with the dual role. The time needed to rotate students between the skill stations and the scenario had to be increased. The rotation time was increased to 10 minutes; this allowed students to complete the skill and get ready for the scenario. The structure of the scenario changed depending on the size of the group. For smaller groups of 20 students, more time was allotted prior to the scenario to practice assessment skills on the manikins. With the initial group of 40 evening students, not everyone was able to participate in the scenario due to time constraints. However, all students attended the reflection session.
P.M. Burke The unanimous request from students was to “repeat the scenario so that we can get it right.” Another issue was the time allocated to the reflection, which was increased from 30 minutes to an hour. For the first two semesters, the objectives (see Table 1) were not discussed prior to the scenario. Basic safety issues such as checking the IV site and confirming the solution for type volume, and rate were neglected. For the second semester, the instructor reviewed the objectives verbally with the students before the scenario and during the introduction. There was no difference in the percentage of students who met the objective. For the third semester, the objectives were again reviewed prior to the scenario and during the introduction, adding objectives written on the board and reviewed immediately before the group participated in the scenario. With the last group, there was a slight increase in the percentage of students who met the objectives. This is consistent with the use of drill and practice and the strategy of advance organizers as described by Dabbagh (n.d.). Another discovery was that when students focus on one task, such as pain assessment, they easily forget the basics of patient safety.
6. Evaluation phase Morrison et al. (2007) identified three different methods of assessment that can be used at different times during the ID process. Those methods are formative, summative, and confirmative. They stated that assessment is a process that provides a measure “of students' abilities and changes in knowledge, skills, and attitudes during and after participation in courses and programs” (p. 444). Formative assessment was used during the initial development of instruction to identify required changes and adaptations need. The worksheet (Table 1) with a checklist of objectives was utilized as a means of formative assessment. Each instructor used the worksheet as a tool to assess the effectiveness of instruction and identify possible gaps in student knowledge. Summative evaluation not only measures student learning but also assesses the cost and continuing expenses of instruction (Morrison et al., 2007). It is especially important for nursing faculty to factor the cost of developing, setting up, and running scenarios. Billings and Halstead (2005, p. 235) stated that “summative evaluation is conducted at the end of a course and is used to determine the extent to which students have achieved the desired learning outcomes.” For this case study, the major outcome is for the student to conduct a postoperative assessment that meets the objectives. Morrison et al. (2007) described confirmative assessment as ongoing and continuous. Confirmative assessment uses multiple databases to provide as broad an analysis as possible. For this case, study data were collected informally from instructors, with written documentation from both faculty and students.
Instructional design simulation
7. Conclusion In conclusion, ID provides a framework to continually evaluate and improve the clinical scenarios offered to entrylevel students. Jeffries (2005) stressed the need to document simulation outcomes, as well as the importance of evaluation and the continued contribution to evidence-based teaching. Jeffries supported the need for more rigorous research into simulation outcomes in nursing education. It is proposed that next semester, we will assess the students' satisfaction with simulation as an instructional method using the NLN questionnaire. As faculty, we must evaluate the areas of clinical practice that need to be addressed. Lasater (2007) cautioned that further research needs to link simulation performance with that of the clinical setting. For example, assessing the IV site is one of the basic safety skills, yet students consistently get distracted and forget this simple step in the assessment process. Tracking students' acquisition of skills as they progress through the program would provide evidence of simulation as a successful instructional strategy.
References Barker, A. (2002). A case study in instructional design for Web-based courses.Nursing Education Perspective, 23(4), 183 Retrieved August 14, 2008, from ERIC database. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
77 Billings, D. M., & Halstead, J. A. (2005). Teaching in nursing: A guide for faculty, 2nd ed. St Louis, MO: Elsevier. Clark, D. (2001). Training media dictionary. Retrieved May 5th, 2008, from the Analysis Phase. http://www.nwlink.com/%7Edonclark/hrd/media. html. Comer, S. K. (2005). Patient care simulators: Role playing to enhance clinical understanding. Nursing Education Perspectives, 26(6), 357−361. Dabbagh, N. (n.d.). The instructional design knowledge base. Retrieved May 5th, 2008, from Nada Dabbagh's Homepage, George Mason University, Instructional Technology Program. http://classweb.gmu. edu/ndabbagh/Resources/IDKB/index.htm. Daley, B. J. (1996). Concept maps: Linking nursing theory to clinical nursing practice. Journal of Continuing Education in Nursing, 27, 17−25. Jeffries, P. R. (2005). Designing simulations for nursing education. In M. Oermann, & K. Heinrich (Eds.), Annual review of nursing education, Vol. 4. (pp. 161−177) New York: Springer. Jeffries, P. R. (2006). Post-operative scenario: Total knee replacement. Scenario presented at the National League for Nurses Technology Conference, Baltimore. The Joint Commission. (2008). 2009 National Patient Safety goals hospital program. Retrieved September 11th, 2008 from. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_ hap_npsgs.htm. Kardong-Edgren, S., Anderson, M., & Michaels, J. (2007). Does simulation fidelity improve student test scores? INACSL Online Journal, 3(1), 8. Lasater, K. (2007). High fidelity simulation and the development of clinical judgment: Students' experiences. Journal of Nursing Education, 46(6), 269−276. Morrison, G. R., Ross, S. M., & Kemp, J. E. (2007). Designing effective instruction, 5th ed. Wiley: Hoboken, NJ. Waldner, M., & Olson, J. (2007). Taking the patient to the classroom: Applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship, 4(1), 1−14 Retrieved August 14, 2008, from CINAL.
www.jtln.org
A simulation case study from an instructional design framework Patricia M. Burke RNC, MSN⁎ Queensborough Community College, Basyside, NY 11364, USA KEYWORDS: Instructional design; Simulation program; Entry-level nursing students
Abstract This study applies the principles of instructional design to the development and evaluation of simulation instruction for entry-level nursing students. The first scenario was unveiled in the fall of 2006 with a group of evening students in the final week of nursing fundamentals. Throughout the next two semesters, the simulation scenario was continuously evaluated and adapted to meet the needs of the students. Instructional design focused on the application of basic skills, patient safety, and student-topatient communication. © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction Instructional design (ID) is a model that is used as a guide for developing and evaluating effective methods of instruction (Morrison, Ross, & Kemp, 2007). Often, an expert in ID acts as a consultant to the subject-matter expert (SME) to develop a “well-organized, easy-to-follow, consistent framework” (Barker, 2002, p. 183). In this report, the instructor is both the SME and the instructional designer. Morrison et al. (2007) described the components of ADDIE (analysis, design, development, implementation, and evaluation), with reference to different theories of ID and the importance of viewing ID as a process that is continuously evolving. Barker (2002, p. 184) stated that the main objective of the ID consultant is to ensure that “expectations for tasks and timing are clear and understandable.” This study demonstrates how ADDIE applies to developing a simulation program for nursing students to be offered at the completion of the Fundamentals of Nursing course. * Corresponding author. E-mail address: [email protected]
According to Waldner and Olson (2007), three types of simulation are used in nursing: task and skill trainers, computer-based simulation, and simulation that replicates the clinical environment. This case study presents details of both task trainers and human patient simulators (HPS). These simulators are full-body manikins that can produce changes in vital signs to mimic that of a clinical scenario. Initially, the college purchased four VitalSim (Laerdal) manikins, with the addition of a microphone unit to allow the HPS to “speak.” The manikins were placed in a room with headwalls that simulated oxygen and suction. The room contained a chart rack, medication cart, narcotics cabinet, and emergency equipment. This room was officially opened as the Virtual Hospital on May 2007. The VitalSim manikins are considered low or medium fidelity, as opposed to the high-fidelity SimMan that exhibits more human responses. Kardong-Edgren, Anderson, and Michaels (2007) discussed the use of low-fidelity simulation in comparison with the more expensive highfidelity manikins. Comer (2005) and Kardong-Edgren et al. identified cost as one of the barriers to implementing simulation. With the use of ID, scenarios using the low-
1557-3087/$ – see front matter © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2010.01.003
74
P.M. Burke
fidelity manikin can be developed to meet a wide variety of learners' needs and skill levels (Fig. 1).
2. Analysis phase In the analysis phase, the characteristics of the learners are identified, delivery options are examined, and a timeline is projected. The learners are students in an associate degree nursing program at a community college located in a borough of New York City. The college has one of the most diverse student populations in the nation. A majority of the students are nontraditional and older, many are immigrants, and English is a second language (ESL). Because there is much competition to obtain a place in the nursing program, most students enter the program with a grade point average of 3.0 or higher. Students who are in the Fundamentals of Nursing course have completed their prerequisites. Prior to the simulation case study, students must pass four critical elements or skills. Students are tested by an individual instructor in the following areas: vital signs, medication administration, physical assessment, and intravenous (IV) infusion administration. Most students work more than 20 hours per week, in addition to their coursework. Students are motivated and competitive, and they utilize the nursing skills practice laboratory on weekends and evenings. Study groups and mentoring begin early in the nursing program. Students who work well together try to stay within the same clinical rotation as this is where the bulk of their time is spent. Groups are formed based on the clinical rotation rather than on culture. For instance, if students live or work close to one hospital, they opt to go there, and their study group is formed. This makes for a diversity of learning
styles and a diversity of cultures. Because of the large number of ESL students in the nursing program, the design of the simulation case study must take into account communication. The Joint Commission (2008) identified communication as the second goal of the National Patient Safety standards. The Joint Commission (2008) stated that, “Ineffective communication is the most frequently cited root cause for sentinel events.”
2.1. Delivery strategies Simulation scenarios provide an innovative teaching strategy that addresses patient safety issues without putting the patient at risk. Waldner and Olson (2007, p. 1) stated that the focus of simulation with entry-level students “is the development of those physical assessment and intervention skills as alternative strategies to help nursing students achieve practice competencies.” With simulation, all students gain from the clinical experience. For example, when administering pain medication, not every student will have to make a decision regarding the route of administration. With the scenario, all students participate in the postscenario reflection and are exposed to the critical-thinking decisionmaking process that is necessary when choosing the right route for medication administration. For students at this level, basic decisions, based on their assessment of the patient, can be difficult. This is consistent with Benner's (1984) theory of the novice nurse.
2.2. Timeline It is imperative that all the faculty work to schedule the scenario after the student has completed all of the critical and skill competencies and the theory related to postoperative assessment. Clark (2001) stressed the importance of focusing on the learners' needs rather than the medium of instruction. He cautions that “trainers become enamored with the latest technology and use it without considering the learner's needs.” If the scenario is scheduled before the students have practiced and are proficient with the skills needed, they will not be confident performing the scenario. It is important that students have adequate time to “get to know” the HPS. Students need to be familiar with assessing the HPS as there are variations. For example, lungs can only be auscultated anteriorly on the manikin.
3. Design phase
Fig. 1
Virtual hospital.
The design phase deals with setting the learning objectives, assessing strategies and content, and selecting the delivery method. Learning objectives are developed to match the theoretical content of the curriculum. Cognitive objectives can be written at different levels of complexity (Billings & Halstead, 2005). Billings and Halstead (2005)
Instructional design simulation
75
stated that objectives are important to provide focus on the necessary course content and as a guide in developing evaluation tools. Objectives, outcomes, and competencies are derived from the curriculum. Morrison et al. (2007) described objectives that deal with the cognitive domain as relating to information or knowledge. A behavioral objective is a precise statement that answers the question of how learners indicate that they have mastered the necessary skills (Morrison et al., 2007). For this case study, the objectives were developed from a scenario provided by the National League for Nursing (NLN). The objectives were then adapted to meet the curriculum content of the fundamentals course. The assessment of the scenario consisted of informal input from the instructors, written documentation of student observation, and analysis of time spent for each objective (Table 1). The decision was made to use the “postoperative pain management” scenario presented at the NLN technology conference (Jeffries, 2006). The NLN provided sample worksheets and doctor's orders. A consideration when using simulation is that it is labor intensive, with one faculty member to 4 or 5 students. Within the group, each student was given a role: family member, two student nurses, observer, or staff nurse. With the initial group of 40 evening students, the remaining 35 students were assigned on a rotation basis to “skill” stations. This allowed students to practice their skills when not participating in the actual scenario. A reflection session took place with the faculty and students after all the scenarios were completed.
4. Development phase Morrison et al. (2007) stated that the primary goal of instructional strategies is to provide a method of instruction Table 1
based on the content. According to Morrison et al., a powerful instructional strategy “motivates the learner to actively make these connections between what the learner already knows and the new information” (p. 146). In nursing, some of the instructional strategies used for students to problem solve are simulation and case studies (Daley, 1996). Dabbagh (n.d.) listed various instructional strategies that can be adapted to content so as to meet the needs of diverse learners. With each of the instructional strategies listed, the emphasis is on applying theory to practice. From the exhaustive list provided, it was determined to focus on five areas that relate to simulation in nursing. The five areas are as follows: 1. 2. 3. 4. 5.
drill and practice, advance organizers, problem-solving activities, case-based reasoning, and collaborative groups.
Dabbagh (n.d.) described drill and practice as using “repeated exercises and individual feedback to master a specified learning objective.” Prior to the simulation, students will practice their skills using the manikins. This combination of drill and practice provides a foundation for the basic skills that are needed at this level. The strategy of advance organizers (Ausubel et al., as cited by Dabbagh, n.d.) will be applied to the simulation scenario. This method builds on what the learner already knows and can be used for learners at different levels. According to Dabbagh (n.d.), “problem-solving activities place more emphasis on learning how to learn, rather than specific content.” Learners focus on problem solving, applying knowledge to the case study (simulation). Problem solving
Objectives and evaluation
Objectives
Evaluation Time started__________
• Provide patient safety • Identify patient using 2 identifiers • Identify self to patient • Assess vital signs • Assess IV administration & site • Perform basic post-op assessment • Evaluate pain: severity • Assess medication record • Administer pain medication as ordered Administer correct choice for a patient who is NPO • Do not give anything to the patient to drink • Offer emotional support to pt & family member • Document assessment & interventions • Reassess pain: severity, location, cause
□ Provide pt safety □ Identify pt using 2 identifiers □ Identify self to pt □ Assess vital signs □ Assess IV administration & site □ Perform basic post-op assessment □ Evaluate pain: severity, location, cause □ Assess medication record, decide re pain relief □ Administer pain medication as ordered (Administer correct choice for a patient who is NPO) □ □ □ □
Do not give anything to the patient to drink Offer emotional support to pt & family member Document assessment & interventions Evaluate pain
Time ended__________ Debriefing: First, student observer will give his/her evaluation. Then instructor will guide debriefing and indicate whether goals were met and if they were timely.
76 is also evident in the postscenario reflection, where students discuss their observations and describe what they have learned. The strategy of multiple perspectives, utilizing both problem-solving activities and case-based reasoning, will be used to reflect on the simulation. The worksheet with objectives (Table 1) is used to guide the instructor during the reflection phase. Discussion during the reflection phase is related to each of the objectives. Students gave feedback regarding whether or not the objectives were met. Having the students work together in collaborative groups promotes teamwork, and according to Dabbagh (n.d.), this provides “a sense of community, and emphasizes approaching the problem from different directions and different perspectives.” As content is evaluated and developed, the instructional strategies must be evaluated to ensure that they support the objectives. Likewise, as the learners change, the instructional strategies must be evaluated to ensure that the learners' needs are met.
5. Implementation phase The scenario was developed and refined over three semesters with three groups of students. Time management was one of the first issues addressed. Initially, the time allowed for “getting to know” the manikin was not sufficient. In subsequent semesters, students were exposed to the HPS early in the course; the HPS were used for taking vital signs and performing assessment skills. Prior to engaging in the scenario, the first hour was assigned to practicing skills with the manikin and becoming familiar with the layout of the Virtual Hospital. Initially, students were given the role of the staff nurse who reported to the incoming students. However, the students were not at the proficiency level to give a concise, timely report, and in subsequent scenarios, faculty gave the report. Another alternative is to provide a taped report as demonstrated by Jeffries (2006). Ongoing evaluation provided insight into how students synthesized the information given in the report. Some took notes; some wrote down incorrect information. Few students felt comfortable questioning or clarifying the information. The role of staff nurse was changed to that of recorder. Previously, the observer had recorded times, interventions, and observations, but some students with the dual role. The time needed to rotate students between the skill stations and the scenario had to be increased. The rotation time was increased to 10 minutes; this allowed students to complete the skill and get ready for the scenario. The structure of the scenario changed depending on the size of the group. For smaller groups of 20 students, more time was allotted prior to the scenario to practice assessment skills on the manikins. With the initial group of 40 evening students, not everyone was able to participate in the scenario due to time constraints. However, all students attended the reflection session.
P.M. Burke The unanimous request from students was to “repeat the scenario so that we can get it right.” Another issue was the time allocated to the reflection, which was increased from 30 minutes to an hour. For the first two semesters, the objectives (see Table 1) were not discussed prior to the scenario. Basic safety issues such as checking the IV site and confirming the solution for type volume, and rate were neglected. For the second semester, the instructor reviewed the objectives verbally with the students before the scenario and during the introduction. There was no difference in the percentage of students who met the objective. For the third semester, the objectives were again reviewed prior to the scenario and during the introduction, adding objectives written on the board and reviewed immediately before the group participated in the scenario. With the last group, there was a slight increase in the percentage of students who met the objectives. This is consistent with the use of drill and practice and the strategy of advance organizers as described by Dabbagh (n.d.). Another discovery was that when students focus on one task, such as pain assessment, they easily forget the basics of patient safety.
6. Evaluation phase Morrison et al. (2007) identified three different methods of assessment that can be used at different times during the ID process. Those methods are formative, summative, and confirmative. They stated that assessment is a process that provides a measure “of students' abilities and changes in knowledge, skills, and attitudes during and after participation in courses and programs” (p. 444). Formative assessment was used during the initial development of instruction to identify required changes and adaptations need. The worksheet (Table 1) with a checklist of objectives was utilized as a means of formative assessment. Each instructor used the worksheet as a tool to assess the effectiveness of instruction and identify possible gaps in student knowledge. Summative evaluation not only measures student learning but also assesses the cost and continuing expenses of instruction (Morrison et al., 2007). It is especially important for nursing faculty to factor the cost of developing, setting up, and running scenarios. Billings and Halstead (2005, p. 235) stated that “summative evaluation is conducted at the end of a course and is used to determine the extent to which students have achieved the desired learning outcomes.” For this case study, the major outcome is for the student to conduct a postoperative assessment that meets the objectives. Morrison et al. (2007) described confirmative assessment as ongoing and continuous. Confirmative assessment uses multiple databases to provide as broad an analysis as possible. For this case, study data were collected informally from instructors, with written documentation from both faculty and students.
Instructional design simulation
7. Conclusion In conclusion, ID provides a framework to continually evaluate and improve the clinical scenarios offered to entrylevel students. Jeffries (2005) stressed the need to document simulation outcomes, as well as the importance of evaluation and the continued contribution to evidence-based teaching. Jeffries supported the need for more rigorous research into simulation outcomes in nursing education. It is proposed that next semester, we will assess the students' satisfaction with simulation as an instructional method using the NLN questionnaire. As faculty, we must evaluate the areas of clinical practice that need to be addressed. Lasater (2007) cautioned that further research needs to link simulation performance with that of the clinical setting. For example, assessing the IV site is one of the basic safety skills, yet students consistently get distracted and forget this simple step in the assessment process. Tracking students' acquisition of skills as they progress through the program would provide evidence of simulation as a successful instructional strategy.
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