- Email: [email protected]
Clinical simulations: Let's get real!
Teaching and Learning in Nursing (2007) 2, 105 – 108
www.jtln.org
Clinical simulations: Let’s get real! Lydia A. Massias MS, CNS, RN*, Carol A. Shimer EdD, RN Department of Nursing, Pasco-Hernando Community College, New Port Richey, FL 34654, USA
KEYWORDS: Simulations; Role-play; Home care
Abstract Simulations have been recommended when clinical facilities are scarce because they provide a similar experience to that which a student would encounter. Pasco-Hernando Community College nursing faculty designed a role-playing home care simulation for students. The students interact with community theater actors in an improvised simulated home health environment. The home care visit interaction is followed by a debriefing session. Here, students identify concerns in the scenario and verbalize their feelings about the experience. D 2007 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction The nursing profession continues to face a nationwide shortage. An anxious health care industry is looking to postsecondary educational institutions to lessen and eventually end the shortage through an increase in nursing student enrollment. This presents a challenge to postsecondary institutions, as there are not enough clinical placements available to support this growth. As a result, there is vigorous competition among nursing schools for a limited number of clinical slots. In response to the increased need for clinical placements, the Florida State Board of Nursing expanded the associate degree nursing student’s scope of practice to include community-based practice (The Florida Nurse Practice Act, 2004). Community-based practice refers to limited hands-on skills that can be performed in certain practice
settings under the guidance of a registered nurse preceptor. These settings include nursing homes, schools, and home health. Pasco-Hernando Community College’s (PHCC) associate degree nursing program, spanning the two counties just north of Tampa, FL, is currently experiencing an insufficient supply of maternal–child clients in community-based practice. In preparation for these types of clinical experiences, the maternal–child faculty decided to create a community-based simulation for their students. A simulation is a representation of reality designed to b. . . allow students to build patient care skills while applying theoretical knowledge in a controlled settingQ (Comer, 2005, p. 358). Creating a suitable simulation is essential to meeting the learner objectives. According to Jeffries (2005), developing a framework for a proper simulation involves three phases: designing, implementing, and evaluating.
2. Designing * Corresponding author. Tel.: +1 727 847 2727; fax: +1 727 816 3309. E-mail addresses: [email protected] [email protected]
The maternal–child faculty undertook four steps during the design phase: selecting a topic, determining goals and
1557-3087/$ – see front matter D 2007 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2007.05.001
106 objectives, creating a scenario, and developing the simulation environment. Faculty decided that the communitybased practice simulation topic would consist of a home health visit to a postpartum client and her family on campus in a mimicked home environment. Issues that the students will encounter in the simulation include the following: postpartum depression, teenage pregnancy, nutrition, health promotion, and safety. Determination of the goals and objectives is the second step in designing a simulation. The goal of the maternal– child simulation is to provide nursing students with a realistic home health visit to a childbearing family. Objectives for this simulation state that the student will: 1. Complete a home safety assessment in the campus laboratory. 2. Complete a health history for a client/family. 3. Identify health promotion teaching needs for client/ family. 4. Identify infant–parent and child–parent relationships. 5. Use critical thinking to formulate measurable outcomes for improved family process and growth. 6. Identify nursing strategies to achieve positive patient outcomes. 7. Identify the role of the maternal/child home health nurse. 8. Discuss personal safety precautions that the maternal/ child home health nurse needs to implement. 9. Differentiate between hospital and home health care of the maternal/child clients (PHCC, 2007, p. 35). Creating the scenario is the third step of designing a simulation. A script was written, describing the characters and detailing their medical problems. A number of safety and psychosocial issues were also written into the scenario. However, no particular instructions were included regarding what the characters should exactly say or how they should act during the role-play simulation because improvisation adds to the realism of the scenario. Development of the simulation environment is the fourth step in the preparation of the role-playing simulation. Halamek et al. (as cited in Feingold, Calaluce, & Kallen, 2004) believe that realism of the simulation requires the scenario to be staged with attention to detail and in a milieu that replicates the real environment. At PHCC, a vacant small room was set up to represent a client’s home. Faculty donated pieces of used furniture and decorations. Furthermore, an artist, who paints sets for community theaters, donated her time to paint a kitchen mural on one wall of the vacant room. Prior to running the simulation, selection of the roleplaying participants had to be made. Initially, faculty posed as the characters in the scenario. During the trial run of the role-playing simulation, it was discovered that the students did not view the characters as realistic, due to their familiarity with the faculty. As a result, it was decided to obtain people with whom the nursing students were
L.A. Massias, C.A. Shimer unfamiliar. The initial thought was to recruit students who were involved in the campus theater group. Unfortunately, scheduling conflicts prevented this from happening. Luckily, actors from a local community theater group could be recruited to portray the patients. The maternal– child course is fortunate that these same actors have been able to perform this simulation numerous times, becoming very familiar with the characters, and thus responding spontaneously to the variations in student interactions.
3. Implementing Prior to the role-play interaction, a briefing session is done. During the session, information about the scenario and clients is presented to the students. The students are told that the clinical group is going to make a home health visit to a postpartum patient and her family. So that the scenario can proceed with optimal learning, students are assigned specific areas to focus on, namely, safety concerns, health care needs, teaching needs, and referrals. Students are encouraged to interact with the patients during the home health visit (Fig. 1). During the running of the simulation, the clinical faculty member leads his or her group to the home health laboratory and knocks on the door. The postpartum mother, dressed in a housecoat, answers the door, and the scenario is underway. Faculty members facilitate the scenario from time to time by interjecting questions to the patients. Termination of the scenario occurs when the objectives have been met; however, 30 minutes is usually adequate time for the home visit.
4. Evaluating Evaluating is the final phase of the role-playing simulation. Following the simulation, the students are taken
Fig. 1 RN students Mark Stefanik, Genifer Westphal, and Andrea Salazar interact with their home health bclientQ (portrayed by actress Catherine Martin).
Clinical simulations: Let’s get real! Table 1
107
Student survey responses
Most valuable
Least valuable
I actually felt like I was attending a home care visit as a nurse. It helped me to understand what the nurse’s role is in a home health setting. It was good to be able to ask questions and have real people answer as they would in real life. It provided an opportunity for critical thinking. The sincerity and creativity of the actresses made it very real. I learned that the different home hazards that people do not realize are harmful. Great learning experience, especially when feedback was provided for us students at the end of the visit. It showed us that going into someone’s home is very different from the hospital setting. It integrates not only hazardous situations but also the psychological/social needs of the family.
The groups are too large. There is not a lot of guidance from instructors regarding how to approach the family. I did not realize that items in the mural were part of scenario, but I realized that it is unrealistic to provide those. There are no real children in the scenario. There is not enough space and time. This is not an actual experience (but very close to actual).
to another room for debriefing. bA debriefing activity reinforces the positive aspects of the [simulation] experience and encourages reflective learning which allows the participant to link theory to practice, research, think critically and discuss how to intervene professionally in very complex situationsQ (Jeffries, 2005, p. 101). The maternal–child faculty developed the following debriefing questions to ensure a consistent experience among the clinical groups.
improved with two students per visit, it is not realistic to ask the actors to volunteer to do this scenario 25 times for a class of 50. In addition, having real infants for the simulation is not appropriate. Student evaluation responses can be seen in Table 1. Limited clinical placements can pose a challenge for providing adequate student learning opportunities. However, faculty should view this challenge as a chance to stretch their creative muscles and use novel approaches to meeting their students’ learning needs. While role-playing simulations are not new teaching strategies, adding an innovative approach to the design can provide a solution to clinical placement problems while enhancing student critical thinking ability. Educators should work from a well-outlined simulation design plan that includes selecting a topic, determining goals and objectives, creating a scenario, and developing an environment. It is important to not overlook the use of a debriefing session as this allows for the students to share their experiences. Finally, a student evaluation of the simulation can provide the necessary feedback for scenario improvement that might otherwise go unnoticed by the faculty.
1. What concerns were identified? ! Safety ! Health care needs 2. What are your specific desired outcomes? ! Priorities 3. What actions should the home health nurse take? ! Teaching ! Referrals 4. What guided your decision-making process? ! What did you see, hear, smell? 5. Did you feel that you needed more information? ! What information would that be? ! How would you obtain this information? 6. If you could do something differently, what would that be? 7. What personal safety precautions should a home health nurse take? 8. How does home care differ from the hospital? At the conclusion of the debriefing session, the students are asked to complete an evaluation form (see Appendix A). Students have raved about this simulation experience. Having actors portray patients has added realism to the simulation. Student feedback has also provided some suggestions to the simulation, such as using real infants instead of dolls and having two students at a time make the home health visit. Although the simulation could be
Having to concentrate on one area while in the home (i.e., safety) meant other opportunities were missed. There is no follow-up visit to family at a later date. I felt unfamiliar in the home environment compared to the hospital setting.
Appendix A. Home care simulation laboratory evaluation
What was the most valuable learning experience for you in home simulation laboratory? What was the least valuable learning experience for you in the home simulation laboratory? Do you have any suggestions or recommendations for future use of the home simulation laboratory in the Maternal– Child Nursing course? If so, what? Thank you for your input.
108
References Comer, S. K. (2005, November/December). Patient care simulations: Role play. Nursing Education Perspectives, 26(6), 357 – 361. Feingold, C. E., Calaluce, M., & Kallen, M. A. (2004, April). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43(4), 156.
L.A. Massias, C.A. Shimer Jeffries, P. R. (2005, March/April). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96. Pasco-Hernando Community College. (2007). Course manual NUR2460C maternal–child nursing. New Port Richey, FL7 Author. The Florida Nurse Practice Act. (2004). State of Florida regulations of profession and occupations, Title XXXII, Chapter 464.
www.jtln.org
Clinical simulations: Let’s get real! Lydia A. Massias MS, CNS, RN*, Carol A. Shimer EdD, RN Department of Nursing, Pasco-Hernando Community College, New Port Richey, FL 34654, USA
KEYWORDS: Simulations; Role-play; Home care
Abstract Simulations have been recommended when clinical facilities are scarce because they provide a similar experience to that which a student would encounter. Pasco-Hernando Community College nursing faculty designed a role-playing home care simulation for students. The students interact with community theater actors in an improvised simulated home health environment. The home care visit interaction is followed by a debriefing session. Here, students identify concerns in the scenario and verbalize their feelings about the experience. D 2007 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction The nursing profession continues to face a nationwide shortage. An anxious health care industry is looking to postsecondary educational institutions to lessen and eventually end the shortage through an increase in nursing student enrollment. This presents a challenge to postsecondary institutions, as there are not enough clinical placements available to support this growth. As a result, there is vigorous competition among nursing schools for a limited number of clinical slots. In response to the increased need for clinical placements, the Florida State Board of Nursing expanded the associate degree nursing student’s scope of practice to include community-based practice (The Florida Nurse Practice Act, 2004). Community-based practice refers to limited hands-on skills that can be performed in certain practice
settings under the guidance of a registered nurse preceptor. These settings include nursing homes, schools, and home health. Pasco-Hernando Community College’s (PHCC) associate degree nursing program, spanning the two counties just north of Tampa, FL, is currently experiencing an insufficient supply of maternal–child clients in community-based practice. In preparation for these types of clinical experiences, the maternal–child faculty decided to create a community-based simulation for their students. A simulation is a representation of reality designed to b. . . allow students to build patient care skills while applying theoretical knowledge in a controlled settingQ (Comer, 2005, p. 358). Creating a suitable simulation is essential to meeting the learner objectives. According to Jeffries (2005), developing a framework for a proper simulation involves three phases: designing, implementing, and evaluating.
2. Designing * Corresponding author. Tel.: +1 727 847 2727; fax: +1 727 816 3309. E-mail addresses: [email protected] [email protected]
The maternal–child faculty undertook four steps during the design phase: selecting a topic, determining goals and
1557-3087/$ – see front matter D 2007 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2007.05.001
106 objectives, creating a scenario, and developing the simulation environment. Faculty decided that the communitybased practice simulation topic would consist of a home health visit to a postpartum client and her family on campus in a mimicked home environment. Issues that the students will encounter in the simulation include the following: postpartum depression, teenage pregnancy, nutrition, health promotion, and safety. Determination of the goals and objectives is the second step in designing a simulation. The goal of the maternal– child simulation is to provide nursing students with a realistic home health visit to a childbearing family. Objectives for this simulation state that the student will: 1. Complete a home safety assessment in the campus laboratory. 2. Complete a health history for a client/family. 3. Identify health promotion teaching needs for client/ family. 4. Identify infant–parent and child–parent relationships. 5. Use critical thinking to formulate measurable outcomes for improved family process and growth. 6. Identify nursing strategies to achieve positive patient outcomes. 7. Identify the role of the maternal/child home health nurse. 8. Discuss personal safety precautions that the maternal/ child home health nurse needs to implement. 9. Differentiate between hospital and home health care of the maternal/child clients (PHCC, 2007, p. 35). Creating the scenario is the third step of designing a simulation. A script was written, describing the characters and detailing their medical problems. A number of safety and psychosocial issues were also written into the scenario. However, no particular instructions were included regarding what the characters should exactly say or how they should act during the role-play simulation because improvisation adds to the realism of the scenario. Development of the simulation environment is the fourth step in the preparation of the role-playing simulation. Halamek et al. (as cited in Feingold, Calaluce, & Kallen, 2004) believe that realism of the simulation requires the scenario to be staged with attention to detail and in a milieu that replicates the real environment. At PHCC, a vacant small room was set up to represent a client’s home. Faculty donated pieces of used furniture and decorations. Furthermore, an artist, who paints sets for community theaters, donated her time to paint a kitchen mural on one wall of the vacant room. Prior to running the simulation, selection of the roleplaying participants had to be made. Initially, faculty posed as the characters in the scenario. During the trial run of the role-playing simulation, it was discovered that the students did not view the characters as realistic, due to their familiarity with the faculty. As a result, it was decided to obtain people with whom the nursing students were
L.A. Massias, C.A. Shimer unfamiliar. The initial thought was to recruit students who were involved in the campus theater group. Unfortunately, scheduling conflicts prevented this from happening. Luckily, actors from a local community theater group could be recruited to portray the patients. The maternal– child course is fortunate that these same actors have been able to perform this simulation numerous times, becoming very familiar with the characters, and thus responding spontaneously to the variations in student interactions.
3. Implementing Prior to the role-play interaction, a briefing session is done. During the session, information about the scenario and clients is presented to the students. The students are told that the clinical group is going to make a home health visit to a postpartum patient and her family. So that the scenario can proceed with optimal learning, students are assigned specific areas to focus on, namely, safety concerns, health care needs, teaching needs, and referrals. Students are encouraged to interact with the patients during the home health visit (Fig. 1). During the running of the simulation, the clinical faculty member leads his or her group to the home health laboratory and knocks on the door. The postpartum mother, dressed in a housecoat, answers the door, and the scenario is underway. Faculty members facilitate the scenario from time to time by interjecting questions to the patients. Termination of the scenario occurs when the objectives have been met; however, 30 minutes is usually adequate time for the home visit.
4. Evaluating Evaluating is the final phase of the role-playing simulation. Following the simulation, the students are taken
Fig. 1 RN students Mark Stefanik, Genifer Westphal, and Andrea Salazar interact with their home health bclientQ (portrayed by actress Catherine Martin).
Clinical simulations: Let’s get real! Table 1
107
Student survey responses
Most valuable
Least valuable
I actually felt like I was attending a home care visit as a nurse. It helped me to understand what the nurse’s role is in a home health setting. It was good to be able to ask questions and have real people answer as they would in real life. It provided an opportunity for critical thinking. The sincerity and creativity of the actresses made it very real. I learned that the different home hazards that people do not realize are harmful. Great learning experience, especially when feedback was provided for us students at the end of the visit. It showed us that going into someone’s home is very different from the hospital setting. It integrates not only hazardous situations but also the psychological/social needs of the family.
The groups are too large. There is not a lot of guidance from instructors regarding how to approach the family. I did not realize that items in the mural were part of scenario, but I realized that it is unrealistic to provide those. There are no real children in the scenario. There is not enough space and time. This is not an actual experience (but very close to actual).
to another room for debriefing. bA debriefing activity reinforces the positive aspects of the [simulation] experience and encourages reflective learning which allows the participant to link theory to practice, research, think critically and discuss how to intervene professionally in very complex situationsQ (Jeffries, 2005, p. 101). The maternal–child faculty developed the following debriefing questions to ensure a consistent experience among the clinical groups.
improved with two students per visit, it is not realistic to ask the actors to volunteer to do this scenario 25 times for a class of 50. In addition, having real infants for the simulation is not appropriate. Student evaluation responses can be seen in Table 1. Limited clinical placements can pose a challenge for providing adequate student learning opportunities. However, faculty should view this challenge as a chance to stretch their creative muscles and use novel approaches to meeting their students’ learning needs. While role-playing simulations are not new teaching strategies, adding an innovative approach to the design can provide a solution to clinical placement problems while enhancing student critical thinking ability. Educators should work from a well-outlined simulation design plan that includes selecting a topic, determining goals and objectives, creating a scenario, and developing an environment. It is important to not overlook the use of a debriefing session as this allows for the students to share their experiences. Finally, a student evaluation of the simulation can provide the necessary feedback for scenario improvement that might otherwise go unnoticed by the faculty.
1. What concerns were identified? ! Safety ! Health care needs 2. What are your specific desired outcomes? ! Priorities 3. What actions should the home health nurse take? ! Teaching ! Referrals 4. What guided your decision-making process? ! What did you see, hear, smell? 5. Did you feel that you needed more information? ! What information would that be? ! How would you obtain this information? 6. If you could do something differently, what would that be? 7. What personal safety precautions should a home health nurse take? 8. How does home care differ from the hospital? At the conclusion of the debriefing session, the students are asked to complete an evaluation form (see Appendix A). Students have raved about this simulation experience. Having actors portray patients has added realism to the simulation. Student feedback has also provided some suggestions to the simulation, such as using real infants instead of dolls and having two students at a time make the home health visit. Although the simulation could be
Having to concentrate on one area while in the home (i.e., safety) meant other opportunities were missed. There is no follow-up visit to family at a later date. I felt unfamiliar in the home environment compared to the hospital setting.
Appendix A. Home care simulation laboratory evaluation
What was the most valuable learning experience for you in home simulation laboratory? What was the least valuable learning experience for you in the home simulation laboratory? Do you have any suggestions or recommendations for future use of the home simulation laboratory in the Maternal– Child Nursing course? If so, what? Thank you for your input.
108
References Comer, S. K. (2005, November/December). Patient care simulations: Role play. Nursing Education Perspectives, 26(6), 357 – 361. Feingold, C. E., Calaluce, M., & Kallen, M. A. (2004, April). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43(4), 156.
L.A. Massias, C.A. Shimer Jeffries, P. R. (2005, March/April). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96. Pasco-Hernando Community College. (2007). Course manual NUR2460C maternal–child nursing. New Port Richey, FL7 Author. The Florida Nurse Practice Act. (2004). State of Florida regulations of profession and occupations, Title XXXII, Chapter 464.