- Email: [email protected]
Using a simulation strategy: An educator’s experience
Nurse Education in Practice (2005) 5, 296–301
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
FOCUS
Using a simulation strategy: An educator’s experience Fiona Arundell
a,*
, Jane Cioffi
b,1
a
School of Nursing, Family and Community Health, University of Western Sydney, Bankstown Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia b School of Nursing, Family and Community Health, University of Western Sydney, Hawkesbury Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia Accepted 2 March 2005
KEYWORDS
Summary As students are expected to apply their knowledge in clinical settings educators need to use learning strategies that provide students with experiences that facilitate knowledge application. The use of simulations has been identified to be such a strategy. However, their use in the classroom has been described as burdensome for educators. Consequently educators may avoid using them. This paper describes the experience of an educator preparing, implementing and evaluating the use of simulations with midwifery students. In conclusion, the educator found the experience to be worthwhile and well received by students. c 2005 Elsevier Ltd. All rights reserved.
Simulations; Classroom; Experience; Educator; Midwifery
Introduction One of the challenges facing midwifery educators is the preparation of student midwives to be safe, effective decision-makers. Most usually in midwifery education students are prepared for clinical decision-making by developing knowledge with lectures and tutorials on midwifery topics. Currently clinical reasoning and decision-making skills are taught primarily during didactic lectures by * Corresponding author. Tel./fax: +64 2 97726361. E-mail address: [email protected]. 1 Tel.: +64 2 45701929; fax: +64 2 45701420.
the lecturer. The lecturer provides students with potential clinical scenarios and explains the clinical reasoning underlying the decisions relevant to the situation. Although the clinical reasoning and decisions the students are exposed to are technically correct they are the passive recipients of the decision-making process. Although information the student receives is correct this style of teaching does not foster their decision-making skills. Students are then expected to apply this knowledge in clinical practice when making clinical judgements often with little guidance. The use of experiential learning can provide an opportunity to actively guide the development of clinical
1471-5953/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2005.03.001
Using a simulation strategy: An educator’s experience decision-making. One experiential learning strategy that has the potential to develop decisionmaking skills prior to entry into practice is the use of simulations in the classroom. The use of simulations in the classroom has been described as burdensome for educators and adding time to teaching sessions (Rauen, 2001). Based on this educators may avoid classroom use of simulations. This paper describes the experience of preparing, using and evaluating simulations in a classroom situation in the hope that it may encourage others to use them.
Background Simulations Simulations have been used extensively in the education of medical students and in recent years have been used more frequently in the education of nurses (Gates et al., 2001; Roberts and While, 1996). As nurse educators are now considering learning-centred more than teaching-centred approaches, clinical simulations afford learning environments that are interactive with an emphasis on cognitive skills, critical thinking and clinical reasoning (Rauen, 2001; Vandrey and Whitman, 2001). From the student perspective simulations have been seen to surpass the more traditional methods of teaching offering clinical applications of concepts in lifelike situations (Vandrey and Whitman, 2001; Wildman and Reeves, 1997). According to Rauen (2001) a simulation is a clinical practice situation that mimics as far as possible the real clinical situation. One of the benefits of this educational tool is students are able to recognise gaps in their knowledge and clinical experience that need to be addressed (Frost, 1996). The use of simulations also provides students with the ability to empower themselves and be self-directed in a safe classroom environment (Drew and Davidson, 1993). This sentiment is reflected by Roberts et al. (1992) who identify the need for nurses in the clinical setting to provide care based on decision-making that is not faulty or weak, therefore not compromising patient care. Simulation use, therefore, can be argued to have advantages for students and educators. Providing students with the opportunity to use simulations requires educators to be confident in their preparation and implementation in the classroom. However, little has been written about this process of
297 preparing and implementing simulations in the classroom.
An educator’s experience Preparing to use simulations in the classroom From the literature various aspects of simulation development are raised. Firstly, if real case study material is used a high degree of representativeness of actual clinical situations can be achieved (Jones, 1989). Approval to use such case material needs to be gained from the relevant ethics committee and information needs to be identified. Further, to enable active searching that imitates an actual assessment a process-based method can be designed within the simulation so the individual making the decision controls the information collected. This according to Barrows and Feltovich (1987) facilitates free progression through the available information so mimicking clinical reality. Consequently actual clinical situations were used for this exercise and the simulation material was designed so information could be gathered over time. Initially clinical assessment situations were selected that commonly present in midwifery practice. Two highly prevalent practice situations were admission of a term woman to the birth unit in normal labour and the presentation of a neonate on the postnatal ward with jaundice. Case studies were developed from a composite of actual cases experienced by the educator for each of these two clinical situations. The clinical information relating to each case study was then grouped under key areas relating to specific areas of assessment. For the normal labour case simulation these areas were: woman’s presentation on arrival, labour status (as stated by pregnant woman on admission); vital signs; urinalysis; dates, ultrasound and gestation; current antenatal history; pathology; physical assessment; palpation/ abdominal examination; fetal status; vaginal loss; vaginal examination; and expectations and coping status with pain. For the jaundice case simulation key areas were: labour history; birth history; neonate’s history since birth from mother; neonate’s physical assessment; neonate’s behaviour and past history of other babies. For each key area information was set out in a series of question/ answer items for ease of access for the simulator student during the simulation activity as shown in Table 1.
298 Table 1 An example of a question/answer item from normal labour case simulation for the area of fetal status Case – Normal labour Area – Fetal status Item – Question Answer Can fetal heart sounds be auscultated? Yes What is fetal heart rate (FHR)? FHR is 136
All the items that were developed addressed information that a midwife would normally collect during an assessment. This format used a processbased method and provided a simulation structure to present information when formulating clinical decisions. As simulations were aimed to elicit clinical reasoning from students a set of decision rules were developed to accompany each simulation. These decision rules were gathered from experienced midwives for the case simulation question/answer items of both normal labour and physiological jaundice. These experienced midwives used past experiences of cases of normal labour and physiological jaundice to formulate decision rules based on an ‘if–then’ format. This format enabled antecedents and consequences of decision rules to be presented. Each of the rules developed embodied a segment of knowledge and followed the approach used by Patel and Groen (1986) who matched clinical information items of the condition of the patient (if – antecedent(s)) to the inference made (then – consequence). This method was followed with an example of a decision rule being if fetal heart rate (FHR) 136 (antecedent) then FHR within normal limits (110–160) (consequence). As the validity of case simulations and decision rules were essential, experienced midwives from clinical and academic settings were invited to form two expert panels. One expert panel evaluated the normal labour simulation and its set of decision rules and the other panel the physiological jaundice simulation and its set of decision rules. The experienced midwives assessed items and rules from two dimensions according to the content validity approach presented by Bausell (1986). The first dimension was whether the item was relevant to the clinical condition and the second was how well the item reflected a case type of the particular condition. A structured questionnaire was used to elicit this evaluation from the panel. The question/answer items and decision rules were then modified from the evaluation comments received.
F. Arundell, J. Cioffi In this preparatory phase strong support and enthusiasm were experienced from both academic and clinical midwives who formed the expert panels. The dependence on others to take part in simulation development did, however, have implications for the period of time allocated to preparation. Preparation was time consuming though no more time consuming than a complex lecture as Rauen (2001) indicated. As the simulations and accompanying decision rules did not rely on expensive models or the use of computers required few resources and were relatively easy to complete for use in the classroom.
Using simulations as a teaching strategy At the beginning of the implementation phase students were intrigued and a little anxious about the variation of presentation of material in this new approach. To address this, reassurance and clear explanations were provided by the lecturer about what would be required and the support that would be available to them during the activity. Students were then asked to self-select a partner and decide on the role each would play in the simulation activity. Each pair required a decision-maker and a simulator. After this the decision-makers waited outside the room while the simulator students were given instructions about their role during the simulation. Simulator students were asked to read the case simulation question/answer items and note the key areas under which the items were organised. Making simulator students familiar with case material helped them to respond to questions the decision-maker student was likely to ask. The decision-maker students then returned to their partners in the room and received instructions about the process of collecting information by asking the simulator student questions to mimic a clinical assessment of that particular presentation. To assist decision-maker students assessment cues of the key areas were organised in random order and displayed using an overhead projector. The decision-maker students were encouraged to say aloud all that they were thinking during the simulation. This strategy enabled the decision-maker student to be more aware of their decision-making process. For example, a student who receives information about the fetal heart rate being 136 responded aloud saying 136 is normal because the range for a term fetus is 110–160. Each pair then commenced the simulation with the simulator student reading the introductory statement to the decision-maker student. This statement introduced the decision-maker
Using a simulation strategy: An educator’s experience student to the clinical situation; for example, a woman presents at the birth unit with abdominal pain. The decision-maker student then began the simulated assessment process by asking questions aimed at exploring the clinical condition. The lecturer circulated amongst the pairs checking they were following the required process and was available if students had a query. The simulation process took students on average twenty minutes to collect enough information to arrive at their final decision about their clinical situation (a term woman presenting in spontaneous labour or a neonate with physiological jaundice). When each pair had completed the simulation they were encouraged to review the case simulation information and reflect on the decision-making process that had occurred. Students were sometimes surprised at their performance in relation to the information that they had overlooked during their assessment. The lecturer noted variability across student decision-making processes despite reaching the same conclusion. The reflection process was entered into spontaneously by the lecturer who encouraged students to feel comfortable about their performance. This was followed by the introduction of decision rules and a discussion of their relevance in the decision-making process. At times the lecturer needed to provide further clinical knowledge and to clarify concepts to promote a greater understanding of the rationales behind the decision rules for students.
Evaluating simulation use in the classroom Students’ evaluation of this simulation activity showed they considered it to be successful. Students liked the fact that practicing midwives had validated the items and decision rules indicating they felt this provided clinical credibility. Initially they were apprehensive about engaging with the activity as it required their active participation unlike the usual passive didactic lecture format with which they were more familiar. However, as they accumulated information and began to build a clinical picture the students relaxed and involved themselves more deeply in the assessment process. Students in the beginning stages of the assessment process were inclined to gather information without processing its relevance, or relating it to other information already gathered or determining directions for ongoing information seeking. The lecturer found that both the simulator and decision-maker students needed coaching to explore the collected information more deeply so the deci-
299 sion-maker student could interrogate the clinical information more effectively, for example in response to the question, ‘What gestation is the woman?’ the decision-making student responds ‘The woman is 39 weeks gestation’. The educator could then facilitate the student to elaborate on their initial question and response by developing clinical meaning and a response such as, ‘If 39 weeks gestation then the woman is full term and therefore labour and delivery is expected at this time with the expectation that the neonate will be healthy at delivery’. By using this strategy the educator reinforced the application of theory to practice. When the decision-maker students arrived at their final decision about the woman’s status the pair examine the case simulation items and evaluate the quality of the decision-maker students’ data collecting and information processing. Students were noted to be very supportive of each other in this process. They frequently expressed amazement at the extent of the simulation information available that they could have collected during the activity. Recognition of this gave students insight into how much clinical information could be used in their decision-making process. When given the decision rules that accompanied the case simulation, students were able to compare the decision rules they had actually used in their decision-making process and became aware of other rules relevant to the case simulation information. This focus on decision rules reinforced the importance of identifying the relevance of information and the need for effective processing and not just the collection of clinical information in the assessment process. On completion of the simulation activity students made many comments that provided insight into their experience. Students described the learning strategy of simulations positively, for example: ‘‘This is a good challenge I like learning like this.’’ ‘‘This is a clever way to learn.’’ Other comments reflected self-evaluation of their decision-making performance and their knowledge. Examples are: ‘‘That made me think.’’ ‘‘I can’t believe I did not collect that information.’’ ‘‘I realise I just do things for the sake of it and I don’t think about them.’’ ‘‘It makes me realise how much I know and what I don’t know.’’ ‘‘I know more than I thought I did.’’
300 Students indicated they considered this learning activity was relevant to actual clinical practice. Typical comments were: ‘‘This will make me think a lot more when I am doing things in the clinical setting.’’ ‘‘I am going to think a lot more about what I am doing next time I do it in the clinical setting.’’ These comments indicated they liked the challenge of the simulation, the active participation and the application of knowledge with clinical relevance. From the lecturer’s perspective the educational experience created by simulations in the classroom provided an opportunity to actively engage with students and encourage them to get the most out of their learning experience. The students found the activity itself easy to follow and quickly adapted to the roles of simulator and decision-maker, using the actual case simulation material with little difficulty. This was achieved by providing a detailed introduction to the activity that made them feel at ease. By not being directional and encouraging students to self-select partners they were comfortable with the activity. When students were initially introduced to the simulation process they were asked to process information received as they progressed through the simulation. However, by visiting each pair the lecturer identified that effective data collection was occurring but processing of information was inadequate. Hence, there was a need to coach students to think more deeply and evaluate the clinical significance of each piece of clinical information before gathering further information. Students responded to this coaching positively and were able to continue without further prompting. Overall, students benefited from this coaching as was reflected in comments they made, for example: ‘‘I have not thought of that.’’ ‘‘I haven’t thought that is why we do that.’’ Aspects of the activity that the lecturer found note worthy were students’ application of theoretical knowledge within their clinical judgements and decisions; knowing students are going beyond the information given to examine consequences of what they do and why they do it; the opportunity to encourage students to see what they can do; and that students were more positive about their active learning than from didactic lecture. Though developing the case simulation material was time consuming the selected case studies were characteristic of everyday midwifery practice and
F. Arundell, J. Cioffi involved fundamental midwifery principles that have endured with little change over time. Further, the assessment and decision-making activities they evoke fall within the independent practice of a midwife. By selecting the more classic midwifery scenarios case simulations lend themselves to repeated use in the classroom and so the time invested in their development is well spent. A comprehensive set of clinically relevant case simulations that foster deeper learning are invaluable as part of a teaching repertoire and further simulations are now planned. As a result of this innovative learning strategy clinical decision-making skills can be nurtured in students, the classroom made more clinically relevant and the emerging clinician better prepared to accept the responsibilities of everyday clinical practice.
Acknowledgements To all the students who participated in the study. To the Course Coordinator, Ms. Nita Purcal, who so willingly contributed to the success of the study. To the Research Assistant, Ms. Rachel Wolfenden. Ethics approval for this study was obtained from the Human Research and Ethics Committee, University of Western Sydney. This study was funded by a Category Five Scholarship, The Nurses Registration Board, New South Wales, Australia.
References Bausell, R.B., 1986. A Practical Guide to Conducting Empirical Research. Harper Row, New York. Barrows, H.S., Feltovich, P.J., 1987. The clinical reasoning process. Medical Education 21, 86–91. Drew, A., Davidson, A., 1993. Simulation based leadership development and team learning. Journal of Management Development 12, 39–52. Frost, M., 1996. An analysis of the scope and value of problem based learning in the education of health care professionals. Journal of Advanced Nursing 24 (5), 1047–1053. Gates, G., Fitzwater, E., Telintelo, S., 2001. Using simulations and standardised patients in interventions. Clinical Nursing Research 10 (4), 378–400. Jones, J.A., 1989. The verbal protocol: a research technique for nursing. Journal of Advanced Nursing 14 (12), 1062– 1070. Patel, V.L., Groen, G.J., 1986. Knowledge based solution strategies in medical reasoning. Cognitive Science 10, 91– 116. Rauen, C.A., 2001. Using simulations to teach critical thinking skills: you can’t just throw the book at them. Critical Care Nursing Clinics of North America 13 (1), 93–103.
Using a simulation strategy: An educator’s experience Roberts, J., While, A.E., 1996. Exploring the process of data acquisition: methodological; challenges encountered and strategies employed. Journal of Advanced Nursing 23 (2), 366–372. Roberts, J., While, A.E., Fitzpatrick, M., 1992. Simulation: current status in nurse education. Nurse Education Today 12 (6), 409–415.
301 Vandrey, C.I., Whitman, K.M., 2001. Simulator training for novice critical care nurse: preparing providers to work with critically ill patients. American Journal of Nursing 101 (9), Critical care extra: 24GG, 24ll, 24KK-LL. Wildman, S., Reeves, M., 1997. The value of simulations in the management education of nurses: students’ perceptions. Journal of Nursing Management 5 (4), 207–215.
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
FOCUS
Using a simulation strategy: An educator’s experience Fiona Arundell
a,*
, Jane Cioffi
b,1
a
School of Nursing, Family and Community Health, University of Western Sydney, Bankstown Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia b School of Nursing, Family and Community Health, University of Western Sydney, Hawkesbury Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia Accepted 2 March 2005
KEYWORDS
Summary As students are expected to apply their knowledge in clinical settings educators need to use learning strategies that provide students with experiences that facilitate knowledge application. The use of simulations has been identified to be such a strategy. However, their use in the classroom has been described as burdensome for educators. Consequently educators may avoid using them. This paper describes the experience of an educator preparing, implementing and evaluating the use of simulations with midwifery students. In conclusion, the educator found the experience to be worthwhile and well received by students. c 2005 Elsevier Ltd. All rights reserved.
Simulations; Classroom; Experience; Educator; Midwifery
Introduction One of the challenges facing midwifery educators is the preparation of student midwives to be safe, effective decision-makers. Most usually in midwifery education students are prepared for clinical decision-making by developing knowledge with lectures and tutorials on midwifery topics. Currently clinical reasoning and decision-making skills are taught primarily during didactic lectures by * Corresponding author. Tel./fax: +64 2 97726361. E-mail address: [email protected]. 1 Tel.: +64 2 45701929; fax: +64 2 45701420.
the lecturer. The lecturer provides students with potential clinical scenarios and explains the clinical reasoning underlying the decisions relevant to the situation. Although the clinical reasoning and decisions the students are exposed to are technically correct they are the passive recipients of the decision-making process. Although information the student receives is correct this style of teaching does not foster their decision-making skills. Students are then expected to apply this knowledge in clinical practice when making clinical judgements often with little guidance. The use of experiential learning can provide an opportunity to actively guide the development of clinical
1471-5953/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2005.03.001
Using a simulation strategy: An educator’s experience decision-making. One experiential learning strategy that has the potential to develop decisionmaking skills prior to entry into practice is the use of simulations in the classroom. The use of simulations in the classroom has been described as burdensome for educators and adding time to teaching sessions (Rauen, 2001). Based on this educators may avoid classroom use of simulations. This paper describes the experience of preparing, using and evaluating simulations in a classroom situation in the hope that it may encourage others to use them.
Background Simulations Simulations have been used extensively in the education of medical students and in recent years have been used more frequently in the education of nurses (Gates et al., 2001; Roberts and While, 1996). As nurse educators are now considering learning-centred more than teaching-centred approaches, clinical simulations afford learning environments that are interactive with an emphasis on cognitive skills, critical thinking and clinical reasoning (Rauen, 2001; Vandrey and Whitman, 2001). From the student perspective simulations have been seen to surpass the more traditional methods of teaching offering clinical applications of concepts in lifelike situations (Vandrey and Whitman, 2001; Wildman and Reeves, 1997). According to Rauen (2001) a simulation is a clinical practice situation that mimics as far as possible the real clinical situation. One of the benefits of this educational tool is students are able to recognise gaps in their knowledge and clinical experience that need to be addressed (Frost, 1996). The use of simulations also provides students with the ability to empower themselves and be self-directed in a safe classroom environment (Drew and Davidson, 1993). This sentiment is reflected by Roberts et al. (1992) who identify the need for nurses in the clinical setting to provide care based on decision-making that is not faulty or weak, therefore not compromising patient care. Simulation use, therefore, can be argued to have advantages for students and educators. Providing students with the opportunity to use simulations requires educators to be confident in their preparation and implementation in the classroom. However, little has been written about this process of
297 preparing and implementing simulations in the classroom.
An educator’s experience Preparing to use simulations in the classroom From the literature various aspects of simulation development are raised. Firstly, if real case study material is used a high degree of representativeness of actual clinical situations can be achieved (Jones, 1989). Approval to use such case material needs to be gained from the relevant ethics committee and information needs to be identified. Further, to enable active searching that imitates an actual assessment a process-based method can be designed within the simulation so the individual making the decision controls the information collected. This according to Barrows and Feltovich (1987) facilitates free progression through the available information so mimicking clinical reality. Consequently actual clinical situations were used for this exercise and the simulation material was designed so information could be gathered over time. Initially clinical assessment situations were selected that commonly present in midwifery practice. Two highly prevalent practice situations were admission of a term woman to the birth unit in normal labour and the presentation of a neonate on the postnatal ward with jaundice. Case studies were developed from a composite of actual cases experienced by the educator for each of these two clinical situations. The clinical information relating to each case study was then grouped under key areas relating to specific areas of assessment. For the normal labour case simulation these areas were: woman’s presentation on arrival, labour status (as stated by pregnant woman on admission); vital signs; urinalysis; dates, ultrasound and gestation; current antenatal history; pathology; physical assessment; palpation/ abdominal examination; fetal status; vaginal loss; vaginal examination; and expectations and coping status with pain. For the jaundice case simulation key areas were: labour history; birth history; neonate’s history since birth from mother; neonate’s physical assessment; neonate’s behaviour and past history of other babies. For each key area information was set out in a series of question/ answer items for ease of access for the simulator student during the simulation activity as shown in Table 1.
298 Table 1 An example of a question/answer item from normal labour case simulation for the area of fetal status Case – Normal labour Area – Fetal status Item – Question Answer Can fetal heart sounds be auscultated? Yes What is fetal heart rate (FHR)? FHR is 136
All the items that were developed addressed information that a midwife would normally collect during an assessment. This format used a processbased method and provided a simulation structure to present information when formulating clinical decisions. As simulations were aimed to elicit clinical reasoning from students a set of decision rules were developed to accompany each simulation. These decision rules were gathered from experienced midwives for the case simulation question/answer items of both normal labour and physiological jaundice. These experienced midwives used past experiences of cases of normal labour and physiological jaundice to formulate decision rules based on an ‘if–then’ format. This format enabled antecedents and consequences of decision rules to be presented. Each of the rules developed embodied a segment of knowledge and followed the approach used by Patel and Groen (1986) who matched clinical information items of the condition of the patient (if – antecedent(s)) to the inference made (then – consequence). This method was followed with an example of a decision rule being if fetal heart rate (FHR) 136 (antecedent) then FHR within normal limits (110–160) (consequence). As the validity of case simulations and decision rules were essential, experienced midwives from clinical and academic settings were invited to form two expert panels. One expert panel evaluated the normal labour simulation and its set of decision rules and the other panel the physiological jaundice simulation and its set of decision rules. The experienced midwives assessed items and rules from two dimensions according to the content validity approach presented by Bausell (1986). The first dimension was whether the item was relevant to the clinical condition and the second was how well the item reflected a case type of the particular condition. A structured questionnaire was used to elicit this evaluation from the panel. The question/answer items and decision rules were then modified from the evaluation comments received.
F. Arundell, J. Cioffi In this preparatory phase strong support and enthusiasm were experienced from both academic and clinical midwives who formed the expert panels. The dependence on others to take part in simulation development did, however, have implications for the period of time allocated to preparation. Preparation was time consuming though no more time consuming than a complex lecture as Rauen (2001) indicated. As the simulations and accompanying decision rules did not rely on expensive models or the use of computers required few resources and were relatively easy to complete for use in the classroom.
Using simulations as a teaching strategy At the beginning of the implementation phase students were intrigued and a little anxious about the variation of presentation of material in this new approach. To address this, reassurance and clear explanations were provided by the lecturer about what would be required and the support that would be available to them during the activity. Students were then asked to self-select a partner and decide on the role each would play in the simulation activity. Each pair required a decision-maker and a simulator. After this the decision-makers waited outside the room while the simulator students were given instructions about their role during the simulation. Simulator students were asked to read the case simulation question/answer items and note the key areas under which the items were organised. Making simulator students familiar with case material helped them to respond to questions the decision-maker student was likely to ask. The decision-maker students then returned to their partners in the room and received instructions about the process of collecting information by asking the simulator student questions to mimic a clinical assessment of that particular presentation. To assist decision-maker students assessment cues of the key areas were organised in random order and displayed using an overhead projector. The decision-maker students were encouraged to say aloud all that they were thinking during the simulation. This strategy enabled the decision-maker student to be more aware of their decision-making process. For example, a student who receives information about the fetal heart rate being 136 responded aloud saying 136 is normal because the range for a term fetus is 110–160. Each pair then commenced the simulation with the simulator student reading the introductory statement to the decision-maker student. This statement introduced the decision-maker
Using a simulation strategy: An educator’s experience student to the clinical situation; for example, a woman presents at the birth unit with abdominal pain. The decision-maker student then began the simulated assessment process by asking questions aimed at exploring the clinical condition. The lecturer circulated amongst the pairs checking they were following the required process and was available if students had a query. The simulation process took students on average twenty minutes to collect enough information to arrive at their final decision about their clinical situation (a term woman presenting in spontaneous labour or a neonate with physiological jaundice). When each pair had completed the simulation they were encouraged to review the case simulation information and reflect on the decision-making process that had occurred. Students were sometimes surprised at their performance in relation to the information that they had overlooked during their assessment. The lecturer noted variability across student decision-making processes despite reaching the same conclusion. The reflection process was entered into spontaneously by the lecturer who encouraged students to feel comfortable about their performance. This was followed by the introduction of decision rules and a discussion of their relevance in the decision-making process. At times the lecturer needed to provide further clinical knowledge and to clarify concepts to promote a greater understanding of the rationales behind the decision rules for students.
Evaluating simulation use in the classroom Students’ evaluation of this simulation activity showed they considered it to be successful. Students liked the fact that practicing midwives had validated the items and decision rules indicating they felt this provided clinical credibility. Initially they were apprehensive about engaging with the activity as it required their active participation unlike the usual passive didactic lecture format with which they were more familiar. However, as they accumulated information and began to build a clinical picture the students relaxed and involved themselves more deeply in the assessment process. Students in the beginning stages of the assessment process were inclined to gather information without processing its relevance, or relating it to other information already gathered or determining directions for ongoing information seeking. The lecturer found that both the simulator and decision-maker students needed coaching to explore the collected information more deeply so the deci-
299 sion-maker student could interrogate the clinical information more effectively, for example in response to the question, ‘What gestation is the woman?’ the decision-making student responds ‘The woman is 39 weeks gestation’. The educator could then facilitate the student to elaborate on their initial question and response by developing clinical meaning and a response such as, ‘If 39 weeks gestation then the woman is full term and therefore labour and delivery is expected at this time with the expectation that the neonate will be healthy at delivery’. By using this strategy the educator reinforced the application of theory to practice. When the decision-maker students arrived at their final decision about the woman’s status the pair examine the case simulation items and evaluate the quality of the decision-maker students’ data collecting and information processing. Students were noted to be very supportive of each other in this process. They frequently expressed amazement at the extent of the simulation information available that they could have collected during the activity. Recognition of this gave students insight into how much clinical information could be used in their decision-making process. When given the decision rules that accompanied the case simulation, students were able to compare the decision rules they had actually used in their decision-making process and became aware of other rules relevant to the case simulation information. This focus on decision rules reinforced the importance of identifying the relevance of information and the need for effective processing and not just the collection of clinical information in the assessment process. On completion of the simulation activity students made many comments that provided insight into their experience. Students described the learning strategy of simulations positively, for example: ‘‘This is a good challenge I like learning like this.’’ ‘‘This is a clever way to learn.’’ Other comments reflected self-evaluation of their decision-making performance and their knowledge. Examples are: ‘‘That made me think.’’ ‘‘I can’t believe I did not collect that information.’’ ‘‘I realise I just do things for the sake of it and I don’t think about them.’’ ‘‘It makes me realise how much I know and what I don’t know.’’ ‘‘I know more than I thought I did.’’
300 Students indicated they considered this learning activity was relevant to actual clinical practice. Typical comments were: ‘‘This will make me think a lot more when I am doing things in the clinical setting.’’ ‘‘I am going to think a lot more about what I am doing next time I do it in the clinical setting.’’ These comments indicated they liked the challenge of the simulation, the active participation and the application of knowledge with clinical relevance. From the lecturer’s perspective the educational experience created by simulations in the classroom provided an opportunity to actively engage with students and encourage them to get the most out of their learning experience. The students found the activity itself easy to follow and quickly adapted to the roles of simulator and decision-maker, using the actual case simulation material with little difficulty. This was achieved by providing a detailed introduction to the activity that made them feel at ease. By not being directional and encouraging students to self-select partners they were comfortable with the activity. When students were initially introduced to the simulation process they were asked to process information received as they progressed through the simulation. However, by visiting each pair the lecturer identified that effective data collection was occurring but processing of information was inadequate. Hence, there was a need to coach students to think more deeply and evaluate the clinical significance of each piece of clinical information before gathering further information. Students responded to this coaching positively and were able to continue without further prompting. Overall, students benefited from this coaching as was reflected in comments they made, for example: ‘‘I have not thought of that.’’ ‘‘I haven’t thought that is why we do that.’’ Aspects of the activity that the lecturer found note worthy were students’ application of theoretical knowledge within their clinical judgements and decisions; knowing students are going beyond the information given to examine consequences of what they do and why they do it; the opportunity to encourage students to see what they can do; and that students were more positive about their active learning than from didactic lecture. Though developing the case simulation material was time consuming the selected case studies were characteristic of everyday midwifery practice and
F. Arundell, J. Cioffi involved fundamental midwifery principles that have endured with little change over time. Further, the assessment and decision-making activities they evoke fall within the independent practice of a midwife. By selecting the more classic midwifery scenarios case simulations lend themselves to repeated use in the classroom and so the time invested in their development is well spent. A comprehensive set of clinically relevant case simulations that foster deeper learning are invaluable as part of a teaching repertoire and further simulations are now planned. As a result of this innovative learning strategy clinical decision-making skills can be nurtured in students, the classroom made more clinically relevant and the emerging clinician better prepared to accept the responsibilities of everyday clinical practice.
Acknowledgements To all the students who participated in the study. To the Course Coordinator, Ms. Nita Purcal, who so willingly contributed to the success of the study. To the Research Assistant, Ms. Rachel Wolfenden. Ethics approval for this study was obtained from the Human Research and Ethics Committee, University of Western Sydney. This study was funded by a Category Five Scholarship, The Nurses Registration Board, New South Wales, Australia.
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