clinical simulations: let's get real!
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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
1557-3087/$ – see front matter D 2007 N
doi:10.1016/j.teln.2007.05.001
* Corresponding author. Tel.: +1 727 8
E-mail addresses: massial@phcc.edu8
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 even-
tually end the shortage through an increase in nursing
student enrollment. This presents a challenge to postsec-
ondary institutions, as there are not enough clinical place-
ments 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
ational Organization for Associate Degree
47 2727; fax: +1 727 816 3309.
shimerc@phcc.edu
settings under the guidance of a registered nurse preceptor.
These settings include nursing homes, schools, and home
health.
Pasco-Hernando Community College’s (PHCC) associ-
ate 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 experi-
ences, 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), devel-
oping a framework for a proper simulation involves three
phases: designing, implementing, and evaluating.
2. Designing
The maternal–child faculty undertook four steps during
the design phase: selecting a topic, determining goals and
Teaching and Learning in Nursing (2007) 2, 105–108
Nursing. Published by Elsevier Inc. All rights reserved.
Fig. 1 RN students Mark Stefanik, Genifer Westphal, and
Andrea Salazar interact with their home health bclientQ (portrayedby actress Catherine Martin).
L.A. Massias, C.A. Shimer106
objectives, creating a scenario, and developing the simula-
tion environment. Faculty decided that the community-
based 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 out-
comes for improved family process and growth.
6. Identify nursing strategies to achieve positive patient
outcomes.
7. Identify the role of thematernal/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. Further-
more, 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 role-
playing 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
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
Table 1 Student survey responses
Most valuable Least valuable
I actually felt like I was attending a home care visit as a nurse. The groups are too large.
It helped me to understand what the nurse’s role is in a home
health setting.
There is not a lot of guidance from instructors regarding how
to approach the family.
It was good to be able to ask questions and have real people
answer as they would in real life.
I did not realize that items in the mural were part of scenario,
but I realized that it is unrealistic to provide those.
It provided an opportunity for critical thinking. There are no real children in the scenario.
The sincerity and creativity of the actresses made it very real. There is not enough space and time.
I learned that the different home hazards that people do not
realize are harmful.
This is not an actual experience (but very close to actual).
Great learning experience, especially when feedback was
provided for us students at the end of the visit.
Having to concentrate on one area while in the home
(i.e., safety) meant other opportunities were missed.
It showed us that going into someone’s home is very different
from the hospital setting.
There is no follow-up visit to family at a later date.
It integrates not only hazardous situations but also the
psychological/social needs of the family.
I felt unfamiliar in the home environment compared to the
hospital setting.
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.
Clinical simulations: Let’s get real! 107
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.
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
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. Howev-
er, 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 simula-
tions are not new teaching strategies, adding an innovative
approach to the design can provide a solution to clinical
placement problems while enhancing student critical think-
ing 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.
Appendix A. Home care simulationlaboratory evaluation
L.A. Massias, C.A. Shimer108
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.
Jeffries, P. R. (2005, March/April). A framework for designing, implement-
ing, 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.
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