clinical simulations: let's get real!

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Page 1: Clinical simulations: Let's get real!

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

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: [email protected]

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.

[email protected]

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.

Page 2: Clinical simulations: Let's get real!

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

Page 3: Clinical simulations: Let's get real!

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

Page 4: Clinical simulations: Let's get real!

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.