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Education in Nursing Expands Simulation

Nursing educators become patients to make patient care real for students

When 118 first-level, first-semester nursing students at The Reading Hospital School of Health Sciences Nursing Program entered the nursing skills laboratory and found their nurse educators lying in the beds dressed in hospital gowns, sounding and acting like real patients, they were shocked. Amidst some nervous giggling, students encountered for the first time an educational strategy in nursing called Standardized Patient Simulation (SPS). Instead of utilizing paid actors trained to portray patients, their familiar nurse educators transformed into the clients who challenged students to develop a rapport, conduct a head-to-toe assessment and perform basic nursing skills as an end of the semester "putting it all together" simulation laboratory.

The students were assigned to one of four different client scenarios. There was a confused, wandering client with low oxygen levels, an emotionally distraught client dealing with a new colostomy, an immobilized client with out-of-bed orders sporting a knee immobilizer and a reluctant-to-talk client with intractable headache pain. The scenes were set, the clients were ready and student nurses began to work in randomly assigned teams of 4-6.

Following the delivery of care, the students wrote a complete care plan addressing the client's priority nursing diagnoses. At the conclusion of the 90-minute simulation sessions, debriefing occurred, feelings were shared, instructors' constructive comments were delivered, and strengths as well as areas to improve were identified.

So why did the nursing school educators decide to implement this unique educational tool?

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Patient Care Simulation

Carol Diehl, MSN, MSEd, RN, the simulation coordinator, orchestrated the idea to use SPS early in the 2-year curriculum. The use of standardized patients, i.e. "a person who has been coached to simulate an actual patient so accurately that the simulation cannot be detected," has been in existence for more than 4 decades. Medical education programs utilized this type of simulation to assist young medical students with communication, interview techniques, physical assessment and evaluation of the human condition.1

Nursing education did not start using this type of simulation until the late 1990s, early 2000. It was found that, for the advanced practice nurse, the SPS was an effective means of preparation for actual clinical practice. Use in traditional nursing education programs has just begun.2

Early in the planning of the foundation nursing course, the course coordinators requested an end-of-course challenge to assess the students' overall knowledge of what was learned during the 16-week semester. At first, the approach was to make a real skills challenge.

When attending a program for simulation in nursing, Diehl was immersed in an SPS. It was found this form of simulation allows multiple students to meet all course objectives within a limited time frame. Using faculty as opposed to paid actors as standardized clients limits expenses during times of budget constraints. Another advantage to using this strategy was the ability to create a milieu using props and moulage that closely resemble a real hospital environment. The course coordinators agreed to trial the role of client actors because they already had the knowledge of how the patient would present.3 The outcome of this first exposure to SPS was a total success.

Nursing Student Perspectives

Overall, student nurses enjoyed the opportunity to interact with real individuals rather than mannequins. During the debriefing sessions, students revealed both positive and negative reflections about the experience.

Positive comments included the following: "We worked well as a team" and "We recognized what we had to do." Other students shared, "It was more like the real world because we had to immediately prioritize and be flexible without clinical preparation the evening before."

Students relied upon technology to assist them with nursing care by using their iPod Touch devices, the online hospital procedure manual and personal recollection. The nursing educators were intrigued with comments such as "It was harder to take care of you because you knew the correct techniques and the way we were supposed to do things; patients don't always know that." Students recognized the experience as "healthy stress, which required multitasking and thinking on our feet." After pensive reflection, students admitted they could have performed some activities differently in their scenarios; however, they were quick to note "the nursing lab is a safe place to make mistakes."

Nursing Educators Note Success

It was difficult for nursing students to refrain from asking the educator/client for direction, but it was equally as challenging for the educator to remain solely in the client role. A vital, integral component of the nursing educator/student relationship is to nurture and provide guidance to students who rely upon faculty as a resource and role model.

For example, it was difficult to avoid providing verbal guidance when the students placed the client on the transfer board incorrectly, the fracture bedpan was positioned upside down under the client and a bed alarm was instituted for a client that did not require this intervention. These examples clearly highlight the differences in using nursing educators versus paid actors for SPS. Student nurses took more risk with faculty as clients because of their comfort level and familiarity.

Nursing instructors were pleasantly surprised with the performance of the students during the simulation. Student performance exceeded the expectations of the experience. Such actions included speaking in hushed tones to the client with headache pain, calling a priest to speak with a client displaying unmet spiritual needs and exhibiting sensitivity during an encounter with the client in denial regarding a newly formed colostomy.

Although the scenarios were similar, each group of students executed individualized nursing care despite identifying the same priority nursing diagnoses for the clients.

Future considerations for the use of SPS at The Reading Hospital School of Health Sciences Nursing Program include using this teaching strategy for multiple patient assignment experience when clinical sites are limited.

In addition, SPS can be utilized for increasingly complex content throughout the curriculum. Since SPS is a relatively new teaching strategy,4 course faculty plan to analyze long-term retention of course content as related to the simulation experience.

In the "putting it all together" nursing lab, student nurses demonstrated all levels of learning - affective, psychomotor and cognitive. This strategy has been a novel addition to the Foundation of Nursing Course and one which is here to stay.

References for this article can be accessed at Click on Resources, then References.

Carol Diehl is simulation coordinator, Carol Ann Ottey is RN educator III, Kara Lesher is RN educator III and Sherry Murphy is RN educator III, all at The Reading Hospital School of Health Sciences-Nursing Program. Reading, PA. Ottey, Lesher and Murphy also serve as course coordinators for the Foundations of Nursing Care I and II courses.


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