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Simulation in Nursing Education

Will laboratory simulation scenarios be considered an adequate substitution for clinical experiences?

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While taking a course on "The Role of Clinical Educators," an interesting question was presented - how will simulation technology in nursing programs benefit future nurses?

More questions followed as the discussion unfolded: can the technology of hi-fidelity simulation improve patient safety and reduce the risk of error and patient harm? Will laboratory simulation scenarios be considered an adequate substitution for clinical experiences?

I was intrigued, prompting me to explore more about simulation in a nursing program.

Observations

I had the opportunity to spend 2 days in a local community college's simulation lab learning the "behind the scenes" of simulation education. Each of the three labs is designed to practice nursing skills, and one lab has the hi-fidelity interactive simulation mannequins to evaluate the nurse's critical-thinking skills and application of nursing judgment. There is also a control room and debriefing room.

The simulation lab has become an integral component in this nursing program. The student nurse is able to safely practice nursing skills on mannequins before performing in the clinical setting. Gone are the days when your first try at a nursing skill is on a live patient.

Using a three-step approach to teaching nursing skills, the students begin in small groups where they receive instruction and demonstration of a particular skill. The students also have an opportunity to practice skills individually with the lab instructors to further hone these skills. Once the student demonstrated the skill to the instructors to complete their validation, they are then able to perform this skill in the clinical setting under supervision. It was interesting to see how the students were still nervous, even in the lab setting.

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The nursing labs have hi- and lo-fidelity interactive mannequins, which are tools that are programmable to respond in a life-like manner, with human characteristics such as pulses, respirations, and blood pressures. They can even receive injections, have a running IV line, or experience a seizure.

Educators could control the vital signs in order to evaluate the student's knowledge seeing how they would react in a real situation. Mannequins are also equipped to have interactive conversations, dictated by the educator using scripted scenarios with appropriate responses and cues for each specific situation.

Utilizing scripted scenarios allows the educator to guide the learning experience, and evaluate the critical-thinking skills and nursing judgment. Scripted scenarios also allow for replication of identical scenarios. An algorithm is used in which the educator responds to the nurse's action in the appropriate way - successfully or unsuccessfully. In this way, student nurses can be introduced to situations that are not common or too acute for a student to participate. Students are oriented to the lab and familiarized with the simulation mannequins prior to the scenarios.

Assessing pulse, respirations and blood pressures are demonstrated, with time given for the students to practice. The mannequins are also able to have functioning IV infusions and receive injections.

The use of simulation technology provides the opportunity for student nurses to experience situations that are rare and/or critical. For example, utilizing the lab to introduce student nurses to a postpartum hemorrhage in the obstetrics rotation provides exposure to an encounter that is extremely critical, but thankfully, not witnessed often.

Each group of students was provided the same scenario and script. Students randomly picked out a role to play, and were briefed as to what their role entailed. The student who drew the "nurse" role was not briefed, allowing the student to react in a manner that authentically reflected her knowledge and ability.

All students were then evaluated in their performance of the role selected based on critical thinking and actions within that role.

Simulations

Beginning with a report from the patient's primary nurse, the student nurse then treats the mannequin as a real patient, doing what they think they would do for a postpartum assessment. The student nurse "entered the patient's room" and started her interaction with the "patient," with the lab instructor in the control room watching the exchange on monitors.

This allowed the instructor to control the mannequin, causing it to "react" to the student's interventions, ask further questions of the student, or respond to questions that may arise. In this case, the handoff report established that the patient was on a normal postpartum course.

However, when the student asked how the patient "was feeling," the patient said she was experiencing signs of being light-headed and dizzy. How the student responds to this comment is one way of evaluating whether the student can put into practice the classroom instruction previously taught. This identical scenario ran four times. It was a closed session, so others could not see ahead of time what to expect. It was interesting how each group responded, or failed to respond in similar ways.

Reflections

The most important part of hi-fidelity simulation is the debriefing. In debriefing, the students are engaged in self-reflection and peer-evaluation of the actions and responses of colleagues.

Recording the scenario allows students to see themselves responding to events and recognize their strengths and weaknesses. They discuss their actions and reactions, with the individual who plays the student nurse inevitably becoming the hardest critic on his or her own behavior. The group's interaction within the scenario is discussed and notes for improvement are shared.

Afterward, the students shared their feelings about the "authenticity" of the situation, mimicking reality. Some said they actually forgot it was a mannequin, and felt it was real. One student remarked even though they knew it was a safe environment, they felt as if this was real, and demonstrated the same quality of care they would give an actual patient. Students also commented they felt that the quality and depth of this learning experience could not be matched in the classroom. They expressed increased confidence with handling a patient with postpartum hemorrhage.

These groups of nursing students experienced similar responses to the identical scenario. Comparable nursing assessment findings and subsequent nursing actions, equivalent patient outcomes, and even similar student self-reflection were observed. This is consistent with the objective of standardized nursing education. Also of note is the value of what happens in a lab setting - mistakes become teachable moments. On mannequins, the mistakes are allowed to play out, with the student realizing the consequences. This is something that would never be permitted on real patients. Learning from their mistakes, this leads to building confidence and competence, resulting in fewer errors and, therefore, increases patient safety.

Will laboratory simulation scenarios be considered an adequate substitution for clinical experiences? It remains to be seen. However, after watching the student nurses interact in a typical simulation lab within a community college nursing program, I believe there may be a chance the increased simulation practice scenarios may lead to improved patient safety and reduce the risk of error and patient harm in the future.

Interactive hi-fidelity simulation scenarios are still fairly new, and it will be interesting to see how it impacts nursing performance when the graduates are practicing are on their own in their workplace.

Joan Cover, an operating room nurse in Connecticut, received her master's of science in nursing from University of Hartford in May 2011.  


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