RHODES, MATTIE L. PhD, RN; CURRAN, CYNTHIA MS, RN
Nurses today are faced with a constantly changing healthcare environment. Patients present with more acute and complex healthcare issues and needs. Shortened length of stay and early discharge are commonplace events. Students are expected to prepare to function in a technologically more sophisticated and increasingly more complex healthcare arena. This has produced an atmosphere in which the nurse is required to make sound clinical judgments about patient care, deliver high-quality care, and be accountable for positive patient outcomes.
Nurse educators increasingly challenged to find adequate clinical experiences to prepare students for such practice demands. Limited exposure to patients brought about by limited clinical time in nursing programs and shortened lengths of stay for patients directly impact the opportunities for experiences with certain types of patient care situations.
Students have a fear of being overwhelmed by a lack of experience.1 Their anxiety level influences their decision making, which is directly related to clinical judgment. High student anxiety can lead to decreased student learning. White2 reports that when students lack confidence in their ability to complete a nursing skill, they focus on their feelings of anxiety in not knowing what to do or their concern that they will make a mistake. The fear of making mistakes is the highest anxiety-producing situation for both junior- and senior-level students.3
Accurate clinical judgment is an essential part of clinical nursing practice. A key aspect of clinical judgment is making decisions regarding which actions are appropriate for a particular client care situation. Critical thinking and clinical reasoning are central parts of clinical judgment. According to Benner's4 theory of “Novice to Expert,” skill acquisition can provide a good basis for explaining how student nurses develop clinical judgment skills for nursing practice. Skill acquisition for clinical judgment is an important and gradual process.
As a teaching method, simulation can be used to assess and evaluate a student's skill acquisition.5,6 The human patient simulator (HPS) is a tool to teach students about complex clinical situations using lifelike examples. This can be used as a solution to ever-changing educational challenges. The HPS may (1) enhance knowledge, (2) facilitate skill acquisition, (3) decrease anxiety, and (4)assist in promoting clinical judgment.
REVIEW OF LITERATURE
Benner4 reported that students pass through levels of proficiency in the acquisition and development of clinical judgment skills, from novice, advanced beginner, competent, proficient, to expert. Benner applied the Dreyfusian model of skill acquisition to nursing in her theory. She conceived that novices, such as beginning students, are taught context-free rules to guide their actions in the clinical area. The student nurse moves through varying levels of proficiency, and most approach at least the levels of advance beginner and competence in educational program.
Undergraduate nursing students' knowledge development and reasoning style results in rule-based reasoning.7 They depend upon rules to guide their performance. These rules are based on scientific principles and nursing process and are guided by the American Nurses Association standards of nursing practice, which address how nurses are expected to plan and deliver patient care.8 When students enter the care arena, they do so without benefit of experience in the situation. The meaning and significance of these rules and their expected behavior remains unclear. Lacking clinical experiences, they rely heavily on rules and abstract principles, progressing gradually to the use of past concrete experiences to guide actions. At this point, they have little or no understanding of the contextual meaning of textbook terms.
Skill acquisition for the novice related to clinical judgment develops over time. Knowledge refinement and repetitive action that occurs with clinical experiences can assist in moving the novice from rule-based, context-free to a more analytical and rational pattern of deliberate critical thinking.9 Students need opportunities to examine and develop their own method of problem solving and reasoning so as to make clinical judgments.5 These opportunities can occur through a variety of learning experiences.
Participation in varied learning experiences provides the opportunity to apply classroom theory in the clinical setting. These experiences can assist in moving the learner from the level of novice to advanced beginner. The advanced beginner has been exposed to selected real-life situations and therefore has more contextual rules. Advanced beginners, however, still need a level of supervision and guidance. They are only beginning to perceive recurrent meaningful patterns in clinical practice.
Undergraduate students' classroom learning, over time, is configured through clinical experiences into meaningful and related information.10 There is an expectation that with more experience, this novice can move from the level of advanced beginner to the level of competence by program completion.
Nurses need critical thinking skills for sound clinical judgment. In the clinical setting, the outcome of critical thinking is clinical judgment.11 Clinical judgment is defined as nursing decisions made about such things as what to assess, what the health data suggest, what to do first, and who should do it.11 Sound clinical judgment means using critical thinking and reasoning to draw valid conclusions and then acting appropriately on the basis of these conclusions.
Critical thinking is a cognitive process of skillfully analyzing, synthesizing, and evaluating information gathered from or generated by observation, experience, reflection, or communication as a guide to belief or action.12 Several proponents have defined critical thinking as a reflective, reasoned thinking process.13–15 Critical thinking is used to make clinical judgments so as to take action on the basis of information processed.
Clinical reasoning is a cognitive process of moving from what one already knows to further knowledge.16 Reasoning is used to make a clinical judgment. Reasoning requires an ability to recall facts, organize them in a meaningful whole, and then apply the information in a clinical patient care situation. Individuals can use reasoning to assist in formulating rules or guidelines as a basis for their practice judgment decisions.
Skill acquisition recognizes that proficiency and expertise are a function of the exposure to a variety of situations. For the learner, these situations become experiences for them and can trigger the appropriate responses. Bandura17 stressed that most learning occurs through observing and modeling behaviors. Information is then stored and coded cognitively and used as a guide for action. Bandura emphasized that the creation of a realistic learning setting incorporating environment, behavior, and thought fosters the acquisition of complex clinical skills. Simulation can assist in providing this realistic exposure for students.
TEACHING STRATEGY USING THE HPS
An exciting and efficient method of teaching undergraduate content and clinical judgment skills is simulation using the HPS. The use of simulation for professional teaching can be traced back to airplane pilot training.18 The HPS has been used in teaching doctors for years,19,20 especially for anesthesia training. Abrahamson and Denson21 first introduced the HPS to the medical community in 1969. They used the simulator to help anesthesia residents learn the skill of endotracheal intubation. Ultimately, they believed that the simulator produced a more skilled individual. Since then, the anesthesia community has utilized the HPS to teach not only technical skills but also crisis management skills. For example, in a study involving the training of anesthesiologists to treat nerve gas intoxication, 25 participants found the simulated training superior to previous traditional training.22 Simulation has also been used extensively in military training.23
Until now, nursing service has used the HPS mostly in the critical care area to teach RNs how to care for the critically ill patient24,25 and to test advanced cardiac life support skills.26 Most recently, HPS is being used in nursing programs with graduate and undergraduate students.27,28 In every aspect of patient care, hands-on experience is the best teacher.
Use of the HPS as a teaching tool in nursing education can provide a more interactive learning environment for students. Not only can students see a variety of complex case scenarios, they can also practice in a real lifelike situation.29 The student is able to work in a more controlled environment and is thus able to focus on making clinical judgments regarding clients' problem situations without fear of harm to clients.24,26 This entire process provides an environment conducive for focusing on critical thinking, clinical reasoning, and clinical judgment skills as well as acquiring knowledge.
There is little information in the literature regarding the use of the HPS in undergraduate nursing education. Implementing this new technology as a teaching tool in nursing education can assist student nurses in improving overall confidence and clinical judgment skills. The value of this simulation environment enables the student to achieve a higher level of advanced beginner or even move to the level of competency in nursing practice.
Development of the Simulation
This pilot project was designed for senior-level nursing students. The overall goal was to improve the critical thinking and clinical judgment skills of students about complex nursing situations. The tool used to accomplish this goal was the HPS. Each session was videotaped.
The HPS used at the University is a full-body mannequin that has the capacity to produce heart sounds and breath sounds and has palpable pulses and intravenous (IV) access. The HPS generates cardiac rhythms, arterial blood pressures, and oxygen saturation, which are all displayed on monitors. The HPS also has many other capabilities. The mannequin is wired to a remote computer in a control room connected to the simulator room. This computer houses the software application that generates the physiological events of the HPS. Thus, the controller can direct the mannequin to talk, blink, and exhibit clinical signs so lifelike that students can easily treat the HPS as though it is a real patient.
A faculty team experienced in the content area developed the case scenario. The scenario was based on recent classroom content and was deemed by faculty to be appropriate for senior-level students.30
In this pilot project, the team of faculty
* functioned as instructional designers, ensuring that all the educational principles and parameters were appropriately included,
* identified and critically analyzed the content,
* identified objectives and conditions for the learning environment (Table 1), and
* identified necessary communication principles and cues.
Each simulator scenario took place in 20-minute time periods. The entire process from orientation to evaluation took 1 hour and 20 minutes for each student group, which was divided as follows: (1) presimulation orientation, 10 minutes; (2) simulation scenario, 20 minutes; (3) debriefing, which included 20 minutes for a videotape review and 30 minutes for the discussion and evaluation.
The case scenario developed by the faculty focused on the management of a patient in hemorrhagic shock. Behaviorally stated objectives were developed prior to the case scenario and used as a reference to design the scenario (see Table 1). Skills incorporated in the scenario had already been taught in the curriculum. To make the experience as real as possible, students were not informed regarding details of the scenario. The case scenario was pretested and rehearsed by the faculty development team and computer controller; appropriate modifications were made.
The physiologic events leading to hemorrhagic shock were programmed into the HPS by the controller. The planning and design of the environment as a real emergency department with the necessary equipment was arranged by faculty. The HPS was programmed to incorporate cues related to physical and psychosocial aspects of acute illness. This included communication cues such as, “I don't feel so good,” “I feel like I am going to throw up,” and “I feel like I have to urinate.” Students were expected to incorporate these cues in their assessment.
This project was carried out during a senior-level acute medical surgical course. Two acute medical surgical faculty members participated. Twenty-one students volunteered to participate in this experience. At this time, each student signed a form of confidentiality and consent to videotape. This was his or her initial exposure to the HPS. Students were informed that this experience will not be graded. The 21 students rotated through the experience in groups of four or five students each. They were given an orientation involving a hands-on time to take blood pressure, listen to heart and lungs sounds, and see that the HPS had the capacity to be catheterized. The students were able to see that IV fluids actually flowed into the HPS and blood could be drawn. Instructions were given at this time to imagine this scenario as real and to treat the injured person (HPS) as they would in an actual emergency. So that faculty could examine their critical thinking processes, students were advised to talk out loud about their ideas of what to do and why. This allowed faculty to detect areas needing clarification and provide necessary guidance. The orientation session took 10 minutes.
Four students arrived at the simulator room in uniform, as they would for a usual clinical day. Specific roles were assigned to the students by faculty and included the following: (1) recorder, responsible for documenting events about the patient; (2) team leader nurse, primarily responsible for leading patient care; and (3) two care providers. All students were expected to be involved in patient care. The role of the faculty was to (1) provide support, (2) facilitate and guide student activities as needed, and (3) monitor appropriateness of interventions.
The students were given the patient's chart and a report from the nurse on the previous shift. As the scenario progressed, the student participants were expected to assess changes in the patient's condition (eg, a drop in blood pressure or increase in heart rate) and to determine interventions. Students were expected to analyze and interpret laboratory results (such as a complete blood cell count and electrolytes). The HPS was programmed to change behavior as the students carried out certain actions. The HPS was then programmed to show signs of the patient going into hemorrhagic shock: blood pressure: 90/50 mm Hg; heart rate: 120 bpm; and respiratory rate: 36 breaths/min. The patient (HPS) then stated, “I have to urinate,” and became increasingly more lethargic. The students decided to call the physician with their findings. The physician ordered: blood draw for a complete blood cell count and electrolytes, type and cross match; urinalysis and Foley catheter insertion; and start IV fluids at a rate of 125 cc per hour. The blood draw was done by the students and sent to the laboratory. Another student inserted a catheter as faculty observed and advised. Laboratory results were phoned back and showed: hematocrit 27 and hemoglobin 7. The physician was notified and a blood transfusion was ordered for the patient. The faculty observed and advised as the students hung the blood; students needed considerable assistance with this skill. The entire scenario lasted approximately 20 minutes (Figure 1).
Immediately afterward, both faculty and students attended a debriefing session in another room. The purposes of the debriefing were to gather the students' perceptions of their performance, the rationale for their actions, and their evaluation of the event. Immediate feedback was important for student participants regarding their judgment and decision-making skills. It was an opportunity to point out the positive actions (reinforcement) as well as suggest other ways of dealing with the case. During this phase, the faculty functioned more as facilitators, offering clarification and guidance.
The videotape was reviewed first, allowing students to visualize the entire event and their interventions. Videotape review in the postsimulation period allowed students to observe themselves as they intervened in the patient care situation. This permitted them to focus their observations on their actions and to critically evaluate their performance with the guidance of the faculty facilitator. Faculty gave constructive criticism and support. Discussion was an important part of the debriefing session. Students were allowed to ask any question at this time and discuss their impressions of the simulation experience. It was an opportunity for an unbiased analysis and discussion of behavior and clarification of feelings occurring during the simulation. This entire process helped the students realize what they had mastered and what they still needed to learn. An evaluation form was completed by each student at that time and handed in anonymously. The debriefing took about 50 minutes, which included a 20-minute review of the videotape and 30 minutes for discussion and completion of evaluation.
Faculty Evaluation of Experience
The experience provided students with the opportunity to problem-solve and engage in critical thinking, as well as practice technical skills safely. As the patient (HPS) exhibited signs of hemorrhage, students identified a change in vital signs that reflected a hypotensive state. They were given the opportunity to make clinical judgments that resulted in an increase in IV fluids. They were also able to correctly analyze the hemoglobin and hematocrit levels and determine the need for a blood transfusion. Students utilized communication skills in developing rapport with the patient. Faculty observed that students worked together as a team for the first time in a clinical situation.
The intent of this project was to describe the use of the HPS as a teaching tool to facilitate skill acquisition and to promote critical thinking.31 The use of HPS promotes application of critical thinking skills.32 The faculty were able to observe the students use critical thinking through their actions and decision making during the simulation, the thoughts expressed during the debriefing, and in their responses from the evaluation survey.
Evaluation of Case Scenario
Faculty were able to evaluate student achievement of simulation scenario objectives related to assessment of vital signs, heart, lungs, and abdominal sounds, and skill acquisition related to urinary catheterization, management of IV fluids, and blood administration. During the blood administration, faculty noted this to be an area of weakness. Students were not as familiar with guidelines for blood administration as they should have been, even though the content had been covered in the curriculum. Most students were able to verbalize signs and symptoms of a transfusion reaction but few of them could initiate the procedure for blood administration.
Evaluation of Debriefing
One of the benefits of debriefing is the immediate feedback that is available to the student. Videotape review was a part of this process. Videotaping can be beneficial for both faculty and students. Self-evaluation can be a useful teaching tool. By reviewing the videotape during the debriefing session, the students had an opportunity to review and evaluate the effectiveness of their own interventions. For example, students realized that they gained knowledge of blood administration by actually hanging the blood during the simulation.
A 13-item survey was developed by the faculty to obtain feedback regarding the students' perceptions of the simulation experience. Students' demographic information was included. Some questions asked were as follows: (1) What did you expect of the simulation? (2) Were faculty supportive and effective? (3) Was the scenario believable? (4) Was the debriefing helpful? (5) Would you recommend use of the simulation experience for undergraduate students? (6) What were the strengths and weaknesses of the experience? and (7) Do you have recommendations for future simulations?
Survey results reflected that the students thought that the experience was positive and one that would be beneficial to any student. Some of the students noted that it was difficult to treat the HPS as a real patient. Students noted that they were using critical thinking skills. They found the faculty guidance and debriefing to be helpful. Overall, they felt that the scenario was realistic. All students stated they would recommend the use of the HPS for undergraduate learning.
On the negative side, they had comments such as “too many students,” “felt disorganized,” “scenario was too short,” and “I don't like role-playing.” This feedback can serve to assist faculty in making necessary changes to provide higher-quality learning experiences in the future.
The HPS is a tool to enhance critical thinking and clinical judgment regarding client care. Active participation by students in an enjoyable way and in a variety of clinical scenarios can strengthen the student's ability to make appropriate clinical decisions. These experiences assist the novice nursing student to progress to the advanced beginner stage of practice.
Although the simulation experience may cause some anxiety, students are better able to focus on patient care since no harm to the patient occurs. Use of simulation scenarios throughout the undergraduate curriculum can be beneficial in enhancing student confidence regarding patient care decisions.32
Simulations can be structured specifically to the level of the student's knowledge, which builds confidence.25 For example, in this current project, a more complex scenario was used to teach higher-level concepts to undergraduate senior-level students.
Planning and designing the project requires the work and time of a small team of faculty. Faculty need time to become familiar with the technology of the HPS. A faculty member, or trained personnel, experienced in managing the simulator and able to troubleshoot any difficulties, must be available. The faculty creating the scenario should be experts in the subject matter. Having content experts within the group eliminates having to seek content validity for the scenario outside the group and therefore saves time. Those creating the objectives and the scenario must be cognizant of the level of the students in their program. This can also be a manner of faculty development and personal satisfaction in learning this new technology.33 Faculty time is needed in creating the scenario, putting the objectives into step-by-step actions, and developing an evaluation tool. Therefore, a disadvantage of a simulation may be the increased time and work needed by a number of faculty members.
Since there is a paucity of information in nursing literature related to the HPS in undergraduate nursing education, descriptive articles, as well as more research studies, need to be published. Future work in this area could include measuring knowledge using the simulator versus didactic teaching and evaluating the performance of technical skills within a scenario.
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