SIMULATION IS a common educational tool used to engage students in a clinical scenario.1,2 It facilitates clinical experiences for nursing students in a manner that ensures consistent learning opportunities in healthcare settings where it can be difficult to control exposure to certain populations, but it does not necessarily ensure educational engagement.3 In active learning, students must be central to the learning activity and able to demonstrate their knowledge and skills in a clinically relevant environment.4
This article discusses how best to engage nursing students in active learning during simulated clinical scenarios and details how one school of nursing developed a new simulation structure.
The current simulation structure
Establishing simulation environments where students can be engaged in their education offers the nursing faculty an opportunity to identify students who may be struggling with comprehension.4 Effective engagement requires that students feel engaged not only while participating in simulated clinical environments, but also while they are observing simulations. At the author's school of nursing, where simulations were focused on the application of skills in a set environment, educators addressed concerns that the simulation program did not fully engage students and even increased their anxiety about learning new skills.
Originally, third-semester nursing students were split across five campuses, each of which ran predetermined simulations on a preestablished schedule to ensure consistency. Before each simulation began, the students reviewed and answered questions to help determine their understanding of a disease process, skill, or intervention pertaining to their experience.
The experience was then divided into five states, or a set of clinical experiences meant to capture a moment during a patient's visit or stay, which allowed 10 student participants to enter simulations and perform clinical skills. These states covered hours, days, or weeks of patient care depending on faculty determinations regarding the most effective way to involve all students and were only loosely connected to the prebriefing activities. Each was developed based on what should be achieved through the completion of skills, focusing on the students' ability to identify and complete predetermined tasks in a timely manner.
Before the simulation began, participants received a bedside report. Before the report, they were required to participate in a 30- to 40-minute presentation based on their prereading, which decreased the total simulation time from 4 hours to 3 hours across all five states.
The use of skills was unevenly distributed, with students in the first or second states completing a large number of skills and those in the remaining states providing education or communication interventions. Similarly, students outside the simulated environment observed with little or no guidance as to what the observation role entailed.
Even after the students were provided with a framework to guide the observation role, such as what was completed by the nurses during the simulation, they were still not fully engaged and were often on their phones or laptops and completing other work that had little to do with the simulation experience. Due to this disengagement, the students later described the simulation environment as stressful in their end-of-semester evaluations, as they felt it did not help their learning and considered it a waste of time. The students further expressed a desire for simulations to be replaced with traditional clinical time.
Looking for inspiration
To address perceptions regarding the lack of student engagement, increased anxiety related to simulations, and the framework of focusing only on skills-based simulations that lacked the complexity of the clinical decision-making required by RNs, the faculty at the author's institution began looking outside of nursing for methods to suspend reality and fully engage students in the learning environment.5 The use of games was one educational engagement strategy that has fostered exploration in learning.5 These games follow the concept of a magic circle, which describes learning environments where the rules of the real world do not apply, allowing for the establishment of new rules, new experiences, and new opportunities to engage students.5
To be successful, the simulation experience needed to provide students with a mock environment to suspend their identity and establish new rules that would allow them to enter as RNs rather than nursing students. These rules required students to operate outside of their lived experience and engage in new experiences to link theoretical knowledge to clinical experience. This suspension of their identity allowed students to enter the magic circle capable of making decisions as an RN that affect patient outcomes, while recognizing that the rules and consequences of the real world did not apply.
As a result, the nursing students understood that simulations were a safe environment in which they could fail without fear of adverse personal or professional consequences or patient harm. This framework guided faculty changes to the simulation structure, with a focus on three key areas: the development of roles, the establishment of student motivation, and positive and constructive feedback surrounding failure.8
The nursing faculty also looked into role-playing strategies to engage students in the simulation experience. In a review of the literature regarding active engagement in simulation, the use of tag team simulation (TTS) was identified as a method that could be replicated within established environments. TTS identifies four roles to aid students in immersing themselves in clinical scenarios, each of which enables support, guidance, action, consequences, and instructive feedback to meet the established learning outcomes of a simulation environment and keep participants engaged:6
- The narrator is typically a faculty member who understands the patient's story and can guide students through responses.
- The protagonist, often played by an actor or educator, represents the patient whose history and medical information are relevant to the simulation.
- Actors include nursing students with unscripted roles based on their knowledge of the concepts in the simulation.
- The audience includes the remaining students, who provide feedback to the actors and, potentially, direction regarding changes in the simulation.
The faculty approached the changes to their simulation structure with these contexts in mind, developing three student-led roles and condensing the five predetermined states of the initial program down to just two predetermined states, depending on the protagonist's patient history. Each simulation met a predetermined concept, such as respiratory, and each protagonist's story was written to fit this concept. Three student-led roles were established:
- The first was the role of an RN. This was the only role that had two students, allowing them to work together and provide peer support. As the student participants were in their final simulation experience before their capstone and final semester, allowing them to enter the room and make similar decisions to those made by newly graduated nurses helped them identify and clarify their critical thinking.7 These roles were unscripted, allowing students to explore their clinical knowledge and skills from previous semesters and immerse themselves in the different scenarios with confidence.
- The second student-led role required students to be involved as the protagonist.6 In this role, students received a script that provided the patient's healthcare and personal background. As protagonists, students portrayed the patient from outside the simulation room and were involved using multimedia equipment such as cameras and microphones, which allowed them to respond to questions, provide feedback about interventions, and maintain conversations as encountered in live patients. Predetermined responses were also provided, which allowed students in the protagonist role to deliver the appropriate patient feedback during the simulation.
This student-led role also served a second function: to provide support as a member of the larger allied healthcare staff. Supplementary support scripts helped answer questions related to the simulation such as medical orders and lab results. Additionally, both the students acting as nurses in the simulation and those acting as the protagonist and support staff outside the room had access to information from their patient's electronic health record (EHR). As orders or results were obtained and entered into the EHR, these would be available to nursing students in patient rooms.
- In the third role, the student was an observer. This role was considered crucial to the simulation, as observers ensure guided, supported debriefing activities that encourage reflection. To provide a structure for the observation, the faculty developed four outcomes based on established debriefing strategies: What we know, What we learned, What was done well, and What needs improvement.8 The observers viewed the simulation through a televised, multicamera system that allowed for live audio interactions. The responses recorded by the observers were based on the students' theoretical and clinical knowledge and demonstration of the appropriate skill levels.
Before entering the simulation, student participants were given a bedside report that outlined what had happened to the patient in the previous shift. The report gave students an opportunity to ask questions, clarify previous treatment plans, and access the most up-to-date patient information. It was provided to students in the roles of both the nurse and the observer, allowing students to develop their own strategies, prioritize their initial assessments, and further understand the clinical scenario.
As the focus of the simulation moved away from completing specific skills to involving all participants in active roles, students were able to transition easily from the protagonist and observer roles to the nurse role, thereby reducing the number of states from five to two. To ensure all students were involved, the simulation was also run in two separate rooms to allow all 8 to 10 students to participate.
To aid with this transition, students in the observer and protagonist roles during the first state were not provided the scripts for the second state. Instead, students taking over the nurse role in the second state would rely on a report provided by those in the nurse role during the first state. The actions and interventions from these students were guided by their own assessments and the information provided through the EHR. Those who transitioned from the nurse role to an observatory and/or protagonist role had a better understanding of the nursing expectations in the clinical scenario, often providing insight and supporting students in the second state, especially in debriefing activities.
To engage students in the debriefing process, the faculty incorporated reflective practices and acted as facilitators to guide students through the reflection process and acknowledge their decision-making. By combining preestablished outcomes with video recordings, the faculty walked students through the simulation experience. Student participants in the RN role had an opportunity to observe themselves and their peers in video recordings and validate their clinical decisions. Similarly, student participants in the observer or protagonist roles were able to explain their understanding, ask questions, and clarify their perceptions.
These perspectives offered further opportunities for reflection. For example, student participants in the nurse role often described being caught up in what clinical tasks needed to be completed rather than focusing on what information was being provided through assessments and interventions. Student participants in the observer or protagonist roles often described frustration when they were unable to provide important information to those in the nurse role due to limited communication or ineffective or incomplete nursing assessments. As observers, the students felt that they understood what their classmates were trying to achieve and were aware of the confusion that developed when those in the nurse role requested specific information from the healthcare team after failing to provide a complete assessment of their own.
At the end of each semester, students at the author's institution complete an online survey to evaluate the course for an additional 1% to their overall grade. These surveys are approved by the Institutional Assessment Committee and function as part of the university's established policies and procedures. Using these incentives, almost 100% of students participated in the evaluations, resulting in approximately 60 responses. Consistency in the survey questions among the five campuses, even those that did not participate in the simulation restructuring, allowed for confidence in the feedback received.
Qualitative feedback from students indicated that they overwhelmingly enjoyed the simulations. They acknowledged that the change provided a more realistic environment that mimicked clinical settings while allowing students to make decisions and experience consequences. Additionally, using multiple roles offered students an opportunity to apply both theoretical knowledge and clinical skills.
Similarly, rotating the simulation roles provided the students an active and essential part in their education. The roles also offered different perspectives, which supported one of the primary goals in the nursing curricula: the ability to view patients holistically.
In the original simulation structure, students identified fear and anxiety associated with simulations. With the introduction and rotation of the nurse, protagonist, and observer roles, however, the students felt less judged, as each member of their group had a role to play and relied on the others for success in the simulated scenario. This focus on group participation allowed for peer-to-peer mentoring, and the students felt supported and encouraged by their classmates.
Based on the initial findings, the faculty at the author's school of nursing has adapted the undergraduate curriculum to the outlined simulation structure. Another study is currently underway to seek student feedback across all three semesters geared toward simulation.
One potential area of exploration is the process of obtaining perspectives from newly graduated nurses who had completed some or all of the new simulation structure and are now in clinical practice. By understanding how these nurses feel about the simulation and how it prepared them for a clinical role, educators may better understand the structure and value of incorporating different nursing roles during clinical simulations.
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