Issues in Mental Health Nursing, 35:815–823, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.917348
Survey of Australian Schools of Nursing Use of Human Patient (Mannequin) Simulation Denise Elizabeth McGarry, RN, BA, MPM, GC (HEd) Charles Sturt University, School of Nursing, Midwifery and Indigenous Health, Bathurst, Australia
Andrew Cashin, RN, RM, B.Ed, M.Ed, PhD Southern Cross University, Nursing, Lismore, Australia
Cathrine Fowler, Professor University of Technology, Sydney, Faculty of Health, Sydney, Australia
Rapid adoption of high-fidelity human patient (mannequin) simulation has occurred in Australian Schools of Nursing in recent years, as it has internationally. This paper reports findings from a 2012 online survey of Australian Schools of Nursing and builds on findings of earlier studies. The survey design allowed direct comparison with a previous study from the USA but limited its scope to the pre-registration (pre-service Bachelor of Nursing) curriculum. It also included extra mental health specific questions. Australian patterns of adoption and application of high-fidelity human patient (mannequin) simulation in the pre-registration nursing curriculum share features with experiences reported in previous US and Australian surveys. A finding of interest in this survey was a small number of Schools of Nursing that reported no current use of high-fidelity human patient (mannequin) simulation and no plans to adopt it, in spite of a governmental capital funding support programme. In-line with prior surveys, mental health applications were meagre. There is an absence of clearly articulated learning theory underpinnings in the use of high-fidelity human patient (mannequin) simulation generally. It appears the first stage of implementation of high-fidelity human patient (mannequin) simulation into the pre-registration nursing curriculum has occurred and the adoption of this pedagogy is entering a new phase.
INTRODUCTION Australian Schools of Nursing (SoN), in common with those in other countries, have rapidly adopted the use of High-Fidelity Human Patient (mannequin) Simulation (HPS). Several common factors suggest that HPS is more than a passing pedagogical fashion. Among the common predisposing factors are improvements in simulation technologies’ responsiveness, affordability, and an increasing shortage of quality clinical placement opporAddress correspondence to Denise Elizabeth McGarry, School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Drive, Bathurst 2795, Australia. E-mail: demcgarry@ optushome.com.au
tunities. In Australia, government initiatives targeted high levels of investment in HPS as a response to these issues (Arthur, Kable, & Levett-Jones, 2011, p. e225). This paper reports a survey undertaken in mid-2012 to provide a snapshot of HPS use in pre-registration nursing curriculums. Its design was based on a prior study from the USA to facilitate comparison, in consultation with the authors (Katz, Peifer, & Armstrong, 2010). Direct comparison added cross-national information. The paper also extended prior understanding of mental health adoption and the application of learning theory to underpin HPS within pre-registration curriculum. BACKGROUND Adoption of HPS in pre-registration nursing curriculums has grown rapidly over the past 15 years in Australia, in-keeping with international trends (McKenna, French, Newton, & Cross, 2007; Murray, Grant, Howarth, & Leigh, 2008; Nehring & Lashley, 2004; Nursing and Midwifery Council, 2007). This is driven in part by the common difficulty of accessing traditional clinical placement environments (Arthur et al., 2011; National Health Workforce Taskforce, 2008, 2009; Nursing and Midwifery Council, 2007). High-fidelity simulation is defined by close replication of the practice environment (fidelity). It has been utilised to augment the deficiencies encountered as the number and quality of placement opportunities decrease in proportion to demand (Kneebone et al., 2005). High-fidelity simulation can provide a controlled and repeatable learning environment, suggesting an advantage over the traditional clinical placement (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; Kardong-Edgren, Starkweather, & Ward, 2008; Kneebone et al., 2005). Between 2004 and 2012, there had been five major surveys of SoN use of HPS published in English. These had been from the USA (Gore, Van Gele, Ravert, & Mabire, 2012; Hayden,
815
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D. E. McGARRY ET AL.
2010; Kardong-Edgren, Willhaus, Bennett, & Hayden, 2012; Katz et al., 2010; Nehring & Lashley, 2004) and Australia (Arthur et al., 2011). These surveys describe the adoption of HPS in Australia and the USA, and build on Nehring and Lashley’s (2004) seminal report. This initial survey by Nehring and Lashley (2004) reported the experience of 34 SoN and six simulation centres, a response rate of 18.5%. A total of 34 were from the USA, the remainder from Japan, Australia, England, New Zealand and two sites in Germany. Participants were identified from a purchasers’ list of Medical Education Technologies, Inc (METI) (http://healthysimulation.com/meti/). This study concluded that HPS use was in a developmental phase characterised by learning to master equipment and to incorporate its use in the curriculum. Until 2012, Nehring and Lashley (2004) was the only study directly comparing HPS use in different countries. Subsequently, Gore et al. (2012) addressed the similarities and differences between HPS adoption and use in USA and other nations. Between 2010 and 2012, three major surveys reported the use of HPS in the USA. The National Council of State Boards of Nursing conducted a nationwide simulation survey of 1,729 USA nursing programmes, partially reported in 2010 (Hayden, 2010) and more fully in 2012 (Kardong-Edgren et al., 2012). Katz et al. (2010) surveyed members of the National League of Nursing and Gore et al. (2012) reported a third survey of the International Nursing Association for Clinical Simulation and Learning (INACSL) membership. The National Council of State Boards of Nursing study addressed limitations of focus or sample characteristics identified in prior US surveys (Hayden, 2010, p. 52). It established the parameters of all simulation usage in the USA and identified a range of strengths, limitations and anticipated developments. Over 1,000 SoN (62% of all pre-licensure nursing programmes) responded to the postal survey. Eight open-field questions were included, requiring short answers that were analysed and codified (Kardong-Edgren et al., 2012, p. e121). In total, 87% of respondents reported the use of some type of simulation and 57% of these reported using simulation in five common clinical courses (Hayden, 2010, p. 55). These courses are: fundamentals of nursing (introductory nursing), medical surgical nursing (first and second stage courses), assessment skills and obstetric subjects. The survey did not specifically investigate use in mental health nursing preparation. However, it reported that HPS was less frequently used for mental health teaching than other clinical practice areas (Hayden, 2010, p. 53). Katz et al. (2010) described uptake of HPS by 209 National League for Nursing (NLN) accredited baccalaureate programmes in 2007. The survey included 13 multiple choice questions and an open-ended field. The response rate was 37.3%. It found that 78.9% of USA SoN used HPS in nursing subjects, particularly those with a close alignment with clinical practice settings. HPS was of great interest to teachers, but its adoption was restricted by limited funding and lack of faculty ‘champions’. Replacement of clinical setting placements by HPS was
unresolved and controversial – but of particular interest. As this survey was restricted to those SoN accredited by the NLN – a subset of pre-registration nursing programmes – generalisability is limited. Another limitation of this survey was that mental health nursing preparation arose only incidentally in the context of clinical subjects generally. The limited use of HPS found in mental health was consistent with the findings reported by Hayden (2010) and Kardong-Edgren et al. (2012). In Australia, Arthur et al. (2011) reported a cross-sectional web-based survey of HPS adoption. It contacted all Australian SoN between April and May 2009 (n = 32), and achieved a response rate of 75%. The survey aimed to determine the nature of simulation used, staff roles, pedagogical underpinnings, assessment practices, computing technology use in laboratories and research and evaluation undertaken (Arthur et al., 2011, p. e221). The 98 questions included fixed response format and open-ended questions. The survey findings confirmed active engagement in simulation by Australian SoN. Nearly half (45%) of SoN that answered this question (n = 22) reported using HPS (Arthur et al., 2011, p. e222). Respondents reported significant commitment to this pedagogy in response to limitations experienced in clinical placements (Arthur et al., 2011, p. e223). Although Australian nurse regulation authorities do not support substitution of clinical placement with HPS, 57% of respondents reported an interest in this (Arthur et al., 2011, pp. e222–223). The survey reported that due to large numbers of undergraduate students, respondents found that HPS ability to meet demand was restricted because of its resource intense nature. Arthur et al. (2011) expressed a concern that the widely variable adoption and use of HPS in Australian SoN was not clearly driven by superior pedagogical qualities, or explicit educational models (Arthur et al., 2011, p. e226). They also noted concern that the reported pattern of simulation use might suggest that simulation’s potential is not being fully exercised (Arthur et al., 2011, p. e222). Gore et al. (2012) reported a 2010 cross-national survey of INACSL members addressing the use of a theory or conceptual framework for simulation, debriefing, interdisciplinary or interprofessional collaboration in simulation, simulation substitution for clinical placement, simulation evaluation, use of commercially prepared scenarios and the types of simulators used. There were 206 US respondents (response rate of 22.9%) and 48 international respondents (respondent rate 26.9%). International membership of INACSL is 54.4% Canadian, and Canadians made up 63% of the international respondents (n = 30). The remaining respondents were from the following regions: Europe (n = 9); Middle East (n = 4); Asia Pacific (n = 2); Atlantic islands (n = 1) and other (n = 2). Gore et al. (2012) compared HPS use between the USA and these international regions as a group. Different practices were reported in the domains of length of debriefing; use of video capture; use of summative evaluation or assessment; simulation substitution for clinical hours; and source of simulation scenario products. This survey did not comment on mental health
817
SURVEY OF AUSTRALIAN SCHOOLS OF NURSING USE OF MANNEQUIN SIMULATION
applications. The response rate limits the generalisability of this survey. The current paper differs from other published surveys because it focusses exclusively on HPS simulation in preregistration nursing, it has an extended focus on mental health applications, and it uses a format derived following consultation with Katz, Peifer and Armstrong (2010). The design enables the findings of this survey to be placed in the context of prior surveys and compared with the patterns of adoption and application from the USA and Australia. METHODS The survey used the online survey platform Survey Monkey (https://www.surveymonkey.com/). It included 25 items. Data were descriptive based on fixed responses; some open-ended answers were interpreted by descriptive thematic analysis. The study was approved by the relevant institutional Human Research Ethics Committee. Participants received written information regarding the study. Data collected were de-identified. Sample Selection and Data Collection The researchers requested support from the Council of Deans of Nursing and Midwifery (Australia and New Zealand) and then identified the Head of School or Dean of the SoN using the Council of Deans website. The researchers e-mailed 38 Australian SoN with the link to the survey and a request that the Dean invite completion by either the Director for Teaching and
Learning or a mental health academic. We sent a follow-up e-mail 8 weeks later to encourage participation. The analysis conducted was all descriptive. Responses to fixed response scales were summated and comparative frequencies reported. Open text answers were short and subjected to descriptive analysis. Reporting was guided by comparative alignment with the previously published surveys, specifically that of Katz et al. (2010). RESULTS Of 38 Australian SoN, 14 replied (36.8%). Respondents did not complete each question, resulting in varying numbers for individual questions. Tables 1 and 2 present the responses to survey questions that correspond to those employed by Katz et al. (2010) to facilitate comparison. Three-quarters (75%) of SoN reported using HPS. Two-thirds of those who do not yet have HPS expressed the intent to purchase it, and 33% reported no plans to purchase HPS. HPS was used for competency or performance evaluations or graded activities by 44% of responding SoN. When used for assessment, 75% assign a pass/fail grade, and only 25% use graded assessment. Respondents were evenly divided in support for the use of HPS to identify students whose developing practice requires remediation. In all, 11% of SoN that reported using HPS reported substituting HPS for clinical hours. Three-quarters (75%) of these 11% of SoN used HPS for less than one in ten (10%) of their clinical
TABLE 1 Stem questions and responses Response Does your SoN have HPS? If your SoN does not yet use HPS is it considering purchase of HPS?
Are your HPS used for basic assessment skills, learning laboratory task and procedures? What overall percentage of HPS use is scenario-based? Scenario source
Are you replacing clinical hours with simulation? Yes If yes, how many hours are replaced with simulation? Are you using simulation for competency or performance evaluations or graded activities? Yes Do you feel that your use of simulation is testing or evaluating student critical thinking? Yes
Corresponding response from Katz et al. (2010)
75% 66% Definite, 8.3% Uncertain, 8.3% No, 8.3% 44% (1st priority)
78.9% 68.6%
Not asked
64.8% (
Survey of Australian Schools of Nursing Use of Human Patient (Mannequin) Simulation Denise Elizabeth McGarry, RN, BA, MPM, GC (HEd) Charles Sturt University, School of Nursing, Midwifery and Indigenous Health, Bathurst, Australia
Andrew Cashin, RN, RM, B.Ed, M.Ed, PhD Southern Cross University, Nursing, Lismore, Australia
Cathrine Fowler, Professor University of Technology, Sydney, Faculty of Health, Sydney, Australia
Rapid adoption of high-fidelity human patient (mannequin) simulation has occurred in Australian Schools of Nursing in recent years, as it has internationally. This paper reports findings from a 2012 online survey of Australian Schools of Nursing and builds on findings of earlier studies. The survey design allowed direct comparison with a previous study from the USA but limited its scope to the pre-registration (pre-service Bachelor of Nursing) curriculum. It also included extra mental health specific questions. Australian patterns of adoption and application of high-fidelity human patient (mannequin) simulation in the pre-registration nursing curriculum share features with experiences reported in previous US and Australian surveys. A finding of interest in this survey was a small number of Schools of Nursing that reported no current use of high-fidelity human patient (mannequin) simulation and no plans to adopt it, in spite of a governmental capital funding support programme. In-line with prior surveys, mental health applications were meagre. There is an absence of clearly articulated learning theory underpinnings in the use of high-fidelity human patient (mannequin) simulation generally. It appears the first stage of implementation of high-fidelity human patient (mannequin) simulation into the pre-registration nursing curriculum has occurred and the adoption of this pedagogy is entering a new phase.
INTRODUCTION Australian Schools of Nursing (SoN), in common with those in other countries, have rapidly adopted the use of High-Fidelity Human Patient (mannequin) Simulation (HPS). Several common factors suggest that HPS is more than a passing pedagogical fashion. Among the common predisposing factors are improvements in simulation technologies’ responsiveness, affordability, and an increasing shortage of quality clinical placement opporAddress correspondence to Denise Elizabeth McGarry, School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Panorama Drive, Bathurst 2795, Australia. E-mail: demcgarry@ optushome.com.au
tunities. In Australia, government initiatives targeted high levels of investment in HPS as a response to these issues (Arthur, Kable, & Levett-Jones, 2011, p. e225). This paper reports a survey undertaken in mid-2012 to provide a snapshot of HPS use in pre-registration nursing curriculums. Its design was based on a prior study from the USA to facilitate comparison, in consultation with the authors (Katz, Peifer, & Armstrong, 2010). Direct comparison added cross-national information. The paper also extended prior understanding of mental health adoption and the application of learning theory to underpin HPS within pre-registration curriculum. BACKGROUND Adoption of HPS in pre-registration nursing curriculums has grown rapidly over the past 15 years in Australia, in-keeping with international trends (McKenna, French, Newton, & Cross, 2007; Murray, Grant, Howarth, & Leigh, 2008; Nehring & Lashley, 2004; Nursing and Midwifery Council, 2007). This is driven in part by the common difficulty of accessing traditional clinical placement environments (Arthur et al., 2011; National Health Workforce Taskforce, 2008, 2009; Nursing and Midwifery Council, 2007). High-fidelity simulation is defined by close replication of the practice environment (fidelity). It has been utilised to augment the deficiencies encountered as the number and quality of placement opportunities decrease in proportion to demand (Kneebone et al., 2005). High-fidelity simulation can provide a controlled and repeatable learning environment, suggesting an advantage over the traditional clinical placement (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; Kardong-Edgren, Starkweather, & Ward, 2008; Kneebone et al., 2005). Between 2004 and 2012, there had been five major surveys of SoN use of HPS published in English. These had been from the USA (Gore, Van Gele, Ravert, & Mabire, 2012; Hayden,
815
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D. E. McGARRY ET AL.
2010; Kardong-Edgren, Willhaus, Bennett, & Hayden, 2012; Katz et al., 2010; Nehring & Lashley, 2004) and Australia (Arthur et al., 2011). These surveys describe the adoption of HPS in Australia and the USA, and build on Nehring and Lashley’s (2004) seminal report. This initial survey by Nehring and Lashley (2004) reported the experience of 34 SoN and six simulation centres, a response rate of 18.5%. A total of 34 were from the USA, the remainder from Japan, Australia, England, New Zealand and two sites in Germany. Participants were identified from a purchasers’ list of Medical Education Technologies, Inc (METI) (http://healthysimulation.com/meti/). This study concluded that HPS use was in a developmental phase characterised by learning to master equipment and to incorporate its use in the curriculum. Until 2012, Nehring and Lashley (2004) was the only study directly comparing HPS use in different countries. Subsequently, Gore et al. (2012) addressed the similarities and differences between HPS adoption and use in USA and other nations. Between 2010 and 2012, three major surveys reported the use of HPS in the USA. The National Council of State Boards of Nursing conducted a nationwide simulation survey of 1,729 USA nursing programmes, partially reported in 2010 (Hayden, 2010) and more fully in 2012 (Kardong-Edgren et al., 2012). Katz et al. (2010) surveyed members of the National League of Nursing and Gore et al. (2012) reported a third survey of the International Nursing Association for Clinical Simulation and Learning (INACSL) membership. The National Council of State Boards of Nursing study addressed limitations of focus or sample characteristics identified in prior US surveys (Hayden, 2010, p. 52). It established the parameters of all simulation usage in the USA and identified a range of strengths, limitations and anticipated developments. Over 1,000 SoN (62% of all pre-licensure nursing programmes) responded to the postal survey. Eight open-field questions were included, requiring short answers that were analysed and codified (Kardong-Edgren et al., 2012, p. e121). In total, 87% of respondents reported the use of some type of simulation and 57% of these reported using simulation in five common clinical courses (Hayden, 2010, p. 55). These courses are: fundamentals of nursing (introductory nursing), medical surgical nursing (first and second stage courses), assessment skills and obstetric subjects. The survey did not specifically investigate use in mental health nursing preparation. However, it reported that HPS was less frequently used for mental health teaching than other clinical practice areas (Hayden, 2010, p. 53). Katz et al. (2010) described uptake of HPS by 209 National League for Nursing (NLN) accredited baccalaureate programmes in 2007. The survey included 13 multiple choice questions and an open-ended field. The response rate was 37.3%. It found that 78.9% of USA SoN used HPS in nursing subjects, particularly those with a close alignment with clinical practice settings. HPS was of great interest to teachers, but its adoption was restricted by limited funding and lack of faculty ‘champions’. Replacement of clinical setting placements by HPS was
unresolved and controversial – but of particular interest. As this survey was restricted to those SoN accredited by the NLN – a subset of pre-registration nursing programmes – generalisability is limited. Another limitation of this survey was that mental health nursing preparation arose only incidentally in the context of clinical subjects generally. The limited use of HPS found in mental health was consistent with the findings reported by Hayden (2010) and Kardong-Edgren et al. (2012). In Australia, Arthur et al. (2011) reported a cross-sectional web-based survey of HPS adoption. It contacted all Australian SoN between April and May 2009 (n = 32), and achieved a response rate of 75%. The survey aimed to determine the nature of simulation used, staff roles, pedagogical underpinnings, assessment practices, computing technology use in laboratories and research and evaluation undertaken (Arthur et al., 2011, p. e221). The 98 questions included fixed response format and open-ended questions. The survey findings confirmed active engagement in simulation by Australian SoN. Nearly half (45%) of SoN that answered this question (n = 22) reported using HPS (Arthur et al., 2011, p. e222). Respondents reported significant commitment to this pedagogy in response to limitations experienced in clinical placements (Arthur et al., 2011, p. e223). Although Australian nurse regulation authorities do not support substitution of clinical placement with HPS, 57% of respondents reported an interest in this (Arthur et al., 2011, pp. e222–223). The survey reported that due to large numbers of undergraduate students, respondents found that HPS ability to meet demand was restricted because of its resource intense nature. Arthur et al. (2011) expressed a concern that the widely variable adoption and use of HPS in Australian SoN was not clearly driven by superior pedagogical qualities, or explicit educational models (Arthur et al., 2011, p. e226). They also noted concern that the reported pattern of simulation use might suggest that simulation’s potential is not being fully exercised (Arthur et al., 2011, p. e222). Gore et al. (2012) reported a 2010 cross-national survey of INACSL members addressing the use of a theory or conceptual framework for simulation, debriefing, interdisciplinary or interprofessional collaboration in simulation, simulation substitution for clinical placement, simulation evaluation, use of commercially prepared scenarios and the types of simulators used. There were 206 US respondents (response rate of 22.9%) and 48 international respondents (respondent rate 26.9%). International membership of INACSL is 54.4% Canadian, and Canadians made up 63% of the international respondents (n = 30). The remaining respondents were from the following regions: Europe (n = 9); Middle East (n = 4); Asia Pacific (n = 2); Atlantic islands (n = 1) and other (n = 2). Gore et al. (2012) compared HPS use between the USA and these international regions as a group. Different practices were reported in the domains of length of debriefing; use of video capture; use of summative evaluation or assessment; simulation substitution for clinical hours; and source of simulation scenario products. This survey did not comment on mental health
817
SURVEY OF AUSTRALIAN SCHOOLS OF NURSING USE OF MANNEQUIN SIMULATION
applications. The response rate limits the generalisability of this survey. The current paper differs from other published surveys because it focusses exclusively on HPS simulation in preregistration nursing, it has an extended focus on mental health applications, and it uses a format derived following consultation with Katz, Peifer and Armstrong (2010). The design enables the findings of this survey to be placed in the context of prior surveys and compared with the patterns of adoption and application from the USA and Australia. METHODS The survey used the online survey platform Survey Monkey (https://www.surveymonkey.com/). It included 25 items. Data were descriptive based on fixed responses; some open-ended answers were interpreted by descriptive thematic analysis. The study was approved by the relevant institutional Human Research Ethics Committee. Participants received written information regarding the study. Data collected were de-identified. Sample Selection and Data Collection The researchers requested support from the Council of Deans of Nursing and Midwifery (Australia and New Zealand) and then identified the Head of School or Dean of the SoN using the Council of Deans website. The researchers e-mailed 38 Australian SoN with the link to the survey and a request that the Dean invite completion by either the Director for Teaching and
Learning or a mental health academic. We sent a follow-up e-mail 8 weeks later to encourage participation. The analysis conducted was all descriptive. Responses to fixed response scales were summated and comparative frequencies reported. Open text answers were short and subjected to descriptive analysis. Reporting was guided by comparative alignment with the previously published surveys, specifically that of Katz et al. (2010). RESULTS Of 38 Australian SoN, 14 replied (36.8%). Respondents did not complete each question, resulting in varying numbers for individual questions. Tables 1 and 2 present the responses to survey questions that correspond to those employed by Katz et al. (2010) to facilitate comparison. Three-quarters (75%) of SoN reported using HPS. Two-thirds of those who do not yet have HPS expressed the intent to purchase it, and 33% reported no plans to purchase HPS. HPS was used for competency or performance evaluations or graded activities by 44% of responding SoN. When used for assessment, 75% assign a pass/fail grade, and only 25% use graded assessment. Respondents were evenly divided in support for the use of HPS to identify students whose developing practice requires remediation. In all, 11% of SoN that reported using HPS reported substituting HPS for clinical hours. Three-quarters (75%) of these 11% of SoN used HPS for less than one in ten (10%) of their clinical
TABLE 1 Stem questions and responses Response Does your SoN have HPS? If your SoN does not yet use HPS is it considering purchase of HPS?
Are your HPS used for basic assessment skills, learning laboratory task and procedures? What overall percentage of HPS use is scenario-based? Scenario source
Are you replacing clinical hours with simulation? Yes If yes, how many hours are replaced with simulation? Are you using simulation for competency or performance evaluations or graded activities? Yes Do you feel that your use of simulation is testing or evaluating student critical thinking? Yes
Corresponding response from Katz et al. (2010)
75% 66% Definite, 8.3% Uncertain, 8.3% No, 8.3% 44% (1st priority)
78.9% 68.6%
Not asked
64.8% (
