Nurse Educator Vol. 38, No. 6, pp. 269-272 Copyright * 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
Weaving the Tapestry of Learning Simulation, Standardized Patients, and Virtual Communities Brian Holland, MSN, RN & Karen Landry, PhD, RN & Angela Mountain, MS, RN, CMSRN Mary Alice Middlebrooks, MSN, RN & Deborah Heim, BSN(c) & Kathy Missildine, PhD, RN, CNE Using situated cognition learning theory, nursing faculty developed simulated clinical learning experiences integrating virtual communities and standardized patients. These learning experiences provide authenticity and realism not easily achieved using the individual techniques in isolation. The authors describe the process of weaving these strategies into a rich learning experience for students.
I was utterly helpless and very frightened. I was familiar with this patient’s history from The Neighborhood, but this was different. Dr. Ocampo was an actual person who was having trouble breathing. My partner and I did everything we knew to do, which wasn’t much since this was our first month in nursing school. We checked his vitals, placed a nasal cannula, sat him up and then looked at each other while he continued to complain of dyspnea. To us this was real; Dr. Ocampo was struggling to breathe and we had no idea what to do for him. Finally our standardized patient bailed us out and suggested we call his doctor. Why hadn’t we thought of that? —Deborah, nursing student eaving multiple teaching strategies such as virtual communities and standardized patients (SPs) in the simulated environment promotes realism, collaborative learning, active participation, and clinical reasoning skills. Nurse educators are increasingly challenged to prepare nursing students to function in a complex and ever-changing healthcare environment. Today’s nursing graduates are faced with increased patient acuity, expanded roles, interprofessional collaboration, increased use of technology, and limited resources.1 Innovative teaching approaches are needed to prepare nursing students to use clinical reasoning in such a multifaceted healthcare environment. Clinical reasoning is using formal and informal thinking to evaluate information and take action.2 Simulated clinical experiences provide a sense of authenticity that may translate into nursing practice and improve clinical reasoning.3 Our college of nursing (CON), a relatively new component of the Texas A&M Health Science Center (TAMHSC), admitted the first class of baccalaureate students in 2008. The CON is
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Author Affiliations: Assistant Professor (Mr Holland, Dr Landry, and Mss Mountain and Middlebrooks), Baccalaureate Nursing Student (Ms Heim), Assistant Dean of Graduate Studies (Dr Missildine), College of Nursing, Texas A&M Health Science Center, Bryan. The authors declare no conflicts of interest. Correspondence: Dr Missildine, College of Nursing, Texas A&M Health Science Center, 8447 State Hwy 47, Bryan, TX 77807 ([email protected]). DOI: 10.1097/01.NNE.0000435265.53612.06
Nurse Educator
located on 2 campuses in rural, central Texas. The CON offers a Bachelor of Science in Nursing (BSN) for the 130 to 180 undergraduate traditional and second degree students enrolled at any point in time. In addition, TAMHSC has schools of medicine, pharmacy, dentistry, and public health. The area boasts 2 hospitals with a total of 404 beds. Clinical learning experiences are limited, especially in the areas of mental health and pediatrics, as our students compete with students from area schools and from other disciplines. As a result, the faculty use the Clinical Learning Resource Center (CLRC) (http://www.tamhsc.edu/clrc) to supplement clinical instruction. The CLRC serves all students in the TAMHSC, providing opportunity for interprofessional education. The 27 000–sq ft facility is a simulated hospital environment, equipped with state-of-the-art high-, medium-, and low-fidelity simulation equipment and an SP program. Despite these resources, competition for learning experiences is intense.
Our Strategy To meet the demand for additional clinical learning experiences and the identified lack of experiences in mental health and pediatrics and to respond to the call from the state of Texas to increase student enrollment, alternative teaching strategies have been developed. Two faculty from the TAMHSC CON applied for and were awarded grant monies from the Texas Higher Education Coordinating Board. The funds provided for the development of virtual clinical learning experiences in Second Life,6 purchase of an electronic health record, and continuing financial support of the SP program. These approaches were combined with the ongoing high-fidelity simulation program and a newly purchased software program, The Neighborhood (TN).7 The Neighborhood is a virtual community that is accessed online by nursing students and faculty. Storylines are designed as unfolding case studies that are applicable across the curriculum. The storylines are of 11 households, 36 household characters of all ages, 6 nursing characters, and 4 healthcare agencies. The characters experience a variety of physical and mental disorders requiring assessment and nursing interventions. Volume 38 & Number 6 & November/December 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Second Life (lindenlab.com) is a 3-dimensional world where individuals create avatars to interact with each other in a virtual environment. Virtual clinical practice sites were designed that provided context to enhance student engagement and learning. This platform is used by universities as an alternative teaching strategy for clinical nursing education.4
Theoretical Framework Situated cognition is a learning theory that is increasingly used by nurse educators as a framework for contextual learning, especially in simulation. The basis of situated cognition is that learning is influenced by the situation in which it occurs. Clinical learning is most effective when it takes place in an authentic environment involving realistic clinical activities in collaboration with others. The development of communities of practice, individuals with a common interest who learn through practice and participation, is considered essential to situated learning.5 Our strategy, the combined use of SPs, simulation, and the virtual learning resources Second Life and TN, created contextual learning experiences that are exemplary of situated cognition and the development of a community of practice. The outcome was learning experiences that actively engaged students individually and collaboratively, emphasizing learning in context, development of salience, and the integration of theory and practice.8
Strategies High- and low-fidelity simulations were constructed based on the Jeffries Simulation Model.9 According to this model, simulations must reflect realism through authenticity. The CLRC was designed with simulated hospital rooms and multiple patient care areas, including emergency room, labor and delivery room, nursery, operating room, clinic rooms, and home environment. A medstation stocked with simulated medications was located in a supply room with supplies for medication administration and patient care. Laptops on wheeled carts were available outside each room, allowing students to document assessments and nursing interventions. The use of a commercially available electronic health record and medstation increased realism by incorporating technology similar to that seen in the practice setting. The medication and supply room added to the realism by simulating real-world practices such as having to leave a patient to obtain a medication or a bag of intravenous fluid. Students are able to practice critical thinking, clinical reasoning, and patient safety in 1 simulation scenario. Second Life is a virtual simulation method used by the CON. Using grant monies, virtual islands were developed and implemented by faculty and Second Life designers. On the islands, 2 virtual hospitals provide contextual mental health and pediatric clinical experiences. These 2 clinical components were chosen because of the limited clinical sites available to the CON. Classrooms, learning resources, and testing areas are also available. Students and faculty are provided orientation materials to establish an avatar and navigate in Second Life. Standardized patients participate in the virtual hospital experience using prefabricated avatars. These avatars are stationary but have the SP’s voice. Verbal interactions between students, faculty, patients, families, and other healthcare professionals are synchronous. A typical mental health virtual clinical learning experience in Second Life is 4 hours in length with a faculty-to-student ratio of 1 to 10. Technical support during the virtual clinical expe270
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rience is essential and readily available for an effective student learning experience. The objectives of this experience were to develop therapeutic communication, patient interview skills, and perform psychosocial and client assessments. Two students were assigned to each SP. The clinical experience began with prebriefing and pretest, which lasts approximately 45 minutes. The students interview the SPs in pairs. The SPs simulate a patient diagnosed with schizophrenia, bipolar disorder, major depressive disorder, or a personality disorder. After completing the patient interview, students access the electronic health record to obtain additional data to complete the client assessment. Observation rooms adjacent to each interviewing room allow faculty to observe the communication process without disrupting the interview. Computer programming allowed select areas of the virtual hospital to be designed so that faculty/student conversations are confidential. Constructive feedback based on observed interviews is provided to students during the simulation debrief, individually or in groups. The pediatric experiences are structured similarly but emphasize physical assessment, interventions, and patientfamily interactions and select nursing skills such as oxygen administration and blood administration. A virtual medstation is available in Second Life to access medications. The ‘‘tracking feature’’ in Second Life allows the faculty member to review the sequencing of each student’s actions. Students prioritize and choose from a list of interventions. This response is then placed on a ‘‘white board’’ to be reviewed by faculty and students, allowing evaluation of clinical reasoning and decision making. Standardized patients were recruited, hired, and trained by staff in the CLRC. The recruited SPs were instructed on how to interpret health conditions from a patient’s point of view. The SPs are instructed to portray the emotional and physical characteristics of a disease process, including the historical elements.10 There are a total of 140 SPs in the program, ranging from infants to elderly patients, including pregnant women. The staff of the CLRC recruits the SPs by means of referral, word of mouth, advertisements in newspapers, and Internet, as well as contacting various community groups. Pediatric patients are recruited primarily through the La Leche League and the home school community. Once hired, the SPs attend a 4-hour training session that is conducted every 2 to 3 months. Upon completing the orientation and background check, SPs choose their individual assignments in the CLRC. Assignments can be made to nursing or medical students and range from interviews to full physical assessments. Standardized patients are paid an hourly wage for their participation. Requests for SPs are sent out via e-mail 2 weeks in advance of a scenario. If there are particular requirements for the disease process that must be met, such as age, pregnancy, gender, or race, recruitment begins 6 weeks before the scenario. Standardized patients are chosen for an individual assignment based on several factors. Patient demographics, reliability, experience acting as an SP, history with the specific scenario being conducted, and faculty preference are a few factors. Specific case materials based on TN characters are created and include information necessary for the SP’s performance. Materials are written for laypersons to include scripting based on student questions or actions to make the scenario clearer. Nurse Educator
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
If a previous video exists of the scenario being conducted, the SP is given access for training purposes. If the SP is experienced, he/she is responsible for the information and for requesting any additional training. On the day of the simulation, SPs arrive 30 minutes before the performance for moulage and final coaching by the CLRC staff as well as by the faculty member responsible for the scenario. The SPs then work through the scenario with students, repeating the same performance to provide a standardized experience for all students. After the completion of the scenario, SPs are trained to provide feedback to students about their performance. The SPs bring TN character to life by acting out the scenario for the students. The integration of SPs and an online virtual community such as TN provides a synergistic learning experience. Standardized patients are able to portray body language and nonverbal cues and provide constructive feedback during debriefing. This type of feedback is absent in high-fidelity simulation. In SP simulations, the equipment and technology are less likely to assume prominence over the human aspects of care, as can occur in high-fidelity simulation. Students can practice therapeutic communication, history taking, physical examination, problem identification, and clinical reasoning in a realistic environment. Limitations exist when using SPs. These limitations include the inability to create an abnormal physiologic response such as changes to vital signs, breath sounds, heart sounds, or other physical characteristics that are available with high-fidelity simulations.11 To overcome these limitations, computer programs and bedside monitors are used to generate physiologic data to challenge students’ clinical reasoning.
Putting It All Together: An Exemplar Objectives The following is an example of incorporating multiple teaching strategies into a nursing simulation to enhance student learning. Four student learning outcomes guide this simulation experience. The student will: 1. develop a comprehensive plan of care based on evidenced-based measures. 2. synthesize subjective and objective data to guide clinical decision making. 3. evaluate health outcomes based on the plan of care and implement therapeutic interventions. 4. collaborate with other healthcare professionals during the simulation experience.
Preparation of Students and SPs Experience with the virtual learning resource, TN, is initiated in the first semester of the BSN program and used consistently throughout the program in conjunction with SPs. The virtual environment is incorporated into the mental health and pediatric nursing courses. One week before the simulation experience for a course, students are given the objectives for the simulation experience and are assigned a character from TN fitting the clinical objectives for the course. The student reviews the patient history in TN and individually develops a plan of care. Before the experience, students discuss their plan of care with clinical faculty emphasizing application of empirical evNurse Educator
idence (objective 1). The student is informed that the simulation experience will last 30 minutes, will be recorded for review and evaluation, and will be followed by a debriefing.
Integrated Learning Experience Simulation encounters are implemented with pairs of students acting as the primary nurse and as an additional care provider. The paired design allows the faculty to observe the communication and decision-making skills of students as a team. A student may be paired with a student at a different level in the program. For example, a senior nursing student can function as a charge nurse with the junior nursing student providing the primary patient care. Nursing students can experience expanded roles by forming and using rapid response or code teams. For our example, the character is a 62-year-old man, Dr Ocampo, admitted to a TN hospital with a diagnosis of class II heart failure. Dr Ocampo is a retired physician and often selfmedicates with "-blockers, angiotensin-converting enzyme inhibitors, and diuretics. Dr Ocampo’s wife has been diagnosed with Alzheimer’s, resulting in significant caregiver strain. After instructor/student review of the plan of care, the instructor, acting as the off-going nurse, gives an ISBARR (introduction, situation, background, assessment, recommendation, repeat) report on the patient.12 The student then logs into the electronic health record to obtain the latest patient information based on the hospital records. The record remains available at the bedside throughout the experience (objective 2). Initial assessment data reveal that Dr Ocampo is mildly short of breath and exhibits significant pedal edema. He appears anxious and asks frequently about his wife. Dr Ocampo has bilateral crackles throughout the lung fields. The student synthesizes assessment data and makes the clinical decision to implement nursing interventions. For example, the student may decide to call the healthcare provider to report assessment findings using an ISBARR format12 (objective 4). The student receives a medication order for an additional dose of diuretic, which is preloaded into the medication system. The student then must make clinical decisions based on the assessment findings, laboratory results, and the healthcare provider orders. After obtaining the medication from the medstation, the student administers the medication, reassesses the patient, and evaluates the response (objective 3). As the simulation progresses, Dr Ocampo becomes increasingly anxious about his wife’s well-being. The student may decide to consult other health professionals, including the physician, respiratory therapist, or a case manager (objective 4). Once the objectives for the scenario are achieved or a specific time period has elapsed, the simulation is ended by faculty. Debriefings Three types of debriefings are conducted to evaluate performance. These are (1) individual student debriefing with faculty and the SP to evaluate student performance, (2) SP debriefing by faculty regarding his/her performance in the simulation, and (3) student group debriefing. The group debriefing takes approximately 30 minutes and occurs after the simulation. Students are given a chance to discuss the patient care experience with the instructor, peers, and SPs. The debriefing provides the students with an opportunity to express frustrations and concerns. Volume 38 & Number 6 & November/December 2013
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The instructor facilitates the process by asking the students to recount what they did well during the scenario and how they could improve. The instructor also highlights areas where the student performed well and helps them rethink key critical behaviors that need improvement. For example, students have indicated that they did not know how to initiate care or how to prioritize interventions. To teach setting priorities, the faculty list key patient care aspects, asking the group which is most important, which is least important. The process is continued until priorities are set for each care item. The SP enriches the debriefing experience by providing the patient perspective. Standardized patients might provide feedback such as ‘‘You didn’t talk to me or tell me what was going on while you were taking care of me’’ or ‘‘You seemed very confident and reassuring in all that you did for me.’’ In the SP debriefing, the faculty and SP discuss the perspective and performance of the SP. The faculty elicits the SPs’ insights for improvement of the learning experience by asking the SPs to express their thoughts and feelings from the patient’s perspective. Students are given the opportunity to provide verbal feedback to the SP during the debriefing process. The faculty/SP debriefing process takes approximately 10 minutes to complete. Once all students have completed the simulation, a student group debriefing takes place with the faculty. The debriefing process of all the students participating in the particular scenario takes approximately 30 minutes. Students are allowed to express how they felt during the simulation and how they approached key learning concepts in the patient care environment. Faculty members facilitate the discussion by asking key questions such as ‘‘What do you feel were the most important concepts in today’s simulation?’’ and ‘‘What was your approach to patient care?’’ or ‘‘How did you prioritize your assessment findings?’’ Students have the opportunity to provide anonymous feedback about the simulation experience by completing an online survey and course evaluations. All scenarios are evaluated by the faculty at the completion of the day through verbal discussion and written evaluation. This dynamic approach to the simulation experience, based on situated cognition theory, provides the opportunity to deliver nursing care in a realistic environment. A community of practice5 is created, incorporating the patient as a facilitator of learning.
What Do Students Think? We have created a learning environment that weaves a variety of teaching strategies into a rich tapestry of student learning. Student comments such as ‘‘I’ve done this before in simulation so now I know what to do for my patient’’ indicate that the integrated learning experience translates to the actual clinical environment. The stories of the characters unfolding over time are authentically recreated by SPs in face-to-face simulations embellished by the faculty to achieve learning outcomes. Over the course of the nursing program, the student encounters the simulated patient and families repeatedly. This essential connection creates a continuum addressing the health needs of patients, families, and communities and development of personal involvement and learning in context.8 Deborah, 1 of our students, said it best:
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My confidence both in simulation and in ‘‘real life’’ has increased immeasurably, which I attribute, at least in part, to the variety of clinical experiences I have had. During a recent clinical rotation I had to give ISBARR to an attending physician about my patient with a small bowel obstruction. I don’t think she even realized that I was a student, because she began giving me rapid-fire instructions about prepping the patient for surgery. I know that my ability to gather the most important information and communicate it in a professional manner is directly a result of my simulation experience. More and more, when I walk into a patient’s room, I am starting to feel like the room is my room, the IVs are my IVs, the patient is my responsibility and I’m a real nurse.
Transformation of Clinical Learning Our vision for the future includes multipatient simulation and interprofessional collaboration within the university and the community. The development of a multipatient simulated hospital unit would include students in various roles including charge nurse, staff nurse, and healthcare providers. The effectiveness of our teaching strategies will be determined by outcomes-based research. By using multiple teaching strategies in the simulated environment, students experience authentic learning based on situated cognition and realism. This type of contextual learning is essential in nursing education to address expanding roles and the dynamics of the healthcare environment faced by today’s nursing students.
References 1. Amer KS. Quality and Safety for Transformational Nursing: Core Competencies. Boston, MA: Pearson; 2013. 2. Simmons B. Clinical reasoning: concept analysis. J Adv Nurs. 2010;66(5):1151-1158. doi:10.1111/j.1365-2648.2010.05262.x. 3. Shinnick MA, Woo MA, Mentes JC. Human patient simulation: state of the science in prelicensure nursing education. J Nurs Educ. 2011; 50(2):65-72. 4. Baker J, Brusco J. Nursing education gets a Second Lifei. AORN J. 2011;94:599-605. doi:10.1016/j.aorn.2011.09.004. 5. Onda E. Situated cognition: its relationship to simulation in nursing education. Clin Simulation Nurs. 2012;8:e273-e280. doi:10.1016/ j.ecns.2010.11.004. 6. Second Life. Your world. Your imagination. Available at http:// secondlife.com. Accessed August 10, 2013. 7. The Neighborhood TM 2.0. Available at http://www.pearson neighborhood.com/. Accessed August 10, 2013. 8. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. Stanford, CA: Jossey-Bass; 2010. 9. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96-103. 10. Association of Standardized Patient Educators. About ASPE. 2013. Available at http://aspeducators.org/about-aspe.php. Accessed August 10, 2013. 11. Brewer EP. Successful techniques for using human patient simulation in nursing education. J Nurs Scholarsh. 2011;43(3):311-317. doi:10 .1111/j.1547-5069.2011.01405.x. 12. Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual Saf Health Care. 2009;18:137-140. doi:10 .1136/qshc.2007.025247.
Nurse Educator
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse Educator
Weaving the Tapestry of Learning Simulation, Standardized Patients, and Virtual Communities Brian Holland, MSN, RN & Karen Landry, PhD, RN & Angela Mountain, MS, RN, CMSRN Mary Alice Middlebrooks, MSN, RN & Deborah Heim, BSN(c) & Kathy Missildine, PhD, RN, CNE Using situated cognition learning theory, nursing faculty developed simulated clinical learning experiences integrating virtual communities and standardized patients. These learning experiences provide authenticity and realism not easily achieved using the individual techniques in isolation. The authors describe the process of weaving these strategies into a rich learning experience for students.
I was utterly helpless and very frightened. I was familiar with this patient’s history from The Neighborhood, but this was different. Dr. Ocampo was an actual person who was having trouble breathing. My partner and I did everything we knew to do, which wasn’t much since this was our first month in nursing school. We checked his vitals, placed a nasal cannula, sat him up and then looked at each other while he continued to complain of dyspnea. To us this was real; Dr. Ocampo was struggling to breathe and we had no idea what to do for him. Finally our standardized patient bailed us out and suggested we call his doctor. Why hadn’t we thought of that? —Deborah, nursing student eaving multiple teaching strategies such as virtual communities and standardized patients (SPs) in the simulated environment promotes realism, collaborative learning, active participation, and clinical reasoning skills. Nurse educators are increasingly challenged to prepare nursing students to function in a complex and ever-changing healthcare environment. Today’s nursing graduates are faced with increased patient acuity, expanded roles, interprofessional collaboration, increased use of technology, and limited resources.1 Innovative teaching approaches are needed to prepare nursing students to use clinical reasoning in such a multifaceted healthcare environment. Clinical reasoning is using formal and informal thinking to evaluate information and take action.2 Simulated clinical experiences provide a sense of authenticity that may translate into nursing practice and improve clinical reasoning.3 Our college of nursing (CON), a relatively new component of the Texas A&M Health Science Center (TAMHSC), admitted the first class of baccalaureate students in 2008. The CON is
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Author Affiliations: Assistant Professor (Mr Holland, Dr Landry, and Mss Mountain and Middlebrooks), Baccalaureate Nursing Student (Ms Heim), Assistant Dean of Graduate Studies (Dr Missildine), College of Nursing, Texas A&M Health Science Center, Bryan. The authors declare no conflicts of interest. Correspondence: Dr Missildine, College of Nursing, Texas A&M Health Science Center, 8447 State Hwy 47, Bryan, TX 77807 ([email protected]). DOI: 10.1097/01.NNE.0000435265.53612.06
Nurse Educator
located on 2 campuses in rural, central Texas. The CON offers a Bachelor of Science in Nursing (BSN) for the 130 to 180 undergraduate traditional and second degree students enrolled at any point in time. In addition, TAMHSC has schools of medicine, pharmacy, dentistry, and public health. The area boasts 2 hospitals with a total of 404 beds. Clinical learning experiences are limited, especially in the areas of mental health and pediatrics, as our students compete with students from area schools and from other disciplines. As a result, the faculty use the Clinical Learning Resource Center (CLRC) (http://www.tamhsc.edu/clrc) to supplement clinical instruction. The CLRC serves all students in the TAMHSC, providing opportunity for interprofessional education. The 27 000–sq ft facility is a simulated hospital environment, equipped with state-of-the-art high-, medium-, and low-fidelity simulation equipment and an SP program. Despite these resources, competition for learning experiences is intense.
Our Strategy To meet the demand for additional clinical learning experiences and the identified lack of experiences in mental health and pediatrics and to respond to the call from the state of Texas to increase student enrollment, alternative teaching strategies have been developed. Two faculty from the TAMHSC CON applied for and were awarded grant monies from the Texas Higher Education Coordinating Board. The funds provided for the development of virtual clinical learning experiences in Second Life,6 purchase of an electronic health record, and continuing financial support of the SP program. These approaches were combined with the ongoing high-fidelity simulation program and a newly purchased software program, The Neighborhood (TN).7 The Neighborhood is a virtual community that is accessed online by nursing students and faculty. Storylines are designed as unfolding case studies that are applicable across the curriculum. The storylines are of 11 households, 36 household characters of all ages, 6 nursing characters, and 4 healthcare agencies. The characters experience a variety of physical and mental disorders requiring assessment and nursing interventions. Volume 38 & Number 6 & November/December 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Second Life (lindenlab.com) is a 3-dimensional world where individuals create avatars to interact with each other in a virtual environment. Virtual clinical practice sites were designed that provided context to enhance student engagement and learning. This platform is used by universities as an alternative teaching strategy for clinical nursing education.4
Theoretical Framework Situated cognition is a learning theory that is increasingly used by nurse educators as a framework for contextual learning, especially in simulation. The basis of situated cognition is that learning is influenced by the situation in which it occurs. Clinical learning is most effective when it takes place in an authentic environment involving realistic clinical activities in collaboration with others. The development of communities of practice, individuals with a common interest who learn through practice and participation, is considered essential to situated learning.5 Our strategy, the combined use of SPs, simulation, and the virtual learning resources Second Life and TN, created contextual learning experiences that are exemplary of situated cognition and the development of a community of practice. The outcome was learning experiences that actively engaged students individually and collaboratively, emphasizing learning in context, development of salience, and the integration of theory and practice.8
Strategies High- and low-fidelity simulations were constructed based on the Jeffries Simulation Model.9 According to this model, simulations must reflect realism through authenticity. The CLRC was designed with simulated hospital rooms and multiple patient care areas, including emergency room, labor and delivery room, nursery, operating room, clinic rooms, and home environment. A medstation stocked with simulated medications was located in a supply room with supplies for medication administration and patient care. Laptops on wheeled carts were available outside each room, allowing students to document assessments and nursing interventions. The use of a commercially available electronic health record and medstation increased realism by incorporating technology similar to that seen in the practice setting. The medication and supply room added to the realism by simulating real-world practices such as having to leave a patient to obtain a medication or a bag of intravenous fluid. Students are able to practice critical thinking, clinical reasoning, and patient safety in 1 simulation scenario. Second Life is a virtual simulation method used by the CON. Using grant monies, virtual islands were developed and implemented by faculty and Second Life designers. On the islands, 2 virtual hospitals provide contextual mental health and pediatric clinical experiences. These 2 clinical components were chosen because of the limited clinical sites available to the CON. Classrooms, learning resources, and testing areas are also available. Students and faculty are provided orientation materials to establish an avatar and navigate in Second Life. Standardized patients participate in the virtual hospital experience using prefabricated avatars. These avatars are stationary but have the SP’s voice. Verbal interactions between students, faculty, patients, families, and other healthcare professionals are synchronous. A typical mental health virtual clinical learning experience in Second Life is 4 hours in length with a faculty-to-student ratio of 1 to 10. Technical support during the virtual clinical expe270
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rience is essential and readily available for an effective student learning experience. The objectives of this experience were to develop therapeutic communication, patient interview skills, and perform psychosocial and client assessments. Two students were assigned to each SP. The clinical experience began with prebriefing and pretest, which lasts approximately 45 minutes. The students interview the SPs in pairs. The SPs simulate a patient diagnosed with schizophrenia, bipolar disorder, major depressive disorder, or a personality disorder. After completing the patient interview, students access the electronic health record to obtain additional data to complete the client assessment. Observation rooms adjacent to each interviewing room allow faculty to observe the communication process without disrupting the interview. Computer programming allowed select areas of the virtual hospital to be designed so that faculty/student conversations are confidential. Constructive feedback based on observed interviews is provided to students during the simulation debrief, individually or in groups. The pediatric experiences are structured similarly but emphasize physical assessment, interventions, and patientfamily interactions and select nursing skills such as oxygen administration and blood administration. A virtual medstation is available in Second Life to access medications. The ‘‘tracking feature’’ in Second Life allows the faculty member to review the sequencing of each student’s actions. Students prioritize and choose from a list of interventions. This response is then placed on a ‘‘white board’’ to be reviewed by faculty and students, allowing evaluation of clinical reasoning and decision making. Standardized patients were recruited, hired, and trained by staff in the CLRC. The recruited SPs were instructed on how to interpret health conditions from a patient’s point of view. The SPs are instructed to portray the emotional and physical characteristics of a disease process, including the historical elements.10 There are a total of 140 SPs in the program, ranging from infants to elderly patients, including pregnant women. The staff of the CLRC recruits the SPs by means of referral, word of mouth, advertisements in newspapers, and Internet, as well as contacting various community groups. Pediatric patients are recruited primarily through the La Leche League and the home school community. Once hired, the SPs attend a 4-hour training session that is conducted every 2 to 3 months. Upon completing the orientation and background check, SPs choose their individual assignments in the CLRC. Assignments can be made to nursing or medical students and range from interviews to full physical assessments. Standardized patients are paid an hourly wage for their participation. Requests for SPs are sent out via e-mail 2 weeks in advance of a scenario. If there are particular requirements for the disease process that must be met, such as age, pregnancy, gender, or race, recruitment begins 6 weeks before the scenario. Standardized patients are chosen for an individual assignment based on several factors. Patient demographics, reliability, experience acting as an SP, history with the specific scenario being conducted, and faculty preference are a few factors. Specific case materials based on TN characters are created and include information necessary for the SP’s performance. Materials are written for laypersons to include scripting based on student questions or actions to make the scenario clearer. Nurse Educator
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
If a previous video exists of the scenario being conducted, the SP is given access for training purposes. If the SP is experienced, he/she is responsible for the information and for requesting any additional training. On the day of the simulation, SPs arrive 30 minutes before the performance for moulage and final coaching by the CLRC staff as well as by the faculty member responsible for the scenario. The SPs then work through the scenario with students, repeating the same performance to provide a standardized experience for all students. After the completion of the scenario, SPs are trained to provide feedback to students about their performance. The SPs bring TN character to life by acting out the scenario for the students. The integration of SPs and an online virtual community such as TN provides a synergistic learning experience. Standardized patients are able to portray body language and nonverbal cues and provide constructive feedback during debriefing. This type of feedback is absent in high-fidelity simulation. In SP simulations, the equipment and technology are less likely to assume prominence over the human aspects of care, as can occur in high-fidelity simulation. Students can practice therapeutic communication, history taking, physical examination, problem identification, and clinical reasoning in a realistic environment. Limitations exist when using SPs. These limitations include the inability to create an abnormal physiologic response such as changes to vital signs, breath sounds, heart sounds, or other physical characteristics that are available with high-fidelity simulations.11 To overcome these limitations, computer programs and bedside monitors are used to generate physiologic data to challenge students’ clinical reasoning.
Putting It All Together: An Exemplar Objectives The following is an example of incorporating multiple teaching strategies into a nursing simulation to enhance student learning. Four student learning outcomes guide this simulation experience. The student will: 1. develop a comprehensive plan of care based on evidenced-based measures. 2. synthesize subjective and objective data to guide clinical decision making. 3. evaluate health outcomes based on the plan of care and implement therapeutic interventions. 4. collaborate with other healthcare professionals during the simulation experience.
Preparation of Students and SPs Experience with the virtual learning resource, TN, is initiated in the first semester of the BSN program and used consistently throughout the program in conjunction with SPs. The virtual environment is incorporated into the mental health and pediatric nursing courses. One week before the simulation experience for a course, students are given the objectives for the simulation experience and are assigned a character from TN fitting the clinical objectives for the course. The student reviews the patient history in TN and individually develops a plan of care. Before the experience, students discuss their plan of care with clinical faculty emphasizing application of empirical evNurse Educator
idence (objective 1). The student is informed that the simulation experience will last 30 minutes, will be recorded for review and evaluation, and will be followed by a debriefing.
Integrated Learning Experience Simulation encounters are implemented with pairs of students acting as the primary nurse and as an additional care provider. The paired design allows the faculty to observe the communication and decision-making skills of students as a team. A student may be paired with a student at a different level in the program. For example, a senior nursing student can function as a charge nurse with the junior nursing student providing the primary patient care. Nursing students can experience expanded roles by forming and using rapid response or code teams. For our example, the character is a 62-year-old man, Dr Ocampo, admitted to a TN hospital with a diagnosis of class II heart failure. Dr Ocampo is a retired physician and often selfmedicates with "-blockers, angiotensin-converting enzyme inhibitors, and diuretics. Dr Ocampo’s wife has been diagnosed with Alzheimer’s, resulting in significant caregiver strain. After instructor/student review of the plan of care, the instructor, acting as the off-going nurse, gives an ISBARR (introduction, situation, background, assessment, recommendation, repeat) report on the patient.12 The student then logs into the electronic health record to obtain the latest patient information based on the hospital records. The record remains available at the bedside throughout the experience (objective 2). Initial assessment data reveal that Dr Ocampo is mildly short of breath and exhibits significant pedal edema. He appears anxious and asks frequently about his wife. Dr Ocampo has bilateral crackles throughout the lung fields. The student synthesizes assessment data and makes the clinical decision to implement nursing interventions. For example, the student may decide to call the healthcare provider to report assessment findings using an ISBARR format12 (objective 4). The student receives a medication order for an additional dose of diuretic, which is preloaded into the medication system. The student then must make clinical decisions based on the assessment findings, laboratory results, and the healthcare provider orders. After obtaining the medication from the medstation, the student administers the medication, reassesses the patient, and evaluates the response (objective 3). As the simulation progresses, Dr Ocampo becomes increasingly anxious about his wife’s well-being. The student may decide to consult other health professionals, including the physician, respiratory therapist, or a case manager (objective 4). Once the objectives for the scenario are achieved or a specific time period has elapsed, the simulation is ended by faculty. Debriefings Three types of debriefings are conducted to evaluate performance. These are (1) individual student debriefing with faculty and the SP to evaluate student performance, (2) SP debriefing by faculty regarding his/her performance in the simulation, and (3) student group debriefing. The group debriefing takes approximately 30 minutes and occurs after the simulation. Students are given a chance to discuss the patient care experience with the instructor, peers, and SPs. The debriefing provides the students with an opportunity to express frustrations and concerns. Volume 38 & Number 6 & November/December 2013
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The instructor facilitates the process by asking the students to recount what they did well during the scenario and how they could improve. The instructor also highlights areas where the student performed well and helps them rethink key critical behaviors that need improvement. For example, students have indicated that they did not know how to initiate care or how to prioritize interventions. To teach setting priorities, the faculty list key patient care aspects, asking the group which is most important, which is least important. The process is continued until priorities are set for each care item. The SP enriches the debriefing experience by providing the patient perspective. Standardized patients might provide feedback such as ‘‘You didn’t talk to me or tell me what was going on while you were taking care of me’’ or ‘‘You seemed very confident and reassuring in all that you did for me.’’ In the SP debriefing, the faculty and SP discuss the perspective and performance of the SP. The faculty elicits the SPs’ insights for improvement of the learning experience by asking the SPs to express their thoughts and feelings from the patient’s perspective. Students are given the opportunity to provide verbal feedback to the SP during the debriefing process. The faculty/SP debriefing process takes approximately 10 minutes to complete. Once all students have completed the simulation, a student group debriefing takes place with the faculty. The debriefing process of all the students participating in the particular scenario takes approximately 30 minutes. Students are allowed to express how they felt during the simulation and how they approached key learning concepts in the patient care environment. Faculty members facilitate the discussion by asking key questions such as ‘‘What do you feel were the most important concepts in today’s simulation?’’ and ‘‘What was your approach to patient care?’’ or ‘‘How did you prioritize your assessment findings?’’ Students have the opportunity to provide anonymous feedback about the simulation experience by completing an online survey and course evaluations. All scenarios are evaluated by the faculty at the completion of the day through verbal discussion and written evaluation. This dynamic approach to the simulation experience, based on situated cognition theory, provides the opportunity to deliver nursing care in a realistic environment. A community of practice5 is created, incorporating the patient as a facilitator of learning.
What Do Students Think? We have created a learning environment that weaves a variety of teaching strategies into a rich tapestry of student learning. Student comments such as ‘‘I’ve done this before in simulation so now I know what to do for my patient’’ indicate that the integrated learning experience translates to the actual clinical environment. The stories of the characters unfolding over time are authentically recreated by SPs in face-to-face simulations embellished by the faculty to achieve learning outcomes. Over the course of the nursing program, the student encounters the simulated patient and families repeatedly. This essential connection creates a continuum addressing the health needs of patients, families, and communities and development of personal involvement and learning in context.8 Deborah, 1 of our students, said it best:
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My confidence both in simulation and in ‘‘real life’’ has increased immeasurably, which I attribute, at least in part, to the variety of clinical experiences I have had. During a recent clinical rotation I had to give ISBARR to an attending physician about my patient with a small bowel obstruction. I don’t think she even realized that I was a student, because she began giving me rapid-fire instructions about prepping the patient for surgery. I know that my ability to gather the most important information and communicate it in a professional manner is directly a result of my simulation experience. More and more, when I walk into a patient’s room, I am starting to feel like the room is my room, the IVs are my IVs, the patient is my responsibility and I’m a real nurse.
Transformation of Clinical Learning Our vision for the future includes multipatient simulation and interprofessional collaboration within the university and the community. The development of a multipatient simulated hospital unit would include students in various roles including charge nurse, staff nurse, and healthcare providers. The effectiveness of our teaching strategies will be determined by outcomes-based research. By using multiple teaching strategies in the simulated environment, students experience authentic learning based on situated cognition and realism. This type of contextual learning is essential in nursing education to address expanding roles and the dynamics of the healthcare environment faced by today’s nursing students.
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