Nursing Education and Technology Empowered Learning: Using Simulations, Simulators Nomenclature, Fidelity, Partials or Full & Hybrid Simulators Use
Teaching and Learning Using Simulations In Nursing Education
The complexities of the health care system coupled with a changing patient population have created a need for nursing students to be prepared to care for all types of patients in a variety of care settings.
Additionally, as health care shifts to community settings, nurse educators have been challenged to find appropriate clinical sites and clinical experiences for nursing students to meet curricula competencies and required clinical experiences.
Because of these challenges, nurse educators are exploring alternative strategies for clinical preparation for nursing students. Simulation offers nurses, students, and health professionals the opportunity to learn in situations that are comparable to actual patient encounters within a controlled learning environment (Alden & Durham, 2012; Katz, Peifer, & Armstrong, 2010) that supports the learners’ transfer of classroom and skills laboratory knowledge to realistic patient interactions (Anderson & Warren, 2011; Halstead, 2006; Meyer, Connors, Hou, & Gajewski, 2011).
Clinical simulation technology is becoming increasingly realistic, and nursing programs are making substantial investments in equipment and learning space. As simulations and related teaching and learning strategies move into nursing programs, and evidence supports clinical simulations as an alternative to actual clinical experiences (Hayden, Smiley, Alexander, Kardong -Edgren, & Jeffries, 2014), nurse educators must be prepared to teach using this methodology.The topic emphasizes:
(1) the types of clinical simulations being developed and implemented in nursing programs
(2) challenges and benefits to student learning, thinking, and practice
(3) a framework and steps to consider when developing and using clinical simulations
(4) the evaluation component to consider when implementing simulations in the teaching learning environment
Simulation
Simulations are activities or events, such as performing basic life support on a patient simulator to manage a cardiac arrest, that mimic real-world practice. Simulations are used when real-world training is too expensive, occurs rarely, or puts participants (or patients) at unnecessary risk.
Simulations provide the opportunity for students to practice within their scope of practice, think critically, problem solve, use clinical reasoning, and care for diverse patients in a nonthreatening, safe environment.
Incorporating simulations into a nursing curriculum as a teaching and learning strategy offers nurse educators the opportunity to support learners’ educational needs by providing them with an interactive, practice-based instructional strategy.
Simulation Nomenclature In Nursing Education
There are various types of simulations. The terms used to describe various aspects of the simulation experience are described here. The simulation nomenclature matrix includes learning domains and tool and environmental realism. Tool and environmental realism are further categorized into types of fidelity low, medium, and high and the context of the fidelity as partial or full.
Fidelity
Fidelity, or the realism of simulations, is described along a continuum from low fidelity to high fidelity relative to the degree to which they approach reality.
• Low fidelity: This type of simulation experience includes case studies to educate students about patient situations, role playing, the use of a partial task trainer or static manikin (eg, plastic model arm to learn how to perform a venipuncture, wound care trainer for wound management) to allow students to perform a task or skill.
Low-level realism is present; however, principles and concepts can still be learned using this type of simulation (International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011).
• Medium fidelity: This type of simulation is technologically sophisticated in that the participants can rely on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario.
These manikins have the ability to auscultate heart sounds and breathing sounds but the chest does not rise. Some examples include VitalSim Anne and VitalSim Kelly.
• High fidelity: This type of simulation involves full-scale, high-fidelity human patient simulators, virtual reality or standardized patients (actress or actors portraying simulated patients that have certain health disruptions) that are extremely realistic and provide a high level of interactivity and realism for the learner (International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011).
Examples include SimMan 3G, SimNewbie , iStan , and METI HPS, as well as a birthing simulator called Victoria and her newborn infant, all of which allow the student to listen to various body sounds and can be programmed to talk and to respond to interventions performed by the students.
Partial or Full-Context Simulations The Context of Simulations Can be Partial or Full
• Partial task trainers: Partial task trainers are those simulations in which a body part, plastic model, or partial manikin is used to depict a certain function and on which a student can practice a particular psychomotor skill.
Examples of partial task trainers include intravenous (IV) cannulation arms and low-technology manikins that are used to help students practice specific psychomotor skills integral to patient care such as inserting urinary catheters or nasogastric tubes.
• Full-context simulations: These simulations include the full context of a scenario, an event, or an activity that replicates reality. For example, a static manikin with limited functions such as VitalSim Kelly is full context but medium fidelity.
The full context of an event can be represented using this type of simulation in a low fidelity manner. High fidelity, full context is a simulated learning experience using a high-fidelity simulator and immersing the participants in a realistic mock code situation or a simulated live birth.
Full-scale patient simulations using sophisticated, high-fidelity patient simulators provide a high level of interactivity and realism for the learner. Less sophisticated, but still educationally useful, are computer-based simulations in which the participant relies on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario.
Studies have shown that the two-dimensional experience has merit in terms of positive learning outcomes and skill acquisition (Jeffries, Woolf, & Linde, 2003).Partial task training devices such as IV arms and haptic (force feedback) IV trainers are used in simulations for psychomotor skills.
The learner is able to practice a skill repeatedly before performing it on a real patient. The partial task trainers typically ensure a satisfactory rate of achievement of objectives and benefit to the participant.
Studies have shown that after having used these task trainers, participants demonstrate a psychomotor skill and use that skill set in the real patient environment (Engum & Jeffries, 2003).
Programs or courses in which the task trainers are used include clinical laboratory courses and modules during which specific skill sets and goals need to be obtained. Another approach to learning is the use of two-dimensional CD-ROMs to provide interactive practice with skills.
Types of Simulation
Simulations variously involve role playing, standardized patients (actors), interactive videos built on gaming platforms, and manikins to teach procedures, decision making, and critical thinking in realistic environments (Ryan et al., 2010). There are a variety of technology-based simulations to support student and novice nurses.
They include computer-based interactive simulations, haptic partial task trainers, and digitally enhanced manikins. Haptic trainers use force feedback to provide opportunities to develop psychomotor skills.
In addition to types of simulations categorized by the equipment or manikin used, there are simulations categorized by the type of pedagogy used when implementing the simulations. These types of simulations are described in the following sections.
Hybrid Simulations
A hybrid simulation is the combination of a standardized patient and the use of a patient simulator in one scenario to depict a clinical event for the learner. For example, the simulation scenario may begin with the student performing a health history on a standardized patient who has just arrived in the emergency department after having been involved in a motor vehicle accident.
As the case evolves, the activity shifts to a patient simulator because of the clinical symptoms that need to be demonstrated by the manikin to reflect reality. This is a hybrid simulation because the history is being performed on a standardized patient and then the scenario shifts to a patient simulator, where the patient is now experiencing “hypovolemic shock” that is being reflected in the vital signs and other clinical findings of the manikin .
A common hybrid simulation in obstetrics involves a low-fidelity task trainer with a standardized patient for simulations of normal birth or complications such as shoulder dystocia. This can be done with a standard actor and the pelvis of a birthing simulator or with the use of the Mama Natalie, which is a low-cost, wearable device that can manually deliver a baby and placenta and simulate postpartum complications.
Unfolding Case Simulations
Another type of simulation is the unfolding case. Unfolding cases evolve over time in an unpredictable manner. An unfolding case may include three to four events that build on each other, providing students an opportunity to plan care across a clinical event, a hospitalization, a care transition or across the life span (Page, Kowlowitz , & Alden, 2010). Unfolding cases can be used to meet a variety of learning goals:
1. To demonstrate hierarchical order so the learner can follow the progression of a health problem and the related nursing care. For example, the first scenario demonstrates the patient being admitted with a head injury caused by a fall; the learner must conduct a focused neurologic assessment.
The unfolding case leads to a second scenario, in which the patient experiences specific neurologic signs (eg, severe headache, widening pulse pressure); the learner must use additional assessment skills. The third case occurs post craniotomy and involves care of the patient after the subdural hematoma is removed.
2. To visualize and prioritize hospital trajectory and care of a patient that progresses. For example, the patient is admitted through the emergency department, with the learner performing an assessment. The second scenario depicts the patient being admitted to the progressive care unit and the third scenario is designed for the learner to prepare the patient with discharge instructions.
3. To provide the learner with a view of care transitions, showing the effect of the health disruption or disease process and nursing interventions required for a particular patient. For example, the first scenario depicts a hospitalized patient newly diagnosed with chronic obstructive pulmonary disease (COPD).
The second scenario progresses to the patient having compromised gas exchange related to COPD and being managed at an ambulatory care center. The third scenario depicts end-stage disease with a focus on end-of-life care with hospice care.
4. To serve as a mechanism to include a variety of important assessments and findings where one event leads to another. For example, the first scenario focuses on hypotension and subtle findings of sepsis and the second scenario centers on the critically ill patient with sepsis and hypotension.