One of the most challenging tasks for faculty who teach beginning nursing students is preparing them for the first experience with real patients. In a controlled laboratory setting, students practice basic skills, such as communication, assessment, personal hygiene, patient safety, and medication administration. While students can use manikins and task trainers for repeated skill practice, the human component of actual patient care is absent.
Following these initial activities in the skills laboratory, nursing students typically report increased feelings of stress and uncertainty about their first patient care experiences. Studies have shown that stress, depression, and anxiety can interfere with learning and lead to impaired clinical performance in nursing students.1 Faculty need to ensure students can safely perform necessary skills prior to caring for patients. Simulation laboratory opportunities that are similar to an actual clinical environment may reduce student uncertainty and reinforce principles of safe practice.2,3
One method of providing students with exposure to "real life" patient care is the use of standardized patients (SPs) in simulation activities. Case scenarios with SPs allow students an opportunity to practice psychomotor, decision making, and communication skills in a safe environment. During the "patient" encounter, students receive constructive feedback relative to the clinical scenario. In addition, this teaching approach provides faculty with further information about student strengths and weaknesses.4
Background
For several semesters, faculty in our nursing program conducted a laboratory activity for students in the fundamentals course the week before their first patient care experience. The goal was to provide a synthesis activity, in which students used a case study to plan and practice organizing a typical clinical day. Students worked in pairs in the laboratory setting to perform basic skills, such as vital signs, hygiene care, and medication administration, on low-fidelity manikins. A clinical care planning form was included in the activity to allow students the opportunity to practice documentation. While students consistently reported the exercise was helpful in regard to practicing organizational skills and care planning, they frequently noted that the human element was missing. Commonly voiced areas of concern were of "not being sure how to talk to patients," as well as performing skills "on real people."
An area of particular unease for students was that of medication administration. In the nursing curriculum, content on medication administration and practice in the laboratory are offered in the fundamentals course, whereas drug calculations are part of the pharmacology course. Despite practice in the laboratory and test-out in methods of medication delivery, students expressed uncertainty when discussing actually giving medications to patients. Student fears seemed to be based on perceived inadequate practice time with various routes of administration and lack of sufficient opportunities to perform drug calculations. Recent studies have reported positive responses from nursing students following simulation of medication administration, particularly in regard to having the opportunity to identify personal knowledge gaps while practicing in a safe environment.5,6
In response to the student concerns, the faculty who taught the pharmacology course created a short medication administration simulation, using a low-fidelity manikin. A postsurgical patient case study that resembled the type of experience students could expect in the first clinical course was chosen for the simulation. Faculty developed learning objectives, preparatory activities, and a grading rubric for the simulation, based on Quality and Safety in Nursing Education (QSEN) prelicensure competencies (see Table, Supplemental Digital Content, http://links.lww.com/NE/A255). These materials were shared with students, and the purpose and goals of the experience were explained. Students were asked to arrive at 10-minute intervals to complete the simulation.
Each student participated in simulation on administration of medication to a patient, using a low-fidelity manikin, and performed a drug calculation. In addition, students were evaluated on therapeutic communication and patient teaching skills. Following the simulation, students completed an online reflective thinking assignment that addressed QSEN competencies.7 Points acquired based on the rubric and online work were applied to the pharmacology course grade. Although postsimulation evaluations were positive, a number of students indicated they were not given sufficient preparation information and did not receive helpful feedback from evaluators. In addition, many students commented about the lack of realism and suggested using a live person, rather than a manikin, for future scenarios. A limitation to use of patient simulators is the potential inability of students to relate to the manikin as a real person, particularly in regard to communication and safety measures. Recent studies have shown student improvement in both areas after simulations using SPs.8,9 Because this simulation experience emphasized patient teaching and safety skills, faculty elected to use SPs in subsequent simulations.
Description of Educational Innovation
One of the major determinants in the decision to add SPs in the simulation experience was cost.10 The nursing program lacks resources to recruit, train, and compensate actors to assist in simulations. Short-term funds were available, however, from a grant earmarked for retention and remediation of nursing students. This could be used to pay actors on an hourly basis for the time they spent in the simulation. Nursing faculty in the pharmacology course researched the use of SPs in various health care disciplines and substituted SPs for the manikins in the existing medication administration simulation. In addition, faculty opted to identify possible SPs within the nursing program. A request was sent to nursing graduate students and faculty to solicit volunteers for the simulation, with 1 graduate student and 3 faculty members indicating their interest. Because the use of people who are familiar to students can reduce the realism of the scenario, upper-level faculty members and new graduate students were chosen as SPs.
The week prior to beginning the simulation activity, faculty met with students to discuss the case study, objectives, preparatory readings, performance expectations, and how they were to interact with the SPs. Additional time was allotted for the orientation, as compared with that in the manikin simulation, because of student comments regarding inadequate preparation prior to the first activity. Information about the case scenario and expected student competencies were retained from the manikin-based simulation, and SP script guidelines were developed and discussed with the volunteers (see Table, Supplemental Digital Content 2, http://links.lww.com/NE/A256). In addition, faculty met and discussed the rubric for scoring for consistency across student encounters. Previous student concerns regarding postsimulation feedback were shared, and faculty evaluators were encouraged to provide students with constructive comments relative to their performance.
Because the simulation required 10 minutes per student, with 2 stations in use simultaneously, first-level faculty cooperated in rescheduling classes for the day of the simulation so all students could participate. Two simulation areas were set up: each was designed to resemble a patient hospital room, with appropriate equipment for the chosen scenario. Standardized patients were dressed in gowns, placed in hospital beds, and connected to oxygen and an IV line. Faculty evaluators were present in the simulation areas to observe student participation in the activity and assess their performance.
Students arrived for the simulation in uniform and were allowed to bring resources they might use in actual clinical practice, such as pharmacology books and personal electronic reference devices. At the beginning of the simulation, faculty at the 2 stations introduced each student to the SP and oriented them to the available equipment and supplies. Students were each allowed 10 minutes to perform the nursing procedure (administering oral metoprolol) and were evaluated with the same rubric used in the previous simulation with a manikin. Standardized patients responded to student questions and comments and asked about their medication, according to the script. In addition, each student was asked to perform a dosage calculation of medication (morphine) and indicate how much should be drawn into a syringe.
Debriefing consisted of oral feedback on student performance by faculty evaluators immediately following the simulation. A commonly voiced theme by students after the simulation was relief at having the opportunity to "practice talking to a patient" and "walk through" the procedure of giving a medication to a live person before the first day of actual patient care. In addition, students shared positive comments with evaluators regarding additional practice time for dosage calculations in a simulated scenario.
Evaluation
Two weeks after the simulation, faculty evaluated the experience with the same tool that had been administered to the group who performed the simulation with a manikin. By that time, students had completed 2 clinical days in a hospital setting. This first clinical course afforded them an opportunity to provide basic patient care. Nursing skill opportunities included conducting health and physical assessments, meeting basic hygiene and comfort needs, performing procedures related to dressings and urinary catheters, and administering medications. The evaluation tool was developed by 4 faculty who teach beginning students and consisted of a 5-point Likert scale from 5 (strongly agree) to 1 (strongly disagree). Students responded to 7 evaluation criteria about the simulation. Two additional open-ended questions asked students to discuss what they liked best about the simulation and what they would change.
A comparison of strongly agree and agree responses from the evaluations of both manikin and SP simulations is shown in Table. While both groups indicated the experience improved their self-confidence and skill performance, one-third of the students who had the manikin simulation indicated they did not receive adequate instructions to prepare for the activity nor were they provided with constructive feedback during debriefing. Written student comments supported these findings. These concerns and others were addressed with students and evaluators prior to the second simulation. Evaluations of students who participated in the SP simulation rated their experience more positively (Table). In addition, 88% of written student comments conveyed an appreciation for the opportunity to practice the skill prior to actual patient care and recommended making the SPs a permanent change to the activity.
Recommendations
Because lack of adequate preparation for the activity was a common perception among students, orientation of students, faculty evaluators, and SPs should include a clear and thorough explanation of the purpose, objectives, and expectations of the experience. Faculty role modeling of the simulation was suggested by a number of students involved in the second simulation and could aid in an understanding of what is required. Use of the same SPs and faculty evaluators each semester would reduce inconsistencies in scoring and provide students with an equitable experience. Rubrics and evaluation results might be shared with faculty who are guiding students in their first patient care experience, to address individual learning needs. A cost analysis and investigation into a continuing source of funds to pay SPs are essential to ensuring ongoing success of the project. Standardized patients in this activity (1 per each of the 2 stations) were payed $50 per hour of service, which consisted of approximately 5 hours of preparation and actual simulation, resulting in a total cost of $500. Simulation facilitators should consider ways to minimize costs without reducing effectiveness of the simulation, such as using upper-class nursing students or other volunteers.11 Finally, the development of a formal research study in this area would provide information to more effectively evaluate the impact of the project on clinical practice.
Conclusions
The changes made following the manikin-based medication administration simulation resulted in an increase in student reports of self-confidence and readiness to perform patient care skills. Faculty revisions in the presimulation time elicited more positive student comments. Following discussion on effective debriefing techniques, faculty evaluators became more proficient at providing meaningful feedback to students. Use of SPs provided students with the opportunity to improve communication skills and apply safety aspects of nursing care. Patient teaching skills were practiced for the first time with a "real person" in a setting where students could make mistakes without fear of patient harm. In addition, individual student learning gaps were identified by both students and faculty prior to the first clinical experience. It is not clear which factor had the greatest impact on improved student ratings: addition of SPs, increased preparation/orientation time, or more consistent debriefing experiences. Faculty believe the initial goal of improving student self-confidence in medication administration was met and plan to continue the activity in future simulations.
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