Nurse educators are faced with a challenge: There is a nursing shortage, but there are limited resources to educate nursing students. Often this is due to a scarcity of clinical sites, faculty, and funding (American Association of Colleges of Nursing, 2012). The goals of nursing education - student acquisition of knowledge and skills to provide safe patient care - have not changed, but traditional clinical education, dependent on patient census, can provide a hit-or-miss approach to learning (Niederhauser, Schloessler, Gubred-Howe, Magnussen, & Codler, 2012), especially in rural settings. A different approach was needed to give students the clinical experiences necessary to become competent nurses.
BACKGROUND
As validated in a study by Schlairet and Pollock (2010), the Texas Board of Nursing (2010) has found simulation to be an effective teaching method when combined with traditional skills labs and direct patient care. However, the cost of a simulation laboratory is a factor warranting consideration. The price tag for simulation laboratories varies with the fidelity level of human simulation manikins. Do schools of nursing need to purchase the most expensive high-fidelity manikins to ensure students get the best experiences?
Lapkin and Levett-Jones (2011) compared the cost-effectiveness of high-fidelity versus medium-fidelity manikins, concluding that the medium-fidelity manikins produced the same effects on clinical reasoning, student satisfaction, and knowledge acquisition at one fifth the cost of high-fidelity equipment. Sharpnack and Madigan (2012) found that low-fidelity simulations and case studies promoted active learning, clinical competence, problem-solving, self-confidence, and collaborative and team-building experiences. Peers engaged in collaborative learning reported positive learning experiences shared information, cross-checked when making clinical decisions, and used group processes when evaluating interventional outcomes (Austria, Baraki, & Doig, 2013). Debriefing in small groups has been found to provide a safe and secure learning condition for nursing students (Tosterud, Hall-Lord, Petzall, & Hedelin, 2014).
In our university, located in a rural area of East Texas, students had previous simulation sessions where they focused on mastering tactile skills, such as administering injections, assessing vital signs, and obtaining measurements, but hands-on experience with pediatric immunizations had been hit or miss. This article reports on a pediatric clinical developed on campus to augment available clinical resources. The purpose of this activity was to increase student understanding of pediatric nursing care (especially immunizations), encourage collegial collaboration, enhance time management skills, and improve documentation competency.
THE SIMULATION PROCEDURE
The course focused on ambulatory pediatric care for students in the second semester of a baccalaureate program. To facilitate learning, six ambulatory pediatric case studies were developed; each provided students with vital signs, measurements, immunization records, a brief background as to the purpose of the visit, and provider orders. Each pediatric patient had unique challenges including undervaccination, infections, and a variety of nutritional needs, including weight concerns, vegan lifestyle, lactose intolerance, and vegetable aversion.
On a given simulation day, one faculty member supervised three different student cohorts rotating through the lab. The nurse faculty member served as a facilitator during the experience, providing students with an overview of the clinic, explaining where to find materials, and answering questions. The students could divide tasks among team members any way they wished. Students were told to complete the tasks within a 90-minute time frame (60 minutes to complete all tasks/30 minutes for documentation and debriefing).
The case studies were loaded onto laptop computers that were available at each station (see case in Figure 1). Students worked in teams of three to four to care for a panel of four children and complete the following tasks: implement provider orders, ascertain vaccine needs, complete and evaluate growth charts, develop a teaching plan, and document nursing actions.
Six low-fidelity manikins were used for this experience; four were station props, and two presented with infections to introduce students to the skill of obtaining cultures. Moulage was used to create an infected leg wound on one manikin and a ruptured eardrum on another; drainage consisted of yogurt with food coloring. Culturettes(R), dressing material, and medications were available.
To enhance understanding of immunizations, the students reviewed patient immunization records, used immunization schedules to select appropriate vaccines, and completed vaccine administration records. Used vaccine vials were collected from a local clinic, and vaccine information sheets, vaccine administration records, and immunization schedules were downloaded from the Centers for Disease Control and Prevention (CDC) website and printed for student use.
Each patient had measurements that needed to be plotted and assessed; body mass index was calculated when appropriate. Using information from growth charts downloaded from the CDC website and patient background information, the students assessed the nutritional needs for their patients and developed a targeted plan that included locating websites for educating parents. During debriefing, student perceptions about the experience were discussed, and each case was reviewed in detail to enhance the learning experience.
RESULTS
A nine-question Likert scale survey was used to evaluate activity effectiveness. Participation was voluntary but encouraged. A total of 110 second-semester students took part in the simulations during spring and fall 2013; 109 students completed the survey, and 94 submitted additional comments.
More than 90 percent of the students found the activity to enhance their charting skills and their understanding of pediatric nursing, immunization schedules, and growth charts. Using a Culturette was viewed positively. Students valued teamwork and felt that the activity fostered their ability to work collaboratively.
Common themes were identified from the comments students provided. Low stress, working as a team, gaining confidence, and improved understanding were the top four themes identified. Comments included the following: "I thought the Pedi lab was very helpful. It was low stress, but still required you to think and work hard to get what you needed done. It also helped me organize my work, thoughts, and documentation"; "We each pitched in and accomplished all that was asked. My favorite part is that we each took turns and everyone had a chance to perform each task"; and "I definitely appreciated this activity. It did open my eyes as to the work and knowledge a pediatric nurse must have. It also showed me I always need to have vaccination information in my memory."
Student comments were used to improve the experience. Debriefing was incorporated after the first session due to student comments. Not all students had the opportunity to use Culturettes. A change was made and instructions were given to include all group members in that experience: reading package instructions together, obtaining the specimen, and assisting in labeling after specimen collection.
DISCUSSION AND CONCLUSION
Because of the university's location setting, pediatric clinical sites were limited in the community. This on-campus clinical experience was created to give students the opportunity to review pediatric patient records, utilize growth charts, choose appropriate vaccinations, develop teaching plans, and improve documentation while working collaboratively within a set time limit. The cost for this experience was limited to the purchase of Culturettes, yogurt, food coloring, dressing materials, and copier paper; most supplies could be bought at institutional contract rates.
One faculty member could supervise up to 12 students in a simulation clinical day. Survey results showed students felt the experience increased their knowledge and confidence, facilitated teamwork and collegiality, and enhanced time management and documentation skills.
The goals for the experience were met, and students responded positively to this on-campus clinical experience. The activity did not require high-fidelity manikins or a large monetary outlay to be effective. The university was fortunate to have manikins to use as props, but these were not essential; a limb prop can be moulaged for the Culturette component. In lieu of electronic charts on laptop computers, patient records can be created on paper, and free patient teaching pamphlets can be obtained from state and local health departments for student use. This activity was created with second semester students as the target audience, but the structure allows for flexibility. The complexity level can be increased for graduate nurse practitioner students.
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