Students in our nursing program repeatedly ask for more simulation exposure in their course evaluations, but our simulation learning center has limitations in time and space availability. Bradshaw and Lowenstein (2013) propose that high-fidelity patient simulation (HFPS) can also be used in the classroom, where students can demonstrate mastery of concepts through active student participation. Therefore, we decided to bring the simulation experience into the classroom.
The purpose of the activity described in this article is to engage students in active learning that allows them to practice clinical decision-making and higher-order learning (Jeffries, 2007). A secondary goal is to increase students' comfort level in working with HFPS prior to a scheduled end-of-semester simulation. Student learning outcomes are as follows: a) perform a focused assessment of a patient presenting with respiratory signs and symptoms, b) interpret assessment data to formulate a plan of care, c) implement effective nursing interventions, d) evaluate the effectiveness of nursing actions, and e) compare and contrast the care of a patient with chronic heart failure to a patient with chronic obstructive pulmonary disease.
This activity is done once during the semester but could readily be done at different times using different patient scenarios. Other faculty within the program have conducted similar classroom simulations.
INNOVATIVE USE OF SIMULATION
This in-class simulation was first conducted during a junior-level medical-surgical course with 48 students. Team-based learning strategies (Michaelsen, Knight, & Fink, 2004) are used in this course, and students work in assigned teams of six or seven students. Each team is assigned one of four roles during the simulation: assessment, diagnosis/outcome, plan/intervention, and additional considerations/evaluation.
The manikin is brought into the classroom at break, on a stretcher, and an emergency room environment is simulated. Supplies and equipment including medications, dressing materials, oxygen, and oxygen delivery devices are also brought to the classroom. A whiteboard is used to document the assessment findings and plan of care.
Teams are randomly assigned to come to the front of the classroom and assume one of the roles as the simulation unfolds. Only the team primarily assigned for each role is at the patient's bedside. The other teams complete the assigned role at their seats to keep them engaged and focused on the simulation. Students report to the entire class at the conclusion of each role. The class then discusses additional aspects of care students identify with their team and add it to the board if pertinent. At the completion of the scenario, the entire class is debriefed. The second simulation is then started and completed in the same manner.
SIMULATION SCENARIO UNFOLDS
The simulation scenario begins with faculty giving the entire class basic information on how the patient presented to the emergency room, including chief complaint, past medical history, and any interventions already implemented, such as labs drawn or diagnostic testing completed. After report, the first student team is assigned to begin the scenario with its assessment. A faculty member assumes the voice of the patient and answers the student's health history questions. The remainder of the class observes, taking notes on the assessment and health history.
After approximately 10 minutes, the team at the bedside presents its findings to the class; the findings are also written on the whiteboard. Additional assessments and/or questions are completed as needed. Students are challenged at this point to keep going with the assessment rather than immediately reacting to the findings and implementing interventions. Faculty reinforce the need to complete the assessment to determine priorities and gather all the needed data. For example, many times students identify low oxygen saturation or another vital sign and immediately want to address the problem before completing all vital signs and cardiorespiratory assessments.
At this time, the second team goes to the front of the classroom. The patient scenario is placed on "pause," and students begin to formulate their problem lists in the form of nursing diagnoses. Again the team at the bedside presents its list as well as its priorities. Students seated in the classroom add to the list, and discussion and debate ensue about priorities, including the need for further assessments or information that must be gathered to make decisions or determine priorities. As a class, consensus is reached about the number one priority. The scenario is resumed, and the next team comes to the bedside to begin interventions.
As students implement interventions, or not, the manikin responds accordingly. For instance, in the heart failure scenario, the patient is short of breath and has low oxygen saturation and low blood pressure. If students apply oxygen and recheck the oxygen saturation, oxygen saturation will begin to rise. Often beginning students will intervene and not evaluate the patient response.
In the classroom scenarios, the importance of evaluating the patient response can be reinforced. For example, if students raise the head of the bed, the patient with low blood pressure will begin to complain of feeling dizzy. With audience participation and Socratic questioning by faculty, students are guided to determine the cause of the change in status, explore other options and interventions, and understand the thinking that was involved in their decision-making.
EVALUATION
When the classroom exercise was done, students were asked to evaluate the in-class HFPS by answering two questions: "What one thing about class today did you find most helpful to your learning?" "What one thing about class today did you find least helpful to your learning?" Of the 18 students who responded, most reported that the simulation was helpful in learning communication and collaboration skills (62.5 percent) and active learning (75 percent). Students reported that the factor that was least helpful to their learning was the physical size of the classroom (12.5 percent) and the number of students collaborating (50 percent). Just more than one third (37.5 percent) reported that the activity increased critical thinking. Students found running out of class time not helpful to their learning and expressed a wish to have the simulation earlier in the semester (50 percent). Future evaluation of this teaching strategy will include an examination of its effect on student learning.
In conclusion, an in-classroom HFPS can be an engaging activity that is valued by students. Challenges include class size, classroom setting, timing, and keeping all learners engaged. It is noteworthy that, although students state that after the classroom simulation they are more comfortable with the high-fidelity patient simulator's capabilities during other simulations, anxiety related to the patient care situation persists.
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