Teaching with simulation scenarios is supported as a positive teaching modality in schools of nursing (Larew, Lessans, Spunt, Foster, & Covington, 2006). Flipped classroom teaching has also been successful in general educational settings and has begun to find its way into schools of nursing as a means to provide active learning opportunities (McLaughlin et al., 2014). This project was developed based on six principles of active learning described by Brookfield (1986) as essential for a teaching-learning transaction to be successful: voluntary learning, respect among participants, collaboration, the aspect of praxis, reflection, and nurturance of a self-directed, empowered adult.
The project was developed by faculty in the Entry Level Master Science in Nursing (ELMSN) program and Health Science Simulation Center (HSSC) at an urban university for students working toward a master's degree as either a family nurse practitioner or case manager. The group of 48 students was divided equally between both tracks. Most students (approximately 75 percent) had careers in other fields prior to starting over in health care. All 48 students were together as one cohort starting from their prelicensure education.
In the second semester (16 weeks) of the prelicensure curriculum, ELMSN students are enrolled in a foundational medical-surgical course. The course includes 4 hours of didactic instruction and 16 hours of onsite clinical experience weekly. For six years, the course required manikin-based simulation for the 25 percent of clinical experience allowed by the California Board of Registered Nursing.
Students participate in two simulation experiences. The first uses Quality and Safety Education for Nurses (QSEN) scenario. The second simulation is based on a standard medical-surgical scenario developed by the National League for Nursing that is appropriate to the students' knowledge level. The simulations are scheduled to provide strategic education on foundational concepts of nursing.
A CREATIVE RESPONSE TO A WORKFORCE PROBLEM
Occasionally, faculty are called upon to engage in quick and creative activities because of workforce problems at clinical sites. For example, in spring 2013, staffing issues at several sites did not allow students to take part in their assigned clinical rotations, and alternative assignments were needed. Fortunately, these downtimes happened after students had already developed care plans for patients and had begun building case study portfolios. To develop a quick and simple means by which students could translate patient care into a simulation scenario, the faculty of record for the course worked with HSSC faculty to modify the standard template for building simulation scenarios.
Course faculty assisted students in choosing appropriate cases to develop for simulation. All faculty agreed that students should experience the full context of simulation, including assisting with debriefing. The response from students to this impromptu exercise was positive. All agreed that the experience should be developed for future classes.
REPLACING ONE CLINICAL DAY WITH SIMULATION
The impromptu experience led faculty to develop a more formal project to replace a clinical day in the medical-surgical course with a simulation experience. The standard template for scenario development, created by HSSC faculty, was 27 pages in length and designed for learners at all levels. The template was modified to a four-page document to address the specific needs of students at the beginner's level of learning. Students are coached on choosing an appropriate patient scenario to use and given instructions on how to complete the simulation template.
As it was clear that not all 48 students would be able to execute their developed scenarios, it was decided that the fairest way to select scenarios for presentation would be to allow the students to choose. Students in the course are divided into six clinical groups of eight students, each assigned to a different medical-surgical unit in an acute care hospital. Each group is instructed to select an appropriate patient scenario for implementation, one where the student had developed a care plan and had cared for the patient for more than one day.
The group assists the selected student to fully develop the case for simulation. A key component for case development is the use of concept mapping, routinely used in the course as part of patient care plan development. Concept mapping, described as a positive teaching strategy for nursing (All & Havens, 1997), allows students to view patterns in a global way, enabling them to think about patient care scenarios with multiple layers and outcomes. Doing the concept map first helps the students think about what is essential for the simulation.
The student-developed case is submitted to the faculty of record and simulation team for review. If there are questions or adjustments, the team contacts the student and faculty for clarification before the scenario is programmed by the HSSC team. On the actual day of the simulation, the student whose case is chosen serves as team leader, ensuring that the scenario is implemented as described and objectives are met. The course instructor and faculty from the simulation team work as coaches, with the student leading the simulation.
Running simulations for six clinical groups typically takes two workdays. Each group is given 2 hours for the simulation assignment: 30 minutes for orientation and prebriefing, 15 minutes for the active simulation, and 45 minutes for debriefing. The remaining 30 minutes allows time for overruns and any important teaching moments that may arise in the debriefing session. As the experience replaces time on the clinical site, the clinical instructor uses the remaining time for learning scenarios to develop critical thinking around decision-making and to conference with each student.
EXAMPLE OF STUDENT-DEVELOPED SCENARIO
More than one student had the opportunity to work with a complicated patient whose story was selected for a simulation. The patient was a 71-year-old man with a long history of renal and heart disease. His past medical history consisted of a video-assisted thorascopic decortication for complex empyema and hemothorax, four-vessel coronary artery bypass, chronic atrial fibrillation, stage 3 kidney disease, type II diabetes, and a pacemaker insertion. His chest tubes remained in due to recurrent effusion; the patient had developed pneumonia and was on hemodialysis. As the patient was hospitalized for three weeks, the group took turns caring for him.
Faculty took the lead for the follow-up debriefing session. The lead student was encouraged to participate in the debriefing, and all students provided feedback and recommendations. Overall, feedback directly following the simulation and in a follow-up satisfaction survey was positive, with constructive suggestions for improvement. Comments included: "Recognized the complexity of the scenario and the significance of monitoring for key symptoms" and "The process of developing the simulation helped me learn more about how to work with a complicated patient." One student objected to having a fellow student assist in debriefing and another told of being uncomfortable with simulation. Students asked for a better explanation of simulation terminology, less complicated forms and help in simplifying the scenarios, and more time for preparation.
REFINING THE INNOVATION
When this idea was first utilized, it was impromptu but very effective. We were fortunate to have at our disposal an engaged and effective simulation faculty team dedicated to student success. We used the students involved in the impromptu sessions to further develop the idea as an actual assignment for future classes. Since then, we have continued to use student involvement to further develop and refine this intervention.
Several improvements have been made based on student and faculty suggestions. Since the first impromptu 2013 session, we developed better templates for simulation use, obtained University of Washington slides and videos on debriefing (Kardong-Edgren, Chiu, & Liner, n.d.) for students to watch prior to their session, developed a clinical faculty guide on how best to assist students, further refined and clarified terms on the simulation template, and explored other courses in which this innovation can be implemented.
The only data collected come from a Survey Monkey(TM) satisfaction survey that used a common Likert scale and asked for comments. The action of clinical reasoning was not specifically targeted as an outcome measure for this exercise. A recommendation for future endeavors is to create a study that addresses clinical reasoning and changes in levels of understanding as possible outcomes using two forms of simulation. The comments from the satisfaction survey certainly support that students appeared to gain an increase in understanding, if not improved clinical reasoning.
Overall, this is a successful educational innovation utilizing two positive techniques of teaching: simulation and a flipped classroom approach. It clearly supports Brookfield's (1986) six effective teaching-learning transactions. Student involvement in making positive changes in curricula helps foster ownership of knowledge and learning and supports the premise of andragogy (Knowles, Holton, & Swanson, 2005). The ELMSN student profile, in general, is that of an adult learner, one who is a highly motivated and engaged. Such learners clearly understand and embrace the use of simulation as a teaching/learning tool.
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