Simulation has become an integral and rewarding part of nursing education. Three years ago, as it transitioned from quarters to semesters, a Midwestern college of nursing and health, with an annual enrollment of approximately 200 students, began requiring all clinical-based nursing courses to be 14 percent simulation. For this college, the simulation experiences include a computerized case study, skills review based on a case scenario using a static manikin, and group simulation experiences using standardized patients or manikins. Simulation provides opportunities to engage in the learning process and allows students to experience a realistic clinical situation in a nonthreatening environment.
The incorporation of 14 percent simulation into each course meant incorporating 8 hours per semester into specialty nursing courses and 16 hours per semester into medical-surgical courses. This provided a challenge for college faculty who, a year prior to the semester transition, had developed limited simulation material for only two of eight clinical-based courses: the pediatrics and public health courses. This article discusses the development of a creative and innovative plan to incorporate independent activities for small groups of students, including skill reviews and scenarios, into a single day to enhance the learning process.
THE SIMULATION DAY
Developing relevant and realistic scenarios presents a challenge for nursing faculty; incorporating eight hours of simulation into the pediatric nursing course required careful consideration. The focus of the lead instructor was to design a plan to improve student knowledge and skills regarding pediatric content for small groups of students to facilitate the learning process. The goal was to meet course objectives by identifying specific areas that students struggle with in the classroom and clinical settings. Small-group learning can promote critical thinking skills, teamwork, and a deeper understanding of content (Meo, 2013; Ravert, 2012).
The students participate in the simulation day on one of their scheduled clinical days, with their clinical group and assigned clinical instructor. The format allows students to take part in the activities without adding an extra day to their busy schedules.
Simulation Day Plan
The eight hours consist of the following: online learning simulation, nursing skills activities, and two simulation scenarios (see Table 1). The students receive the simulation objectives, patient history, and provider's orders prior to the simulation day (Franklin et al., 2013).
ONLINE LEARNING
The online learning module, developed by the lead instructor, includes information on how to complete a developmental assessment on children between the ages of six months and five years of age. For the simulation day, a clinical group is divided so that four students complete the nursing skills activities and the other four participate in the two scenarios. The clinical instructor and simulator driver run the scenario and spend time debriefing with the students as they relate skill content to lecture material. The groups then switch so that students in each group experience both activities.
In the nursing skills laboratory, students care for two simulated pediatric patients, a patient with asthma and a postoperative appendectomy patient. At the end of the day, students as a group discuss the nursing skills worksheets and summarize the content covered in the scenarios.
SKILL DEVELOPMENT
The three nursing skills activities were developed to allow students to perform them independently. They include wound assessment with electronic documentation, the identification of errors in written physician orders, and the selection of appropriate syringes.
For wound documentation, the students are provided patient information describing five different surgical incisions. Students must assess the incisions and document their findings electronically. They can immediately review their documentation for accuracy and learn from their mistakes.
The second skill, reviewing physician orders, requires the students to review three different sets of orders and answer specific questions that focus on identifying errors. These include pain medication dosage orders that are too high, lack of an order for an antiseizure medication that is needed for a patient with a history of seizures, and an order of acetaminophen with codeine for a patient with a history of a codeine allergy.
The last skill involves observation of a poster showing intradermal, subcutaneous, and intramuscular syringes. The student must select the correct syringe and needle for the patient scenario (e.g., a 50-unit insulin syringe if 32 units of insulin are ordered).
SIMULATION SCENARIOS
Two scenarios were developed and formatted utilizing a template developed for all clinical-based nursing courses to organize and manage information. The template was modified to include student learning outcomes in accordance with the pediatric course syllabus from the National League for Nursing Simulation Design Template (Aschenbrenner, Milgrom, & Settles, 2012). The overall goal was to help students feel confident and successful in caring for pediatric patients. This was the first semester that the students were in the hospital setting for clinical, and efforts were made to match the objectives of the scenarios with students' level of clinical experience and knowledge (Lioce et al., 2013). An additional goal was to allow students to work on skills they may not encounter in the clinical setting.
The first scenario, caring for a pediatric asthma patient, was developed by the lead instructor to address student weaknesses identified during clinical experiences. It was modified from its initial conception to address current practice guidelines (Hockenberry & Wilson, 2013; Lioce et al., 2013). Initially, the scenario had students teaching the patient the proper use of an expiratory peak flow meter and administering an intravenous antibiotic. The intravenous antibiotic was removed from the scenario to reflect current nursing care. The scenario now focuses on basic nursing skills, such as performing a physical assessment, administering an oral medication, administering oxygen per nasal cannula, and the reassessment and evaluation of the overall nursing care of the patient following nursing interventions.
The second scenario involves the care of a postoperative appendectomy patient. Students perform the following: a postoperative physical assessment, nasogastric intermittent suctioning, fluid replacement with intravenous fluids, and the administration of intravenous pain medication - skills students may not have the opportunity to perform in the clinical setting.
Student and Faculty Evaluations
Every semester, the lead faculty member conducts a meeting of clinical and nursing laboratory instructors to discuss the simulation experiences. To make improvements for the next semester, information is also obtained from student surveys.
Faculty and student input confirms that smaller groups during simulation have a positive impact on student learning (Meo, 2013; Ravert, 2012). Faculty continue to request small groups to allow more students the opportunity to participate in the scenario and improve their cognitive, psychomotor, and affective skills. Students request more scenarios and would like to participate more often as the primary and secondary nurses. Although student observers also learn from the scenarios, students overall want active roles in small groups to engage in their learning process.
CONCLUSION
The simulation day has been a work in progress with appropriate changes continually being made to improve the simulation experience for the pediatric nursing students. Other lead faculty have followed in the footsteps of the lead pediatric faculty member in developing, implementing, and evaluating successful simulation days, which also include skill reviews and patient scenarios to improve the problem solving and critical thinking skills of students. Simulation can be successfully incorporated across the curriculum with small groups of students to increase student participation and enhance student learning in nursing education.
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