As the need for nurses continues to grow, so do nursing school enrollments. According to a recent survey of baccalaureate and graduate nursing programs, entry level baccalaureate enrollments increased 4.2 percent despite a capped number of nursing faculty and resource constraints (American Association of Colleges of Nursing [AACN], 2014). As a result, the numbers of students in nursing classrooms are increasing, whereas the number of nurse faculty remains constant (AACN, 2015).
Teaching large numbers of students presents challenges for active learning, an essential characteristic of adult learning. Today's nurse educators must find creative ways to ensure that students in large classrooms are actively engaging. A review of literature on simulation-based learning concluded that human patient simulation (HPS) is an effective teaching and learning method that fosters development, synthesis, and application of knowledge in a replica of a real experience (Cant & Cooper, 2009). Traditionally used as a method of clinical instruction, HPS assists faculty with pattern recognition and the application of classroom knowledge into clinical practice. The success of HPS as a clinical instruction tool likely indicates that students would also benefit from its use in the classroom setting. HPS may be an effective teaching strategy not only in a simulation lab with small student numbers but also in classroom settings with large numbers of students (Moyer, 2016).
Structuring nursing student clinical assignments to include life-threatening patient conditions is not an attainable goal. These high-risk experiences are usually not available for all students or are too life-threatening to entrust to students. Delivering classroom content on life-threatening situations without clinical reinforcement will increase the likelihood that students will be unable to act prudently when they experience these situations in the clinical setting.
HPS provides opportunities to experience high-risk, low-frequency clinical situations in which the learner must apply classroom and clinical knowledge to a simulated patient situation. Classroom instructors can use HPS to bridge the gap between classroom-delivered content and its application into practice by transforming the classroom into a clinical setting that provides rich experiences laced with clinical reasoning opportunities.
DESCRIPTION OF TEACHING STRATEGY
One adult health course in a baccalaureate program uniquely uses HPS technology to teach content related to cardiac dysrhythmias, potentially life-threatening conditions that occur infrequently in the clinical setting. This strategy is employed to provide necessary experience to all students, foster clinical judgment, facilitate patient safety, and promote confidence in practice.
Electrocardiographic (ECG) rhythm interpretation is traditionally taught through the analysis of static cardiac telemetry strips; classroom instructors teach this basic ECG strip interpretation to junior-level nursing students. Although necessary, this method alone is insufficient to arm students with the skills needed to quickly analyze real-time ECG tracings on a telemetry monitor. To assist nursing students in making the transition from telemetry strip analysis to real-time rhythm analysis, classroom instructors use the HPS bedside hemodynamic monitor to teach live rhythm interpretation. By connecting the HPS computer and bedside hemodynamic monitor to large projector presentation screens in the classroom, faculty are able to display the simulation monitor to every student in the classroom.
Prior to the classroom experience, the instructor delivers an hour-long presentation on the pathophysiology, causes, clinical manifestations, and treatments of various basic dysrhythmias. To ease the application of this content into patient care, the remainder of the classtime is spent applying the newly learned content. The instructor provides a brief medical history on the simulated patient and then projects the cardiac monitor onto two large classroom screens. As simulated cardiac dysrhythmias and vital signs are displayed, students become engaged in the topic and begin their assessment and interpretation of the data.
Initially the classroom instructor provides several minutes of quiet reflection to facilitate the students' assessment of the data. Students are expected to assess the rhythm, determine whether the patient is hemodynamically stable through the assessment of vital signs (blood pressure, temperature, respirations, pulse, and oxygen saturation), formulate nursing interventions, and anticipate possible treatments if indicated. Projecting the simulated patient's deteriorating vital signs via a hemodynamic monitor allows students to visualize the patient's physiological response to the dysrhythmia.
As they witness the patient's hemodynamic deterioration, students become frightened, nervous, or excited. In this situation, they are more likely to engage and participate in a classroom discussion than students who are merely delivered classroom dysrhythmia content through lecture.
Following quiet reflection, students break into small groups of four to discuss their analysis of the simulated dysrhythmia and determine if a plan of action is warranted. They are encouraged to discuss their thoughts with one another as they work critically through the scenario, sharing feedback with one another until a consensus is reached. When each group has had the opportunity to devise a course of action based on critical analysis of the data, the classroom instructor calls on groups to discuss their interpretations.
After receiving instructions from the groups, the instructor begins to administer treatments to the HPS, programming treatments such as electrical cardioversion, defibrillation, electrical pacing, and medication therapy into the scenario. Students will witness a drop in heart rate after giving a calcium channel blocker, visualize spikes from defibrillation on the ECG tracing, and note a rhythm change from atrial fibrillation to sinus rhythm following an electrical cardioversion.
The students' evaluation of the patient's response to correctly selected treatment will result in vital signs that stabilize and return to baseline. If students unknowingly administer an incorrect treatment, they will either witness no change in the patient's hemodynamic status or active deterioration from inappropriate nursing interventions. Because the instructor does not have to intervene for the sake of patient safety, students are allowed to see the negative effects that inappropriate nursing interventions may have on the patient's physiological state. Following the simulation, the instructor provides time for debriefing and student self-reflection.
CASE EXAMPLE
After teaching dysrhythmia treatments in a classroom setting, an instructor in a junior-level adult health course projected a real-time simulation tracing of a third-degree heart block on projectors in the classroom. Individually and in small groups, students determined that the patient was unstable, expressing concerns over the patient's critically low heart rate and blood pressure. Students also noted that the patient's oxygen saturation was 82 percent.
Viewing the live telemetry monitor, students assessed that the projected rhythm was a third-degree heart block, unstable secondary to its slow rate and inability to produce organized and sufficient mechanical contractions of the heart. Students used their analytical skills to determine that the patient's deteriorating state required quick intervention to increased cardiac output. Working in small groups, students planned interventions including medication and electrical therapy to increase the patient's heart rate and restore the patient's hemodynamic state. Students implemented their plan as they gave orders for the instructor to administer atropine to the patient.
An evaluation of the atropine therapy revealed that the patient's heart rate increased slightly; however, the vital signs showed no improvement. Understanding that the atropine therapy did not improve the patient's condition, students then requested that their instructor initiate electrical cardiac pacing at 70 beats per minute. Students then assessed the electrical tracing to determine if the pacemaker was correctly firing and producing "capture." Following the increase to 70 beats per minute, the patient's vital signs stabilized.
When the patient was successfully stabilized, the instructor led a reflective discussion on the scenario, giving students the opportunity to ask questions or discuss concerns they encountered while engaging in this active learning strategy. If students would have chosen an incorrect treatment for an unstable third-degree heart block, the patient's condition would be allowed to deteriorate in full view of the students. Evaluation of their incorrect interventions helped students learn the importance of continual evaluation of nursing interventions.
CONCLUSION
Nursing programs that employ HPS technology have an opportunity to create powerful active learning strategies for students in the classroom (Berndt et al., 2015). Best practice in teaching and learning through simulation engages students in active learning, which results in improved clinical reasoning skills (Shin, Park, & Kim, 2015). Nurses who possess effective clinical reasoning skills ensure patient safety and positive patient outcomes.
This resourceful and innovative use of HPS technology allows students to experience the urgency and necessity of accurate clinical decision-making under the stressor of time. The method also facilitates immediate feedback on the quality of the students' clinical decision-making. As the situation turns urgent, students often respond emotionally and may become nervous or excited. In this situation, students are more likely to participate and develop interventions to rapidly stabilize the patient.
HPS is a feasible bridge for the gap between clinical practice and theory (Moyer, 2016) through the promotion of problem-based learning. As faculty recreate realistic patient scenarios, students will be more prepared, knowledgeable, and autonomous in clinical practice. The benefits of this learning activity will be evident as students accurately identify life-threatening cardiac dysrhythmias and take appropriate actions to ensure patient safety. Having gained the experience of managing a patient with an unstable dysrhythmia, nursing students will be more prepared to correctly and safely intervene in their own nursing practice.
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