Nurse educators agree that simulation can be used to overcome the limitations of traditional clinical education. However, the use of high-fidelity manikins presents a challenge for practicing therapeutic patient education because nonverbal cues, such as facial expressions, hand gestures, and intonations, are not easily portrayed. Simulation using standardized patients (SPs) offers opportunities for role-playing such skills in an interactive environment, but nursing students, who often struggle with anxiety in providing patient education due to lack of confidence and experience in the clinical setting, may find SPs too intimidating.
When humor is used in conjunction with the simulated environment (Sideras et al., 2013), student anxiety may be diffused, thus facilitating an increase in understanding the content related to the simulation objectives. This article describes an innovative approach to a complex patient teaching scenario using SPs, humor, and therapeutic communication.
BACKGROUND
SPs are individuals who are trained to accurately portray a patient role for nursing students and other health care professionals (Jeffries & Clochesy, 2012). Faculty can strategically use SPs to promote competency in clinical skills, such as obtaining health history and physical assessment data, establishing therapeutic communication, delivering patient education, and modeling professional behaviors (Jeffries & Clochesy, 2012). SPs have been found to be effective in reducing student anxiety while teaching psychosocial care, particularly within mental health, end-of-life, and spiritual care arenas (Eaton, Floyd, & Brooks, 2012; Fink, Linnard-Palmer, Ganley, Catolico, & Phillips, 2014; Kameg, Szpak, Cline, & Mcdermott, 2014; Ndiwane, Koul, & Theroux, 2014). From the literature, SPs can provide a realistic, low-stakes learning environment that supports the development of affective domain competencies such as relationship building, professional behaviors, and collaborative skills.
Given that students often struggle with anxiety over their performance in the clinical setting (Kameg et al., 2014), faculty are encouraged to develop and implement strategies to promote positive learning environments. The appropriate use of humor may contribute to an overall positive classroom environment while diffusing academic stress and anxiety and increasing creativity (Rowles, 2012). In order to be perceived as authentic to students, humor is most effective in small doses; excessive use may be viewed as "trying too hard" and may affect the perceived credibility of the faculty member.
By grabbing a student's attention and interest, humor can be used to emphasize an important instructional point in both the classroom and clinical settings. Later it serves as an anchor for content retention and recall. Faculty used humor in their teaching but need to be mindful to avoid jokes that may be perceived as demeaning, ridiculing, racist, or otherwise inappropriately biased (Rowles, 2012).
THE TEACHING STRATEGY
An authentic learning approach to Kolb's (1984) theory of experiential learning served as the theoretical framework for this patient teaching activity. Kolb describes four components of learning: abstract conceptualization, which involves knowledge and logic; active experimentation, which applies knowledge to a situation involving interventions; concrete experience, which is the engagement of the learner in the activity; and reflective observation, which utilizes self-evaluation to make links between expected and actual outcomes. Connecting theoretical learning to the experiential application of knowledge within the work or clinical environment, authentic learning challenges students to "think outside the box" and implement creative, inquisitive alternatives. This means that faculty must allow creativity to flow and resist the urge to supply students with the "right" answers or hints (Candela, 2012).
In reviewing standardized exam scores from previous cohorts, the authors identified a consistent weakness in scores related to the following areas: stress and coping, effective communication, patient education, and advocacy/legal-ethical issues. While noting that among novice nursing students these are typically anxiety-inducing areas of weakness (Fink et al., 2014; Kameg, Howard, Clochesy, Mitchell, & Suresky, 2010), the authors attempted to find an innovative and humorous way for students to practice through role-playing with an SP.
Participants for the simulation scenario included 112 students enrolled in a baccalaureate fundamentals course. The clinical requirements for the course consist of a total of 225 hours, with 12 hours designated for clinical simulation. Student learning objectives for this simulated experience are as follows: a) identify patient education needs through conversation and assessment; b) provide pertinent patient teaching using appropriate communication techniques; and c) redirect the nurse-patient conversation as needed, all while maintaining professional behaviors.
INTRODUCING MS. BIBBY
Ms. Bibby, a fictional character created approximately 10 years ago, has an ever-evolving personality. A tried-and-true rural Southern woman, Ms. Bibby believes in eating generous doses of her "meat and threes," visiting the beauty shop every Friday afternoon, going to church, and having a little fun while she can. At approximately 80 years old and rather plump for her short stature, Ms. Bibby's specific health history varies slightly, depending on each group of students that she meets. However, much of her education needs seem to relate to her chronic history of diabetes ("high sugar"), hypertension ("high blood"), and arthritis ("my friend Arthur"). Mentally, however, Ms. Bibby is sharp as a tack, often bearing quick wit and a mischievous sense of humor.
Students are introduced to Ms. Bibby during clinical time in a practice lab setting. Prior to the simulated scenario, students are divided into small groups (typically five to eight members), are assigned a patient education topic to teach, and are given 15 minutes to collaborate a game plan of what and how to teach the topic. After the planning phase is complete, faculty announce that "a very special guest" is on her way to visit the clinical lab.
During Ms. Bibby's visit, student volunteers attempt to conduct their prepared patient education, but Ms. Bibby uses her humor, wit, and charm to subtly divert the conversation off-topic, often by producing amusing items from her purse. Ms. Bibby strives for authenticity in hopes that students may apply what they have learned from her to their future patient education sessions. In addition to keeping Ms. Bibby on track, students are also responsible for verifying her level of knowledge and retention of information on the specified topic.
DISCUSSION
Ms. Bibby is one of many creative methods used to teach nursing students about methods for conducting patient education. Ms. Bibby is spontaneously interactive, which promotes a unique and unpredicted learning experience. As students experiment and role-play different approaches for gathering information from Ms. Bibby, both her verbal and nonverbal responses result in fun and laughter from the whole class.
Limitations and challenges to this teaching strategy do exist. Because of time and other constraints, individualized one-on-one time with Ms. Bibby is limited; therefore, she is better suited toward interacting with groups of various sizes. In addition, classroom audience cues and participation help feed interactions between Ms. Bibby and the students providing health education. Even though Ms. Bibby is good at drawing quieter students out of their shells, group dynamics influence the simulation, and the more responsive, playful groups report having more fun and getting more out of the learning experience than groups who are less talkative or shy. Lastly, it takes Ms. Bibby approximately 30 to 45 minutes to get into costume with her prepared props prior to her classroom arrival, so real-time communication between the SP and the course faculty is necessary to limit student downtime.
CONCLUSION
Working with novice nursing students brings unique challenges when attempting to teach and engage them in therapeutic communication. The use of an SP is a low-cost option that can improve "soft" skills among students. Humor helps create a safe learning space, reduce anxiety, and promote greater retention of information.
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