Participating in hands-on critical care is a limited opportunity in undergraduate nursing education. This revised course, featuring an innovative and flipped classroom, aimed to expose students to the critically ill patient and introduce basic critical care skills in a simulated intensive care unit (ICU) environment. Using simulation, didactic learning, and creative teaching practices, this innovative classroom upgrade provides a way to disseminate technology into nursing education.
BACKGROUND
A flipped classroom is a developing pedagogy with opportunities to bridge the education-practice gap in nursing education. Class time is reserved for active learning, with lecture material assigned as homework to be completed before class. Active learning can be promoted in the flipped classroom by increasing student engagement and self-efficacy (Presti, 2016). This pedagogy also allows students to develop and apply the critical thinking skills needed for their nursing practice (Betihavas, Bridgman, Kornhaber, & Cross, 2016). Strategies in a flipped classroom help nursing students in making sensible and accurate clinical decisions related to scenarios like those met in practice (Njie-Carr et al., 2017).
Nursing faculty are responsible for ensuring students acquire the knowledge, skills, and confidence necessary to support their clinical practice as novice nurses. Insufficient experiences may make it difficult for students to obtain the experiences they need to build confidence in caring for critically ill patients. Using high-fidelity simulation critical care scenarios, student nurses' confidence and competency can increase in a safe learning environment (Brien, Charette, & Goudreau, 2017; Rushton, 2015). Simulation furthers learning by helping nursing students transfer theory into practice, building teamwork and raising professional awareness (Badir et al., 2015). Competencies are gained as students establish connections between prior and present knowledge in preparation for practice in a real-life setting.
CLASSROOM INTENSIVE CARE
This course, a 15-week elective for traditional undergraduate nursing students during the last semester of their senior year, was redesigned shortly after a new simulation center was opened in the school of nursing. The simulation center offers SimMan 3G (Laerdal Medical), live streaming technology, and video recording with sound. It provides fully immersive, integrative experiences that offer the look and feel of an ICU. Two faculty, with long experience in critical care, were charged with redesigning the course, which, in past years, was taught by one instructor in two sections. With the course redesign, the sections are combined, providing students with a shared and equal learning experience.
The class meets once a week for two and a half hours, one week for classroom work and the next week for high-fidelity simulation, for a total of five simulations (cardiac, respiratory, neuro, gastrointestinal, septic shock). Each body system is presented in the course of two weeks, with two weeks reserved for special topics (code management) and special populations (geriatrics, obstetrics, pediatrics, perianesthesia) in the ICU. Students are taught using narrative medicine and literature reflective of patient experiences in critical care. They are also asked to critique and appraise current evidence from critical care nursing journal articles.
For the classroom portion of the course, a 14-bed ICU was created within the traditional academic setting. It was achieved by rearranging classroom furniture and assigning students a patient (a doll) to care for during class time. The 70 students enrolled in the class are referred to as ICU "staff" throughout the course. Throughout the class, they are asked to care for (turn and position) their "patients." At times, staff will accidently drop patients from the desks to clear space for books or laptops. If a patient is found on the floor, staff is questioned about the fall, and a patient safety conversation ensues.
Structure of the Class Day
The class is divided into four parts. The first 15 minutes is reserved for a faculty-created short quiz to validate major concepts from assigned, preclass readings. Socrative(C) learning software is used to answer the quiz questions, and immediate feedback is provided. The next 60 minutes are dedicated to didactic learning. Students are asked to receive "report" on a critical care patient using a handoff tool (adapted and used with permission from a local ICU). Content is presented by faculty with emphasis on the critical care nursing management of advanced hemodynamics, ventilators, intracranial pressure control, and sepsis. Content is presented systematically by body system, and concepts become more advanced as the course progresses.
At the halfway point of the class, a short break is offered, and students are encouraged to take a 10-minute active walk. Encouraging physical activity during a long lecture facilitates learning (Fenesi, Lucibello, Kim, & Heisz, 2018) and encourages an overall culture of health and wellness. Upon return, faculty assume the role of the ICU provider and "round" with students for approximately 45 minutes. Patient issues are identified by students through the use of a Daily Goal Tool (adopted and used with permission from a local ICU). This tool includes such items as patient issues pertaining to neuro, cardiac, bowel, and bladder assessments, and mechanical ventilation, tube, lines, drains, deep vein thrombosis prophylaxis, and skin issues. Students handle ICU equipment and prepare for simulation experiences while using critical thinking skills. They are encouraged to practice a questioning attitude about hot topics in critical care such as central line access, urinary catheters, and early initiation of antibiotics. In the remaining time, simulation goals and objectives for the following week that support the main clinical concepts from the didactic material are presented.
Structure of the Simulation Day
A scenario is presented based on the previous classroom content. Approximately 15 students per week have hands-on experience with the simulation scenario; the remaining students actively observe the simulation through live streaming technology and are given the role of "active observers." Active observers are given checklists focused on areas of safety, communication, and skills specific to the case study. One faculty acts as a confederate during the simulation scenario; the second faculty member remains in the classroom to oversee active observers and begins the debriefing discussion. The debriefing is structured and guided in a way that first promotes the positive aspects of the simulation. Then, body system concepts from the didactic learning are synthesized using the simulation objectives.
STRENGTHS, CHALLENGES, AND RECOMMENDATIONS
Students with an interest in critical care nursing are able to opt into this course, which is offered to all seniors as an elective. The two faculty members organized the course by body systems and rotate lecturing responsibilities based on their own clinical expertise and experiences. A major strength of the course redesign is that students who may not have a formal clinical rotation are given hands-on opportunities to practice critical care skills. The course allows for guided, hands-on handling of critical care equipment (e.g., transducers, a line calibration, in-line suctioning) in the academic classroom.
Although the course was offered to students in past semesters, this was the first time it was offered by these faculty using the flipped classroom method. Thus, certain challenges have emerged, and many lessons have been learned along the way, specifically regarding course pacing, online technology, and student engagement. Although the majority of students have a strong interest in caring for critically ill patients, some struggle in the flipped classroom environment and are new to the concept of self-guided learning. They need encouragement to apply full presence and engagement to the in-class discussions and activities. These challenges have been considered when improving the course for future semesters. Engaging undergraduate baccalaureate students in critical care nursing through the flipped classroom methodology is an innovative method for delivering critical care nursing concepts. At the conclusion of the semester-long course, student evaluations reflect that time spent in simulation leads to increased confidence. Students have stated that simulation brings to life the importance of critical care nursing and is a great way to understand advanced nursing concepts without a designated clinical rotation. The feedback has been positive about integrating simulation in the classroom, validating National League for Nursing (2015) recommendations.
The evaluations of the classroom experience have also been positive, noting that faculty relate real-life experiences to enhance the understanding of critical care concepts. Students speak positively about the opportunity to practice critical care skills as part of their preparation for the next week's simulation.
Applying for grant money to expand available technology and equipment will enable faculty to obtain needed critical care supplies and equipment. Bringing in multidisciplinary experts in critical care, such as physicians, physical therapists, and pharmacists, will also add to the students' immersive experience. In times of difficult clinical placement, bringing the ICU to the classroom is an innovative and pragmatic approach to undergraduate education for those interested in pursuing critical care.
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