Skills and simulation labs are vital to the nursing education process. "Today's health care environments are complex and require highly developed problem-solving and decision-making skills, as well as a strong knowledge background" (Partin, Payne, & Slemmons, 2011, p. 188). It is important to plan skills lab experiences carefully to optimize learning, particularly in specialty areas where students often start clinical rotations without having received sufficient didactic experiences in the classroom. As educators, we enhance the learning process when we ensure that students have adequate knowledge to enter their clinical rotations and feel well prepared, competent, and confident, with the critical thinking skills required for specific specialty areas.
LAB PREPARATION AND PLANNING
Preparing the lab is crucial for student success. Unfortunately, an extensive review of journal articles and texts uncovered little available information for establishing a specialty laboratory curriculum at the undergraduate level, beyond foundational skills. What, then, does one teach students entering specialty settings? To answer this question and assist others with this challenge, we developed a holistic, stepwise approach to ensure that students receive ample preclinical preparation in specialty fields.
Step 1: Identify Key "Knowledge" Stakeholders
Unlike most adult-oriented fields of nursing, there is little prestructured or suggested laboratory content for specialty settings. To provide current and relevant content, we developed a list of key "knowledge" stakeholders that included students, clinical instructors, floor nurses, hospital nurse educators, and comparable programs. Formal and informal surveys and interviews were conducted with each stakeholder to develop a framework for lab instruction.
Students were provided with informal and formal surveys regarding their lab instruction, preparedness to enter the clinical setting, and items they would like included in future labs. The surveys yielded rich information about what students expected in the clinical setting and how instruction either filled in or failed to cover gaps in preparatory knowledge. Students noted they wanted "hands-on" and "interactive" instruction that would mimic the real health environment. They also wanted the opportunity to practice both common and rarely experienced skills.
Current and former clinical instructors served as vital knowledge stakeholders in the process, functioning as a bridge between the university and hospital setting. In interviews and responses to questionnaires, instructors identified strengths and gaps in laboratory content. They encouraged the transition of the lab into an interactive experience that would develop critical thinking and clinical reasoning. They also felt it is important to review foundational skills with a specialty focus, as students tend to feel ill-prepared to tackle known tasks on specialty patients.
Floor nurses and hospital nurse educators at collaborating facilities were either interviewed or responded to questionnaires. They were asked questions such as these: What skills do you frequently see students struggle with in this setting? What is one area that you would like students to be better versed in prior to attending clinical? What might be helpful for students in new graduate residency programs to learn prior to graduation? What specialty acronyms would be important for students to know? What are common specialty medications? Are there specialty procedures that are vital to know prior to entering the clinical setting? This methodology provided rich and current content suggestions. Although some of the content was slightly beyond the "nurse generalist" approach of most institutions, we used this opportunity for dialogue to develop expectations and stronger relationships with the associated facilities.
Finally, a review of comparable institutions was used to guide content. This involved speaking with educators in other nursing programs, locally and in other areas, about how they structure their lab content for specialty areas. These interviews helped identify content concepts seen as important across the nation. We uncovered certain inconsistencies that reminded us of the paucity of literature in this area.
Step 2: Analyzing Data/Developing Content
Common themes were identified and categorized into prelaboratory work and laboratory skills stations. As time in the laboratory setting is traditionally sparse, the decision was made to utilize a flipped classroom approach for labs. Items that could be covered with self-study and applied in the laboratory setting were included in prework content, allowing for ample time for active participation and application in the laboratory setting.
LAB PREWORK
Because of the timing of clinical placements, specialty labs were introduced prior to the beginning of didactic content. Early introduction to such content in the course progression allowed for a deeper didactic learning experience. Prework was structured as "ticket-in" preadmission packets designed to facilitate the learning of material and promote active learning and critical thinking prior to receiving hands-on experience (Staykova, Stewart, & Staykov, 2016). A packet was developed for each lab day to allow students to come to lab prepared to learn, reducing lecture time in the lab and allowing instructors to engage students in active learning activities. Interactive learning sessions with hands-on opportunities help students link theoretical concepts with evidence-based practice (Partin et al., 2011).
Each ticket-in focused on accessible content, for example, terminology, normal vital sign ranges, medication calculations, and procedural steps. Preparatory work provided question-and-answer sections and resources such as websites, videos, commonly used algorithms, and textbook information. This work was seen as a tool to help students benefit from the educational experience.
LAB STRUCTURE
Obstetric and pediatric labs days took place in the first two weeks of class and prior to the beginning of clinical rotations. The first three days were three to four hours in length; the fourth day consisted of a three-hour simulation. The sessions for the first three days were developed to cover key concepts identified in the stakeholder interviews; they consisted of brief lectures, videos, and games to ensure content knowledge, stations with specific skills and check-off goals, and low-fidelity simulations with debriefing. Sessions were grouped according to targeted topic content. The high-fidelity simulations on the fourth day for both specialty areas were developed to put content together into one or two scenarios. Students who participate in simulation are found to have a higher level of confidence when entering the clinical setting (Partin et al., 2011). By the end of the labs, the expectation was that students would be capable of entering the clinical setting knowing basic terminology, medications, focused assessments, care and education of the family, nursing management of common complications, and escalation of care. Students were assessed in skills in the final simulation.
The obstetrics lab and simulation days were organized as follows: Day 1, Care of the Patient During Pregnancy (prenatal care and education, labor support and care, basic fetal monitoring, medications); Day 2, Postpartum and Breastfeeding (postpartum maternal assessment, postpartum hemorrhage, perineal care, medications and vaccinations, maternal discharge teaching, breastfeeding and lactation); Day 3, Care of the Newborn (newborn assessment and vital signs, newborn measurements, general newborn care and testing, medications and vaccinations, discharge teaching). The Day 4 high-fidelity simulation, Putting It All Together, consisted of simulation of normal spontaneous vaginal delivery, newborn assessment, vital signs, measurements, and breastfeeding teaching.
The pediatric lab and simulation days were organized as follows: Day 1, Pediatric Basics/Primary Care and Beyond (growth and development, immunization station, fluid balance, peripheral venous access, monitoring, securement, and behavioral holds, and well-child visit low-fidelity simulation); Day 2, The Hospitalized Patient (respiratory readiness [oxygen therapy, lung assessment, respiratory resuscitation], Pediatric Early Warning System and pain scoring, Cardiopulmonary Resuscitation review, anaphylaxis low-fidelity simulation); Day 3, Pediatric Decompensation (tubes [pediatric nasogastric tubes, Salem sumps, straight catheter procedures], tracheostomies, trach mucus plug and working the case backwards, full decompensation [cardiac arrest] low-fidelity simulations). The Day 4 high-fidelity simulation consisted of a complex hypovolemic shock scenario that integrated fluid balance, peripheral access, Pediatric Early Warning System scoring and care escalation, respiratory and cardiac support, and family-centered communication.
Step 3: Reassess
Following completion of each student cycle through the specialty labs, surveys and interviews were again utilized to assess student competence, confidence, and knowledge. Prework and laboratory stations were revised as needed. In three semesters of each new specialty, preliminary feedback from students, faculty, and hospital staff noted markedly improved confidence, competence, and student readiness. Moreover, a number of hospital educators and clinical scholars noted that our students were some of the best prepared to date. A quantitative and qualitative analysis is currently being conducted on the results.
CONCLUSION
The goal of the specialized OB/PEDS lab and simulation days were to prepare students to enter the clinical area feeling well prepared, competent, confident, and with improved critical thinking skills. This preparation was not intended to be comprehensive but rather a sturdy foundation to be built upon as students progressed through the didactic and clinical portion of the class. Just as we started this process talking to lab faculty, clinical faculty, and students to help form the labs and simulations, we are now conducting research on how successful the new process is in our goals for students entering the clinical setting.
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