Simulation in the health professions has rapidly become an integral part of clinical education, from prelicensure nursing programs through orientation, residencies, and continuing education (Johnston et al., 2018). As the field of simulation has grown, many new career paths in health care education have developed. However, few nursing students have experience operating high-fidelity manikins, simulation software, and other cutting-edge technologies, which may limit their interest in the field of simulation as a career. Despite an abundance of literature that describes the use of simulation as an effective active learning strategy in nursing education, no literature was located on training prelicensure nursing students to operate the cutting-edge technology that is used in simulation (Cant & Cooper, 2017; Park et al., 2013).
The "Do-Si-Do Simulation Model" is an innovative strategy, developed by the author of this article, where students participate in simulation scenarios as both the nurse in the simulation room in one scene and as the control room operator for the next scene as the case scenario unfolds. The use of this strategy requires that students learn how to operate high-fidelity simulation manikins as well as audiovisual simulation software. This strategy helps address the issue of limited human resources typically required to run simulation experiences. The purpose of this exploratory study was to gain insight on student perceptions of the use of the model in nursing education as an active learning strategy and determine if this strategy should be used in future courses.
THE DO-SI-DO STRATEGY
All students were junior nursing students enrolled in a baccalaureate nursing program at a private liberal arts college/university in the Midwest. The institutional review board of the college/university approved the study. The topic for the selected laboratory session in the study was blood administration.
In the first scenario, two students were in the simulation room functioning in the role of the nurse. Upon entering the simulation room, the students were provided with a report for a patient who required a blood transfusion. As this happened, two additional students were in the control room providing vocal responses for the manikin and making the physiological changes on the manikin and bedside monitor.
The students in the control room received a brief orientation to the software and audio equipment. They were provided with the same patient report as the students in the simulation room, but they were also provided with a script to follow throughout the scenario. One faculty member remained in the control room to observe and guide the students throughout the experience. The faculty assisted and intervened when situations arose in the room that were unanticipated and not included in the provided script. Students in the simulation room, acting as nurses, completed the pretransfusion assessment and initiated the infusion while verbally interacting with the student who played the role of the patient. Once the blood product transfusion was initiated and documentation was complete, the scene ended, and the students exchanged positions as in the Do-Si-Do dance movement.
During the second round, the students acting as nurses found that the patient was having a transfusion reaction and they needed to respond appropriately. They completed the transfusion reaction protocol while the patient provided verbal responses, and appropriate physiological changes were made on the manikin and bedside monitors. The students in the control room were given a script to follow but were allowed to respond appropriately to questions from the students in the simulation room.
Students participated in two different scenarios, and each student had two experiences as the nurse in the simulation room and as the control room operator. After students completed each scenario, all eight participating students took part in a short debriefing facilitated by the faculty member who assisted in the control room. The Plus-Delta debriefing technique was used because of the focus on psychomotor skill performance in this laboratory session, and the time for debriefing was limited to 15 minutes (Kainth, 2021). Because the allotted debriefing time was only 15 minutes, due to scheduling limitations in the simulation laboratory space, the debriefing focused primarily on the interventions that occurred in the simulation with little time for student reflection. Additional debriefing time would be beneficial for future replications of this simulation model.
At the completion of the simulation experience and debriefing, students voluntarily completed an anonymous survey. The survey included eight 5-point Likert-type scale questions regarding their perceptions of the learning activity and two open-ended questions. Twenty-four participants provided responses to the two open-ended questions included in the survey. Themes were identified by inductive analysis for each open-ended question using the Percy et el. (2015) method; a theme identification threshold of 10 percent was used for reporting the themes.
The first open-ended question asked students to describe the strengths of this type of simulation experience. Two themes emerged in the analysis: having decreased anxiety during the simulation (n = 13, 54 percent) and being able to participate in the simulation from a different perspective (n = 11, 46 percent). The second question asked students to provide recommendations for use of the Do-Si-Do model in future simulations. One theme emerged from the analysis. The majority of students indicated the model should continue to be used with usage increased in the future (n = 17, 71 percent).
Using a 5-point Likert type scale (1 = strongly disagree, 5 = strongly agree), it was found that students saw the experience as a positive learning experience (4.88), and they would like to have the model used in future courses (4.79). Students specifically addressed their perceptions of being control room operators. They indicated that participating in the simulation as the control room operator enhanced their learning (4.75) and produced less anxiety than being in the simulation room (4.75). When asked about having peers as control room operators versus faculty, students indicated that having peers as operators decreased their anxiety (4.54); they preferred having peers as operators rather than faculty (4.13). Preferring peers in the control room and reporting decreased anxiety may be attributed to students knowing that the simulation experience would not be graded by faculty and would not affect their course grades.
Students reported that the simulation software in the control room was easy to use (4.63). When asked about whether they would consider a career in health care simulation, student ratings were 3.71. This finding is likely due to the experience being their first exposure to health care simulation as a potential career. Moreover, many undergraduate students enter school with the idea of pursuing more traditional nursing roles after graduation.
LESSONS LEARNED
The creation of the scenarios and development of the scripts with control room instructions required a faculty time investment of nearly four hours. Faculty who participated in the development and debriefing anecdotally had positive reviews of the experience and indicated that the time investment was reasonable for the value of the learning experience. This strategy could be applied to many simulation experiences within nursing education, and it is likely that the time needed to create new scenarios would decrease with each application. In addition, as students develop comfort using the technology, less orientation time will be required for students in the control room.
Further research is needed to examine the effect of the strategy on academic achievement to determine if it should be used in future courses. This innovative strategy should be further explored to stimulate interest in nursing education simulation as a career interest and provide opportunities for simulation in nursing programs with limited resources.
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