Simulation has become an integral part of nursing curriculums, especially with the insufficient supply of nurse practitioner (NP) clinical sites. Additionally, with interprofessional clinical training experiences for NP students expanding, there are still inconsistencies in faculty oversight.1 Subsequently, NP education needs a more efficient, standardized, and sustainable way to provide students with opportunities to care for complex patients and practice skills.2 Simulation supports competency-based education and allows NP students to practice in a safe environment. Using simulation in NP education can help support standardizing and measuring clinical competencies, all while using a familiar validated theory and framework.2 An NP student may be able to work through a single patient case scenario, or a select topic area, but requiring NP students to analyze patient care data in a consecutive visit format as they would in primary care settings is not evident in the literature.
Numerous studies have shown that multiple high-fidelity simulations are an effective way to improve the learners' critical thinking, clinical reasoning, and confidence.3 However, there is limited research in this area with NP students. Multiple high-fidelity simulations allow learners to apply theory to practice and faculty to assess students to identify knowledge gaps.3 Structuring a simulation to include multiple high-fidelity scenarios enables the learners to experience a realistic day in practice, which increases their self-confidence when in the actual clinical setting.4
Development and Implementation
Process
An innovative teaching strategy was developed that included 3 different consecutive episodic respiratory illness visits for each NP student in a telemedicine simulation format using Zoom Video Communications, Inc, and standardized patients. Three students were assigned a link and appointment times for 3 standardized live patient visits. Each visit was 20 minutes in length since the cases were straightforward, were not complex, and contained a single episodic complaint. After each student completed 3 visits, the student wrote a subjective, objective, assessment, and plan (SOAP) note and make a call to a pharmacist for a prescription (audio submission).
The case scenarios were derived from episodic content taught in the previous week in the didactic portion of the course. Rubrics for each of the cases centered on the salient aspects of a patient encounter. A select example of one simulation scenario and rubric can be found in the Supplemental Digital Content Table (available at: http://links.lww.com/NE/B259). Course faculty graded the telemedicine simulation and SOAP note. A pharmacist graded the audio recording that included a rubric developed by faculty.
Student Preparation and Prebrief
There were 3 students enrolled in the course who were assigned telemedicine article readings at the start of the semester. Two of the 3 students reported observing their preceptors doing a telemedicine simulation during their clinical experiences. Course faculty facilitated class discussions about the process for a telemedicine patient visit that included content areas such as confidentiality and potential internet or technology limitations.
Student preparation included class discussion of potential scenarios and a practice discussion about potential encounters during the assignment. At the start of the course, students were provided a sample telemedicine simulation template and rubric to use during the simulated patient visits. The learning objectives for the telemedicine simulations, SOAP notes, and pharmacist audio submissions for all 3 consecutive patient encounters can be found in the Table.
Debrief and Student Feedback
An anonymous evaluation survey was completed after the simulation. The themes that emerged from the students' feedback were that more simulations should be included in future courses, consecutive simulations in a row, and the telemedicine component helped to prepare them for clinical practice. The pharmacy call was beneficial to the students' learning, and all reported that they had not experienced this yet in their clinical setting. Students also appreciated the autonomy within the simulation in being "on the spot" and having the full responsibility to diagnose and formulate a plan of care.
Faculty and students met individually to discuss cases and then as a group in the following didactic class to review possible future approaches to consecutive telemedicine simulations. During the debrief with faculty, students elaborated on comments, citing examples of more rigorous content to be included such as neurology differentials and complex cases in future simulations. The debrief allowed for reflection that although they were anxious prior to the simulation, they were surprised with how meaningful it became to their learning.
Conclusions
Multiple patient simulations, such as this one, should be facilitated more often, as it gives the students a realistic experience that could mimic patient care and could be used to supplement clinical practice site visits and as a formative and/or summative assessment. In the future, this simulation structure should be repeated with a larger cohort of NP students. Also, research using simulation in NP education is essential to provide evidence that simulation can support learning outcomes of NP competencies.
Consecutive simulations can capture a student's level of understanding content across most NP courses and be used in a variety of other ways. For example, faculty could incorporate ethical, legal, and social determinants of health considerations for simulated patients. Additionally, faculty could tailor the rigor of the cases as the students progress through the program beginning with prerequisites and extending throughout the entire program. Providing students with a series of consecutive telemedicine simulations renders an opportunity for them to experience the challenge of caring for consecutive patients in a row with multiple diagnosis and time constraints as they would in real practice upon graduation.
References