Traditional clinical experiences that provide opportunities to learn critical thinking skills in a hands-on setting are the best option for nursing students to acquire competencies, such as critical thinking, that are needed for success as a registered nurse (Bensinger, 2020; Mancini et al., 2019). However, clinical experiences differ among baccalaureate nursing programs. Pediatric clinical units vary in availability, patient populations, skill sets, and acuity levels, leaving students with inconsistent learning and limited chances to care for patients with certain disease processes, decreasing the opportunities for critical thinking to be learned. Therefore, additional modalities of exposing students to patient care should be used.
Simulation is one modality that allows students to participate in and analyze real-life clinical events in a safe and controlled environment. By providing opportunities for students to serve in the nurse's role, simulation improves students' confidence, knowledge, and skills in high-acuity situations (Aebersold, 2018; Lavoie & Clarke, 2017). Furthermore, simulation can provide equitable nursing experiences away from the traditional clinical setting and enable students to transfer the knowledge they gain to clinical practice. The purpose of this educational innovation, which involved post-conference simulation, was to provide undergraduate nursing students with expanded opportunities for enhancing critical thinking during high-acuity scenarios.
THE INNOVATION AND THE SCENARIOS
Undergraduate students enrolled in a pediatric nursing course were scheduled 90 hours of pediatric-specific clinical activities, including traditional clinical and simulation experiences. Students completed traditional pediatric clinical hours at a children's hospital on the campus of an academic medical center; the post-conference simulation took place in the school of nursing's clinical simulation laboratory, also located on the medical center campus.
Students completed four weeks of traditional 12-hour clinical shifts at the children's hospital, with the last two hours of each shift devoted to a post-conference simulation. The students and clinical faculty would leave the clinical unit and walk to the school of nursing's simulation laboratory to participate in the post-conference simulation. One scenario was performed each week with students assigned to either the nurse or observer role.
To begin the simulation, each group of students participated in a prebriefing session. The students assigned to the observer role were given an observation form for use in the debriefing discussion. The students in the nurse's role were given an SBAR (situation, background, assessment, and recommendation) report. Faculty served as simulation facilitators. Each scenario ran for 15 minutes and was followed by a debriefing session that focused simultaneously on the simulation and the day's traditional clinical experiences. The debriefings led to in-depth discussions connecting the simulation to real-life patient care. The activity, created as a face-to-face post-conference simulation, was conducted virtually when the pandemic began. Student feedback from online evaluations was comparable for the virtual and face-to-face simulation activities; full details are available upon request from the author.
A needs assessment to identify knowledge gaps in the course curriculum was performed before the scenarios were developed. This involved evaluating the previous year's clinical experiences and standardized test results. The pediatric scenarios developed involved respiratory, hematologic, neurological, or cardiovascular complications. Each scenario allowed students to identify a change in the patient's condition, interpret assessment findings, and utilize critical thinking to implement appropriate interventions. The scenarios also allowed students to practice active listening and therapeutic communication skills.
EVALUATION FINDINGS
Of 49 students who participated in the simulations, 42 completed the evaluation. The majority were female (91 percent) and ranged in age from 19 to 22 years (86 percent).
Evaluation data revealed that students gained confidence in identifying and analyzing changes in the patient's condition. Results showed that 83 percent (n = 35) strongly agreed about feeling more confident with assessment skills. Eighty-six percent of respondents (n = 36) strongly agreed that the scenarios provided the opportunity to practice clinical decision-making. One student stated that the simulations were "very beneficial, connects dots and allows us to be nurses in situations we would probably just be flies on the wall during clinicals."
Evaluation data also indicated that students were able to think critically and initiate nursing interventions based on the information gathered throughout the scenario. Eighty-one percent (n = 34) strongly agreed they felt better prepared to respond to changes in the patient's condition. Students also reported feeling more confident in performing skills, with strongly agree selected by 36 respondents (86 percent). One student stated that as a student nurse, "we would not be able to do this kind of stuff in clinical - the actual nurses would take over[horizontal ellipsis]."
Another finding expressed in the students' evaluations was that the simulations provided more consistent exposure to patient populations and skillsets. One student explained: "I liked learning things that we did not get to experience on the floor." The high-acuity scenarios allowed students "the chance to practice emergency situations in a safe and controlled environment" and "prepared me for a life-threatening situation that could occur with a patient."
CONCLUSION
The post-conference simulations were designed as an educational innovation to enhance critical thinking opportunities by providing equitable learning experiences for students in a pediatric course. These experiences allowed all students to identify and analyze changes in the same patient's condition and then determine appropriate nursing interventions based on the clinical findings. Following the simulation experiences, responses from the evaluations revealed increased confidence and preparedness to identify, think critically, and intervene in patient care.
The authors identified many strengths of this educational activity. According to Bensinger (2020), critical thinking is an essential part of nursing; therefore, providing students with more opportunities to practice this learned skill is crucial in nursing education. Post-conference simulation allowed for experiences with high-acuity situations in a safe learning environment. Another strength was that the scenarios provided exposure to consistent learning opportunities for all students despite varying clinical units. In addition, debriefing sessions and post-conference discussions allowed students to reflect on their experiences. The sessions served to reinforce the importance of transferring knowledge gained from the simulation to caring for patients in the clinical setting. The last strength was its flexibility. Scenarios could be adjusted to be utilized in a variety of formats, including in-person and virtual learning environments. Simulation scenarios can also be adjusted to fit a variety of clinical courses, including adult health, obstetrics, and mental health nursing.
The authors also detected a few limitations. The post-conference simulations were performed and evaluated as a single-site, single-semester implementation. Further repetition of the activity is needed to evaluate the effectiveness of this educational opportunity. In addition, student feedback from the clinical experiences was obtained from self-reported evaluations. In the future, objective measures should be incorporated to evaluate the students' critical thinking, along with confidence, knowledge, and skills gained.
The findings demonstrate that post-conference simulation provides students with equitable experiences that are beneficial to their learning. Not only can these opportunities increase the students' confidence, but students also feel more prepared to think critically in the role of the nurse. Therefore, the widespread use of post-conference simulation is recommended to enhance critical thinking in traditional clinical experiences and bridge the gap from education to practice.
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