High-fidelity patient simulators are increasingly used in the education and training of healthcare professionals. Increased attention to patient safety demands, innovation in education, and accelerating advances in diagnostic and therapeutic procedures have generated interest in this area.
Simulators are used to teach basic skills such as the measurement of blood pressure and assessment of heart and lung sounds, and more advanced clinical skills such as emergency airway management and trauma resuscitation. The simulation experience offers distinct educational advantages, especially for learning how to recognize and treat rare, complex clinical problems in a safe and controlled environment. Although simulation is becoming an increasingly common component of the acute care NP (ACNP) curriculum, data regarding the impact of simulation on student performance and acceptance are lacking.
The University of Illinois at Chicago (UIC) recently incorporated critical care simulation into its ACNP program. In order to evaluate this new method of teaching and determine the importance of adding simulation to the curriculum, a pilot study was conducted to assess several student outcomes. The specific purpose of this study was to determine the effect of simulation on knowledge acquisition and confidence, and to study ACNP student perception of the importance of simulator training. Based on data in medical students and residents,1-3 investigators hypothesized that the ACNP students' confidence in managing a critically ill patient would increase, that simulation would improve acquired knowledge, and that this method of teaching would be positively accepted.
Simulation Justification
ACNP program coordinators throughout the country have integrated simulation into their ACNP curriculum. Mounting evidence supports the use of high-fidelity patient simulation to teach procedural skills, advanced cardiac life support, management of critically ill patients, and to evaluate quality of care.4-7 However, review of the literature on the use of patient simulation in ACNP education revealed minimal data. Although use of high-fidelity patient simulation allows students to practice without risk, advanced practice nursing educators must weigh the benefits associated with this method of teaching against the high cost of technology and the potential for simulation to diminish patient contact time. Therefore, the study was designed to investigate several outcomes to provide justification for the integration of high-fidelity simulation into ACNP curriculum.
Materials and Methods
The study design was a prospective, pretest-posttest study without a control group. The institutional review board at the UIC approved the study. Seven senior ACNP students participated in a one-time, 2.5-hour simulation on a patient with pneumonia and septic shock. The scenario consisted of a patient presenting to the intensive care unit with recent onset cough, fever, and shortness of breath. Students were charged initially with taking a brief history and conducting a directed physical examination demonstrating a tachypneic and febrile patient with bilateral crackles on chest examination. Students were aided variably by faculty members at the bedside to generate a working diagnosis, titrate supplemental oxygen, initiate appropriate antibiotics, and insert peripheral intravenous catheters for rapid fluid resuscitation. Students were further required to intubate the patient for refractory hypoxemia and altered mental status, choose ventilator settings, and place a central venous catheter to measure central venous pressure and initiate vasopressor support.
Evidence-based knowledge and confidence were assessed by a 13-question validated written test and a 2-question, 5-point Likert scale survey, respectively. After simulation, students further completed a 5-question, 5-point Likert scale survey assessing satisfaction with the experience and their opinions regarding the importance of simulation in ACNP training. Written test scores were analyzed using a paired t-test and reported as mean correct responses with standard deviation. Confidence in managing a patient in circulatory shock and managing a patient requiring mechanical ventilation was assessed before and after simulation, and was analyzed using a paired t-test. Postsimulation perception was assessed by a 5-point Likert scale survey with responses ranging from "disagree" to "strongly agree."
Results
All students completed the pre and postwritten tests, pre and postconfidence surveys, and the postsimulation perception survey. Mean correct responses on the written test increased after simulation (7.1 +/- 2.4 versus 10.3 +/- 1.5, P=0.019). Six of seven students improved their number of correct responses; one student had the same number of correct responses before and after simulation. Student confidence in their ability to manage a mechanically ventilated patient improved after simulation from generally "somewhat not confident" to "very confident," P=0.031; confidence in managing circulatory shock improved from generally "somewhat not confident" to "very confident," P=0.007. Students either "agreed" or "strongly agreed" that simulation enhanced critical thinking skills and evidence-based practice, and that the experience was fun, realistic, and should be a mandatory part of ACNP education.
Results indicate that a one-time, 2.5-hour critical care simulation session increased knowledge acquisition and confidence in senior ACNP students. After participating in the session, students felt more confident in managing a patient in circulatory shock requiring mechanical ventilation. These results are consistent with the findings of other studies regarding simulation in medical education. Limitations include the fact that while knowledge acquisition was measured objectively via pre and posttests, researchers did not measure simulation or real-life performance before and after educational intervention occurred. In addition, while self-assessed confidence increased after simulation, this does not necessarily imply increased skill.8
Positive Reinforcement
While data reported in this study are limited, they are favorable and do support our plan to further incorporate simulation as a component of ACNP curriculum. However, as the use of simulation increases in healthcare education, it is essential to remember that there is no replacement for direct patient contact time.
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