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imulation is the reproduction of on a real patient, which indicates uations can be presented.
the essential features of a real- that most students prefer experien- Errors can be corrected and dis-
life situation. Although nurse tial learning. In fact, many students cussed immediately.
educators strive to mimic reality in have experienced high levels of tech- Consistent and comparable
their practice laboratories, they find nology throughout their prior educa- experiences can occur for all stu-
tion, which has afforded them oppor- dents.
tunities for experiential learning. In addition to these benefits, com-
Received: March 4, 2004 As faculty, we know that practice munication, teamwork, and delega-
Accepted: June 15, 2004 and reflective learning are also criti- tion can be simulated. Thus, a mix of
Ms. Medley is Clinical Assistant cal elements of students clinical technical and non-technical experi-
Professor, and Dr. Horne is a retired faculty learning, but several factors prohibit ences can be offered.
member, College of Nursing, University of initial learning, practice, and reflec-
Florida, Gainesville, Florida. tion in todays academic and health
Address correspondence to Catherine care settings. Reduced faculty Interactive Critical Thinking
F. Medley, MSN, RN, Clinical Assistant resources and greater numbers of Current uses of simulation tech-
Professor, College of Nursing, University of students limit the actual time that nology have shown that it offers an
Florida, PO Box J100187, Gainesville, FL students are exposed to patients. excellent approach for developing
32610; e-mail: medlecf@nursing.ufl.edu Initial learning in a real patient set- interactive critical thinking. It has
been used to great extent in anesthe- interface with the computer, the data while non-technical objectives
sia education for students trained in emitted from the mannequin will include judgment, decision making,
intubation (Fletcher, 1995). The U.S. change based on student interven- teamwork, and delegation (Raemer,
Air Force also uses interactive tech- tions and decisions. A faculty member 2003).
nology to simulate a medical unit, an can manually control the computer, Replicate reality as closely as
exercise which develops competence or small subprograms can be stored possible through the environment
in skills, priority setting, organiza- and programmed into the scenario. and equipment. A simulated patient
tion of care, leadership, and delega- For example, a stored subprogram area should contain props such as
tion (Eaves & Flagg, 2001). More may alter blood pressure and heart medical records, patient care plans, a
recently, hospitals are using simula- rate in response to administration of telephone for simulated conversa-
tion laboratories to provide orienta- a specific medication. These small tions, drug and laboratory book refer-
tion to new nurses and specialty programs are unlimited in scope and ences, and the equipment needed to
units, conduct ongoing competency use. complete the required tasks. Student
checks, and enhance risk manage- To maximize the use of the high- roles should be taken seriously, as
ment training. In addition, colleges fidelity equipment such as SimMan should team member roles if a group
and universities are beginning to use (Laerdal Medical Corporation, is participating in the activity.
simulated models in advanced nurs- Wappingers Falls, New York), scenar- Use video equipment to record
ing practice graduate education. ios and case studies, which can be the activities for later use in debrief-
However, the area in which simula- either simple or complex, can be ing conferences.
tion technology is least used, despite developed by faculty and pro- Conduct a debriefing confer-
its great potential, is undergraduate grammed into the simulation com- ence, which is a time for participants
nursing education. puter. These programs provide feed- and observers to engage in group dis-
back and pathways for correct and cussion and learning based on the
incorrect interventions, giving stu- actions taken by the participants.
Scope of Use With dents the consequences of those inter- Rationales for clinical decisions can
Undergraduate Nursing ventions, which lead eventually to be discussed, suggestions for alterna-
Students either resolution of the problem or, in tive actions made, feelings related to
Many types of simulation equip- some cases, death of the patient. In the situation shared, and mistakes
ment are available to nurse educa- this way, the high-fidelity, interactive identified. During the debriefing ses-
tors, so teaching through simulation simulation allows students to learn sion, only selected portions of the
can make use of a wide variety of through critical problem solving. videotape should be shown to make
methods and techniques. Models the desired point. Instructors should
range from equipment that teaches a focus on the exact actions taken and
simple, single skill (e.g., inserting an Process for Instruction evaluate the communication and
intravenous access into an arm; While teaching methods will vary interaction between participants.
assessing vital signs, such as heart, based on the teaching and learning The debriefing session need not be
lung, and bowel sounds) to very objectives, the basic tenets for using lengthy but should be carefully
advanced, realistic equipment that simulation technology remain the planned and led by an experienced
can simulate reality-based scenarios same as for any teaching instrument. faculty member who can engage stu-
in a clinical setting, such as an inten- Educators need to: dents in this important time of learn-
sive care unit. Fletcher (1995) Determine the content best ing, while not criticizing or making
described the term fidelity as the taught through simulation. The students feel inadequate. The
degree of accuracy depicted by the method of teaching should reflect the debriefing seminar is essential and
simulation, compared to the real best and most resourceful approach must not be omitted because most of
experience. Whereas static or low- to meeting teaching and learning the learning occurs at this time.
fidelity models are useful for practice objectives. Some topics do not lend
and testing of specific skills, high- themselves to simulation; for these,
fidelity models challenge students to traditional teaching methods still Leveling Content From
make clinical decisions based on data work best. Simple to Complex
obtained from assessments and inter- Determine the learning objec- Simulation equipment can be used
ventions. tives. It is critical that objectives be on several levels for undergraduate
High-fidelity models are often life- very specific when developing a simu- education, progressing from simple
size mannequins with features such lation learning experience. Two to skills practice and evaluation to com-
as palpable pulses, visible respira- four learning objectives are generally plex scenarios involving teams of stu-
tions, measurable blood pressure and ideal, and both technical and non- dents and critical problem solving.
pulse oximetry, vocal sounds, open technical objectives should be includ- Early use of simulation technology
orifices, and minimal movement, all ed. Technical objectives include may begin with technical skills (e.g.,
programmed by computer. Through knowledge, skills, and algorithms, blood pressure, pulse, respiration,
oral and nasal pharyngeal airways) patient acuity, simulated technology tion computer. Experienced faculty
and components of assessment (e.g., with more complex scenarios offers a are necessary to operate the simula-
heart, lung, and gastrointestinal safe, controlled, and interactive envi- tor and manage the complexity of
assessment, including identification ronment for this capstone course. patient responses resulting from stu-
of anatomical landmarks). Simulated technology allows all stu- dent interventions. With strong clini-
When students perform these dents the opportunity to meet the cal and teaching backgrounds, faculty
assessments on their peers, findings same clinical objectives through var- members can create realistic, chal-
are usually within normal ranges, ied scenarios. lenging situations for students to
and so-called peer patients can help develop clinical decision-making
students who are unsure. Simulation skills.
technology allows skills or assess- Complex Realistic Simulation Faculty support can be augmented
ments to be changed, performed, and To conduct a complex, realistic with technical and laboratory assis-
documented for each student. In simulation experience for undergrad- tant personnel for videotaping and
addition, it allows follow-up interven- uate students, students are first laboratory set-up. These staff mem-
tions or communications to be made divided into two groups: one for par- bers can also role play non-health
as appropriate. The follow up can be ticipants with assigned roles and one care personnel, such as family mem-
as simple as notifying the nursing for students to observe. The nursing bers. Simulation technology does not
faculty or staff nurse in a timely man- learning center can be set up with a necessarily decrease faculty assign-
ner if a patient has an elevated tem- team of 4 to 6 patients, using both ment time, but it does provide compa-
perature. Incorrect follow up can simulated models and live volun- rable learning experiences across stu-
result in negative patient conse- teers. Faculty members guide the ses- dents, effective methods for clinical
quences; if an intervention is not cor- sion by observing simulator respons- instruction, safe and realistic settings
rectly accomplished, temperature es, which result from student inter- for learning, and protected opportuni-
rises, heart and respiratory rates ventions and clinical decisions. ties for independent clinical decision
increase, and family members and Student teams collaborate to provide making.
the physician become upset. necessary care, perform necessary
After simple programs are devel- procedures, and determine appropri-
oped and used, they can become com- ate clinical decisions for their Pursuing Opportunities for
ponents of more complex scenarios. patients. This method allows stu- Collaboration
For example, vital sign or assessment dents to make independent decisions Nursing faculty need not remain
simulations can be incorporated into and experience the consequences of isolated while learning to use simu-
other, more complex simulation their decisions without the possibility lated technology. Departments within
lessons, such as proper use and of harming patients. While the simu- the school, and even faculty across
assessment of a patient in restraints lated environment can feel real, stu- the state and the nation, can collabo-
or administration of a blood transfu- dents know their patients are safe, rate and share successes. Web sites
sion. A scenario to assess a patient which allows for learning with less can be developed to share informa-
with a chest tube may be expanded to anxiety for all involved. tion and even simulated programs.
include detection of and care for a Finally, clinicians need to collabo-
patient with a pneumothorax. rate with researchers to validate the
Administration of antipyretic or anti- Faculty Resources usefulness of simulation technology.
hypertensive medications and cardiac Because high-fidelity simulators Although many educators believe this
glycocides can also become simple are very sophisticated, faculty mem- method is superior, no data currently
enhancements for complex cases. bers need time and instruction to exists to validate the belief that
Basic nursing scenarios can be used to become skilled in teaching with such undergraduate nursing students
develop situations specific to neonatal models, to explore methods of appli- learn better through simulated tech-
care, pediatrics, community health, or cation, and to develop scenarios. nology. In a broader literature search
mental health. Simulation scenarios Preprogrammed simulated scenarios of other disciplines, research to sup-
are limited only by the imagination. available for nursing are limited; port improved learning from simula-
Most nursing programs have a most are intended primarily for med- tion is lacking, although some educa-
capstone course toward the end of ical interventions or emergency train- tional simulation programs report
their undergraduate curriculum that ing, rather than for basic nursing evaluative data. Even when pretest-
combines and synthesizes knowledge education. Faculty must adapt pre- posttest data were used, comparative
learned throughout the program. programmed scenarios to create new methods were not included. No
Students in this course are expected scenarios that maximize the benefits research that used a rigorous design
to demonstrate sound, safe clinical of simulation technology in under- to demonstrate differences in learn-
decision making. Again, with limited graduate nursing education. ing between traditional methods and
time and clinical resources, shortened After scenarios are written, they high-fidelity simulation methods
length of patient stays, and high must be programmed into the simula- were found.