Nursing Education and Substitution and Make Up for Clinical Environment and Challenges or Benefit of Simulation Use

Simulations Used for Clinical Substitution and
Clinical Make Up In Nursing Education

    Simulations are currently being
used in clinical settings to substitute for real clinical time for various
reasons. For some schools of nursing, the issue of finding quality, appropriate
clinical sites is a challenge for faculty, particularly in specialty areas such
as pediatrics or maternal health (Hayden, Kegan, Kardong -Edgren, & Smiley,
2014; Meyer et al., 2011). 

    Nurse educators have substituted clinical time in
many cases for time in the simulation area to provide nursing students
appropriate clinical experiences that are developed and implemented through
clinical simulations. 

    In some instances, schools of nursing are labeling
clinical times as “off-campus” clinical for actual experiences in health care
institutions and “on-campus clinical” when the clinical experience is obtained
in the simulation laboratory.

    At New York University, adult health courses are
being delivered with 50% off campus clinical (real clinical time) and 50%
on-campus clinical to help with their clinical faculty shortage and competition
for clinical sites (Richardson, Goldsant , Simmons, Gilmartin, & Jeffries,
2014). 

    In some schools of nursing, clinical simulations are being used for
“clinical make-up” days for those students missing clinical because of illness,
weather, or other unforeseen causes. There can be an entire “clinical day” set
up in the simulation lab for clinical hours. 

    Some nurse educators use virtual
simulations (computer based learning) that has a debriefing component and
scoring to meet clinical make-up hours when needed and when the content fits
with the curriculum needs. 

    A landmark multisite study conducted by the National
Council of State Boards of Nursing (NCSBN) explored the clinical competency of
new graduates on their transition to practice based on their participation in
either a control group, a group that substituted 25% of real clinical hours for
simulations, or a group that substituted 50% of their clinical hours for
simulation. 

    The study report stated,
substantial evidence [demonstrates] that up to 50% simulation can be
effectively substituted for traditional clinical experience in all prelicensure
core nursing courses under conditions that are comparable to those described in
the study. 

    These conditions include faculty members who are formally trained in
simulation pedagogy, an adequate number of faculty members to support the
student learners, subject matter experts who conduct theory based debriefing,
[and] equipment and supplies to create a realistic environment. (Hayden,
Smiley, Alexander, Kardong , & Jef ries , 2014, p. S38).

    The NCSBN also
stated that the State Boards of Nursing should feel assured about the validity
of simulation programs if nursing schools have enough dedicated staff members
and resources to maintain the program on an ongoing basis. 

    These findings are
significant for the nurse educator community because too often quality clinical
sites are difficult to find; health care agencies are limiting the amount of
practice and procedures students can actually perform in the clinical setting;
and, the client census is diminishing in the acute care settings such that
clinical experiences are limited and focus only on the acute care population.

Challenges of Using Simulations For Clinical Environment In Nursing Education

    Simulations can offer nurse
educators and health care providers a significant educational method that meets
the needs of today’s learners by providing them with interactive,
practice-based instructional strategies. Implementing and testing the use of
simulations in educational practice has both challenges and benefits. 

    Most of
the challenges of using clinical simulations center on educators’ preparation
for using simulations and inter professional simulations. Before using
simulations as a learning strategy, the faculty must have:

1. A firm foundation in
experiential learning

2. Clear learning objectives for
the simulation experience

3. A detailed design taking into
account that an educator facilitates learning (versus tells the learner)

4. Sufficient time for learners to
experience the simulation, to reflect on the experience, and to make meaning of
the experience

5. Faculty development in the area
of simulation pedagogy; the teaching strategy is student-centered, which for
many is a paradigm shift in teaching

6. Strategic ways to quantify and
document clinical simulation hours towards licensure or certification

7. When using IPE simulation, there
must be alignment of student clinical placements across the professions;
preparation of all faculty and preceptors involved; commitment from all
professions to making IPE experiences a priority; and adequate financial,
human, and spatial resources.

Benefits of Using Simulations For Clinical Environment In Nursing Education

The benefits of using
simulations include:

1. Active involvement of students
in their learning process. By interacting with the simulation, examples, and
exercises, the learner is required to use a higher order of learning rather
than simply mimicking the teacher role model. Decision-making and critical
thinking skills are reinforced through this teaching modality.

2. More effective use of faculty in
the teaching of clinical skills and interventions. In a simulated experience,
faculty members have an opportunity to observe students more closely and to
allow students to demonstrate their potential more fully. Feedback or
debriefing by faculty is a powerful learning tool.

3. Increased student flexibility to
practice based on their schedules. The learner can access the simulation at his
or her convenience and is not required to practice the skills in front of an
instructor, although that option remains available for those who need extra
instruction or reinforcement. The learner can revisit a skill multiple times in
an environment that is safe, nonthreatening, and conducive to learning.

4. Improved student instruction.
Student instruction is improved through better consistency of teaching;
increased learner satisfaction in both the classroom and the clinical setting;
the opportunity for safer, non-threatening practice of skills and decision
making; and a state-of-the-art learning environment.

5. Effective competency check for
undergraduates, new graduates, or new nurses going through orientation. The
simulation experience provides a competency check of the participants’
knowledge, skills, and problem-solving abilities in a nonthreatening, safe environment.

6. Correction of errors
immediately. Students can learn by being immersed in their learning experience
and then being debriefed after the encounter on what was right and what needed
to be done differently.

7. Standardized, consistent, and
comparable experiences for all students. Educators can create consistent,
standardized teaching activities so that all students in a clinical course can
experience an important clinical event, assessment activity, or other essential
clinical learning encounter.

8. Opportunities for collaboration
and IPE. This provides an avenue for safe and effective patient care through
knowledge and understanding of other professionals’ roles and skills that all
students in a clinical course can experience.

    As educators are incorporating
simulations into their courses and into the nursing curriculum, major
challenges and benefits have been noted. Faculty must consider both challenges
and benefits as the simulation pedagogy is adopted into courses and the nursing
curriculum.