Nursing Education and Technology Empowered Learning: Using Simulations, Simulators Nomenclature, Fidelity, Partials or Full & Hybrid Simulators Use

Teaching and Learning Using Simulations In Nursing Education

    The complexities of the health care
system coupled with a changing patient population have created a need for
nursing students to be prepared to care for all types of patients in a variety
of care settings. 

    Additionally, as health care shifts to community settings,
nurse educators have been challenged to find appropriate clinical sites and
clinical experiences for nursing students to meet curricula competencies and
required clinical experiences. 

    Because of these challenges, nurse educators are
exploring alternative strategies for clinical preparation for nursing students.
Simulation offers nurses, students, and health professionals the opportunity to
learn in situations that are comparable to actual patient encounters within a
controlled learning environment (Alden & Durham, 2012; Katz, Peifer, &
Armstrong, 2010) that supports the learners’ transfer of classroom and skills
laboratory knowledge to realistic patient interactions (Anderson & Warren,
2011; Halstead, 2006; Meyer, Connors, Hou, & Gajewski, 2011). 

   Clinical
simulation technology is becoming increasingly realistic, and nursing programs
are making substantial investments in equipment and learning space. As
simulations and related teaching and learning strategies move into nursing
programs, and evidence supports clinical simulations as an alternative to
actual clinical experiences (Hayden, Smiley, Alexander, Kardong -Edgren, &
Jeffries, 2014), nurse educators must be prepared to teach using this
methodology.The topic emphasizes:

(1) the types of clinical simulations being developed and
implemented in nursing programs

(2) challenges and benefits to student
learning, thinking, and practice

(3) a framework and steps to consider when
developing and using clinical simulations

(4) the evaluation component to
consider when implementing simulations in the teaching learning environment

Simulation

    Simulations are activities or
events, such as performing basic life support on a patient simulator to manage
a cardiac arrest, that mimic real-world practice. Simulations are used when
real-world training is too expensive, occurs rarely, or puts participants (or
patients) at unnecessary risk. 

    Simulations provide the opportunity for students
to practice within their scope of practice, think critically, problem solve,
use clinical reasoning, and care for diverse patients in a nonthreatening, safe
environment. 

    Incorporating simulations into a nursing curriculum as a teaching
and learning strategy offers nurse educators the opportunity to support
learners’ educational needs by providing them with an interactive,
practice-based instructional strategy.

Simulation Nomenclature In Nursing Education

    There are various types of
simulations. The terms used to describe various aspects of the simulation
experience are described here. The simulation nomenclature matrix includes
learning domains and tool and environmental realism. Tool and environmental realism
are further categorized into types of fidelity low, medium, and high and the
context of the fidelity as partial or full.

Fidelity

    Fidelity, or the realism of
simulations, is described along a continuum from low fidelity to high
fidelity relative to the degree to which they approach reality. 

• Low fidelity:
This type of simulation experience includes case studies to educate students
about patient situations, role playing, the use of a partial task trainer or
static manikin (eg, plastic model arm to learn how to perform a venipuncture,
wound care trainer for wound management) to allow students to perform a task or
skill. 

    Low-level realism is present; however, principles and concepts can still
be learned using this type of simulation (International Nursing Association for
Clinical Simulation and Learning [INACSL] Board of Directors, 2011). 

• Medium
fidelity: This type of simulation is technologically sophisticated in that the
participants can rely on a two-dimensional, focused experience to solve
problems, perform skills, and make decisions during the clinical scenario. 

    These manikins have the ability to auscultate heart sounds and breathing sounds
but the chest does not rise. Some examples include VitalSim Anne and VitalSim
Kelly. 

• High fidelity: This type of simulation involves full-scale,
high-fidelity human patient simulators, virtual reality or standardized
patients (actress or actors portraying simulated patients that have certain
health disruptions) that are extremely realistic and provide a high level of
interactivity and realism for the learner (International Nursing Association
for Clinical Simulation and Learning [INACSL] Board of Directors, 2011). 

    Examples include SimMan 3G, SimNewbie , iStan , and METI HPS, as well as a
birthing simulator called Victoria and her newborn infant, all of which allow
the student to listen to various body sounds and can be programmed to talk and
to respond to interventions performed by the students.

Partial or Full-Context Simulations

The Context of Simulations Can be Partial or Full

• Partial task trainers: Partial
task trainers are those simulations in which a body part, plastic model, or
partial manikin is used to depict a certain function and on which a student can
practice a particular psychomotor skill. 

    Examples of partial task trainers
include intravenous (IV) cannulation arms and low-technology manikins that are
used to help students practice specific psychomotor skills integral to patient
care such as inserting urinary catheters or nasogastric tubes.

• Full-context simulations: These
simulations include the full context of a scenario, an event, or an activity
that replicates reality. For example, a static manikin with limited functions
such as VitalSim Kelly is full context but medium fidelity. 

    The full context of
an event can be represented using this type of simulation in a low fidelity
manner. High fidelity, full context is a simulated learning experience using a
high-fidelity simulator and immersing the participants in a realistic mock code
situation or a simulated live birth. 

    Full-scale patient simulations using
sophisticated, high-fidelity patient simulators provide a high level of
interactivity and realism for the learner. Less sophisticated, but still
educationally useful, are computer-based simulations in which the participant
relies on a two-dimensional, focused experience to solve problems, perform
skills, and make decisions during the clinical scenario. 

    Studies have shown
that the two-dimensional experience has merit in terms of positive learning
outcomes and skill acquisition (Jeffries, Woolf, & Linde, 2003).Partial task training devices such
as IV arms and haptic (force feedback) IV trainers are used in simulations for
psychomotor skills. 

    The learner is able to practice a skill repeatedly before
performing it on a real patient. The partial task trainers typically ensure a
satisfactory rate of achievement of objectives and benefit to the participant. 

    Studies have shown that after having used these task trainers, participants
demonstrate a psychomotor skill and use that skill set in the real patient
environment (Engum & Jeffries, 2003). 

    Programs or courses in which the task
trainers are used include clinical laboratory courses and modules during which
specific skill sets and goals need to be obtained. Another approach to learning
is the use of two-dimensional CD-ROMs to provide interactive practice with
skills.

Types of Simulation

    Simulations variously involve role
playing, standardized patients (actors), interactive videos built on gaming
platforms, and manikins to teach procedures, decision making, and critical
thinking in realistic environments (Ryan et al., 2010). There are a variety of
technology-based simulations to support student and novice nurses. 

    They include
computer-based interactive simulations, haptic partial task trainers, and
digitally enhanced manikins. Haptic trainers use force feedback to provide
opportunities to develop psychomotor skills. 

    In addition to types of
simulations categorized by the equipment or manikin used, there are simulations
categorized by the type of pedagogy used when implementing the simulations.
These types of simulations are described in the following sections.

Hybrid Simulations

    A hybrid simulation is the
combination of a standardized patient and the use of a patient simulator in one
scenario to depict a clinical event for the learner. For example, the
simulation scenario may begin with the student performing a health history on a
standardized patient who has just arrived in the emergency department after
having been involved in a motor vehicle accident. 

    As the case evolves, the
activity shifts to a patient simulator because of the clinical symptoms that
need to be demonstrated by the manikin to reflect reality. This is a hybrid
simulation because the history is being performed on a standardized patient and
then the scenario shifts to a patient simulator, where the patient is now
experiencing “hypovolemic shock” that is being reflected in the vital signs and
other clinical findings of the manikin . 

    A common hybrid simulation in
obstetrics involves a low-fidelity task trainer with a standardized patient for
simulations of normal birth or complications such as shoulder dystocia. This can
be done with a standard actor and the pelvis of a birthing simulator or with
the use of the Mama Natalie, which is a low-cost, wearable device that can
manually deliver a baby and placenta and simulate postpartum complications.

Unfolding Case Simulations

    Another type of simulation is the
unfolding case. Unfolding cases evolve over time in an unpredictable manner. An
unfolding case may include three to four events that build on each other,
providing students an opportunity to plan care across a clinical event, a
hospitalization, a care transition or across the life span (Page, Kowlowitz ,
& Alden, 2010). Unfolding cases can be used to meet a variety of learning
goals:

1. To demonstrate hierarchical
order so the learner can follow the progression of a health problem and the
related nursing care. For example, the first scenario demonstrates the patient
being admitted with a head injury caused by a fall; the learner must conduct a
focused neurologic assessment. 

    The unfolding case leads to a second scenario,
in which the patient experiences specific neurologic signs (eg, severe
headache, widening pulse pressure); the learner must use additional assessment
skills. The third case occurs post craniotomy and involves care of the patient
after the subdural hematoma is removed.

2. To visualize and prioritize
hospital trajectory and care of a patient that progresses. For example, the
patient is admitted through the emergency department, with the learner
performing an assessment. The second scenario depicts the patient being admitted
to the progressive care unit and the third scenario is designed for the learner
to prepare the patient with discharge instructions.

3. To provide the learner with a
view of care transitions, showing the effect of the health disruption or
disease process and nursing interventions required for a particular patient.
For example, the first scenario depicts a hospitalized patient newly diagnosed
with chronic obstructive pulmonary disease (COPD). 

    The second scenario
progresses to the patient having compromised gas exchange related to COPD and
being managed at an ambulatory care center. The third scenario depicts
end-stage disease with a focus on end-of-life care with hospice care.

4. To serve as a mechanism to
include a variety of important assessments and findings where one event leads
to another. For example, the first scenario focuses on hypotension and subtle
findings of sepsis and the second scenario centers on the critically ill
patient with sepsis and hypotension.