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Scholarship of Teaching and Learning Grant Final Report Implementation of Simulation Using High Fidelity Manikins: An Intervention to Enhance Learning and Performance for Advance Practice Nurses in Pediatrics Marie H Thomas, PhD, FNP‐BC, CNE Kathleen Jordan, DNP, FNP‐BC, ENP‐BC, SANE-P Colette Townsend‐Chambers, MSN, RN Developing the requisite knowledge and skill set to perform as a highly competent advanced practice nurse (APN) is an art and a science. Of utmost importance, the APN must be able to critically appraise a clinical situation and intervene appropriately in the provision of safe and effective care, and high-fidelity simulation is a method to enhance this ability in a protected and nonthreatening environment. The purpose of this project was to evaluate the effectiveness of pediatric simulation scenarios using high-fidelity manikins on student learning outcomes related to assessment skills, clinical knowledge, clinical reasoning/decision making, and self-efficacy in APNs. There is a growing body of evidence that supports high-fidelity simulation as an effective pedagogy and andragogy to promote critical thinking, problem solving, and enhancement of the knowledge and skill set required of the APN. Multiple studies have been conducted that support simulation as an effective method of teaching and learning leading to an improvement in confidence, performance and clinical judgment, and reduction of medical errors (Brannan, J.D., White, A., & Bezanson, J.L., 2008; Jeffries & Rizzolo, 2006). In a systematic review conducted by Harder (2010) to evaluate the effects of simulation on student learning, it was demonstrated that clinical skills are enhanced through simulation as compared to traditional learning methods. The most salient advantages of using high-fidelity simulation to enhance the performance of the APN include: 1) student engagement in an active learning strategy executed during each simulation experience that in itself has been demonstrated to promote knowledge retention; 2) exposure to realistic replications of clinical case scenarios in a safe and nonthreatening environment which enhance quality and safety when applied to the real clinical setting, particularly in an urgent or emergent clinical situation; 3) an opportunity for the student to manage a medical problem while simultaneously engaging in patient and family-centered care; and 4) the ability for the student to engage in self-reflection and peer-review as a method to assess and support critical thinking and clinical decision making skills (Hyland, Weeks, Ficorelli & Vandermeek-Warren, 2012; Jeffries & Rizzolo, 2006; Ravert, 2008).The Institute of Medicine (IOM) blueprint report, The Future of Nursing: Leading Change, Advancing Health (2010) calls for a transformation to ensure appropriate healthcare. The IOM supports the use of high fidelity simulation as one method to facilitate this transformation. Student engagement in high-fidelity simulation has the potential to develop and enhance the confidence, knowledge, skill set and self-efficacy required of the APN to meet the increasing demands of health care environment. To date, there is limited research on the use of high-fidelity simulation in the education of APNs, and exploratory outcome data is needed to support this method of teaching and learning. MethodsThe Jeffries Model for Simulation (2005) was the guide used in the development of four pediatric clinical simulations of commonly encountered health care situations by APNs and represented situations commonly encountered by primary health care providers as identified by the Agency for Healthcare Research and Quality (Weir, Hao & Owens, 2013). The four simulation scenarios were developed and designed to incorporate active learning, requiring student engagement in assessment, diagnosis, clinical decision-making, implementation of a course of treatment, and interacting with family (Appendix A). All clinical scenarios included changes in physiologic responses based on age, level of development, family dynamics, appropriate laboratory values, and imaging studies as appropriate to the scenario.All four pediatric simulation scenarios were provided to students in a small group format allowing for focused assessment, pertinent history taking, identification of diagnosis, development of appropriate treatment plan, and documentation. The Jeffries model (2005) supports the use of small student groups to allow time to gather information, diagnose, and plan a course of treatment. Eight clinical hours were devoted to the 4 different pediatric simulation scenarios permitting each student at least two opportunities to participate in the simulated clinical office visits. Participation in the simulation scenarios were required and were counted as part of the APN student’s designated clinical hours for the graduate nursing course Advanced Primary Care of Children and Adolescents (NUNP 6260). Both faculty and student evaluation of the scenarios and the student experience during the simulated office visits were collected to allow for future refinement and modification of the process. Simulations were videotaped allowing a mechanism to review the scenario and provide opportunities for guided reflection during debriefing. Faculty and peer feedback was provided to encourage and reinforce performance, knowledge, and clinical decision-making. Student-student and student-faculty interactions are designed to encourage collaboration in evaluating the pediatric patient’s situation and implementing the appropriate plan of care as well as promote achievement of the goals of each simulation and meet the learning outcomes for the course. Students were evaluated on age appropriate assessment skills, clinical-decision making and development of the differential diagnosis, planning an appropriate course of treatment, interaction with the family, and overall integrative knowledge of the care needed including laboratory values and pharmacology as appropriate. Evaluation Evaluation of the student learning outcomes was conducted through the use of the Student Satisfaction and Self-Confidence Learning instruments developed by the National League for Nursing (NLN) and Laerdal Medical Company (Jeffries & Rizzolo, 2006). Permission to use these instruments was obtained from the NLN. Upon completion of the high-fidelity simulation experience, the student participants completed three hard-copy instruments that have been previously tested for validity and reliability by content experts in simulation development and testing. The first tool was a Simulation Design Scale, a 20-item questionnaire using a five-point Likert scale designed to evaluate the design features of the simulations used in the study, and the importance of those features to the learner (Appendix B). The second tool was an Education Practices Questionnaire, consisting of 16-items using a five-point Likert scale designed to measure whether four education practices are present in the simulation (active learning, collaboration, diverse ways of learning, and expectations), and the importance of each practice to the learner (Appendix C). The third tool was a Student Satisfaction and Self-Confidence in Leaning Questionnaire, consisting of 13-items using a five-point Likert scale designed to measure student satisfaction with the simulation activity and self-confidence in learning (Appendix D). ResultsFamily nurse practitioner students enrolled in a pediatric clinical course completed four different clinical simulations representing common pediatric problems seen in primary care. Twenty of the volunteers (19 female and 1 male) completed all four simulations; one student (a female) completed two simulations. The demographic variables of the study group were as follows: all of the students were B.S.N. graduates, and held an active North Carolina Nursing License and were enrolled in the fifth semester of a Family Nurse Practitioner M.S.N. program at a state university. All of the student participants had a minimum of one year of nursing experience. Ninety-four Jeffries/NLN simulation questionnaires were completed anonymously and submitted for analysis. Each student was asked to complete three evaluation tools after each of the four clinical simulations. The Jeffries/NLN evaluation tools include: Student Satisfaction and Self-Confidence in Learning, Simulation Design Scale, and Educational Practices Questionnaire. The questionnaires use Likert scales of 1-5 with 5 representing strongly agree and 1 representing strongly disagree. Data from the questionnaires were analyzed using SPSS. The Student Satisfaction and Self-Confidence in Learning Scale is a 13-item questionnaire designed to measure student attitudes regarding the simulation experience. The first five items are designed to elicit information about student satisfaction with simulation; the remaining questions focus on student self-confidence. Results from the Student Satisfaction items indicated that the students felt the simulation was a valuable teaching tool to support their clinical education. Ninety-six percent of the students agreed or strongly agreed that the simulation was effective in enhancing their clinical knowledge and the simulation was an effective teaching tool. Ninety-four percent of the students felt the simulation enhanced their self-confidence in handling common conditions presented in pediatric practice. The Simulation Design Scale is a 20-item questionnaire focusing on the individual elements of the simulation ranging from learning objectives to realism. On the Simulation Design Scale an average of 96.2 percent of the students agreed or strongly agreed that the simulation was effectively designed and clinically applicable to their practice and learning needs. Ninety-two percent of students felt instructors’ questions helped them to think critically; 89.2% strongly agreed that the instructors’ effectively facilitated the simulation experience. Eighty-two percent strongly agreed that they were challenged in their thinking and decision-making skills and better prepared them to care for actual patients. Students commented favorably on the instructor feedback they received during the experience; 91.8 % felt the feedback and comments were helpful and perceived their instructors as facilitators. On the 16-item Educational Practices Questionnaire, 94.5% of students felt the simulation experience was effective. A goal of the research study was to investigate student-student and student-faculty collaboration in assessment, diagnosis and treatment of pediatric patients in primary care. Ninety one percent of the students agree or strongly agree that simulation supported active learning, 87.4% felt the experience encouraged collaboration and 89.5% felt simulation was a unique method of teaching. Eighty nine percent of students felt the learning outcomes, goals and expectations were clear for the simulation. The following chart indicates the overall results of the study.DiscussionOverall, the students reported the simulation experiences as very helpful and a good preparation for clinical. Students also stated they would have benefited from an orientation to simulation as experiences with simulation varied from none to having extensive experience with simulation in their Baccalaureate program. The ability to ask questions and collaborate with peers was considered very positive experience. The majority felt the use of simulation should continue and be part of the future curriculum. Simulation can and should be developed to support clinical experiences for APN students. Future plans are incorporating simulation experiences in the advanced adult health curriculum and the women’s health curriculum. Continued research is needed to identify the type and amount of simulation need to maximize patient safety and quality of care.Appendix APediatric Clinical Scenarios#1. Simulation Design Template: AsthmaExpected Simulation Run Time: 30 minutes Client Name: Michael DavisGender: MaleAge: 8 yearsHistorian: Mother and patientCC: Cough and wheezingWeight: 30 kg Height – 52 inchesVital Signs: P – 128 RR – 36 T 99 oral SaO2 – 92%Allergies: No known drug allergies Medications: Zyrtec, Albuterol Immunizations: Current per CDC recommendationsPast Medical History: Diagnosed with asthma three years ago. History of seasonal allergies, and intermittent wheezing with change of seasons. Last episode of wheezing was several months ago. RSV in infancy x2. History of Present Illness: Michael Davis is an 8-year-old male who is brought into your pediatric primary care office with the chief complaint of cough and wheezing for 2 days. He has a history of asthma but it is very well controlled and he rarely has to use his Albuterol. He has both a nebulizer and a MDI with spacer and mask. His mother states that since the weather has changed and the pollen has appeared he has been having watery eyes, a stuffy nose, and a mild cough. Over the past 2 days he has started wheezing and coughing more. His mother reports that she has been administering Albuterol via nebulizer his nebulizer every four hours. Last night he woke up during the night coughing and wheezing and he had to have an albuterol treatment. His teacher also said that he has had to go to the nurses’ office at school yesterday for a treatment after playing outdoor during recess. Social History: Lives with mother and father. He has two older school-age siblings, ages 5 and 10. His 10-year-old sibling has asthma. He is in the third grade at school, plays baseball and soccer. Objectives:1. Perform a comprehensive history and physical examination on the patient.2. Correctly diagnose the clinical condition and acuity level of the patient.3. Order the appropriate interventions. Order appropriate diagnostic tests if needed.4. Reevaluate the patient after implementing interventions and modify plan of care as needed.4. Accurately diagnose and implement a plan of care for the patient (intermittent asthma) using the asthma action plan. Include discharge teaching and discussion of follow-up and return precautions. Write prescriptions for needed medications.Scenario Progression OutlineTIMEMANIKEN ACTIONSEXPECTED INTERVENTIONS2 MinutesSitting in high-fowlers position on stretcherWash handsIntroduce self to motherInitiate history5 minutesTachypnea with RR 36, tachycardia with heart rate 128, Sa02 – 92%, inspiratory and expiratory wheezing, coughing frequently, intercostal retractions PEFR - 175Complete a history and physical examination (Findings: Pt. is in mild respiratory distress, moist mucous membranes, pharynx without erythema, boggy nasal mucosa, normal skin turgor, brisk capillary refill, lungs with inspiratory and expiratory wheezing bilaterally, abdomen with normal bowel sounds, soft, non-tender, moves all extremities equally)Assess Peak Flow5 minutesUnchangedExplain concerns of physical examination findings to mother and patient. Discuss plan of care. Verify allergies. Order Albuterol 2.5 – 5 mg and Atrovent 0.5 mg HHN. Order steroids – loading dose with 2 mg/kg of Orapred (15 mg/5 ml = 20 ml or two 30 mg ODT’s)5 minutesPt. reports that he is feeling better. Wheezing is increased, however air exchange is improved. SaO2 – 95%PEFR - 225Inquire as to how pt. is feeling. Auscultate lungs. Assess peak flow. Explain that a second Albuterol 2.5 – 5.0 mg will be administered. Order treatment.5 minutesPt. reports that he is feeling much better. Lungs with minimal wheezing, RR: 20 Sa02 – 98%.PEFR - 230Confirm success of therapy with pt. and mother. Discuss home care to include: Albuterol 2.5 mg HHN every 4 hours as needed Orapred @ 1 mg/kg for 4 more days (10 mg or one thirty ODT). Continue ZyrtecDiscuss possibility of needing an inhaled steroid if symptoms are difficult to controlReview asthma plan and provide to pt. and motherDiscuss return precautions: worsening wheezing, coughing, chest tightness or SOB. Advise to return to the ED or office during office hours. Use asthma action plan.Equipment Needed:Pulse OximeterPeak flow meterStethoscope Nebulizer for Albuterol/Atrovent administrationPeak Flow Meter ChartAsthma action plan formBlank Prescription Debriefing / Guided Reflection Questions for This Simulation1. What assessment data is important in determining degree of respiratory distress in children? 2. What were your priorities for this patient? 3. How did the team determine who would do what? How did you communicate? 4. What did you do well? Were your interventions effective? 5. To Observers: What questions or comments do you have for the team? #2. Simulation Design Template: Child MaltreatmentExpected Simulation Run Time: 30 minutes Client Name: Steven MorrisonGender: MaleAge: 6 weeksHistorian: Mother CC: Fussy, and ? pain in left legWeight: 4.2 kg Vital Signs: P – 136 RR – 32 T 100.8 ?Allergies: No known drug allergies Immunizations: Current per CDC recommendationsPast Medical History: Patient was a full-term vaginal delivery @ 39 weeks gestation. Mother was a G1P1. There were no complications during pregnancy, labor or delivery. Apgar’s were 8 and 9. Birth weight was 3.2 kg.History of Present Illness: “Patient appears to be fussy since he woke up this morning. He is bottle-fed (Gerber Gentle) and normally takes about 4 ounces every 3-4 hours. This morning he only drank 2 ounces of formula. He is normally not a fussy baby and this morning has been very fussy, doesn’t want to be put down and cries especially hard when I change his diaper or dress him. He acts like his left leg might be hurting him. My husband got up to feed him during the night and told me that he drank his whole 4 ounce bottle”.Social History: Lives with mother and father. He is an only child. Mother is a stay at home mom, and he does not attend daycare Objectives:1. Perform a comprehensive history and physical examination on the patient, identifying left leg pain.2. Identify a list of differential diagnoses.3. Order the appropriate diagnostic tests.4. Accurately diagnose and implement a plan of care for the patient.Scenario Progression OutlineTIMEMANIKEN ACTIONSEXPECTED INTERVENTIONS2 MinutesBeing held by motherWash handsIntroduce self to motherInitiate history5 minutesCries with movement and palpation of left legComplete a history and physical examination5 minutesLying on exam tableExplain concerns of physical examination finding to mother, discuss plan of care and order x-ray of left femur10 minutesLying on exam tableReview x-ray findingsInform primary nurse of plan of careConsult with pediatric orthopedics Notify law enforcement and DSSContact EMS for transferDiscuss x-ray findings and plan of care with mother TIMEMANIKEN ACTIONSEXPECTED INTERVENTIONS2 MinutesLying on exam tableSeizure activity – lasting 1 minutes and spontaneously resolvesPlace infant on side, maintain open airway, administer oxygen, monitor vital signsInitiate peripheral IV5 minutesLying on exam tableGives report to EMSNotify orthopedic surgeonNotify emergency department (ED) as patient will now go to the EDTransfer of patient to the EDCritical Behaviors1. Preform a complete head to toe exam, identifying fussy infant with full anterior fontanel, and tenderness on palpation of left femur. 2. Preform neurovascular assessment of left leg. 3. Identify and treat acute pain.4. Order x-ray. Interpret x-ray.5. Consult with orthopedics and arrange for transfer. Notify Police and DSS. 6. Order splint. Discuss plan of care with patient’s mother.7. Identify seizure. Protect airway. Reevaluate pt. after seizure.8. Notify ED. Monitor pt. until EMS arrives for transfer.Equipment Needed: Gauze (to place over anterior fontanel)O2 with tubingPulse OxSplint for legDebriefing / Guided Reflection Questions for This Simulation1. How did you feel taking care of Steven and his mom? 2. What were your priorities for this patient? 3. How did the team determine who would do what? How did you communicate? 4. What did you do well? Were your interventions effective? 5. To Observers: What questions or comments do you have for the team? #3. Simulation Design Template: Gastroenteritis with DehydrationExpected Simulation Run Time: 30 minutes Client Name: Brittany SmithGender: FemaleAge: 18 monthsHistorian: Mother CC: Vomiting, diarrhea and feverWeight: 10.9 kg Vital Signs: P – 136 RR – 32 T 100.5 ? SaO2 – 99%Allergies: No known drug allergies Immunizations: Current per CDC recommendationsPast Medical History: Otitis media x 1, 6 six months ago that cleared with one course of Amoxicillin. No previous hospitalizations or surgeries.History of Present Illness: 10:00 AM Brittany Smith is an 18 month old who is brought into your pediatric primary care office with the chief complaint of vomiting and diarrhea. Her mother states that for the past 2 of days she has had vomiting, diarrhea, and a low-grade fever with T max of 101.4. Her mother reports that Brittany has been unable to keep anything down all day today, and vomits even after sips of Pedialyte. She also reports that she has not changed a wet diaper since last night.Social History: Lives with mother and father. She has two older school-age siblings who are healthy. She attends daycare and mother reports that several children in her daycare have had similar symptoms this week. Objectives:1. Perform a comprehensive history and physical examination on the patient, identifying mild dehydration.2. Identify a list of differential diagnoses.3. Order the appropriate interventions. Order appropriate diagnostic tests.4. Accurately diagnose and implement a plan of care for the patient.Scenario Progression OutlineTIMEMANIKEN ACTIONSEXPECTED INTERVENTIONS2 MinutesBeing held by motherWash handsIntroduce self to motherInitiate history5 minutesCries when approached by examiner (tears present). Easily consolable by mother. Complete a history and physical examination (Findings: pt is in NAD, nontoxic, but does not appear to feel well, positive tears, mildly dry mucous membranes, normal skin turgor, brisk capillary refill, lungs CTA bilaterally, mild tachycardia, abdomen with hyperactive bowel sounds, soft, non-tender, diaper moist with urine)5 minutesLying on exam tableExplain concerns of physical examination findings to mother: mild dehydration; discuss plan of care (Zofran 0.15mg/kg po followed by a po challenge in 20 minutes). If pt is able to tolerate po then we will discharge to home, if unable to tolerate po challenge then we will give IV bolus and check UA and BMP. Offer mother opportunity to verbalize questions and concerns. 10 minutesFollowing po challenge of 30 ml of Pedialyte, pt is sitting on mothers lap looking at a book. NO further vomiting or diarrhea.Discuss plan of care for discharge to include:Self-limited viral gastroenteritisSymptomatic home care: oral replacement of fluids 5 ml every 5 minutes. Goal is 50 ml/4 hours. As vomiting decrease offer larger amounts of fluids more frequentlyNo fruit juice, sorts drinks or sugary drinksAdvance diet slowly as tolerated to full dietReturn to office or ED if pt is unable to keep fluids down, abdominal pain, blood in stoolsDebriefing / Guided Reflection Questions for This Simulation1. What assessment data is important in determining degree of dehydration in children? At what point do you initiate IV fluids? What fluid would you start with and at what rate?2. What were your priorities for this patient? 3. How did the team determine who would do what? How did you communicate? 4. What did you do well? Were your interventions effective? 5. To Observers: What questions or comments do you have for the team? #4. Simulation Design Template: Supracondylar FractureDate: April 2015Course: NUNP 6460 Expected Simulation Run Time: 30 minutes Setting: Urgent Care CenterBrief Description of Client Name: Christopher JohnstonGender: MaleAge: 6 yearsHistorian: Mother CC: Fell off monkey bars and injured right armWeight: 24 kg Vital Signs: P - 128 RR - 28 BP - 116/78 T – 99.2 SaO2 – 99% Allergies: No known drug allergies Immunizations: Current per CDC recommendationsPast Medical History: Patient is healthy with no medical history. No previous hospitalizations. Does not take any medications on a daily basis.History of Present Illness: As per pt’s mother, Christopher was at school during recess swinging on the monkey bars and fell off and landed on his right arm on a dirt covered ground surface. Her mother reports that the teacher assistant (TA) was standing there and saw him fall. The TA informed her mother that he did not lose consciousness, and cried immediately and was complaining of right arm pain. The teacher assistant reported that it was difficult to console him. The teacher assistant stated that she asked Christopher if anything else hurt and he reported “just my arm”. The TA carried him into the nurses office. Ice and a splint were applied and the nurse called Chistopher’s mother. Social History: Lives with mother and father. He has two younger siblings and everyone at home is healthy. Mother is a stay at home mom. Objectives:1. Perform a comprehensive history and physical examination on the patient, identifying any other areas of injury. Perform a detailed neurovascular assessment of the right arm. 2. Identify a list of differential diagnoses.3. Order the appropriate diagnostic tests.4. Accurately diagnose and implement a plan of care for the patient.Scenario Progression OutlineTIMEMANIKEN ACTIONSEXPECTED INTERVENTIONS2 MinutesLying on the stretcherWash handsIntroduce self to motherInitiate history5 minutesCrying and stating “don’t touch my arm, it hurts”, sobs with palpation of right arm; and states that her left knee abrasion hurts. States that nothing else hurts. Continues sobbing in plete a head–to-toe history and physical examination5 minutesLying on exam tableDiscuss plan of care with pt and mother. Explain that pain medication will be given IV to maintain NPO status, in case pt. needs surgical intervention, and an x-ray will be ordered. Orthopedics will be contacted after the x-ray.Verify that the patient does not have any allergies and verify stable vital signs. Order IV morphine at 0.1 mg/kg = 2 - 2.4 mg morphine IVPOrder a long arm splint with arm in position of comfort. Elevate extremity on a pillow. Perform neurovascular assessment before and after splint is applied.Order a PA and lateral view of the right elbow.10 minutesLying on exam tableReview x-ray findings and consult orthopedics. Inform primary nurse of plan of careNotify emergency department as pt will be transferred to the ED.Evaluate pt’s pain level and assess neurovascular status of right arm/handDiscuss plan of care with motherContact EMS for transfer5 minutesLying on exam tableGives report to EMSTransfer of patient to the EDCritical behaviors:1. Preform a complete head to toe exam, identifying right elbow injury and left knee abrasion.2. Preform neurovascular assessment of right distal arm. Apply splint and reassess neurovascular status of distal right arm.3. Identify and treat acute pain.4. Order x-ray. Interpret x-ray.5. Consult with orthopedics and arrange for transfer.6. Discuss plan of care with pt’s mother.7. Reevaluate neurovascular status and level of pain.Equipment Needed:SplintIV for pain medication (can use intranasal fentanyl), or IMX-rayVital sign machineIce and pillow for elevation of extremityDebriefing / Guided Reflection Questions for This Simulation1. What were the priorities of care for Jennifer?2. How did the team determine who would do what? How did you communicate? 4. What did you do well? Were your interventions effective? 5. To Observers: What questions or comments do you have for the team? Appendix B ................
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