Joshua Lincoln, B.A., R.N., M.S.N. - Home



Practicum Evaluation Paper

Joshua C. Lincoln

Ferris State University

Abstract

This paper reviews the educational and theoretical basis for a practicum using High Fidelity Simulation (HFS) for Ferris State University’s Masters in nursing program. Included are the issues this student faced, the projects he was involved in, and the theoretical frameworks used to create said projects. Also included are the evaluations of this practicum by the student and his preceptor. The projects included are peri-mortem simulation, arterial blood gas (ABG) interpretation, and electrocardiogram (EKG) interpretation. This student relied heavily on Howard Gardner’s theory of multiple intelligences, David Kolb’s experiential theory, Madeleine Leininger’s transcultural theory, and Patricia Benner’s Novice to Expert.

Keywords: High Fidelity Simulation, Multiple intelligences, Kolb’s learning theory, Leininger’s transcultural theory, Benner’s novice to expert.

Clinical Practicum Paper

The National League of Nursing (NLN) identifies eight core competencies necessary to be a successful and competent nurse educator: (a) facilitate learning, (b) facilitate learner development and socialization, (c) use assessment and evaluation strategies, (d) participate in curriculum design and evaluation of program outcomes, (e) function as a change agent and leader, (f) pursue continuous quality improvement in the nurse educator role, (g) engage in scholarship, and (h) to function with the educational environment (National League of Nursing, 2005). These competencies served as goals and objectives in the clinical practicum in the education track to obtain the Master’s of Nursing through Ferris State University. The purpose of this paper is to describe the practicum, examine any issues, concerns and challenges during the course of the practicum, address strategies and approaches to the issues anchored by evidence-based theory, and reflect upon practicum outcomes through self-evaluation and preceptor evaluation. This student will address the core competencies through creating, implementing, and evaluating high fidelity simulation. He will educate obstetric nurses on arterial blood gases (ABG’s) and electrocardiograms (EKG’s) in an effort to prepare them for their upcoming advanced cardiac life support training. This student also did extensive research on teaching styles and theories to assist him in improving his own teaching methods.

Theoretical Framework

The eight core competencies outlined by the NLN can seem a daunting task to achieve. The first step in achieving these goals is to base instruction and planning on a theoretical framework. Current knowledge of educational theories and research will act as the foundation for educational practice. Once the foundation is established, educators can apply the theories and research into practice by creating multiple learning opportunities for students. The theoretical framework used during the course of this practicum focuses on the work of Gardner, Kolb, Leininger, and Benner. The knowledge of their educational theories provided this student the basis for instructional practice.

Application of Knowledge from Theory and Research

According to the NLN, the future emphasis in nursing education is not only what people learn, but how they learn and how that information translates into practice (NLN, 2005). To facilitate learning, which is the first core competency outlined by the NLN, nurse educators need to be well versed in the theoretical framework of education and learning theories. Part of the theoretical framework revolves around different learning styles. The concept of different learning styles suggests an educator can tailor instruction to the individual’s learning needs based on their optimal learning modality. These different learning modalities have been explored by researchers such as Howard Gardner and David Kolb. Howard Gardner presented his theory as multiple intelligences. According to Gardner, there are nine different intelligences: visual-spatial, bodily-kinesthetic, musical, interpersonal, intrapersonal, linguistic, logical-mathematical, existential, and naturalistic (McFarlane, 2011).

Assessing different learning styles is relatively easy as there are several online inventories educators can use to evaluate students’ learning styles. The inventory contains learning scenarios in which the test-taker would have to agree or disagree or rate based on a Likert scale. For example, the test-taker would check mark or rate a statement if it were true. If the test-taker were to agree with this particular statement and other statements like it, this affinity would most likely indicate that the test-taker would have a particular intelligence (http:/​/​​howardgardnermultipleintelligences.htm). Students with the interpersonal intelligence have an affinity for problem-solving within groups (McFarlane, 2011). This was a main area in which this student focused as interpersonal intelligence is essential for the multidisciplinary framework in which nursing exists.

David Kolb’s theory revolves around a four stage learning cycle and four different learning styles that transpire as a result of that cycle (McLeod, 2013). His theory is mainly based on learning by experience. The first part of the cycle is called concrete experience. This is any new exposure to a given situation. This new experience leads the learner to the second part of the cycle-reflection. Reflection upon the new experience will help bridge gaps between what was just encountered and any previous knowledge. The third step is called abstract conceptualization. New ideas or changes will occur based on the reflection of the new experiences. The fourth cycle is active experimentation. This is the application of the new ideas or changes to future situations (McLeod, 2013).

Four different learning styles emerge from the learning cycle. The first is diverging. These individuals like to look at things from different perspectives and prefer to watch rather than do. Students could elect to act as the problem solver in a group scenario. The second learning style is assimilating. These individuals are focused on ideas and concepts rather than people and they prefer information in the form of lecture and reading. This particular learner would probably not like group work where many individuals are putting in their ideas. This student would likely prefer reading about simulation in articles or in textbooks (McLeod, 2013). The third learning style is converging. These individuals like to solve problems and answer questions. They are interested in technical tasks and less interested in social and interpersonal issues. The fourth learning style is accommodating. This individual likes hands-on activities and relies on intuition over logic. These individuals rely on others for information, but will then carry out their own analysis (McLeod, 2013). All of these modalities are covered by the use of simulation in training. Training participants will have an opportunity to use any of these four roles to better their understanding thus increase their level of expertise. Learning about how students or nurses gain expertise is an important aspect of this practicum so it can be utilized in the simulations and lecture portions. It also is important for nurse educators to present material in a culturally competent manner (NLN, 2005).

Two theorists whose work in educational theory specifically addresses nursing education are Leininger and Benner. Their work gives nurse educators a more succinct framework from which to base instructional practice. In the 1970s, Madeleine Leininger’s pioneering work was at the forefront of cultural sensitivity in nursing. Her theory of transcultural nursing translates to increased cultural sensitivity and better care in the nursing profession. Leininger’s focus was to increase patient care by facilitating change in curricula in nursing programs (Hughes & Hood, 2007). Leininger’s work encourages nurse educators to integrate cultural awareness into their instruction. Cultural awareness which, if broken down, refers to the recognition to an existence of a fact or a set of facts (Schim, Doorenboos, Benkert, & Miller, 2007). Facts and statistics are often presented at cultural awareness training sessions, but without active discussion and true learning about different cultures (Schim, Doorenboos, Benkert, & Miller, 2007).

Leininger’s theory involves so much more than the presentation of facts and numbers. Although facts have their place, it is a dangerous practice for nurses to assume that all patients from a specific race, for example, will have the same needs. Leininger stresses the need for students to acquire a knowledge base for different cultures, but be sensitive while trying to apply the knowledge in practice (Schim, Doorenboos, Benkert, & Miller, 2007). This student used these principles in developing both the simulation and classroom lecture portions of this practicum. More valuably, since this student has never taught in the clinical setting, he utilized the landmark work by Patricia Benner on the theory of skill acquisition to mold the educational sessions.

Patricia Benner published her work on nursing skill acquisition detailing how novice nurses transition to advanced beginner, competent, proficient, and expert. Benner theorized how nurses go through these various stages as work towards gaining expertise (Benner, 1984). As delineated in Benner (1982) nurses traverse through five levels of skill attainment to achieve the expert level. Novice is the first level which is described as a nurse who is analyzing signs and symptoms without a true situational awareness and is constrained by strict guidelines without regard for individual circumstance. The advanced beginner “is one who can demonstrate marginally acceptable performance” (Benner, 1982). According to English, (1993) this level should be attained after a foundational program in nursing school.

The third level is competent. A competent nurse is starting be become more

self-actualized and less constrained by institutional guidelines (Benner, 1982). This nurse is starting to become aware of the intricacies of processes and begins to become more attuned to outcome based nursing. The proficient nurse is able to be more situationally aware and focuses on the patient as a whole using a more holistic view of medicine (Benner, 1982; Benner, 1985; Benner, 2010). This allows the nurse to modify care based on experience and make decisions based on his or her analytical processes and abstract abilities. The final level is the expert nurse. An expert nurse can base decisions on an intuitive grasp of situations without having to go through the minutia of the novice (Benner, 1982; Benner, 1985; Benner, 2010). They are thinking on a theoretical plane, using both mid-range and grand theory to practice. The issue faced during this practicum was dealing with nurses at different levels of expertise and how to mold the education setting to the betterment of all involved. In creating the simulation this student decided to focus on peri-mortem cesarean section (c-section) deliveries as this was an issue of which none of the nurses were comfortable. This will be addressed in greater detail later in this paper.

Application of Knowledge from Practice

Educators have specific curricula they must deliver, but it is the educator’s choice in the method of deliver or how they put it into practice. Applying educational theory into practice may seem challenging for educators due to a plethora of teaching strategies and methods available. It is imperative teachers explore these various teaching strategies as the student population becomes more diverse. Based on the work of Gardner and Kolb, students are different and have unique learning needs. One method educators may employ to address the theory of multiple intelligences and different learning styles is differentiated instruction.

Differentiating instruction means recognizing students’ different learning styles and needs, tailoring lessons to those needs, and designing fair assessments for those lessons as to gage student learning (Heacox, 2002). Educators grounded in only one delivery method are truly cheating their students. Interpersonal intelligence is based on the idea that students learn through interaction with others in a group (MacFarlane, 2011). For this practicum, being aware of these different styles allowed me the flexibility to modify my educational approach depending on the reactions from the various groups of students. In the classroom setting, the educator could set up small-group discussions around a particular theme or topic. For example, students could participate in group discussions about post-simulation lab training. Students would work together to figure out what went wrong and what went right or any other topic the instructor would like to focus upon. Another example of employing the work of Gardner is using the simulator itself. This is hands-on learning or what Gardner would refer to as the

bodily-kinesthetic intelligence (McFarlane, 2011). Modeling nursing procedures via the simulator would particularly appeal to those who would learn best by hands-on tasks that are interactive. Simulation would also fit Kolb’s work on the learning cycle and the resulting learning styles. If, in general, students learn through the experiences they encounter, then working through scenarios via high fidelity simulation (HFS) would act as an appropriate application of theory being put into practice. During the simulation experience, students will move through the learning cycle as outlined by Kolb. For most nurses, working with HFS is a new experience. As the nurses continue through the simulation training, they will naturally progress through the cycle as facilitated by the nurse educator. As a result of the new experiences with the simulator, connections will be made from what they previously knew and what they just experienced. This will allow them to generate ideas they will apply in the future. A debriefing in the form of group discussion would work nicely in this situation as the students work through the last three phases of Kolb’s learning cycle. This group dynamic also allows for students to demonstrate their particular learning style as described by Kolb. For example, some students will demonstrate the converging learning style by asking questions and using problem-solving skills (McLeod, 2013).

Jigsaws are a type of cooperative learning strategy used to promote discussion and student-led learning (Hotler, 2013). This type of strategy is ideal for promoting student interaction and an excellent method to allow students to foster self-learning. It is also a great benefit as this method can be adapted to almost any type of theme or topic. The basic premise of this method is as follows. The teacher will address the main topic to be discussed. The teacher will then divide students into groups giving each of the groups a subtheme. For example, consider there are three subthemes to the topic. Each group will have time to read an article and discuss the main points about their theme. This is considered round one. In round two, one (or possible multiple) of the members from each group will move to another group acting as the resident expert on the topic. The expert will relay the information about their theme, while the others will offer information on their topic. This rotation will take place once more in round three so that there is one expert from each of the subthemes in each group. At this point, everyone in the class should be well-versed on the subthemes of the original topic (Hotler, 2013). The use of cooperative learning can be used to discuss cultural sensitivity in support of Leininger’s work in transcultural nursing. Transcultural nursing is a method used in nursing programs to increase cultural awareness. This method is designed to increase cultural competencies and to break-down any misconceptions or negative feelings about people who are of different from the student (Hughes & Hood, 2007).

Role of the Nurse Educator

The role of the nurse educator throughout the course of the practicum diverged from the nursing faculty point of view. The learning group did not consist of nursing students. The learning group was made up of trained nurses. However, the eight core competencies identified by the NLN were appropriately applied, as the trained nurses were introduced to new concepts which would increase and diversify their knowledge base. Along the duration of the practicum, this student used educational theory and practice to create appropriate instruction mirroring how faculty educators would prepare for instruction utilized in nursing programs.

Practicum Overview

The clinical practicum took place at Mercy Hospital of Cadillac (MHC). Currently MHC is partnered with Munson Healthcare and Trinity Health. MHC has 97 licensed beds with over 700 employees including 85 medical staff. Lori Barnes, RNC and Director of Nursing Education and Obstetrics, acted as the preceptor, mentor and guide throughout the practicum experience. The primary emphasis of the practicum was the education of the obstetrics staff. The content involved HFS, ABG, and EKG interpretation. The content delivery was a mix teaching methods. The practicum also included case reviews, peer-reviews, and high-risk medication education. These experiences offered opportunities to collaborate with other hospital staff and work with the obstetrics team outside of the role of educator.

Description and Analysis of Clinical Project

The clinical practicum experience involved countless hours of research, planning, time in the “classroom”, meetings, conferences, peer-revision and self-reflection. The process as a whole has been challenging, but rewarding as it provided this student opportunities to apply theory and evidence-based methodology for instruction. The experiences and knowledge gained will provide great opportunities for the future as a practicing nurse educator. The practicum teaching experience revolved heavily around simulation training. Other teaching opportunities came in the form of ABG and EKG interpretation. The description and analysis of each of the educational topics will be discussed below and supported by the educational theories, research, and practice previously discussed.

Simulation Training

Simulation has been used in the way of anatomical models in nursing education since the 1970s with simple manikins. Through the years, these early models evolved into amazing technological wonders (Minnesota Nursing Accent, 2010). Integrating technologically advanced simulations will improve clinical skills, immerse students in life-like situations and assist them in determining a proper course of action (Gordon & Buckley, 2009). The primary goal of this practicum was to research, create, implement, assess, and analyze a simulation for the obstetrics staff at MHC. The staff included in the simulation was executed in a multidisciplinary manner. Dr. Sarah Helm (obstetrician) and Dr. Joseph Santangelo (pediatrician) were consulted and involved with the development of the simulation. This student conducted a great deal of research regarding the formatting of simulation, but was encouraged to write the simulation in a branching manner. Thus the simulation created was a peri-mortem c-section with the goal of deciphering if medical and nursing staff could recognize when a peri-mortem section was warranted and could work together as a team to locate the medical tools necessary to perform the procedure.

The HFS used in the training is called NOELLE. NOELLE is specifically designed for obstetrical simulation wherein babies can actually be delivered. For c-sections, NOELLE’s body can actually be surgically cut and a baby removed. The scenario developed for this practicum was a 26 year old post motor vehicle accident that is 37 weeks gestation. In the briefing session prior to the simulation the staff was only told those details and that she was sent up from the emergency department (ED) after being cleared quickly. At MHC there have been some issues with the ED sending pregnant patients to OB without assessing them thoroughly (Personal communication Lori Barnes, May 16th, 2013). When the staff enters, they encounter a tachycardic patient who is complaining of extreme abdominal pain. The fetal rate is high normal with no variability. The patient quickly progresses to supra-ventricular tachycardia and the fetal rate becomes tachycardic with no variability. The goal at this stage is to see how the nursing and medical staff mobilizes their support staff and how they use closed communication. The final stage is the patient is in electro-mechanical dissociation (EMD) and the fetal rate drops to 60 with deep decelerations. The goal at this stage is to see if staff notice the EMD and begin CPR and mobilize the code blue team. Thus far, this student has facilitated three simulations and in each case, nursing and medical staff were very slow at mobilizing support staff. They also did not recognize the patient being in EMD. They were focused on verifying the heart rate by reading the EKG rather than checking the pulse on the patient. This unfortunately was exactly what was expected, but it offered a great opportunity for learning about not focusing on technology but on the patient itself. In the first simulation trial the patient was in EMD for four minutes before the participants actually palpated the pulse. Personally it was difficult to watch the nursing and medical staff struggle so greatly, but it provided wonderful material to discuss during the post-simulation debriefing. To see the full simulation, see appendix A.

Dr. Helm led each debriefing session by first asking each participant what went right, then what went wrong, and finally what can be improved and how. Each session provided wonderful learning opportunities for all participants. Each OB nurse recognized they are not prepared for a situation that progresses to a peri-mortem c-section and they need more training. They were also intimidated by the fact the code team was not available and the OB staff had to run the code themselves. None of the OB staff is Advance Cardiac Life Support (ACLS) certified. They will be trained in late August.

The use of simulation in education practice incorporates the theories and research of Gardner, Kolb, Leininger, and Benner. The bodily-kinesthetic intelligence was addressed through the simulation training providing a hands-on and physically taxing scenario. Everything involved in the simulation scenario discussed above was as realistic as possible. Students were in an actual hospital room with all the equipment that would normally be there. They were scrambling around the room and performing CPR on the “patient”. Campbell and Daley (2009) describe how important it is to have high environmental fidelity, high equipment fidelity, and high psychological fidelity to support the technological simulator. The environmental setting in which the simulation takes place should be as authentic as possible. If the students feel like they are physically placed in a real-life situation, that looks and fits the scenario, then positive outcomes are more likely to be produced (Campbell and Daley, 2009). This is also the case if the equipment is authentic and again, looks and fits the scenario. This includes staging the room with standard equipment or tools that would normally be there for nursing use. The combination of environmental and equipment fidelity adds to the third component which is the psychological fidelity. Psychological fidelity reflects how believable the situation is based on student perception. Successful simulation will take place when students feel it is a real-life scenario (Campbell and Daley, 2009). This high-action, high-tension scenario facilitated learning about how to mobilize the team, situational awareness, closed communication, resource management, delegation, and teamwork.

None of the students had ever been involved in a severe trauma based maternal distress simulation. This was a new experience for all the interdisciplinary team members included in the training session. This relates directly to the work of Kolb and his experiential learning theory. The students were exposed to a cycle of activities where knowledge was gained through the transformation of experience (McLeod, 2009). The situations students were placed in provided experiences from which they can obtain insights. These insights will be used in future real-life scenarios and decision-making processes. As a result of the simulation experience, the students reported they need to learn more. This might sound like an odd comment, but it was an eye-opening experience. The students are aware of the areas in which they are deficient and are prepared to create more learning opportunities. They discussed the need for more training and preparation in the post-simulation debriefing.

Most of the learning took place in the debriefing as students were able to talk through what just took place. Debriefing integrated the work of Benner through a “cue-based system with escalating prompts to move students through recognition to assessment to intervention to problem resolution” (Campbell and Daley, 2009, p. 5). Utilizing this system during the debriefing allowed students to focus and process one problem at a time. Benner’s research into the levels of skill attainment and proficiency are very applicable to understanding how nursing educators can achieve expertise in the technological aspects of nursing and how they can instill that expertise to their pupils. The trained nurses who completed the simulation training and debriefing are on the path to Benner’s expert nurse as they acquire and develop new skills.

ABG and EKG Interpretation Training

The practice of differentiated instruction and cooperative learning is evident throughout the simulation training. All the students benefited from the hands-on role play, yet some need a different method to really drive home intended learning concepts. Some students may display the interpersonal intelligence which makes the debriefing a valuable part of the instruction. Debriefing acted as another avenue to foster learning targeting those who learn best from a group dynamic. Cooperative learning strategies were utilized in the debriefing to allow for student-centered learning as they discussed issues together as a group. Following the debriefing session this student utilized a PowerPoint (PPT) he created to teach the OB staff how to interpret ABG’s. These sessions consisted of lecture via a PowerPoint presentation and student-centered learning through the cooperative learning strategy. The goal of these sessions were to familiarize the OB staff with the steps needed to properly interpret ABG’s to help prepare them for their upcoming ACLS training. This lecture appealed to those who are audio-visual-spatial and logical-mathematical learners. These are the students who like to see and hear in order to interpret information. It also includes students who learn best from outlines, organization and technical jargon. The response to the training was excellent as each student was able to properly interpret ABG’s. Students were also asked to create scenarios for other students to interpret utilizing logical pathophysiology for each patient. This task proved slightly more difficult for the nurses as this student forced them to teach each other. The final portion of the preparation for the OB nurses ACLS training will be teaching them basic EKG interpretation. This student has created a PPT to assist the students and will utilize lecture, student centered learning, and jigsaw methodologies to assist their learning. These sessions are scheduled to take place in early August.

Issues, Concerns, and Challenges

Many issues, concerns, and challenges arose during the course of the practicum experience. One of the most irritating was the constant changing of schedules as coordination of educational sessions was very difficult when planning and working according to the hospital’s timeframe. After attending many simulation meetings with both my preceptor and other clinical nurse educators, it was clear they wanted this student to create a scenario using no particular methodology. Given the circumstances this student was forced to rewrite almost all previous work done. However, the lesson learned is that working hospitals and school based education are sometimes vastly different in their methodologies. While being irritated at first, this actually taught this student the importance of being flexible in his teaching approach. Some of the issues and concerns experienced were the lack of faculty training, buy-in to the importance of simulation, and the lack of critical thinking skills. Another issue that may arise is the cost of simulation. This was not an issue discussed during the practicum, but it is important to mention as nursing programs implement simulation into curricula.

Schedules

The clinical practicum required 300 hours in which to complete the project. The number of hours was not the challenge, but keeping the hours on schedule before the course ended proved to be somewhat difficult. The constant changing of the schedule on the hospital’s side was extremely frustrating. Simulation sessions have been cancelled at the last minute and other unforeseen schedule issues took place, in turn, affecting teaching opportunities either in their entirety or in length. This student had to learn to be very flexible and, as previously written, learned there is a vast difference between academic and in-hospital nursing education. Incorporating simulation and creating realistic and purposeful scenarios into education will take valuable time and staff coordination (The Minnesota Nursing Accent, 2010). Perhaps this was part of the reason schedules were altered. The time of my preceptor and other hospital staff is already stretched too thin. This issue of scheduling directly relates to the importance of flexibility as outlined by the NLN (National League of Nursing, 2005). Remaining flexible and being able to adapt to situations as a teacher and as a practicing nurse are valuable and important skills to practice.

Faculty Training and Buy-In

According to Campbell and Daley (2009), educators who are advocates for technology use in their nursing programs are more than likely to be comfortable with technology, but this may not the case for the faculty as a whole. Often times, nursing students arrive to their programs more technologically savvy than their instructors (Campbell & Daley, 2009). There are many roadblocks in using HFS in nursing programs, but a lack of faculty training is among the most crucial in nursing pedagogy today (Campbell & Daley, 2009). If the ultimate goal of simulation is to increase patient safety and standards of nursing practice, nurse educators need to begin with developing effective simulation curriculum. The same can be said for continuing education in the hospital setting.

The lack of simulation training of nursing staff became evident during the course of the practicum. Only one of the nurses involved with simulation can actually run the simulator. This student had to educate his preceptor on how to properly utilize the HFS. For example, the simulation leader did not understand how to make pulses, blood pressure, and EKG abnormalities work. It was a challenge to realize that an expensive HFS was not being utilized for all its capabilities and expectations for learning outcomes. For this student one of the most evident issues regarding simulation is the lack of support from nursing and medical staff. The buy-in from staff was not there. If this lack of support continues, the lack of training seems likely to continue as well.

Lack of Critical Thinking Skills

It was evident the nurses were deficient in critical thinking skills not only during the simulation training, but in the EKG and ABG interpretation training sessions. The nurses had a difficult time making informed decisions and putting them into effective practice. There was a clear lack of closed communication that added to confusion. They were also too focused on interpreting information from technological monitors rather than treating the patient. This is an ethical concern this student had to face while administering the simulation. A professional nurse does not rely on technology, but focuses on the patient and the signs and symptoms each patient is demonstrating. According to Mann (2012) critical thinking and clinical reasoning are imperative for professional nursing practice and have been identified as essential skills of nurses. Most nursing programs are geared at mastering content without an emphasis on honing critical thinking skills (Mann, 2012). According to del Bueno (2005), research indicates that most of the graduate nurses today do not meet entry-level expectations for clinical judgment and only one-third of these entry-level nurses meet adequate entry-level critical thinking skills. This student realized the over-reliance on technology to stimulate critical thinking skills can be detrimental. In one simulation Dr. Helm and the entire nursing team did not realize the simulated patient was in electro-mechanical dissociation for four minutes. Ethically, as a nurse educator it is imperative that nurses or student nurses do not become over reliant on technologies and learn to treat the patient. This student’s ethical argument with the medical staff was very frustrating as they maintained that technology is wrong less frequently than people. This is only true if the people utilizing the technology are competent. This experience taught this student that most of the nursing and medical staff is too reliant on the technology and eventually a patient will suffer for that. The entire purpose of teaching the OB staff to learn to interpret ABG’s from a pathophysiological standpoint rather than simply reading them was to get them to focus on the patient and not simply the ABG’s. The same method is being used by this student to teach them basic EKG interpretation. The nurses have to understand physiologically what is happening to the heart and patient not simply to be able to name the rhythm.

Costs of Simulation

Investing in simulation equipment is an expensive investment (Lapkin & Levett-Jones, 2011). Prices can range from $30,000-$200,000 depending on the degree of fidelity (Durham & Alden, 2008). According to Lapkin and Levette-Jones, investing in medium-fideltiy equipment will be most cost effective than investing in high-fidelity equipment. There are two reasons for this. The increased cost of high-fidelity simulation is not justified as it does not equate to greater clinical reasoning and that medium-fidelity simulation requires less training to use (Lapkin & Levett-Jones, 2011). Depending on budget and educational needs, nursing program institutions or teaching hospitals need to research simulation technologies that will meet their needs and their budgets.

Strategies and Approaches Used to Address Challenges

Integrating Simulation into Nursing Curriculum

Daley and Campbell (2009) do not believe that a major and formal curricular change must occur because of the addition of simulation. Simulation is a learning tool to support curricular goals already established and has been used for decades. The highly technical simulators available today may seem a little intimidating thus creating the false need of rewriting curriculum (Daley and Campbell, 2009). Institutions should ease into integrating simulation by simply rewording course objectives and reworking a practice module into a simulated practice-module (Daley and Campbell, 2009). This will hopefully reduce negative feelings about integrating simulation teaching and allow more faculty members to get on board with simulation initiatives.

Once institutions are ready to integrate simulation they can work on some of the major pitfalls. Because most current nurse educators did not grow up with computers, their inherent abilities to adapt to the technologies can be limited (Durham & Alden, 2008). This will not preclude nurse educators from learning, but fear of new technology can create resistance to implementation (Durham and Alden, 2008). According to Degroot (2009), fears about new technology can be alleviated by administration and faculty support. Once the faculty or staff recognizes the importance of simulation training, they can begin the task on working it into their educational curriculum. The companies designing and producing simulators previously would train faculty for free, but the norm today is the “train the trainer’s initiative” (Daley & Campbell, 2010, p. 15). This initiative would involve one or two faculty members to become the resident expert or experts and train the rest of the staff. This is certainly something MHC should invest in as they are not fully utilizing the capabilities of NOELLE.

Critical Thinking Through Simulation

Nursing students are not specifically taught how to use critical thinking and clinical judgment (Mann, 2012). These skills are usually put into practice within the clinical setting, but with limited exposure time in clinical practice, these skills are not fostered effectively (Mann, 2012). According to Mann (2012), the use simulation is an effective strategy to increase students’ cognitive skills as well as build confidence. Integrating simulation into nursing school curriculum will help supplement limited clinical experience and work to build the skills needed before they enter the workforce. It was apparent to this student that, despite working with professional nurses, the ability to think critically and use clinical judgment was lacking in some areas. The opportunity to expose the nurses to new scenarios through simulation was amazing for this student as he could see the nurses making new connections and feeling more confident in less frequent scenarios of nursing practice.

Evaluation of Clinical Practicum

The self and preceptor evaluations can be seen in Appendix B. The evaluations used were a five point Likert evaluation with an area for additional comments. Likert scales are a common form of evaluations used for the evaluation of feelings about particular topics of study (Polit & Beck, 2008).

Conclusion

Simulation training offers unlimited learning opportunities, but is not utilized to its fullest potential (Campbell & Daley, 2009). Embracing the potential and integrating simulation training into nursing education can unlock a variety of positive learning outcomes. This potential became evident after the simulation training in this clinical practicum. The positivity was very rewarding and this student felt very successful and confident in the overall process. Alongside the hands-on simulation, a more traditional style of teaching via PPT was employed to deliver information using a different format targeting a different style of learner. Yet another learning style was used in the debriefing session after both the simulation and the PPT presentation. Teachers who can address different learning styles through differentiating instruction will see an increase of student success. Many of the core competencies of a nurse educator revolve around the central idea that we need to constantly be adaptive learners as teachers and that will instill our students with the desire to do the same. A nurse educator is a student first and a teacher second. Remembering this will disallow stagnation which this student learned by having to adapt to new situations throughout this practicum.

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Appendix A

Peri-mortem Simulation Outline

Simulation scenario for MHC OB department

PART I

Initial: Patient arrives in OB from ER. Cleared Quickly. Patient HX: 37wk gestation. 26 y/o no significant obstetrical dx. Unremarkable pregnancy.

Vitals:

HR: 122 regular

BP: 110/60

RR: 26

O2 Sat: 92% R/A.

Pain: 8/10

Abdominal Assessment: Firm/tender w/ guarding.

Vaginal Assessment: No visible bleeding.

LOC: A & O x4

FHR: 150 flat

PART II- Dr. Helm enters

Vitals:

HR: 135 regular

BP: 105/56

RR: 30

O2 Sat: 90% R/A.

Pain: 9/10

Abdominal Assessment: Firm/tender w/ guarding.

Vaginal Assessment: No visible bleeding.

LOC: A & O x4

FHR: 170 flat

Dr. Orders-EKG-RSR, possible vaginal check, Labs, IV’s

Part III

Vitals:

HR: 165 SVT

BP: 80/40

RR: 32

O2 Sat: 85% R/A.

Pain: no response

Abdominal Assessment: Firm/responds with groaning to painful stimuli.

Vaginal Assessment: No visible bleeding.

LOC: no appropriate response.

FHR: Deep decelerations leading to bradycardia at 60 BPM

Part III B

Vitals:

HR: PEA. Rate on monitor 200

BP: 0/0

RR: 0

O2 Sat: 80% Full facemask if done.

Pain: no response

Abdominal Assessment: Rigid no response

Vaginal Assessment: No visible bleeding.

LOC: no appropriate response.

FHR: Bradycardia at 60 BPM

Appendix B

Preceptor Evaluation Form

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Student Self Evaluation Form

Please complete the evaluation form below by circling the appropriate number that best fits your evaluation of the educational activity.

After completing the practicum the student will fill out the following self-evaluation form.

Using the following scale, please respond to these statements regarding this education activity:

5 = strongly agree 4 = agree 3 = neutral 2 = disagree 1 = strongly disagree

The practicum was useful and helpful for the student 5 4 3 2 1

The participants in the simulations seemed interested and actively participated. 5 4 3 2 1

The student would recommend this type of practicum to future nursing education students. 5 4 3 2 1

The student felt comfortable with preparing and implementing the simulations. 5 4 3 2 1

The student felt comfortable and prepared for peer review sessions. 5 4 3 2 1

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The student feels his learning experience from shadowing a clinical nursing education was instructional and helpful 5 4 3 2 1

The student felt supported by his preceptor 5 4 3 2 1

The student feels the peer review sessions were instructional and will provide evidence based changes that will improve patient safety. . 5 4 3 2 1

The student felt weekly meeting with his preceptor were productive and educational 5 4 3 2 1

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The student feels time spent at MCC and LCC to learn more about simulation administration was productive 5 4 3 2 1

There were no areas of the presentation that needed improvement. 5 4 3 2 1

The student feels the overall experience of the practicum will help him become a better nurse educator 5 4 3 2 1

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Total ___54/55

Percentage ___98%

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Joshua C. Lincoln

Please use the following page to list any other comments/suggestions regarding this educational activity.

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Comments: I learned so much from this practicum. The difficulty in teaching in a hospital setting is so much different than in a classroom. I am very proud of what I did.

Comments: The nurses and my facilitators were incredibly supportive although schedules were constantly being changed. I also ended up being involved with about 10 extra projects, but it taught me to be flexible in my teaching style which is one of the core competencies of a nurse educator

Comments: Absolutely, learning in hospital education is so very different than in the academic setting. I think a good blend would be the perfect scenario.

Comments: I actually was very uncomfortable at the beginning, but I did an incredible amount of research and after writing simulations for MHC and now writing for MCC I feel very comfortable now.

Comments: I was always nervous for these session as I did not know what my role was, but watching how Lori handles the situations taught me how to teach and educate without being confrontational even when it is a very contentious situation.

Comments: See above

Comments: I had and am having incredible medical issues this term and was always supported by my preceptor. She is wonderful.

Comments: No question, the ability to utilize the LFD model demonstrated how dialog can alleviate stress and create a positive learning environment. Although I did not get to do a lot of this, I definitely see it as a positive experience.

Comments: We were a team. I was not just the intern; I was treated as an equal thus the staff treated me that way. I could not have asked for a better preceptor.

Comments: Although I did not do anything with LCC as schedules would not permit it. I did spend a great deal of time discussing simulation and its uses with an MCC instructor along with the use of unfolding case studies. I have written and am in the process of writing some more simulations for each nursing class for MCC per the instructors request.

Comments: Absolutely, I feel more well rounded and better prepared to educate both in the academic setting and the hospital setting.

Additional Comments:

To be honest I was dreading this class. I have been very ill and did not think I could do it. However, I have learned so much that I want to actually teach using simulations. I also learned a lot about myself. I made it through this in spite of the issues I had when I very easily could have quit. The support of Dr. Colley, my preceptor, and my wife were essential. I have learned so much about the differences in how people learn. Most importantly, with all the changes I had to make along the way, which created a lot more work, taught me to be malleable and to that every experience is a learning one.

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