CREATE AND FACILITATE A CLINICAL SIMULATION

A clinical simulation presents the learner with a carefully planned, simulated patient management situation. Clinical simulations are an

excellent method for developing cognitive or clinical decision-making skills. The learner interacts with persons and things in the environment, applies previous knowledge and skills to respond to a problem, and receives feedback about those responses without having to be concerned about real-life consequences. Clinical simulations are often conducted with a small group of students—one student may be the primary responder while other students provide feedback, or all students in the group may be involved in the exercise.

Simulations can take a variety of forms:

zWritten simulations are pencil-and-paper presentations of actual

problems or cases about which the learner must make decisions as if performing in the real-life situation. After making each decision, the learner receives feedback on the effects of that decision, and incorporates it into the next decision. These simulations may be used in assessing students’ knowledge.

zRole play simulations allow the learner to take on the role of an

individual involved in a clinical situation. The main purpose is to give the learner new insights into behaviors and feelings of other people.

zMediated simulations use audio or visual media to present the

interacting may be shown, or audiotapes of heart sounds may be played to provide information for the learner to use in the simulation.

zPhysical simulators, or anatomic models, closely resemble the

human body (or parts of it), and are often used for developing psychomotor skills. A physical simulator may be used along with a role play in a clinical simulation that requires students also to demonstrate technical skills.

zLive simulated patients involve the use of persons trained to act

the role of the patient. They are given a very specific script to follow while interacting with the student. The interaction may be videotaped or observed so that feedback can be provided to the student.

Clinical simulations are useful to:

zHelp students practice responding to emergency situations. When

the topic of the clinical simulation is responding to an emergency, the simulation helps students learn to make quick decisions and deal with pressure in a safe environment.

zHelp students develop critical thinking skills. Clinical simulations allow students to receive feedback on their problem-solving and decision-making skills as they practice managing a patient problem. Later, the experience gained during the clinical simulation should help students to feel more confident and improve their clinical judgment when in a similar situation.

zAssess students’ ability to integrate knowledge, skills, and attitudes into providing healthcare in a simulated setting. Clinical simulations are often included in observed structured clinical examinations (OCSE) as described in Prepare and Use Skills Assessments.

The following are some advantages of clinical simulations:

zThe same clinical simulation can be used repeatedly until the

students master the situation it presents. It can also be adapted to address different causes for the problem it presents, different treatment options, or different outcomes.

zTime can be shortened or lengthened in a clinical simulation. Students can move through a situation more rapidly than in real life because, for example, they do not need to wait for laboratory test results. They can also take more time than is actually available

in life-threatening situations to collect information, discuss the situation with their teacher, and make decisions as they practice and master these skills, without harm to the patient.

zClinical simulations can be tailored to specific instructional objectives. Because they can be easily adapted to specific needs and interests, both teachers and students are motivated to use them. To create a clinical simulation, follow these steps:

zDefine the objective of the clinical simulation and the expected outcome. Will it be used to help students practice responding to emergency situations? Will it be used to walk students through a clinical problem that will also require a demonstration of skills? Will it be used to help students develop decision-making skills while managing a simulated patient scenario? Will it be used to assess students’ skills or knowledge? The objective of the clinical simulation will determine the kind of simulation created.

zBased on your objectives, prepare a case from your past experience that relates to the learning objectives. You may ask students to share cases from their own clinical experiences. Document the necessary information from the case including diagnostic data, treatment, and outcomes. Create a list of questions to ask students about how they would have chosen to manage the case.

zCreate a patient scenario that includes the problem, the related lab and diagnostic results, and possible outcomes for different interventions. Document this information so that you do not have to re-create scenarios. Whether creating a scenario for an emergency situation or a patient management situation, prepare detailed data to be shared with students and possible outcomes. List the questions to be asked and the potential answers for possible interventions.

To facilitate a clinical simulation, follow these steps:

Present a Case

zAsk two or three students to prepare a case for presentation from their clinical experience. Tell them to be prepared for all clinical and theoretical aspects of the case.

zWhen it is time to present, have the students share the presenting complaint.

zStop them, ask other students what they think the problem or diagnosis could be, and tell them to explain their answers. Ask other students to respond to this information. Ask questions to prompt students to think through possible problems and provide additional data as needed.

zAllow the students to present additional relevant data.

zStop again, ask the students if they have changed their views, or

what their next steps would be, and why.

zContinue this process of allowing information to be revealed in steps, and asking and responding to students’ answers. Guide the discussion by providing essential information when needed, asking related questions to help students make decisions, and giving them feedback on their proposed diagnoses and interventions.

This type of clinical simulation is more effective with senior-level students who have had more experience with managing patients. Be sure to protect patient confidentiality during this activity.

Structure a Patient Scenario in a Simulated Practice Setting

This method is more involved because it may require students also to demonstrate a skill or “act out” a situation. Structured scenarios may include responding to a clinical problem or an emergency situation. Before you begin, discuss the following with the students:

zClarify the objectives of the activity, whether to develop decision-

making skills, practice handling an emergency, or manage a sick patient.

zDiscuss how the student or students should perform the clinical skills. Should they talk it through or demonstrate the skill?

zIf you are using a clinical simulation to help students develop life-

saving skills, give students clear instructions about their individual roles during the clinical simulation. Who will act as the physician? Who will act as the nurse? Who will run for supplies? Who will be responsible for documenting interventions?

zIf you are using a tool such as an algorithm or recording form, find

out if the students are familiar with it; if necessary, explain it to them and describe how you will use it as a teaching tool.

zDefine your role during the activity. Will you only ask questions or will you also provide information, along with feedback, at key points?

zDiscuss time constraints. Is there any time limit on responding or completing the activity?

To conduct a clinical simulation involving models:

zSet up the area as realistically as possible. Provide anatomic models and any equipment or supplies that would be needed.

zPresent the initial information about the patient or the situation.

Begin by providing relatively little information.

zHave a student respond to that information and identify what other

information is needed. You respond with additional information and ask that student or other students what their next steps might be. You may ask the student to demonstrate on the model the actions she or he would then choose to take. Respond by asking the student such questions as, “Why would you choose that intervention?” or “Are you sure you want to do that?” in order to understand their rationale for intervention.

zContinue to provide pieces of information and ask questions of the students. “What would you do next?” “What information would you need now?” “Why did you make that decision?”

zProvide the student or students with feedback on their responses. Ask questions to check their understanding and help them continue to develop their cognitive skills.

Refer to the sample clinical simulation (Sample 7-4) at the end of this module. The sample includes questions to ask and possible responses, along with data to share with the student. This sample may serve as a guide for developing additional clinical simulations.