SIMULATION DESIGN:
ENGAGING LARGE GROUPS OF FAMILY NURSE PRACTITIONER STUDENTS
Susan Garnett, MSN, FNP-BC
Josie Weiss, PhD, FNP-BC, FAANP Jill Winland-Brown, EdD, FNP-BC Christine E. Lynn College of Nursing
Florida Atlantic University Boca Raton, FL
HPSN World 2013 June 30-July 2, 2013
A LITTLE BIT ABOUT US
MY PARTNERS IN SIMULATION!
SESSION DESCRIPTION:
This presentation will address the development of a hybrid design for
simulated clinical experiences (SCEs) with large groups of family nurse practitioner
students.
The rationale for and the evolution of the large group design will be discussed.
Description (cont.)
Advantages and disadvantages of each progressive model will be described,
including:
• Large group design- the game show format with a lifeline
• Observer/participant model
• Initial and follow-up visit model • Mentor/mentee model
Description (cont.)
Student feedback comments and
suggestions for future modifications
will be presented.
LEARNING OBJECTIVES
At the completion of this program, the participant will be able to:
1. Discuss the rationale for the development of the large group design.
2. Identify advantages/disadvantages of each
model: game show format, observer/participant, initial and follow-up visit, and mentor/mentee models.
3. Describe potential future modifications to the large group design.
Why use simulation to teach primary care to nurse practitioner students?
TELL ME AND I FORGET. TEACH ME AND I LEARN. INVOLVE ME AND I REMEMBER.
Rationale for the Development of
Large Group Design
• Large class size (30+)
• Limited faculty resources (3-4 faculty with no course relief for simulation)
• Budget constraints
• Opportunity to provide equivalent clinical
experiences to all students/substitute for clinical hours
• Opportunity to incorporate the caring philosophy of our college into primary care scenarios
Getting Started
• In the fall of 2008, when we first set out to use simulation as a teaching tool in our
family nurse practitioner program, there was nothing in the literature about using
simulation to teach clinical management in primary care nurse practitioner programs, and little about providing simulation to
To date, only two references about using simulation to teach primary care
management in a family nurse practitioner program have been identified in the
literature:
• Pittman (2012)
• Bryant in Campbell & Daley (Eds.) (2013)
Evolution of the Large Group
Design
• Began with game show format
• Expanded on this basic model to
participant/observer with the
acquisition of video streaming
capability in 2011
Game Show Format
Description
• Game show format using a ‘lifeline’.
• Multiple roles (up to 17) - randomly drawn • Alternate the SCE with at least one other
activity – such as a suturing workshop • Half of the class in each activity and
alternate
Game Show Format with
Lifeline
• Advantages
This model allowed us to use
simulation as a teaching tool and engage all the students in various parts of the primary care patient visit • Disadvantages
With 25-30 students, required repeating the scenario twice to accommodate
everyone (and required an alternate activity)
The Process of Primary Care
SCE Development
Identify current topic in didactic course:
• low frequency, high risk
or
• common and significant in primary
care
The Process (cont.)
• Create the patient’s story- not just the presenting diagnosis but the whole person
• Make it fun –use humor
• Make it challenging- complex diagnoses, co-morbidities
• Make the simulator “human” with moulage and real life situations/relationships
The Process (cont.)
• Develop script:
review evidence-based practice,
national guidelines for the diagnoses • Create pertinent lab reports, EKG strips,
and photographs to project on video
screen to augment the exam findings of the simulator
Augment the exam findings for
the simulator
Ear Exam
Or to show diagnostic study
results
The Process (cont.)
• Write learning objectives
• Plan who will play role(s) of the patient/ family members
• Plan student roles
• Plan and acquire moulage based on characters in script: gender, clothing, accessories, props, makeup
The Process (cont.)
Prior to simulation day: Set up scenario:
• clinic exam room milieu • moulage the simulator
• program the simulator per the script or write plan to do “on the fly”
• Provide script & orient the “voice of the
Day of the Simulation:
Day of the simulation (cont.)
Brief the student group:
• Review objectives of the SCE (posted
on BB with schedule 1 week prior)
• Provide brief introduction to the
patient:
Name, age, gender, chief
Day of the Simulation (cont.)
• Start scenario
• Facilitate as needed throughout • Debriefing
Debriefing/Guided Reflection
• “Assess how well objectives have been met
• Clarify misconceptions • Correct errors
• Emphasize correct, appropriate and safe nursing care and decision making”
Jeffries & Rogers in
Jeffries (Ed.) 2007, p. 29
Observer-Participant Model
We were able to implement this model in the Fall of 2011 due to the creativity of our IT
staff in installing a live video stream from the lab to a nearby classroom - using spare
Observer-Participant Model
(cont.)
• Kaplan et al (2012) describe their study of the use of a participation vs. observation model in an undergraduate nursing program whereby “accommodating large student groups in finite periods of time”
• “Half of the students actively participate while their cohort observes” “Both groups participate in the debriefing process”
• Result: There was no significant difference on test scores between observers/participants for this content
Observer-Participant Model
(cont.)
• Campbell & LoGiudice (in Campbell & Daley, 2013) also describe the use of a participant & observer model using video to another classroom and debriefing all together.
– This model used one group (3 students) participating and their cohort observing.
Two Scenario
Observer-Participant Model
• Our model utilizes two scenarios so that all students participate in one scenario and
observe the other (i.e. one pediatric patient, one OB patient)
- Builds on game show format; half the class participates first, other half observes first, then they alternate
Two Scenario
Observer-Participant Model
(cont
.)
• Advantages:
Exposure to twice as many scenarios
Debrief all together after both groups finish SCE
• Disadvantages:
Requires either two rooms large enough to accommodate the entire class or
streaming from one room to another (both ways)
Initial & Follow-up Visit Model
Builds on observer-participant model
• First group does the initial clinic visit with a simulated patient while the other group
observes
• Both groups alternate rooms and the
second group does the time-lapse follow-up visit on the same patient – evaluating the treatment plan recommended by the first group
Initial & Follow-up Visit Model
(cont.)
Advantages:
First observer group is more engaged in initial visit since they will be
responsible for follow-up visit Disadvantages:
Students who observe first and
participate second score higher on evaluations- need to alternate them during each semester
Initial & Follow-up Visit Model
(cont.)
Challenge:
• To keep students who participated in
initial visit engaged when observing
the follow-up visit-
- have added writing a SOAP note
during the SCE to keep them
engaged
Mentor/Mentee Model
• A unique and interesting way to encourage a bonding experience between 2 classes who otherwise have no interaction
• Randomly paired students in first clinical course (mentees) with students in final clinical course (mentors) N=54
• Posted article on mentoring on Blackboard one week prior
Mentor-Mentee Model (cont.)
Wagner & Seymour (2007) described a mentoring model in nursing based on a
caring philosophy, which we felt was a good fit and adopted for our simulation program.
Mentor/Mentee Model (cont.)
Advantages:
Instead of a lifeline, first year
students (mentees) have a second
year (more experienced) mentor
Mentor/Mentee Model (cont.)
Disadvantages:
Group size (54) requires alternating with
another activity and repeating the initial visit and follow-up visit with observer &
participant groups am & pm • Labor intensive for faculty • Heroic for volunteer actors
Evaluation & Revision
We “tweaked” each model continually in response to student comments in post-simulation evaluations
For example:
• SCEs are conducted in “real time”
• The student “teams” are given time to prepare for their roles
• There is always a “live” family member to communicate with
Evaluation and Revision (cont.)
• As each student pair completes their role in the scenario, we open up the
microphone between the classrooms to
allow for comments, questions, discussion between the groups
• After each scenario, we do a debriefing/
Evaluation and Revision (cont.)
• “Take Home Points”
clinical pearls and evidence-based practice guidelines & references are posted on Blackboard following the simulation to reinforce learning
Evaluation & Revision (cont.)
• Research:
With the capability of live video stream and the use of the mentor/mentee
model, we now had two cohorts to compare
Developed an evaluation tool-
SCE Caring Evaluation Tool© Needed a theoretical framework
THEORETICAL FRAMEWORK
KOLB’S EXPERIENTIAL LEARNING CYCLE (Kolb,1984)
ADAPTATION TO SIMULATED
CLINICAL EXPERIENCES
DIDACTIC CONTENT
↓
CONCRETE EXPERIENCE (SCE)→
↑ ↓
TESTING IN OBSERVATION NEW SITUATIONS & REFLECTION
↑ ↓
← ABSTRACT ←
CONCEPTUALIZATION
Incorporation of INACSL
Standards of Best Practice
1.Terminology
2.Professional Integrity of Participant 3.Participant Objectives
4.Facilitation Methods 5.Simulation Facilitator
6.The Debriefing Process
7.Evaluation of Expected Outcomes
INACSL Board of Directors, (August, 2011).
Student Comments
About Observer-participant model:
“Being on the observation side is helpful because it allows you to take all the
information in and critically think about it
without having to worry about participating.” “I felt that participating in the other
simulation was more valuable and I was able to learn/retain more by being “hands on” and put on the spot.”
Student Comments
“4 sessions were better than 2…it did give us a little time pressure seen in real world situations” “The addition of the follow-up visit was
WONDERFUL! Thank you!”
“Excellent experience- critical thinking challenge – sharing of knowledge, very beneficial”
“Very useful- no OB experience prior. Learned a lot.”
“”Enjoyed it. Learned much as had no patients in Peds with diabetes or hypertension.”
Student Comments
About mentee/mentor model:
“It’s nice to have a patient experience
without the fear of making a mistake. I feel more confident in my skills after this
simulation. I also valued the opportunity to learn from senior students and their helpful tips.”
Student Comments
“Able to see and hear various perspectives related to assessment, diagnostics,
diagnosis, plan of care and education. At clinical I am only able to have the
experience of one clinician who may not be as up-to-date on current guidelines.”
“It was great to bounce ideas off my mentor and hear her rationale.”
Student Comments- Mentor/
Mentee
“In regards to our clinical
mentorship day last Friday, I just wanted to drop a line to all of you to say thank you for such a wonderful
experience. …my mentor… was fantastic. She was
friendly, supportive,
encouraging, and provided insight into organizing
patient care and the use of iPad tools for clinical
Mentor/Mentee Evaluation
Please rank your perception of the
effectiveness of the mentor/mentee design for simulated clinical experiences:
• Somewhat Very Extremely • Ineffective Effective Effective Effective • 1 2 3 4 N=48
Overall, 83% rated mentor/mentee design very to extremely effective
Value of SCE Compared to
Clinical Experience
How does this simulated clinical experience
compare with the same amount of time at your clinical sites?
(Please circle one)
Much less Less About More Much more Valuable valuable the same valuable valuable
1 2 3 4 5
Value of SCE Compared to
Clinical Experience
74-88% rated the SCEs as equally as valuable, more valuable or much more valuable compared to clinical sites
Comments to Value of SCE
vs. Clinical Site
• “In the simulation we actually have the time to discuss our decisions in detail” • “Less stress, more interaction, more
perspectives”
• “It allows (us) to spend more time
analyzing and preparing our diagnoses/ plan, etc.. It is also nice to work with classmates”
Comments to Value of SCE vs.
Clinical Site (cont.)
• “It’s good to have an opportunity to talk
about why each student feels certain tests, procedures should be done. A chance to spend a lot of time discussing real life
scenarios and using the info in actual clinical situations”
• “I enjoyed seeing how everyone else
approached situations and their take on it. Less stressful”
Comments to Value of SCE vs.
Clinical Site (cont.)
• “Access to many opinions and styles with more time to diagnose and make a plan of care”
• “Multiple viewpoints with same scenario- challenge critical thinking, teamwork,
Current Hybrid Model
• Hybrid= of mixed origin
(Collins English Dictionary - Complete & Unabridged 2003)
• High fidelity HPS (METIman™ and PediaSIM™) • Community volunteer actors to play the voice of
the patient or family members
• Supplement with videos, photos, lab reports, etc so the observers can see what the participating students are seeing during the exam - and to augment the simulator’s capabilities – when necessary
Current Applications
Spring semester, First year students:
Orientation to primary care clinical experience
• Orientation to simulation
• Professional Integrity contract
Current Applications (cont.)
Primary Care scenario –
Participant-Observer model with Initial & Follow-up visits
Initial visit demonstrated by faculty
• How to approach patients & families • How to present findings to a preceptor • How to write a concise SOAP note
• Assignment: ID 10 things faculty did wrong or omitted
Current Applications (cont.)
• 9 student volunteers conduct the follow-up visit on same patient
• Other ½ class in alternate activity “Building
Confidence in Clinical Presentations”, then they alternate
• Requires repeating scenarios in AM & PM with 35 students
Current Applications (cont.)
Second Spring Semester SCE Mentor/mentee design–
Pair first and second year FNP students in observer/participant design
AM:
½ of cohort in primary care SCE - initial & follow-up visit
½ in alternate activity (game show of board certification questions)
Current Applications (cont.)
Fall semester
OB/Women’s Health, Pediatrics 1st 8 hour clinical conference:
• AM: Suture and local anesthesia workshop • PM: Pediatric SCE: Initial visit and
Current Applications (cont.)
2nd 8 hour clinical conference:
AM:
• Initial OB scenario (participants & observers) • Initial Pediatric scenario (participants &
observers) PM:
• Follow-up OB visit (participants & observers) • Follow-up Pediatric scenario (participants &
Future Modifications
• Incorporate AACN Master’s Essentials into simulation development
(Grossman in Campbell & Daley, p.368)
• Introduce a family genogram to allow the students to follow the same family
throughout the program
Future Modifications (cont.)
• Incorporate EHR
• Strengthen the mentor role
provide enhanced preparation to increase value to student to act as mentor
American Association of Colleges of Nursing. (2011). The
essentials of master’s education in nursing. Washington, DC: Author.
Benjamin Franklin. (n.d.). BrainyQuote.com. Retrieved February 27, 2013, from BrainyQuote.com Web site: http://
www.brainyquote.com/quotes/quotes/b/benjaminfr383997.html Bryant, K. (2013). Diabetes management – Nurse practitioner. In S. H. Campbell, & Daley, K.M. (Eds.), Simulation scenarios for
nursing educators: Making it real. (2nd ed., pp.317-327). New York,
NY: Springer Publishing Company.
References (cont.)
Campbell, S.H. & LoGiudice, J. (2013). Abdominal pain in a woman of childbearing age. In S.H. Campbell, & Daley, K.M. (Eds.), Simulation
scenarios for nursing educators: Making it real. (2nd ed., pp.353-363).
New York, NY: Springer Publishing Company.
Grossman, S.C. (2013). Primary care patient with gastrointestinal problems: Graduate program advanced physiology and
pathophysiology. In S.H. Campbell & Daley, K.M. (Eds.), Simulation
scenarios for nursing educators: Making it real. (2nd ed., pp.317-327).
References (cont.)
Jeffries P. R. & Rogers, K.J. (2007). Theoretical Framework for Simulation Design. In P.R. Jeffries (Ed.), Simulation in nursing
education: From conceptualization to evaluation. (pp. 21-33). New
York, NY: National League for Nursing.
Kolb, David A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, N.J: Prentice-Hall, Inc. Kaplan, B. G., Abraham, C., & Gary, R. (2012). Effects of participation vs. observation of a simulation experience on testing outcomes:
Implications for logistical planning for a school of nursing. International
References (cont.)
O’Shea, E. R. (2013). Care of an onfant with congenital heart disease status postcardiac surgical repair. In S.H. Campbell & Daley, K.M. (Eds.), Simulation scenarios for nursing educators: Making it real. (2nd
ed., pp.317-327). New York, NY: Springer Publishing Company.
Pittman, O. A. (2012) The use of simulation with advanced practice nursing students. Journal of the American Academy of Nurse
Practitioners, 24, 516-520. doi: 10.1111/j.1745-7599.2012.00760.x
The INASCL Board of Directors (2011, August). Standards of best practice: Simulation. Clinical Simulation in Nursing, 7(4S), s1-s20. doi: 10.1016/j.ecns.2011.05.011
References (cont.)
Wagner, A.L. & Seymour, M.E. (2007). A model of caring mentorship for nursing. Journal for Nurses in Staff Development, 23 (5), 201-211.
