Scholarship of Teaching and Learning Grant

1

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 supportshigh-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; JeffriesRizzolo, 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, FicorelliVandermeek-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.

Methods

The 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).

Results

Family 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.

Discussion

Overall, 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 A

Pediatric Clinical Scenarios

#1. Simulation Design Template: Asthma

ExpectedSimulationRunTime:30 minutes

Client Name: Michael Davis
Gender: Male
Age: 8 years
Historian: Mother and patient
CC: Cough and wheezing
Weight: 30 kg
Height – 52 inches
Vital Signs: P – 128 RR – 36 T 99 oral SaO2 – 92%
Allergies: No known drug allergies
Medications: Zyrtec, Albuterol
Immunizations: Current per CDC recommendations
Past Medical History: Diagnosed withasthma 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 Outline

TIME / MANIKEN ACTIONS / EXPECTED INTERVENTIONS
2 Minutes / Sitting in high-fowlers position on stretcher / Wash hands
Introduce self to mother
Initiate history
5 minutes / Tachypnea with RR 36, tachycardia with heart rate 128, Sa02 – 92%, inspiratory and expiratory wheezing, coughing frequently, intercostal retractions
PEFR - 175 / Complete 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 Flow
5 minutes / Unchanged / Explain 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 minutes / Pt. reports that he is feeling better. Wheezing is increased, however air exchange is improved. SaO2 – 95%
PEFR - 225 / Inquire 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 minutes / Pt. reports that he is feeling much better. Lungs with minimal wheezing, RR: 20 Sa02 – 98%.
PEFR - 230 / Confirm 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 Zyrtec
• Discuss possibility of needing an inhaled steroid if symptoms are difficult to control
• Review asthma plan and provide to pt. and mother
• Discuss 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 Oximeter

Peak flow meter

Stethoscope

Nebulizer for Albuterol/Atrovent administration

Peak Flow Meter Chart

Asthma action plan form

Blank Prescription

Debriefing / Guided Reflection Questions for This Simulation

1. 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 Maltreatment

ExpectedSimulationRunTime:30 minutes

Client Name: Steven Morrison
Gender: Male
Age: 6 weeks
Historian: Mother
CC: Fussy, and ? pain in left leg
Weight: 4.2 kg
Vital Signs: P – 136 RR – 32 T 100.8 ®
Allergies: No known drug allergies
Immunizations: Current per CDC recommendations
Past 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 Outline

TIME / MANIKEN ACTIONS / EXPECTED INTERVENTIONS
2 Minutes / Being held by mother / Wash hands
Introduce self to mother
Initiate history
5 minutes / Cries with movement and palpation of left leg / Complete a history and physical examination
5 minutes / Lying on exam table / Explain concerns of physical examination finding to mother, discuss plan of care and order x-ray of left femur
10 minutes / Lying on exam table / Review x-ray findings
Inform primary nurse of plan of care
Consult with pediatric orthopedics
Notify law enforcement and DSS
Contact EMS for transfer
Discuss x-ray findings and plan of care with mother
TIME / MANIKEN ACTIONS / EXPECTED INTERVENTIONS
2 Minutes / Lying on exam table
Seizure activity – lasting 1 minutes and spontaneously resolves / Place infant on side, maintain open airway, administer oxygen, monitor vital signs
Initiate peripheral IV
5 minutes / Lying on exam table / Gives report to EMS
Notify orthopedic surgeon
Notify emergency department (ED) as patient will now go to the ED
Transfer of patient to the ED

Critical Behaviors