For example, one of the videos showed a patient who was placed in restraints inappropriately. The discussion centered on how the use was inappropriate and possible alternatives to restraints. A multi-faceted educational approach aimed at improving nurse competencies in diabetes self-management was initiated with 21 ambulatory care nurses. Each scenario required nurses to identify underlying issues for the patient, collaboratively create mutual goals, and consider next steps for the patient. Three unfolding scenarios were developed using high-fidelity simulation.
The simulation scenarios focused on acute respiratory failure requiring intubation; atrial fibrillation requiring treatment; and mental status changes. These were areas of high volume on the unit and important for overall patient care. In an intensive care unit, several simulation scenarios were developed and implemented to support nurses who needed to learn a new procedure using complex technical equipment for very critically ill patients.
The focus here was on troubleshooting alarms with the equipment and managing patient responses to therapy. Simulation has demonstrated effectiveness as a method to train practicing nurses for new procedures, communication processes, and both skill based and non-skill based techniques. This can be done using a variety of methodologies, ranging from simple role-play to use of high-fidelity and virtual simulators. Simulation can provide an effective mechanism for improving competency in a given area.
For example, if a manager reviews unit data and notes an increase in response time to codes e. Similarly, unit leadership may note a reduction in collaboration occurring among the multi-disciplinary team. Simulation scenarios requiring communication among the team may assist in improving collaboration and subsequent patient care. Simulation can also be considered as an evaluation method. For example, new hires could be required to successfully complete a series of skill-based simulations e. Simulation could also be used to ensure annual competencies as described in the unfolding case exemplar or to remediate poor performing employees.
In addition to its usefulness in nursing education, simulation provides a suitable methodology for deliberately performing skills necessary to be an effective practicing nurse. Many of these simulations can be done without a costly, high fidelity mannequin. One must only consider the overall purpose of the simulation and be creative. She has an extensive background in simulation using both high-fidelity simulators and virtual reality simulation using Second Life.
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Her professional and academic career is focused on advancing the science of education through the development of innovative and effective educational techniques and technologies. Aebersold has conducted research using various types of learning pedagogies including simulation and virtual reality simulation and has developed evaluation tools for use in simulation to evaluate student performance.
The aim of her research program is to improve nursing care delivery and patient outcomes through the utilization of technology and clinical information. This has included the development of numerous simulations for the virtual environment and high-fidelity simulator. Recently, Dr. Tschannen completed a funded study which involved the design of a virtual nursing unit using Second Life. The virtual environment has been used for didactic teaching as well as an environment for training related to quality, patient safety, teamwork, and communication.
Aebersold, M. Using virtual simulations in second life for teaching and learning in nursing education. Wankel Eds. Use of simulation in stroke unit education. Andreatta, P. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatric Critical Care Medicine, 12 1 , Benner, P. Educating nurses: A call for radical transformation.
Washington, DC: Carnegie Foundation. Birch, L. Taylor, K. Obstetric skills drills: Evaluation of teaching methods. Nurse Education Today, 27 8 , Brown, R. Design and implementation of a virtual world training simulation of ICU first hour handover processes. Australian Critical Care, 25 3 , Buckley, T. The effectiveness of high fidelity simulation on medical—surgical registered nurses' ability to recognise and respond to clinical emergencies.
Nurse Education Today, 31 7 , Buykx, P. Patient deterioration simulation experiences: Impact on teaching and learning. Collegian, 19 3 , Cumin, D. A systematic review of simulation for multidisciplinary team training in operating rooms. Fransen, A. Effect of obstetric team training on team performance and medical technical skills: A randomised controlled trial. Gaba, D. The future vision of simulation in health care. Galloway, S.
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Simulation techniques to bridge the gap between novice and competent healthcare professionals. Goldsworthy, S. High fidelity simulation in critical care: A Canadian perspective. Harder, B. Use of simulation in teaching and learning in health sciences: A systematic review. The Journal of Nursing Education, 49 1 , Jeffries, P. Simulation in nursing education. New York: National League for Nursing.
Kardong-Edgren, S. Van Gele, P. Lapkin, S. Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6 6 , e McGaghie, W. A critical review of simulation-based medical education research: Medical Education, 44 1 , Nagle, B. Incorporating scenario-based simulation into a hospital nursing education program. Journal of Continuing Education in Nursing, 40 1 , National Research Council. The future of nursing: Leading change, advancing health.
Retrieved from www. Orledge, J. The use of simulation in healthcare: From systems issues, to team building, to task training, to education and high stakes examinations. Current Opinion in Critical Care, 18 4 , Page, A. Keeping patients safe: Transforming the work environment of nurses. Phipps, M. Outcomes from a labor and delivery team training program with simulation component. American Journal of Obstetrics and Gynecology, 1 , 3. Pilcher, J. Neonatal Network: NN, 31 5 , Rauen, C. Simulation as a teaching strategy for nursing education and orientation in cardiac surgery.
Critical Care Nurse, 24 3 , Riley, W. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Roots, A. Simulation training for hyperacute stroke unit nurses. Rosen, M. King, H. Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine residents.
Schmidt, E. Simulation exercises as a patient safety strategy: A systematic review. Annals of Internal Medicine, 5 Pt 2 , Schubert, C. Effect of simulation on nursing knowledge and critical thinking in failure to rescue events. Journal of Continuing Education in Nursing, 43 10 , Shea-Lewis, A. Teamwork: Crew resource management in a community hospital. Shearer, J. High-fidelity simulation and safety: An integrative review.
The Journal of Nursing Education, 52 1 , Stirling, K. The benefits of a ward simulation exercise as a learning experience. Theilen, U.
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Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. Resuscitation, 84 2 , Tschannen, D. Journal of Nursing Education and Practice, 2 3 , Wayne, D. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest, 1 , Wolf, L. The use of human patient simulation in ED triage training can improve nursing confidence and patient outcomes. Journal of Emergency Nursing, 34 2 , OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.
Find Out More Benefit for Members Members have access to current topic More Letter to the Editor Thank you for giving us the opportunity to respond to the letter to the editor written by Lisa Palucci. We are pleased to see her interest in older adults with multimorbidity and advancing models of care and care coordination for this growing population group. Continue Reading View all Letters DOI: Vol18No02Man06 Key words: Simulation, patient safety, staff education, nursing education, learning methods, practice, critical care, staff development, quality, training The IOM report on nursing work environments recommends simulation as a method to support nurses in the ongoing acquisition of knowledge and skills.
Table 1. High-Fidelity Simulations Simulations that utilize computerized manikins Mid-Fidelity Simulations Simulations that utilize standardized patients, computer programs or video games Low-Fidelity Simulations Simulations that use role play, non-computerized manikins or task- trainers Task-Trainers Simulators that are used to practice a skill such as an IV arm that is used to practice IV insertions skills In-situ simulation This refers to bringing the simulation and simulator to the site where the learner is practicing.
Review of Selected Simulation Research This article is not an exhaustive review of the literature on simulation or the impact of simulation on patient outcomes, but rather considers selected publications to direct readers to emerging evidence and provide some context for the later discussion about simulation in nursing practice. Table 2. Patient Outcomes Safety Culture Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital Riley et al.
Patient Outcomes Safety Culture Outcomes from a labor and delivery team training program with simulation component Phipps et al. This included nurses and physicians. Use of Simulation in the Nursing Practice Environment Simulation has been used in a variety of ways in the practice setting. Developing a Simulation Program Developing a simulation program can be done as an institutional endeavor in which target areas for simulation are identified or it can be created on a unit or program level.
Table 3. Winter Institute for Simulation Education and Research WISER classes newsletters information on simulation center design conferences symposium on nursing simulation www. Exemplars of Simulation in the Practice Area Even the brief review above provides multiple examples of simulation in a variety of practice settings using several different simulation techniques. Video Unfolding Case Simulations A variety of simulation methodologies can be used for education and training of practicing nurses.
Ambulatory Care A multi-faceted educational approach aimed at improving nurse competencies in diabetes self-management was initiated with 21 ambulatory care nurses. All participants were informed of the objective and design of the study and a written consent received from the participants for interviews and they were free to leave focus group if they wish. The qualitative analysis led to the emergence of the four themes from the focus group data.
From the students' point of view," initial clinical anxiety", "theory-practice gap", clinical supervision"," professional role", was considered as important factors in clinical experience. This theme emerged from all focus group discussion where students described the difficulties experienced at the beginning of placement. Almost all of the students had identified feeling anxious in their initial clinical placement.
Worrying about giving the wrong information to the patient was one of the issues brought up by students. On the first day I was so anxious about giving the wrong information to the patient. I remember one of the patients asked me what my diagnosis is. How can you look after me if you do not know what my diagnosis is? From all the focus group sessions, the students stated that the first month of their training in clinical placement was anxiety producing for them.
The most stressful situation is when we make the next step. I mean Almost all of the fourth year students in the focus group sessions felt that their stress reduced as their training and experience progressed. Another cause of student's anxiety in initial clinical experience was the students' concern about the possibility of harming a patient through their lack of knowledge in the second year.
In the first day of clinical placement two patients were assigned to me. One of them had IV fluid. When I introduced myself to her, I noticed her IV was running out. I was really scared and I did not know what to do and I called my instructor. Fear of failure and making mistakes concerning nursing procedures was expressed by another student.
She said:. I was so anxious when I had to change the colostomy dressing of my 24 years old patient. It took me 45 minutes to change the dressing. I went ten times to the clinic to bring the stuff. My heart rate was increasing and my hand was shaking. I was very embarrassed in front of my patient and instructor. I will never forget that day. Sellek researched anxiety-creating incidents for nursing students. He suggested that the ward is the best place to learn but very few of the learner's needs are met in this setting.
Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing [ 11 ]. The category theory-practice gap emerged from all focus discussion where almost every student in the focus group sessions described in some way the lack of integration of theory into clinical practice. I have learnt so many things in the class, but there is not much more chance to do them in actual settings. When I just learned theory for example about a disease such as diabetic mellitus and then I go on the ward and see the real patient with diabetic mellitus, I relate it back to what I learned in class and that way it will remain in my mind.
It is not happen sometimes. The literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly [ 20 , 21 ]. The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap [ 21 ]. Rolfe suggests that by reconsidering the relationship between theory and practise the gap can be closed.
He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theory-practice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practising nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalise from what they learnt in theory [ 22 ]. Clinical supervision is recognised as a developmental opportunity to develop clinical leadership. Working with the practitioners through the milieu of clinical supervision is a powerful way of enabling them to realize desirable practice [ 23 ].
Clinical nursing supervision is an ongoing systematic process that encourages and supports improved professional practice. One of the students said:. Sometimes we are taught mostly by the Head Nurse or other Nursing staff. The ward staff are not concerned about what students learn, they are busy with their duties and they are unable to have both an educational and a service role. Some of the nursing staff have good interaction with nursing students and they are interested in helping students in the clinical placement but they are not aware of the skills and strategies which are necessary in clinical education and are not prepared for their role to act as an instructor in the clinical placement.
The students mostly mentioned their instructor's role as an evaluative person. The majority of students had the perception that their instructors have a more evaluative role than a teaching role. The literature suggests that the clinical nurse supervisors should expressed their existence as a role model for the supervisees [ 24 ]. One view that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.
We just do basic nursing care, very basic. You know Anyone can do it. We spend four years studying nursing but we do not feel we are doing a professional job. The role of the professional nurse and nursing auxiliaries was another issue discussed by one of the students:. The role of auxiliaries such as registered practical nurse and Nurses Aids are the same as the role of the professional nurse. We spend four years and we have learned that nursing is a professional job and it requires training and skills and knowledge, but when we see that Nurses Aids are doing the same things, it can not be considered a professional job.
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The result of student's views toward clinical experience showed that they were not satisfied with the clinical component of their education. Four themes of concern for students were 'initial clinical anxiety', 'theory-practice gap', 'clinical supervision', and 'professional role'. The nursing students clearly identified that the initial clinical experience is very stressful for them. Students in the second year experienced more anxiety compared with third and fourth year students.
This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of anxiety in second year [ 26 , 27 ]. Neary identified three main categories of concern for students which are the fear of doing harm to patients, the sense of not belonging to the nursing team and of not being fully competent on registration [ 28 ] which are similar to what our students mentioned in the focus group discussions.
Jinks and Patmon also found that students felt they had an insufficiency in clinical skills upon completion of pre-registration program [ 29 ]. Initial clinical experience was the most anxiety producing part of student clinical experience. In this study fear of making mistake fear of failure and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. This finding is supported by Hart and Rotem [ 4 ] and Stephens [ 30 ].
Developing confidence is an important component of clinical nursing practice [ 31 ]. Development of confidence should be facilitated by the process of nursing education; as a result students become competent and confident. Differences between actual and expected behaviour in the clinical placement creates conflicts in nursing students. Nursing students receive instructions which are different to what they have been taught in the classroom. Students feel anxious and this anxiety has effect on their performance [ 32 ].
The existence of theory-practice gap in nursing has been an issue of concern for many years as it has been shown to delay student learning. All the students in this study clearly demonstrated that there is a gap between theory and practice. This finding is supported by other studies such as Ferguson and Jinks [ 33 ] and Hewison and Wildman [ 34 ] and Bjork [ 35 ].
Discrepancy between theory and practice has long been a source of concern to teachers, practitioners and learners. It deeply rooted in the history of nurse education. Theory-practice gap has been recognised for over 50 years in nursing. This issue is said to have caused the movement of nurse education into higher education sector [ 34 ]. Clinical supervision was one of the main themes in this study. According to participant, instructor role in assisting student nurses to reach professional excellence is very important. In this study, the majority of students had the perception that their instructors have a more evaluative role than a teaching role.
About half of the students mentioned that some of the head Nurse Nursing Unit Manager and Staff Nurses are very good in supervising us in the clinical area. The clinical instructor or mentors can play an important role in student nurses' self-confidence, promote role socialization, and encourage independence which leads to clinical competency [ 36 ]. A supportive and socialising role was identified by the students as the mentor's function.
This finding is similar to the finding of Earnshaw [ 37 ]. According to Begat and Severinsson supporting nurses by clinical nurse specialist reported that they may have a positive effect on their perceptions of well-being and less anxiety and physical symptoms [ 25 ]. The students identified factors that influence their professional socialisation. Professional role and hierarchy of occupation were factors which were frequently expressed by the students. Self-evaluation of professional knowledge, values and skills contribute to the professional's self-concept [ 38 ].
The professional role encompasses skills, knowledge and behaviour learned through professional socialisation [ 39 ]. The acquisition of career attitudes, values and motives which are held by society are important stages in the socialisation process [ 40 ]. According to Corwin autonomy, independence, decision-making and innovation are achieved through professional self-concept Lengacher discussed the importance of faculty staff in the socialisation process of students and in preparing them for reality in practice. One view that was expressed by second and third year student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.
The finding of this study and the literature support the need to rethink about the clinical skills training in nursing education. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. There were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education.
Nursing students expressed their views and mentioned their worry about the initial clinical anxiety, theory-practice gap, professional role and clinical supervision. They mentioned that integration of both theory and practice with good clinical supervision enabling them to feel that they are enough competent to take care of the patients. The result of this study would help us as educators to design strategies for more effective clinical teaching. The results of this study should be considered by nursing education and nursing practice professionals.
Faculties of nursing need to be concerned about solving student problems in education and clinical practice. The findings support the need for Faculty of Nursing to plan nursing curriculum in a way that nursing students be involved actively in their education.
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