Simulation in Nursing Training - Article Example

? Simulation in Nursing Training Executive Summary Simulation has emerged as a useful learning tool in nurse training as the trainee nurses can enhance their skills by learning and practicing various procedures and repeat them till they acquire proficiency. It is an effective method of refining the skills and providing professional education to the trainee nurses without putting the safety of the patients at risk. By repeating the procedures the trainees gain confidence and are better prepared for training in actual life. It also improves communication skills and the students learn to work as a team. Simulation prepares the trainees for unexpected medical events and medical emergencies. Simulators are of various kinds; in their most common form they are available as different anatomical parts, computer programs and life size mannequins. In their most modern form the mannequins are fitted with sensors and provide instant feedback to the learner. This enables the trainees to correct their mistakes immediately instead of waiting for the instructor to tell them where they went wrong. Simulation is not only beneficial for the learners, the nurses can also enhance their skills and learn new procedures through this technique. Although expensive, this method of teaching is reliable and effective. Simulation in Nursing Training Nursing is one of the careers in which learning through practice is the best way to gain knowledge. Earlier the nurses learnt on patients through trial and error, but this process was quite risky as one mistake on their part could cause death. The learning environment was so tense that some students gave up their studies as they could not cope with the daily stress. To deal with this situation various techniques including practicum, case scenarios as well as simulation were adopted. Simulation is currently one of the best teaching methodologies in both clinical and academic settings. Defined by Dutta et al. (2006, p. 301) “simulation is the set of techniques for re-creating the aspects of the real world typically to replace or amplify actual experiences”. The adoption of simulation led to the development of critical thinking skills and enabled the students to practically put into use the clinical teachings in a risk free environment. Simulation also enabled the students to learn and practice procedural skills and develop crisis management skills; it also infuses teamwork spirit among students (Joint Commission Resources, 2008). Simulation based education in nursing became popular because as students the nurses did not get the required clinical educational experience that would prepare them for handling emergencies and other hospital situations (Gaberson & Oermann, 2010). Simulation plays an important role in the training of nurses as it enhances the quality of education by meeting the training needs better. Most institutes have adopted full scale simulation training. Simulation has proved to be a useful learning tool as it supports the theoretical and conceptual background of the nursing education (Campbell & Daley, 2008). In healthcare where the safety of the patients and accuracy of care is given utmost importance, simulation and simulators provide a less threatening environment for practice (Sanford, 2010). Simulation based teaching in nursing prepares the students for independent practice through technical skill development and advanced clinical learning. It also prepares the nurses for high risk situations such as traumas which may occur infrequently (Gaberson & Oermann, 2010). An interactive and participative environment can be created with simulation and the learners can overcome their weaknesses with the instant feedback provided by most simulators. Although numerous skills can be learnt through simulation, it is an exceptional teaching strategy for critical care nursing. In case of critically ill patients, nurses are required to collect, examine and respond accordingly to the data collected and all these skills can be acquired through simulation. The beauty of this method is that it allows the learners to apply their theoretical knowledge into practice in a systematic manner. Through simulation the nurses also learn to recognize the relationships among various clinical parameters to incorporate data. There are some drawbacks associated with simulation based teaching as well for instance it is quite expensive to set up as most equipment is costly and the operating cost and maintenance cost is high too. Another criticism this type of learning faces is that the responses are not real (Bradshaw & Lowenstein, 2010). Simulations can be a number of things; they can be devices, life like virtual situations and artificial social situations that replicate events, problems or conditions that occur during professional encounter. Among the various types of simulation used in teaching clinical and behavioral skills are low fidelity mannequins, high fidelity mannequins, anatomical models, computer aided instructions, role playing games, standardized patients, task trainers or part-task trainers, computer based programs and virtual reality simulators (Morris & Faulk, 2012). Virtual Reality Simulation Nursing education is one of the fields where computer technology has accelerated and enhanced the learning process. Virtual reality simulation is one of the strategies of computer technology which has aided nursing education. This type of simulator produces three dimensional images through which the learner can interact using audio, video and touch sensations. In this type of simulator an image is produced through computer modeling and advanced computer programming; the trainee interacts with this image. The sensing instruments used enable the computer to keep a track of the user’s movement. How does it Work VRS works in two steps; firstly lifelike images and objects are produced through three dimensional views and secondly stereo images are used to create a sense of being in a simulated environment. A clinical environment for the nurses can be reproduced with VRS where interaction with virtual patients and resources takes place. Virtual reality simulators are of two types; the first one creates a simple virtual environment visible on the computer screen and easily controlled by peripherals such as mouse or keyboard or joy stick. The second one creates a complex totally immersive virtual environment displayed on a head mounted stereoscopic unit. The user needs additional gear such as sensor containing gloves and special goggles to interact in this environment. The visual and audio feedback produced by the virtual reality simulators is very much lifelike and with the advancement in touch and pressure feedback (haptic), the tactile experience of the trainees has improved as well. The VRS can be used to enhance and evaluate both individual and combined skills thereby allowing the trainee nurses to learn without putting the patient’s safety at risk. The VRS not only provides a realistic experience in a risk free environment but also provides post experience feedback. Complex procedures like carotid artery stent replacement, laparoscopic surgery, sigmidoscopy, bronchoscopy, arthroscopy and ultrasound procedures can be taught with the virtual reality simulator. Intravenous catheter insertion can also be learnt through virtual reality simulator. With virtual reality simulators the nurses can learn to check the vital signs of the patients, insert catheters intravenously and the haptic feedback can be used to create the feeling of anatomical parts and tissues. The Phanthom Omni is commonly used in nursing labs to teach the trainees how to insert catheters intravenously. Step by step guidelines are provided which are similar to those followed in real life for instance the trainee has to wait 30 seconds after disinfecting the site. As the angle of insertion is highly critical, the trainee can feel the angles at which the needle can be inserted. The trainees can also palpate a vein with this VRS. Use of VRS in Nursing Education and Practice Virtual reality simulators provide real life scenarios for student nurses and are most effective in determining the health assessment skills both basic and advanced; they develop critical thinking skills and teamwork. VRS is also effective in measuring performance of the trainees. An advantage of the VRS is that information on trainees can be collected on the computer; this information can then be used to compare with other students. The drawback of this kind of simulator is that the number of programs written and tested is limited and there is a constant need to create more modules or update newer ones thereby making this technique expensive. Task Trainers Task trainers are the most common type of simulators (Nehring & Lashley, 2010). They are of two types; partial or part task trainers and complex task trainers. Also known as static or low tech trainers, the part task trainers are specially designed to duplicate a body part. These types of simulators are useful in teaching the basic elements of the skills or procedures and help in the development of psychomotor skills. Once the trainee learns the basic know how of the skills, he/she can acquire the advanced skills by practicing the procedure under supervision on actual patients. Part task trainers can vary from simple objects (such as food items) to body parts such as arm, intubation head etc. For instance earlier trainees practiced the procedure of giving injections on oranges, sutures were practiced on bananas and epidurals were learnt on watermelons. The trainees can learn the procedures venipuncture and intravenous cannulation, on the modern part task trainers such as the model of an arm. The trainees can also learn to take blood pressure on the arm. Airway skills can be practiced on head and thorax models. Suturing can be practiced on synthetic skin pads another form of part task trainers. Intubation mannequins and machines used in processes such as resuscitation, surgery or EMS scenarios are other examples of part task trainers. IV Hand by Life form, Blood Pressure Training arm from Laderdal and Wound Care model also from Laderdal are some part task trainers commonly found in nursing education labs. The advantage of part task trainers is that the procedures can be practiced repeatedly until the trainee becomes competent and confident. Another thing that goes in its favor is that it does not cost much and therefore the labs can procure multiple models so that a greater number of students can practice on them simultaneously. The disadvantage of part task trainers is that it is low fidelity and is thus suitable for beginners only. Also as it focuses on a single task, it is not that effective. To overcome this disadvantage the part trainers are often used in along with other simulators. For example for practicing suturing of lacerations or deep cuts the part task trainer synthetic skin pad can be strapped on the arm of a standardized patient actor. The pad is made of soft material and has a cut in it; the trainee learns to sew the wound. Partial task trainers are also used along with complex task trainers. While part task trainer simulators focus on the development of psychomotor skills, complex task trainer simulators train the nurses on more technological specific tasks and procedures such as ultrasound, intubation, laparoscopy and endoscopy. The complex task trainer simulators rely on virtual reality and haptic (touch, pressure) system. Haptic technology senses the users’ touch and can determine the amount of pressure applied. Complex and part task trainers are used together in surgical procedures such as laparoscopy (Durham & Alden, 2008). Surgical Sally, Dexter Non-Anatomic Endoscopic Dexterity Training System and Blue Phantom™ Central Venous Access Head/Neck/Upper Torso (ultrasound training model) are some examples of complex task trainers. The Virtual IV is a complex task trainer designed by Laderdal Manufacturing in which the user can feel an IV catheter being inserted in a virtual patient through computer based scenarios combined with a haptic device. The virtual patient responds to the user either verbally or physically (by bleeding). The drawback of this technology is that it is relatively expensive. Use of Task Trainers in Nursing Education and Practice The student nurse gets to focus on and practice specific procedure such as suturing, venipuncture, casting, IV catheter, splinting etc. The part task trainers are the most cost effective method of practicing these skills. The student nurse gains the necessary skills to perform clinical procedures. Task trainers help the nurses to learn bimanual examination and endocervical biopsy. Low Fidelity Mannequins Low fidelity mannequins replicate some areas of real experience but not too realistically. This type of simulator uses mannequins on which primary care skills such as moving, lifting, positioning etc and procedures like tracheal suctioning, IV catheter insertion, tube insertion and bathing etc can be practiced. These simulators do not respond to how they are being practiced upon by the user (Ball, 2011). One of the popular low fidelity mannequins used in nursing labs is the Susie Simon made by Gaumard Company. Besides the basic skills, student nurses can also practice procedures like fitting the patient with an ostomy bag, insertion of urethral catheter and giving an enema. Low cost and ease of use are the plus points of low fidelity mannequins. High Fidelity Mannequins High Fidelity mannequins are those that interact dynamically with the users. These mannequins are computer operated and are manufactured with advanced features such as palpable pulses, chest wall that replicates respiration, breath and bowel sounds and programmable heart. These mannequins are programmed to respond to the various procedures being practiced on them. Child delivery procedures are also simulated by high fidelity mannequins. Sim Man, Baby Hal and Noelle are high fidelity mannequins used in nursing labs. Use of Low and High Fidelity Mannequins in Nurse Education and Practice Both low and high fidelity mannequins are highly useful in developing clinical skills as student nurses collect information such as the history, drugs, allergies, laboratory values and other data about the simulated patient helpful in clinical decision making. The student nurses also learn to access electronic data as well as access the information systems present on the computer. In short these kinds of simulators develop technical and clinical skills in student nurses regarding where to find the patient’s data and how to use it. The advantages of low fidelity mannequins are restricted to the development of gross psychomotor skills but high fidelity mannequins can be used in the learning of community health, critical care, pediatrics and nurse anesthesia. It enhances critical thinking skills and improves clinical judgment (Nehring & Lashley, 2010). The use of low and high fidelity mannequins has increased in nurse education and has resulted in a decrease in time. The expense for residency programs and orientation has also decreased. A safer environment for both patients and nurses is also possible because of the high fidelity mannequins. Competency in testing skills is also achieved with high fidelity mannequins. The SimMan 3G Manufactured by Laedral SimMan 3G is a high fidelity adult simulator with the most advanced simulation technology. It is easy to use and comes with pre-programmed scenarios. It also allows the user to program new scenarios and has integrated video recorders which facilitate in debriefing. It has many true to life features and blinks and talks when care is being provided thereby creating a real life scenario. It is completely wireless and innovative and responds to different situations automatically. It comes with an internal blood reservoir on which accident scenes can be build-up. For instance it can depict bleeding from arterial and venous blood vessels if the wound models are connected to the built in blood reservoir. It can replicate full range of convulsions and seizures from minor to full convulsion. It generates palpable pulses, correct blood pressure surges and ECG results and gives instant and accurate feedback when CPR is performed. Even the eyes of the SimMan 3G are programmed to respond to different scenarios. The response to drug interactions is one of its best features of this mannequin. Sim Baby Sim Baby is another outstanding high fidelity simulator from Laedral for practicing and perfecting infant care skills. It is user friendly and also allows the user to build different levels of scenarios. It has a realistic anatomy that provides instant feedback to the various interventions by the user. It also has webcam recording feature for automatic debriefing. Role Playing Role-play has been used in nursing education forever, especially for development of therapeutic communication skills (Babatsikou & Gerogianni, 2012). Role playing is regarded as an experimental learning technique which requires the learners to act out case scenarios in order to learn the desired skills. The learners can assume the role of a health care professional, nurse, patient, family member of the patient and observer. There are two types of roles; the response based role in which the learner actor has no control over the material and the process based role in which the learner exhibits decision making ability and has control over the material and can therefore collect data and combine it with other information available to build a clear concept. Use of Role Play in Nursing Education and Practice This form of simulation encourages cognitive process through the learning opportunities it provides. Standardized Patient Actors Standardized patient actor is another simulator which can be used in nursing education. Standardized patients are especially trained actors or volunteers who play the part of actors with certain symptoms and diseases (Youngberg, 2012). This type of simulation is used when therapies and interventions are not required. The standardized patient actors learn about diseases or health concerns they are portraying and are able to respond to the questions put up by the trainees. The trainees learn by taking the history of these mock patients and physically examine them. This improves the cognitive skills and develops clinical judgment. The trainees are either supervised by the instructor in person or the entire process is videotaped for assessment. Besides history taking and physical examination, the trainees also practice handling complex situations such as delivering bad news. Desktop Simulators and Virtual World Simple desktop computers can also be used as simulators in nursing education. In the simplest form it can be a computer program showing an operation and in the advanced form the program has a simulated patient. The trainee interacts with the simulated patient and can check on its x-rays, lab results etc on the screen of the computer. Therapies and interventions can be performed on the simulated patient which responds to the course of action taken. In its more complex form the simulation creates a virtual environment where more than one user can work on the same patient simultaneously. It is a 2D world in which each user is assigned an “avatar” that interacts with other avatars and they can assume different clinical roles in the virtual clinical world. In this type of simulation too information about the patient is collected, action to be taken is decided and the response of the patient observed (Stanford School of Medicine, 2012). Setting up a Simulation Nursing Lab The Purpose of the Simulation Nursing Lab is to increase the competence and confidence of the student nurses and staff nurses in the following areas i) Theoretical Knowledge ii) Psychomotor Skills iii) Critical Thinking iv) Clinical Judgment v) Communication vi) Collaboration The purpose of simulators in a nursing lab is to provide a realistic environment for patient care and to offer the learners the best opportunity to develop critical thinking skills and practice patient care in a safe environment. The simulation lab will cater to the learning needs of the students as well as the staff. Students By offering simulation based education, students can be attracted to nursing programs. Role playing, video games, virtual reality, task trainers and mannequins attract students more than standard course books as they add “fun” to learning. The skills and techniques essential for undergraduate nursing education can be easily learnt through simulation. The psychomotor skills can be practiced with the use of part task trainers as they can be used over and over again until perfection is achieved. With the use of low and high fidelity mannequin simulators, the students will learn through practice as the mannequins will give an immediate feedback to every action taken. Students learn through mistakes and simulation provides the correct environment in which students make mistakes and then correct them; something not possible in an actual clinic. Simulation based education reduces the learning time involved and as it is quite effective, it prepares the students better for working directly with patients. It also initiates communication among the students and inculcates teamwork. Simulation in nursing labs also helps in retaining the students and therefore indirectly addresses the shortage of nursing staff as well. Training Staff The simulation lab is beneficial for the existing nursing staff as well because it updates them with new technologies and will lead to skill proficiency. In the present day scenario where technology is rapidly developing, simulation based education familiarizes the nursing staff with the current technologies. Most simulators are designed keeping the convenience of the user in mind and are easy to use. Accurate performance evaluation for both students and nursing staff can be done through simulation. Cost of Simulation The actual operating cost of simulation lab depends upon the size and range of the program and can be anywhere between $1000 to $ 20,000 per annum (National Council of State Boards of Nursing, 2009). Gates (2008) and Mcintosh et al. (2005) also highlighted costs of establishing and maintaining a highly sophisticated simulation lab as approx. $876,485 per year for creating a lab and approx. $361,245 per year for maintaining it. Following table presents the figures. Types of Costs Costs per annum Operating Cost $1000 to $ 20,000 (depending upon the size and range) Cost of Establishing Simulation Lab Approx. $876,485 per year Cost of Maintaining Simulation Lab Approx. $361,245 per year Table I – Cost of Simulation However besides the annual operating cost, the maintenance cost of the equipment, the clinical supplies and the warranty support should also be considered. Besides the program fee in which they are enroll, the students will also have to pay the lab charges. List of Equipment Required Following table shows the list of equipment required for setting up a simulation lab besides the general setting of the lab which may include furniture and setting up a virtual health center like settings. Equipment Price Simulators SimMan 3G (Laderal) Sim Baby (Laderal) $66,5000 $27,395 Mannequin Susie Simon $835 Task Trainers IV Hand (LifeForm) $270 Desktop Computers Cost depends upon market rate and company etc. Video Cameras Cost depends upon market rate and company etc. Table II – List of Equipment and Prices The Simulation lab will have one Sim Man 3G and one Sim Baby as high fidelity simulators. Both mannequins are currently the most advanced simulators and a number of procedures related to respiratory track, cardio, accidents, drug administration, seziures can be learnt on the Sim Man 3G whereas Sim Baby is most helpful in developing skills pertaining to infant care. They are expensive but with the number of procedures being practiced on them, they cover the cost. Susie Simon a low fidelity mannequin will be purchased to teach the basic skills like catherization, cannulation, fixing ostomy bag and giving enema. IV insertion is one task which most trainees find challenging for this purpose IV hand will be purchased. The trainees will also learn by downloading software on the desktop and interacting with simulated patients in the virtual world. Video camera is necessary to keep a track of the on-site activities of the trainees and the staff and to evaluate them. References Babatsikou, F. P., & Gerogianni, G. K. (2012). The importance of role-play in nursing practice. Quarterly scientific - online publication of A’ Nursing Department, Technological Educational Institute of Athens. Health Science Journal 6 (1). Retrieved on 24th Dec, 2012 from http://www.hsj.gr/volume6/issue1/611.pdf Ball, M. J. (2011). Nursing Informatics: Where Technology and Caring Meet. New York: Springer Publishing. Bradshaw, M, & Lowenstein, A. (2010). Innovative Teaching Strategies in Nursing and Related Health Professions. 5th edn. USA: Jones & Bartlett Publishers. Campbell, S. H., & Daley, K. (2008). Simulation Scenarios for Nurse Educators: Making it Real. New York: Springer Publishing Company. Dutta, S., Gaba, D., & Krummel, T. (2006). To stimulate or not to stimulate: what is the question? Annals of Surgery 243 (3), 301. Durham, C. F. & Alden, K. R. (2008). Enhancing Patient Safety in Nursing Education through Patient. In Hughes, R. (ed.). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Vol. 3.  US: Agency for Healthcare Research & Quality. Gaberson, K., & Oermann, M. (2010). Clinical Teaching Strategies in Nursing. 3rd edn. New York: Springer Publishing. Gates, M. (2008). Developing a simulation center for your nursing school. Paper presented at the Technology Integration in Nursing Education and Practice Conference. Durham, NC. Joint Commission Resources. (2008). Medical Team Training: Strategies for Improving Patient Care and Communication. Illinois: Joint Commission Resources Mcintosh, C., Macario, A., Flanangan, B., & Gaba, D.M. (2005). Simulation: What does it really cost. Poster session presented at the SimTecT 2005 Healthcare Symposium. Brisbane, Australia. Morris, A. H., & Faulk, D. R. (2012). Transformative Learning in Nursing: A Guide for Nurse Educators. New York: Springer Publishing. National Council of State Boards of Nursing. (2009). The Effect of High-Fidelity Simulation on Nursing Students’ Knowledge and Performance: A Pilot Study. NCSBN. Retrieved on 25th Dec, 2012 from https://www.ncsbn.org/09_SimulationStudy_Vol40_web_with_cover.pdf Nehring, W., & Lashley, F. (2010). High-Fidelity Patient Simulation in Nursing Education. USA: Jones & Bartlett Publishers. Sanford, P. G. (2010). Simulation in Nursing Education: A Review of the Research. The Qualitative Report 15 (4), 1006-1011. Stanford School of Medicine. (2012). Desktop Simulators and Virtual World. Centre of Immersive and Simulation-Based Learning. Retrieved on 26th Dec, 2012 from http://cisl.stanford.edu/what_is/sim_modalities/desktop_sim.html Youngberg, B. J. (2012). Patient Safety Handbook. USA: Jones & Bartlett Publishers. Read More