of nursing education appears promising because research suggests that the use of HPS facilitates the ... The use of this technology addresses patient safety.
Human simulators in nursing education
Alsacia L. Pacsi. MS. RN. FNR CEN. CCRN
Abstract The purpose of this paper is to discuss and explore the historical perspectives, capacities, and usage of human patient simulators (HPS) in clinical simulations and propose future uses for HPS in nursing education. The use of HPS at all levels of nursing education appears promising because research suggests that the use of HPS facilitates the development of students' physical assessment and critical thinking skills in a user-friendly environment (Spunt, Foster, & Adams, 2004). By combining HPS scenarios with lectures and actual clinical experiences, students become actively engaged and confident in their competency of the nursing process in multiple clinical arenas. The use of this technology addresses patient safety because the student is able to refine skills and develop competency in a simulated environment. Developments in computer technologies have thoroughly reformed nursing education (Saba & McCormick, 2006). Due to such developments, students who are now accustomed to using computers expect this tool to be incorporated into their education (Saba & McCormick, 2006). One exciting new technology is the field of human patient simulators (HPS), computerized life-sized mannequins that have the ability to formulate realistic case scenarios that can be altered rapidly to meet the instructors' educational goals. The purpose of this paper is to discuss historical perspectives of HPS, explore
the capabilities and use of HPS, review studies to support the use of HPS in nursing education, discuss the effectiveness of the HPS in clinical simulations, and propose future uses for HPS.
Historical perspectives Historically, the first HPS, 'Mrs. Chase.' was developed in the late I 950s (Herrmann, 1981). The model comprised a torso and separate computerized software. Mrs. Chase was used to help nursing students perfect their physical assessment skills. In the 1960s, the 'Harvey' model was created (Herrmann,
1981 ). This model contained a heart and lungs that helped students distinguish between normal and abnormal cardiopulmonary findings. The first fully-equipped computerized human simulator was Sim One. which was mainly used for endotracheal intubations in both medical and graduate nurse anesthesia programs (Caba 6 DeAndra, 1988). The HPS that are presently being utilized, for example MetiMan, Laerdal SimMan, and BabySim, come fully equipped with computer software and can be connected to laptop or
Alsacia L. Pacsi is a nursing lecturer at Lehman College. City University of New York in Bronx. NY. She specializes in emergency and critical care nursing and is a doctoral nursing science student at the City University of New York Qraduate Center. This paper was inspired by a course assignment by Margaret
Lunney, PhD. RN. Journal of the New York State Nurses Association, Fall/Winter 2008-2009
Hunnan sinnulatars in nursing education desktop computers (Nehring, Lashley, & Ellis, 2002). The MetiMan and Laerdal SimMan high-fidelity HPS, each comprising a mouth and airway, are able to blink and speak, have chest walls that visibly expand on inspiration and relax on expiration, and generate audible lung and heart sounds that are programmable. These mannequins may be intubated, and receive bag and mask ventilation. When the device is connected to a monitor, an instructor can program cardiac rhythm, pulse oximetry reading, and both venous and arterial pressures (SullivanMann, 2007; Peteani, 2004). These iHPS can also be programmed to produce human-like responses to numerous disease states and reactions to treatments and interventions such as intravenous (IV) medication administration, intubation, ventilation, catheterization, and cardiopuimonary resuscitation.
Capabilities and uses of HPS Desktop or laptop computers have been used in classrooms primarily to facilitate communication and the acquisition of knowledge (Saba 6 McCormick, 2006). Gurrent applications now facilitate and support clinical learning as well.
of simulation in respect to skill development and/or knowledge acquisition (Ravert, 2002). The review author identified the need for more research that focuses on the most effective way to use simulation. The disadvantages noted in previous studies were the inconsistencies in the patient outcomes related to the simulation experiences presented, as well as the cost of high-fidelity HPS. A study was performed to investigate the effects of using HPS for remediation of graduate-level nurse anesthesia students, compared to the traditional method of addressing students' knowledge deficits before returning them to the clinical setting (Leah & Koop, 2004). The students who were weak in the clinical settings worked in a simulation center v/ith HPS that were preprogrammed with standardized case scenarios. Each student's mannequin was programmed by the instructor to strengthen his or her area(s) of weakness in the clinical arena. The researchers discovered that the most important aspect of remediation was debriefing, which could determine how much more simulation practice the student needed (Leah & Koop, 2004).
Research examined whether the use of HPS would address problems faced in the traditional descriptive-teaching style (McGausland, Gurran, This kind of hands-on & Gataldi, 2004). Using the nursing process work offers students as the framework, 72 nursing students in a baccalaureate program participated in the study. various case scenarios The educators created simulation objectives and can present around congestive heart failure (GHF). The clinical presentation and a simulation of a students with situations physician's orders were incorporated and they may not encounter tailored to meet the objectives. The students were provided with reading materials and during their assigned objectives and were instructed to review the HPS facilitate the application of theory clinical rotations. drugs used in GHF. The educator's role was to practice. According to Tilghman (2006), to serve as a facilitator. Eighty-three percent incorporating new technologies in nursing ' of the students indicated that pre-scenario education provides an opportunity to heighten reference materials were helpful. Eighty-two percent indicated they student learning. These devices also provide future nurses with the had come prepared to make decisions. Ninety-seven percent of the skills necessary to flourish in a healthcare market that focuses on the students indicated that the simulation experience would help them development of technologies to promote patient safety and improve when confronted with actual critical situations in the future. Ninetytheir outcomes. six percent believed that the simulation taught them significant lessons and that debriefing was beneficial. The experience was rated HPS represent the most up-to-date simulation technology utilized as positive by 90%, with 58% indicating the experience was excellent by educators to instruct healthcare providers at all levels and in all (McGausland et al., 2004). disciplines (Bremner, Aduddell, Bennett, & VanGeest, 2006). Simulation Many colleges and universities have simulation centers that are open for students to practice and develop their basic technical skills, as well as foster critical thinking, decision making, delegation, and team work. Simulation experiences are made possible through the use of technologically-equipped mannequins. This kind of hands-on work offers students various case scenarios and can present students with situations they may not encounter during their assigned clinical rotations.
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also provides an objective way to assess and evaluate students' decision-making processes prior to actual live patient contact. The HPS can be used to create clinical situations that help students bridge theory and practice in a controlled environment, permitting students to focus without fear of harming an actual patient (Spunt, Foster, & Adams, 2004).
Review of the literature In a systematic review of quantitative studies to determine the effect of simulation on education and learning, Ravert (2002) collected 513 references related to computer-based and healthcare simulation. Of these studies, 23 clearly involved simulation and only nine were quantitative. Seventy-five percent of the studies had positive results
An exploratory descriptive study was performed to evaluate the advantages and limitations of using high-fidelity HPS to simulate clinical scenarios (Bearson & Wiker, 2005). The researchers substituted a 2-hour session using the HPS for i clinical day for 2 groups of firstyear baccalaureate students. The number of students was not specified. These students were doing their clinical rotation with postoperative patients. Each student group was given 3 different scenarios in the simulation class, which were related to postoperative patients. Each student group provided total care for 2 consecutive hours using the HPS. The results, using the Likert scale, indicated increased knowledge of medication side effects and differences in patients' responses, and the confidence and ability to administer medications safely.
Journal of the New York State Nurses Association, Fall/Winter 2008-2009
• Hunnan sinnulatars in nursing educatian
Ttie use otHPS facilitates the development of students' physioal assessment and oritioal thinking skills, whioh are essential far providing effective and efficient oare.
A pilot study was performed with 21 senior-level medical-surgical nursing students (Rhodes & Curran, 2005). Their goal was to improve the students' critical thinking skills. Rhodes and Curran used HPS to facilitate this process. A 13-item survey developed by the faculty was given to the students and addressed their perceptions of the simulation experience. The results were positive. Eaculty noted that students were able to accomplish the simulation objectives addressing physical assessment and skill acquisition related to IV monitoring, urinary catherization, and blood transfusion. They noted that the students' main area of weakness was the procedure for blood administration. The results indicated that the HPS was an effective tool to promote critical thinking related to patient care (Rhodes 6 Curran, 2005). In 2004, 190 students participated in a study that was developed by the University of Maryland Baltimore School of Nursing, based on Benner's theoretical framework addressing the attributes and learning needs of nurses at varying degrees of clinical competency (Larew, Lessans, Spunt, Eoster, OConvington, 2006). Benner's theory states that students with higher competency levels should be able to develop a nursing diagnosis and intervene faster based on the subtle cues of the simulated patient (Larew et al., 2006). The objective of the project was to address the needs of the novice practitioner. Students worked with standardized, clinically accurate data that was programmed into SimMan. The study demonstrated that novice students needed more prompts before diagnosing the problem than those students with higher levels of competencies (Larew et al., 2006). The study also supported Benner's theory that students with higher competency levels would be able to develop a nursing diagnosis and intervene faster than the less competent students (Larew et al., 2006). A pilot study evaluated the learning outcomes of students using the Laerdal SimMan HPS (Radhakrishnan, Roche, & Cunningham, 2007). A convenience sample
10
(10 females and 2 males) of homogeneous second-degree, senior baccalaureate nursing students were studied to compare their clinical performance with and without HPS exercises and to identify areas in which the use of HPS was beneficial. Students in groups of 6 were randomly assigned to the intervention or control group. Those involved in the study had previously completed 320 hours of internships. Performance addressed safety, basic assessment, prioritization, problem-focused assessment, appropriate interventions, delegation, and communication. Students in both groups were evaluated at the end of the mandatory simulation exercise by using the Clinical Simulation Evaluation Tool (CSET). The results indicated that in safety and basic assessment, students in the intervention group scored higher. In focused assessment, interventions, delegation, and communication, no significant difference was noted between the intervention and the control groups (Radhakrishnan et al., 2007).
Effectiveness in clinical simulations Studies related to the use and effectiveness of HPS show they may be utilized to test each student's level of clinical competency and critical thinking skills (Rhodes & Curran, 2005). HPS are effective at all levels of education (graduate and undergraduate), but they are also time-consuming and costly to utilize (Hravnak, Tuite, & Baldisseri, 2005: Leach & Koop, 2004: McCausland, 2004). The use of HPS facilitates the development of students' physical assessment and critical thinking skills, which are essential for providing effective and efficient care. Simulation technology cultivates the refinement of nursing competency without the student being in an actual clinical environment (Larew et al., 2006). Case scenarios should also be created by faculty experts in the field. Eaculty must be familiar with and comfortable in using HPS and scenarios should coincide with current lecture content.
Journal of the New York State Nurses Associafian, Fall/Winter 2008-2009
Future uses The future use of HPS will provide more opportunities to expose students to acute patient scenarios in which they can intervene safely. Exposing students to HPS on a regular basis throughout the curriculum would enable faculty to present case scenarios in which the students would be developing basic skills. The complexity of the cases can be increased over time to integrate technical skills and promote critical thinking. Also, review of videotaped student-HPS interactions and the debriefing process would provide for both quantitative and qualitative research and is supported by Larew and colleagues (2006). Utilization of simulation technology would also enable the faculty to provide 1:1 supervision of clinical competencies for each student and would facilitate tailoring remediation to meet individual needs.
Conclusion The HPS can be an effective tool for students and faculty to use in combination with other teaching methods to facilitate mastery of clinical skills and promote critical thinking. Studies are needed, however, with larger sample sizes to expand and validate previous findings, particularly with undergraduate nursing students. Expanded research would add to the reliability of studies to date and facilitate the development of programs to meet students' needs. Qualitative studies looking at HPS use demonstrate positive results. However, more quantitative studies are needed to demonstrate effectiveness. Standardized objective measurements should be formulated to measure student outcomes. In addition, debriefing is essential to the simulation process because it allows the student to view his or her performance and discuss it with the instructor (Larew et al., 2006: Henneman & Cunningham, 2005). By utilizing debriefing, the students' strengths and weaknesses can be evaluated and appropriate changes can be made to address the students' needs.
Hunnan simulatars In nursing education The author anticipates that HPS and simulation technology will be used more often as patient acuity rises and competition for clinical placements increases. Nursing faculty will play a vital role in this process through the development of theory-based simulation
H
protocols that focus on the essential elements of nursing practice. The patient-simulation medium provides opportunities for student learning that utilize critical thinking and hands-on experience for skill development and assessment (Larew et al., 2006). HPS
and simulation technology will continue to play an important role in developing nursing students' clinical competencies in controlled environments.
Bremner. M., Aduddeil, K.. Bennet, D.. & VanGeest, J. (2006). The use of human patient Simulators: Best practices with novice nursing students. Nurse Educator. 3/(4), 170-174.
McCausland, L, Curran, C. & Cataldi. R (2004). Use of a human simulator for undergraduate nurse education. intemalional Journal of Nursing Education Scholarship, /(I), 1-17.
Ravert, P. (^2002). An integrative review of computerbased simulation in the education process. Computers. Informatics. Nursing. 20(5). 203-208.
Caba, D. M., & DeAndra, fl. (1988). A comprehensive anesthesia simulation environment: Recreating the operating room for research and training. Mneslhesiology. 69(3), 387-394.
Nehring. W , Lashley. ?.. 6 Ellis, W. (2002). Critical incident nursing management using human patient simulators. Nursing Education Perspectives. 23(3), 128-132.
Herrmann, E. K. ( 1981 ). Mrs. Chase: A noble and enduring
Peteani, L. (2004). Enhancing clinical practice and education with high-fideiity human patient simulators. Nurse Educator, 29(1), 25-30.
REFERENCES
f\gurt. flmerieari journal of Nursing. 8/(10), 16. Larew, C , Lessans. S.. Spunt, D., Foster, D., & Covington, B. (2006). Innovations in clinical simulation: Application of Benner's theory in an interactive patient care simulation. Nursing Education Perspectives. 27(1). 16-21.
Radhakrishnan, K., Roche, J.,& Cunningham, H. (2007). Measuring clinical practice parameters with human patient simulation: A pilot study Intemational¡oumal of Nursing Education Scholarship. 4(1), I -1 I.
Rhodes. M., & Curran. C. (2005). Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. Computers. Informatics. Nursing. 23(5), 256-262. Saba, V K., 6 McCormick. K. fl. (2006). Essentials of nursing informatics (4"' ed.). New York: McCraw Hill. Spunt, D.. Dawn, M., & Adams, K (2004). Mock code: A clinical simulation module. Nurse Educator. 29(50), 192-194. Tilghman, J. (2006). Innovation approaches to use of technological advances in nursing education. T^merican Black Nurses Faculty journal. 17(3), 99.
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