Comparing learning outcomes for medium and high fidelity human patient simulation manikins in nursing education

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1 Comparing learning outcomes for medium and high fidelity human patient simulation manikins in nursing education Prof. Tracy Levett-Jones Deputy Head of School (Teaching and Learning) School of Nursing and Midwifery, The University of Newcastle 1

2 The journey begins 2 Laerdal SimMan 3G manikins (in a box) No simulation unit (but 10 clinical skills centres) Identified problems with clinical reasoning skills in final semester students $220,000 project grant 2

3 Project Aims Quasi-experimental study: To identify the conditions under which simulation (high and medium fidelity) impacts nursing students clinical reasoning, satisfaction and knowledge acquisition. Systematic review: To appraise the evidence related to the capacity of high fidelity manikins to improve students clinical reasoning skills. Cross-sectional survey: To explore the range and types of simulation used in Australian nursing programs and the pedagogical principles that underpin their use. Delphi study: To develop quality indicators for the use of simulation To develop a range of teaching and learning resources to support nursing students and educators in the use of simulation 3

4 Student satisfaction Statistically significant differences were not apparent between 2 nd (n = 268) or 3 rd year (n = 76) students exposed to medium or high fidelity manikins during a quasi-experimental study: Experimental group (HF): mean 4.472/5 Control group (MF): mean 4.415/5 2 nd year students - t (208) = , p > rd year students - t (74) = , p > 0.05 *Measured using the Satisfaction with Simulation Experience Scale (SSES) 4

5 Student satisfaction Need for more simulation experiences - We should have simulations much more often at least once per week. Simulation should complement but not replace clinical placements - It should not replace the valuable clinical placement hours but should definitely be incorporated throughout the program in every clinical course. Application of knowledge and skills to the simulation - The simulation helped to bring everything together - knowledge, skills and clinical reasoning Clinical reasoning - The simulation helped me to think like a nurse Safe environment to learn - The simulation mirrored a real-life situation where you knew your mistakes were learning opportunities that could not affect a real patient. Value of learning experience - I learnt more in the simulation than in hours of lectures. 5

6 Knowledge acquisition n = 76 (third year students) No statistically significant differences in mean scores were found between the control (medium fidelity) and experimental (high fidelity) groups at either point in time (before simulation, following simulation, or 2 weeks later) Control group: 11.8 (Test 1) 12.8 (Test 3) Experimental group: 12.5 (Test 1) 13.2(Test 3) The improvement was not statistically significant, F (2, 66) = 3.29, p > 0.05 *Measured using a 21 item multiple choice test from TestGen a validated item bank 6

7

8 Contemplate what you have learnt from this process and what you would do differently next time. Describe or list facts, context, objects or people. Review current information (e.g. handover reports, patient history, patient charts, results of investigations and nursing/medical assessments previously undertaken). Gather new information (e.g. undertake patient assessment) Recall knowledge (e.g. physiology, pathophysiology, pharmacology, epidemiology, therapeutics, context of care, ethics, law etc) Evaluate the effectiveness of actions and outcomes. Ask: has the situation improved now? Select a course of action between different alternatives available. Describe what you want to happen, a desired outcome, a time frame. Synthesise facts and inferences to make a definitive diagnosis of the patient s problem. Interpret: analyse data to come to an understanding of signs or symptoms. Compare normal Vs abnormal. Discriminate: distinguish relevant from irrelevant information; recognise inconsistencies, narrow down the information to what is most important and recognise gaps in cues collected. Relate: discover new relationships or patterns; cluster cues together to identify relationships between them. Infer: make deductions or form opinions that follow logically by interpreting subjective and objective cues; consider alternatives and consequences. Match current situation to past situations or current patient to past patients (usually an expert thought process). Predict an outcome (usually an expert thought process).

9 Clinical reasoning n = 38 (second year students) Clinical reasoning scores ranged from 10 to 74 Control group (MF): mean (SD = ) Experimental group (HF): mean (SD = ) Statistically significant difference: t (36) = , p < *Measured via observation of simulation experience and using a validated clinical reasoning checklist (next page) 9

10 CLINICAL REASONING CHECKLIST - HYPERVOLAEMIA Students receive one point for every item on the checklist performed correctly and in the proper sequence. They receive a score of zero for any item not performed, performed out of sequence or performed incorrectly. Scenario: An 76 year old man, day 2 post-op following a bowel resection, with hypervolaemia and early stage pulmonary oedema Process Description Behaviour Comments Considers the patient situation Observes context and patient situation Verbalises key observations from handover and initial view of patient: 1. Patient s age 2. Recent surgery 3. Previous fluid challenges 4. IV 125 ml/hr 5. PCA 6. Patient s restlessness 7. Patient s distress/confusion 8. Other relevant observation/s Collect cues/ information 1 Reviews current information (e.g. handover reports, patient history, patient charts, results of investigations and nursing/medical assessments previously undertaken) Reviews: 1. Temp 2. HR 3. RR 4. BP 5. O 2 sats 6. Urine output This resource was created as part of an ATLC Project titled Examining the impact of simulated patients and information and communication technology on nursing students' clinical reasoning

11 7. IV rate 8. FBC cumulative balance 9. Medical notes 10. Nursing notes Gathers new information (e.g. undertake patient assessment) Recalls knowledge (e.g. physiology, pathophysiology, pharmacology, epidemiology, therapeutics, culture, context of care, ethics, law etc) Assesses: 1. Asks patient how they are feeling 2. HR 3. BP 4. RR 5. Temp 6. O 2 saturation 7. PCA 8. Catheter drainage 9. Lung auscultation 10. Cognitive status 11. O 2 flow rate 12. Pain 13. BGL 14. Condition of wound 15. Peripheral oedema Verbalises: 1. BP is related to fluid status 2. Resolution of third space fluid shift can result in increased intravascular volume 3. Post-operatively confusion in older patients can result from Older patients can have renal insufficiency The 5. Normal electrolyte levels are Morphine can cause vasodilation and reduce urine output 2 This resource was created as part of an ATLC Project titled Examining the impact of simulated patients and information and communication technology on nursing students' clinical reasoning

12 Process information Interprets: analyse data to come to an understanding of signs or symptoms. Compare normal Vs abnormal. Discriminates: distinguish relevant from irrelevant information; recognise inconsistencies, narrow down the information to what is most important and recognise gaps in cues collected. Relates: discover new relationships or patterns; cluster cues together to identify relationships between them. Infers: make deductions or form opinions that follow logically by interpreting subjective and objective Verbalises: 1. HR high 2. BP high 3. RR high 4. O 2 saturation low 5. Urine output low 6. Lung auscultation audible wheeze 7. Cognitive status confused 8. Cumulative balance positive 9. O 2 flow rate 2L min 10. BGL normal Identifies and verbalises: 1. HR high 2. BP high 3. RR high 4. O 2 saturation low 5. Urine output low 6. Cognitive status confused 7. Electrolyte levels abnormal 8. Cumulative fluid balance shows positive balance 9. Other relevant information Verbalises: 1. Hypertension and tachycardia can result from increased intravascular volume 2. Increased intravascular volume can result in hypoxia, tachypnoea and wheeze 3. A decreased urine output can exacerbate fluid volume excess 4. Other relevant clinical pattern/s 5. Increased intravascular volume can cause confusion Verbalises: 1. The patient s cognitive changes may be the result of hypervolaemia and hypoxia 3 This resource was created as part of an ATLC Project titled Examining the impact of simulated patients and information and communication technology on nursing students' clinical reasoning

13 Identify problem / issue cues; consider alternatives and consequences. Matches current situation to past situations or current patient to past patients (usually an expert thought process) Predicts an outcome (usually an expert thought process) Synthesises facts and inferences to make a definitive diagnosis of the patient s problem. 2. The patient s wheeze may be from pulmonary oedema 3. The patient confusion may be because of hypoxia or cerebral oedema Verbalises: 1. I have seen this before when... Verbalises: 1. If we don t get an order for a diuretic the patient s condition will deteriorate 2. The patient could have a respiratory arrest Verbalises: 1. The patient is hypervolaemic 2. The patient has pulmonary oedema Establish goals Describes what you want to happen, a desired outcome, a time frame. Verbalises: 1. Improved oxygenation levels within 20-30mins 2. Improved vital signs within 60 mins 3. Increased urine output within 15 mins 4. Decreased confusion with 120 mins 5. Improved RR, BP, HR within 60 mins Take action 4 Selects a course of action between different alternatives available Initiates: 1. Increase oxygen flow rate to 10 L via Hudson mask 2. Sit patient in high Fowler s position 3. Monitor O 2 sats 4. Reduce IV rate 5. Phone MO using ISBAR 6. Obtain order for diuretic 7. Administer diuretic 8. Monitor vital signs 9. Monitor urine output This resource was created as part of an ATLC Project titled Examining the impact of simulated patients and information and communication technology on nursing students' clinical reasoning

14 Evaluate Reflect on process and new learning Evaluates the effectiveness of outcomes and actions. Ask: has the situation improved now? Contemplates what you have learnt from this process and what you could have done differently. Reviews: 1. O 2 sats 2. RR 3. Urine output 4. BP 5. HR 6. Lung sounds 7. Cognitive status For debriefing: Next time I would I should have If I had I now understand 5 This resource was created as part of an ATLC Project titled Examining the impact of simulated patients and information and communication technology on nursing students' clinical reasoning

15 Clinical reasoning A systematic review of the effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: The review included 8 studies conducted between 1999 to 2009 that met inclusion criteria. There is some evidence to indicate the use of HPSMs may improve learning outcomes fundamental to clinical reasoning (i.e. knowledge acquisition and critical thinking) However, there is a lack of unequivocal evidence of the effectiveness of using high-fidelity HPSMs in the teaching of clinical reasoning skills to undergraduate nursing students. There were significant methodological limitations in the papers reviewed. 10

16 Debriefing A systematic review of the effectiveness of debriefing in simulation-based learning: Systematic review: 13 RCTs involving HF simulations (range of health professionals). Performance in technical and nontechnical skills such as: vital signs assessment; psychomotor skills; cardiopulmonary resuscitation; task management; team working; and situation awareness significantly improved pre-test to post-test regardless of the type of debriefing conducted. No statistically significant differences in any outcomes between participants exposed to the different debriefing types. 11

17 Assumptions Simulation = manikins High fidelity = highly technical 12

18 Simulation: possibilities for teaching & learning Cyril Smith Video 13

19 Simulation: possibilities for teaching & learning atch?v=kdgstjeadf0 atch?v=g- YMIbF3_1c&feature=relat ed 14

20 Simulation: possibilities for teaching & learning Clinical Reasoning Scenario: dll?session= &name=tll531& password=tracy 15

21 Simulation: Possibilities for research Communication, clinical reasoning and patient outcomes n = 39 pairs of students A significant correlation between clinical reasoning and communication scores was obtained, Pearson Chi Square = 3.967, df =1, P<0.05. NOTECH table (next slide) 19 simulation MF - Video 2 simulation MF - Video 16

22 Teamwork and communication skills Domains Person-centred care Teamwork and cooperation Communication and interaction Leadership and management Problem solving and decision making Situational awareness Adherence to guidelines Documentation Elements Including patient/family in discussion Seeking and considering patient s social and medical history Equipping patients with the skills to identify problems and to play an active role in their medication management Awareness of and respecting the roles of team members Supporting others Understanding needs of the team Managing conflict Asking for help Valuing others contribution Sharing accountability and responsibility Maintaining eye contact Demonstrating open body language Being polite and friendly Active listening Discussing together Asking questions Coordinating actions Expressing concerns freely Speaking up when unsure Communicating openly including handover (ISBAR) Taking the initiative Maintaining clinical standards Delegating Demonstrating gradated assertiveness Creating a no-blame culture Collaborative problem solving Shared option generation Shared risk assessment Shared decision making Reviewing outcomes Noticing Anticipating identifying future problems and discussing contingencies Recognising the capabilities of others, cross-checking, and contacting outside sources when necessary Being familiar and adhering to relevant guidelines, policies and evidence-based resources Documenting clearly, accurately, contemporaneously and concisely Accessing and clarifying medical records Ref: Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Quality & Safety in Health Care 2009;18:104-08

23 References Levett-Jones, T. (in press). Clinical reasoning: Learning to think like a nurse. Sydney, Pearson. Levett-Jones, T. Gilligan, C., Lapkin, S. & Hoffman, K. (in press). Interprofessional education for the quality use of medicines: Designing authentic multimedia learning resources. Nurse Education Today. Lapkin, S. & Levett-Jones, T. (2011). A cost-utility analysis of medium versus high fidelity human patient simulation manikins in nursing education, Journal of Clinical Nursing. Levett-Jones, T. Lapkin, S., Hoffman, K. Arthur, C. & Roche, J.(2011) A comparison of knowledge acquisition in students exposed to medium versus high fidelity human patient simulation manikins Nurse Education in Practice. 11, Levett-Jones, T., McCoy, M., Lapkin, S., Noble, D., Hoffman, K., Dempsey, J., Arthur, C. & Roche, J. (2011). The development and psychometric testing of the Satisfaction with Simulation Experience Scale. Nurse Education Today. 31(7), Hoffman, K. Dempsey, J., Levett-Jones, T., Noble, D., Hickey, N., Jeong, S., Hunter, S. & Norton, C.(2010). The design and implementation of an interactive computerised decision support framework (ICDSF) as a strategy to improve nursing students clinical reasoning skills. Nurse Education Today, 31(6),

24 References Lapkin, S., Levett-Jones, T., Bellchambers, H. & Fernandez, R. (2010). The effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207-e222 Arthur, C. Kable, A. & Levett-Jones, T. (2010). Human patient simulation manikins and information communication technology use in Australian schools of nursing: A cross sectional survey. Clinical Simulation in Nursing Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The five rights of clinical reasoning: an educational model to enhance nursing students ability to identify and manage clinically at risk patients. Nurse Education Today. 30(6), Hoffman, K., Levett-Jones, T., Dempsey, J., Noble, D. & Kenny, R. (under review). Examining the impact of interpersonal communication and teamwork skills on nursing students' clinical reasoning ability and decision outcomes. Nurse Education Today. Lapkin, S., Fernandez, R., Levett-Jones, T. & Bellchambers, H. (2010). The effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: A systematic review. JBI Library of Systematic Reviews (JBI000287), 8(16) Lapkin, S., Levett-Jones, T. (2011). The effectiveness of simulation debriefing in: A systematic review. Joanna Briggs Library of Systematic Review Protocols 18

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