Nursing education is the foundational pillar that enables future nurses to become competent and knowledgeable in their respective practices. This education was normally provided to nursing students through various didactic theoretical lectures and practical clinical training but recently, the use of advanced simulation technology as an adjunct educational tool has slowly become a significant addition to student centric learning.
History of Simulation
The concept of simulation practice can be traced back to the fields of military, aviation, and nuclear power (with military having used simulation the longest), dating back to the 18th century. Simulation was initially created as a cost-effective strategy for training professionals because it was considered exorbitant to train in these areas in the real world. As the years progressed however, the healthcare profession realized the practicality and usefulness of incorporating advanced simulation technology into educational practice and as a result, spurred the growing movement of simulation in healthcare training settings and educational establishments around the world.
The Impact of Simulation on Nursing Students
The emergence of computer technology has led to the development of innovative tools for healthcare professionals such as simulation technology and patient simulators Simulation technologies have had a profound effect on the nursing profession because it allows nursing students to apply their recently learned skills and knowledge to solve real life scenarios in a safe and structured setting.
In a typical simulation session, two students are often asked to participate and mimic the roles of a registered nurse or a certified nurse assistant (CNA). The rest of the remaining students are then asked to go to a separate room and observe the scenario through a one-way mirror and a live video stream. At the start of the session, the facilitator usually gives report on the patient, which allows the students to familiarize themselves with the patient’s situation, history, charts, and medications in order to successfully manage and implement high quality nursing care for the patient. As the simulation progresses, the facilitator controls the patient’s prognosis and provides cues to the team to enhance the realism of the situation. Once the simulation is completed, the students are then asked to head back to the debriefing room to discuss their experiences.
During the debriefing session, the students learn through self-reflection, group interaction, and questions asked by the facilitator. The use of group discussion engages students in reflective learning and enables the group members to consider a situation from multiple perspectives and consider other alternatives in order to broaden their scope of practice and clinical understanding. By performing simulation scenarios on a regular basis, students are able to develop better critical thinking skills, decision-making abilities, and application of theoretical knowledge in real-life situations.
Facilitating Simulation into Nursing Practice
According to the Institute of Medicine (IOM), approximately 98,000 people die every year from medical errors in U.S. hospitals, and a significant number of those deaths are associated with medication errors. This means that adverse events affect nearly 1 of 10 patients in the hospital setting. Based on this staggering number, the IOM called for a systematic change in healthcare practices and identified simulation practice as a resource to address the needed reform. By fostering experiential learning, simulation ingrains good nursing habits early, while discouraging bad nursing habits from forming before it becomes second nature.
In addition to allowing individuals to hone their nursing skills, simulation has also proven to increase student confidence and self-efficacy once they transition into the clinical setting. Nursing efficacy is an important aspect in nursing practice because it gives the students the confidence required to provide excellent nursing care to their patients. By incorporating what they have learned in simulation, more students are self-reliant in their capabilities, which are invaluable in ensuring that patient safety is implemented in the hospital setting.
Implications for Future Nursing Practice and Further Study
The shortage of availability of clinical sites is quickly becoming the norm for many nursing schools due to changing healthcare reform and the struggling economic crisis. One solution to combat the shortage of clinical sites however is to utilize simulation practice to replicate essential aspects of clinical situations for beginning nursing students. The National Council of State Boards of Nursing is currently conducting a landmark, longitudinal study to examine the knowledge and clinical competency outcomes of students when simulation technology is used in the place of actual clinical experiences. Although calls for additional research in these areas need to be performed, simulation is still quickly gaining momentum as the gold standard for effective learning practice in nursing education.
Technology in health care is always changing and improving—this means faster, more accurate, and safer ways to do your job. Here’s the scoop on the latest and what’s coming in the not-too-distant future.
Technology has been making our lives easier throughout history. While some people are concerned that more efficient technology prevents nurses from spending time with patients, experts say that this couldn’t be further from the truth.
“There is a fear that technology takes nurses away from the patient to spend time at the computer. As interface capabilities increase, more time can be spent with the patient,” argues Nikkia Whitaker, MSN, RN, CCRN, clinical technology integration manager at Dayton Children’s Hospital. “Having systems work together to decrease multiple workflows and eliminate manual processes is what will help nurses appreciate the emergence of technology.”
Get Ready, ‘Cause Here it Comes
Remember when you were a kid and you wondered if eventually robots would take over the world? That’s not happening exactly, but robots are being implemented in health care. And don’t worry; your job is safe.
Both large and small technologies are revolutionizing the nursing practice in so many ways, says Divina Grossman, PhD, RN, FAAN, president and chief academic officer at University of St. Augustine for Health Sciences. “One example is the deployment of robots, such as those that deliver patient medications from the pharmacy to hospital units, automate the preparation of chemotherapy and other drug admixtures, take patient vital signs, deliver food to patient rooms, or transport linens throughout the hospital,” says Grossman.
Robots, though, are just a small part of what is going on technologically in health care. Grossman says that mobile technologies, used by themselves or with other technologies, can reduce clinical errors, improve quality and safety, and reduce the physical burden of care for bedside nurses. “Hand-held devices like iPhones with different apps can be used for accessing and charting patient information at the point of care; linking barcoded drugs, treatments, and patients accurately; communicating between patients and nurses across different rooms or areas; remotely detecting motion in bed of patients at risk for falls; and obtaining diagnostic test results at the bedside are a few examples,” explains Grossman. “The tasks of lifting, positioning, and moving patients—which historically have caused frequent back strain and physical injuries for nurses—can now be done using smart technology systems and can even be operated remotely.”
Cathy Turner, BSN, MBA, RN-BC, associate vice president of MEDITECH, agrees that the use of smartphones is part of an ongoing trend to help support nurses in their delivery of care. “Nurses do many different things during a shift of care, and they interact with patients in different ways. Sometimes a device such as a Workstation on Wheels is the appropriate vehicle for the workflow, but there may be times where something smaller may be less intrusive,” Turner explains. “Smartphone devices are able to deliver that flexibility. The smaller devices may be something nurses are already using for calls, secure texting, etc. Why not be able to do a quick medication administration using scanning and documentation tools fully integrated into the Electronic Health Record [EHR]? The other advantage to this type of device is that it is similar to a patient’s use of their portal from an app on their phone. This provides a nice opportunity to share what they are doing on their device on behalf of the patient and provides a teachable moment for the patient using the portal.”
But there are even more types of technology that can directly help nurses who are working with patients. “Wearable technology, telephone monitoring, and nanotechnology further expand the ability to monitor patients’ physiologic parameters—not just episodically as snapshots, but continuously for diagnostic, therapeutic, and clinical evaluation purposes,” says Grossman. For example, “with a noncompliant patient, a sensor can detect whether and when a patient took their medication and have the information transmitted electronically to a nurse through an app on a mobile device. Medication dosages can be adjusted commensurate with serum levels throughout the day; these can also be correlated with levels of blood pressure, heart rate, oxygen saturation, stress or anxiety measured by the same wearable devices,
EHR, an Oldie, but a Goodie
While EHRs aren’t exactly from the stone age, they are the most familiar and most widely used technologies in health care today. But they have also come a long way.
“[EHRs] and Point of Care documentation devices are probably among the most adopted technologies,” says Majd Alwan, PhD, senior vice president of technology at LeadingAge, as well as the executive director of the LeadingAge Center for Aging Services Technologies. “What is new: over the past couple of years, many of these technologies have undergone significant improvement through successive upgrades. They are now much more user-friendly, touch- and even voice-enabled, mobile friendly (to provide access through tablets and smart phones), and have better clinical decision support system, information exchange, and analytics capabilities.”
“Nurses typically spend more time with patients and contribute more information to the patient record than any other member on the care team. While this entails a lot of responsibility, there is also a lot of flexibility and freedom that comes from using an integrated EHR solution. An effective EHR gives nurses more meaningful time back with their patients, and results in less time on documentation,” says Turner. “While there is perception that EHRs are too complex and impede the patient/provider relationship, an EHR designed to support nursing workflows improves both the patient experience and the quality of care that the nurse can provide.”
Turner also says that nurses no longer just enter information and observations into their patients’ EHRs. In fact, EHRs actually give back to the nursing field. “[EHRs are] providing actionable data, clinical decision support, and surveillance tools that allow nurses to proactively meet the needs of their patients,” she says.
In addition, says Turner, EHRs can suggest problems to be addressed as well as the actions that can then be taken. “They can ensure that patient safety protocols are in place, allowing the nurse to focus on more of their time and energy on the patient,” she says. “Surveillance tools monitor EHR data and identify patients at risk. Nurses spend a great deal of time documenting the care a patient receives. The surveillance tools analyze that documentation along with lab results and other data, and push notifications and actionable items to the nurses, giving them that time back.”
These surveillance tools are also able to monitor many patients through watchlists and let nurses know who needs immediate attention. “Watchlists can be built around fall risk, sepsis, CLABSI, VTE, or other potential risks that may affect a patient’s health. These lists give back to nurses, saving them time and giving them the most up-to-date information needed to effectively treat their patients,” says Turner. “I remember reading a heartbreaking story of a parent who lost their child to sepsis. The words that stuck with me: the parent implored that clinicians ask: ‘What if it’s sepsis?’ Surveillance will ask. And direct, appropriate care actions can be taken.”
Learning Via Simulation
While nursing students will always work directly with actual patients before they graduate, the use of simulations beforehand enables them to practice different procedures safely and to learn about rare procedures or cases that they may not often see. “Students are able to learn in a safe environment and can pace their learning activities; not all students learn the same way,” says Nadia Sultana, DNP, MBA, RN-BC, clinical assistant professor and nursing informatics program director at NYU Rory Meyers College of Nursing. “Simulation centers have been planned to include technology that is similar to the work environment.”
Grossman gives an example of how simulation can help nurses learn without an increased risk for patients. “Nurse practitioner students can learn complex skills such as suturing or draining wounds, placing central lines, or inserting of chest tubes before they perform these procedures on live patients in real health care environments. Faculty also have the ability to create dynamic computer-based simulation scenarios to enable nursing students to learn how to adapt their clinical treatment decisions to fluctuations in the patient’s condition,” she says. “With simulation, the ‘patient’ can be of any age and racial background since human patient simulators can be infants, children, or adults and come in different skin tones and physical features. Through computer-based scenarios, simulated patients can become hypotensive, tachycardic, or hypoxemic, and nursing students can learn how to tailor or adapt clinical treatment decision accordingly.”
Students can also be acquainted with rare conditions via simulation. “They can learn how to assess those patients using simulators. For example, a student may not be able to encounter a live patient with Tetralogy of Fallot in the clinic during the semester, but he or she can auscultate, palpate, and assess the relevant findings using the Harvey cardiology simulator. This simulator can mimic 50 different cardiac conditions and also simulate any cardiac disease in a realistic way,” Grossman explains. “The ability to learn interprofessional practice and teamwork using simulated case scenarios like a post-disaster situation or an acute stroke patient in the ER with teams of students from multiple programs—nursing, medicine, PA, et cetera—is also possible with simulation. Thus, nursing and other health care students can learn how to communicate with each other and collaborate in the care management of an individual patient or groups of patients through simulation before they are assigned to care for live patients.”
An even more advanced type of simulation is coming—virtual reality—and both student nurses and experienced ones are going to be stunned with how realistic it will be.
“Virtual reality or augmented reality simulation…depart from the conventional treatment simulation with three-dimensional image data and computer software. Implementation of virtual simulation requires the ability to transfer the planned treatment geometry from the computer to the treatment room in a way which is accurate, reproducible, and efficient enough for routine use,” says Grossman. “Haptics are an example of virtual reality technology where the nursing student can do patient assessment and examination and feel the virtual patient’s skin and body, with the ability to perform clinical interventions. Using engaging and immersive technology like Google Glass or HoloLens, the student can feel being in the real-world health environment, move around freely, interact with the patient and others, carry out tests and treatments, and learn from their mistakes while in the lab or simulation center without compromising patient safety.”
Have no Fear
If the thoughts of working with some of this technology scares you, don’t worry. The facility will provide you with the training you need, and the technology will make health care safer and allow you more time with patients.
“It is easy to be afraid of change, but you must always keep in mind what is best for the patient. Put yourself in the patient’s position and imagine how much safer they must feel to know that so many systems are working to support their care,” says Whitaker. “Do not be afraid to advance. A nurse’s touch will always be valued and needed, but technology can help bring nursing care to the highest level.”
Keondra Rustan, RN, MSN, PhD(c), visiting assistant professor at Linfield College in Portland, OR, has overcome many challenges in her decade-long career as a nurse and nurse educator. Raised in a single-parent home with limited resources, she discovered how she could channel her interest in science into a nursing career by reaching out to mentors along the way.
Today, she shares her story and offers advice to other minority nursing students and nurses who may face similar challenges in their education and careers.
How long have you been in the nursing field and what has been your career history until now?
I have been a nurse for nine and a half years. I started out working in cardiac health care in Virginia. I did cardiac stepdown, some cath lab work, and I floated to some cardiac ICUs. I then went to the ICU where I learned a great deal and developed some professionalism and leadership traits. I then went on to become an assistant manager of an ICU and IMCU. I finished my master’s degree and became a professor at a private college where I rediscovered simulation and developed a great love for it. I became the simulation lab coordinator and for a time was the interim director of the LPN program, and went on to become the assistant director of the LPN program so that I could make more time for my doctoral schooling.
I am currently working in the dissertation phase of my doctoral program and enjoying my work at Linfield College as a visiting assistant professor working in simulation as lead faculty.
What inspired you to enter the nursing profession?
At first I didn’t want to be a nurse. I went through all of my primary schooling without having the decision of wanting to be a nurse. I wanted to be a scientist at first like those scientists in Jurassic Park.
Later on in high school I decided that I wanted to be a scientist that could help cure diseases and study microbes. However, I lost my grandmother when I was in high school and some of the care that she received wasn’t the best and lacked empathy. I decided that I wanted to help people more directly and show them that they aren’t just a room number but a thriving person who was deserving of care. I wanted to be a person who made a difference in the lives of others.
As nurses we often aren’t remembered individually; but if a patient has less exacerbations and starts feeling better because of your care and the education that you provided, it is very rewarding.
What inspired you to become a nurse educator?
I discovered that I liked teaching by precepting new nurses and nursing students. I enjoyed seeing the potential in them. I loved teaching them how to do things based on evidence and why it was so important for it to be done that way. I wanted to show them how to provide holistic care to patients and help them grow into future leaders.
I also enjoyed telling them stories so they could directly apply the teachings to their practice. Most importantly, I wanted them to have things I did not have prior to becoming a nurse: resources and a mentor. I wanted to apply these principles on a broader and larger scale so I went into the field of nurse education.
I would say the first year or so I was not very good at it. Or at least I did not feel as though I was a good teacher. I did not have a mentor or anyone to show me the ropes so I just taught them the way I was thought, which did not work.
What challenges have you faced in your career and how have you overcome them?
In my career my biggest challenges have come from lack of resources and lack of mentors. I grew up in a low-income single parent home with no vehicle. We did not have the funding or access to resources to get informed about career programs while in high school or even most scholarships. I wasn’t aggressive enough in thinking of my future and did not have enough drive when I was younger to seek those resources.
Once I decided to become a nurse, I didn’t really know how to become one, what nurses actually did, and what type of nurse I wanted to be (even when I graduated I still did not know that part). I had a lot of ideas, but I did not know how to bring them into fruition.
I overcame the lack of resources and lack of mentoring by joining organizations (good old-fashion Google search) based on my interests. When I was obtaining my BSN I got accepted into Sigma Theta Tau (the nursing honor society). Going to those conferences really opened a lot of doors for me. I am so grateful for the aid of the nurses and educators that I have met throughout my nursing career. They were able to point me into a lot of great directions. I am still growing and have a great deal more that I want to accomplish.
What challenges do you see minority nursing students face and what is your advice for them?
I see lack of resources as a big one and lack of mentors. Minority students (and I include males in this) have a high risk of falling through the cracks in nursing school. There seems to be a reluctance to seek aid when dealing with difficulties. It is hard to get over, because typically it is culturally ingrained.
My advice is to seek help right away when you are having trouble. If your school does not assign faculty mentors, seek out an instructor that you feel you can connect with. Shadow a nurse if you are not experienced with the duties of a nurse, so you have an idea of if it is right for you. Don’t be afraid to ask for help; if you do not understand, seek help (think of the patient’s safety).
Most nursing schools have scholarships, open labs, writing labs, and tutors available for their students; make use of these resources and give yourself support. View any setback as a learning opportunity and grow from the experience. Never stop learning even after you are licensed and working on the floor. Google search some nursing organizations (you can even join some as a student for a cheaper price) and they can lead you down some interesting paths. Also, once you obtain your knowledge, pass it on. You never know who you will be helping with your expertise and experience.
Where do you see yourself in 5-10 years?
I see myself with at least 10 articles published and maybe a book, of course having obtained my PhD. I want to still be educating nursing students and maybe have obtained my NP. I want to continue to learn and grow each day to become the best educator that I can be. I want to do more in community and be a greater help to those in need.
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