Innovations in clinical simulation: application of Benner's theory in an interactive patient care simulation by Charles Larew, Sherrie Lessans, Debra

Spunt, Dawn Foster, Barbara Covington ABSTRACT This article introduces the University of Maryland Baltimore School of Nursing clinical simulation protocol structure and lessons learned while using this protocol in a mandatory learning experience for over 190 adult health students. Students use a SimMan[TM] manikin in a high-fidelity, interactive clinical simulation to provide care to "unstable patients:' Benner's concepts regarding the performance characteristics and learning needs of nurses with varying levels of clinical competency were incorporated into the development of the simulation. The simulation provides a positive learning experience in which students refine their patient management skills and collaborate with multidisciplinary team members to resolve common postoperative problems. NURSE EDUCATORS have long relied on clinical rotations to provide rich contextual and experiential learning for students. The nature of clinical learning, however, is that clinical opportunities vary depending on the care needs of the available patients. Educators are also challenged in providing safe opportunities for students to practice patientmonitoring functions and effective management skills in rapidly changing patient situations. Simulations that provide structured experiential learning opportunities can support clinical learning in these two critical domains. * The University of Maryland Baltimore School of Nursing (UMB SON) has developed a unique enrichment experience for adult health nursing students that uses highly interactive patient care simulations. This experience, which challenges students to identify and resolve multiple common postoperative patient problems, applies Benner's concepts regarding the performance characteristics and learning needs of nurses at differing levels of clinical competency (1). Students at various levels gain new insight into their perceptual awareness of emerging clinical problems, develop strategies for patient management, and practice the communication skills necessary for collaborative problem solving with members of the multidisciplinary health care team. History and Background Simulation is the artificial representation of a phenomenon or activity. This constructed reality allows participants to experience a realistic situation without real-world risks (2). The use of simulation as an educational technique has been widely adapted by the military and health care fields for both training and performance evaluations and is the key method of training for mass casuality and catastrophic event responses. Nursing's early use of simulation included teaching psychomotor skills and competency testing. Use in nursing curricula has expanded to include the development of critical thinking and the practice of skills within the affective domain (3). Clinical simulation is now incorporated into certification or licensure examinations for certain health care providers. For example, physician licensing exams include 10 hours of simulated patient encounters (4), and radiation technicians and nurse first assistants use clinical simulations to demonstrate competency (5,6).

At the UMB SON, simulation has been used for learning and competency evaluation in both the undergraduate and graduate programs for a number of years. The school has multiple simulation labs for teaching assessment skills and evaluating clinical procedures. Work with interactive teaching simulations has included the use of a Laerdal SimMan[TM], a computerized, physiologi cally competent manikin, for mock resuscitations and scenarios containing a multitude of patient problems and complex care needs. However, it was noted that challenging novice students with complex patient care simulations resulted in their feeling overwhelmed and anxious. The decision was made to develop a new protocol to provide positive learning experiences that challenge students at their current level of functioning. Development of the Clinical Simulation Protocol The new protocol was designed as a nongraded, but mandatory, learning experience for baccalaureate adult health students. It was implemented with more than 190 juniors and seniors during the spring and summer of 2004. It is based on Benner's conceptual framework regarding the performance characteristics of nurses with different levels of clinical competency. According to Benner, "expert human decision makers can get a gestalt of the situation and proceed to follow-up on vague, subtle changes in the patient's condition with a confirmatory search aided by the whole health care team" (1, pp. xviii-xix). The goal for the development of the protocol was to support successful performance and learning by novice practitioners, while providing challenges to higher functioning students. Standardized, reproducible, clinically accurate simulated patient care experiences were developed to provide opportunities for students to identify common patient problems and demonstrate appropriate interventions. Simulations would allow students to practice higher level nursing functions, including collaborative practice. The school had a wealth of existing resources that were used in the development of the project. Adult health clinical faculty assisted the Clinical Simulation Lab staff in developing scenarios. A hospital room with a nursing station was simulated, and medical records for common postoperative problems were created. The SimMan was outfitted with tubes, drains, wounds, and dressings consistent with the clinical history. An adjoining observation room with one-way mirrors was set up as a control center for operating the computerized manikin and the audiovisual equipment, including a video camera, wireless microphones on both student and facilitator, videocassette recorder, and television monitor. A pair of Motorola open-channel portable radios allowed the facilitator to convey the patient's scripted responses, and a direct line phone between the nursing station and the control center allowed the student to simulate consultations with team members. The Design and Structure of the Protocol The simulation challenges the student's patient-monitoring abilities through the use of subtle cues regarding multiple common postoperative problems embedded into the patient history and clinical presentation. These cues are followed by sets of escalating prompts that highlight specific patient problems. The intent is to assist the student in recognizing patient problems. Additional prompt sets guide the student's focused assessment and intervention. Figure 1 illustrates the use of baseline cues and escalating prompts.

The use of baseline cues and escalating prompts is a unique feature of this protocol. Baseline cues are presented via the medical record available for student review, a taped nursing change-of-shift report, and patient assessment data collected at the bedside. Some students identify patient problems on the basis of the subtle baseline cues and proceed to apply the nursing process. Students who do not recognize the problem are given escalating prompts either by manipulation of the patient's physiological status or through scripted verbal prompts. Each patient problem has subtle baseline cues, a first-level prompt, and a second-level prompt. The second-level prompt is an obvious tip-off. Table 1 presents the escalating verbal prompts used for the patient problem "alternation in comfort/pain." The escalating prompt set for the hypoxemia problem is presented in Table 2. Benner's theory predicts that nurses with higher competencies will identify problems more quickly based on subtle cues (1). This was illustrated during initial testing of the protocol by an experienced trauma critical care nurse who identified multiple patient problems from the baseline cues. Conversely, the authors found that these same baseline cues and first-level prompts were too subtle for many of the novice adult health students, who often needed second-level prompts before recognizing a patient problem. Baseline cues and first-level prompts that had low recognition were modified. A critical design feature of the simulation protocol is that scripted patient and team member prompts proceed from vague to specific. For example, the prompt set for alteration in comfort/pain includes a first-level prompt, "I'm a little sore," followed by a second-level prompt, "My belly hurts." The intent of escalating prompts is to aid the student in recognizing a problem and initiating a focused assessment. Prompts by multidisciplinary team members also follow a vague-to-specific progression, assisting the student to perform focused problem-oriented assessments and appropriate interventions. Table 3 presents the prompt set used by a team member regarding a patient's hypoxemia. Benner reports that the ability to communicate and collaborate with multidisciplinary team members is a hallmark of an expert nurse (1). The scenario is crafted to encourage, or even require, collaboration with a team member to resolve patient problems. In this way, students have the opportunity to practice their interdisciplinary communication skills. The team members' prompts direct students toward developing professional telephone etiquette and the ability to present a brief, yet complete, focused patient report. Lessons Learned During the development and testing of the protocol, the designers identified three issues that must be considered when designing scenarios for the novice student. These include complexity of patient care needs, the order of problem presentation, and scenario pacing.

Another limitation is that this simulation protocol requires constant facilitator observation of the student's performance. This is necessary to determine the proper timing of prompts and provide appropriate patient or team member scripted responses. The simulation protocol uses specialized facilities, including high-tech simulation and audiovisual equipment; high quality technical support is needed. Therefore, replication of this environment may be cost prohibitive for many nursing programs. However, these simulation protocol guidelines and templates can be applied to a wide range of simulation modalities. High-tech resources are not necessary to create a successful clinical simulation. Future Directions The UMB SON simulation protocol offers a number of new opportunities for student learning experiences. It also has applications for competency testing and educational research. One educational application is for students to review their simulation videotapes and engage in self-evaluation. This, coupled with an instructor's feedback, would increase the student's awareness of his or her patient-care skills and identify areas needing improvement. Digital technology could even allow instructors to highlight sections and embed comments within the video that the student could access after performing a selfcritique. References: United States Medical Licensing Examination. (2004). Bulletin of information. [Online].Available:www.usmle.org/bulletin/2005/TOC.htm.> (5.) American Registry of Radiologic Technologists. (2005). Competency requirements for primary certification. [Online].Available: www.arrt.org/ web/content.jsp?include=/licensing/bdeoexam.htm#format. Association of Operating Room Nurses.(2004). AORN recommended educational standards for RN first assistant programs. [On-line]. Available: www. findarticles.com/p/articles/mi_mOFSL/is_3_82/ai_n15648934. http://findarticles.com/p/articles/mi_hb3317/is_1_27/ai_n29248909/?tag=content;col1

REACTION: Lets first talk about the Novice to Expert Theory of Patricia Benner. The theory talks about the concept that the nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences and that development of knowledge in applied nursing is composed of the extension of practical knowledge. She cited 5 levels of nursing experience: novice, advanced beginner, competent, proficient and expert. When we talk about novice, these are the student nurses who do not have experience and are taught general rules to help perform tasks. Advanced Beginners on the other hand are fresh nurses who demonstrates acceptable performance. When we say competent, these are nurses with 2-3 years of experience while Proficient nurses have more holistic understanding and better decision-making. Finally, Expert nurses no longer relies on principles, rules, or guidelines to connect situations and determine actions but has intuitive grasp of clinical situations. The University of Maryland Baltimore School of Nursing used the theory of Benner to make a better clinical simulation according the 5 level of expertise of nurses. The simulation provides a positive learning experience in which students refine their patient management skills and collaborate with multidisciplinary team members to resolve common postoperative problems. Through this close-to reality simulation, student nurses will be given the chance to better understand how things really work in the real world. Through this article, nursing school should be able to pick up some much needed information to improve the type of teaching instructions in nursing schools. With the application of the theories, we will be able to better understand who things should and could work. As a nurse, Benners theory is really true in nature. Being a volunteer nurse for 7 months I could feel how much I had improved from my first day as a registered nurse up until today. I may only be an advanced beginner in Benners theory but I know that I had improved a whole lot. I could better understand the expertise level cited by Benner because I personally experience how her theory works. We have our supervisors who had worked for a long time and they would know everything there is to know while we also have senior staffs who had stayed for 2-3 year and are also able to solve most problems. Its just interesting that we are able to practice the theories in reality that see that they truly affect our nursing lives and profession.

AILYN GRACE F. RIMANDO