Nursing Faculty Matters, October 2011
The most up-to-date simulation techniques – using live actors trained to simulate real patients – are bringing a new level of realism to nursing education. —By Tom Kivett
“When I talk to nursing educators about patient simulation, they usually fall into one of three groups: those who want to do it, those who are already doing it, and those who want to do it better,” said Leland J. Rockstraw, PhD, RN, Assistant Dean of Simulation, Clinical & Technology Learning Operations, Drexel University College of Nursing and Health Professions. “For those who want to do it better, we’ve found that of all the elements in our simulation lab, students seem to get the most out of their experiences with both standardized patients and human patient simulators.”
Drexel is the first and one of the few nursing colleges in the U.S. to utilize trained actors, or standardized patients (SPs) as they are called, with undergraduate nursing students. Since 2002, it has been using SPs as part of the regular course work for all of its undergraduate nurses.
In the past, actors trained to mimic real patients have been used extensively to teach physicians, graduate nursing students, and physician assistants. But today, simulation has become more realistic and more pervasive. Although simulation is not going to eliminate the need for good clinical training any time soon, SPs are transforming nursing education and enriching the learning experience.
The more common form of simulation used in nursing programs is patient simulation using computerized mannequins, or more formally, a Human Patient Simulator (HPS), to provide students a safe environment to practice routine tasks such as intubation, placing an IV, and even childbirth. But, a mannequin cannot begin to replicate the behavioral aspects of a real patient. A real-life actor trained as an SP raises the bar of reality on the simulation experience.
“The use of standardized patients allows us to push students well beyond their comfort zones and creates a powerful experiential learning environment,” continued Dr. Rockstraw. “They allow us to measure students objectively but without any interruptions during the patient examination. This approach never takes away their focus.”
Drexel uses both SPs and HPS mannequins, or skins and plastics as Dr. Rockstraw calls them. Sometimes they are used separately at different stations and, at other times, they are utilized simultaneously in a hybrid simulation that tests both a student’s physical and behavioral skills.
Broadens Student Experience
“Even after all the years in school and with all their clinicals, there are still some things many nursing students never get to see or do,” said Linda Wilson, PhD, RN, CPAN, CAPA, BC, CNE, Assistant Dean for Special Projects, Simulation and CNE Accreditation, Drexel University College of Nursing and Health Professions. “Simulation using SPs and HPSs allows them to practice things they never would have experienced before leaving the program.”
Because an SP provides a safe environment where if the student makes a mistake the patient cannot be harmed, students are not afraid to try something new. SPs are trained to look for certain skills and measure them objectively. As a result, they allow educators to measure the competence level of each student against a set of criteria. These experiences are digitally captured so students can view them afterward to see what they did and did not do. This process helps build professional mannerisms and forges skills that last a lifetime.
At Drexel, students have a variety of simulation experiences but at the end of the program they do a “Comprehensive Standardized Patient Simulation Experience.” This experience tests their skills in a Sim Lab set up to look like a physician’s office replete with waiting area and examination room. Students are required to do a complete history, a focused physical exam and any appropriate patient teaching.
“We train all of our standardized patient actors so they offer a consistent, realistic experience for each student,” continued Dr. Wilson. “Part of the power of using the SP is that it allows for immediate feedback after the experience ends.”
The SP is given a script from which to base the patient role and never leaves the role while in the examination room – which enhances the realism. Drexel does experiences by diagnosis, so, for example, if patient has chest pains, the student will need to go in and do a cardiac exam.
Faculty members are able to set which diagnosis will be studied on that particular day. At the end if the program, the evaluation will test for one of 20 diagnoses listed in the student syllabus. However, the student does not learn which one will be tested until the day of the experience.
Prior to the simulation experience, the SP is briefed on how to react, the proper responses to potential student questions, and what specifically to look for. There is a checklist of all items Drexel expects a student to do and the SP is trained to look for each item. For example, students should introduce him/herself with name and title, wash hands before starting the exam, act in a professional manner, etc. Each student also is posed with a challenge question to answer.
After the experience, which typically last about 40 minutes, the SP goes directly to a computer to complete the checklist of items detailing the student’s performance. After the list is completed, the SP and the student return to the examination room for feedback. There, the SP comes out of role and transitions into teaching mode where he talks about positives and areas for improvement.
A Lasting Impression
“The amazing advantage of using SPs is that they are real people,” said Dr. Wilson. “They can show emotion, any type of anxiety, and they cry – all factors that enrich the experience.”
Working with an SP, students quickly forget that the experience is a simulation because it seems so real. At the end, the bonus, which they will likely not experience again in real-life: an opportunity for a patient to tell them how they made them feel and if they were comfortable.
“Students always say that’s the best part of the whole experience,” added Dr. Wilson. “Many of them will remember that incident forever. My students often say, ‘I’ll never forget what that patient told me.’”
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