Although formal nursing education has its roots in didactic learning; a larger venue for the integration of this formal learning takes place predominantly in the acute care setting.  As such; one of the issues at the Hampton University School of Nursing (HUSON) is an issue that is all too familiar to many nursing programs in our area and to nursing programs nationwide; finding adequate clinical experiences for our student.  Along with the oft-reported nursing faculty shortage; in the Hampton Roads area of Virginia; we have seen a proliferation of nursing programs opening within the past 15 years.  At the current count; there are 15 nursing programs within 25 miles of the main campus of Hampton University with either Associate Degree or Bachelor Degree programs as their initial entry to practice (Table 1). With this proliferation of schools comes the inevitable scramble for quality clinical experiences. Couple these issues with the shorter patient inpatient admittances; and limited access to patient’s electronic medical records and it becomes a challenge to provide a realistic experience for our nursing student. With nursing competence based on a combination of theoretical knowledge and “hands-on” clinical knowledge; appropriate and relevant clinical learning opportunities play a critical role in the attainment of professional capabilities needed by the nurse to perform at the bedside effectively.

Table 1: Registered Nursing Programs in 25 Miles of Hampton University.

Spector & Echternacht noted that in a study less than 50% of employers answered; “Yes definitely;” when asked if new graduates are ready to provide safe; effective care [1].  Similarly Berkow Virkstis Stewart & Conway conducted a study that found that the bottom-rated competencies (such as taking initiative; tracking multiple responsibilities; conflict resolution; ability to prioritize; and understanding quality improvement) would be better taught in an experiential environment [2]. Based on this information; HUSON faculty looked at our current clinical environment opportunities for our student patient engagements and sought to come up with a way to provide a realistic; high acuity patient experience. We wanted to address; with our student nurses; their ability to engage the bottom rated competencies of initiative taking; assessing and tracking multiple responsibilities; and ability to prioritize care in their simulation exercise. We turned to the Manikin and Standardized Patient (MSPs) Simulation lab at the Eastern Virginia Medical School as a way to bridge the gap between the shortage of clinical site experiences and meaningful patient encounters for our students. We also wanted to take into account the Quality and Safety Education for Nurses (QSEN) competencies; so we formulated a plan to incorporate Manikin and Standardized Patient Electronic Simulation opportunities into our curriculum to provide enhanced educational opportunities for our students.  The framework of the experience was rooted in the QSEN competencies of Patient-Centered Care; Teamwork and Collaboration; Evidence-Based Information; and Safety [3]. Oh Jeon & Koh performed a meta-analysis of simulation-based learning using standardized patients and their study suggest that simulation-based learning using standardized patients might have a positive impact on self-efficacy and learning motivation that affects knowledge and clinical skill acquisition [4].  Anecdotally; we perceived that students in our nursing clinical lab; which does not have standardized patients; but instead uses manikins alone; perceived these experiences to be stressful and of less value than live patient encounters; seen in the acute care setting. Therefore we performed a literature search in hopes of finding ways to overcome the student’s biases toward nursing clinical lab settings.  The literature noted that reinforcing the teamwork approach and incorporating simulation into later phases of learning can promote knowledge development; skill acquisition; and self-confidence [5].

With this information; we sought to create an MSP scenario for our senior level Med-Surg students; and have them work in teams of 3 nurses in caring for a post-operative patient newly arrived at the Medical-Surgical Unit of an acute care facility.  We were able to write into the scenario various degrees of patient complexity in a more realistic; standardized and repeatable way than we could have done in our traditional nursing lab.  The complexity of the patient scenario reflected our QSEN goal of providing an opportunity for the team to incorporate the latest evidence-based information; focusing on patient-centered care.  The nursing faculty was mindful that by utilizing the MSPs in a teamwork approach; the nursing students were able to practice skills in a challenging patient scenario without causing harm to an actual patient. In the MSP scenario; the student nurse teams initially performed assessment and care on the manikin; who was voiced by a trained Standardized Patient. Integrated into the manikin were standard care outputs seen on a patient care monitor; such as heart rate; PSO2; CO2; blood pressure; heart rate; and respiratory rate.  We were able to build into the scenario critical lab values that could be accessed by the student nurse teams. During the manikin encounter; the lab technician was able to adjust the critical values to reflect the post-operative bleeding scenario that we attempted to get across to the student nursing teams.  The manikin was able to go into ventricular tachycardia with a decrease in blood pressure and PSO2; among other values to reflect the drop in blood volume. To better enhance the realism of the scenario; a Standardized Patient was integrated into the room to act as a distressed family member.  The student nurse team was tasked with not only caring for the rapidly decompensating patient but also with the distressed family member; which added to the realism of the scenario. At the end of the scenario; a debrief occurred where the nursing educators were able to glean from the student nurse teams; their understanding of the situation and lend impart any information that they deemed relevant to the situation.  After the debrief; a follow-on simulation took place wherein a Simulated Patient (SP) was utilized in place of the manikin.  This SP enacted a scenario where the patient has now stable after having been treated for the bleeding and is to be discharged.  The student nurse team is tasked with caring for the discharge of the patient; in a less stressful encounter. This two-part MSP encounter was replayed several times; with several different nurse student teams as a way of providing a reproducible educational experience.  The feedback from these experiences was immediate from not only the patient’s subjective experience but also from the manikin’s objective data sets. Any deficiencies in care assessment were corrected by the nursing faculty immediately; and timely feedback was given to the student nursing teams. These MSP encounters; when engaged by a nursing student teams; provide an effective learning and teaching pedagogy in a safe and reproducible environment. As seen from the chart below; taking into account the small sample size; the feedback from the nursing students regarding their experience with MSP is positive and encouraging; nonetheless.

In the classic nursing education classroom setting; learning is derived and rooted in behaviorism; where there is information processing; and information organization is in a sequential; step by step process of reasoning and learning. This type of learning allows for the integration of in-depth knowledge that the nursing student needs to formulate decisions that are rooted in sound nursing rationales. With the MSLs; the learning opportunity turns more toward cognitivism; where the learning builds on and integrates the previously gained knowledge to make increase their decision-making skills. This cognitive approach in simulation training uses modeling and contemplative practice; which allows the learner to “deconstruct and reconstruct” the simulation training to extend and apply their existing nursing knowledge to generate new nursing processes; thereby gaining new knowledge. The MSP simulation lab learning experience provides the nursing students with internal process objectives where they are able to focus on thinking; understanding; and organizing their patient processes; increasing their judgment; evaluation; and reasoning skills in a reproducible environment. By way of reinforcing this contention; Viale (2013) stated that cognitivism postulates that individuals can acquire and store information that can be combined with further information.  By being able to master the scenarios with repeated exposures; all while in the safe environment of the MSLs; allows the nursing student to increase their competence and dealing with the high acuity client. These repeated opportunities aid in increasing the cognitive process and increasing meaningful outcomes scenario performances.  Conner & Norman theorized that a strong sense of competence facilitates cognitive processes and performance in a wide variety of settings; including quality of decision making; goal setting; and academic achievement [6]. These qualities are the type that we are developing in our nursing student; so the experience aligns with the HUSON student goals and outcomes. Lewis mentioned that it is important that curriculum and clinical experiences needs to be up to date and prepared to meet the continual changes in its environment [7].  With the previously stated clinical obstacles; we need to be more creative in the way of development and clinical engagement to provide the HUSON students with a more experiential learning experience [8].

The integrative higher level thinking required to successfully problem solve the MSP experience provides our nursing student with experiences that many times; cannot be reproduced in the acute care setting.  The MSP provides a summative assessment tool to measure high acuity problems in a more realistic; stressful setting for the nursing students that can better reflect the acute care environment. We must keep in mind that SPs in clinical simulations; while a boon to nursing educators and students are not a panacea for all of the previously mentioned issues.  While SPs can provide a high acuity patient simulation without the risks imposed on a real patient; there are limitations in creating plausible; stress-filled encounters with the students.

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3. Luo S, Kalman M. A technology training protocol for meeting QSEN goals: Focusing on meaningful learning. Nursing Forum. 2017; 53: 20-26.
4. Oh P, Jeon KD, Koh MS. The effects of simulation-based learning using standardized patients in nursing students: A meta-analysis. Nurse Education Today. 2015; 35: 6-15.
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