Enhancing Pediatric Advanced Practice Nursing Education
Enhancing Pediatric Advanced Practice Nursing Education
Role identification, in our experience, was a key ingredient to running a successful simulation and an area where students needed clear guidelines. Students worked in teams of four or five and were provided with distinct roles that were rotated for subsequent scenarios. Studies have shown that a group of four or five is ideal for simulations. The student roles were PNP preceptor, PNP student, parent (caregiver), and observer. Because an effective team member understands the roles of other members, role expectations were clearly outlined before the start of a simulation and reinforced as needed during a simulation. The distinct roles were designed to allow for different perspectives and team members with varying levels of knowledge to promote teamwork. Simulation experiences have been demonstrated as a useful way to improve teamwork skills in problem solving and decision making. As such, students were encouraged to discuss treatment options and assist each other within their respective roles.
The parent (caregiver) role required special consideration regarding role expectation. Students in the parent role were given additional data including medical, family, and social history information and were prompted to provide information that was beyond the capabilities of the manikin such as pallor and fatigue. In this manner, assessment data elicited during the course of a scenario came from both the parent and from the child.
Role-playing activities such as motivational interviewing and history taking are already an important part of our PC/AC PNP curriculum. The students are familiar with the technique of "mind mapping," which is used throughout the clinical seminars as a form of reflection and consideration of the "why" and "how come" involved in critical thinking. (Fig 1) We believe that these presimulation activities contributed to the students' capacity for scenario participation.
(Enlarge Image)
Figure 1.
Mind mapping process. A guided exercise in which students are asked to share the cognitive process of formulating a diagnosis based upon incremental data provided at specific intervals. Students are requested to share rationale for every decision, reflecting upon each aspect of clinical decision making. There is no predetermined exact answer.
Faculty plays an integral part in the success of a scenario and needs new skill sets not only for scenario development but also for participating in scenarios. Faculty facilitators played three distinct roles in each scenario that significantly contributed to the success of the scenarios. Facilitators must thoroughly understand the content of a scenario, the possible range of student interactions and interventions, and the associated patient responses. One faculty played the role of expert observer, whereas a second faculty served as the expert registered nurse (RN), and the third faculty, based in the control room, was the simulator programmer and the voice of the child. The expert faculty observer viewed the scenario without any interference, allowing this faculty member time to articulate constructive feedback during debriefing. The second faculty, in the role of expert RN, was the scenario content expert and served as director of the scenario by guiding the course of action indirectly through asking targeted questions of all players, controlling the timing of the scenario, and providing necessary data as would be done in reality. The third faculty, the simulator programmer, who had expertise in the use of simulation manikins, helped provide indirect guidance through giving timely clinical signals and cues from the perspective of the child.
We pondered whether to provide the students resources for simulation preparation. Adult learning theory supported the decision to rely on student self-direction and motivation to be prepared for simulation; therefore, students were provided with broad topic areas rather than specific references and practice guidelines. Likewise, providing minimal information at the start of a scenario proved beneficial to the performance of a thorough age-appropriate assessment. In general, we provided information suitable for the setting: the child's name, age, and primary complaint when the setting was the emergency department or clinic, and a brief history when the setting was inpatient.
It is necessary to prepare the simulation area with appropriate tools to support the unfolding simulation and student performance. Detailed attention must be paid to what Lasater labels as "cosmic reality," the provision of the outward appearance of reality whenever possible. Physical signs and findings such as rashes, diaphoresis, breath sounds, and vital signs mimicked reality as did the availability of supportive technology such as cardiopulmonary monitoring, software resources, and electronically available diagnostic results. It is, in addition, helpful to have information pertinent to a specific scenario available as a case unfolded. An example of this is the recommended method of determining bolus and maintenance fluid amounts and rates. In our experience, these informational tools were sometimes introduced during a scenario if the students required this type of assistance or became part of the debriefing process.
Typically, it is recommended that scenarios progress uninterrupted by the facilitators. However, we found it necessary to occasionally interrupt and debrief during the course of a scenario when patient safety was at risk. It is thought that the most effective time to address an error with potential negative consequences is immediately after the error. This allows students to regroup and resume at an earlier point in the scenario where they can assimilate new knowledge. These moments invariably became part of the guided reflection at the end of the scenario where students articulated their cognitive processes, the potential effects of their actions, and how they restructured their thinking.
The actual performance of skills during a scenario has to be carefully considered for time management and student proficiency. During a scenario, it is difficult to meet skill performance objectives particularly if they are time consuming. A recent national study of specialty roles of nurse practitioners identified that AC nurse practitioners are more likely than other nurse practitioners "to engage in activities related to initiating and managing complex technologic support in hemodynamically unstable patients and initiating and managing technologic support in chronically ill patients." In recognition of the importance of proficient skill performance for PNP students, this potential problem was controlled by having separate skill workshops taught by clinical experts that were coordinated with simulation experiences.
Scenario Preparation and Implementation
Role identification, in our experience, was a key ingredient to running a successful simulation and an area where students needed clear guidelines. Students worked in teams of four or five and were provided with distinct roles that were rotated for subsequent scenarios. Studies have shown that a group of four or five is ideal for simulations. The student roles were PNP preceptor, PNP student, parent (caregiver), and observer. Because an effective team member understands the roles of other members, role expectations were clearly outlined before the start of a simulation and reinforced as needed during a simulation. The distinct roles were designed to allow for different perspectives and team members with varying levels of knowledge to promote teamwork. Simulation experiences have been demonstrated as a useful way to improve teamwork skills in problem solving and decision making. As such, students were encouraged to discuss treatment options and assist each other within their respective roles.
The parent (caregiver) role required special consideration regarding role expectation. Students in the parent role were given additional data including medical, family, and social history information and were prompted to provide information that was beyond the capabilities of the manikin such as pallor and fatigue. In this manner, assessment data elicited during the course of a scenario came from both the parent and from the child.
Role-playing activities such as motivational interviewing and history taking are already an important part of our PC/AC PNP curriculum. The students are familiar with the technique of "mind mapping," which is used throughout the clinical seminars as a form of reflection and consideration of the "why" and "how come" involved in critical thinking. (Fig 1) We believe that these presimulation activities contributed to the students' capacity for scenario participation.
(Enlarge Image)
Figure 1.
Mind mapping process. A guided exercise in which students are asked to share the cognitive process of formulating a diagnosis based upon incremental data provided at specific intervals. Students are requested to share rationale for every decision, reflecting upon each aspect of clinical decision making. There is no predetermined exact answer.
Faculty plays an integral part in the success of a scenario and needs new skill sets not only for scenario development but also for participating in scenarios. Faculty facilitators played three distinct roles in each scenario that significantly contributed to the success of the scenarios. Facilitators must thoroughly understand the content of a scenario, the possible range of student interactions and interventions, and the associated patient responses. One faculty played the role of expert observer, whereas a second faculty served as the expert registered nurse (RN), and the third faculty, based in the control room, was the simulator programmer and the voice of the child. The expert faculty observer viewed the scenario without any interference, allowing this faculty member time to articulate constructive feedback during debriefing. The second faculty, in the role of expert RN, was the scenario content expert and served as director of the scenario by guiding the course of action indirectly through asking targeted questions of all players, controlling the timing of the scenario, and providing necessary data as would be done in reality. The third faculty, the simulator programmer, who had expertise in the use of simulation manikins, helped provide indirect guidance through giving timely clinical signals and cues from the perspective of the child.
We pondered whether to provide the students resources for simulation preparation. Adult learning theory supported the decision to rely on student self-direction and motivation to be prepared for simulation; therefore, students were provided with broad topic areas rather than specific references and practice guidelines. Likewise, providing minimal information at the start of a scenario proved beneficial to the performance of a thorough age-appropriate assessment. In general, we provided information suitable for the setting: the child's name, age, and primary complaint when the setting was the emergency department or clinic, and a brief history when the setting was inpatient.
It is necessary to prepare the simulation area with appropriate tools to support the unfolding simulation and student performance. Detailed attention must be paid to what Lasater labels as "cosmic reality," the provision of the outward appearance of reality whenever possible. Physical signs and findings such as rashes, diaphoresis, breath sounds, and vital signs mimicked reality as did the availability of supportive technology such as cardiopulmonary monitoring, software resources, and electronically available diagnostic results. It is, in addition, helpful to have information pertinent to a specific scenario available as a case unfolded. An example of this is the recommended method of determining bolus and maintenance fluid amounts and rates. In our experience, these informational tools were sometimes introduced during a scenario if the students required this type of assistance or became part of the debriefing process.
Typically, it is recommended that scenarios progress uninterrupted by the facilitators. However, we found it necessary to occasionally interrupt and debrief during the course of a scenario when patient safety was at risk. It is thought that the most effective time to address an error with potential negative consequences is immediately after the error. This allows students to regroup and resume at an earlier point in the scenario where they can assimilate new knowledge. These moments invariably became part of the guided reflection at the end of the scenario where students articulated their cognitive processes, the potential effects of their actions, and how they restructured their thinking.
The actual performance of skills during a scenario has to be carefully considered for time management and student proficiency. During a scenario, it is difficult to meet skill performance objectives particularly if they are time consuming. A recent national study of specialty roles of nurse practitioners identified that AC nurse practitioners are more likely than other nurse practitioners "to engage in activities related to initiating and managing complex technologic support in hemodynamically unstable patients and initiating and managing technologic support in chronically ill patients." In recognition of the importance of proficient skill performance for PNP students, this potential problem was controlled by having separate skill workshops taught by clinical experts that were coordinated with simulation experiences.
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