education
The impact of peer-led simulations on student nurses Tracey Valler-Jones
T
his paper discusses a research project that involved student-led simulation sessions. The students were empowered to run and facilitate their own scenario as an alternative to the more usual facilitator-led session whereby students are the passive participants.
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Background In order to become reflective practitioners, students are required to learn from their errors, to reflect. There is a wealth of evidence in the educational literature that students of health care tend to learn predominantly by doing (Papp et al, 2003). Making mistakes can enable the learner to develop their knowledge base (Alverson et al, 2004; Reilly and Spratt, 2007); however, within health care, the impact of making mistakes can have detrimental consequences and so the emphasis is on risk aversion or risk management (Alaszewskit and Burgess, 2007).Therefore, in order for students to develop these skills, educational institutes are required to empower their students with the knowledge to practise within their chosen fields having undergone suitable preparation that enables them to do this. To achieve this, students need exposure to the myriad of situations they may have to deal with and be allowed to develop the coping strategies as well as the knowledge required. Reduced placement hours and the ensuing competition for clinical experiences among health professions has necessitated the creation of innovative learning experiences in which students can practice skills in a safe environment, where errors in clinical judgment will not result in harm to living patients (Bambini et al, 2009). In order for this to be effective, the students need to be able to familarise themselves with the sights and sounds of the clinical area within a low-stress environment that allows repetitive practice with no consequences (Bush, 2009). The use of scenario simulation as a teaching-learning strategy has become increasingly popular (Henneman et al, 2007; Reilly and Spratt, 2007) as it mimics real life without harming the patient (Gordon et al, 2004; Cantrell, 2008), and improves patient outcomes (Zendejas et al, 2013). Simulations allow students to make mistakes safely in lieu of real-life situations, learn from those mistakes and ultimately improve performance by subsequent avoidance of these mistakes (Alverson et al, 2004; McCaughey and Traynor, 2010). It has also been shown to increase students’ confidence in what to expect and how to conduct themselves in the clinical setting (Bambini et al, 2009; Schroedl et al, 2012) and a study by Alinier et al (2006) demonstrated that it was a valuable tool to equip students with the minimum of skills. In fact, many authors advocate simulation as a prerequisite to clinical
British Journal of Nursing, 2014, Vol 23, No 6
Abstract
Background: Simulation within nurse education has been widely accepted as an educational approach. However, this is mainly led by the facilitator with the student maintaining a passive role in the learning. Objectives: This paper describes a study that was undertaken to analyse the effectiveness of peer-led simulations in the undergraduate nursing programme. Design: A mixed-method approach was used for this study design. Settings: This study took place in a simulation suite within a university in the Midlands. Participants: Twenty four second-year child branch students were purposively selected to take part. Methods: Students designed and facilitated a simulation based on the care of a critically ill child. Formal assessment of the learning was collected via the use of a structured clinical examination. Students completed an evaluation of their perceived confidence and competence levels. Results: There was 100% pass rate in the assessment of students’ clinical competence following the simulation. Thematic analysis of the evaluation highlighted the learning achieved by the students, not only of their clinical skills but also their personal development. Conclusions: The use of peer-led simulation promotes new learning and is a valuable educational approach. Key words: Simulation ■ Peer learning ■ Debriefing Student-led ■ Facilitation
■
experience (Haskvitz and Koop, 2004; Kneebone et al, 2004; Issenberg et al, 2005). Simulations may also promote students’ confidence at actual clinical sites owing to an increased sense of self-efficacy in practice (Bambini et al, 2009).Those of higher efficacy appear to view obstacles as undemanding by improvement of their self-reliance and management skills, and their continuing effort to improve. According to Bandura (2004): ‘The stronger the perceived self-efficacy, the higher the goals people set for themselves and the firmer their commitment to them’.
Learning by teaching Effective teaching is a process by which the teacher demonstrates educational content such as knowledge, or
Tracey Valler-Jones is Academic Lecturer in Nursing. University of Birmingham Accepted for publication: March 2014
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Scenario Title: Patient’s Name: Hospital Number:
DOB:
Age:
Scenario type: Year of training:
Module Code:
Author and e-mail: Learning Objectives: Keyword – systems: Learning Activities: Participant assignments: Be realistic with the level of expertise you have. Nurse: Nurse: Medical: Scribe: Session plan ■■ Brief
students on aim and learning outcomes for session mechanism management of [insert medical condition] ■■ Explain the outlay of the room and what to use and how. e.g., telephone, how to use bed, scribe’s record. ■■ Explain the scenario. ■■ COMMENCE SCENARIO ■■ Review video ■■ Use debriefing guide to reflect on scenario ■■ Revise
skills to a student within a context and is a complementary process to learning. Shifting the responsibility of knowledge acquisition from teacher to student, particularly in a simulated setting can help students develop an in-depth understanding of concepts fundamental to their development as a nurse. A social theory of learning that links with this is called situated learning (Lave and Venger, 1991). This focuses on understanding knowledge and learning in context, and emphasises that the learner engages with others to develop collective understanding as part of a community of practice. Situated learning views learning as a social practice and considers that new knowledge can be generated from practice. It is also related to Vygotsky’s (1978) notion of learning through social development whereby skills, abilities, behaviours and knowledge are gained or improved through interaction with others and then integration into the individual mental structure. Consistent with the constructivism view that students in higher education must engage in and take responsibility for their learning, Bigg (1993) feels that what the student does is actually more important in determining what is learned than what the teacher does. Knowles (1975) emphasises that adults are self-directed and expect to take responsibility for decisions. He argues that there is convincing evidence that people who take the initiative in learning (proactive learners) learn more things, and learn better, than reactive learners who are waiting to be taught (Knowles et al, 2005): ‘They enter into learning more purposefully and with greater motivation. They also tend to retain and make use of what they learn better and
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longer than do the reactive learners.’ (Knowles 1975: 14) Learning becomes meaningful when knowledge is incorporated into structures of knowledge already possessed by the individual. To produce this, meaningful learning should consist of a logical sequence of processes and consistency in the internal structure of the material. The student must have ideas that will act as a link between preexisting cognitive structure of learning and new ideas. They are invited into the learning process, which encourages them to take responsibility for their learning, and can lead to an increase in self-directed learning skills.This allows the student to take the initiative, diagnose their learning needs, formulate goals, identify human and material resources, choose and implement appropriate learning strategies, and evaluate learning outcomes (Loyens et al, 2008). Through this form of peer-led simulation, the student has an opportunity to think and reflect, practice, and interact with others while learning with and from peers and expert facilitators.
Methodology The simulation exercise Ethical approval was gained via the University’s ethics review committee. Although the teaching strategy was part of an approved module with structured learning aims and outcomes, all students were informed of the nature of the project. Information letters were given and written consent was gained. Students were given the opportunity to ask questions and, as the learning opportunities within the module remained the same whether they chose to actively partake in the peer-led simulation or not, no one student was disadvantaged. Students could withdraw from the peer-led simulation activity but would still remain part of the overall learning. Purposive sampling was used to access cohorts of second-year child field of practice preregistration student nurses (n=12 per cohort). In order to accommodate the positive aspects of enquirybased learning with those of simulation, students were given an opportunity to develop and facilitate a clinical scenario. This was built into a module focusing on the care of the critically ill child. They had the possibility to choose any type of situation that they may have been involved in and the resulting sequelae; however, they were provided with ground rules in order for the learning outcomes of the module to be achieved. All clinical situations had to include a critical event whereby the simulated mannequin had a noticeable deterioration and required airway and cardiovascular resuscitation. The rationale for this was that as part of the assessment process for the module, the students have to demonstrate a safe and effective resuscitation of a neonate, baby or child, including airway management and drug administration via an Objective Structured Clinical Examination (OSCE). Each scenario would take between 15 and 20 minutes, to include a structured debrief for the participating team. This was to be followed by a peer debrief from the rest of the group and the facilitator. Students were divided into groups of four and sample
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Table 1. Skills simulation
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education
Table 2. Simulation debriefing guide – [insert title of scenario] Observation
Understanding
Response
Was there anything with the condition of [insert child’s name] that informed your management of the situation? ■■ Anxiety level ■■ Position adopted
What do you understand about care of [insert child’s name] What do you understand about the signs and symptoms of [insert medical condition]?
How did you use this knowledge in the scenario?
What role did you notice other staff took in this scenario?
How did that impact upon the supervision of the situation?
How did you determine if your interventions were effective?
Attitudes & Behaviours: interaction with the peer group seemed to ■■ What happened to make it ■■ Communication with [insert child’s name] and her family seemed to ■■ What happened to make it ■■ The
Go well……………Have difficulties Go well……………Have difficulties Go well……………Have difficulties Go well……………Have difficulties
Effective Evaluating: ■■ What did you learn today from managing this simulation? ■■ What do you need to review? ■■ What do you want to know more about?
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simulation templates were provided (Table 1). Resources such as mock paperwork, ECG and blood results were made available as requested and skills stations were set up for students to practice in order to develop their levels of confidence. Sessions were scheduled to allow the students to research and rehearse their own scenario. The students had to provide a written template with the progress of their simulation mapped out and needed to understand what the consequence of actions would be dependent on what the participant would do. This allowed them to develop their knowledge base. The project did not require any extra commitment on the part of the students as all practice sessions were scheduled within the allocated module. Although the actual peerled facilitation was timetabled, there were no penalties for those students who did not wish to participate. However, all students took an active part in the simulation event. It could be argued that the primary motivating factor was based on the OSCE assessment, and yet all information and guidance in order to achieve a successful outcome were delivered throughout the module. Therefore, involvement in the peerled simulation event was not a prerequisite. Each group of four students developed their own simulation within the specified criteria and although these were their own preferences, they decided as a whole that they wished to look at differing age groups and conditions in order to expand their knowledge. For this reason, they discussed and organised their simulation so that three divergent simulations would ultimately be performed. All simulations had a deterioration built in that required the participants to perform resuscitation adhering to the European Resuscitation Guidelines (Resuscitation Council UK, 2010).
Debriefing As part of the learning process, each student group was offered feedback following completion of their simulation by the group who wrote and facilitated it. This allowed for opportunities to explore and evaluate their performance as
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well as assist them in their reflective learning. Salvodelli et al (2006) found that providing feedback significantly improved the skills of the participants when compared with those who did not receive feedback. In order for the feedback to be meaningful for students, they needed to be active in discussions of their performance and the events of the simulation exercise. Therefore, ground rules were drawn up along with a structured format for the actual feedback (Table 2). Target behaviours expected from the scenario were identified to offer structure for the student facilitators. This would then enable them to distinguish and evaluate areas of performance without the risk of personal criticisms of their peers. Examples of these were recognition of the potential for the heart rate to fall with the increased hypoxia in the neonate scenario and so setting up the cardiac monitor, and examining the pupillary reaction in the child scenario when he complained of a headache. This shaping of the format for the feedback enabled learning points to be highlighted but reduced the risk of intimidating all involved. Each simulation had a group of student facilitators and a group of students undertaking the simulation. While involved in the simulation, students may have only had a limited picture of what happened; they may only have observed those parts their position allowed them to (Peters and Vissers, 2004). Therefore, the third group (students who were not involved in the actual event) was able to take an objective view of the whole incident. The advantage of this was that all students had opportunity to be a facilitator, an active participant in the simulation and an observer throughout the session. At the conclusion of the session, all students were debriefed by the facilitator. The debrief is an essential part of any simulation session. It is crucial for a successful learning process and, to be successful, the facilitator must provide a supportive environment in which the debriefing can take place (Rall et al, 2000). In fact, Fanning and Gaba (2007) suggest that it is the ethical duty of the facilitator to provide a safe and confidential scene for debriefing. Both Shinnick et al (2011) and Jeffries and Rizzolo (2006) feel it is more important than the simulation itself. It allows the student to evaluate
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Results Quantitative analysis Over 2 years, all child branch students took part in developing a simulation as well as participating in a peer-facilitated simulation. This was an overall total of 24 students. They were also responsible for providing feedback to their peers. Evaluation of the knowledge gained was assessed via the OSCE at the end of the module as this is widely considered to be a reliable form of assessment (Gormley, 2011). The criteria for the OSCE examination was constructed using local policy in conjunction with NHS protocols, guidelines from the National Patient Safety Agency, European Resuscitation Guidelines (Resuscitation Council UK, 2010) and The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty and Lister, 2011). The students’ performance was assessed by two examiners with video recording enabled for internal and external moderation purposes and the examiners received training in the use of the mark sheet. Compulsory items such as correct placement of hands for chest compressions were used to ensure that any safety issues would lead to a fail regardless of the overall percentage grade. A minimum of 16 items out of 20 (80%) was required to pass. The students who gained a pass in both cohorts totalled 100% with students identifying that they felt confident with their performance and their understanding of the assessment and management of a critically ill child. An eight-item, five-point (strongly disagree, disagree, neutral, agree, strongly agree) pre- and post-simulation intervention Likert scale questionnaire/module evaluation was specifically designed, taking approximately 10 minutes to complete and was based on the clinical acquisition skills survey (CASS) developed by Meechan et al (2011). The questionnaire was scrutinised by five nurse academics and practice facilitation staff for face validity before being used
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for this study. Pre-simulation activity confidence and competence levels were taken at the mid-point evaluation. Post simulation activity confidence and competence levels were taken at the end of the module. The tool aimed to elicit quantitative data regarding students’ perceptions in three key areas: ■■ Their perceived ‘confidence levels’ of caring for a critically ill child before and after their educational experience of peer-led simulations (three items) ■■ Their perceived ‘competence levels’ of caring for a critically ill child before and after their preparation via the peer-led simulation (three items) ■■ Their perception of the usefulness of skills and knowledge acquired and ability to ‘transfer into the clinical environment’ (two items). The responses were scored in such a way that positively endorsed statements and non-endorsement of negative statements were assigned a higher score. Therefore, each student had a maximum of 40 points; for those with a high level of perceived confidence and competence and a minimum of 8 for a negative perceived confidence and competence level. A paired sample t-test was used to compare scores pre and post the simulation intervention and this demonstrated a statistically significant increase (p=0.001) in perceived confidence and competence levels following the peer-led simulation with a mean increase of 55.62. Review of the process of learning was garnered from the end of module evaluations with a 4.8 out of 5.0 satisfaction rating. Students were also invited to add comments that could be used for a simplistic thematic analysis.
Qualitative analysis Thematic analysis of the comments identified satisfaction and a sense of achievement about taking part in the simulated activities. Emerging themes also pointed towards students’ feelings about their own improved confidence to deal with similar clinical situations within their placements. As they had to question their own assumptions on the progression of resulting clinical sequelae in order to ensure they were able to effectively manage the group they were facilitating, they felt their learning had taken a more rounded approach. ‘It was a very useful teaching session; I would appreciate the opportunity to take part in more of these sessions. It was also encouraging to have the opportunity to discuss the scenario with tutors that I am familiar with afterward’ ‘As the facilitators my group had to know what to do depending on how they reacted to some change in condition…meant I had to learn loads more that I would have done had I just taken part in a simulation’ Students appreciated the opportunity to work within small groups to help develop cooperation in development of their knowledge: ‘...working in small groups, communication was good between students’
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their own performance as well as that of their peers and can increase their understanding of the clinical experience. Simulation followed by debriefing can provide students the opportunity to discuss what they have learned and to ensure that activities are not left unfinished. It also enables them to identify what they have accomplished. As a result, students of diverse learning styles can be accommodated and students with varying backgrounds are able to benefit from the experience (Cioffi, 2001; Jeffries, 2005) It also allows students to be led through a purposive discussion of the experience so they can reflect on it (Lederman, 1992; Fanning and Gaba, 2007; Lasater, 2007). However, a poor debrief can harm the student (Rall et al, 2000). Fanning and Gaba (2007) suggest that, although few students respond well to humiliating styles of debriefing, they may find that debriefings that avoid criticisms or analysis result in a failure to learn anything. The facilitator designed the debrief to include an objective observation about and subjective judgment of the students’ actions to allow the students to acquire knowledge in a structured manner while exploring the personal nature of the experience. This approach has been advocated by Rudolph et al (2006) as they believe it helps instructors manage the apparent tension between sharing critical, evaluative judgments while maintaining a trusting relationship with trainees.
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education
‘I felt well supported throughout the session. This was an enjoyable session once I got over my initial nerves.’ This point is further emphasised by Kahn and O’Rourke (2005) as nurturing collaborative peer support, which in turn fosters a deep approach to learning. However, some students identified that they were unsure of their roles and that this led to anxiety, especially as they felt they would be judged by their peers. This can have a paradoxical effect as increasing anxiety levels can reduce the receptivity of the learning (Mandler and Sarason, 1952) ‘It was scary knowing that we would be watched by others and they would be making judgements on how we ran the scenario…’ ‘…it was intimidating being asked how to respond to the situation by people who were the same as me. I felt I should have known what to do and they would think me stupid’ There was also recognition that embracing this educational approach required a sea change in the learning process. ‘We felt that as students we should have been more organised, although nerves were also an issue here, as this was a new way of learning to us’ Relinquishing the control of the process to the students is an important aspect in the facilitation of learning and this can have implications for how the role of the facilitator is seen. ‘Initially it felt as though we were doing the lecturer’s job for her…’ This comment, although not common, has connotations that can impact on the effectiveness of the facilitator. The student-centred principles of freedom and independence in learning can be a difficult concept to grasp and can lead to non-valuing behaviour by some lecturers (Moore, 2009). When students express this thought, the credibility of the lack of control concept from facilitators can lead to anxiety about their own purpose (Lekalakala-Mokgele, 2010).Yet, the student further qualified this with: ‘…but now I have done it I have learned so much, not just about the care of the child in our scenario but about myself ’
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Discussion The author recognises that the sample is relatively small and that the data were collected from one field of practice within one higher education institution; therefore, the findings must be interpreted with some element of caution. Subsequent studies would be required to investigate if students’ levels of confidence and competence are unique to this particular higher education institution or whether this educational approach is appropriate to others. It has also been undertaken with a small cohort that enabled the researcher to mitigate
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against any anomalies owing to differing approaches and support that the students might receive. The study did not review the retention of knowledge gained however, anecdotal evidence from yearly mandatory updates of life support indicated that those students performed better and more confidently when assessed. According to the pyramid model conceptualised by Miller (1990), there are four domains of competence (Figure 1). These levels are: ■■ Knows (knowledge)—recall of basic facts, principles, and theories ■■ Knows how (applied knowledge)—ability to solve problems, make decisions, and describe procedures ■■ Shows how (performance)—demonstration of skills in a controlled setting ■■ Does (action)—behaviour in real practice. It could be argued that the students, on the basis of their facilitation role, are actually at the ‘shows how’ level following the exercise. Further studies on their performance are planned for the future and it is hoped that the impact of this educational approach will move them towards the ‘does’ level at a rate that shows improvement from what would routinely be expected. In order to ascertain the relative merits of this approach, it would be necessary to follow up the students and compare their relative knowledge base and retention of skills with a control group. However, the comparative anomalies that this would incur render this difficult. As all the child branch students took part, it would be problematic to compare with others and the differing exposures and educational approaches of the other branches would not allow for crossbranch comparisons.
Conclusion Although this was a relatively small study, the results demonstrate that this is a valuable approach to support the learning of student nurses. The move from facilitator-led to student-led simulations encourages proactive learning and
Does
Professional authenticity
‘The scenario was a good learning tool’
Shows how
Knows how
Knows
Miller’s1.pyramid clinicalofcompetence Figure Miller’s ofpyramid clinical competence
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Key points n Shifting
the responsibility of knowledge acquisition from teacher to student can help students develop an in-depth understanding of concepts fundamental to their development as a nurse
n The
use of peer-led simulations is a valuable approach to student learning
n With
support student nurses are able to effectively facilitate simulations
n Debriefing
enables students to reflect on their own performance as well as that of their peers and can increase understanding of the clinical experience
n Students
identified satisfaction and a sense of achievement from taking part in the peer-led simulations
the provision of a safe and nurturing environment enabled optimal learning opportunities. While it is recognised that simulations can be resource intensive the wealth of literature about its relative merits as BJN an educational approach cannot be ignored. Conflict of interest: none
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Alaszewski A, Burgess A (2007) Risk, time and reason. Health, Risk & Society, 9(4): 349-58 Alinier G, Hunt B, Gordon R, Harwood C (2006) Effectiveness of intermediate -fidelity simulation training technology in undergraduate nursing education. J Adv Nurs 54(3): 359-69 Alverson DC, Saiki SMJ, Jacobs J, Saland L, Keep MF, Norenberg J (2004) Distributed interactive virtual environments for collaborative experiential learning and training independent of distance over Internet2. Stud Health Technol Inform 98: 7–12 Bambini D, Washburn J, Perkins R (2009) Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nurs Educ Perspect 30(2): 79-82 Bandura A (2004) Health promotion by social cognitive means. Health Educ Behav 31(2): 143–64 Biggs J 1(993) What do inventories of students’ learning processes really measure? A theoretical review and clarification. Br J Educ Psychol 63(1): 3-19 Bush H (2009) Practice makes perfect. Michigan medical school uses simulation center training to produce more competent, confident students. Hosp Health Netw 83(3): 28-30 Cantrell MA (2008) The importance of debriefing in clinical simulations. Clinical Simulation in Nursing 4(2): e19-e23 Cioffi J (2001) Clinical simulations: Development & Validation. Nurse Educ Today 21(6): 477-86 Dougherty L, Lister S (2011).The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Blackwell Publishing, Oxford Fanning RM, Gaba DM (2007) The role of debriefing in simulation–based learning. Simul Healthc 2(2): 115-25 Gordon J, Oriol N, Cooper J (2004) Bringing good teaching cases ‘to life’: a simulator-based medical education service. Acad Med 79(1): 23–7 Gormley G (2011) Summative OSCEs in undergraduate medical education. Ulster Med J 80(3): 127–32 Haskvitz IM, Koop EC (2004) Students struggling in clinical? A new role for the patient simulator. J Nurs Educ 43(4): 181-4 Henneman EA, Cunningham H, Roche JP, Curnin M (2007) Human patient simulation: Teaching students to provide safe care. Nurse Educ 32(5): 212−7 Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese, RJ (2005) Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 27(1): 10-28
Jeffries PR, Rizzolo MA (2006) Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi-method study. National League for Nursing, New York Jefferies PR (2005) A framework for designing, implementing, and evaluating simulations used as a teaching strategies in nursing. Nurs Educ Perspect 26(2): 96-103 Khan P, O’Rourke K (2005) ‘Understanding enquiry-based learning’. In: Barrett T, MacLabhrainn I, Fallon H, eds. Handbook of enquiry and problem based learning. CELT, Galway. http://tinyurl.com/mttzqjd (accessed 17 March 2014) Kneebone RL, Scott W, Darzi A, Horrocks M (2004) Simulation and clinical practice: strengthening the relationship. Med Educ 38(10): 1095–1103 Knowles MS (1975) Self-Directed Learning. A guide for learners and teachers. Englewood Cliffs, Prentice Hall/Cambridge Knowles MS, Holton III EF, Swanson R (2005) The adult learner: the definitive classic in adult education and human resource development. Elsevier Lasater K (2007) Clinical judgment development: Using simulation to create an assessment rubric. J Nurs Educ 46(11): 496-503 Lave J, Wenger E (1991) Situated Learning: Legitimate Peripheral Participation. Cambridge University Press, Lederman Lederman LC (1992) Debriefing:Toward a systematic assessment of theory and practice. Simulation & Gaming 23(2): 145–60 Lekalakala-Mokgele E (2010) Facilitation in problem-based learning: Experiencing the locus of control. Nurse Educ Today 30(7): 638–42. doi: 10.1016/j.nedt.2009.12.017 Loyens S, Magda J, Rikers R (2008) Self-Directed Learning in Problem-Based Learning and its Relationships with Self-Regulated Learning. Educ Psychol Rev 20(4): 411. DOI 10.1007/s10648-008-9082-7 Mandler G, Sarason SB (1952) A study of anxiety and learning. J Abnorm Psychol. 47(2): 166-73 McCaughey C, Traynor MK (2010) The role of simulation in nurse education. Nurse Educ Today 30(8): 827-32 Miller GE (1990) The assessment of clinical skills, competence and performance. Acad Med 65(9 Suppl): 563-7 Meechan R, Jones H, Valler-Jones T (2011) Students’ perspectives on skills acquisition and confidence. Br J Nurs 20(7): 445-50 Moore J (2009) An exploration of lecturer as facilitator within the context of problem-based learning. Nurse Educ Today 29(2): 150–6. doi: 10.1016/j. nedt.2008.08.004 Papp I, Markkanen M, von Bonsdorff M (2003) Clinical environment as a learning environment: student nurses’ perceptions concerning clinical learning experiences. Nurse Educ Today 23(4): 262-8 Peters VAM, Vissers GAN (2004) A simple classification model for debriefing simulation games. Simulation Gaming 35(1): 70-84. doi: 10.1177/1046878103253719 Rall M, Manser T, Howard SK (2000) Key elements of debriefing for simulator training. Eur J Anaesthesiol 17(8): 516–7 Reilly A, Spratt C (2007) The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: A case report from the University of Tasmania. Nurse Educ Today 27(6): 542-50 Resuscitation Council UK (2010) Resuscitation Guidelines 2010. http:// tinyurl.com/3ram3db (accessed 18 March 2012) Rudolph JW, Simon R, Dufresne RL, Raemer DB (2006) There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc 1(1): 49-55 Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ (2006) Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology 105(2): 279-85 Schroedl, CJ, Corbridge, TC, Cohen ER et al (2012) Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: A randomized trial. J Crit Care 27(2): 219.e7–219.e13. doi: 10.1016/j.jcrc.2011.08.006 Shinnick M, Woo M, Horwich T, Steadman R (2011) Debriefing: The Most Important Component in Simulation? Clinical Simulation in Nursing 7(3): e105-e111. http://tinyurl.com/mah4say (accessed 17 March 2014) Vygotsky LS (1978) Mind in society. Harvard University Press, Cambridge Zendejas B, Brydges R, Wang AT, Cook DA (2013) Patient Outcomes in Simulation-Based Medical Education: A Systematic Review. J Gen Intern Med. 28(8): 1078-89 doi: 10.1007/s11606-012-2264-5
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The impact of peer-led simulations on student nurses Tracey Valler-Jones
T
his paper discusses a research project that involved student-led simulation sessions. The students were empowered to run and facilitate their own scenario as an alternative to the more usual facilitator-led session whereby students are the passive participants.
© 2014 MA Healthcare Ltd
Background In order to become reflective practitioners, students are required to learn from their errors, to reflect. There is a wealth of evidence in the educational literature that students of health care tend to learn predominantly by doing (Papp et al, 2003). Making mistakes can enable the learner to develop their knowledge base (Alverson et al, 2004; Reilly and Spratt, 2007); however, within health care, the impact of making mistakes can have detrimental consequences and so the emphasis is on risk aversion or risk management (Alaszewskit and Burgess, 2007).Therefore, in order for students to develop these skills, educational institutes are required to empower their students with the knowledge to practise within their chosen fields having undergone suitable preparation that enables them to do this. To achieve this, students need exposure to the myriad of situations they may have to deal with and be allowed to develop the coping strategies as well as the knowledge required. Reduced placement hours and the ensuing competition for clinical experiences among health professions has necessitated the creation of innovative learning experiences in which students can practice skills in a safe environment, where errors in clinical judgment will not result in harm to living patients (Bambini et al, 2009). In order for this to be effective, the students need to be able to familarise themselves with the sights and sounds of the clinical area within a low-stress environment that allows repetitive practice with no consequences (Bush, 2009). The use of scenario simulation as a teaching-learning strategy has become increasingly popular (Henneman et al, 2007; Reilly and Spratt, 2007) as it mimics real life without harming the patient (Gordon et al, 2004; Cantrell, 2008), and improves patient outcomes (Zendejas et al, 2013). Simulations allow students to make mistakes safely in lieu of real-life situations, learn from those mistakes and ultimately improve performance by subsequent avoidance of these mistakes (Alverson et al, 2004; McCaughey and Traynor, 2010). It has also been shown to increase students’ confidence in what to expect and how to conduct themselves in the clinical setting (Bambini et al, 2009; Schroedl et al, 2012) and a study by Alinier et al (2006) demonstrated that it was a valuable tool to equip students with the minimum of skills. In fact, many authors advocate simulation as a prerequisite to clinical
British Journal of Nursing, 2014, Vol 23, No 6
Abstract
Background: Simulation within nurse education has been widely accepted as an educational approach. However, this is mainly led by the facilitator with the student maintaining a passive role in the learning. Objectives: This paper describes a study that was undertaken to analyse the effectiveness of peer-led simulations in the undergraduate nursing programme. Design: A mixed-method approach was used for this study design. Settings: This study took place in a simulation suite within a university in the Midlands. Participants: Twenty four second-year child branch students were purposively selected to take part. Methods: Students designed and facilitated a simulation based on the care of a critically ill child. Formal assessment of the learning was collected via the use of a structured clinical examination. Students completed an evaluation of their perceived confidence and competence levels. Results: There was 100% pass rate in the assessment of students’ clinical competence following the simulation. Thematic analysis of the evaluation highlighted the learning achieved by the students, not only of their clinical skills but also their personal development. Conclusions: The use of peer-led simulation promotes new learning and is a valuable educational approach. Key words: Simulation ■ Peer learning ■ Debriefing Student-led ■ Facilitation
■
experience (Haskvitz and Koop, 2004; Kneebone et al, 2004; Issenberg et al, 2005). Simulations may also promote students’ confidence at actual clinical sites owing to an increased sense of self-efficacy in practice (Bambini et al, 2009).Those of higher efficacy appear to view obstacles as undemanding by improvement of their self-reliance and management skills, and their continuing effort to improve. According to Bandura (2004): ‘The stronger the perceived self-efficacy, the higher the goals people set for themselves and the firmer their commitment to them’.
Learning by teaching Effective teaching is a process by which the teacher demonstrates educational content such as knowledge, or
Tracey Valler-Jones is Academic Lecturer in Nursing. University of Birmingham Accepted for publication: March 2014
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Scenario Title: Patient’s Name: Hospital Number:
DOB:
Age:
Scenario type: Year of training:
Module Code:
Author and e-mail: Learning Objectives: Keyword – systems: Learning Activities: Participant assignments: Be realistic with the level of expertise you have. Nurse: Nurse: Medical: Scribe: Session plan ■■ Brief
students on aim and learning outcomes for session mechanism management of [insert medical condition] ■■ Explain the outlay of the room and what to use and how. e.g., telephone, how to use bed, scribe’s record. ■■ Explain the scenario. ■■ COMMENCE SCENARIO ■■ Review video ■■ Use debriefing guide to reflect on scenario ■■ Revise
skills to a student within a context and is a complementary process to learning. Shifting the responsibility of knowledge acquisition from teacher to student, particularly in a simulated setting can help students develop an in-depth understanding of concepts fundamental to their development as a nurse. A social theory of learning that links with this is called situated learning (Lave and Venger, 1991). This focuses on understanding knowledge and learning in context, and emphasises that the learner engages with others to develop collective understanding as part of a community of practice. Situated learning views learning as a social practice and considers that new knowledge can be generated from practice. It is also related to Vygotsky’s (1978) notion of learning through social development whereby skills, abilities, behaviours and knowledge are gained or improved through interaction with others and then integration into the individual mental structure. Consistent with the constructivism view that students in higher education must engage in and take responsibility for their learning, Bigg (1993) feels that what the student does is actually more important in determining what is learned than what the teacher does. Knowles (1975) emphasises that adults are self-directed and expect to take responsibility for decisions. He argues that there is convincing evidence that people who take the initiative in learning (proactive learners) learn more things, and learn better, than reactive learners who are waiting to be taught (Knowles et al, 2005): ‘They enter into learning more purposefully and with greater motivation. They also tend to retain and make use of what they learn better and
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longer than do the reactive learners.’ (Knowles 1975: 14) Learning becomes meaningful when knowledge is incorporated into structures of knowledge already possessed by the individual. To produce this, meaningful learning should consist of a logical sequence of processes and consistency in the internal structure of the material. The student must have ideas that will act as a link between preexisting cognitive structure of learning and new ideas. They are invited into the learning process, which encourages them to take responsibility for their learning, and can lead to an increase in self-directed learning skills.This allows the student to take the initiative, diagnose their learning needs, formulate goals, identify human and material resources, choose and implement appropriate learning strategies, and evaluate learning outcomes (Loyens et al, 2008). Through this form of peer-led simulation, the student has an opportunity to think and reflect, practice, and interact with others while learning with and from peers and expert facilitators.
Methodology The simulation exercise Ethical approval was gained via the University’s ethics review committee. Although the teaching strategy was part of an approved module with structured learning aims and outcomes, all students were informed of the nature of the project. Information letters were given and written consent was gained. Students were given the opportunity to ask questions and, as the learning opportunities within the module remained the same whether they chose to actively partake in the peer-led simulation or not, no one student was disadvantaged. Students could withdraw from the peer-led simulation activity but would still remain part of the overall learning. Purposive sampling was used to access cohorts of second-year child field of practice preregistration student nurses (n=12 per cohort). In order to accommodate the positive aspects of enquirybased learning with those of simulation, students were given an opportunity to develop and facilitate a clinical scenario. This was built into a module focusing on the care of the critically ill child. They had the possibility to choose any type of situation that they may have been involved in and the resulting sequelae; however, they were provided with ground rules in order for the learning outcomes of the module to be achieved. All clinical situations had to include a critical event whereby the simulated mannequin had a noticeable deterioration and required airway and cardiovascular resuscitation. The rationale for this was that as part of the assessment process for the module, the students have to demonstrate a safe and effective resuscitation of a neonate, baby or child, including airway management and drug administration via an Objective Structured Clinical Examination (OSCE). Each scenario would take between 15 and 20 minutes, to include a structured debrief for the participating team. This was to be followed by a peer debrief from the rest of the group and the facilitator. Students were divided into groups of four and sample
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Table 1. Skills simulation
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education
Table 2. Simulation debriefing guide – [insert title of scenario] Observation
Understanding
Response
Was there anything with the condition of [insert child’s name] that informed your management of the situation? ■■ Anxiety level ■■ Position adopted
What do you understand about care of [insert child’s name] What do you understand about the signs and symptoms of [insert medical condition]?
How did you use this knowledge in the scenario?
What role did you notice other staff took in this scenario?
How did that impact upon the supervision of the situation?
How did you determine if your interventions were effective?
Attitudes & Behaviours: interaction with the peer group seemed to ■■ What happened to make it ■■ Communication with [insert child’s name] and her family seemed to ■■ What happened to make it ■■ The
Go well……………Have difficulties Go well……………Have difficulties Go well……………Have difficulties Go well……………Have difficulties
Effective Evaluating: ■■ What did you learn today from managing this simulation? ■■ What do you need to review? ■■ What do you want to know more about?
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simulation templates were provided (Table 1). Resources such as mock paperwork, ECG and blood results were made available as requested and skills stations were set up for students to practice in order to develop their levels of confidence. Sessions were scheduled to allow the students to research and rehearse their own scenario. The students had to provide a written template with the progress of their simulation mapped out and needed to understand what the consequence of actions would be dependent on what the participant would do. This allowed them to develop their knowledge base. The project did not require any extra commitment on the part of the students as all practice sessions were scheduled within the allocated module. Although the actual peerled facilitation was timetabled, there were no penalties for those students who did not wish to participate. However, all students took an active part in the simulation event. It could be argued that the primary motivating factor was based on the OSCE assessment, and yet all information and guidance in order to achieve a successful outcome were delivered throughout the module. Therefore, involvement in the peerled simulation event was not a prerequisite. Each group of four students developed their own simulation within the specified criteria and although these were their own preferences, they decided as a whole that they wished to look at differing age groups and conditions in order to expand their knowledge. For this reason, they discussed and organised their simulation so that three divergent simulations would ultimately be performed. All simulations had a deterioration built in that required the participants to perform resuscitation adhering to the European Resuscitation Guidelines (Resuscitation Council UK, 2010).
Debriefing As part of the learning process, each student group was offered feedback following completion of their simulation by the group who wrote and facilitated it. This allowed for opportunities to explore and evaluate their performance as
British Journal of Nursing, 2014, Vol 23, No 6
well as assist them in their reflective learning. Salvodelli et al (2006) found that providing feedback significantly improved the skills of the participants when compared with those who did not receive feedback. In order for the feedback to be meaningful for students, they needed to be active in discussions of their performance and the events of the simulation exercise. Therefore, ground rules were drawn up along with a structured format for the actual feedback (Table 2). Target behaviours expected from the scenario were identified to offer structure for the student facilitators. This would then enable them to distinguish and evaluate areas of performance without the risk of personal criticisms of their peers. Examples of these were recognition of the potential for the heart rate to fall with the increased hypoxia in the neonate scenario and so setting up the cardiac monitor, and examining the pupillary reaction in the child scenario when he complained of a headache. This shaping of the format for the feedback enabled learning points to be highlighted but reduced the risk of intimidating all involved. Each simulation had a group of student facilitators and a group of students undertaking the simulation. While involved in the simulation, students may have only had a limited picture of what happened; they may only have observed those parts their position allowed them to (Peters and Vissers, 2004). Therefore, the third group (students who were not involved in the actual event) was able to take an objective view of the whole incident. The advantage of this was that all students had opportunity to be a facilitator, an active participant in the simulation and an observer throughout the session. At the conclusion of the session, all students were debriefed by the facilitator. The debrief is an essential part of any simulation session. It is crucial for a successful learning process and, to be successful, the facilitator must provide a supportive environment in which the debriefing can take place (Rall et al, 2000). In fact, Fanning and Gaba (2007) suggest that it is the ethical duty of the facilitator to provide a safe and confidential scene for debriefing. Both Shinnick et al (2011) and Jeffries and Rizzolo (2006) feel it is more important than the simulation itself. It allows the student to evaluate
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Results Quantitative analysis Over 2 years, all child branch students took part in developing a simulation as well as participating in a peer-facilitated simulation. This was an overall total of 24 students. They were also responsible for providing feedback to their peers. Evaluation of the knowledge gained was assessed via the OSCE at the end of the module as this is widely considered to be a reliable form of assessment (Gormley, 2011). The criteria for the OSCE examination was constructed using local policy in conjunction with NHS protocols, guidelines from the National Patient Safety Agency, European Resuscitation Guidelines (Resuscitation Council UK, 2010) and The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty and Lister, 2011). The students’ performance was assessed by two examiners with video recording enabled for internal and external moderation purposes and the examiners received training in the use of the mark sheet. Compulsory items such as correct placement of hands for chest compressions were used to ensure that any safety issues would lead to a fail regardless of the overall percentage grade. A minimum of 16 items out of 20 (80%) was required to pass. The students who gained a pass in both cohorts totalled 100% with students identifying that they felt confident with their performance and their understanding of the assessment and management of a critically ill child. An eight-item, five-point (strongly disagree, disagree, neutral, agree, strongly agree) pre- and post-simulation intervention Likert scale questionnaire/module evaluation was specifically designed, taking approximately 10 minutes to complete and was based on the clinical acquisition skills survey (CASS) developed by Meechan et al (2011). The questionnaire was scrutinised by five nurse academics and practice facilitation staff for face validity before being used
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for this study. Pre-simulation activity confidence and competence levels were taken at the mid-point evaluation. Post simulation activity confidence and competence levels were taken at the end of the module. The tool aimed to elicit quantitative data regarding students’ perceptions in three key areas: ■■ Their perceived ‘confidence levels’ of caring for a critically ill child before and after their educational experience of peer-led simulations (three items) ■■ Their perceived ‘competence levels’ of caring for a critically ill child before and after their preparation via the peer-led simulation (three items) ■■ Their perception of the usefulness of skills and knowledge acquired and ability to ‘transfer into the clinical environment’ (two items). The responses were scored in such a way that positively endorsed statements and non-endorsement of negative statements were assigned a higher score. Therefore, each student had a maximum of 40 points; for those with a high level of perceived confidence and competence and a minimum of 8 for a negative perceived confidence and competence level. A paired sample t-test was used to compare scores pre and post the simulation intervention and this demonstrated a statistically significant increase (p=0.001) in perceived confidence and competence levels following the peer-led simulation with a mean increase of 55.62. Review of the process of learning was garnered from the end of module evaluations with a 4.8 out of 5.0 satisfaction rating. Students were also invited to add comments that could be used for a simplistic thematic analysis.
Qualitative analysis Thematic analysis of the comments identified satisfaction and a sense of achievement about taking part in the simulated activities. Emerging themes also pointed towards students’ feelings about their own improved confidence to deal with similar clinical situations within their placements. As they had to question their own assumptions on the progression of resulting clinical sequelae in order to ensure they were able to effectively manage the group they were facilitating, they felt their learning had taken a more rounded approach. ‘It was a very useful teaching session; I would appreciate the opportunity to take part in more of these sessions. It was also encouraging to have the opportunity to discuss the scenario with tutors that I am familiar with afterward’ ‘As the facilitators my group had to know what to do depending on how they reacted to some change in condition…meant I had to learn loads more that I would have done had I just taken part in a simulation’ Students appreciated the opportunity to work within small groups to help develop cooperation in development of their knowledge: ‘...working in small groups, communication was good between students’
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their own performance as well as that of their peers and can increase their understanding of the clinical experience. Simulation followed by debriefing can provide students the opportunity to discuss what they have learned and to ensure that activities are not left unfinished. It also enables them to identify what they have accomplished. As a result, students of diverse learning styles can be accommodated and students with varying backgrounds are able to benefit from the experience (Cioffi, 2001; Jeffries, 2005) It also allows students to be led through a purposive discussion of the experience so they can reflect on it (Lederman, 1992; Fanning and Gaba, 2007; Lasater, 2007). However, a poor debrief can harm the student (Rall et al, 2000). Fanning and Gaba (2007) suggest that, although few students respond well to humiliating styles of debriefing, they may find that debriefings that avoid criticisms or analysis result in a failure to learn anything. The facilitator designed the debrief to include an objective observation about and subjective judgment of the students’ actions to allow the students to acquire knowledge in a structured manner while exploring the personal nature of the experience. This approach has been advocated by Rudolph et al (2006) as they believe it helps instructors manage the apparent tension between sharing critical, evaluative judgments while maintaining a trusting relationship with trainees.
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education
‘I felt well supported throughout the session. This was an enjoyable session once I got over my initial nerves.’ This point is further emphasised by Kahn and O’Rourke (2005) as nurturing collaborative peer support, which in turn fosters a deep approach to learning. However, some students identified that they were unsure of their roles and that this led to anxiety, especially as they felt they would be judged by their peers. This can have a paradoxical effect as increasing anxiety levels can reduce the receptivity of the learning (Mandler and Sarason, 1952) ‘It was scary knowing that we would be watched by others and they would be making judgements on how we ran the scenario…’ ‘…it was intimidating being asked how to respond to the situation by people who were the same as me. I felt I should have known what to do and they would think me stupid’ There was also recognition that embracing this educational approach required a sea change in the learning process. ‘We felt that as students we should have been more organised, although nerves were also an issue here, as this was a new way of learning to us’ Relinquishing the control of the process to the students is an important aspect in the facilitation of learning and this can have implications for how the role of the facilitator is seen. ‘Initially it felt as though we were doing the lecturer’s job for her…’ This comment, although not common, has connotations that can impact on the effectiveness of the facilitator. The student-centred principles of freedom and independence in learning can be a difficult concept to grasp and can lead to non-valuing behaviour by some lecturers (Moore, 2009). When students express this thought, the credibility of the lack of control concept from facilitators can lead to anxiety about their own purpose (Lekalakala-Mokgele, 2010).Yet, the student further qualified this with: ‘…but now I have done it I have learned so much, not just about the care of the child in our scenario but about myself ’
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Discussion The author recognises that the sample is relatively small and that the data were collected from one field of practice within one higher education institution; therefore, the findings must be interpreted with some element of caution. Subsequent studies would be required to investigate if students’ levels of confidence and competence are unique to this particular higher education institution or whether this educational approach is appropriate to others. It has also been undertaken with a small cohort that enabled the researcher to mitigate
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against any anomalies owing to differing approaches and support that the students might receive. The study did not review the retention of knowledge gained however, anecdotal evidence from yearly mandatory updates of life support indicated that those students performed better and more confidently when assessed. According to the pyramid model conceptualised by Miller (1990), there are four domains of competence (Figure 1). These levels are: ■■ Knows (knowledge)—recall of basic facts, principles, and theories ■■ Knows how (applied knowledge)—ability to solve problems, make decisions, and describe procedures ■■ Shows how (performance)—demonstration of skills in a controlled setting ■■ Does (action)—behaviour in real practice. It could be argued that the students, on the basis of their facilitation role, are actually at the ‘shows how’ level following the exercise. Further studies on their performance are planned for the future and it is hoped that the impact of this educational approach will move them towards the ‘does’ level at a rate that shows improvement from what would routinely be expected. In order to ascertain the relative merits of this approach, it would be necessary to follow up the students and compare their relative knowledge base and retention of skills with a control group. However, the comparative anomalies that this would incur render this difficult. As all the child branch students took part, it would be problematic to compare with others and the differing exposures and educational approaches of the other branches would not allow for crossbranch comparisons.
Conclusion Although this was a relatively small study, the results demonstrate that this is a valuable approach to support the learning of student nurses. The move from facilitator-led to student-led simulations encourages proactive learning and
Does
Professional authenticity
‘The scenario was a good learning tool’
Shows how
Knows how
Knows
Miller’s1.pyramid clinicalofcompetence Figure Miller’s ofpyramid clinical competence
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Key points n Shifting
the responsibility of knowledge acquisition from teacher to student can help students develop an in-depth understanding of concepts fundamental to their development as a nurse
n The
use of peer-led simulations is a valuable approach to student learning
n With
support student nurses are able to effectively facilitate simulations
n Debriefing
enables students to reflect on their own performance as well as that of their peers and can increase understanding of the clinical experience
n Students
identified satisfaction and a sense of achievement from taking part in the peer-led simulations
the provision of a safe and nurturing environment enabled optimal learning opportunities. While it is recognised that simulations can be resource intensive the wealth of literature about its relative merits as BJN an educational approach cannot be ignored. Conflict of interest: none
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Alaszewski A, Burgess A (2007) Risk, time and reason. Health, Risk & Society, 9(4): 349-58 Alinier G, Hunt B, Gordon R, Harwood C (2006) Effectiveness of intermediate -fidelity simulation training technology in undergraduate nursing education. J Adv Nurs 54(3): 359-69 Alverson DC, Saiki SMJ, Jacobs J, Saland L, Keep MF, Norenberg J (2004) Distributed interactive virtual environments for collaborative experiential learning and training independent of distance over Internet2. Stud Health Technol Inform 98: 7–12 Bambini D, Washburn J, Perkins R (2009) Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nurs Educ Perspect 30(2): 79-82 Bandura A (2004) Health promotion by social cognitive means. Health Educ Behav 31(2): 143–64 Biggs J 1(993) What do inventories of students’ learning processes really measure? A theoretical review and clarification. Br J Educ Psychol 63(1): 3-19 Bush H (2009) Practice makes perfect. Michigan medical school uses simulation center training to produce more competent, confident students. Hosp Health Netw 83(3): 28-30 Cantrell MA (2008) The importance of debriefing in clinical simulations. Clinical Simulation in Nursing 4(2): e19-e23 Cioffi J (2001) Clinical simulations: Development & Validation. Nurse Educ Today 21(6): 477-86 Dougherty L, Lister S (2011).The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Blackwell Publishing, Oxford Fanning RM, Gaba DM (2007) The role of debriefing in simulation–based learning. Simul Healthc 2(2): 115-25 Gordon J, Oriol N, Cooper J (2004) Bringing good teaching cases ‘to life’: a simulator-based medical education service. Acad Med 79(1): 23–7 Gormley G (2011) Summative OSCEs in undergraduate medical education. Ulster Med J 80(3): 127–32 Haskvitz IM, Koop EC (2004) Students struggling in clinical? A new role for the patient simulator. J Nurs Educ 43(4): 181-4 Henneman EA, Cunningham H, Roche JP, Curnin M (2007) Human patient simulation: Teaching students to provide safe care. Nurse Educ 32(5): 212−7 Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese, RJ (2005) Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 27(1): 10-28
Jeffries PR, Rizzolo MA (2006) Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi-method study. National League for Nursing, New York Jefferies PR (2005) A framework for designing, implementing, and evaluating simulations used as a teaching strategies in nursing. Nurs Educ Perspect 26(2): 96-103 Khan P, O’Rourke K (2005) ‘Understanding enquiry-based learning’. In: Barrett T, MacLabhrainn I, Fallon H, eds. Handbook of enquiry and problem based learning. CELT, Galway. http://tinyurl.com/mttzqjd (accessed 17 March 2014) Kneebone RL, Scott W, Darzi A, Horrocks M (2004) Simulation and clinical practice: strengthening the relationship. Med Educ 38(10): 1095–1103 Knowles MS (1975) Self-Directed Learning. A guide for learners and teachers. Englewood Cliffs, Prentice Hall/Cambridge Knowles MS, Holton III EF, Swanson R (2005) The adult learner: the definitive classic in adult education and human resource development. Elsevier Lasater K (2007) Clinical judgment development: Using simulation to create an assessment rubric. J Nurs Educ 46(11): 496-503 Lave J, Wenger E (1991) Situated Learning: Legitimate Peripheral Participation. Cambridge University Press, Lederman Lederman LC (1992) Debriefing:Toward a systematic assessment of theory and practice. Simulation & Gaming 23(2): 145–60 Lekalakala-Mokgele E (2010) Facilitation in problem-based learning: Experiencing the locus of control. Nurse Educ Today 30(7): 638–42. doi: 10.1016/j.nedt.2009.12.017 Loyens S, Magda J, Rikers R (2008) Self-Directed Learning in Problem-Based Learning and its Relationships with Self-Regulated Learning. Educ Psychol Rev 20(4): 411. DOI 10.1007/s10648-008-9082-7 Mandler G, Sarason SB (1952) A study of anxiety and learning. J Abnorm Psychol. 47(2): 166-73 McCaughey C, Traynor MK (2010) The role of simulation in nurse education. Nurse Educ Today 30(8): 827-32 Miller GE (1990) The assessment of clinical skills, competence and performance. Acad Med 65(9 Suppl): 563-7 Meechan R, Jones H, Valler-Jones T (2011) Students’ perspectives on skills acquisition and confidence. Br J Nurs 20(7): 445-50 Moore J (2009) An exploration of lecturer as facilitator within the context of problem-based learning. Nurse Educ Today 29(2): 150–6. doi: 10.1016/j. nedt.2008.08.004 Papp I, Markkanen M, von Bonsdorff M (2003) Clinical environment as a learning environment: student nurses’ perceptions concerning clinical learning experiences. Nurse Educ Today 23(4): 262-8 Peters VAM, Vissers GAN (2004) A simple classification model for debriefing simulation games. Simulation Gaming 35(1): 70-84. doi: 10.1177/1046878103253719 Rall M, Manser T, Howard SK (2000) Key elements of debriefing for simulator training. Eur J Anaesthesiol 17(8): 516–7 Reilly A, Spratt C (2007) The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: A case report from the University of Tasmania. Nurse Educ Today 27(6): 542-50 Resuscitation Council UK (2010) Resuscitation Guidelines 2010. http:// tinyurl.com/3ram3db (accessed 18 March 2012) Rudolph JW, Simon R, Dufresne RL, Raemer DB (2006) There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc 1(1): 49-55 Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ (2006) Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology 105(2): 279-85 Schroedl, CJ, Corbridge, TC, Cohen ER et al (2012) Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: A randomized trial. J Crit Care 27(2): 219.e7–219.e13. doi: 10.1016/j.jcrc.2011.08.006 Shinnick M, Woo M, Horwich T, Steadman R (2011) Debriefing: The Most Important Component in Simulation? Clinical Simulation in Nursing 7(3): e105-e111. http://tinyurl.com/mah4say (accessed 17 March 2014) Vygotsky LS (1978) Mind in society. Harvard University Press, Cambridge Zendejas B, Brydges R, Wang AT, Cook DA (2013) Patient Outcomes in Simulation-Based Medical Education: A Systematic Review. J Gen Intern Med. 28(8): 1078-89 doi: 10.1007/s11606-012-2264-5
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