This article describes the use of a real apartment for home visit simulations. Use of the apartment creates realism not otherwise available in the traditional simulation center setting while maintaining a structured and safe environment for students. The result is a unique, active learning experience.
It is well documented that simulation, by integrating clinical concepts, promoting problem-solving skills, and preparing students to manage complex clinical situations they will likely experience in clinical practice, is an effective teaching strategy for nursing education (Walshe, O'Brien, Murphy, & Hartigan, 2013). Distelhorst and Wyss (2013) found that a good way to prepare students to function in a variety of health care settings is to use simulation scenarios that focus on community health nursing concepts.
Health care reform has started to shift the focus of nursing education from the acute care setting to the community setting. Now more than ever, there are opportunities for entry-level nurses to work in a variety of community settings, but the unpredictable nature of community health nursing requires a high level of critical thinking that is difficult to teach in traditional clinical and classroom settings (Distelhorst & Wyss, 2013). One area with which nursing students are most unfamiliar and uncomfortable is the home visit. Community health nursing students who experienced a simulated home visit reported an increased comfort level and greater self-confidence during an actual home visit (Richards, Simpson, Aaltonen, Krebs, & Davis, 2010).
BACKGROUND
In fall 2013, a local hospital offered our small Midwestern college of nursing the use of a vacant first-floor one-bedroom apartment for community simulation experiences. The college could use the apartment rent free, with the hospital responsible for maintenance of the apartment and the college responsible for supplies needed to run the simulations, keeping the apartment clean, and setting up Internet Wi-Fi for faculty and student use.
The apartment is located one block from the college in an older, low-income neighborhood adjacent to a Dairy Queen, two small medical clinics, several bars, and a gas station. It has a working gas stove and a refrigerator. Furniture was obtained from the hospital's used furniture warehouse and donations from faculty. Two apartment units in the building were occupied by other tenants.
The college already had a model of a one-bedroom efficiency apartment in the simulation center for senior-level community simulation experiences, and junior-level students followed a home health nurse for a clinical day as part of their clinical rotation. Because of the timing of the apartment acquisition, simulations could not be conducted at the apartment until the spring semester of 2014.
THE SIMULATED HOME CARE VISIT
The initial learning experience focused on 35 junior-level students enrolled in a medical-surgical course. The students comprised five clinical groups, with an average of 8 to 10 students per group. Three faculty participated in running the simulated home care visit.
The simulation utilized whole-person nursing curricular concepts through student interactions with the client, family, friends, and the community. Learning outcomes were as follows: a) identify safety issues for the client as well as the home health nurse in a realistic home setting, b) identify the basic roles of the home health nurse in a realistic home setting, and c) identify community agencies the home health nurse may utilize to meet client needs.
Simulation Script
The home care simulation script was created by a community health clinical faculty member with extensive home visit experience and two medical-surgical faculty members. The script provided real-life hands-on experience for the students. It guided faculty involved in running the simulation to ensure that each session had similar learning experiences. Prior to the clinical, the students were given the scenario of a client with a history of congestive heart failure, chronic obstructive pulmonary disease, and type 2 diabetes.
Student Orientation
Each clinical group received an orientation prior to the simulated home visit. The clinical group was divided into smaller groups of three to four students for the simulation. Students were provided a home health supply bag with items needed for the simulation. The students not directly assigned to the simulation were instructed to assess the inside and outside of the house for safety concerns and the surrounding neighborhood to identify community resources. All students were told to dress appropriately for the weather.
Home Visit Simulation
The simulated home health visit utilized three clinical faculty members. One portrayed the client; another observed and helped direct the simulation; the third portrayed a concerned friend, provided cues for the completion of the simulation, and observed students' performances. The apartment was set up with trash strewn about, scattered alcohol containers, cigarettes and an ash tray in the bedroom, simulated rodents and spiders placed around the home, a live cat, and a litter box.
Each group of students was expected to function together as home health nurses during the visit. The students began the simulation by knocking on the apartment door and waiting to be invited in. Upon entering, they were taken to the client's bedroom by the friend. Once in the client's bedroom, they were to complete an assessment and provide the required care. After 30 minutes, the simulation was concluded, and the groups switched places. The faculty members evaluated the students' behaviors in the areas of assessment, communication, critical thinking, and technical skills.
Debriefing
Debriefing took place after each small-group session and with the entire clinical group at the end of the simulation. During the debriefing process, three themes emerged as a result of this learning experience. First, students indicated they felt uncomfortable being in the client's bedroom. Second, they reported a higher degree of comfort and control in a structured hospital setting compared to an unstructured home setting. Third, students stated that distractions embedded in the simulation made it difficult for them to complete the assessment. The distractions they identified were as follows: unclean home environment (trash on floor, alcohol bottles scattered around, and cigarettes), a cat roaming freely, interacting with the uncooperative client, and having to gain control of a distracting friend.
Four themes emerged from the written reflections students completed following the learning experience. A universal theme was students having an "eye-opening experience" about the role of the home care nurse. Second, students identified the need to utilize whole-person nursing concepts to meet the needs of the client. Third, students felt they had to put on their "nurse's face" in order to be nonjudgmental and respectful toward the client and friend during the visit. Lastly, students had difficulty communicating with the client and friend out of fear of saying something wrong and offending them.
AREAS OF CHANGE
Faculty identified multiple changes to improve the overall learning experience for the students: limit small groups to two to three, provide more structured oversight for students during the neighborhood assessment, allow students time to prioritize the main issues and identify what was most important to the patient at that moment, have students prep on community resources, and ensure that a faculty member with community health nursing experience facilitates the debriefings. The effectiveness of these changes will be evaluated by faculty after the scenario is run through debriefing involving students and faculty.
New scenarios incorporating a variety of home visit experiences will be added for a senior-level community health nursing course. Junior-level medical-surgical faculty have discussed adding a simulation scenario as well. Research is needed to evaluate the effectiveness of all these learning experiences.
We have a number recommendations for those considering the use of a real apartment for simulations: a) stage the apartment to accurately reflect real-life experiences and ensure that the apartment setup can be changed for a variety of simulation scenarios, b) collaborate with alumni and diverse community members to portray different simulated roles and invite the collaboration of interprofessional team members and community agency staff, c) ensure that Wi-Fi is available in the apartment, and d) try to incorporate what is actually happening at the moment in the neighborhood for another layer of realism.
CONCLUSION
The students indicated that the simulated home care visit in the apartment was a positive, eye-opening, and realistic experience that required them to look at the whole person, think critically, and communicate effectively. The experience taught students to expect the unexpected in the home setting and helped them become more aware of resources in the community, the role of the home care nurse, and overall safety issues.
REFERENCES