Simulation, defined as a method of allowing an individual the experience of a real-world situation in a practice learning environment (Lopreiato et al., 2016), has become a standard teaching strategy in the clinical laboratory setting of schools of nursing. Although there are many examples of simulation in the clinical laboratory setting, both nationally and internationally, simulation usage decreases in the classroom setting (Walters, Potetz, & Fedesco, 2017). Combining simulation and role modeling as a teaching strategy presents a unique opportunity to develop student knowledge, skills, and attitudes (Wayne & Lotz, 2013). With the addition of reflective discussion and debriefing, the strategy enhances student learning.
The goal of this teaching strategy is to introduce newer nursing students to simulation in preparation for future simulations of increasing complexity. The school of nursing, a moderate-sized baccalaureate program in the Southeast, had used traditional simulation for eight years. Typically, small groups of students would be given preparatory work, such as case studies or questions related to the simulation scenario, to complete before coming to the simulation center. Students then received report from faculty while providing care to either a standardized patient or high-fidelity manikin while faculty observed from a control room. After students completed the simulation, faculty-led debriefing provided for reflection and feedback.
As an alternative to the live simulation experience, faculty used recorded simulations to role model effective verbal and behavioral communication skills and teamwork in the clinical setting. The recorded simulations, created for third-semester nursing students in an adult health course, presented an emergency room admission. Four faculty members prerecorded two scenarios, one with ineffective communication and admission assessment skills and the other with effective skills. The faculty members took on different roles: admission nurse, scribe nurse, intervention nurse, and nurse giving handoff report. The nurse who gave the handoff report also provided the voice for a physician and the patient.
The role modeling focused on teamwork and both effective and ineffective verbal and behavioral communication skills. First, students viewed the ineffective scenario in the classroom, and faculty led them in a reflective discussion regarding errors and corrective behaviors. Next, they watched the effective scenario, which was also followed by reflective discussion. It is important to note that behaviors, referred to as inappropriate, were not physically harmful but were characteristic of communication behaviors that are sometimes exhibited by nurses, such as having a conversation with a coworker in the presence of the patient.
Faculty used the debriefing to explain concepts that were missed or poorly understood and provide rationales. Students decided if behaviors were appropriate, attempted to correct inappropriate behaviors, and reflected on what was learned from the scenario. The process of reflection allowed students to reinforce old knowledge and construct new knowledge based on what was presented.
Participating students had only 8 to 10 eight-hour clinical days before viewing the simulation scenario. These students received no simulation the first semester and participated in only two to three skill-type simulations in the second semester.
ROLE MODELING, OBSERVATION, AND REFLECTION
Role modeling occurs when someone demonstrates a skill, behavior, or attitude that is then imitated by an observer. Because it can be used effectively to demonstrate skills and explain rationales and behaviors, role modeling is an effective teaching and learning strategy (Aronson, Glynn, & Squires, 2013). Significant to role modeling is observational learning, a component of Bandura's social learning theory. Bandura (1977) theorized that individuals can learn by observing the behaviors of others and the reactions that the behaviors elicit. Both role modeling and inductive learning begin with observation. The inductive approach allows the learner to observe a behavior or task, use what he or she already knows, and build upon that knowledge (Gavriel, 2015; Smart, Witt, & Scott, 2012).
Reflection is often a component of debriefing, which took place in this project during reflective conversation. The International Nursing Association for Clinical Simulation and Learning (INACSL) Standard: Debriefing states that "essential learning occurs in the debriefing phase" (INASCL, 2016, p. S21). The INACSL Standards Committee (2016) guided the debriefing process with an emphasis on establishing trust, open communication, and being open to feedback. Faculty used Socratic questioning, with probing questions such as, "What was wrong with this nurse-patient interaction and why?" to stimulate reflective learning. Students were able to reflect on the nurse-patient interactions they observed. Kolb's theory of experiential learning suggests that reflection is a strategy that can help learners grasp concepts (Kolb, 1984; Kolb & Kolb, 2017; Maree & Van Rensburg, 2013).
DISCUSSION
As a result of the role modeling teaching strategy, students demonstrated critical thinking, making inferences and comparisons about the two scenarios. They were able to make observations and form a general overview of how an admission assessment should be completed. They also discussed which appropriate nurse-patient therapeutic communication techniques should have been used during the admission process and the role body language plays in nurse-patient communication. Faculty found they were able to facilitate clinical reasoning skills through coaching and questioning in a safe space if students needed guidance. In addition, students appeared more comfortable making critical judgments about faculty than when they had to critique the performance of their peers, allowing them to see more clearly the clinical reasoning for the correct behavior. Discussing what made a particular behavior a bad choice and then discussing the rationale for the proper behavior reaffirmed clinical reasoning.
Although no evaluation tool was used for this classroom teaching strategy, faculty found that students displayed more interaction during the reflective discussions in the classroom after the role-play simulations than they had previously displayed during traditional debriefing in the simulation laboratory. Faculty also noted an increase in critical thinking in later, more complex simulations with these same students (such as a simulation of a critical patient who was in diabetic ketoacidosis) than with students who previously participated in simulation. Future research is planned to evaluate the effectiveness of this teaching strategy more objectively through the use of a formal evaluation tool.
This teaching strategy can be used to address a variety of topics with nursing students and can be especially useful in nursing programs with limited simulation resources. This school of nursing's simulation center has continuous video recording, so the recordings used in the classroom were easy to obtain from the simulation laboratory. For programs that do not have this resource, a smartphone or tablet could also be utilized for recording.
High-fidelity simulation is utilized in nursing curricula around the world. Nurse educators should continue to examine ways to incorporate innovative teaching and learning strategies to further promote student engagement. One of these strategies can be classroom simulations.
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