The efficacy of simulated experiences as equivalents for nursing student clinical time is well documented (Aebersold, 2018; Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014; Jeffries, Rodgers, & Adamson, 2015). A variety of methods may be used for simulation learning and evaluation. These experiences address the growing need for finding quality clinical sites (Gunowa, Elliott, & McBride, 2018; Husson, Zulkosky, Getter, & Kamerer, 2014; Reynolds, Cooper-Stanton, & Potter 2018).
Simulation is particularly useful for community health nursing courses when home health visits are included in course clinical experiences. Home health clinical education presents unique challenges. Student experiences are inconsistent (Wheeler & McNelis, 2014), and learning may be passive, not active, depending on the degree to which the home health nurse engages students in clinical decision-making. As students travel with a home health nurse, faculty are unable to observe them directly.
BACKGROUND
Hayden et al. (2014) determined that simulation is a viable substitute for traditional clinical experience; in their seminal study, no statistically significant differences were found in end-of-program competencies or first-time NCLEX(R)-RN pass rates among groups spending zero, 25 percent, or 50 percent of their clinical time in simulation. Their study involved some schools that did not offer community nursing courses.
Outcomes for simulation for a home health clinical experience have been reported. Husson et al. (2014) found that students had more experiences during one day of simulation than in a day of traditional home visits. Wheeler and McNelis (2014) reported that a home health simulation improved student confidence and enhanced communication skills. Home health simulation was shown to increase student awareness and interest in the specialty of community nursing (Gunowa et al., 2018) and to improve confidence for nurses transitioning from acute care to home care (Center, Faragher, Bitner, & Cheuvront, 2014).
In creating robust simulations with prebriefing and debriefing, it is usually necessary to assign more than one student to the simulation. However, there is little research regarding the impact of participation in simulation roles other than that of nurse. The purpose of this study was to explore student perceptions related to a home visit simulation scenario, specifically to determine whether the simulation scenario impacted students' ability to meet the learning objectives and whether playing the role of nurse or nursing student influenced learning outcomes. Two home health simulation scenarios (diabetes and heart failure) were developed with student learning objectives linked to the clinical decision-making necessary for the visit. The scenarios had been piloted in previous semesters with revisions made based on student and faculty feedback. Evidence collected in previous semesters suggested that students playing the role of the nursing student achieved the learning objectives. Two research questions were asked: 1) What are student perceptions of their ability to meet simulation learning objectives during a simulated home visit scenario? 2) What are student perceptions of the role of "nurse" and the role of "nursing student" in enabling students to meet the learning objectives in a simulated home visit scenario?
METHOD
This study was conducted in a senior-level baccalaureate community health course at a liberal arts college in Pennsylvania. Institutional review board approval was obtained. A convenience sample of 44 students who took the course in the spring 2018 semester was used.
Students participated in two home visit scenarios (diabetes self-management and heart failure). Each student was the nurse for one scenario and led the visit, and the nursing student for the other scenario, acting primarily as observer. They reverse roles in the second scenario. The patients were retired nurse volunteers; the simulation coordinator provided an orientation with background information and a guide for the narrative with responses to likely questions. Student learning objectives common to both scenarios included initiating the home visit, maintaining a positive visit environment, and identifying visit priorities. In the diabetes scenario, the patient presented with a knowledge deficit in self-care management and an unwillingness to perform the insulin injection, requiring the nurse to prioritize the insulin injection and utilize motivational interviewing techniques. The heart failure scenario included a focused assessment and medication reconciliation with a discrepancy between the medications in the weekly "pill box" and the medication orders. The nurse was required to complete the medication reconciliation by identifying and appropriately acting on the discrepancy (notifying the provider).
Faculty conducted a simulation prebriefing, observed the simulation through a one-way mirror, and conducted the debriefing. In a class session preceding the simulation, the principal investigator, a course faculty member, explained the study. Students were given a letter of explanation and told that completion of the simulation evaluation would constitute consent to participate; evaluation forms and an envelope were distributed following the debriefing. Sealed envelopes were given to the simulation director and maintained in a locked file until course grades were submitted. The evaluation consisted of a 5-point Likert scale to rate the extent to which the simulation supported students' ability to meet all learning objectives (1 = disagree, 5 = agree). Descriptive statistics and significance testing were run on each score based on whether the respondent was acting as a nurse or nursing student for the simulation.
RESULTS
A total of 44 traditional prelicensure students completed each simulation scenario and evaluation. An independent-sample t test was conducted to compare objective score ratings for students in both roles. No significant differences in mean scores were found between groups (p > .05). In the diabetes scenario, the nurse mean score was 4.62 (SD = 0.34); the nursing student means score was 4.50 (SD = 0.54); t(41) = 0.829, p = .412. In the heart failure scenario, the nurse mean score was 4.62 (SD = 0.50); the nursing student mean score was 4.69 (SD = 0.36); t(42) = -0.596, p = .555.
Overall, these results suggest that the study participants, regardless of home visit scenario, believed they were able to meet the learning objectives. There were no significant differences between roles, indicating both roles were equally effective in helping students meet the learning objectives for home visit scenarios.
A space for comments was included in the evaluation form. Students expressed an appreciation for being able to communicate with a live "patient" and reflected on the clinical decision-making that was required for the visit. One student wrote: "I realized the difference between watching my home health nurse do the visit and having to think about what to do on my own." In both the debriefing and evaluation comments, students in the role of nursing student gave feedback that spoke to the value of the role in meeting the objectives. In a nursing course where direct faculty observation of student performance is difficult, home visit simulation provides faculty with the opportunity to observe and facilitate student learning in meeting objectives for a home visit scenario.
This study had some limitations. Volunteers who played the role of the patient were retired RNs, not trained standardized patients. Although they were enthusiastic about supporting student learning, there was a lack of consistency in the simulations, which may have influenced the experience for students. Furthermore, the study was conducted using a small convenience sample with student perceptions of meeting learning objectives the only outcome measure. There was no control group for comparison because all students were required to complete the simulation as part of their coursework. The sample consisted of all students in the class, and the study was conducted by a course faculty member. Although students were told that the surveys would be anonymous and secured until after grades were submitted, it is possible that students may have felt compelled to give favorable ratings while completing the evaluation.
CONCLUSION
Home health visit scenarios that require clinical decision-making can support student learning in a community health nursing clinical course. As the demand for home care increases, more home health nurses will be needed (Storfjell, 2018). Home visit simulations create an opportunity for students to meet learning objectives. Further research is needed to understand how strategies for home visit simulations impact student learning outcomes.
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