and Elaine Della Vecchia, PhD, RN
Sparacino, L. & Della Vecchia, E. (February 2013) Using high-fidelity simulation to close the teaching and learning gap. Online Journal of Nursing Informatics (OJNI), vol. 17 (1), Available at http://ojni.org/issues/?p=2392
To provide a positive educational experience that incorporated technology into the curriculum, a four-phase medication administration lesson plan was developed and implemented. The plan was aimed at improving teaching and learning related to the complex medication process and medication safety. Multiple teaching and learning strategies were employed, of which high-fidelity simulation was incorporated into the experience with the intent of enhancing the learning environment. This article presents the teaching and learning experiences used to educate student nurses about the complex process of safe medication administration and demonstrates the potential of simulation to improve learning. Findings support the use of simulation as a teaching tool that affords students an opportunity to gain new knowledge and apply previously acquired knowledge, as well as establish the value of technology as a necessary tool to provide an educational experience that completes the teaching/learning process.
Keywords: simulation, technology, medication administration, teaching and learning, education
As the concern for medication safety increases, nurse educators are compelled to implement teaching and learning strategies that allow students to gain knowledge, as well as analyze and synthesize information related to safe medication administration. Nurse educators recognize the need to consider multiple learning preferences to promote a positive learning environment (Adeniran & Smith-Glasgow, 2010). It is therefore necessary to implement a variety of teaching strategies to promote active learning among all students (Louie, 2009).
To effectively teach students safe medication administration, a four-phased medication teaching plan was developed. The plan provided an opportunity for the students to achieve confidence in medication administration and medication safety. Phase 1 concentrated on didactic learning sessions aimed at increasing the cognitive and psychomotor elements of the medication administration process. A variety of teaching learning strategies, such as PowerPoint® presentations, videos on the process of safe medication administration and return demonstration were employed.
The second phase focused on the students attending multiple days of clinical rotation on the medical or surgical units of several major health care institutions. Students engaged in the actual process of medication administration using a one-on-one instructor-to-student ratio. As part of this activity, students were required to develop reflections of the experience based on evidence-based practices and knowledge obtained during Phase 1. Phase 3 included a high-fidelity simulation day involving participation in two complex simulation experiences, debriefing sessions, and self-learning modules which concentrated on pharmacology and medication calculation.
During Phase 4, the students returned to clinical rotation, where they actively participated in the medication administration process using the principles of safe medication administration learned in the first three phases of the plan. This methodology included independent assessment and administration of medication to multiple patients, during which the instructor’s role was kept supervisory. Phase 4 also included a medication administration competency evaluation in the nursing skills lab. As was the case in Phase 3, this competency involved the use of high-fidelity simulation. Skills competency evaluation is routinely performed at the end of each semester and uses a rubric grading system to establish competency of a predetermined skill set. However, prior to the implementation of the four-phase teaching plan, 50% of the students required additional instruction before being able to pass the end-of-semester skills competency test. This new plan sought to increase the percentage of students who passed the competency exam on the first attempt.
The emphasis was to provide an experience of knowledge attainment using a variety of practical experiences. Tactile, kinesthetic, and visual learning environments provided as part of the program were intended to enhance the knowledge attainment and skills needed to safely administer medications. The simulation experience in Phase 3 afforded an opportunity for all students to discover if knowledge attainment had occurred by providing a technology-rich environment that demanded students to transfer theory to practice to achieve positive outcomes during the simulation experience. An evaluation of the simulation experience during Phase 3 offered the program designers insight into students’ level of satisfaction with the teaching and learning methodology. An increase in the percentage of students who were able to successfully complete the skills competency exam at the end of the semester supported the program design as a methodology that enhances learning of safe medication administration practices.
Patient safety is a concern of all healthcare workers. It is an accepted belief that a patient should not experience any adverse effects as long as there are means to prevent them (The Joint Commission, 2008). Adequately ensuring that all patients are correctly identified prior to any interaction with a healthcare worker, setting standards to decrease errors involving look-alike and sound-alike drugs, and assuring accuracy of medication safety across the healthcare continuum are safety initiatives in which all nurses must be competent and comfortable to ensure patient safety when administering medications (The Joint Commission, 2008). Students must acquire and gain confidence implementing multiple skills to ensure these safety initiatives are maintained. Opportunities must be provided to students to help them use their knowledge and skills to engage patients in an open-ended systematic manner and to ensure that knowledge of medications is clearly and accurately transmitted to patients (Croley, 2009).
Nurses are at the forefront of medication administration. Often viewed as guardians, nurses must have knowledge of the medication to be administered, understand the potential physiological and psychological reactions, serve as patient educators, and collaborate with other members of the healthcare team to ensure optimal patient outcomes (Castledine, 2009). Students must be challenged to develop expertise in multiple cognitive concepts, as well as psychomotor skills to achieve patient safety when administering medications.
Choosing clinical experiences that provide students with hands-on practice relating to specific content areas is becoming increasingly challenging (Shinnick, 2010). Nurse educators are challenged to apply teaching methods that foster clinical expertise in a limited time frame. Educational experiences must take into consideration patient safety as well as faculty and clinical site shortages (Shinnick, 2010). Simulation may assist educators in allowing students to develop expertise in medication administration in a safe, nonthreatening environment (Sears, Goldsworthy, & Goodman, 2010). Students perceive a greater quality, value, and satisfaction with learning experiences involving simulation (Jeffries & Rizollo, 2006). Participation in simulation experiences helps students with knowledge transfer, as well as the ability to synthesize concepts.
The process of debriefing following simulation allows students and faculty to identify areas of strengths and weakness (Dreifuerst, 2009). However, nurse educators are cautioned to consider the methods and environments in which simulation is employed (Schiavenato, 2009). Expertise must be demonstrated in developing and facilitating simulation scenarios as well as choosing whether to use simulation as a substitution for or addition to an adjunct teaching method. Evaluating the use of technology as an independent entity and as a component of a complete teaching and learning program has the potential to strengthen the use of technology as a vital component in the teaching and learning process.
Nurse educators are continuously confronted with the task of creating positive learning environments that allow all students to become actively engaged (Jeffries, 2007). This challenge requires educators to develop an understanding of the learning needs of students (Adeniran & Smith-Glasgow, 2010). Faculty must be committed to becoming facilitators of learning and adapt a philosophy of understanding the education process from the eyes of the student (Brookfield, 1995).
Adults enter the educational experience with varying degrees of prior assumptions. Adult learners see meaning in education when an understanding of the importance and significance in what they are learning is clearly defined (Mezirow, 2000). They also excel in the learning process when they are afforded the opportunity to use previously learned experiences and they are given the chance to achieve autonomy in thinking (Mezirow, 2000). This autonomy can be achieved by developing teaching strategies that incorporate several techniques, such a visual, auditory, and tactile (Louie,2009). Using simulation in a technology rich-atmosphere encourages independent thought in a safe, controlled environment.
The goal of this four-phase teaching learning plan was to provide a variety of experiences to develop safe medication administration practice in student nurses. The authors believe the literature supports the use of simulation as a successful strategy that infuses technology into the learning experience. However, technology is often viewed as an added or additional component to the learning experience. The teaching learning process should include technologies that provide experiences to allow students who may hold inhibitions to use the technology enough to gain necessary knowledge and skills without feeling overwhelmed by the technology-rich milieu. Simulation in conjunction with clinical experience and a didactic experience involving multiple teaching techniques was formulated into a medication administration lesson plan with the intent of providing a diverse learning experience. Evaluation was based on student perception of the technology and the ability to demonstrate competency in safe medication administration.
Participants for this project consisted of the junior class of a baccalaureate nursing program in an urban college. The program is accredited by Commission on Collegiate Nursing Education. Students progress though the program in cohorts that begins in their second semester sophomore year. The student population was considered to be culturally diverse relative to ethnicity, religion, and socioeconomic status. However, the participant population was considered to be exceptionally small (16 students). All students participated in all four phases of the teaching experience as a requirement of the clinical course.
Phase 1 constituted participation in a didactic learning experience. Students were assigned reading material that included chapters in the text, handouts placed on Blackboard™, and articles outlining evidence-based practice in safe medication administration. A combination of lecture, narrative pedagogy, demonstration and return demonstration, and PowerPoint presentations were used during this experience. The didactic lesson spanned three 7-hour clinical days. The class was held in the nursing practice laboratory to facilitate the demonstration-return-demonstration portion of the learning experience. Students were provided opportunities to practice and apply the theoretical concepts that were introduced in class with the nursing laboratory faculty. All students enrolled in the course attended the practice hours. Laboratory faculty provided feedback to the students and reported a high level of student engagement. There was no formative or summative evaluation used during Phase 1.
In Phase 2, the students participated in two clinical days during which concentrations on medication administration procedures were highlighted. A one-on-one instructor–to-student atmosphere was maintained to afford students the opportunity to perfect transfer of theory to practice and ensure safe medication delivery. Students completed reflections of the experience and their performance during the instruction and practice. These reflections were used by the clinical faculty to assign appropriate learning experiences that were congruent with program learning objectives. The departmental student clinical performance evaluation tool provided clinical instructors with guidelines for evaluating student learning and performance
Phase 3 centered on the use of technology. A medication simulation day provided all students with two high-fidelity simulation experiences. The simulation scenarios were developed by the course faculty who had attended multiple courses on scenario development and implementation. The scenarios followed the National League for Nursing (2010) simulation design template. Simulation scenarios were developed with the purpose of enhancing students’ ability to apply theory to practice during the medication administration process, as well as monitor individual student competencies. The scenarios were used several times prior to the implementation of the four-phase program with student participants of different academic cohorts. A debriefing session followed each simulation experience. Debriefing consisted of a guided reflection aimed at identifying areas of strengths and limitation, as well as allowing students to identify individual areas in which they needed greater understanding.
During the first simulation experience, students encountered a postoperative patient experiencing severe pain. The patient had been admitted through the emergency department with complaints of sudden severe lower abdominal pain. A diagnosis of acute appendicitis was rendered and the patient received emergency surgery. The scenario began with the patient’s arrival on the surgical unit immediately following discharge from the post anesthesia recovery unit. Students were challenged to complete a physical assessment focusing on pain assessment and vital signs, interpretation of a medication order set, administration of appropriate pain medication, and evaluation of effectiveness of medication administration. A group of four students participated in the simulation experience and each student was assigned a role. The roles were medication nurse, assessment nurse, documentation nurse, and family member. In the debriefing session that followed, participants reflected on the effectiveness of each role, as well as the team’s ability to achieve desired patient outcomes.
The second simulation exercise involved a patient experiencing chest pain secondary to a myocardial infarction. This time, the patient was in the final stages of the discharge process when he suddenly complained of severe midsternal chest pain. Assigned roles were changed for this experience so no student experienced the same role expectations twice. Students were challenged with being able to recognize the severity of the situation, change task from discharge preparation to assessing the patient, administering medications, reassessing, and evaluating the effectiveness of interventions. For both scenarios, an instructor was present. The instructor only participated when prompted by the students and kept participation minimal to allow students autonomy in thinking and acting. A debriefing session followed the simulation.
Because all students participated in the class, learning stations were established and students were divided into four groups. While one group participated in the high-fidelity simulation, the other three groups participated in a variety of simultaneously held stations of learning. The stations included two small group discussions of case studies, and a medication calculation practice station. Instructors were assigned to each station as facilitators. The facilitator served as a resource person.
Phase 4 combined the remainder of the clinical experience with skills competency testing in the nursing skills practice lab. During clinical hours, students actively participated in the administration of medication to multiple assigned patients. Students were encouraged to assume a more independent role in the medication administration process, with the instructor overseeing to ensure no errors occurred. Phase 4 culminated with the students returning to the skills lab and performing competency testing and demonstrating the medication administration process using high-fidelity simulation.
The investigative process consisted of two steps. The first step was aimed at gathering data of students’ perceptions of their ability to competently implement safe practice techniques taught during phases 1 and 2 into the medication administration simulation experience of Phase 3. A Likert-type student survey was administered to assess student perception of the usefulness of the simulation experience and to determine success in learning during phases 1, 2, and 4. The tool administered had been used for the past two years by faculty in the department of nursing to determine if students believed simulation exercises in the lab enabled them to transfer classroom theory to practice. The ability of the students to implement cognitive and psychomotor skills acquired during phases 1 and 2 with confidence during the simulation experience provided validity that learning was achieved.
Questions covered the following concepts, assessment skills, knowledge of medication administration, communication skills, and relating theory to practice. Reliability of the instrument was measured through stability or test-retest. The tool was administered after student participation in the simulation experience in Phase 3 and again following the skills competency evaluation at the conclusion of the semester in the nursing skills practice lab. The reliability coefficient was found to be 0.82.
The second aim was to compare the number of students who were successful in passing the skills competency testing without remediation to previous years. Records on student achievement in terms of student competency testing were kept by the lab coordinator. The number of students requiring remediation and retesting is monitored on an ongoing basis.
Upon conclusion of the Phase 3 simulation experience, the following results were attained (see Table 1). Seventy-five percent of the students reported believing the experience enhanced assessment skills or added to their knowledge of medication administration. Eighty-one percent indicated the experience either moderately or completely enhanced their ability to communicate with patients. Eighty-eight percent identified the experience as moderately or completely allowing for the transfer of knowledge to theory, applying theory to practice, increasing confidence in interdisciplinary communication, and improving the ability to prioritize patient care. Two responses to the surveys indicated that none of the objectives were achieved.
One hundred percent of the students successfully demonstrated competency during the end-of-semester medication administration skills evaluation. The results of the survey given to students after the medication skills competency evaluation mirrored the findings during Phase 3 of the four-phase teaching/learning plan for medication administration.
In the two years preceding the four-phase teaching learning program, 50% of students needed remediation after their first attempt at the skills competency exam. After implementing the four-phase program, the percentage of students requiring remediation to pass medication skills competency dropped to 25%. This decrease remained consistent for the two years during which the program was conducted.
Table 1. Student Survey Results (N = 16)
In addition to the quantitative data presented in Table 1, students offered multiple comments. These comments were mostly directed at the ability of the simulation experience to provide a positive environment that reinforced learning. Comments also indicated that students felt apprehensive when administering medications during Phase 2 of the experience. One student’s comment provided a summary of the many other comments offered by students. The student stated, “I was very nervous administering medications in the early clinical experience, but after the simulation I was able to administer medications with ease.”
Implementation of a plan that incorporated multiple teaching and learning methodologies was instrumental in assisting students to successfully develop competency in safe medication administration practices. The simulation experience in Phase 3 promoted the successful use of technology in education. Student satisfaction, as indicated by the survey results, as well as the improvement on the end-of-semester competency evaluations support use of this program that successfully introduced technology into the curriculum of medication administration education. Fostering patient safety through implementation of multiple skills and interventions during the medication administration process is essential (The Joint Commission, 2008). Confidence in implementing the multiple skills needed for safe medication administration was demonstrated through student responses on the evaluation tool. Confirmation in learning was also evident, as indicated by increased student success on the end-of-semester medication administration competency evaluation.
The project was perceived as a preliminary study and presented multiple limitations. The size of the sample is considered a limitation. However, results of the survey provide positive support for the continuation of the plan. An additional limitation was that medication administration skills were formally evaluated in the skills lab at the end of the semester and not during Phase 3.
This project adds to the body of knowledge that supports multiple teaching methods as necessary for a positive learning experience. Results of the study suggest that a multifaceted teaching structure enhances success in learning the complex process of safe medication administration. The high level of satisfaction with the four-phase experience suggests learning has occurred; however, what remains unclear is which phase in the program fostered the greatest satisfaction in learning. Further investigation is needed to evaluate the impact each phase had on students’ ability to gain confidence in medication administration.
Nurse educators are concerned about whether to incorporate technology to promote improvement of students’ educational experience. Part of the concern involves meeting the diverse learning preferences held by students among this group. The project supports implementing multiple teaching strategies to offer learning experiences that all students perceive as providing an opportunity for individual values and beliefs to affect the acquisition and syntheses of knowledge. The project also supports the belief that developing teaching strategies to include technology fosters enhanced student learning. As technology continues to play a vital role in the educational process, faculty need to continue to evaluate its effectiveness. It remains crucial to evaluate the technology used, as well as its use and placement in the teaching and learning process. Applying the concepts and framework of this study to different specialties within nursing education offer the potential to provide evidence to expanding simulation as a common teaching pedagogy for nurse educators. The authors acknowledge the limitations and suggest that the study can be replicated in a variety of educational environments and with larger study populations.
NYIT DON Medication Simulation Evaluation Tool©
Please indicate on a scale from 1 to 7, 1 being the lowest and 7 being the highest, the extent to which the simulation program has achieved the following objectives.
1. Did participation in the simulation experience support the transfer of knowledge/theory to practice?
1 2 3 4 5 6 7
Not achieved Moderately achieved Achieved
2. Did participation in the simulation experience allow you to build/refine your patient communication skills?
1 2 3 4 5 6 7
Not achieved Moderately Achieved Achieved
3. Confidence in performing assessment skills was gained as a result of participation in the simulation experience.
1 2 3 4 5 6 7
Not achieved Moderately Achieved Achieved
4. Did participation in the simulation experience assist in understanding information learned in the classroom?
1 2 3 4 5 6 7
Not achieved Moderately Achieved Achieved
5. Did participation in the simulation experience help you with peer communication?
1 2 3 4 5 6 7
Not achieved Moderately Achieved Achieved
6. The ability to better be able to prioritize time was gained as a result of participation in the simulation experience.
1 2 3 4 5 6 7
Not achieved Moderately Achieved Achieved
7. The self learning modules helped increase knowledge with regard to medication administration?
1 2 3 4 5 6 7
Not achieved Moderately Achieved Achieved
Please provide any additional comments below. Please consider sharing your thoughts on the following viewpoints. Use the back of this survey if more room is needed.
1. The best aspect of the simulation experience was…
2. The simulation experience provided a learning environment that allowed for a free exchange of ideas.
3. The simulation experience increased my confidence in providing patient care.
© Property of the NYIT Department of Nursing. Reprinted with permission.
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Lisa is an instructor at New York Institute of Technology, Department of Nursing. She is the Coordinator of Simulation and Technology across the nursing curriculum, as well as the coordinator of the nursing arts lab. Instructional expertise includes medical/surgical nursing, critical care, and technology in education. L. Sparacino received her Master of Science degree in nursing education from Molloy College, Rockville Center, New York and is currently working on her dissertation in partial fulfillment of a doctor of Philosophy in Nursing Education from Capella University.
Elaine is a Nurse Manager at Saint Francis Hospital, Roslyn New York. She is also an instructor at The University of Phoenix. Dr. Della Vecchia’s expertise includes, medical/surgical nursing, critical care, distance learning, and simulation. She received her Master of Science degree in Nursing Education and Administration from the University of Phoenix, and Doctorate of Philosophy in Education from Capella University.