Unfolding Case Study Using Human Patient Simulation in an Advanced Practice Nursing ProgramL INDA A. MASON BARBER, PHD, RN, ANP -C

ASSISTANT PROFESSOR

TANNER HEALTH SYSTEM SCHOOL OF NURSING

UNIVERSITY OF WEST GEORGIA

DisclosurePresenter has no actual or potential conflicts of interest in relation to this program/presentation.

ObjectivesDescribe use of HPS with standardized patients as adjunct to precepted clinical experiences in an APN program

Describe use of a simulated unfolding case study using standardized patients for formative evaluation of clinical knowledge, skills, and attitudes of APN students

IntroductionLimitations for clinical placement of APN students increasing (AACN, 2015; Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2012)

HPS with standardized patients offers viable adjunct to clinical experiences (AACN, 2015; Hayden et al., 2014)

IntroductionHPS provides effective learning experiences for undergraduate nursing students (Cant & Cooper, 2012; Hayden et al., 2014; Norman, J., 2012)

Limited knowledge related to use of HPS for education and evaluation of APN students

BackgroundFaculty interest in assessing current knowledge, skills, and attitudes of students in their last semester of a FNP program

Limitations to evaluations conducted by preceptors (Ebbert & Connors, 2004)

Focus on identifying gaps in teaching and learning

Unfolding Case Study“An unfolding case is one that evolves over time in a manner that is unpredictable to the learner. New situations develop and are revealed with each encounter” (NLN, n.d., para. 1).

Gauge critical thinking, diagnostic reasoning, and clinical judgment (Carr, K., 2015; Reese, 2011)

Opportunity for patient follow up and evaluation of effectiveness of plan of care (Reese, 2011)

Standardized Patients (SPs)Persons following a scripted scenario who present in a consistent manner as patients with a specific health condition during an educational or evaluative experience in nursing (Gibbons et al., 2002)

Demonstration of communication and clinical skills in obtaining a health history, completing a physical examination, and outlining a plan of care (Gibbons et al., 2002; Theroux & Pearce, 2006)

Use of SPs in nursing education linked to positive outcomes (Ebbert & Connors, 2004; Gibbons et al., 2002; Robinson-Smith, Bradley, & Meakim, 2009; Theroux & Pearce, 2006)

Participants25 Masters level nursing students in final semester of FNP program

Currently participating in precepted clinical experiences in out-patient setting

All students enrolled in final adult health course

SettingPrivate nursing school in the Southeastern United States

State-of-the-art Clinical Skills Laboratory

3 fully equipped examination rooms; simulated office or clinic setting

1 computer lab

1 debriefing room

Patient Scenarios (Unfolding Case)Learning objectives based on current clinical practice guidelines, Nurse Practitioner Core Competencies (NONPF, 2012), and program outcomes

Scenarios consistent with “Standards of Best Practice: Simulation” outlined by the International Nursing Association for Clinical Simulation and Learning (INACSL, 2013)

Realistic scenarios encountered in a primary care setting

Stations (Unfolding case)1 – Evaluation of patient with c/o hand, hip, and knee pain

2 – Electronic documentation of patient encounter

3 – Follow up evaluation of patient now with c/o abdominal pain

4 – Electronic documentation of patient encounter

5 – Follow up evaluation of patient now with c/o severe abdominal pain and hematemesis

6 – Electronic documentation of patient encounter

7 – Group debriefing, faculty feedback, student self-evaluation

Patient ChartsStandard forms (i.e., demographics and insurance information; medication list; self-report health, family, & social history form)

Intake sheet with vital signs and chief complaint

Updated lab results, diagnostic test results, etc. from previous patient encounter (as appropriate)

Faculty2 faculty in chart review area

1 faculty observer/evaluator per patient room (total of 3)

1-2 faculty assisting in computer lab (documentation station)

1 faculty as a standardized patient

Clinical lab faculty assistance with set up of lab and facilitation student rotation through stations

All faculty in debriefing

Faculty and Standardized Patient Preparation1-2 weeks before experience◦Patient charts and patient scripts

◦Background diagnostic and treatment information related to osteoarthritis, peptic ulcer disease, GI bleed

◦Checklist of expected student learner behaviors and interventions at each stage of the case

◦Questions to facilitate debriefing

Faculty and Standardized Patient PreparationDay of experience

◦Review and prebriefing regarding flow of scenarios by faculty coordinator

◦Clarification of expectations of SPs and students

Student Preparation1 week before experience◦Reviewed objectives for experience◦Outlined expectations for the day

Day of experience◦Signed confidentiality agreement◦Provided flowsheet and documentation forms◦Prebriefing including review and reinforcement of expectations

ProceduresReview of patient charts and supporting data pertinent to each encounter prior to and during each “office visit”

Students presented with SPs for evaluation in simulated office or clinic setting (2 students per station)

Unfolding case study with three time-lapsed scenarios

ProceduresFocused history and physical assessment

Differential diagnoses and treatment plan including prescriptions, diagnostics, referrals, patient education

Electronic documentation (SOAP note)

DebriefingIndividual debriefing following each patient encounter

Group debriefing once all stations completed

Questions provided to facilitate debriefing

Students completed self-evaluations

Results – Opportunities for EvaluationInterviewing skills

Physical assessment

Development of differential diagnoses

Ordering diagnostics

Writing prescriptions

Patient education

Writing admission orders

Use of resources and references

ResultsReinforcement of student clinical knowledge

Student self-identification of challenges and opportunities

Identification of gaps in teaching and learning by students and faculty

Resource intensive experience

ConclusionsHPS using standardized patients and an unfolding case study approach may be a viable adjunct to traditional preceptedexperiences for reinforcing knowledge, skills, and attitudes and assessing student learning in an APN program.

Identification of teaching and learning needs of students related to clinical knowledge, skills, and attitudes may be derived from these experiences.

ConclusionsDebriefing, feedback, and student self-evaluation are important components of simulated learning experiences.

Implications for educational and clinical practice and research are evident.

ReferencesAmerican Association of Colleges of Nursing. (2015). Re-envisioning the clinical education of advanced practice registered nurses [white paper]. Retrieved from www.aacn.nche.edu/aacn-publications/white-papers/APRN-Clinical-Education.pdf

Cant, R. P., & Cooper, S. J. (2012). Simulation-based learning in nurse education: systematic review. Journal of Advanced Nursing, 66, 3-15. doi:10.1111/j.1365-2648.2009.05240.x

Carr, K. (2015). Using the unfolding case study in midwifery education. Journal of Midwifery & Women’s Health, 60, 283-290. doi:10.1111/jmwh.12293

Ebbert, D. W., & Connors, H. (2004). Standardized patient experiences: Evaluation of clinical performance and nurse practitioner student satisfaction. Nursing Education Perspectives, 25, 12-15. doi: 10.1043/1094-2831(2004)025<0012:SPEEOC>2.0.CO;2

Fitzgerald, C., Kantrowitz-Gordon, I., Katz, J., & Hirsch, A. (2012). Advanced practice nursing education: Challenges and strategies. Nursing Research and Practice, 2012, Article ID 854918, 8 pages. http://dx.doi.org/10.1155/2012/854918

Gibbons, S. W., Adamo, G., Padden, D., Ricciardi, R., Graziano, M., Levine, E., & Hawkins, R. (2002). Clinical evaluation in advanced practice nursing education: Using standardized patients in health assessment. Journal of Nursing Education, 41, 215-221. doi:10.3928/0148-4834-20020501-07

Hayden, J. K., Smiley, R. A., Alexander, M. A., Kardong-Edgren, S., & Jeffries, P. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5, July 2014 supplement.

ReferencesNational League for Nursing (NLN). (n.d.). Unfolding cases. Retrieved from www.nln.org/professional-development-programs/teaching-resources/aging/ace-s/unfolding-cases

NONPF. (2012). Nurse practitioner core competencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenciesfinal2012.pdf

Norman, J. (2012). Systematic review of the literature on simulation in nursing education. The ABNF Journal, 23, 24-28. Retrieved from https://www.questia.com/library/p3582/abnf-journal

Reese, C. E. (2011). Unfolding case studies. The Journal of Continuing Education in Nursing, 42, 344-345. doi:10.3928/00220124-20110722-04

Robinson-Smith, G., Bradley, P. K., & Meakim, C. (2009). Evaluating the use of standardized patients in undergraduate psychiatric nursing experiences. Clinical Simulation in Nursing, 5, e203-e211. doi:10.1016/j.ecns.2009.07.001

Theroux, R., & Pearce, C. (2006). Graduate students’ experiences with standardized patients as adjuncts for teaching pelvic examinations. Journal of American Academy Nurse Practitioners, 18, 429-435. doi:10.1111/j.1745-7599.2006.00158.x