COVER STORY: Clinical Trial
Photo courtesy Kirkwood Community College
Study Aims to Measure Efficacy Of High-Tech Patient Simulators
By Paul Bradley
In college nursing and allied health departments across the country, they are becoming as ubiquitous as the stethoscope: high-tech, computer-driven patient simulators controlled by educators to deliver physiologically appropriate responses to student interventions.
There is little question the devices have many advantages. The remarkably lifelike machines can augment clinical settings, which are in short supply in many parts of the country. Simulated experiences provide students with the opportunity to take part in patient care scenarios they may otherwise not experience in actual clinical settings: breeched births, for example, or severe allergic reactions.
Simulation also offers an avenue for educators to assess clinical judgment and critical thinking of their charges without jeopardizing patient safety. Learners can make mistakes without the need for intervention by medical experts to stop patient harm. By seeing the outcome of their mistakes, learners gain insight into the consequences of their errors.
But despite the eager embrace and widespread use of the machines, little is known about whether and how they advance academic outcomes or improve clinical skills and patient outcomes. Academic research on the topic is sparse, and mostly confined to whether students were satisfied with their simulation training and whether the technology built confidence among students. That could soon change, however.
A pioneering study being conducted by the National Council of State Boards of Nursing is examining the use of simulators in pre-licensure nursing programs throughout the country. The study, which will follow students through college and into their clinical practice — the study cohort graduates from nursing school this May — aims to guide state boards of nursing in determining how much simulation should count in satisfying clinical requirements for nurses.
“The information that will be gained from this research is desperately needed by nursing regulators and educators, and will impact the future of nursing education,” said Jennifer Hayden, project director for the study.
The study will highlight best practices in simulation use, evaluate the learning occurring with various amounts of simulation substituting for clinical hours, establish simulation standards and learning experiences in each core clinical course and evaluate new graduates’ abilities to translate educational experiences into the workplace.
NCSBN is monitoring students from five associate degree nursing programs and five baccalaureate degree nursing programs throughout the United States. Study teams are monitoring students upon completion of each clinical course, after one year in the nursing program, upon graduation and finally, one year post-graduation. The research gathered by the study teams will be reported to NCSBN, which will assess nursing knowledge, clinical competence and student satisfaction with the education they received.
Few people question the utility of the simulators, and colleges have been willing to invest in them. High-fidelity models cost about $65,000, and some more advanced machines can cost as much as $250,000. Many have been purchased with grant money.
The machines have a high “gee-whiz” factor. They are almost eerily lifelike. They breathe, blink, cry, moan and sweat, allowing nursing students to acquire the full range of skills they’ll need in their jobs, from drawing blood to delivering babies to preparing toddlers for surgery.
For colleges struggling to find clinical placements for students, they fill a critical role. In some areas, a dozen or more schools of nursing are competing to find a limited number of clinical placements for their students. In addition, many hospitals, fearing legal liability, are reluctant to let students do any more than observe in areas like pediatrics. Then there is the problem of finding nursing instructors with masters’ degrees to supervise the students in their clinical settings.
As a result, clinical placements have become a significant choke point in nursing education, said Michael McLaughlin, director of the Katz Family Healthcare Simulation Center at Kirkwood Community College in Cedar Rapids, Iowa.
The center opened in the fall of 2009 on Kirkwood’s main campus. It’s a 12,000-square foot facility that serves students in 17 credit and non-credit nursing and allied health programs as well as area hospitals, EMS agencies, medical facilities and individual health care providers.
It’s a testament to state-of-the-art technology, equipped with seven high-fidelity medical simulators, an extensive audio/visual system and a six-room, seven-bed simulated hospital environment. Walk into the center, and you get the feeling you’re in an actual hospital.
“What really sets us apart is that we were built from the ground up as a simulated hospital,” McLaughlin said. “We serve about 300 students a term, nursing students, respiratory therapists, paramedics and occupational therapists.”
McLaughlin sees several advantages in the high-fidelity, computer-controlled simulators, which bring a large degree of realism to health care education.
“One of the biggest advantages of the simulators is that they give students the chance to make mistakes,” he said. “With a real person, the consequences of a mistake can be very serious. We joke that this is the place where you can kill your patient. We’ll just restart it.”
The simulators also allow educators to standardize the instruction process, exposing nursing students to the same learning environment, he said. Clinical settings, by contrast, can vary greatly.
Despite the advantages of the machines, there are few answers on whether training on simulators improves academic performance, clinical skills or patient outcomes. Those are among the questions the NCSBN Simulation Study intends to answer, giving states the knowledge they need to craft rules on whether — and how much — training on simulators should count toward satisfying clinical requirements.
Currently, even students who are trained on simulators must complete hundreds of hours of training in actual clinical settings.
The study is evaluating the learning occurring with various amounts of simulation substituting for clinical hours. Students from each of the 10 study sites have been randomly assigned to one of three groups: a group where up to 10 percent of the time normally spent at clinical sites will be spent in simulation, a group where 25 percent of the time normally spent at clinical sites will be spent in simulation or a group where 50 percent of the time normally spent at clinical sites will be spent in simulation.
Said Hayden: “Boards of nursing around the country have been asking, ‘can we use simulators in place of clinical settings?’ There are no clear answers in the literature. People think the simulators are a really good idea, but nobody really knows.”
Following the students post-graduation is particularly noteworthy, Hayden said. Researchers will be able to evaluate how well new graduate nurses are able to apply the knowledge they have acquired during nursing school to their practice as new nurses, providing a link that has not been studied in previous simulation studies. Researchers will examine and compare clinical and simulation experiences, competencies and level of practice. The follow-up of graduates into their first year of practice will focus on retention of new nurses and clinical judgment after graduation.
McLaughlin is among those who is hoping the study yields meaningful results about the efficacy of simulation technology.
“We need to show that using this technology has tangible outcomes,” he said. “We need to show how it impacts patient safety. The next frontier will be documenting how simulation technology affects patient outcomes, rather than just the education of nurses.”