Creative clinical solutions: aligning simulation with authentic clinical experiences.

Various factors, including the fact that in fast-paced, acute care settings, students have little time to reflect on a client's situation and provide appropriate and thoughtful nursing interventions, led our faculty to develop real-life, real-time scenarios for a simulated clinical setting. Senior students studying Complex Illness and Disease Management are assigned to 15 weeks of eight-hour clinicals in an acute care setting. Now, three sessions with a high-fidelity simulation (HFS) manikin are spaced throughout the semester. The eight-hour authentic clinical scenario mimics the entire hospitalization experience, from admission to discharge of a client. The scenario is designed to enhance students' critical thinking skills and promote confidence and comfort in the clinical arena. While skills lab use of HFS focuses primarily on learning skills and tasks, the simulation clinical focuses on solving problems, teamwork, understanding complex disease processes, decision making, and critical thinking. A focus on tasks and skills is one component of the scenario, but only in relation to caring for the client. Project Development Authentic simulated clinical scenarios have been developed in the expectation that this format can replace observational clinical experiences in such areas as cardiac catheterization labs, endoscopy units, and emergency departments, which offer few benefits for learners. Clinical observations provide limited opportunities to learn problem solving, and they are used frequently as a way to decrease student-faculty numbers in the clinical arena. Real-time simulations are designed to foster the synthesis of pre-requisite and co-requisite knowledge. The first challenges in developing this new model of clinical experience were writing authentic scenarios that would parallel didactic course content, programming the manikin in a timely and accurate manner, and creating an environment that would require students to interact and collaborate. Helping students maintain enthusiasm for eight hours was another important requirement. Before implementation, faculty wrote three detailed scenarios using didactic content from the senior-level course. (See Figure.) To ensure that students would take a holistic approach with their clients, the scenarios included past medical history, social history, diagnostics and lab values, client history, and medications. The Simulation Clinical Experience Activities during an entire day of clinical involve report, assessment, prioritization of nursing interventions, management of care with collaborating personnel, documentation, interaction with significant others, and planning of discharge and dietary instructions if needed. Students are encouraged to interact with each other and faculty in order to gain confidence in devising nursing care plans for complex clients. Debriefing sessions, where students reflect on what transpired during the scenario and changes that need to be implemented in the future, are held in a controlled environment. Twice weekly, 46 students are placed in eight groups of five to six students. These groups are selected from different clinical groups to promote teamwork and an exchange of ideas. Students are then rotated to simulated clinicals held in the school of nursing labs. Scenarios all relate to the didactic portion of the course. In addition, the simulations incorporate concepts from prerequisite and co-requisite courses, such as pharmacology, basic illness and disease management, care of the aging, human growth and development, nutrition, and concepts of professional nursing. Students arrive in their uniforms, approaching the experience as if they were in a hospital setting. The manikin is appropriately outfitted with interchangeable body parts, a wig, and specific manifestation data pertaining to disease process and course content. Each student is assigned a role that reflects an intra- and interdisciplinary work setting, for example, a primary nurse, assistant nurse manager, physician, nursing assistant, documentation nurse, or significant other. …