In the Acute Care Nurse Practitioner (ACNP) program in the School of Nursing, our graduates are educated to function, in collaboration with physicians, as principle providers of care for acutely and critically ill patients. One of the biggest challenges that I, and all educators of health care providers, face is how can we move from knowledge acquisition in the classroom to astute clinical action at the bedside?
We can provide the didactic background knowledge for technical skills and patient management in the classroom, but it is more difficult to find ways to guide students in the integration of this knowledge and these skills into clinical practice. Traditionally, this synthesis of didactics into practice occurs within the context of supervised patient care in clinical practica. However, opportunities for the diagnosis and management of specific patient care situations during the clinical practicum are limited by the lack of a guarantee that patients will be unstable or develop a particular problem during the timeframe of the student’s clinical rotation. Also, patient safety is our first priority; therefore, students are closely monitored because we cannot allow them to act on a wrong decision. As a result, they can never actually have the indelible learning experience of recognizing the consequences of their faulty judgment.
The most successful way I’ve found to bridge the knowledge-action gap for ACNP students is using the High Fidelity Human Simulation (HFHS) Laboratory by John O’Donnell, director of our Nurse Anesthesia Program. Simulation is an attempt to re-create the most important aspects of a clinical situation in an artificial environment so that when these conditions occur in a real-life clinical setting, they are more readily understood and managed. Simulated experiences allow the ACNP students to respond to crises in a controlled environment.
HFHS includes an average-sized adult anatomic model equipped with an interactive software package that allows the operator to simulate physiologic conditions encountered in clinical practice. HFHS also includes a video package, allowing faculty to film trainees (with their permission) while they respond to clinical situations, which we later view with the student.
Using simulation to augment didactic content offers many advantages, the most important being that there is no risk to patients. For example, in a real clinical practica, if a student is not making the appropriate choices to treat a patient’s hypotension or shortness of breath, the clinical preceptor intervenes. But in the HFHS Lab, the “patient” can be allowed to deteriorate, and in the debriefing process the student can be actively involved in critiquing his or her own performance. This provides opportunities for reflection about where decision making needs to be improved or speeded up, or what other options could have been chosen to result in a better or more timely patient outcome.
I can also ensure that the students are exposed to a variety of clinical situations in order to validate crisis management skills in the lab. Furthermore, in the simulated scenario, I can control not only the nature of the patient care problem, but also the setting and level of support available to the student to manage the situation—for example, how does your management change when you don’t have all of the equipment or personnel that you are used to having?
Of course, the realism of the “patient” and responses are limited to the functions of the simulator and will never fully match that of an actual patient. Performance anxiety may also be an issue for students, but we hold fast to the belief that it is better for students to experience anxiety when first managing clinical emergencies in a protected environment where mistakes are not detrimental to the “patient.”
HFHS can be time consuming and labor intensive for faculty: it requires meticulous development of the scenarios, extensive lab setup, and ongoing lab maintenance. Despite this and other disadvantages, including cost, space constraints, and the need for technical support, I value HFHS as the best solution I’ve found to bridge to knowledge-action gap for my ACNP students. It allows me to employ a very powerful learning tool—allowing students to make mistakes and then learn from them—without putting patients at risk.
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