Vol.7, No.1 April 2001
Editorial | Contents
Computer mediated simulation learning opportunities
Non-Refereed Paper
Author
John Oliffe RN, Grad Cert. Paediatrics
Grad Dip Adult Ed, M.Ed.
(Deakin University, Australia)
oliffe@deakin.edu.au
Fax 613 92446159, Ph 613 9244-6625
Carole Rushton RN, Grad Dip Community Health, MM
Certificate in Sexual and Reproductive Health
(Deakin University, Australia)
Key words: Undergraduate nursing education, Information technology, Computer mediated learning, Simulation learning, Laboratory learning
Abstract
Market approaches have effected both the health care and higher education sectors in Australia. As a result of changes to funding the nursing profession has had to develop strategies in an effort to continue to provide adequate under-graduate nursing education. Specifically, new education challenges have occurred due to the shortage of experienced clinical nursing staff and reduced supply of clinical placements for undergraduate students. In light of the market forces we discuss computers as providers of simulation learning opportunities and a viable means of responding to the constraints and improving undergraduate nurse education.
Background
The impact of market approaches to health and education have had disparate effects on the nursing profession. In Australia, market forces have fostered a leaner and meaner health care system in which nurses, as one of the largest consumers of health care funds in terms of dollars paid in salaries and wages, have been adversely effected. The rationalist economic policies have resulted in increased part-time employees, fewer experienced nurses and reduced staff support structures (Considine & Buchanan 1999; Healy & McKay 1999; Human Services Victoria 1999). As a consequence there is increased pressure on nurses in the health care system and raised expectations of those about to enter it. New graduates are expected to perform at levels higher than they are capable, because the workloads of institutions that employ them demand it (Human Services Victoria 1999).
In nursing education, market approaches have forced higher education organisations to produce more nurses, a practice stimulated by monetary rewards through the sale of knowledge and economies of scale congruent with working with larger numbers of students. Competition between organisations that educate nurses, has lead to shortages of adequately trained staff to facilitate student learning and difficulties providing relevant, meaningful clinical placements for students (Human Services Victoria 1999; Duke 1996; Bethune et al. 1999). As a result students spend fewer hours in clinical placement than some earlier tertiary courses. This is not to imply that more clinical hours necessarily produce more competent students. Rather, concerns arise regarding competence where students undertake clinical placements supervised by non-nurse health workers (Bethune et al.1999).
A case for computer mediated simulation
As clinical practice has become more complex, and demand for undergraduate clinical placements threatens to exceed supply, simulation learning provides a legitimate means of gaining practice experience without having to contend with the realities of a clinical situation. In the broadest sense, simulation is a replication of the essential aspects of reality so that reality can be better understood, controlled and practiced (Fibson 1985). The nursing laboratory is an appropriate environment for simulation, providing visual, auditory and kinesthetic learning opportunities and a seamless continuum for application and synthesis of content introduced in tutorials and lectures.
However Gaberson & Oermann (1999) identify that nursing laboratories may have a single, limited purpose, such as skill practice before entering the clinical environment, or they may serve multiple functions as a learning resource center. The integration of networked computers to Deakin University's nursing laboratories in the form of permanent computer stations has helped realise a laboratory based learning resource centre.
Of particular note has been the realisation of student access to multimedia and Internet case studies in the nursing laboratory environment. Well-designed, pedagogically informed information technologies provide a valuable dimension to simulation learning. Multimedia includes CD-ROM, virtual reality and the Internet that combine video, audio, text and graphics presented using computer technology. Interactive multimedia case studies provide clinical scenarios that unfold as students respond to questions and develop hypotheses to provided cues. Such programs facilitate learning, enabling students to sufficiently reflect on complex concepts via interaction with content as well as with other students and facilitators. Students are encouraged to experience a problem or situation from a variety of perspectives and orientations that require decision-making and foster self-awareness, as well as self-correction.
We have included an evaluation of various CD-ROM's, Internet case studies and computer assisted simulation patients in an effort to introduce some of the many resources available.
CD ROM's
A CD ROM study partner containing 13 interactive patient case studies accompanies Elaine Mariebs’ Human Anatomy and Physiology (1997). Each case study has staggered chronological patient histories providing cues and related quizzes that facilitate student hypotheses and clinical decision making. The quizzes are multi-choice and drag and drop and have rationales for both correct and incorrect answers. The case studies are realistic and facilitate synthesis and application of anatomy and physiology principles. When congruent with subject content, the case studies enhance laboratory learning providing cues that help the student identify learning needs and related psychomotor skills.
Whaley and Wong's Nursing Care of Infants and Children (1999) CD ROM companion provides critical thinking exercises and case studies. The questions are predominately multi choice both text and diagrammatic drag and drop, rationales for correct and incorrect answers are provided. One particularly useful application in this program is the facility to develop nursing care plans for specific patient presentations with a print option. This CD-ROM provides low level interactivity but provides a useful introduction to Paediatric nursing.
Internet case studies
http://www.lib.iun.indiana.edu/careplan.htm provides a menu for on-line medical case studies and nursing care plans. There are varying degrees of interactivity however the interactive patient at http://medicus.marshall.edu/medicus.htm although designed for medicos, provides some challenging interactive presentations with audio files and e-mail feedback for participants.
Computer assisted simulation patients
Computer software integrated with resuscitation manikins providing realistic heart and breath sounds and representative EKG's. The sophistication of the program design determines the degree of interactivity, however many cardiac simulators provide the opportunity for students to integrate theory to practice and develop psychomotor skills.
The Heartsim range from Laerdal provides resuscitation manikins with many options, including audible breath sounds, palpable carotid pulses, IV cannulation and intubation facility, along with a plethora (2500) of cardiac rhythm variations. There is a bank of pre designed patient cardiac scenarios and the option for the facilitator to design and save scenarios. The rhythms are visualised with a laptop computer and larger groups can be catered for with the use of a LCD projector. The program provides assessment of student decision making and compression and ventilation techniques. This is a terrific program particularly useful for postgraduate nursing students. The software responds to the interventions selected during the simulation prompting on going student assessment of the patient.
Less complicated (and expensive) but effective, especially at undergraduate level is the Skillmeter Resusci Anne from Laerdal. The manikin is connected to a skillmeter that provides the user with real time feedback on compressions and vetilations using bargraphs. A print out option is also available which provides participants with quantified post practice evaluation of compression rate and compression / ventilation ratio.
Education underpinnings of simulation
Simulation learning is congruent with contemporary education theories of constructivism and andragogy that underpin curriculums including Problem-based Learning (PBL). Constructivism is a philosophy of learning founded on the premise that, by reflecting on experiences, the learner constructs an understanding of the world they live in. Students generate rules and mental models that they use to make sense of their experiences. Learning, therefore is the process of adjusting the mental models to accommodate new experiences. Nicaise & Barnes (1996) identify the constructivist approach to teaching can be enhanced through the application of computer technology resources. We have found that the potential benefits of the use of computers in simulation learning are maximised by facilitation strategies such as open-ended questions and promotion of extensive dialogue among students, encouraging connections between facts and fostering of new understandings. As with all education materials, content relevance and design is paramount to the effectiveness of multi-media. The facilitator as content expert must evaluate program suitability and student accessibility prior to incorporating multi media to nursing laboratories. Ideally the use of computer mediated simulation should decrease program design responsibilities for facilitators.
Many computer programs are espoused as being interactive and bringing text and concepts to life. The sophistication of design impacts on the usability, relevance and acceptance by facilitators and students alike. Indeed many students currently in higher education grew up with multi media programs, much the same as baby boomers grew up with television. Beware! The result is a discerning sophisticated user who will not invest time in poor programs. Many universities are experiencing an implementation dip in developing effective information technology resources capable of supporting teaching and learning. Institution investments of time, money and energy have resulted in limited short-term returns, producing programs that are often inferior to industry product. The ultimate lesson in all this is to not use multi media for the sake of attempting to appear contemporary; the reality is that you may be a slave to fashion rather than an innovator!
In conclusion it has been our experience that computer-assisted simulation provides a valuable source of learning for students. Its inclusion has added a valuable dimension to our Nursing Laboratories. The principles of its use are generic to all 'good education'. The facilitator must identify audience, evaluate materials (prior to and after the session) and develop strategies to empower the learner. On the side of caution we advocate the need for further research into the benefits of simulation.
References
Bethune E, Wellard S, Williams A, Mischkulnig D, Rushton C. An exploration: clinical learning programs in undergraduate pre-registration Bachelor of Nursing Courses. School of Nursing, Deakin University, Mebourne, Victoria, Australia; 1999.
Considine G, Buchanan S. The hidden costs of understaffing: an analysis of contemporary nurses work in Victoria. (A report for the Victorian Branch of the Australian Nurses Federation). Australian Centre for Industrial Relations and Training (ACIRRT). University of Sydney;1999.
Duke M. Clinical evaluation - difficulties experienced by sessional clinical teachers of nursing: a qualitative study. Journal of Advanced Nursing 1996;23: 408 - 414.
Fibson WJ. Simulation as a strategy for teaching in the college laboratory, In: Infante MS. The Clinical Laboratory in Nursing Education second edition, New York, A Wiley Medical Publication;1985.
Gaberson KB, Oermann MH. Clinical Teaching Strategies in Nursing, New York, Springer Publishing Company;1999.
Healy C, McKay M. Identifying sources of stress and job satisfaction in the nursing environment. Australian Journal of Advanced Nursing 1999;17 (2):30 - 35.
Human Services Victoria, Nurse Labourforce Projections Victoria 1998-2009, Human Services Victoria, Public Health and Development Division, March 1999.
Nicaise M, Barnes D. The union of technology, constructivism, and teacher education. Journal of Teacher Education, 1996;47(3):205.
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