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Running head: SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS
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How Integrated Simulations and Unfolding Case Studies Decrease the Potential for Medication
Errors Among Nursing Students
Joshua C. Lincoln
Ferris State University
SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS
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Abstract
Traditional teaching strategies can leave students feeling unprepared for the clinical environment
thus decreasing patient safety. This paper discusses the benefits of integrated simulation and
unfolding case studies as strategies for nursing education. These strategies are used as an adjunct
to traditional clinical and didactic teaching methods. Nursing educators and administrators need
to understand how these strategies increase patient safety specifically in regard to medication
errors. Faculty must also be aware of the monetary investment, human resources, facilities and
time needed to properly implement these teaching strategies.
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How Integrated Simulations and Unfolding Case Studies Decrease the Potential for Medication
Errors Among Nursing Students
Nursing students must learn to practice safely and effectively using evidence-based
practice. A major mission of the Quality and Safety Education for Nurses project (QSEN) is to
increase future nurses’ knowledge, skill, and attitudes to improve the quality and safety of
healthcare (Cronenwett et al., 2007). It is difficult for students to be exposed to enough patient
care situations due to the lack of both clinical sites and variability among patients (Sears,
Goldsworthy, & Goodman, 2010). In some cases time is wasted in clinical settings due to a lack
of learning opportunities. In addition, students in these clinical situations risk harming patients
due to lack of supervision and experience. (Lewis, Strachan, & Smith, 2012).
Medication errors are a major concern for patient safety (Reid-Searl, Moxham, &
Happell, 2010). It is safer for students to learn about these errors from integrated simulations
and unfolding case studies where they can commit errors without causing patient harm (Durham
& Alden, 2008). These teaching strategies also provide a good format for reflection, teamwork
and confidence building (Blum & Parcells, 2012). Waiting until a clinical rotation to expose
students to real life situations is both dangerous for patients and intimidating to students (Lewis
et al., 2012). Innovative methods must be implemented to facilitate student learning. This paper
discusses integrated simulation training and unfolding case studies as strategies to help nursing
students recognize and reduce medication errors. Also discussed is the application of Patricia
Benner’s model of skill acquisition, Gardner’s multiple intelligences and how they relate to these
teaching strategies.
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Simulations
Simulation has been widely used to approximate stressful situations in many different
industries (Blum & Parcells, 2012). However, the use of simulation in the medical field has only
recently been embraced (Kane-Gill & Smithburger, 2011). Patients can experience many
different adverse events of which medication errors are the most prevalent (Reid-Searl et al.,
2010). The use of clinical simulation is a logical teaching strategy to assist students in
integrating pharmacological knowledge with clinical application (Kane-Gill & Smithburger,
2011). Nurse educators can use these simulations as a method to expose nursing students to
errors and ways to prevent them (Sears et al., 2010). Simulation training also improves clinical
skills and lowers the possibility for medication errors and near misses (Gordon & Buckley,
2009). According to Gordon and Buckley, integrated simulations immerse students in life-like
situations and assist them in determining a proper course of action. Logically, issues related to
medications errors are reduced by increasing nursing students’ exposure to medication
administration prior to entering the clinical environment (Sears et al., 2010). These integrated
simulations present benefits and challenges for the educational community.
Issues in Education
Lack of clinical availability for students is a limiting factor in the number of nurses
currently being trained (Sears et al., 2010). Therefore, clinical simulations are effective methods
to supplement clinical experience. In simulations students are exposed to situations never
experienced during clinical rotations (Scalese et al., 2007). Also, students may not be exposed to
many different medications being administered during clinical rotations. This makes clinical
simulation a more efficient use of time by helping student nurses get exposure to more
medications and possible errors (Scalese et al., 2007). A nurse educator must develop an
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integrated, multidisciplinary simulation to effectively assist students in learning about possible
medication errors. It is irresponsible to assume all these skills can be learned at the bedside with
an average clinical instructor to student ratio of 1 to 10 (Durham & Alden, 2008). Simulation
needs to be implemented by all nursing schools as an adjunct to traditional clinical training.
Integrative simulators, also called high fidelity, provide the most realistic scenarios for student
nurses (Durham & Alden, 2008). However, there are some logistical issues institutions must be
aware of before choosing the type of simulator to purchase.
Logistics of Simulation
There are numerous aspects to simulation to be considered before nursing faculty and
administration decide whether to purchase. Aspects to be considered are the type of simulator,
the initial investment, space available, faculty time and resources. Also the benefit to students
and methods of evaluation are important considerations (Durham & Alden, 2008).
Types of Simulation
There are numerous types of simulators available for purchase. They are classified as
part-task, simulated patient, screen-based computer, complex task trainers, and integrated
simulators (Durham & Alden, 2008). Part-task trainers are lower technology implements
replicating a single part or portion of the body (Durham & Alden, 2008). An example of these
would be a cardio-pulmonary resuscitation (CPR) trainer or an arm for intravenous (IV) access.
Simulated patient training is commonly role-playing between instructors and students. This type
of simulation is most beneficial for psychiatric nursing practice (Durham & Alden, 2008).
Screen-based computer simulation can mimic physiology. Students can make clinical decisions
and observe reactions on these computers (Durham & Alden, 2008). This type of simulation is
often used in anatomy and physiology classes to help students observe physiology in action.
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Complex task trainers are more advanced computer simulations. These are used to practice skills
like pelvic exams where educators cannot easily observe student performance. These simulators
are responsive to touch and pressure making them a valuable tool for delicate examination
practice (Durham & Alden, 2008). Integrated simulators are a combination of computer and task
trainers capable of mimicking almost every physiological process. They provide students with
an immersive and realistic representation of clinical experience. Integrated simulators can also
record student interventions to allow for accurate and comprehensive debriefing after the
simulation. This provides students with immediate feedback and reflection on how to improve
their interventions (Durham & Alden, 2008). Integrated simulation provides the most realistic
experience for students as it allows them to practice situations rarely encountered in traditional
clinical settings. Integrated simulators also present faculty the opportunity to facilitate consistent
levels of exposure to patients with less common diseases or medication orders. Of all the
simulators available these are the most expensive (Durham & Alden, 2008).
Costs of Simulation.
Simulation equipment is expensive as an initial investment (Lapkin & Levett-Jones,
2011). It can range from $30,000-$200,000 depending upon the fidelity or technology (Durham
& Alden, 2008). According to Lapkin and Levette-Jones, the investment in medium fidelity
equipment is more cost effective than high fidelity equipment. Lapkin and Levette-Jones
determined the increased cost of high fidelity simulation is not justified as it does not equate to
greater clinical reasoning. Medium fidelity equipment also requires less expertise to use, thus
faculty adjustments to the simulation technologies are easier. Regardless of this, the use of high
fidelity simulation provides better realism, immersion, skill utilization and teamwork building
than any type of simulation (Lewis et al., 2012). To offset the initial investment schools can
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partner with local hospitals, rent out the simulator, or apply for grants (Durham & Alden, 2008).
The overall long-term benefit of high fidelity simulation outweighs the costs if schools can defer
them with partnerships. Graduating nurses have clearly demonstrated greater confidence,
teamwork, and most importantly less medication errors or near misses from using high fidelity
integrated simulators (Blum & Parcells, 2012).
Space Available
The space needed to accommodate simulation technologies varies with the type of
scenario. In more sophisticated simulation labs the space required may involve multiple
simulation and observation rooms, computer labs, and debriefing areas. In a more simplified
version the simulators and computers occupy little space and can be utilized in a standard
classroom if necessary (Durham & Alden, 2008). Ideally the simulations would occur within a
nursing practice lab to increase the realism for students. This holds true for all computer based
simulators (Durham & Alden, 2008). The normal faculty to student ratio in a simulation is 1 to 5
(Durham & Alden, 2008). This can be a limiting factor for the use of integrated simulations.
Faculty Time and Resources
There are legitimate concerns about the availability and ability for nursing faculty to
effectively utilize more advance simulation technology. Faculty concerns are related to
increased time demands for preparation and administration of simulations. The complexities of
integrated simulators can be daunting for many nursing instructors. Most current instructors did
not grow up with computers, thus their inherent abilities to adapt to the technologies can be
limited (Durham & Alden, 2008). This does not preclude them from learning, but fear of the
technology can create resistance to implementation (Durham & Alden, 2008). With
administration and faculty support, those fears can be alleviated (Degroot, 2009). According to
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DeGroot, faculty members attending immersive weekend training sessions indicated increased
confidence with technologies and lowered resistance to implementation. To provide the best
possible clinical training for students, instructors must become familiar with integrated
simulators. Administration can support this by funding professional development conferences.
Faculty attending these conferences can then mentor colleagues (Degroot, 2009).
Benefits to Students
Integrated simulation increases student confidence, skill performance, teamwork, and
critical thinking without posing a risk to patients. Most importantly it allows students to make
medication errors while introducing them to possible consequences without harming the patient
(Durham & Alden, 2008). According to the Joint Commission, patient safety related to
medication errors is an enormous issue in health care today (Durham & Alden, 2008). Adverse
drug events (ADE’s) can occur at any time while a patient is in a health care institution.
Integrated simulation assist students to safely administer medications because it forces them to
realistically calculate dosages, IV rates, identify proper patients and routes, and observe for
adverse effects (Durham & Alden, 2008).
Evaluation of Effectiveness
The only truly meaningful test of integrated simulation training is the actual transfer of
lessons learned to the clinical environment (Durham & Alden, 2008). In the short term however,
educators must evaluate students’ feelings about the effectiveness of the training. Following the
simulation the instructor will de-brief each student individually as well as part of the group. Part
of the process involves a self-assessment by the student. They answer questions with not agree,
somewhat agree, strongly agree or not applicable which will be assigned number values to be
analyzed using a Likert scale. The questions answered are regarding understanding of
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medications used, perception of areas for needed improvement, decision making and assessment
skills, confidence, and critical thinking. This in combination with post-scenario debriefing
allows students to reflect on their interventions, medication administrations, and patient
reactions. These sessions should also be videotaped for further evaluation by faculty to identify
simulation needs for the future (Durham & Alden, 2008).
Simulations Prevention of Medication Errors Strategic Teaching Plan
The role of a nurse educator in planning and implementing an integrated simulation is
very important. If the faculty is not prepared, the simulation will not be as effective (Durham &
Alden, 2008). The faculty must understand the goal of the simulation, the context of the learning
experience, the level of student in the scenario, the time allotted, the student experience with
simulators, the available staff, the equipment being used and the method of evaluation (Durham
& Alden, 2008). To effectively accomplish this, faculty must have pre-simulation briefings to
ensure all the above areas are addressed and fully understood. The faculty must also believe
there is a real benefit to the simulation to effectively administer it (Page, Kowlowitz, & Alden,
2010).
The benefit of exposing students to life-like medication situations is evident (Sears et al.,
2010). The key is to develop an effective integrated teaching simulation regarding medications
and any potential errors. Studies indicate students feel safer in simulation environments (Gordon
& Buckley, 2009). An important consideration is students must feel comfortable enough in
simulation training to makes mistakes. If students feel they will be punished, the simulations
effectiveness is reduced (Gordon & Buckley, 2009). Students must also recognize nurses alone
are not always the cause for medication errors. Physicians, pharmacists, and technology are also
causes for medication errors. Because of this, a true integrated simulation should include
SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS
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relevant technology, students or faculty portraying physicians, pharmacists, and any other
relevant health care providers (Gordon & Buckley, 2009). According to Gordon and Buckley,
the development of interpersonal skills in simulation training is important in facilitating the
effectiveness of the training. Teamwork among health care workers actually lessens the chances
of making a medication error (Kane-Gill & Smithburger, 2011). Thus, using integrated
simulation is a more effective method for teaching students about both medications and the
errors inherent in their administration. Integrated simulations are not the only educational
strategy to assist students in enhancing patient safety.
Unfolding Case Studies
In accordance with QSEN competencies nurse educators can use unfolding case studies
to help student nurses understand the complexities of patient care to encourage patient safety and
student learning (Durham & Sherwood, 2008). “This innovative instructional strategy allows
learners to evaluate a situation as it unfolds, practice assessment and communication skills, and
reflect on potential problems and solutions” (Page, et al., 2010 p. 225). An unfolding case study
takes traditional case studies further by including all skills and competencies needed in real
world scenarios. Traditional case studies frequently focus more on the pathophysiology of
disease without considering the psycho-motor skills, cultural competence and clinical knowledge
of students. Like integrated simulation, unfolding case studies approach student learning by
immersing students in real-life situations (Page et al., 2010). They differ from integrated
simulations because they can be implemented without the need of expensive equipment and
increases in faculty training, or facilities. Unfolding case studies can be utilized in a classroom
format using cooperative learning strategies (Day, 2011). They are also utilized by giving an
individual student a case study to work through independently (Durham & Sherwood, 2008).
SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS
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Like integrated simulations, unfolding case studies can be used to help students identify possible
medication errors or medication issues linked to the case being studied (Day, 2011). A key
difference between traditional and unfolding case studies is the latter frequently does not have all
information available (Billings, Kowalski, & Reese, 2011). This more accurately simulates real
world scenarios wherein nurses rarely have all information required to treat patients. Students
are forced to think critically about the case and justify interventions based on clinical judgments.
Unfolding case studies approximates realistic nursing practice in a more accurate manner than
traditional case studies (Billings et al., 2011).
Issues in Education
The reality is all nursing schools initially cannot afford high fidelity simulation labs.
Unfolding case studies provide instructors the opportunity to utilize real patient scenarios to help
students learn evidence-based practice (Day, 2011). Integrated simulation is a wonderful adjunct
to clinical training, but it is limited by cost, faculty training, number of students, and student and
staff familiarity with simulators. Unfolding case studies can fill the gap as they are not limited
by the above factors (Day, 2011). This integrated teaching strategy utilizes cases reflective of
the topics currently being studied didactically. Each student in class can simultaneously, through
handout or internet, be given the same case study. Students can work independently or
cooperatively. Students then present their findings as a group or individually in class and are
given the opportunity to defend their interventions based on physiology and evidence-based
practice (Billings et al., 2011).
Unfolding Case Study Development
To develop an unfolding case study a nurse educator must consider the objectives to be
accomplished by the study. The instructor must know what to expect from the student, what core
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competencies will be highlighted, and the level of student (Billings et al., 2011). Faculty should
work cooperatively to create the unfolding case study as it will limit the amount of time needed
by the individual instructor. According to Billings et al., the timing of the study must also be
considered. The instructors must determine if the case will unfold over a day, week, or
throughout the entire course (Billings et al., 2011). Every case study should highlight
medication issues, including errors, as they are the most common medical mistake in health care
(Reid-Searl et al., 2010). Each study can be evaluated by grading, journaling or using student
self-evaluation forms. It is not always necessary to grade an unfolding case study as through
cooperative discussion instructors can evaluate what competencies students are either proficient
or deficient (Day, 2011).
Logistics of Unfolding Case Studies
Unfolding case studies can be time consuming as they take forethought in development.
It can also take a great deal of class time if the instructor and students are using cooperative
learning and classroom reflection (Page et al., 2010). The cost is greatly reduced as compared to
integrated simulation and limited only by the expertise and creativity of the instructors. The
equipment needed for these case studies are generally paper handouts and a classroom.
Employment of an expert is valuable to independently review each case study for errors and
content (Page et al., 2010). Evaluation of the effectiveness of the case study should be done by
testing, student review, and debriefing by instructors to adequately determine the efficacy of the
unfolding case study (Page et al., 2010).
Theoretical Background
The theoretical backgrounds utilized for this paper are Patricia Benner’s novice to expert
and Gardner’s theory of multiple intelligences. In 1984, Patricia Benner published her landmark
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work on skill acquisition detailing how novice nurses transition to advanced beginner,
competent, proficient, and expert. Benner contended students and nurses progress through these
stages toward the goal of gaining expertise (Benner, 1984). One of the major issues with nursing
graduates is their inability to transition from the novice level within the timeframe of orientation.
Integrated simulation and unfolding case studies help students to make the transition from novice
to advanced beginner with greater efficiency and regularity (Benner, Sutphen, Leonard, & Day,
2010). The use of unfolding case studies and integrated simulation is reinforced by Benner’s
assertion that nurses gained expertise based on real world experience.
Howard Gardner’s theory of multiple intelligences is applicable to adult learning theory
and modern classroom instruction (Gardner, 1983/2011). It provides the theoretical framework
for nursing instructors to create diverse, cooperative, and interactive classroom exercises. By
extension, integrated simulation and unfolding case studies help to engage the students using
Gardner’s theory. There are 7 intelligences formulated by Gardner (1983). They are
verbal/linguistic, logical/mathematical, visual/spatial, bodily/kinesthetic, musical/rhythmic,
intrapersonal, and interpersonal (Gardner, 1983). Educators need to incorporate these
intelligences in integrated simulation or unfolding case studies. Learners are not simply one type
of intelligence, thus these methods are a more integrative approach at information dissemination
and delivery.
Conclusion
Integrated simulation and unfolding case studies present modalities to assist nursing
students in gaining expertise. Medication errors account for a majority of adverse events in
health care. Simulation and unfolding case studies are very beneficial in helping student nurses
recognize and hopefully minimize these errors. Benner and Gardner’s theories support the idea
SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS
of immersion as a tool for learning. Their theories will assist educators in creating simulations
and unfolding case studies that facilitate engagement without the risk of harming a patient or
punitive action against students. It is imperative nursing educators continue to utilize these
integrative teaching tools to assist student nurses in becoming true professionals. The costs in
money or human resources are far outweighed by the benefits received by the reduction of
medication errors and increased patient safety.
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