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Running head: SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 1 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 2 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. SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 3 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. SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 4 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 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 5 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. SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 6 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 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 7 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 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 8 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 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 9 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 10 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 11 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 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 12 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 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 13 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. 14 SIMULATIONS, CASE STUDIES, AND MEDICATION ERRORS 15 References Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco: Jossey-Bass. Billings, D., Kowalski, K., & Reese, C. (2011). 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