1. Assuring quality nursing skills development through practising on a high-fidelity human patient simulator (HPS) Paula Hodgson, Faculty of Education, University of Hong Kong Edmond T.F. Tong, School of Nursing, The Hong Kong Polytechnic University

2. ‘I have injected a medicine into the simulated patient within a second. If this were a real case, the patient would have died.’Student nurse

3. METI simulator With these simulators, you have a patient that: Blinks, variable pupil size, chest moves with respirations Normal/abnormal heart, lung, bowel sounds All pulses, blood pressure measurement Waveform monitors can be used or disabled to include: ECG, SpO2, temperature, NIBP, arterial line, CVP, pulmonary artery catheter, EtCO2, thermodilutioncardiac output. Source: Medical Education Technologies, Inc. (METI)

4. Potential for professional learning through human patient simulation (HPS) Students can Visualize the physiological effects (Nehring, Ellis and Lashley2001). Be placed under stress in the simulated situation (Dalleyet al. 2004). Reflecton the rationale for their actions (Greenawald2008). Be better prepared for their future careers without risking lives of patients (Jones 1995, Forrest et al. 2002). Rehearse communication skills in the simulated environment to avoid preventable medical errors and reduce litigation and unnecessary human sufferings (Reader, Flin and Cuthbertson2007).

5. Background of the study Practised two patient simulation sessions in scenarios on patients with stroke and thrombolytic therapy and burn injury as a part of the curriculum in the final year of an undergraduate nursing programme running in the Hong Kong Polytechnic University.

6. Intended learning outcomes of the simulated practice Students can have the opportunity to Demonstrate integrated nursing knowledge to conduct appropriate assessment and critical analysis; Practiserisk-free treatments; Communicate effectively with medical, other healthcare professionals, and family members or close relatives when patient’s condition turns critical.

7. Arrangement of HPS Working in groups of four or five, each group (Team in-charge, 2~3 nurses, 1 recording), will discuss what assessment is needed and what appropriate actions are to be taken during the 20 minute practice. Source: Medical Education Technologies, Inc. (METI)

8. Having good preparation before practising HPS: providing reading resources and doing online quizzes Assurance of quality learning (1)

9. Staff providing onsite supervision: Promptthe students if they fail to react on the spot; Askfor additional patient information such as the latest laboratory results and orders of the new healthcare provider; Notmake any comments on how students manage the simulated patient or interactions between group members during the simulated practice. Assurance of quality learning (2)

10. Post-HPS evaluation Receivefeedback from the facilitator on their performance after completing the HPS. Assurance of quality learning (3)

11. HPS in practice

12. HPS survey: five top-scoring items 20 items of simulated clinical experience from Medical Education Technologies, Inc. (METI) (5-point Likert scale; 5=strongly agree and 1=strongly disagree); N=150

13. HPS survey: five bottom-scoring items

14. Perceived value experienced by nursing students when doing HPS (1) Cognitive learning: Read the background information of the patient, such as age, medical history, family background (with wife and children) and additional information before sending to A&E; Be alert to the need for assessmentusing the criteria, such as complications, inclusion and exclusion criteria.

15. Perceived value experienced by nursing students when doing HPS (2) Self-regulated learning Did pre-HPS quiz to find out how well I understood the concepts about thrombolytic therapy (focus of this HPS); Searched related information from the internet other than notes prepared by the lecturer. ‘Helped me to think clearly during the simulation [considering types of assessment]’.

16. Perceived value experienced by nursing students when doing HPS (3) Situated learning: ‘Despite all the preparation, i.e. reading materials, as being a student, I felt nervous.’ Group 1 ‘Observed actions not taken when Gp1 was in action; We (Gp 2) followed actionsthat were being missed. As I knew the process better, I felt more relaxed, i.e. not feeling involuntary shaking.’ Group 2

17. Perceived value experienced by nursing students when doing HPS (4) Learning from mistakes: ‘I was informed by the instructor that the simulated patient could only move a certain degree. As I was not sure about the standard - the best motor response, I skipped it and just put a low score. Instead, I asked the simulated patient to show me the tongue. After this practice, I'm aware of how to assess and make judgement on different range of motor response according to the standard. Also, I learn that best motor response to measure the side that was not affected by the stroke, but not the affected side.’

18. Perceived value experienced by nursing students when doing HPS (5) Learning from mistakes: ‘Although the upper blood pressure (BP) was over 180 before, we were doing the steps in a hurry and assumed that we (the next group) continued to make another injection without checking the patient’s changing condition. In fact the BP was gradually lowered and should require NO further injection. An instruction by the doctor was missed, that is making another injection is necessary if the blood pressure remained high 10 minutes afterwards. It was not included in the medical record but was roughly written in a draft note. This reminds me that any notes taken should be properly written in the medical record so that there is clear communication between groups.’

19. Perceived value experienced by nursing students when doing HPS (6) Learning to communicate: ‘As we were doing the assessment, we did not know the Chinese term - dead air over the phone. And the family member was even more worried about the patient because we stopped in the middle of a sentence. In fact we're just trying to translate in our head.’ ‘We do not know the appropriate words to describe the worsening condition happening in the hospitalization when communicating with the family members… not sure how critical or the patient might reach the stage of dying and whether they should call the rest of the family members to the hospital when the condition turns critical.’

20. Perceived value experienced by nursing students when doing HPS (7) Post-HPS evaluation: ‘As the simulation of clinical practice, I believe that there is room for error. As we evaluate actions taken, I think there is a greater impact with deeperimpression of learning.’

21. Perceived value experienced by nursing students when doing HPS (8) It is observed that students can benefit from thinking on the spot in the simulated environment because they need to demonstrate critical thinking skills, in particular what assessment to make and to build confidence in handling stress when patient condition changes drastically (Bearnson and Wiker 2005, Jarzemsky and McGrath 2008).

22. Perceived value experienced by nursing students when doing HPS (9) Overall: ‘The simulated practice helped me to realize that in ‘authentic’ situations, conditions can change by the minute. It's different from exercising in the laboratory or reading from reference materials, which typically describe what theories are. In real situations, so many factors contribute to what appropriate actions are to be taken. Knowing theories only is inadequate to provide professional care even in this case. Need to know how to apply theories flexiblyin practice and should not be one size fits all.’

23. ‘We vividlyremembered it. We can't afford to make errors in real situation.’Student nurse

24. Assurance of quality Heightened awareness of critical thinking, communication skills, and handling stress in professional nursing practice through situated HPS learning

25. Bearnson, C. S. and Wiker, K. M. (2005). Human patient simulators: A new face in baccalaureate nursing education at Brigham Young University. Journal of Nursing Education, 44(9), 421-424. Dalley, P., Robinson, B., Weller, J. and Caldwell, C. (2004). The use of high-fidelity human patient simulation and the introduction of new anesthesia delivery systems. Anesthesia and Analgesia, 99(6), 1737-1741. Forrest, F., Taylor, M., Postlethwaite, K. and Aspinall, R. (2002). Use of a high-fidelity simulator to develop testing of the technical performance of novice anaesthetists. British Journal of Anaesthesia, 88(3), 338-344. Greenawald, D. A. (2008). Live! From the sim lab: Broadcasting a simulated patient - care scenario as a teaching-learning strategy in a nursing fundamentals clinical lab. Clinical Simulation in Nursing, 4(2), e11-e14. Jarzemsky, P.A. and McGrath, J. (2008). Look before you leap: lessons learned when introducing clinical simulation. Nurse Educator. 33(2), 90-95. Jones, K. (1995). Simulations: A handbook for teachers and trainers (3rd edn). London: Kogan Page. Nehring, W. M., Ellis, W. E. and Lashley, F. R. (2001). Human patient simulators in nursing education: An overview. Simulation and Gaming, 32(2), 194-204. Reader, T. W., Flin, R. and Cuthbertson, B. H. (2007). Communication skills and error in the intensive care unit. Current Opinion in Critical Care, 13(6), 732-736. References

26. Q&A Assuring quality nursing skills development through practising on a high-fidelity human patient simulator

27. THANK YOU Contact: Paula Hodgson: etpaula@hku.hk Edmond T.F. Tong: hsetong@inet.polyu.edu.hk