Enhancing Simulated Learning for Students (part 1)

A quality, safe, controlled simulated learning environment can effectively provide clinical experiences for entry-level nurses to meet the challenge of workforce readiness. This posting is the first in a series where you will learn about infusing common situational realities of nursing into simulated scenarios and how this combination allows students to practice communication, manage their emotions, and contend with a variety of atypical circumstances while caring for clients, further narrowing the education-to-practice gap.

How do students learn to take care of common challenges of situational realities of nursing like (a) Providing care to difficult clients that are disagreeable, unpleasant, or non-compliant to treatments, diet or activity level ordered, (b) Working with families that are continuously trying to find fault with the client’s care, argumentative, or non-supportive of the client, (c) Civility issues involving being taken advantage of, manipulated, or bullied by other nursing staff?

Let’s look at the difficult client. Students are frequently assigned to clients that are pleasant, agreeable, and compliant to treatments to gain experiences in providing nursing care and build confidence. What happens when they become nurses and begin taking care of clients that are not agreeable, pleasant, friendly, or compliant?

Students can gain experience working with difficult clients in a safe, controlled simulated environment. Here are some examples of how to infuse difficult client nursing realities into simulated scenarios:

  • A client with CHF on a no-salt diet is yelling at anyone that comes in her room to give her salt packets.
  • A client is shouting angrily and acting edgy about needing to have a cigarette as he tries to light up one in his bathroom.
  • A client with an NG tube is angry and complaining about being thirsty so pulls out the tube to drink some water.

How about civility issues? Typically, nursing faculty encourage a culture of peer support and helpfulness with students. A newly hired nurse may think “Everyone will like me and support me.”  Would co-workers truly take advantage of a fresh new nurse? Or manipulate the nurse?  Or even bully the person?

Susie, a character I portray, is a certified nursing assistant. She is not pleasant, sometimes comes across mean-sounding, is bossy, tries to get the students to do her work, and, oh yeah, she doesn’t like nursing students. Students are told she is a difficult co-worker that will provide them practice communicating, delegating, or getting help from as she is assigned to their clients. Here are some examples of how to infuse civility nursing realities into simulated scenarios:

  • Susie avoids giving the glucometer results to the student unless the student helps her make some beds.
  • Susie is giving sugar packs to a diabetic, and when confronted about it, blames the client.
  • Susie is asked by a client to get some ice water, so Susie tells the student assigned to the client to do it.

When students work with situational realities of nursing in a simulated scenario, they can become frustrated, anxious, intimidated, and feel inadequate to handle the situation.  After a few minutes, sometimes I will hear “I am stuck.” or “I’ll just do it myself.” Other times, all the negative emotions from the client or Susie are displaced onto the student and the student feels bad. For students to best learn from these situations, I stop the scenario with a “time-out” so we can discuss what’s happening. I ask students if what they are doing is working and am told “No.” I help students to realize that if what they were doing or saying wasn’t working they need to change their approach. We discuss the need not to absorb displaced anger personally, but instead understand the person is expressing feelings in reaction to what he (she) is experiencing. Suggestions of what to do or say are given to help the situation end more positively for the client and student.

Stopping the scenario allows students to disengage from it, think about it, and decide on changes in what they might do or say to positively manage the situation with the client or Susie. The scenario is then “turned back on” so students can try a different tactic which reinforces their reasoning and problem-solving processing. Students hear this message, “If what you are doing is not working, stop doing it, and change your tactic.” As with any simulated scenario, a debriefing is done afterwards that includes reflective thinking, processing of the situation, identifying what worked, what didn’t work, and lessons learned.

It is a fabulous moment when beginning students initially saying, “I don’t know what to say or what to do” grow to become students confidently saying, “I can see that you are very unhappy about not seasoning your food with salt. Let’s discuss some other seasonings that may be tasty to you but not cause you to retain fluids.”

Look for future postings in this series with suggestions for improving simulated scenarios or clinical to help broaden the learning experiences for students. Also take a minute and send me what you are doing at your college to enhance the simulated experience for students. I would love to hear from you.

Barbara Callahan, MEd, RN, NCC, CHSE