Teaching and Learning in Nursing
Volume 7, Issue 1 , Pages 2-5, January 2012

Bringing simulation to life through a therapeutic encounter: a pedagogical approach used for associate degree nursing students1

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Abstract 

Human patient simulation is oftentimes incorporated in the educational process for instructing nursing students and has proven to be instrumental in narrowing the gap between theoretical foundations and clinical practice within a safe learning environment. Although this pedagogical approach can be a beneficial adjunct to the traditional lecture in nursing education, it does lack one component, which is contact with a human being. Nurse educators can be instrumental in enhancing the learning process when using simulation by incorporating this key element of patient care, the therapeutic encounter.

Keywords: Simulation, Nursing education, Nursing students/educators, Therapeutic encounter

 

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1. Introduction 

In the last decade, the use of human patient simulation in nursing has become increasingly more prevalent and is a valuable instructional adjunct for those case scenarios that are difficult to create in a clinical setting (Adamson, 2010; Howard, Englert, Kameg, & Perozzi, 2011; Seropian, Brown, Gavilanes, & Driggers, 2004). There is a wide array of simulators being used in health care education today, and the simulator can range from a low-fidelity simulator to high-fidelity simulators with just about everything in between. The higher the simulator fidelity, the higher the potential for a more lifelike or “real” simulated-patient scenario (Seropian et al., 2004). Some patient simulators can offer the ability to display both physiological and psychological responses; even death can be simulated with some specific models. Although use of the human patient simulator has the ability to provide a variety of simulated learning scenarios, effective implementation of this pedagogical approach may still have its disadvantages. One aspect of the simulation process that cannot be easily reenacted with all situations unless a high-fidelity simulator is present is the nurse–client therapeutic interaction or therapeutic encounter with a human being (Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009). The human aspect of nursing care can be lost with use of human patient simulation in some cases; therefore, the opportunity to use therapeutic techniques and build a therapeutic relationship lacks. The human aspect of nursing has always been included in traditional clinical education of nursing students, and without the face-to-face contact with patients, students miss a vital element of providing holistic care. Some simulated experiences simply do not include the human aspect that occurs during a clinical experience of caring for patients (Berndt, 2010, Jansen et al., 2009).

Although it is not the intent of this article to detail the historical journey of simulation and its passage into nursing curricula, it is significant to highlight that the integration of simulation as a pedagogical approach for educating nursing students has made significant strides in the academic arena. Furthermore, high-fidelity simulation certainly has its place interwoven throughout the curriculums of undergraduate and graduate nursing schools, as well as other health care programs. Simulation has been put to the test in several research studies and proven its relevancy in education (Solnick & Weiss, 2007).

The objective of this article is to emphasize the need for nurse educators to incorporate teaching approaches that enhance therapeutic techniques, including the nurse–patient relationship while using patient simulators. In some simulations, actors can be scripted into the scenario so students have the ability to communicate with a person; however, the communication that takes place can be limited by the “script” written for the scenario. Nonverbal cues and unpredictable emotional responses that typically occur with patient care can be lacking with actors' scripted responses (Brown, 2008). Even a client's cultural practices may impact the communication and therapeutic relationship (Mitchell, Fioravanti, Founds, Hoffmann, & Libman, 2010). Role-playing during simulation has proven effective in some cases for introducing the therapeutic content and incorporating this material during the debriefing of the simulation, but, again, this can be limited. This article will describe one unique teaching methodology for enhancing the learning experience while incorporating use of a human patient simulator in the nursing classroom. This approach was used while instructing undergraduate degree nursing students and included the use of simulation coupled with a therapeutic encounter with an individual who had been involved in a situation related to the case study that was presented. Prior permission was given by the individual for his information to be shared with the students as a learning opportunity, and institutional board approval was obtained.

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2. Educational methodology 

Typically, incorporation of simulation in nursing curricula includes three basic steps; these three steps include the following: (a) a briefing period where the case is introduced and students have the opportunity to mentally prepare for the simulation experience; (b) simulation of the actual scenario or case study occurs, and the students implement the nursing process while providing patient care; and (c) the final step in the process is a follow-up or debriefing of the scenario with faculty present to provide feedback to the students (Cant & Cooper, 2009). It is during the debriefing that students have the opportunity to reflect upon their actions, thoughts, and feelings about providing care to the patient in the case study. This is an important step for students learning to reflect upon course content and then prepare to apply learned information into clinical practice (Cant & Cooper, 2009). In some cases, the simulation can be visually recorded, allowing students to view the provided nursing care. In our teaching methodology, we provided two additional steps in the learning process: (a) the therapeutic encounter and (b) the group process. The additional steps were used to teach students about the significance of the therapeutic nurse–client relationship and to engage the affective domain of learning.

In the development of curriculum in any course, the educational strategies that are used are dictated by the objectives that are to be accomplished. In this case, the objectives of the simulation were created based on the curriculum and outcomes related to the simulation of an actual human being's experiences. One of the benefits of simulation is the unique manner in which the objectives of the course may be accomplished, and in this case, the objectives of the simulation were congruent with the fundamental concepts that were previously taught in the classroom setting.

In preparation for the simulation, students were told about a case exemplar in which they would be providing care. Predesigned case exemplars are commonly used in educational settings when simulation is being implemented. However, for this educational process, a case exemplar was constructed from a man who granted prior permission to use his story to help educate nursing students. His case, “Meeting Smiley” (anonymous nickname used for confidentiality), is detailed below. The history and physical assessment criteria were provided for the students during the briefing stage and varied slightly from the actual person's situation to meet the objectives for the course.

Smiley is a 56-year-old male who has been impeccable healthy his entire life. He was a carpenter by trade, which made him comfortable operating heavy machinery and power tools, such as a chainsaw. He was trimming dead tree limbs in the backyard from a bucket of a backhoe. As he began to lean forward to trim back the dead branches in the trees, he accidentally became unstable on his feet and lost his balance and fell. Smiley was able to throw the running chainsaw to his side, but he was unable to grip the backhoe and pull himself to safety. Within seconds he fell approximately twelve feet to the ground where he landed on both hands and his left hip. He remained conscious and was able to tell paramedics that he suffered a broken hip and that both wrists were fractured. He was in severe pain from the impact.

On the day of simulation, students were randomly assigned in groups of 8–10 and briefed on their predetermined roles and responsibilities for the simulation process. Simulation was then executed, and at the conclusion of their simulation, groups were combined for the debriefing period, which was orchestrated by faculty and the simulation center coordinator. At this time, students were asked to submit inquiring questions that they would have asked “Smiley” if he were a real client verses a simulated case. The students prepared a myriad of questions encompassing the physiological, spiritual, psychosocial domains. Many of the physiological-based questions were centered around pain control and medical complications, whereas the psychosocial questions focused on coping, stress, anxiety, and his support systems or lack thereof. Students were unaware that in the following class period, they would actually have the opportunity to have a therapeutic encounter with the man known as Smiley.

A therapeutic encounter is an opportunity for the nurse or students in this case to meet with the client. The interaction even if informal and/or limited can be significant for the clients healing process and for the nurse's development of self-awareness and compassion (Varcarolis & Halter, 2010). The therapeutic encounter in this educational process took place in the next session with the students, and it was at that time Smiley and his wife were introduced to the students. The questions that students prepared in the debriefing session were presented to the couple, and together, they took the students through their journey of a horrifying accident and remarkable recovery. At the end of the formal questions that were prepared in advance, an open forum was permitted for students to ask additional questions to both Smiley and his wife. This session took approximately 30 minutes and greatly impacted the learning process. Students were extremely engaged in the experience.

In the final group process phase of the educational experience, which was facilitated by faculty members, students were given the opportunity to process how the experience of meeting Smiley impacted them and their learning. Students were asked to reflect upon two questions:

1.What were some of your thoughts about meeting the real person from the simulation scenario?

2.How can you relate this experience to your own learning?

Based upon written and verbal responses, students felt that the experience had provided them a deeper meaningful connection and that the integration of meeting Smiley was invaluable.

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3. Outcomes 

There were numerous learning moments during the therapeutic encounter; however, through discussion in the final group process, there were three dominate themes that appeared to impact the students' affective learning the most. These themes included the significance of support systems in the healing process, communication between nurses and patients, and lifestyle alterations that can occur after a traumatic event. Without the additional steps (therapeutic encounter and group process), the identified themes would not have emerged with the depth that occurred for the students.

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4. Support systems 

When asked by one student, “what brought you through this experience and how did you cope?” Without hesitation Smiley turned to his wife and quietly said to the students, “she is the reason I made it through this.” This was a critical learning moment for students that never would have transpired in the simulation center. The overwhelming silence in the classroom at that moment was deafening. The connection between Smiley and his wife was so powerful that it triggered a learning experience that students were able to visually see and affectively feel. The authors believe this was a clear demonstration of affective learning for students that would not have taken place without the therapeutic encounter. Interwoven in much of Smiley's dialog was how family and friends were a central influence for “lifting my spirits” and “encouraging me to keep going.” These comments were profound and confirmed to the students how influential support systems are in the healing process. Students may not have considered this factor as thoroughly had they not had the opportunity to speak with the actual person in the simulated case.

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5. Communication 

Therapeutic communication between nurse and patient played a vital role in Smiley's recovery. Numerous times he stressed the significance of how an interaction even if simplistic in nature would calm his anxieties and assist in bringing meaning to the situation. He emphasized the importance of “telling me what was going to happen next” as a beneficial tool in recovery. Communication is a key element in therapeutic nurse–patient encounters, and truly, it was essential in this scenario. Students can be told that communication is important, but hearing it firsthand from Smiley had a profound impact, which was further underscored through his nonverbal cues. In addition, he emphasized how important it was for the nurses to build rapport with him and his family. He explained to the students that he felt safer with a nurse he could trust.

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6. Lifestyle alterations 

Potential alterations in lifestyle were discussed in the final group phase of the learning process. Students were well aware of the fact that the man in the simulated case would have changes in his lifestyle after the accident. Common lifestyle alterations that students highlighted were situations such as eating, driving, walking, and working. However, there were many unforeseen modifications that Smiley shared with the students that made coping with this injury challenging. For example, Smiley's one love was to play guitar, yet the impact of his fall damaged both hands and wrists, which left him unable to play. This enjoyment was robbed from Smiley, and his story of this loss was important for students to hear and process. Students need to realize that alterations in daily living may go beyond the typical or obvious. The therapeutic encounter paved the way for discussion about grief and loss issues.

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7. Implications for nurse educators 

As nurse educators, we are constantly searching for innovative teaching/learning techniques, and although simulation is not new to nursing, the concept of coupling the actual human being used in the case scenario with simulation has proven to be an effective educational tool in addressing both the physiological and psychological domains of an individual. Ensuring that students have a true understanding of the possible complications and their ability to manage them is the challenge of nurse educators. The ability of the student to use the nursing process and their critical thinking skills at the bedside is the essence of our existence as nurse educators. These abilities are difficult to assess and to measure and often are found to be problematic until later in the curriculum. One tool to assist with this dilemma is the use of simulation coupled with actual case scenarios.

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8. Conclusion 

There is no doubt that simulation is a vital pedagogical approach to educating nursing students; however, adding an opportunity for a therapeutic encounter between students and the human being can enhance the learning. It is paramount as nurse educators that we attempt to provide therapeutic connections for our students as “humans have a built-in need to relate to others […] (Varcarolis & Halter, 2010).” By orchestrating a therapeutic encounter with Smiley in conjunction with the simulated case study, it provided a deeper meaningful experience for the students. Noted from the student's comments was a higher sensitivity to empathy, rapport, and self-awareness, which are key aspects that may not have been introduced by simulation alone. The availability and openness of the actual person who had lived through this situation became an invaluable learning experience for nursing students.

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References 

  1. Adamson K. Integrating human patient simulation into associate degree nursing curricula; Faculty experiences, barriers, and facilitators. Clinical Simulation in Nursing. 2010;6:e75–e81
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1 No grant or other financial assistance received. No prior presentations.

PII: S1557-3087(11)00090-4

doi:10.1016/j.teln.2011.09.003

Teaching and Learning in Nursing
Volume 7, Issue 1 , Pages 2-5, January 2012

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