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Human touch in a virtual world

Can simulated learning environments teach nursing students important interpersonal skills? Flynn Murphy reports on the debate surrounding the challenges and opportunities.

Rapid advances in new technology have made simulated learning environments available to a growing number of nursing students for practical training.

Supported with funding from the federal government, simulation has the potential to reduce the number of clinical placement hours for students at a time when capacity is stretched. But is there a risk of losing exposure to important interpersonal skills with reduced patient contact?

Last month, Nursing Review reported on the work of Dr John Hurley, a senior lecturer at Southern Cross University, who argued for the importance of emotional intelligence in nursing education. He called for better training for nursing students in self-awareness and interpersonal communication.

Reflecting on simulated learning, Hurley acknowledged the power of such technologies as teaching tools, and the ingenuity of their design, but added that they risk depersonalising what nursing is about. “They can never teach interpersonal interaction. They can never simulate, whether it’s role play or interaction, the full demands of what nursing is all about.”

The University of Technology, Sydney is one tertiary institution that is leading the way in maximising the opportunities of simulation technology. Last year it invested $2.6 million in seven new clinical simulation labs, building on a federal government grant of $2.4 million. Five of the labs feature the very latest in robotic mannequin technology, or patient simulators.

These mannequins have a range of different capabilities: they variously can blink and react to light, have complex airway systems, mimic an arrest, chests that rise and fall and pulses. There are some where trainers can put words into their mouths from behind a one-way pane of glass in a high-tech control room. The labs are also decked out with a number of different “task-trainers” – limbs, torsos, and other “body bits” which allow students to practise different clinical procedures, such as inserting urinary catheters.

Michelle Kelly, director of simulation and technologies at the UTS nursing faculty, said the use of robotic simulation was as a special teaching tool that helps to build student confidence and complements rather than completely replaces on-the-job training.

“If you have a trainer giving feedback in real time via a mannequin then you are getting pretty close to reality when students are preparing a patient, and telling them what’s going to happen, and how it’s going to feel.”

“We have simulation integrated right across our curriculum. We just finished giving 480 students three hours [of individual time with the mannequins]. They get that in their first year, and second and third year are similar.”

Kelly said the use of mannequins was one aspect of a wider approach that included role play and other techniques. “There are several experiences of learning, and you layer one on top of another.

You might start just practising a skill on a task-trainer, and then you can practise it on a full-body mannequin, and then that can be combined with a clinical placement. There are some things that you can only get experience in through a [clinical] setting.”

She said an advantage of the use of mannequins was that they could ensure that students met course outcomes by offering a controlled experience in a wide range of scenarios. “In clinical [placements], the experiences they will get can be very hit and miss. But here we can guarantee that our students will get an understanding of how to manage and respond to a patient who has an acute episode of asthma, an acute episode of chest pain, who’s going into cardiac failure – so that when it happens in clinical they can recall that experience and be ahead of the game in knowing how to respond.”

Emily Baldwin, 28, is in the second year of her nursing degree at UTS. She began using the new lab this year, and said she couldn’t imagine undergoing a nursing degree without it. “I’d feel very vulnerable going out on placement without having done what I’ve done on the labs. I guess I’m pretty fortunate in that regard.”

One of Baldwin’s most memorable experiences is the use of a simulated newborn baby. “I hadn’t realised how really difficult it would be to try and count the pulse of a newborn baby, because it’s just so fast. If you’re out on placement and you’ve never done something like that, you’re petrified.”

Baldwin said students got out what they put in when it came to simulation. “It depends on the dynamic of the class. Earlier this semester [a mannequin] was programmed to arrest, and we did our CPR, and as a team of nurses you get into different roles and you respond to a deteriorating patient. If everybody gets right into it you do get the adrenaline going. I certainly did.”

“At the end of the day it’s not real, and it would be different in a real-life scenario, and we know that, but it kind of gives you an idea of what to expect. It reduces the fear for when that actually happens.”

When asked about how much individual time students spend with the simulated patients, Baldwin said there needed to be more of it.

But mannequins are not the only method of simulation. The MASK-ED technique, pioneered by CQUniversity associate professor Kerry Reid-Searl, is gaining momentum as a pedagogical method.

Reid-Searl has been in the news recently as the “educator in the mask”. She uses advanced prosthetics to impersonate a series of characters that allow her to engage with her students as both a patient and educator. And now she’s teaching the techniques to other nursing educators in two-day workshops. “There’s a whole pedagogy behind it,” she said. “It’s just not me donning some props – there’s a course and user guide.”

Reid-Searl said mannequins can teach some things that she cannot. But she pointed out her props are far less expensive (about $2500 to $4500 for a prosthetic face), the preparation time to carry out a practical scenario is far shorter, and her control and capacity for spontaneity is greater.

“Once you’ve got your props and pieces and worked out how they fit in and out of the curriculum, you can have a simulation prepared in three minutes.”

Reid-Searl’s characters all have specially-designed histories that allow them to perform an educator role, such as Cyril Smith, a retired butcher who has read all of his nursing-student granddaughter’s textbooks.

“Unlike a regular actor, I can control and direct the learning. Actors work with a set script and they can’t grab those teachable moments. And if I just go and do a role play using my face, there’s a power imbalance between the lecturer and the students, and they never really take me totally seriously,” said Reid-Searl.

“The biggest things are the realism, the spontaneity and the humanness – I can do a seven-minute scenario as Cyril and know which concepts need to be addressed, but I can grab whatever teaching moment I see. By having the nurse educator becoming the patient, every character that’s created is a platform for teaching.”

Reid-Searl acknowledged the importance of task-trainers, but pointed out that they “don’t ever give a spontaneous human response”.

“I go in with what I call the five senses of learning: can I see it? Can I feel it? Can I hear it? Can I touch it? Can I say it? My characters allow me to address all of those. A mannequin in a bed just doesn’t fit the bill.”

Reid-Searl’s method is also effective when it comes to the teaching of emotional intelligence.

Especially when it comes to parts of the body beyond the face. “Last week we were doing a lesson on the application of Uro Sheath [catheters]. The level of embarrassment that students get, you don’t see in a textbook. I have whole torsos that I put on, with genitalia and the works. There’s tubing inside my props that allow them to function.

“So I can look at the anxiety in the student’s face and say something like ‘are you worried about touching that darling?’ – and that becomes a teachable moment. What are you going to do in that situation as a nurse? Where is that in a textbook?”

Reid-Searl said her characters also gave students a sense of continuity that was currently lacking given the transient nature of modern student nursing placements. “Cyril meets the students in week one, and he pops in all the time. Back when we were training as nurses in a hospital, we’d have our regular patients and we were part of the hospital environment, and we belonged there.”

She said acting experience was not required to become an educator in a mask. “The real key is the level of knowledge, and the ability to think quickly and transfer information that can be quite complex into simple stuff for the students to understand.

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