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Comparison of communication outcomes in traditional versus simulation strategies in nursing and medical students.

AS PATIENT COMPLEXITY CONTINUES TO INCREASE AND CLINICAL FACILITY SPACE BECOMES TIGHTER, SIMULATION HAS EMERGED AS A STRATEGY TO ACHIEVE CURRICULAR COMPETENCIES IN BOTH NURSING AND MEDICINE. Studies comparing the effectiveness of simulation strategies versus traditional strategies are on the rise as educators embark upon this new approach to facilitating student learning.

At the same time, health care discipline educators are being called upon to incorporate more interprofessional learning in the curriculum. An Institute of Medicine (IOM) report (2002) appealed to health educators to demonstrate five core essentials, one of these being interprofessional education. This call was restated in a subsequent IOM report (2010). Further, growing concerns in health care with regard to patient safety have led to the understanding that interprofessional communication is a critical area involved in patient errors (Joint Commission, 2011).

While research on the use of simulation strategies in health care disciplines is increasing, this research tends to be housed in discipline-specific silos. The purpose of this study is to understand interprofessional communication (nursing and medicine) within the context of the educational environment (traditional versus simulation).

Literature Review There are numerous reports in both medical and nursing education on the use of simulation. This review is confined to primary research reports in the literature, particularly with the use of high-fidelity or human patient simulators.

MEDICAL EDUCATION Medical student education has been using simulators for longer than nursing, so it follows that there is more research literature on the use of simulation in medical education. The majority of the research focuses on psychomotor and assessment skill development.

High-fidelity simulation (HFS) was used to construct an emergency patient simulation encounter for 202 first- and second-year medical students that was based on concepts of neuroscience (the autonomic nervous system).The study used a post-encounter survey that rated the experience based on: the ability of the simulation to enhance the clinical scenario, facilitator effectiveness, actors, correlation of the scenario to patient care, value of the simulation approach, and overall presentation. On a five-point Likert-type scale, students overwhelming gave the encounter an "outstanding" rating, with no students rating the encounter below "good," which was the middle rating (Fitch, 2007).

MacDowall (2006) investigated medical students' perceived confidence regarding their competence in a variety of psychomotor skills using HPS. Twenty-three students rated their confidence level of their competence before and after the simulation encounter. Confidence was shown to increase at a statistically significant level as a result of participating in the encounter.

In a comparison study evaluating the effectiveness of simulation, 155 fourth-year medical students and 67 second- and third-year medical students participated in a cardiology review course for internal medicine using a cardiac simulator during a one-year period. The comparison group consisted of historical data from 53 previous students from the same medical program. Fourth-year students showed a 4.3 percent improvement in test scores, while second-and third-year students showed a 6.4 percent improvement, both gains statistically significant (Issenberg et al., 2002).

Not all studies have shown significant differences in simulation strategy when compared with traditional strategies. A randomized controlled trial was used to compare simulation and traditional methods of education. Thirty-eight third-year medical students received either simulation or lecture on medical scenarios involving myocardial infarction and reactive airway disease. The study showed no significant differences between the groups on pre- and posttesting results. The lack of significant results could be attributed to the sample sizes being smaller than in other studies (Gordon et al., 2006).

In a study involving interphysician communication, 134 medical students in the Netherlands participated in two simulated patient encounters and completed a pre- and posttest survey on communication indicators such as: constructing lists of patient findings, patient problems, differential diagnoses, action plans, and executing the action plan of a colleague. All five indicators were improved at a statistically significant level (Sijsterman, Jaspers, Bloemendaal, & Schoonderwaldt, 2007).

Finally, in a study highly relevant to the study in this article, 101 nursing students and 121 medical students and residents evaluated a simulation encounter regarding a teamwork approach to ACLS education. Students reported that the encounter was valuable for understanding team roles, that the encounters should be mandatory for all nursing and medical students, and that they desired more interprofessional training (Dagnone, McGraw, Pulling, & Patteson, 2008).

NURSING EDUCATION In a study of 42 senior-level nurse anesthesia students, researchers were interested in determining whether a simulated experience was perceived as "real" enough to constitute a valuable clinical encounter by faculty. Student participants were videotaped and three reviewers, knowledgeable about the surgical setting and trained as reviewers, rated the level to which the scenarios were realistic using a variety of indicators. With acceptable interrater reliability, the study showed that simulation was an acceptable "realistic" encounter (Hotchkiss, Biddle, & Fallacaro, 2002).

Nurse anesthetist students were the focus of another study where a pre- and posttest design was used to measure the effect on self-efficacy related to a general anesthesia scenario requiring the identification and management of an anaphylaxis event. All students participated in the simulation event. Pre- and posttest scores showed a significant difference in the students' perceived self-efficacy (Gee, 2006).

In an evaluation of HFS, students and faculty rated how realistic and transferrable skills were from the simulation environment. While all faculty believed the simulation to be transferrable, only approximately 50 percent of the students believed the same. Further, faculty identified the need for additional time and resources to implement simulation (Feingold, Calaluce, & Kallen, 2004).

Thirty-six midwifery students were randomly assigned to either a simulation group involving normal labor and physiologic jaundice or lectures on the same material. Students who were in the simulation group were more likely to collect more clinical information, revisit clinical information less, make fewer formative inferences, reported higher confidence levels, and reached a decision (Cioffi, Purcal, & Arundell, 2005).

Using a qualitative approach, simulation was studied in first-term nursing students. Themes that emerged as a result of examining the student experience with HFS indicate that clinical decision-making could be supported with a simulation approach and that simulation may provide a "value-added" approach in conjunction with traditional clinical experiences (Lasater, 2007).

Student perceptions of intraprofessional (within nursing) team education was examined using a qualitative approach (Leonard, Shuhaibar, & Chen, 2011). In this study, third-and fourth-year nursing students engaged in a scenario where they had to manage a pediatric and adult simulated situation. The researchers found three key themes: role recognition and differentiation, adaptation to team environment, and professional solidarity.

SUMMARY OF LITERATURE REVIEW There are few studies that use a comparison technique of simulation versus another method, and few studies that investigate the impact of simulation on the development of communication skills. Further, none of the studies found addressed the call from the IOM reports with regard to improving interprofessional collaboration in health professions programs. This study fills a crucial gap in the literature by investigating the ability of the simulated environment, versus a traditional environment, for the development of interprofessional communication skills.

Simulation Model and Intervention The model used to build the simulation experience was the Jeffries simulation model (Jeffries, 2007). In the model, students and educators bring characteristics to the learning activity that have an impact on the outcome and must be considered in order to affect the outcome. In addition, educational practices are considered that evolve from student and educator interaction, as well as the expectations set for the experience beforehand.

In this study, the interaction becomes more complex as two differing sets of students must be considered in the design of the educational experience. Further, since this is a comparison study involving a nonsimulation technique, the design must equally accommodate the differing learning environments.

The characteristics of simulation design are also critical to learning outcomes, including objectives, level of fidelity, problem solving, student support, and debriefing. In this study, the communication objectives across both the nursing and medical curricula were merged into interprofessional terminology to meet the desired outcome. The level of fidelity was a variable under study with high fidelity being compared to traditional roundtable (no fidelity).The problem-solving issue or context was a mock code in an advanced cardiac life support (ACLS) scenario, a "common ground" area for both senior nursing and second-year medical students. As the study was focused on outcomes of the experience itself, minimal student support and debriefing was provided. Therefore, the data was "pure," evolving only from the learning environment and interactions between the students.

Method A prospective, descriptive survey design was used that included both quantitative and qualitative data. Institutional Review Board (IRB) approval was obtained for the study.

PARTICIPANTS Convenience sampling was used to recruit participants for this study. Forty-eight senior bachelor of science in nursing (BSN) students and 20 second-year medical students were eligible to participate. Students participated in the clinical scenario as a part of their clinical time and then gave consent with regard to whether their data could be used for research purposes.After accounting for consent and complete surveys, data from 41 nursing and 19 medical students were used for data analysis. Thirty participants were in each group.

PROCEDURES Students were divided into teams involving two medical students and three to four nursing students and then randomly assigned to either the traditional roundtable or the simulation intervention. The traditional roundtable (no fidelity) consisted of a facilitator providing the scenario as an unfolding case, similar to the algorithm in the simulation scenario. Nursing and medical students sat together at a table where they could discuss and decide upon their interventions at critical points as the scenario progressed. The high-fidelity simulation consisted of a manikin in a patient bed with monitoring equipment available; all students stood by the side of the manikin as the scenario evolved.

The context for interaction was a mock code scenario used for ACLS training purposes. A single facilitator was available for both groups. The purpose of the facilitator was to unfold the code scenario in the traditional roundtable groups, and to provide additional information about the patient context that might not be available in the simulation experience. A single scribe was available for each group to track which interventions were made over the course of the scenario.

After participating in the scenario, students were provided with a survey to complete on a variety of indicators including: sense of role on the clinical team, changing viewpoints on role on clinical team, stress of the experience, managing group interaction, nervousness, and respectful communication. Minimal or no debriefing was provided so that student perceptions regarding the interventions would not be confounded by facilitator interaction.

Results QUANTITATIVE DATA The results for nominal level data (yes/no) are provided in Table 1. Qualitative data for these questions are provided in the next section. The results of comparison group data analysis are provided in Table 2.

As shown in Table 1, both nursing and medical students overwhelmingly noted that the encounter was helpful in the context of learning interprofessional communication skills (100 percent), and that they had a better sense of their role on the clinical team (98.3 percent). The majority of students (55 percent) also had a change in how they viewed their role on the clinical team; this finding is explored further in the qualitative analysis.

Table 2 shows that there were no differences between nursing and medical groups on any of the indicators (stress, group management, nervousness, and respect). The only significant difference between interventions was the level of stress, with the simulation group experiencing significantly more stress during their encounter than the roundtable group. This result is interesting when juxtaposed against the results between intervention groups on the variable of nervousness, which was nearing significance, but not for this sample size.

QUALITATIVE DATA All students were given the opportunity to comment on the "yes/no" questions in the survey, and every student took advantage of the opportunity. Students commented on the following indicators: a) having a better sense of your role on the clinical team; b) something that surprised you or changed your view of your role on the clinical team; and c) helpfulness of the encounter.

SUMMARY OF QUALITATIVE DATA Across all groups, role differentiation was noted, with an overall appreciation for the experience to interact with another discipline also noted. In addition, students commented on the ability to gain more practice with codes, a situation that is not predictable and not common in the clinical setting. The effect of the importance of interprofessional communication is illustrated with the following quotes: "It is so much better to know what to expect in the future and have respect for your colleagues"; "Working with the medical students made the scenario much more realistic and we should work together more often because that is real life"; and "It was good to work with people we did not know--we did not know what they had learned and it was a good trust exercise"

COMPARISON OF COMMENTS BETWEEN NURSING AND MEDICAL STUDENTS One of the most interesting findings in the qualitative data is the identification of the types of roles of the team members.While the majority of medical and nursing students identified the medical students as the leaders of the scenario, several students in both groups noted that it was important for everyone's input to be considered before decisions in patient care were made. In comments by medical students, the term most frequently used to reflect their role was that of leader. For nursing students, the words autonomous and independence were used to describe their experience, especially with respect to questioning orders.

COMPARISON OF COMMENTS BETWEEN SIMULATION AND ROUNDTABLE GROUPS The most appreciable difference in comments between the simulation and roundtable groups was the ability of the simulation group to gain a better sense of timing during events, resulting in more comments about the realism of the encounter. Participants in the simulation groups also more clearly defined the multiple roles within the scenario and the ability (particularly of the nursing students) to assume a variety of roles.

INTERACTION COMMENTS AMONG THE FOUR GROUPS In comparing comments across the four types of groups (nursing-simulation, medicine-simulation, nursing-roundtable, medicine-roundtable) there were some interesting and unexpected trends. Nursing students in the simulation group identified more frequently with the dependent role with regard to being directed what to do in the scenario and waited for a doctor's order. In fact, one student commented, "We waited around more for orders--in nursing school, we were taught much more independence"

Along the same lines, while medical students in both simulation and roundtable groups identified their role as "leader" comments regarding the leadership role were stronger and more frequent in the simulation group than in the roundtable group.

Discussion This study provides a stepping point for understanding some of the nuances of interprofessional communication and how simulation may affect interactions. It adds to the body of literature that addresses how simulation can be used to promote communication skill development in an interprofessional environment.

The qualitative data were particularly compelling with regard to the development of interprofessional communication skills. Students frequently reported the need to practice communication between nurses and physicians before graduating because that was "real life." Both medical and nursing students reported and appreciation for each other's skill levels and abilities in the management of patient care. Of particular interest to the researchers was the identification of how important teamwork was in order to achieve a successful patient outcome. The components teamwork and communication are the main tenets addressed in both the Institute of Medicine and Joint Commission calls for increased patient safety.

While this study showed a difference quantitatively in the perceived stress between simulation and roundtable groups, there were no other significant differences between groups. Qualitative data, however, showed differences in how students across the four groups perceived their roles and their experiences. It was particularly interesting to note that nursing students in the simulation group allowed medical students in the group to assume more of a leadership role, though that was not true of every simulation group. It is apparent that individual characteristics within group membership have an effect on the learning experience whereas the type of experience itself is negligible. In the context of Jeffries' simulation model (2007), student characteristics appeared to have more, or at least equal, impact on the outcomes than the educational design characteristics.

Nursing and medical students valued being in a situation where they could interact with each other and practice in a safe environment. Students also appreciated gaining more experience in running code situations regardless of the type of environment provided for them. These outcomes lend support to the IOM's recommendation regarding interprofessional encounters during the education process, that is, students need and want interprofessional communication during their education so they have a better understanding of roles and communication once they are licensed.

Limitations The one-time encounter of this study is a limitation, as well as the sample size of 60. Replication of the study in other health professions schools would lend a stronger evidence base to the concepts under study. Because no tools existed that were specific enough to measure the concepts under study, it was difficult to capture the true elements of interprofessional communication. Lastly, the data provided were all student perception data. No objective data by observers was collected.

Implications and Recommendations Based on the study results, a collaborative effort between nursing and medical students is a valuable encounter. These encounters may be facilitated in a variety of formats. The value-added component of simulation is the ability to better attain a sense of timing and realism in patient situations. While scheduling is often difficult between the two curricula, and matching skills sets between the two disciplines requires extra time, the value attributed to the encounters by both groups of students is worth the effort.

Results from this study will be used to create and test a communication rubric so that a trained observer may provide objective evaluation of team members in both simulation and traditional learning environments. The rubric would be used to identify whether a participant was at a novice level or moving toward an expert level, which elements of their communication could be improved, and how those elements could be improved, in a manner that provides both formative and summative evaluation. It is also recommended that future studies further investigate the interaction between interprofessional learning and learning environments.

Conclusion Providing opportunities for interprofessional communication is valued by both nursing and medical students. These opportunities may be enhanced through providing a realistic environment afforded by high-fidelity simulation. As this study demonstrates, undergraduate nursing students and medical students may benefit from the encounters that harness the decision-making skills of both disciplines.


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About the Authors Deanna L. Reising, PhD, RN, ACNS-BC, ANEF, is an associate professor, Indiana University School of Nursing, Bloomington. Douglas E. Carr, MD, FACS, is a lecturer in the Medical Sciences Program, Indiana University School of Medicine, Bloomington. Roberta A. Shea, MSN, RN, CCNS, is an assistant clinical professor, Indiana University School of Nursing, Bloomington. Jason M. King, BSN, RN, is clinical director of oncology, at Bloomington Hospital, Bloomington, Indiana. Contact Dr. Reising at for more information.
Table 1. Nominal Level Data Analysis
(41 nursing students/ 19 medical students)


Do you have a better sense of your 98.3%(59) 1.7%(1)
role on the clinical team?
Was there something that surprised you 55% (33) 40%(24)
or changed your view of your role on
the clinical team?
Do you have remaining questions 10%(6) 73.3% (44)
about how clinical teams function?
Was the encounter helpful? 100%(60) 0%(0)

Table 2. Comparison Group Data Analysis


I found this exercise to Nursing 2.88 Table 2.34
be stressful
Overall Mean = 2.92, SD = 1.01, Medicine 3.00 Simulation 3.40
Range = I-5 (p = .668) (p = .000) *
I learned that I could manage the Nursing 4.00 Table 3.97
stress of group interactions
in a code situation
Overall Mean = 4.00, SD = 0.61, Medicine 4.00 Simulation 4.03
Range = 2-5 (p = 1.00) (p = .676)
I was less nervous at the end Nursing 4.12 Table 3.93
of the encounter than at the
start of the encounter
Overall Mean = 4.05, SD = 0.70, Medicine 3.89 Simulation 4.20
Range = 2-5 (p = .245) (p = .137)
I was respectful when others Nursing 4.39 Table 4.31
offered suggestions regarding
the situation
Overall Mean = 4.38, SD = 0.52, Medicine 4.37 Simulation 4.47
Range = 3-5 (p = .882) (p = .257)

* = Significant

Note."Table" group under the Intervention column is the roundtable
or traditional group; Rating scale I to 5, with I being low and 5 being
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Author:Reising, Deanna L.; Carr, Douglas E.; Shea, Roberta A.; King, Jason M.
Publication:Nursing Education Perspectives
Date:Sep 1, 2011
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