Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study

Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study

Nurse Education Today 34 (2014) e53–e57 Contents lists available at ScienceDirect Nurse Education Today journal homepage: Use...

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Nurse Education Today 34 (2014) e53–e57

Contents lists available at ScienceDirect

Nurse Education Today journal homepage:

Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study☆,☆☆ Cynthia Foronda a,⁎, Karina Gattamorta b,1, Kenya Snowden b, Eric B. Bauman c,2 a b c

Johns Hopkins University, 525 N. Wolfe Street, Baltimore, MD, United States University of Miami, School of Nursing and Health Studies, 5030 Brunson Ave, Coral Gables, FL 33124, United States Clinical Playground, LLC, PO Box 5421, Madison, WI 53705, United States

a r t i c l e

i n f o

Article history: Accepted 16 October 2013 Keywords: Virtual Simulation Nursing Education Baccalaureate Online Interprofessional Safety

s u m m a r y Background: According to The Joint Commission (2012), the leading cause of sentinel events in the United States was miscommunication. Lack of thorough and accurate communication remains a serious challenge in healthcare and an educational priority in schools of nursing. Virtual clinical simulation is an online educational approach where students use avatars to practice various skills. Objectives: The purpose of this pilot study was to evaluate the educational innovation of using virtual clinical simulation to improve communication skills of BSN students. The objectives of the simulations were to 1) recognize significant patient data and 2) accurately perform the ISBAR communication technique. Design: The study used a within-group, time-series design with eight students. Students participated in two synchronous virtual simulations in an online virtual clinical environment called CliniSpace™. Students performed in groups of four to five students. Methods: Students performed in two virtual simulations in groups of four to five students. Student performances were scored by two raters using the CliniSpace™ ISBAR Rating Sheet. Field notes from debriefing sessions were analyzed for content. Results: Mean group student performance scores more than doubled from performance one to performance two. This change was found to be statistically significant, p b .001. Field notes revealed that students listened to how their peers communicated and learned from them. Students expressed having less anxiety, knowing what to expect, and having “better flow” with communication. Students verbalized learning to assess the patient prior to calling the physician and to give a recommendation to the physician. © 2013 Elsevier Ltd. All rights reserved.

Introduction According to The Joint Commission (TJC), 1243 sentinel events were reported in the United States between 2004 and 2011 (The Joint Commission, 2012). Communication was identified as the root cause in 61% of the most frequently identified causes (The Joint Commission, 2012). A 2013 United States Hospital National Patient Safety Goal is to “Improve the effectiveness of communication among caregivers” (The ☆ Funding: This project was supported by funds from Sigma Theta Tau International, Beta Tau Chapter, award amount $1000.00. The first author was a participant in the 2013 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education and Pocket Nurse. ☆☆ Conflict of interest: Eric Bauman served as a paid consultant for Innovation in Learning, Inc., developer of CliniSpace™. Eric Bauman served a paid consultant for the first author with partial funding from the Sigma Theta Tau International, Beta Tau Chapter award. ⁎ Corresponding author at: Johns Hopkins University, 525 N. Wolfe St., Baltimore, MD, 21205, United States. E-mail addresses: [email protected] (C. Foronda), [email protected] (K. Gattamorta), [email protected] (K. Snowden), [email protected] (E.B. Bauman). 1 Tel.: +1 305 284 1572. 2 Tel.: +1 305 284 4135. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.

Joint Commission, 2013, p. 2). Lack of thorough and accurate communication remains a serious challenge in healthcare and an educational priority in schools of nursing and health professions. The United Kingdom Department of Health (DOH) stated that “improving patient safety involves assessing how patients could be harmed, preventing or managing risks, reporting and analysing incidents, learning from such incidents and implementing solutions to minimise the likelihood of them reoccurring” (Department of Health, 2012, para. 1). In reference to the occurrence of medication errors, “Insufficient knowledge can be due to a failing of an individual … but it can also be due to a system failure, such as failure by school or hospital authorities to prepare staff adequately to fulfill their responsibilities” (Lu et al., 2013, p. 25). Because medication errors and sentinel events have been linked to miscommunication and lack of education, the authors decided to evaluate the effectiveness of using virtual simulation to teach communication skills to baccalaureate nursing (BSN) students. Background In 2001, the United States Institute of Medicine (IOM) proposed ten rules in the redesign of healthcare delivery systems. The tenth rule was


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direction for “Cooperation among Clinicians,” emphasizing collaboration and communication to ensure an appropriate exchange of information (Institute of Medicine, 2001, p. 9.). Healthcare organizations were directed to improve teamwork by using a standardized approach to hand off communications (Kesten, 2011). Originally developed by the United States military to decrease errors in high-risk military operations (Mahlmeister, 2005), the SBAR communication technique was proposed as a framework applicable to healthcare as well. The SBAR method of communication addresses four key facets of effective communication: situation (S), background (B), assessment (A), and recommendation (R). With time, the SBAR framework evolved to include starting communications by stating one's identity or identification (I) to become what is known now as the ISBAR method. Leading healthcare organizations throughout the world are endorsing the ISBAR method as the standard (Australian Commission for Safety and Quality in Health Care, 2012; Quality and Safety Education for Nurses, 2012; World Health Organization, 2013). The World Health Organization (WHO) recommends ISBAR as an effective communication model for medical students and includes direction to teach the skill of communication within the Patient Safety Curriculum (World Health Organization, 2013). The Australian Commission on Safety and Quality in Health Care (ACSQHC) supports ISBAR to promote effective handover in interhospital transfers (Australian Commission for Safety and Quality in Health Care, 2012). Quality and Safety Education for Nurses (QSEN) recommends SBAR as a framework to teach inter- and intradisciplinary communication skills (Quality and Safety Education for Nurses, 2012). Interprofessional collaboration and education are important (Leape et al., 2009), and ISBAR provides a mutually understood, consistent framework to promote communication exchange among disciplines as well as a foundation for educators to structure teaching activities. The IOM Future of Nursing Report: Leading Change Advancing Health recommends the use of high-fidelity simulation technologies as a means of providing clinical experience to nursing students (Institute of Medicine, 2010). Virtual clinical simulation (VCS) as described in this article, is a synchronous, multiperson, online 3D immersive training environment that can expose students to the challenges of nursing practice in a safe, engaging, dynamic, accessible, and situated environment. Among VCS technologies, the CliniSpace™ platform offers a highfidelity environment that is user-friendly, refined for health professions, and well suited to authentically replicate a clinical setting (Fig. 1). The environment has been specifically designed for nurse education and provides an environment that may be manipulated by faculty. VCS within the CliniSpace environment occurs using live dialog that allows for real-time or synchronous communication. Virtual patients respond appropriately to verbal interactions role played by the facilitator. Similar

to mannequin-based simulation, virtual patients respond physiologically to clinical interventions. Changes in vital signs and general appearance change as computer settings are modified by the faculty member. According to Allen and Seaman (2013), online enrollment in higher education in the United States has been steadily increasing for the last ten years. There are many reasons for this movement including student convenience, advancing technology, changing student demographics, and learning preferences. Virtual clinical simulation, based on tenets of social and experiential learning theory, may be a promising pedagogy of the future. With VCS, students and faculty are able to participate in live clinical simulations from the comfort of their homes. VCS spans boundaries and allows students of various disciplines and locations to participate together virtually. Despite the potential of this innovative and engaging online learning approach for nurse education, there is limited research on the effectiveness of VCS for improving clinical skills such as communication. There are no published research studies on the effectiveness of CliniSpace in nursing education. Three educational studies describe the use of virtual clinical simulations, other than CliniSpace, with nursing students (Aebersold et al., 2011; Broom et al., 2009; McCallum et al., 2011). The simulations resulted in both positive and negative feedback from students. The advantages of the virtual simulations for students included developing knowledge and helping with clinical practice (Broom et al., 2009); improving decision-making and learning (McCallum et al., 2011); being “better than or as good as [mannequin-based] SimMan®”; and serving as an effective system for practice of skills (Aebersold et al., 2011, p. e5). The negative elements related to virtual simulation included delays related to technical issues (Aebersold et al., 2011; Broom et al., 2009), students wanting more involvement in choosing their avatars (Aebersold et al., 2011), delays and restrictions due to text-chat (Aebersold et al., 2011; McCallum et al., 2011), and students rationalizing that “they are not the real thing” (Broom et al., 2009). Jeffries' (2005) Simulation Model served as the conceptual framework of this study. According to Jeffries (2005), this framework provides a context for relating the likely variables in simulations. The major components, Teacher, Student, Educational Practices, and Design Characteristics and Simulation, are proposed to influence Outcomes. The Outcomes “are proposed to be influenced by the degree to which best practices in education are incorporated in the design and implementation of the simulations” (p. 97). Student outcomes include learning, skill performance, learner satisfaction, critical thinking, and self-confidence (p. 97). The use of this framework guided the evaluation methods of this study, specifically, investigating the outcomes of learning and skill performance. The purpose of this study was to evaluate the use of VCS to improve communication skills of baccalaureate nursing students. The aim of the

Fig. 1. Image from CliniSpace™. Reprinted by permission of Innovation in Learning, Inc. (2013).

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VCS was to facilitate and demonstrate enhanced skill performance of communication. The research question was, “Do students' ISBAR performance ratings improve through use of CliniSpace VCS?” The use of VCS needs to be tested to determine student outcomes and provide direction for educators. VCS is an innovative pedagogy that may have translational and transformative potential for web-based nursing education. Furthermore, future sentinel events may be prevented through improved education and practice with communication.

Methods Design and Sample This study received institutional review board approval from the university affiliated with the second and third authors. Waiver of consent was granted to use student data collected as part of standard curriculum evaluation for research purposes. The candidates for inclusion in the sample were nine baccalaureate level students enrolled in the online Career Pathways course. The students were registered nurses who were studying in the third semester of the five-semester curriculum to complete a baccalaureate degree in nursing. Due to technical difficulties, only eight students successfully logged into the platform to participate in the virtual simulation; thus, only eight students' data were included in the evaluation. As a part of their grade, students were required to perform two group virtual simulations. As preparation for the simulations, students were provided an asynchronous online module including text outlining the importance of communication in healthcare. Students were directed to review a PowerPoint presentation describing the use of ISBAR with listed examples of appropriate and inappropriate dialogs. The link to access the virtual world was uniform, but each student had to use a unique signin and password. A video orientation was posted to show students how to install the plug-ins and show the functions of the platform. For example, instructions were provided on how to choose and move the avatars and use the mouse to perform functions. Students had the ability to take vital signs and give medications virtually. Once an item was selected, a menu appeared giving the student various options or actions to choose from related to the item. This feature allowed for students to use critical thinking and decision-making skills by choosing interventions. The platform had an electronic health record for review and a real time “wave form display” that demonstrated the virtual patient's current vital signs, oxygen saturation, and heart rhythm. The planned times of the simulation and the various roles and timeslots to be played were designated so students knew ahead of time which roles they would play and when. The roles included primary nurse, nursing assistant, patient, and observer. Students rotated roles so all students had opportunity to play each role, although, the faculty stepped in and role played the patient occasionally to guide the simulation. An introduction to the virtual patient was provided in a handout similar to the patient's medical record. Students were given the responsibility to introduce themselves, look up the patient's history through the electronic medical record (EMR), delegate appropriately, formulate nursing diagnoses, plan interventions, implement interventions, evaluate interventions, communicate with the patient therapeutically throughout, and communicate using ISBAR as necessary to healthcare providers. Students were informed that the focus of the exercise was communication using ISBAR, and the performance rubric was posted ahead of time so that the students could amply prepare. The study used a within-group, time-series design with two virtual simulations. Students were evaluated on their communication performance while in the role of primary nurse according to ISBAR categories after a simulation scenario on osteomyelitis (performance one) and again after a scenario on abdominal pain (performance two). The first simulation and second simulation were arranged two weeks apart to allow time for reflection and learning to occur. The study compared


student scores from performance one to performance two to support the incremental effects of the simulation exercise. Structure of Simulations The objectives of both simulations were to 1) recognize significant patient data and 2) accurately perform the ISBAR communication technique. Students were clustered into groups of four or five students per simulation on the multi-user platform. Students were provided instructions to log onto the platform at the scheduled simulation start time. The faculty and students waited approximately 5 to 10 min for all students to log in. Students chose one of six provided avatars to represent themselves and typed in their names, which appeared above the avatar. Students called into a designated conference line as a proactive measure to prevent technical issues with communication including echoing or lack of audio. Two faculty members jointly facilitated each simulation. The faculty members played ancillary personnel, medical providers, advanced practice nurses and acted as patient at times, manipulating the display of vital signs to create changes based on the patient's status or students' interventions. Within each planned “state” in time, a problem would arise prompting the need to call the physician or nurse practitioner. Students were directed to use ISBAR in their phone communications. The two faculty members rated the individual's ISBAR performance as the phone communications were taking place. The raters conducted their ratings concurrently and independently. Following each simulation performance, a debriefing session was held. The following guiding questions were used in the debriefing: “What do you think went well with the simulation? What did not go so well? What might you do differently? What did you learn from each other? How did it feel?” The investigator, who served as one of the raters, took field notes during the debriefing sessions. The group simulations lasted approximately 1 1/2 to 2 h each including the debriefing sessions. Measures Communication performance was measured using the CliniSpace ISBAR Rating Sheet©. Permission was granted to use CliniSpace and the rating instrument. The instrument contains 4 items in a rubric format that are scored from 0 (does not meet any criteria for ISBAR) to 4 (meets all criteria for ISBAR). Each of the five components of ISBAR, presenting identification, situation, background, assessment, and a recommendation, was scored so the maximum score one could obtain on the tool was a 20. Students were scored on their performance of ISBAR when acting as the primary nurse communicating with a healthcare provider over a phone call. The psychometric properties of this instrument had not been evaluated prior to this study. The authors were not able to locate any other existing instrument to measure communication in a simulated environment. However, this instrument was developed by an academic using the ISBAR framework for a virtually simulated healthcare environment and this study served to provide preliminary psychometric data. Data Management and Analysis A statistician manually entered rating scores for each student into a SPSS Statistics, Version 19, 2010, file using double data entry to ensure data quality. The data were stored on a secure server. Personal identifiers of student participants were removed and replaced with codes. The mean scores of the two faculty ratings were used as the unit of analysis. The analyses included descriptive statistics and a dependent samples t-test to compare the means of performance 1 and performance 2 scores on the CliniSpace ISBAR Rating Sheet. A faculty member typed field notes during debriefing sessions. The lead author performed a content analysis of the notes from the debriefing sessions extracting key themes and poignant quotes.


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Results Psychometric Results This study examined preliminary reliability and validity on the instrument. Inter-rater reliability was examined across the two raters and was found to be r = .84, p b .001. According to Griffin-Sobel (2003), reliability coefficients of .70 and above are acceptable for newly developed instruments. Additionally, performance ratings on the second simulation were compared to final grades. While a positive relationship was found (r = .35), this relationship was not statistically significant (p = .395). Study Results The students' communication performance scores as rated on the CliniSpace ISBAR Rating Sheet increased significantly from performance one to performance two. The lowest mean score (the averaged score between the two raters) on performance one was a 3.5. The highest mean score on performance one was a 14.5. The lowest mean score on performance two was a 13, and the highest mean score on performance two was a 19. The average score of all students on the CliniSpace ISBAR Rating Sheet at performance one was found to be 6.94 ± 3.58 and at performance two 16.13 ± 1.81. This change was found to be statistically significant, t (7) = 6.36, p b .001. Content analysis from the debriefing session revealed students appreciated learning from their peers. After the first simulation, students indicated that they listened to how their peers communicated with ISBAR before and after them. Students expressed having less anxiety, knowing what to expect, having “better flow” with communication and that “things ran more smoothly.” Students verbalized learning to assess the patient prior to calling the advanced practitioner. One student reflected, “I forgot to give a recommendation” to the provider. After the second simulation, students expressed feeling more prepared and that they enjoyed the second simulation more. One student stated, “We were feeling a little more confident about our role. We were much more familiarized with our surroundings. We interacted well with both patient and doctor, giving him the proper information and reiterating the order, confirming the order…” A second student stated, “We all reviewed ISBAR and became more comfortable with it. That was key. We were able to communicate better with the doctor and rest of the team.” Discussion The results of this study demonstrate improved communication performance and understanding of ISBAR among BSN students using VCS technology. In this study, the students' mean performance scores more than doubled from performance one to performance two. These findings support the previous findings of Broom et al. (2009), McCallum et al. (2011), and Aebersold et al. (2011) that virtual clinical simulation may help to develop general nursing knowledge. Longerterm studies are necessary to evaluate if this learning is retained over time and transferred into practice. Multi-group designs are needed to evaluate whether VCS is more effective than other teaching modalities. For example, research comparing the student outcomes related to VCS compared to mannequin-based simulation would be helpful to guide education efforts. Consistent with a study by Aebersold et al. (2011), a technical issue occurred in this study, a common risk of working with new technology. One student was unable to participate in this study because she could not log in. Until this technology becomes more mainstreamed, faculty need to focus much effort in developing sound log-in directions as well as troubleshooting solutions. The faculty had posted a video demonstrating instructions for downloading the plug-in and logging in, but it is uncertain whether the student viewed it. Performing a trial

run to ensure all students are able to access the platform and that audio equipment is functioning appropriately is suggested. Having an information technology expert available via phone is ideal. Future research directions include evaluating a larger sample with a more refined instrument. Instead of having faculty role play the physician or nurse practitioner, it is recommended that medical students or nurse practitioner students participate in the VCS with BSN students to promote interprofessional education. Research is warranted to evaluate the use of VCS to improve additional skill sets such as assessment, decision-making, prioritizing, and other important cognitive skills in nursing. Research on the effects of education for staff nurses is lacking. As the students in this study were practicing RNs, this pedagogy could potentially be used with staff nurses as an educational competency or prevention measure to reduce sentinel events from miscommunication. Limitations This study was intended as a preliminary pilot evaluation. The design was limited in that there was no comparison group, the study sample was small, and there was no opportunity for obtaining a measure of the dependent variable prior to exposure to the CliniSpace technology. Further, the instrument used in this study, CliniSpace ISBAR Rating Sheet, had not previously been evaluated in research. The study contributed by providing an opportunity to gather preliminary interrater and internal consistency data on the measure. The VCS technology was new, thus, its implementation was not yet fully refined for teaching purposes. Due to echoing and lack of audio in prior simulations, and the focus of communication in the exercise, the decision was made to proactively use phone conferencing instead of risk voice-over internet challenges. Therefore, the full scope of the virtual platform was not explored. Because the students rotated roles, students who performed first may have been at a disadvantage to those who performed last. To attend to this possible predicament, students who performed last for the first simulation were scheduled to perform first in the second simulation. The order of performance may have affected score attainment, although, a benefit of the exercise was the repetition component of hearing ISBAR communication amongst peers. Conclusion This study served as a starting point to validate a new pedagogy in online health education. The research findings demonstrated that students' ISBAR performance scores improved significantly from the first performance to the second performance. Students verbalized that their comfort with communicating using ISBAR improved from the simulations. The study findings suggest that using virtual simulation as described in this study was an effective means of teaching communication using ISBAR. Nurse education is at an exciting time with rapid change. The walls of traditional nursing education are being knocked down and expanded to include interprofessional communication as healthcare has accepted the team approach is necessary for optimal patient outcomes (Pronovost and Vohr, 2010). Educators are encouraged to consider advances in technology and use research to guide best practices in education to better prepare students for clinical practice. VCS is a practical innovation that engages students, incorporates technology in a convenient setting, and results in student learning. VCS transforms the previous conceptions of online education and is a warranted pedagogy worth future exploration in nurse education. Acknowledgment The authors wish to thank Parvati Dev, PhD, and Wm. LeRoy Heinrichs, MD, PhD, of Innovation in Learning, Inc., developers of CliniSpace.

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