Peer-Lead Learning in Simulation

In Autumn 2011, I used a new teaching approach with my first-year BSN Health Assessment students.  The approach merged simulation with peer teaching.  Below, I describe the steps that I used, followed by “lessons learned.”

Students attend lecture as a large group (about 65 students) and attend lab in small groups (about 12 students).  To start the exercise, students completed group work in lecture to become the “expert” on an assigned case study.  The cases represented various health issues and diverse populations.  After a lecture presentation and demonstration of a system or regional examination by the instructor, students gathered in their assigned lab groups and wrote expected subjective and objective findings related to the system/region along with relevant nursing diagnoses.  My co-teacher and I circulated among the groups to provide facilitation, particularly to make sure the more reserved or shy students were engaged. 

After mid-term, students began to work on planning the actual simulation scenario.  Lab sections were subdivided into 4-5 students.  Students were instructed that they would participate in two simulations: one as Facilitator, one as Learner.  Facilitators’ roles were assigned in advance and included (1) giving shift report to the learners to start the scenario, (2) playing the role of the patient (either acting or providing the voice for the simulator), (3) playing the role of a friend/family member, and (4) leading the debriefing.  The Learners’ roles were assigned day of the simulation so all students would arrive prepared to play an active role in the simulation. Two learners played the role of the nurse and were expected to assess vital signs and perform inpatient shift reassessment. The rest of the learners were active observers and were given a checklist to keep them interested as they watched the simulation.

To prepare for the simulation, students they were given a template for giving report using the SBAR format (Situation, Background, Assessment, Recommendation – read more at the Institute for Healthcare Improvement Website).  The group members worked together to fill out the report form.  In formulating a head-to-toe report, students facilitated each others’ review of the overall course content.  Next, students were given a template for scripting their acting roles.  The group decided together how the roles would be played.   They were given the following questions:

For the patient role

• What is the patient’s present mood?   Level of consciousness?
• How will the patient interact (friendly and helpful, withdrawn, antagonistic, etc.)?
• What are cues you might give to the nurse about your status if asked?  (e.g., hungry, in pain, want to be left alone, concerned about health, etc.).

For the friend/family role:

• What is the person’s present mood?  LOC?
• How will the person interact with the nurses (friendly and helpful, withdrawn, antagonistic, etc.)?
• How will the person interact with the patient?
• What are cues you might give to the nurse about your status if asked?  (e.g., curious about what’s going on, worried about care, etc.).

Students were given props to help the students get into the roles, and to help them have fun with the exercise.  The student debriefers were given examples of questions to ask that they reviewed before the simulation day.  They were given brief instruction in debriefing using the Plus/Delta method.  Using this method, the debriefer first asks what went well, and then asks what the learner would change. Students were encouraged to add their own debriefing questions based on the scenario.

Finally we had the simulation day during the student labs.  Students spent about 45 minutes in the simulation exercise and spent the rest of the lab session practicing physical examination.  Of the 45 minutes, 15 minutes were spent in orientation, 15 minutes running the scenario, and 15 minutes debriefing.  As the instructor, I oriented the students to the learning objectives and the overall purpose of the exercise.  I cued each simulation to begin, and I provided the transition from the scenario to debriefing.  I was present at debriefing, but interjected only when the inexperienced debriefer required assistance.

Overall, the simulations exercise was a success.  Students were given the opportunity to provide anonymous feedback.  On a scale of 1 (not useful) to 5 (very useful) students rated the exercise and average of 3.9 (range 2-5), and 87% of the students reported that they would recommend including the exercise in the course in the future.   Many of the students reported that the simulation scenario and debriefing felt rushed.  They would have liked more time.  In addition, the students would have liked the simulation preparation to occur over fewer sessions (we used part of three class sessions in preparation).  Students reported that a major benefit was feeling what it was like to perform with various distractions such as having the patient or family talking.  The student debriefers were highly professional and respectful, and the others were willing to openly share both positive feedback and suggestions for improvement.

Based on this experience, I plan to include this exercise in next years’ Health Assessment course.  The simulation preparation will take place in one session that immediately precedes the simulation day.  In addition, I will have two lab days designated for simulation so that each group can have more time and feel less rushed.  Finally, some of the cases did not translate well to simulation, and it was quite difficult to stage six different simulations in a limited lab space.  I plan to use more case studies to illustrate examples in lecture, but reduce the number of case studies used for simulation to three.

Simulation is an active learning strategy, but as with lecture, it can be used in a prescriptive manner in which it is controlled by the instructor, or a collaborative manner engaging the learners in their own instruction.  Our experience engaging students in peer-teaching using simulation was highly successful.  I would encourage instructors not only to try our model, but also to be creative about other ways to engage your own unique student groups.  And if you find something good, remember to pass it on!