Are There Limits to How Far We Can Take Simulated Clinical Training?

The fact that NPs and other APRNs are in short supply these days has made the profession a lot more attractive and a lot more lucrative. The demand has been spurred by a national shortage of doctors combined with the solid patient outcomes generated by APRNs.

But this, in turn, has put pressures on the APRN community that have been difficult to manage. The skyrocketing demand for nurse practitioners has set up a roadblock in the training pipeline. The American Association of Colleges of Nursing’s 2016-2017 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing report found that American nursing schools had turned away more that 64,000 qualified candidates for reasons that included:

  • Shortage of faculty
  • Limited number of clinical sites
  • Limited classroom space
  • Not enough clinical preceptors
  • Budget constraints

Traditionally, each and every one of those graduates would have accumulated their required 500 clinical experience hours on live patients under the immediate supervision of a skilled preceptor before being licensed.

The problem is that those preceptors, both practicing APRNs and physicians, are in increasingly short supply. APRN preceptors in particular are hard for students to come by, and yet many nurse practitioners feel that it is critical to work under another NP during training. Although their medical expertise is unquestioned, the skills and approach adopted by physicians can be at odds with the APRN model.

As an alternative, some schools are exploring a training alternative that has the community in turmoil: patient simulation.

Is Patient Simulation an Experiment or a Solution?

Patient simulation can take on many different formats. Chances are, you’re already using some of them as part of any standard APRN program.

  • PC-based interactions
  • Virtual patients
  • Partial task trainers
  • Human patient simulators
  • Standardized patients

Low-Tech Solutions Still Have a Place

These simulations may be part of ordinary classes and can make use of specialized equipment such as mannequins, ordinary computer screens, or role-playing scenarios using actors.

These actors take on the role of the standardized patient: a scenario where they are trained to deliver responses to students that conform to a specific malady or condition. The interaction takes place in a fully equipped patient examination room. It can be a one-time scenario, or be programmed to unfold over time, with follow-up visits that are part of the exercise occurring just as they would normally in live patient interaction.

This offers faculty enormous latitude to both observe and control the patient interaction scenarios that their students are faced with. Because the actors can present the full range of emotions and responses that any real patient can, they are often favored over the more dryly technical simulation approaches.

Technology is Augmenting Training, But Will Soon Take Over

Computer-driven mannequin systems have made considerable advances in recent years. The descendants of the original Resuci Anne have gained tremendous functionality, with instrumentation to reveal subtle procedural techniques and mistakes for instructors to evaluate. All kinds of different procedures and responses can be simulated, from catheterization to airway insertion.

Web-based simulators have also become popular in classroom programs. ALICE, the Artificial Learning Interface for Clinical Education, was tested in Germany in 2015 to great success. Students from the digital generation are familiar with the interface and format, effectively making learning just another game to master.

Can Simulation Replace Clinical Experience?

Using these techniques as components of actual clinical service is considerably more controversial than simply using them as learning aids, however.

No simulation has yet been invented to adequately replicate the experience of pulling a 10-hour shift and having your last patient vomit all over you.

For all the potential failings, however, no lesser an authority than the American Association of Colleges of Nursing (AACN) has come out in support of the use of human patient simulators and standardized patient simulators in nurse practitioner training.

AACN isn’t on board with entirely replacing clinical experience, but the organization seems open to allowing simulated time to count for at least some of the current 500 hour standard.

Licensing authorities also appear to be on board with some level of simulation support in official standards. A 2014 nation-wide study sponsored by the National Council of State Boards of Nursing concluded that up to half of the 500 hours could be replaced by high-quality simulation with no degradation in the quality of educational outcomes.

There are also hidden advantages to patient simulation over traditional clinical experience. The race to find the perfect practicum opportunity is rarely won… the positions that student APRNs find tend to be pot luck. While many programs require that clinical experience be acquired within the sub-specialty area you are studying, there’s no real way to mandate the quality of that experience. A clinical placement in the ER of a busy urban medical center will result in quantitatively and qualitatively different kinds of injuries and medical issues than you could ever hope to find in a sleepy rural hospital, even within the same area of practice.

Simulated programs, however, don’t have to suffer from those same kinds of limitations. A full range of clinical exposure can be programmed into the simulated experience, not only ensuring that each student will learn the same set of skills (ensuring consistent quality among program graduates) but also that those skills will cover the gamut of what faculty consider essential training for the APRN role.

A simulation also avoids one of the most classic critiques of practicum, which is the potential for genuine improper treatment of patients. Although in theory this is exactly the situation that preceptorship is designed to stave off, in practice the strains on preceptors and the vagaries of actual medical visits give the average APRN student ample opportunity to misdiagnose patients without sufficient oversight.You can’t kill a simulation.

There’s Still a Downside to Relying on Training Through Simulation

Critics point out that this is also one of the drawbacks of simulation: the knowledge that the student is not working with a live patient has less impact than real cases. And the use of set-piece scenarios, while helpful for replication and consistency in the learning experience, can’t reproduce the unique and sometimes strange reality of genuine clinical cases. Responding to those unusual outliers is part of the point of acquiring clinical experience.

They also point out that there is little if any evidence that simulation is an adequate replacement for face-to-face patient visits in APRN training. But proponents note that there isn’t any formal evidence supporting the current standards for clinical experience, either.

With the continuing shortage of trained faculty and willing preceptors, however, it’s likely that more and more programs will explore simulation as a clinical experience alternative.


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