Discovering Clinical Imagination Through the Use of the Person-and Family-Centred Care Best Practice Guideline
Summary
Clinical simulation is used in nursing education to bring learners to imagine themselves immersed in a similar clinical situation in real-life. For nursing students, simulation-based experiences represent an opportunity to imagine the possible solutions to real health-care issues (Gaba, 2007; Kneebone, 2009). Pursuing the AMS fellowship came from a desire to reflect on the term clinical imagination, a term used by Benner, Sutphen, Leonard, and Day (2010) for rehearsed situations potentially faced by nurses in practice. For students engaging in simulation-based experiences, the degree of believability of a clinical activity is best described by its resemblance to reality in clinical practice. As the situation becomes as close to reality as possible, the level of fidelity ranges from low, medium, or high (International Nursing Association for Clinical Simulation and Learning [INACSL] Standards Committee, 2016). Fidelity is also dependent on physical factors in the environment such as the resources, the equipment, and the psychological factors of emotions, beliefs, and self-awareness. The degree of realism is also greatly influenced by the social factors of learning that affect motivation such as goal attainment, group dynamics, and the level of trust in this learning modality (Dieckmann, Gaba, & Rall, 2007; INACSL Standards Committee, 2016).
I am intrigued that nursing students instill their trust in simulation enough to visualize themselves in clinical practice during their simulation-based experiences and I am amazed to see them step in and out of their acting roles in order to execute the thought process that leads them to perform the nursing role (Fey, Scrandis, Daniels, & Haut, 2014). Since clinical imagination may also be closely connected to clinical judgment and inherently tied to the provision of safe, I am passionate about simulation for the opportunity it provides for us to engage in the ethics of care. For the nursing student to make proper judgment, clinical imagination may be required to adeptly identify abnormal, critical, and life threatening clinical findings (Benner & Tanner, 1987; Benner, Tanner, & Chesla, 1996; Tanner, 2006).
The overall purpose of the AMS Fellowship was to uncover how simulation-based experiences may foster the development of clinical imagination and clinical forethought. Moreover, if learners take part in a simulation-based experiences which integrate the Person-and Family-Centred Care RNAO Best Practice Guideline, their learning may lead them to sorting out their thoughts, generally recompose, and execute what they imagine a nurse in practice would do in a similar situation in practice. Learning may occur in simulation when participants are challenged to demonstrate their knowledge of the next steps in the nursing process and the ability to detect symptoms, perform assessment, and intervene appropriately is exposed for the rest of the health care team to see. Embracing simulation requires accepting the vulnerability and exposure as a way to learn from and with others. The simulation team may then collaborate and discuss safe provision of care (Zulkosky, White, Price, & Pretz, 2016). I also wonder if the tension of being observed also requires learners to move in and out of their imaginative thinking and whether or not learners embrace being imaginative and creative in nursing education?
Outcomes
I see significance in the shaping of clinical imagination in simulation-based experience and as a simulationist, I am marked by the level of trust instilled by learners engaging in simulation scenarios, especially under circumstances where mandatory hours are replaced with simulation-based experiences. The essence of playing the role of the nurse in simulation requires full immersion into one’s imagination of what it may mean to be dedicated to the ethics of caring, to do what is right in complex clinical situations, and to respond skillfully in life-altering situations. In my fellowship, I explored Benner’s term clinical imagination and the ways that nursing students may shape their clinical imagination in simulation-based experiences by conducting a literature review on the use of clinical imagination in nursing. Then, I devoted time to the creation of a maternal-child simulation-based experience using the Person-and Family-Centred Care RNAO BPG which will be implemented in the Nipissing University's School of Nursing's collaborative Program. The maternal-child simulation scenario incorporates a simulated hospital experience where multiple scenarios are unfolding within the same timeline. The nurse’s shift would begin with a team huddle where the health care team at the end of their shift would be required to perform a safe hand-over of information to the incoming health care team. The team leader will be asked to best match the experience, and the skill mix of the team to each case therefore prioritization each clinical scenario. Simulated patients will be participating in each of the five scenarios to have them strategically unfold concurrently. There will be varying degree of urgency and level of skills required to safely and competently care for the patients in the simulated maternal-child unit. During the debriefing stage, the team will be asked to use an arts-based approach to assess and reflect on their performance and the person and family’s response to the provision of care. As a next step to the fellowship, I intend to evaluate the simulation project though the use of narrative inquiry.
Preparing the twenty-first century nurse for practice calls for meaningful clinical experiences aimed at developing practice readiness (RNAO, 2016). The nursing practicum in the collaborative program at Nipissing University incorporates various models of clinical practice education from a facilitated practicum where a clinical instructor supervises a group of eight students in the practical setting to the preceptorship model, in which the learner enters a one-to-one relationship with a clinical expert (CASN, 2004). As part of the AMS fellowship, I designed a maternal-child simulation scenario using the Person-and Family-Centred Care RNAO Best Practice Guideline to embrace the experiential learning environment as a way to build the clinical imagination of the relational practice required to work in the perinatal setting. The classroom experience needs to carefully integrate theoretical aspects of the clinical practice guideline but also create imaginative and creative activities to ensure that learning objectives in simulation effectively assess the clinical performance of learners in the clinical practicum (College of Nurses of Ontario, 2014; Ralph, Walker, & Randolph, 2010).
By designing a scenario in which multiple situations unfold at the same time as part of the AMS fellowship, I aim to incorporate the appropriate level of fidelity needed to fit the learning objectives to influence the realism of the simulation (CASN, 2015; INACSL Standards Committee, 2016; Raemer et al., 2011). If the learner is expected to embody the role portrayed in simulation and to effectively utilize the RNAO best practice guideline, realism needs to be careful considered. Since the replacement of clinical placement hours continues to remain controversial in nursing education, simulation-based experience ideally provides learners with opportunities that would otherwise be inconsistent due to limited availability of placement, competition from other programs, and high enrolment for smaller-sized specialized units (Breymier et al., 2015; CASN, 2015; Jeffries et al., 2015; RNAO, 2016). The implementation phase of the scenario requires a mutual understanding of the learning objectives set by the learner and the faculty (Jeffries et al., 2015; Parker, McNeill, & Howard, 2015).
Overall experience
As a simulationist, my favorite moments occur in the simulation debrief, a planned session in every simulation designed to improve future performance, where learners are guided through their reflection by recounting the emotions from the simulation experience (Gardner, 2013; INACSL Standards Committee, 2016; Levett-Jones & Lapkin, 2014). The maternal-child simulation scenario designed in the AMS fellowship includes an instructor-led debriefing to foster the discovery of skills, emotions, and attitude and to equip the learner to respond to a similar situation in practice (Luctkar-Flude, Wilson-Keates, Tyerman, Larocque, & Brown, 2017; Jeffries et al., 2015). Learners are expected to engage in conversation and reflection through modeling, repetition, and imagery of various cues to clinical situations and the debriefing environment in the simulation scenario represents a safe place to engage in dialogue on the use of RNAO best practice guidelines (Gardner, 2013). My favorite part of the fellowship lies in the opportunity to develop an arts-based approach to debriefing. If debriefing leads to the transfer of skill and knowledge, then bringing an understanding of the components of patient safety and the development of professional roles through artistic impression may create conversation about clinical imagination (INACSL Standards Committee, 2016). The debriefing stage in the designed simulation scenario is aligned with learning objectives to foster psychological safety and to assure open communication, confidentiality, immediate feedback, and self-reflection (INACSL Standards Committee, 2016). The uniqueness of this scenario is that artistic impressions will be used to capture the nursing student’s views on safe and competent care.
References
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