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Critical Thinking or Task Training--What are we trying to achieve with simulation?

Updated: Aug 24, 2018

Nursing education has bought into high-fidelity human patient simulator-based training. Grants from simulator companies and educational organizations provided funds for schools to acquire all different types of simulators, from acute care to OB to pediatric to trauma, etc., to provide safe learning experiences for students. But, how do these types of experiences facilitate learning specifically in what nurses need to know? While there are certainly benefits to learning in these short scenarios, they focus on skills and without a broader, holistic approach that is consistent with the centrality of nursing, the level of critical thinking achieved is relatively low. 

Let's take an example. A common simulator-based scenario in nursing programs centers on deep vein thrombosis (DVT) and pulmonary embolism (PE). In a 10 minute scenario, the objectives focus on identifying the symptoms of DVT and PE and taking the actions necessary to intervene and get needed initial treatment to the patient. Students are typically given the objectives and reading assignments ahead of the simulation and come prepared to participate. Admittedly, there may be some critical thinking skill development for students in putting together what is going on with the patient (although through their readings they already know what is going to happen in most cases), assessing the patient correctly, administering oxygen by non-rebreather mask, etc., and deciding to call the provider. And, the debrief will generally get at some critical thinking, such as identifying relevant lab and assessment results that pertain to this medical diagnosis, and then discussing what actions the nurse should take. If the instructor facilitates this debriefing session well, learning will take place. 

But, what is ultimately achieved, in my view, is the understanding of a set of actions to take if nurses encounter a patient in this situation. This essentially becomes task training, especially if it is done in a short 10 minute scenario. Truly, it is immensely difficult to achieve critical thinking in the typical 10 minute scenario with the accompanying debriefing that we see in nursing curricula. Objectives for these sessions often center on identifying, describing, and discussing, not analyzing, applying, integrating, synthesizing, or evaluating, which would achieve much higher level learning.

Don't get me wrong, I think this type of training is needed, but only as a first step, and certainly not as the emphasis, (in many cases the only emphasis) of the simulation curriculum in nursing education. The problem is that this type of simulation, in its emphasis on task training, does not go far enough; it stops before it gets to the actual centrality of nursing. In reality, these scenarios apply to medicine and other healthcare disciplines just as much as they do to nursing. In a curriculum that focuses on preparing nurses for actual practice, students should experience these types of scenarios early in the program, and then subsequently participate in simulations meant for them to analyze situations, apply earlier learning, integrate, and synthesize these concepts with multiple patients and in different contexts while maintaining a holistic nursing-focused approach. Nurses in in acute care settings have multi-patient assignments of 4, 5, or sometimes 6 or more patients. They need to be able to set priorities by thinking through what problems and potential risks exist for each of their patients. And, they need to be able to anticipate, prevent, or intervene as situations arise, while keeping all of their patients safe. So, the complexity is much greater and requires a much higher level of critical thinking than is exhibited in a typical 10 minute scenario. The real focus needs to be on simulations involving complex multi-patient scenarios over very significantly extended timelines.

Today's typical nursing simulation involves only one disease process and focuses almost entirely on that disease process (and thus medical care). Real nursing care requires a unique nursing approach with multiple patients, (and therefore multiple medical diagnoses), and even multiple co-morbidities for each patient. Further, in real life, the risk for DVT/PE (or other critical event) is not generally as obvious as in the scenario that is presented to students; perhaps there isn't an orthopedic problem that makes DVT/PE an obvious risk. Dealing with these more complex situations is how critical thinking is developed and refined. Schools should be taking the standard nursing simulation experience much further than they are. Students should be applying learning concepts in different and more complex situations that are closer to real world nursing care.

Too often faculty may not understand what critical thinking is and how to recognize it in students. My experience has been that instructors often talk about critical thinking experiences which were not that at all. Instead they were actually talking about task training involving simple regurgitation of knowledge, not about situations where students needed to examine and analyze data, differentiate between relevant and non-relevant information, make decisions about the importance of data, and take action.That is where we need to be taking our students. And, this is what we accomplish with our integrated simulations. We take simulation to a whole new level, using multi-patient scenarios lasting up to 72-hours (3 or 4 shifts per 24-hour day for 3 days) where students must make decisions continuously, while talking with their patients and providers, and providing safe high quality, patient-centered care.

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