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Why our Sim Patients are not Standardized Patients.

We've had many questions about why we do not use standardized patients (SPs) in our integrated simulations. Some think this is because of budgets and the costs of employing SPs. That's not it at all. Here's why. It's the student learning experience.

Students as patients are an important feature of our integrated simulations, and our research supports it. When we first began our 48- and 72-hour continuous integrated sims (and in our12 hour day-long sims that we design), we saw the opportunity for an empathy building experience for students participating in our simulations. Even for the students who are in the nurse role, we believed it was important they also spend time as patients in order to get a sense of what it's like to be one and to understand more specifically what the patient they are portraying is going through in this situation.

We build student learning outcomes (SLOs) specifically for this approach. We emphasize empathy and patient and relationship centered care. We ask questions in their reflection assignment that address those areas as well as quality care, areas of concern, and how the experience could impact their own nursing practice. We also build in family and social histories that impact care, such as homelessness, Alzheimer's disease, psych/mental health issues and addiction, and end of life, all within the context of complex medical-surgical conditions that have serious implications for the patient, the family, and for interprofessional collaboration. This has always been a positive experience for students. To ensure they take it seriously, there is generally a journalling and other assignments that accompany the experience.

Over time, we have expanded the SLOs for the students to also look more specifically at nursing care, since with a multi-patient scenario their nurse will have other patients and each patient will have downtime. We ask student patients to look up the disease process, labs data, procedures, and meds of the patient they are portraying and consider the nursing care needs of this patient; at times we have asked the student patients to complete a nursing care plan on their patient. It's a great learning experience. We always tell them to ask about every medication that the nurse gives to them, to insure that they have the opportunity to be a recipient of patient teaching.

Standardized patients participate in simulations using a medical model approach. They generally participate in short 10-15 minute simulations that focus on medical diagnosis in clinic-type environments that primarily benefit medical students, residents, or nurse practitioners. A standardized patient will generally learn one short script and play that part multiple times as different students progress through the same medical clinic type scenario.

On the other hand, our 48- or 72-hour integrated scenarios involve intensive team scripting that utilizes many hours to develop a single scenario (once training objectives are identified). The script includes an over-arching timeline that contains all the events for all patients (more than 60 in our most recent sim), orders, lab data, EHR data, and patient scripts (which may last from a few hours to 3 days). When the time for the sim arrives, our student patients participate in a detailed briefing which provides information about their patient roles and the portrayal of their patients, and they receive realtime guidance via their scripts when they arrive at the sim. We provide moulage information on the patient scripts; and while faculty provide most of the moulage, students also participate in their own moulage. As their shifts end and another group of students arrive for the patient role, students are asked to handoff to the next student patient. This gives them some experience, albeit in a different manner, in performing handoffs that cover what happened to the patient during their shift.

We have even had graduate students (NP, nurse educator, and PhD students) in the patient role, and their feedback indicated they took away a better understanding of what their own patients experience in the hospital. Grad students have discussed how distressing it is to ask for pain medication and for it to be delayed a significant period of time, and they indicate that they become more cognizant of the impact of these kinds of delays and other issues on their patients.

We usually suggest that students get clinical hours for the patient role, although sometimes faculty have made it extra credit (which is very popular among students). For clinical hours, students performing one 12 hr shift in the patient role during the semester have gotten credit from two or three clinical courses in that semester (4-6 hrs from each course).

Our integrated simulation experiences focus on a view of nursing as: caring in the human health experience (Newman), and the student patient experience fits perfectly within that nursing view. Our integrated simulations are holistic experiences, and everyone in the simulation (including faculty) benefits in mutiple ways that go beyond the formal training objectives for the integrated sim. We believe that our nursing students' participation in a simulated patient learning experience will have an impact on them that they will carry with them into their practice as a professional nurse.

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