The Role of Computer-Assisted Simulation in Nurse Practitioner Education

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90 JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS

RESEARCH

The Role of Computer-Assisted Simulationin Nurse Practitioner Education

Mary Jo Goolsby, EdD, MSN, APRN-C

INTRODUCTION

One interesting aspect of nurse practitioner (NP) education is that eachstudent, to a large extent, has an individualized program of study. Studentsin any given program take the same core courses and select similar elec-tives. However, their clinicals are very individualized in the quantity andquality of experience each offers on any given day. Computer assisted sim-ulations (CAS) provide one means of standardizing access to certain typesof patient problems. For instance, if the faculty felt strongly that all stu-dents should be able to diagnose and initiate treatment for appendicitis orMeniere’s disease, these experiences could be provided to all studentsthrough a CAS. However, prior to relying on CAS learning experiences,there is a need to develop an awareness of the degree to which such pro-grams can teach transferable clinical abilities, as well as how students solvesuch problems.

Currently, existing programs exhibit great diversity in the numbers ofrequired semester and clinical clock hours, variety of clinical practice sites, andnumbers and preparation of preceptors. Graduate nursing education is costlyin time, funds, and energy to faculty, preceptors, and students. An under-standing of what various teaching modalities have to offer NP students willhelp educators and students capitalize on the resources they have available.

The purpose of this study was to develop a better understanding of onemodality available to NP educators. This article describes the findings of aseries of qualitative observations made as eight NP students participated ina CAS learning experience, with an intent of developing an understandingof the following issues:1) What role does CAS play in NP education?2) How do NP students solve CAS case studies?

ECOLOGICAL PSYCHOLOGY PERSPECTIVE

This study was designed using an ecological psychology perspective,which proposes that psychological behavior is tied both to one’s internal,physiologic make-up as well as one’s outer, environmental arena. Behaviorincludes objective, or molecular, aspects, performed by the subordinateparts of the individual and goal-directed subjective, or molar, aspects per-formed under one's cognition and by one's whole being. Similarly, thebehavioral environment also has both subjective and objective compo-nents. The subjective environment is the individual’s perception of his orher setting. The objective environment, or milieu, is a behavior setting thatmeets specific criteria. By definition, behavior settings must be self-gener-ated, or occur without effort by the researcher. They must occupy a time-space location and have a boundary that separates internal behaviors fromthose in other settings (Barker, 1968; Jacobs, 1987).

PurposeTo develop a better understanding of the roleof computer-assisted simulations (CAS) innurse practitioner (NP) education by observ-ing 4 pairs of students complete a CAS case.

Data SourcesQualitative observational study of 8 studentsperforming in a computer laboratory and aseries of post-observation interviews.Observations were recorded, refined, coded,and quantified based on the theoretical frame-work of ecological psychology.

ConclusionsEach pair of students established their own “per-sonalities” for the completion of the task.Misinterpretation of information was commonand the absence of a live patient interactionaffected the reasoning process of the students.The students demonstrated the ability to devel-op a perspective on the case based on previousnursing experience. Students generally obtainedadequate data on which to base differential/finaldiagnoses. Observations provided informationregarding strengths and weaknesses of studentsand methods used to solve scenarios.

Implications for PracticeAll students agreed that the CAS scenarios wererealistic, useful learning experiences, and thatthe knowledge gained would be transferable toreal clinical situations. Such experiences provideuseful experience with terminology, sequencingof the examination, and decision-making.

Key WordsComputer-assisted simulations; computer-assisted instruction; OSCA; nurse practitionereducation

AuthorMary Jo Goolsby, EdD, MSN, APRN-C, anadult nurse practitioner, directs the PatientCare Research Department at UniversityHealth Care System in Augusta, Georgia and isan educational consultant. Contact Dr.Goolsby by E-mail at [email protected]

VOLUME 13, ISSUE 2, FEBRUARY 2001 91

Behavior settings are not neutral sites to which just any behaviorcan be imported. Similarly, behaviors performed in a givenbehavior setting may not be transferable to other settings.Behavior settings have standing behavior patterns that remain thesame as individual participants change; however, behavior mayinfluence setting. The behavior and setting suit one another.Other settings exist that are synomorphic, or similar, to a givenbehavior setting. Behavior between synomorphic behavior set-tings is often interdependent and occurrences in one setting mayinfluence the other (Barker, 1968).

Ecological psychology includes both the behavioral environ-ment and associated goal-directed behavior. Methodologies basedon this philosophical tradition include descriptions of settings(behavior setting survey) and/or individual behavior (specimenrecord). The researcher remains neutral and records all behaviorsspecific to a situation. The record should include not only goal-directed behavior, but relevant aspects of the environment, andprovide a record of everything that is done and in what mannerit is performed. Additionally, the researcher records feelings aboutthe behavior and its meaning. Once recorded, observations arelater refined, coded, and quantified (Jacobs, 1987).

The ecological psychology perspective is quite applicable tothe study of NP students’ completion of and learning by com-puter simulations. Using this perspective, a set of assertions,applied throughout the study, were developed:1) A school’s computer-learning lab comprises a behavior-specif-

ic setting with a specific spatial location and a set of behaviorsperformed by different students that exist independent of aresearcher’s presence.

2) Participants in CAS learning are influenced by the arrange-ments of the behavior setting, including seating, computerequipment, lighting, distractions.

3) Participants in CAS learning are influenced by the limita-tions, functions, and abilities of the program software.

4) Participants in CAS learning are influenced by the availabili-ty of resources on clinical matters.

5) Participants in CAS learning are influenced by the program’sability to provide a realistic simulation.

6) CAS can provide repetition in clinical decision making,resulting in transferable, critical thinking skills.

7) CAS learning can provide access to clinical problems notreadily or routinely encountered in clinical settings.

REVIEW OF THE LITERATURE

There is a wide variation among master’s nursing programs ingeneral and NP programs, specifically. Program diversity isfound in numbers of semester and clinical hours, clinical-experi-ential arrangements, core and specialty courses, student charac-teristics, and other factors (Burns et al., 1993; Goolsby, 2000;Selleck, & Gregory, 1994; Stokes, Whitis, & Moore-Thrasher,1997). Nurse practitioner students identify the realism of learn-ing experiences as important to the ability to learn transferableknowledge in such settings (Knafl, 1979). Additionally, numer-ous aspects of clinical settings have been identified as detracting

from experiential learning: “no shows,” lack of space, limitedpreceptor time, the need to modify assessments to maintain theclinic schedule (Knafl, 1979; Osco, 1994).

Lange and colleagues (1997) evaluated a computerized pro-gram’s (Iliad) ability to teach diagnostic reasoning to NP stu-dents. Based on the responses of nine volunteer NP students, nostatistical difference was identified in successful CAS comple-tion, based on prior experience. Support was offered for studentorientation to CAS hardware and software prior to the learningexperience and recommendations were made for a conference orseminar to follow CAS the exercise in order to provide an avenuethrough which students could integrate CAS learning with otherexperiences.

When working with computer-based instruction, prior com-puter-related experience has been shown to be important. A sam-ple of both undergraduate and graduate students enrolled inWeb-based courses identified lack of both computer skills andaccess to necessary computer equipment as potential barriers tolearning in the program (Thiele, Allen, & Stucky, 1999).Similarly, observations of associate degree nursing students com-pleting CAS programs identified an association between lack ofprior computer skills and the likelihood that the user would beunsure how to complete the assignment or would become easilyfrustrated (Weiss, & Gutyon-Simmons, 1998). Overall, however,students consistently rate the experience of participating in com-puter-based learning very positively (Granely, & Fullerton, 1998;Jeffries, 2000; Lange et al., 1997; Madorin, & Iwasiw, 2000;Thiele, Allen, & Stucky, 1999; Weiss, & Guyton-Simmons,1998).

Another type of simulation, objective structured clinicalassessment (OSCA), has not been found to contribute signifi-cantly to clinical knowledge of NP students. The OSCA consistsof a series of simulated case scenarios through which students areeducated and evaluated, with “dummy” patients presenting spe-cific complaints and findings through interactions with each stu-dent during a time-limited interval. Following the patient-stu-dent interaction, students respond to questions on their case.While OSCA participation was not found to be related to courseexam scores, NP students have evaluated the simulations as apositive clinical learning experience (Bramble, 1994).Videotaped and phone simulations have also been very positive-ly critiqued by baccalaureate students as helping them to devel-op critical thinking skills when paired with guidance from clini-cal faculty (Johnson, Zerwic, & Thies, 1999). A report of obser-vations made during an OSCA program for medical residentsidentified the use of simulations in detecting areas of deficit instudent problem solving and interpersonal skills and in identify-ing areas of curricular weakness (Kwolek, Witzke, Blue,Schwartz, & Sloan, 1997).

Various CAS programs have been rated by second year med-ical students, using a six-point Likert-type scale. Programs wererated according to associated perceived learning, program feed-back, and control. One of the series investigated was theMedCaps® series, used in this study. The students ratedMedCaps® 4.33 on perceived learning and 4.83 on the amountof feedback provided. They rated the program strong (4.58) on


the degree of control provided students and subjectively indicat-ed that the program was not overly demanding when comparedto others. No real comparative statistics were applied, but theMedCaps® program compared favorably to others included inthe study (Xakellis, & Gjerde, 1990).

Boys in White (Becker, 1965) provides a classic, detaileddescription of the experiences of one medical school’s students.Through observations made over a full year, two concepts impor-tant to clinical learning were identified and then developedthrough expansive discussion: medical responsibility and clinicalexperience. Medical responsibility refers to one’s growing aware-ness that, by accepting the care of an individual, one accepts theresponsibility to facilitate positive outcomes, while minimizinguntoward events. Clinical experience is described as the awarenessthat one cannot treat patients solely with book knowledge, butthat clinical practice is also needed. The knowledge that comesthrough clinical experience and the assumptions of medicalresponsibility both come through extensive clinical practice.

In a very recent publication (Mallow, & Gilje, 2000), a callwas issued for further dialogue regarding technology-based nurs-ing education. In this context, technology-based instructionalmethods include the use of presentation software, Web-basedinstruction, and CAS, among others. The ability of technology-based methods to contribute to the development of criticalthinking is recognized. However, the authors also stress theimportance of nursing students developing a range of communi-cation skills and social processes, while recognizing the impor-tance of knowing patients as human beings, as opposed to aseries of health problems.

In summary, the literature shows that students find CAS exer-cises worthwhile and realistic. The work of Becker (1965) andMallow and Gilje (2000) put the use of CAS in perspective forthis study. The concepts of “medical responsibility,” acceptingthe responsibility to facilitate positive outcomes for our patients,and “clinical experience,” recognizing the importance of experi-ential learning, are both essential to NP education. It is of inter-est, then, to know how, if at all, simulations contribute to thedevelopment of NP students and how, if at all, knowledgegained through these exercises can be transferred to the clinicalsetting. Such knowledge can contribute to further dialogue relat-ed to the use of technology-based instruction.

METHODOLOGY

This qualitative study was designed based on an ecologicalpsychology perspective and utilized a series of observations andpost-observation interviews. Participants included eight familyNP (FNP) students who had completed one year of study in amoderate sized, graduate NP program. The majority of the stu-dents (n = 7) were in their 30s and one student was over 40. Fivewere female. All had used computers for word-processing andinternet access for course-related work, if not otherwise. Priorcoursework included health assessment, family crisis manage-ment, and their first actual NP clinical experience with over 200hours of clinical clock hours. The eight were the only students

enrolled in a clinical elective, developed to allow an additional90 clinical hours, including a seminar, over the summer break.The course required the completion of at least one MedCap®clinical simulation, with the students working alone or in pairs.

SAMPLE

Twenty-two students enrolled in the same elective one yearearlier had each completed at least one simulation and com-mented on the experience in their clinical logs. All found theexperience very helpful, realistic, and positive. However, itseemed important to know more than their “thumbs up” or“thumbs down” appraisal. The eight participants were eachapproached by the researcher and informed of her interest inlearning how the CAS programs worked for students, how stu-dents solved problems, and what the strengths and weaknesses ofthe programs were. All readily agreed to allow the observer to bepresent as they performed at least one CAS. All students electedto work in pairs, which made it easier to follow their thoughtsand actions, since they generally interacted verbally throughoutthe simulation.

PROCEDURES

At different, predetermined times, student pairs were met inthe computer lab and allowed to select their cases and proceed asthey would have without an observer. Boxes containing seven toeight computer discs each were labeled to indicate the types ofcases included with terms such as “family practice problems,”“problems of adult health,” and “infectious disease problems.”Students consistently selected either a family practice or adulthealth series. Although a decision had been made not to limit stu-dents to specific programs, two different cases were duplicated bydifferent pairs, making some comparisons possible. To minimizeany potential self-consciousness caused by the observation, a judg-ment was made not to tape the observations. Instead, observationswere recorded in a series of quick notes indicating some portion ofall that was said along with non-verbal behavior. Additional quicknotes were made as reminders of thoughts that would later becomeobserver comments. During the first observation, an attempt wasmade to remain neutral and avoid providing information to thestudents. However, the first pair had some difficulties with theprogram and it was then determined that providing informationessential to CAS completion would not jeopardize the study. Eachof the students was completing the programs for his or her firsttime and required some degree of assistance, which often consist-ed of a reminder to consult the CAS documentation.

Once the students had completed their CAS and receivedfeedback through the program, they were asked a series of ques-tions. The questions evolved a little through the process. In atleast one observation, the students so enjoyed working the CASthat the interview was done in small pieces as they performedone case after another. One member of this pair was included inlater interviews. The recorder’s notes, her ability to attend to and


recognize all aspects of the physical and behavioral setting, andthe minor interaction, are all sources of potential bias in thisstudy.

THE FINDINGS: SITE SURVEY

The study took place in the behavior setting of interest: theschool of nursing computer lab. The computer lab is a large,open, carpeted, and well-lighted room. Long tables, with com-puter stations poised at comfortable distances, are arrangedaround the room. Typically, several students are present, workingindividually or in small groups on CAS programs, Internetaccess, or word processing. Near the center of the room, there isa bookshelf holding a variety of software programs and relateddocumentation and texts; there is always at least one computerlab staff member available to assist students. During each of theobservations, the same computer assistant was present and help-ful in locating disks and programs. There were four to six otherstudents working at the computers along the right wall duringeach observation. There were typically no interruptions duringthe simulations.

The equipment used by the subjects of ecological psycholo-gists is of interest. The MedCaps® programs provide text-basedsimulations. They initially provide the participant with a chiefcomplaint and brief history of the present illness. The partici-pant then chooses how to proceed from a menu of options,which include obtaining various aspects of history, physicalexam, diagnostic tests, or making diagnosis. A history must beobtained and an initial differential diagnosis identified beforeone can proceed to the physical examination. The simulationends once a formal diagnosis has been made, with no opportu-nity provided for the development of a plan of care. On com-pletion, the program provides feedback on the time entailed inand the costs associated with the assessment, and the final diag-nosis chosen. Rationale is provided for the correct solution, aswell as why others should have been excluded.

FINDINGS AND DISCUSSION: BEHAVIOR OBSERVATIONS

Each of the four pairs observed established their own “per-sonality.” All arrived with an arsenal of texts and resources andall but one pair referred to them during the exercise. One pair(#3) tried to “strong arm” their way through two cases and, oncompletion, one member bragged to the other that they had notonce used a text.

Members of two pairs (#2 and #4) worked together in analmost orchestrated manner, as one. They frequently took turnsentering data, referring to resources, and freely discussed the casewith one another. Another pair (#1) worked in an amiable, coor-dinated manner, though they were more reserved in their inter-action and one member assumed more responsibility for thecases than the other. The remaining pair (#3), who have verysimilar backgrounds and have worked together as students and

nurses, seemed to be working almost independently of oneanother-taking turns with cases. However, with the exception oftechnical problems stemming largely from semantics, all eight ofthe students were reasonably comfortable with their CAS and itappeared they would each have been able to perform individual-ly. Pair #4 even laid out the groundwork for each other, indicat-ing that they should talk aloud so that they would know theother’s thoughts.

Each pair had some degree of difficulty with the software.Although each set of simulations was accompanied by a brief textor manual describing the program and giving general instruc-tions, there was a lack of consistency between the manuals andnone seemed complete by itself. When two booklets were usedat once, students found the program easier. The most frequentproblems were related to identifying a question, request, or diag-nosis worded so that the program would recognize it and therewere, on average, five instances in which there was some briefconfusion in finding an accepted term with each program. Withpersistence, however, all were able to obtain needed data.

In each observation, students were able to ask questions byentering items that would elicit history. They sought history thatwas directly related to the patient’s presenting complaint as wellas seeking supportive history. Related questions further elaborat-ed one of the systems likely to be involved in the chief com-plaint. Supportive history included questions on family historyor habits — both of which provide meaningful information nec-essary for a holistic assessment. There was a great variety in thenumber of questions asked of the simulated patient. Much ofthis depended, in part, on the complexity of the presentation.For instance, students requested three to four added pieces ofhistory of present illness and history related to the associated sys-tem for problems such as vaginitis and up to nine related ques-tions when faced with a more complex problem of appendicitis.An approximately equal number of supportive history questionswere asked as well, including questions regarding occupation andother sociocultural data. The third pair initially asked no ques-tions. In spite of being presented with a complex case, they onlyobtained a brief history when the program would not allow themto proceed to physical exam otherwise.

Similarly, observations of physical assessment actions werecoded by whether an action was supportive or directed towardobtaining physical exam data directly related to the complaint.Three to four physical assessment techniques were selected oneach program for both direct and related data. The first pair pur-sued more physical exam than did the others, requesting data for12 actions. However, most of their exam was very focused to thesystem involved and did not reflect a “shotgun” approach to theexamination. On reflection, it is believed that all but the firstpair could have obtained more physical data on which to basetheir diagnosis and fully exclude other possibilities. However, itwas determined that each obtained an adequate amount of phys-ical data.

The number of diagnostic tests ordered was recorded andcoded. The mounting of a “wet prep” microscopic slide andinspection of a urine specimen, both performed in the “office”were completed at no cost to the patient. Other diagnostic stud-


ies included basic laboratory studies such as blood chemistries orhematologic counts. For the purpose of making the studentspecify what individual tests are warranted by the case, the pro-grams do not allow one to order “panels” of laboratory tests.Diagnostic studies also included radiologic studies such as x-raysor computed tomography (CT) scans. The cost of the work-up,one of the evaluative measures of each simulation, is solely basedon the cost of diagnostic studies. Additionally, the time requiredfor diagnosis was based, in part, on the time required to obtainrequested diagnostic test results. For simple problems, studentsselected one to three tests; for more complex problems, studentsselected four to five tests. In clinical practice sites, diagnostictesting is one area that a student has no opportunity to select,prior to consulting with the preceptor. They each appeared toenjoy independently selecting diagnostic studies and it wasbelieved that they did so in a rational manner.

Throughout the observations, the frequency with which thepairs seemed to make interpretations of the findings presentedby the system was noted. The ability to even recognize interpre-tations as such was, of course, dependent on their verbalizingsome interpretive comment. For example, the third pair just“plowed through” their two cases with few words. Without com-ments, it appeared that they made their diagnosis based on theinitial presentation of the patient and did further work-up onlyas required prior to choosing their diagnosis. Compared to theother pairs, they demonstrated little interpretation, and evenseemed to miss certain findings. The frequency with which pairsmade interpretive statements was highly variable, ranging from 2to 15 times per case. Examples of interpretive statements areincluded for clarification. During the first pair’s case, they foundthat their patient had not had a tetanus shot in years. Althoughunrelated to his primary complaint, one student stated, “Heneeds a tetanus!” Her partner concurred, stating, “Especiallyworking around a farm!” Other examples were more related tointerpretations directed toward solving the case. The fourth pairmade an interpretive statement almost every time they saw apiece of information. When their patient had a low blood pres-sure and elevated fever, they indicated, “Well, he’s a little febrileand his blood pressure is down from dehydration.” The patient,who had appendicitis, had a tender right rectum, hemorrhoids,and blood in his stool. One student suggested, “That’s the sideof the appendix.” The other added, “He didn’t have a rigidabdomen. His guaiac was positive...could be the aspirin or hishemorrhoids. Those could be red herrings, though.” Pair mem-bers stopped to confer with one another 1-17 times per case.

The first two pairs took notes throughout the exercise. Thethird and fourth did not. Interestingly, the last two pairs eachbecame “lost” in their case at least once. One student would sim-ply turn to the other and state, “I’m lost!” While the programallows for pieces of information to be printed out, none of thestudents took advantage of this ability. Admittedly, it would havebeen a nuisance to do so, as the printer was on an adjacent deskand printing pages would have required a constant up and downmovement. Printing the data would also slow the process.

The technical manual, or software documentation, suppliedwith each case was referred to two to six times per case. The soft-

ware manual was generally referred to in determining what termsthe software would accept and the variety of diagnostic studiesavailable. Additionally, all but the third pair used the clinicaltexts one to three times per case. They referred to clinical textswhen the simulation provided data, such as lab findings, withwhich the students were unfamiliar. This occurred with a differ-ential breakdown of white blood cells, abdominal findings con-sistent with peritonitis, and other studies. Students also typical-ly referred to their texts when ready to commit to a diagnosis.

The first pair was unsuccessful in selecting a final diagnosis.One member typed in a final diagnosis that was not wordedexactly as one that had been earlier listed in the differential diag-nosis list, a requirement of the program. Although the termentered was clinically correct, she could not get feedback basedon the actual diagnosis. The second pair was torn between twodiagnoses on the same case. Although they first selected thewrong response, they entered it in such as way that it was not“final.” They were then able to revise their choice and receivethorough feedback from the system. All other cases observedwere successfully solved. Interestingly, the case that caused pairs#1 and #2 problems was the “common cold,” for which they haddifficulty excluding the diagnosis allergy. The case also includedsome distractors that both pairs misinterpreted, leading themdown the wrong path.

In every case, students misinterpreted information, addedinformation, or did not indicate that they recognized the signif-icance of certain findings. For example, the patient with thecommon cold was found to have a little fluid behind a tympan-ic membrane and a sense of fullness in that ear. Both pairs #1and #2 later said he had complained of ear pain and had indica-tions of an otitis media (not serous otitis). Although an appen-dicitis patient was also found to have abnormal lung sounds andlesions on his chest x-ray, the third pair never commented on hisprobable lung disease. The same pair, failing to obtain a pastmedical history, was unaware that the patient had previously suf-fered a stroke. When he had weakness and decreased reflexes onone side, they shrugged off those findings as possibly related todehydration and pursued his abdominal complaints. In noinstance did the researcher correct any misinterpretations orpoint out information that the students had missed. Failure toobtain an adequate history or accurately recall or interpret find-ings could happen as easily in clinical practice as in a simulationand are significant errors.

One point that was evident throughout the experience wasthat the students were affected by the absence of a real setting. Inother words, the time of year, type of weather, location of visit,and actual patient were invisible to them. This caused variousproblems for each pair. A member of the first pair, when facedwith the patient with the common cold, mentioned twice thatshe wanted to know what time of year it was. This could cer-tainly be an important piece of data. In at least two cases, stu-dents agreed to pretend they were working in an emergencyroom (ER). The third pair, faced with a patient with an urgentproblem, truly believed the scenario had indicated they were inthe ER. Only later, on review, did they realize that they had con-fabulated this piece of information.


During each observation, students mentioned, at least once,how their past experience helped them approach the particularcase. Members of the third and fourth pairs had critical care andER backgrounds. Faced with urgent problems, they indicated itwas nice to be able to use their previous professional experienceto address situations in an efficient, fast manner. Three of thepairs, referring to the potential that a patient similar to the onepresented by their case might present to the ER, indicated thatin that setting they would obtain the full spectrum of diagnosticstudies. These finding support Barker’s discussion of developinga perspective built on experience to utilize in clinical practice.

All but the third pair indicated some thought that could beinterpreted as a sense of responsibility for their patient. The first,faced with the common cold symptoms, identified that thepatient’s tetanus shot was outdated and he was at risk for injury,working around farm equipment. This indicated a concern formore than the presenting symptom-a holistic view. The samepair seemed almost ecstatic to learn this patient was a non-smoker. When obtaining the history on the patient with vagini-tis, the second pair learned that she had several small children,lived in public housing, and both she and her husband worked.One member of the pair commented, “We’ll have to be carefulabout costs for her.” This indicated a concern to avoid incurringunreasonable costs, just to cover themselves. The fourth pair wasvery attentive to the many health problems of the patient withappendicitis and worried about his home situation, long-termcare plans, and a variety of other issues. They clearly reflected thecase management role of the NP, even when dealing with a sim-ulated, acutely ill patient. Responsibility is something thatBarker felt medical students learned through exposure. One ofthe strengths of NPs lies in the fact that they are, first, nurses.They come to the NP role with a set of beliefs and expectationsregarding the patient-nurse relationship. It was heartening to seethis reflected, even in tiny ways, even in these brief simulations.

FINDINGS AND DISCUSSION: INTERVIEWS

In addition to observations of problem solving, the researcherwas able to interview each pair of students once they had com-pleted their CAS. All verified that the patients and case scenar-ios presented by the CAS were quite realistic in description.They said that they could picture the patient presenting to oneof their settings and felt that it would be exactly as described.They indicated that CAS could assist students in learning theterminology associated with various diseases. Other advantagesof the CAS included allowing time for the novice to think aboutthe next step and look up information. They said it helped to beable to focus without distractions. However, the first pair feltthat, to be truly realistic, it should set a time limit and “lock out”after that time has passed. They felt that one could not improve,if allowed to dally all day on one situation.

Asked where CAS should be introduced to a NP program, allfelt it should be introduced early. They all recalled suggestionsduring the previous semester that they utilize the CAS. However,none were familiar with the programs and elected not to try it,

as their completion did not constitute a course assignment. Theysuggested that students in health assessment lab be introduced toone CAS, selected by faculty, and complete it alone or in pairs,with an instructor available for assistance.

Like all teaching modalities, CAS will not benefit all students.The third pair, for instance, seemed to enjoy the simulations,while wanting to get through them as fast as possible. Theyappeared to leave the experience totally unchanged by it. The suc-cess of such programs would depend on student learning style.

All students were pleased with the feedback they received fromthe CAS. They said they did not receive such detailed feedback inthe actual clinical setting. The CAS not only critiqued their diag-nosis, but listed other possible problems they had not consideredand provided the rationale for considering each. It critiqued theiruse of time and diagnostic funds. In all cases, the students scoredexceptionally well on both accounts. Even when their initial diag-nosis was incorrect, their diagnosis was the one indicated as thesecond most likely diagnosis.

All of the pairs believed that the information learned throughCAS would be transferable to clinical settings. They indicated abelief that their CAS exposed them to new information. Itrequired and allowed time for use of references and clustering ofsigns and symptoms representative of a given diagnosis. Theybelieved that repetition from completing several cases wouldhelp their future clinical abilities. The fourth pair discussed, atlength, the ability of CAS to place the student into an activelearning role. They said that texts and lectures had a place intheir learning but that it was difficult to recall all of the infor-mation until it had been put in perspective and applied througha clinical case.

After sorting through the observations and initial interviews,several questions were posed via E-mail, to one member fromeach of the second and fourth pairs. They were asked to describetheir strategy(ies) for clinical problem solving and when theybegan to develop a differential diagnosis. This question was trig-gered when each pair was surprised that they were asked to iden-tify a differential diagnosis once they had completed the historyportion of the CAS. One mentioned that she approached situa-tions analytically, pairing analysis with logic. She made an initialhypothesis and differential diagnosis and then determined towhat degree the history and physical findings supported herhypothesis. Next, she set out to further support her assumptionthrough the use of appropriate diagnostic studies. She said thatshe began forming her flexible differential diagnosis the momentshe met the patient and began her history.

The other said that she had found it helpful to keep an openmind, rather than to jump to conclusions. She tried to avoidallowing anything said by the staff to mislead her, but sought torecognize the importance of a systematic history. She said thiswas the “old nursing process” she had used for 22 years. She triedto recognize all of the possibilities, with an awareness of whatresources she did and did not have at her disposal. She felt thatshe did not really begin to formulate a differential diagnosis untilher history was complete and she was ready to perform her phys-ical exam. The observations of her history taking sequencewould indicate that she did form an inkling of a differential diag-


nosis early in the encounter. However, because she does follow aprescribed method for obtaining a history, she may not recognizethat she is focusing prior to its completion-or she may be correctin her self-assessment.

Each was asked what could best be learned from each of theresources and experiences he or she had available: texts, lectures,clinical, preceptor discussions, and CAS. The second pair mem-ber indicated that she preferred learning from real-life experi-ences and felt that CAS, texts, and lectures were supportive ofclinical learning. She was inspired to see the immediate impactof her actions on a patient and said that a patient experience uti-lized all of her senses so that, in absence of a real patient, learn-ing was diminished. She strongly felt that each opportunity andresource had much to offer. The fourth pair member focused onother aspects of the question and indicated that she learned mostfrom the “active” experiences provided by both clinical and CAS,where the requirement to exercise judgment helped her toremember. She felt that observations of her preceptors fellbetween passive and active learning and that she learned fromobserving the ways in which others interacted with patients andtrying to follow their thought processes through each encounter.She felt that, although uncomfortable, it was also quite helpfulto have her preceptor quiz her, following experiences.

IMPLICATIONS

The experience of observing eight NP students perform CASwas quite enlightening. It provided an awareness of many aspectsof CAS that had not previously been apparent to the observer.First, it became obvious that the patient and setting are ofteninvisible in simulations that do not include either an in depthprinted description of such content or include a visual compo-nent. Each CAS provides a general description of the patient, aswell as ample other information to include social factors, whensought. However, this information disappears from the screenwhen the next question is asked, providing a very artificial situ-ation. There are, of course, updated versions of CAS that provideaudio and video feedback to the student that should be studied.

Computer assisted simulation programs do not require thatparticipants perform as they would in a real clinical situation, forexample, word questions appropriately or perform the tech-niques of a physical examination competently to receive infor-mation. No interpersonal skills are required. Instead, one needonly select a key word to receive the information desired. Again,this is a very artificial situation, failing to simulate actual clinicalpractice. One does not simply say “genitourinary” and receive afull history of symptoms related to this system. Similarly, onedoes not say “abdomen” and learn that the abdomen is diffuselytender, with right lower quadrant rebound tenderness, lacksbowel sounds in the lower fields, and has no scars. If assessmentswere so easy, providers would certainly find clinical data gather-ing an easy situation. An educator must keep this limitation inmind when assigning CAS. This observation certainly supportsthe recent call for dialogue regarding how technology is used innursing education (Mallow, & Gilje, 2000).

In contrast, these CAS do provide experience with terminolo-gy, sequencing of exam, clustering for diagnosis, and decisionmaking. Decision readiness is one characteristic with which stu-dents have difficulty. They often allow the preceptor to tell themwhat is wrong, rather than go out on a limb with their own diag-nosis. Clinical experiences are often in less than optimal environ-ments where the need for student learning sometimes conflictswith a mandated clinic schedule, space allotments, preceptor andpatient availability, or other limitations. Computer assisted simu-lations would be helpful in supplementing students’ learning anddevelopment of clinical confidence. Another strength of the pro-grams is the ability to provide participants with salient feedback.In a clinical setting, time is limited and preceptors rarely havetime to provide that quality or quantity of feedback they wouldhope to, but which is automatic for many CAS programs.

As mentioned earlier, the CAS programs have the ability topresent select patient problems that might not otherwise beavailable to all students. The utilization of CAS, with casesselected by faculty, could be a positive addition to a clinical pro-gram. The students observed seemed to enjoy the CAS. Anenjoyable learning experience is more likely to be utilized. Thesefindings of positive appraisal are similar to those reported in ear-lier discussions of CAS in the literature review.

Faculty using CAS in their courses should be available to workwith students and help them critique their performance and assistwith trouble shooting “glitches” in the programs, as suggested byothers (Weiss, & Guyton-Simmons, 1998; Johnson, Zerwic, &Theis, 1999). The third pair, although successful in their diag-noses, missed considerable data and would have benefited froman organized program through which to complete the CAS. Aftertheir CAS was completed, the observer used the opportunity todiscuss how they might have more holistically addressed theircases. Such an approach would be essential when faced with thecomplexities of a living patient. The discussion was positivelyreceived. Observations of students in simulated situations do pro-vide information regarding potential strengths and weaknesses ofthe individual students and the curriculum.

Large amounts of data were obtained while observing eight NPstudents working in pairs to complete six CAS. The sample sizewas small but represented all students enrolled in one NP electiveclass. The observations were adequate to begin answering both ofthe research questions. The observations and interviews both pro-vided information on how NP students solve not only CAS, butother clinical problems. Additionally, the students freely providedvery rational feedback on how CAS could best be utilized in a for-mal NP program and the roles the cases might serve. Onlythrough repeated observations with other groups of studentswould the generalizability of these findings be determined.

The findings of this and other qualitative examinations of NPstudents and CAS should be used in the development of furtherquantitative studies. A qualitative study provides an immenseamount of rich information. The data obtained could be used todevelop quantitative tools. Such tools could include checklists tobe completed by researchers in observing students or surveyscompleted by the students who had completed CAS and othermodalities. ❚

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1 Year (12) 2 Years (24) 3 Years (36)Domestic $38.00 $58.00 $78.00Canada $63.00 $108.00 $153.00Foreign $108.00 $198.00 $288.00

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The Role of Computer-Assisted Simulation in Nurse Practitioner Education