Dr. Patricia Schuldenfrei, R.N., is Program Coordinator for Associate Degree Nursing at Massachusetts Bay Community College, Wellesley Campus.
Cynthia Zafft, R.N., is a Learning Specialist and a Facilitator in Critical Thinking at Massachusetts Bay Community College, Wellesley Campus.
Learning to fly a fighter jet is dangerous. To protect both the novice pilot and the public, the Air Force offers initial experience in realistic flight simulators. Similarly, nursing has a long history of using simulation to allow students risk-free practice of fine motor skills. Anyone who has visited a nursing program is familiar with groups of freshmen giving injections into gel-filled pillows or changing complex dressings on a mannequin. Like the flight simulator, the nursing lab is a place where initial practice takes place and mistakes occur, but students have the opportunity to analyze and refine their behavior. No matter how grievous the error here, no one is hurt. We use simulated experience as a valuable learning tool in psychomotor development, but could we also use it to teach the cognitive and affective skills of nursing management?
Role play, a form of simulation, is appropriate for "trying out" newly acquired interpersonal behaviors. Associate degree nursing students need to learn basic managerial skills, yet in the past, one difference between associate degree and baccalaureate degree nursing education was that managerial instruction was offered solely in the four-year setting. Community college graduates were to provide hands on care at the bedside and work under the managerial supervision of baccalaureate graduates. In today's health care reform economy, however, employers are hesitant to use professional nurses to provide routine personal care. The increased use of assistive personnel has changed the role of all nurses to a more managerial one (Vaughan-Wrobel & Tygart, 1993; Lowenstein & Sowell, 1992). Therefore, community colleges now need to educate student nurses to be effective managers.
In response to this challenge, associate degree nursing programs, while redesigning their curricula to include education in leadership, are finding few meaningful classroom models (Riskin & Zenas, 1989.) Presenting didactic information about the role of nurse manager and the basics of management theory is useful but far from sufficient. The students must also practice these skills in the clinical areas to integrate them into their professional lives. Moving from safe class discussion to a frightening health care facility with simply didactic knowledge is not only overwhelming to students but it is unfair. An intermediate step is needed to allow for exploration, experimentation, and reflection. Taking into consideration the complexity of leadership skills, as well as the resources available within our adult students, we chose to develop a role play simulation to create a bridge between the classroom and the clinical site.
This bridging experience relies upon several characteristics of leadership skill development. Nursing management requires integration of many interpersonal skills (Tomlinson, Clark & Faulkner, 1984a; 1984b), such as dealing with peers and delegating to other health care workers. The nurse leader also requires intrapersonal skills in setting priorities, delineating job responsibilities, and assessing changing situations as they arise. Faculty teaching leadership skills to adult learners need to consider their special attributes and provide realistic and relevant learning situations. Adult students prefer concrete application to abstract theory. Being experienced learners but novice managers, they see the practical value of actively engaging in new problem solving methods (Werner-McCullough & L'Orange, 1985). With this in mind, we designed a nursing management scenario for students to role play, giving them the opportunity to practice a complex combination of skills in a non-threatening environment (Holmes, 1991).
We placed students in small groups of five or six students and
assigned roles, such as the night nurse signing out, the day aide,
and several students working together in the role of the day nurse. A
final student acted as a recorder to document the behavior within the
group. We gave directions that "the day nurse" was to prepare to care
for six hospitalized patients. On a printed report, we shared some
information about each client, but vital information was deliberately
omitted to allow students the opportunity to question and clarify the
assignment. Students then worked together to find the missing
information, plan the nurse's day, delegate tasks to ancillary
workers, and deal with patient issues as they arose. Each group
addressed the needs of each client and decided which tasks could be
performed by the aide and which needed professional nursing
assistance. 
"How
important is it?" Students repeated this phrase many times as they
made decisions on patients' care. "Mr. Adams needs to be at x-ray by
9:00 AM, but I have three complex intravenous medications to give at
8:30." "Can the Johnsons wait until after lunch to learn about
providing care for their mother at home?" Discussion was brisk as
plans were set. When the students were comfortable with their plans,
the instructors interrupted with new data, such as informing the
students of a patient emergency in progress. For example, "It is now
10:00 AM; Mrs. Cole is having chest pain; Mr. Wilson is having a loud
argument with a staff member in the hall." The student group had to
reassign priorities and make judgments for nursing action. At the
conclusion of the three-hour class, each student recorder summarized
the experience and the feelings that emerged. The entire group joined
in "debriefing" and final discussion.
The role play demonstrated to faculty that students had mastered skills and knowledge taught earlier in the nursing program. Information that students had previously studied and practiced, such as how to respond to the patient with chest pain, was confidently used. The students enthusiastically applied the management skills we had recently discussed, but here their application was at a more novice level. In evaluating its use, the role play scenario is appropriate as a learning tool for a variety of reasons:
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--Students are given an opportunity to practice new skills in an environment that is both physically and emotionally safe. No patient is harmed by an inappropriate decision; no one outside the group is aware of a poorly thought-out plan. --Students are autonomous in their thinking. Each group solves the situations presented in a slightly different manner. Students learn to work with ambiguity and find there are several "right" ways to deal with each situation. --Students explore their feelings concerning professional roles. |
There were many comments concerning the pressures and responsibilities of management, an important consideration in management teaching but something which is difficult to convey in lecture format. The faculty enjoyed an unexpected positive outcome. We found that the role play allowed us to assess the transfer of learning from earlier work. Students were asked to plan on the spot to deal with physical and interpersonal patient care emergencies They used sound nursing judgment, drawing on their experience from previous classes. Faculty could also identify difficulties which would require additional structured learning opportunities. In community colleges, the student body is a group of individuals diverse in age, experience, and academic history. To best meet their needs, faculty must develop a variety of teaching strategies. Methods such as role play provide unique learning avenues that engage students in an active classroom role. This is especially important in the career programs where students need to use the information they learn immediately. Like the flight simulator, the exercise developed a beginning level of skill and confidence. It was not, however, the "real thing." The leadership opportunities provided in the clinical areas added more depth while workplace experience will add further dimensions in leadership skill. Associate degree nursing education is ready for take-off!
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SPRING 1997 |