Comparison of Virtual Patient Simulation With Mannequin-Based Simulation for Improving Clinical Performances in Assessing and Managing Clinical Deterioration: Randomized Controlled Trial

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Original Paper

Comparison of Virtual Patient Simulation With Mannequin-Based Simulation for Improving Clinical Performances in Assessing and Managing Clinical Deterioration: Randomized Controlled Trial

Sok Ying Liaw1, PhD;
Sally Wai-Chi Chan2, PhD;
Fun-Gee Chen3, MBBS, MMed (Anaesth);
Shing Chuan Hooi4, MBBS, PhD;
Chiang Siau3, MBBS, MMed(Anaesth)

1Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
2School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
3Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
4Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

Corresponding Author:
Sok Ying Liaw, PhD

Alice Lee Centre for Nursing Studies
Yong Loo Lin School of Medicine
National University of Singapore
Alice Lee Centre for Nursing Studies. Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive
Singapore 117597,
Phone: 65 65167451
Fax: 65 67767135

1]. A 6-hour mannequin-based simulation program, known as RAPIDS (Rescuing a Patient in Deteriorating Situations) was implemented as part of a core learning activity in an undergraduate nursing program. A randomized controlled study has shown that the RAPIDS program using ABDCDE (Airway, Breathing, Circulation, Disability, and Expose/Examine) and SBAR (Situation, Background, Assessment, and Recommendation) mnemonics effectively developed nursing students’ clinical competencies in assessing, managing deterioration, and communicating patient’s deterioration to the team doctor [2]. However, it is unclear how best to maintain these competencies post-RAPIDS training.

A qualitative study was conducted to examine the effect of the RAPIDS program on the nursing students’ performances in the clinical practice. The study showed the benefits of mannequin-based simulation in preparing the nursing students for their encounters with deteriorating ward patients. To optimize their retention and transfer of learning in RAPIDS, the study recommended regular reinforcement with follow-up simulation training using the ABCDE and SBAR mnemonics [3]. Previous studies have supported the use of mannequin-based simulation in the acquisition of clinical skills but have also demonstrated their limitations [1,4]. Because mannequin-based simulation involves a small number of students at one time, a considerable amount of faculty time is required to conduct repeated sessions. Besides faculty time, the availability of simulation facilities and scheduling issues are major challenges faced by educators when implementing mannequin-based simulation. These challenges made it difficult to be certain whether it is the best follow-up learning method to maintain or enhance previously acquired skills.

Virtual patient simulation has fewer of these resource constraints compared to mannequin-based simulation. It is capable of creating high-fidelity simulation by applying the features identified in a systematic review. With the capacity for exhibiting a high level of interactivity and realism, a wide range of clinical scenarios with guided reflection can be designed into the virtual patient simulation [5]. In addition, it can cater to a large number of learners simultaneously and be used by learners repeatedly when needed. Being accessible anytime and anywhere, it can also be integrated into curricula in a more flexible manner [6]. Although the use of virtual patient simulations have been widely adopted for training health professionals [7-9], more research is required to inform how to effectively design and integrate them into curricula [10,11].

A virtual patient simulation was designed and developed for use as an instructional learning strategy to revise RAPIDS training. We conducted a randomized controlled study to determine the efficacy of virtual patient simulation, by comparing it with mannequin-based simulation, in improving the nursing students’ clinical performances in assessing and managing deterioration. A survey was also conducted to evaluate learners’ perception towards the newly developed instructional strategy.

Design and Development of Virtual Patient Simulation

The virtual patient simulation, known as e-RAPIDS, was developed at National University of Singapore (NUS) by a group of academic staff, clinicians, and educational technologists. This single user interactive multimedia simulation was created using Flash software and run on a secure server hosted by NUS. The contents were developed based on the following learning objectives: (1) Demonstrate a systematic approach using the ABCDE mnemonic to assess and manage clinically deteriorated patient, and (2) Demonstrate effective communication skills using the SBAR tool to report patient deterioration to doctor. Five simulation scenarios associated with acute medical conditions (acute coronary syndrome, hypoglycemia, hypovolemic shock, sepsis, septic shock) were used. Common deteriorating conditions such as airway obstruction, breathlessness, hypotension, tachycardia, oliguria, altered consciousness, and abnormal temperature were embedded in these scenarios. All the scenarios applied the same clinical case history of a virtual patient who was admitted to a hospital with multiple medical conditions and comorbidities (Figure 1). The complexity of the case history allowed sequential simulation of deteriorating events at different phases of the virtual patient’s hospitalization. Appropriate clinical findings and responses of the virtual patient were developed for each scenario.

Figure 2 presents the path of virtual patient simulation scenarios. The learner can choose to participate in any scenarios by clicking on the patient’s day of admission (part A in Figure 2). The deteriorating events occur on first, third, sixth, eighth, and tenth day of admission. Once inside the virtual ward, the learner receives a handover report on the case history and the latest update of the virtual patient’s condition (part B in Figure 2). After the handover, the learner, who plays the role of the nurse, is presented with a virtual patient with deteriorating conditions. The learner is required to assess and manage the virtual patient’s deteriorating condition by clicking on the actions from the ABCDE control menus (part C in Figure 2). There are over 30 actions programmed into the simulation. The clicking of a specific action may lead to an arrow sign that directs the learner to click on specific equipment or an item in the virtual ward. Immediate feedback, including information and physiological changes, was programmed into the system to respond to the learner’s actions. The information generated from an action is delivered through the virtual nurse’s verbalization with texts displayed in the form of speech bubbles. The physiological parameters including heart rate, blood pressure, and oxygenation are displayed on an electronic monitor in the virtual ward. SBAR control menus are used in the program to aid the learner in reporting about the patient’s deterioration.

At the end of each scenario, the learner enters a “debriefing” screen (part D in Figure 2), which consists of (1) five debriefing questions, (2) an evaluation tool adapted from a validated and reliable tool known as RAPIDS tool, and (3) a performance score. The debriefing questions lead the learner to reflect on the deteriorating situation and actions they have taken. Using a checklist format and brief explanation, the evaluation tool provides feedback to the learners on the appropriate and inappropriate actions taken in the simulation scenario. A score is automatically calculated from the evaluation tool based on the learner’s actions in the scenario (part D in Figure 2).

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