New UAH center consolidates use of simulators to train student nurses

Dr. Lori Lioce

New Learning and Technology Resource Center Executive Director Lori Lioce in a simulation control room in UAH’s Nursing Building.

Michael Mercier | UAH

The University of Alabama in Huntsville College of Nursing has formed a new Learning and Technology Resource Center (LTRC) to consolidate its use of technology and lifelike patient simulators to train students and to further research in healthcare simulation education.

Dr. Lori Lioce is the new executive director of the LTRC. Formerly the college's simulation coordinator, Lioce is a UAH clinical associate professor and doctor of nursing practice (DNP), family nursing practitioner (FNP), Certified Healthcare Simulation Educator (CHSE) and Fellow of the American Association of Nurse Practitioners (FAANP).

"The new generation of learners really learns hands-on and with a lot of interaction with technology," says Lioce, who has researched and written about the use of simulators in nursing education. "Before the simulators, we had no way to standardize the educational experience so that every student could realize the same core clinical experiences."

UAH has been building its simulation program since 2010 she says, and the nursing college is finding that students immersed in simulation and debriefing learn core concepts and techniques more quickly.

Students interact with a variety of robotic patients that are run via software in a control room that has a one-way mirror offering a view into the patient room. UAH has simulators for adult care, obstetrics and pediatrics (infant and neonatal care). Video cameras record interactions and procedures and a microphone allows clinical experts in the control room to speak for the patient or the healthcare provider.

My goal is to do a complete mock hospital here that’s open 24 hours a day, and have the nurses working in shifts.

Dr. Lori Lioce
Executive director
Learning and Technology Resource Center
UAH College of Nursing

"It's not a punitive learning experience because of the way the debriefing is done," she says. "The student experience is much more positive and participative, and as the teacher, you become the facilitator of the learning process."

Faculty function to advance education by encouraging discussion, inquiry and interaction among students who are more engaged in the process during simulation than previously.

"The faculty are no longer 'the sage on the stage,' as they used to be in the days of lectures," Lioce says. "In fact, we're trying to increase immersive learning and minimize one way dialogue - traditional lecturing - to improve the process."

That evolution spurred creation of the 10,000-square-foot LTRC. Dean Marsha Howell Adams is combining the College of Nursing's Instructional Technology, Charger Hospital and Learning Resource Center into one. The center will function to increase simulation and clinical laboratory experiences, to provide more faculty-student engagement, to improve evaluation of learning and to expand research to advance the science of simulation in healthcare.

"One of my goals is to implement a complete mock hospital that's open 24 hours a day for a week each semester, and have the nurses working in shifts," says Lioce, who is also vice president of operations for the International Nursing Association for Clinical Simulation and Learning and chairs its standards committee. That committee has formulated nine interdisciplinary standards of best practice for simulation education use that are now being internationally reviewed for interprofessional global application and consensus.

The move to patient simulators started a decade ago in response to high demand for nurses and the resulting increase in nursing student enrollment nationwide. High student populations and concerns about liability limited nursing student access to hospitalized patients, Lioce says, and in many cases students are relegated to observing clinical procedures rather than interacting directly with the patients.

"Now, we have so many new nursing students and we struggle to find clinical training sites," she says. "Healthcare simulation replaces some of the clinical experiences we are unable to provide in a hospital."

In debriefing sessions, students self-evaluate performance and are also evaluated by their peer student group guided by a trained facilitator. This immersive learning environment boosts their learning engagement, provides students with evidentiary feedback of their performance and heightens their satisfaction and confidence with the learning process, says Lioce.

In the most recent available data, nursing students reported a 94 percent increase in critical thinking skills, a 75 percent increase in confidence in their ability to recognize changes in real patient conditions and a 73 percent better understanding of the classroom material.

And what the students encounter when they interact with the simulator is uncanny. High fidelity patient simulators breathe, have heartbeats, have bodily fluids, and can realistically undergo all the normal procedures a nurse might encounter, including being intubated, catheterized and phlebotomized.

Besides audio and video recordings for later review, the simulation control room provides a physiological readout of each nursing action performed and its result.

"We can make a lung collapse, and you won't have the sounds of breathing from that lung," Lioce says as she looks at computer monitors in a control room. "It's amazing. If a student makes the wrong decision, they get to see the results of that immediately. They'll have to react to that change in their patient, and the biggest advantage of using simulators is being able to teach on-demand the continual reassessment of a patient's condition."

Recording the sessions also gives students a window to their psychological and physiological stress reactions, something Dr. Karen Frith from the college has studied using a volunteer group that was monitored with equipment developed by Dr. Emil Jovanov, an associate professor of electrical and computer engineering.

"Every student who comes in here has a different reaction, and that's a part of what we do, is to learn from that reaction," Lioce says. "It's equally interesting to watch student interactions, and to see them form into teams to discuss treatment, abnormal findings and medication effects."

As they debrief, students evaluate what they did correctly and where they can improve, and then their peers evaluate their strengths and weaknesses.

"This is the fun part for me, seeing their reaction when they really 'get it,'" Lioce says. "We ask them to reflect and analyze their own behaviors and decisions about their patients based on what they have learned in the program and then ask, 'What would you do differently next time?' without any consequence to a live patient."

The recorded sessions also highlight instances when students violate clinical protocols, like failing to use aseptic techniques. It's all about improving prospective nurse's use of their knowledge, skills, attitudes and behavior to benefit patient outcomes, Lioce says.

"It's fascinating work that is impacting healthcare," she says, "and the innovation makes me love my job."



Lori Lioce

Jim Steele