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Pediatric Simulation in Pre- Licensure Nursing | OMICS International
ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Pediatric Simulation in Pre- Licensure Nursing

Kathryn Kushto-Reese1*, Shawna S. Mudd1, Elizabeth Sloand1 and Sandra M. Swoboda2
1Department of Acute and Chronic Care, Johns Hopkins University, School of Nursing, Baltimore, Maryland, USA
2Johns Hopkins University, Schools of Medicine and Nursing, Baltimore, Maryland, USA
Corresponding Author : Kathryn Kushto-Reese
Department of Acute and Chronic Care
Johns Hopkins University School of Nursing
Baltimore, Maryland 21205, USA
Tel: 410-614-5299
Fax: 410-955-7463
Received January 29, 2015; Accepted May 19, 2015; Published May 21, 2015
Citation: Kushto-Reese K, Mudd SS , Sloand E, Swoboda SM (2015) Pediatric Simulation in Pre- Licensure Nursing. J Preg Child Health 2:164. doi: 10.4172/2376-127X.1000164
Copyright: © 2015 Kushto-Reese K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Pediatric nursing is an area that has shown to be associated with higher levels of fear, anxiety and perceived challenge than other clinical settings for the pre-licensure nursing student. A simulation curriculum has been developed to address the complexities that students face in the pediatric clinical setting. This curriculum addresses common pediatric diagnoses both in acute and ambulatory settings and provides students an opportunity to practice essential pediatric communication skills, family centered care, pediatric skills and safety issues commonly encountered in pediatric nursing practice. Core competencies from American Colleges of Nursing (AACN), Pediatric Nursing: Scope and Standards of Practice and Quality and Safety Education for Nurses (QSEN) are incorporated into the pediatric simulations for this course. Students perform in various roles during simulations e.g. nurse, parents, family member or child in order to assimilate caring for children with complex needs in the clinical setting. Simulation can ensure that all students learn common core curricula concepts in their pediatric course. Students reported that exposure to various simulations before and during their pediatric clinical experiences contributed to their learning of pediatric skills. They also reported that simulations provided them with an opportunity to practice communication skills with parents and with children of various age and developmental stages and in difficult situations. These opportunities contributed to increased confidence levels and also helped to decrease some associated anxiety during their pediatric rotation.

Pediatrics; Simulation; Adolescents; Healthcare
Learning the intricacies of pediatrics is often one of the most overwhelming tasks for pre-licensure nursing students. For many students, caring for the pediatric patient is associated with higher levels of fear, anxiety, and perceived challenge than older patients, which can adversely affect student performance [1,2]. Traditional clinical placements in pediatrics include the hospital, ambulatory locations, and school-based health settings. Care of the patient in the pediatric setting is complex and dynamic. Because pediatrics spans the developmental stages from infancy through young adulthood, each age group has specific and unique characteristics that must be considered when providing care. Pediatric nursing requires a family-centered approach, which includes the patient, parents, siblings, and extended family members. This approach is carried out within the context of care that is based on the child’s age, development, and medical condition [3]. This expanded family focus and the need to incorporate child development combines to create greater challenge for students. This article will give an overview of simulation and its use in pediatric nursing education. It contributes to the literature by describing a comprehensive approach to effective use of simulation in the pediatric course.
The use of on-campus clinical simulation as a successful pedagogy in nursing education has gained widespread acceptance in many academic settings as a response to the changing clinical environment, including fewer student opportunities for patient exposure and decreased numbers of clinical nursing faculty. Simulation can enhance course and program outcomes, bridge the education-practice gap, increase exposure to rare medical situations, and provide a safe, risk free, controlled learning environment. This encourages and supports the learner’s ability to transfer didactic content from the classroom to realistic patient interactions in a simulated environment [2-5]. Research has shown that simulation based nursing education, when conducted with best practices, can be an effective substitute for a portion of clinical hours [6].
Using high fidelity simulators allows students to engage in complex practice situations, ensuring that they will learn the skills and develop the confidence necessary to provide safe and effective nursing care when they are in a real life clinical setting [1]. In addition, nurse educators have a responsibility to help address the problem of medical errors, which are often related to communication failures [7]. These communication failures can occur among nurses and other health professional team members, as well as between nurse and family [8]. Simulation is an effective teaching strategy to help students refine critical communication skills and prepare for potential errors in a riskfree environment [9].
Simulation-based education supports the cognitive, psychomotor, and affective skill learning that is fundamental to caring for infants, children and adolescents [1]. Faculty have used both high fidelity and low fidelity simulations as an adjunct to direct care clinical experiences to expose students to specific pediatric clinical skills, including medication administration and communication with family and other healthcare providers [4]. Medication administration in the pediatric setting offers new challenges for nursing students and many clinical sites do not allow students to administer medications. Pediatric dosing of medications is precise and is based on the patient’s weight. There are also different mechanisms and routes of delivery in pediatrics including oral syringes, syringe pumps, IV pumps, and other delivery devices that may lead to an overall greater potential for patient harm due to errors. The simulation environment is an effective teaching strategy for pediatric medication administration and can help prevent potential errors and catastrophic outcomes. Several studies support the need for simulation practice as a way to avoid errors in general and errors in the delivery of medications [10-14].
Another critically important skill in pediatric nursing is communication with families and children of different developmental stages. Simulation scenarios can be patient or family-centered where students can use appropriate communication techniques with parents and with patients of different ages. Students can practice speaking to stressed and concerned parents and learn how to modify their communication with an infant or older child using appropriate developmental techniques [15].
Pediatric simulation
Senior pre-licensure baccalaureate nursing students in their pediatric course at a large urban university school of nursing study the unique health and developmental needs of infants, children and adolescents. During this course, students focus on family-centered care that incorporates health screening, teaching, and health education, including a strong developmental and health promotion focus across all clinical settings. Students learn principles involved in assessment, planning, and implementation of nursing interventions appropriate for children with various complex health problems that are specific to children and manifest in unique ways. In both the acute and community-based clinical settings, students learn to use the nursing process to provide safe, comprehensive care to children in diverse settings across the care continuum and to improve the overall health of children. The pediatric course at our institution occurs in the third semester and contains didactic content and the completion of 112 hours of clinical practice, of which 16 hours are simulation-based learning. Course and clinical objectives are based upon the American Association of Colleges of Nursing (AACN), The Essentials of Baccalaureate Education [16], Pediatric Nursing: Scope and Standards of Practice [17] and the Quality and Safety Education for Nurses project [18]. All students at our institution are second degree, accelerated students. In the pediatric rotation, essential aspects of the clinical experience are standardized, so that all students regardless of their clinical placement (acute or ambulatory) are exposed to core concepts of interprofessional communication, family and child communication (both difficult conversations and patient education), and medication safety. The on campus simulation experience consists of 2 eight hour days that incorporate a blend of age-specific simulations, guided by best practices through the International Nursing Association of Clinical Simulation and Learning Standards [19] and pediatric oriented skills stations. The following competencies from the aforementioned Associations are incorporated into the simulation scenarios; fundamental safety, patient and family communication, health education, and growth and developmental theory. Skills stations to address these competencies include pediatric CPR, weight-based medication calculations, and specialized pediatric equipment (syringe pumps, tube feeding pumps, gastrostomy tubes, nebulization treatments), and health screening tools such as, vaccination schedules and growth charts).
Specific simulation scenarios are chosen based on our highly specialized inner city setting, high frequency of occurrence of illnesses/diseases seen in the pediatric settings, and by results of a nationwide NCSBN survey of nursing schools that identified the most common health and wellness issues relevant to pediatric curricula [20]. Scenarios occur in the acute and ambulatory settings and include a child experiencing seizures, respiratory distress (asthma and respiratory syncytial virus), sickle cell disease, newly diagnosed leukemia, pre-operative and postoperative care (acute appendicitis and musculoskeletal trauma), head trauma, penetrating trauma, birth anomalies, and a high school bullying scenario related to gender identity issues. High and low fidelity simulations allow students the opportunity to incorporate and practice both psychosocial and psychomotor skills. In all scenarios, students use communication skills that require knowledge of developmental stages of the child and critical thinking and reasoning skills for decision making. For example, one scenario focuses on the care of a ten month old infant in respiratory distress. The nurses make decisions and initiate interventions for the child’s respiratory needs based upon a nursing assessment that incorporates knowledge from previously learned didactic content and skills practice. During the scenario, students are expected to apply their knowledge of growth and development in caring for the infant using appropriate toys or security objects and by including the parent in the child’s care. Students are also expected to teach the parent about nonpharmacologic methods of pain and anxiety control. These scenarios are complex and communication with families in these circumstances requires student preparation and practice. Students share their reaction to the experience during debriefing, which occurs afterwards.
Patient and family communication and education
Teaching and preparing families to provide for their child’s healthcare needs at home and helping them to prevent accidents and illnesses are major aspects of pediatric care; therefore, several simulations give students the opportunity to practice family education related to the patients’ primary diseases. Students practice providing education and support that will enable and empower families to care for their child’s needs away from the clinical setting. For example, in one scenario, a five year old is admitted for a sickle cell pain crisis. The student nurses in the scenario complete a history with the family and begin teaching the parents about how to prevent a crisis and manage an emergency. In this scenario, students also play the role of the family member (mother, father, grandparent, etc.). The student playing the parent asks questions about the child’s care and provides a teach-back explanation about the information the nurse gives them, while also providing emotional support for their sick and crying child.
Interprofessional communication and medication safety
The above case of a 5 year old child with sickle cell disease requiring pain medication combines the concepts of interprofessional communication and medication safety in one simulation scenario. In the scenario, the parent insists the patient be treated with more pain medicine, requiring the student to notify the provider. The student then calls the provider and reports using SBAR; Situation, Background, Assessment and Recommendation. SBAR is a communication technique first used by the military and adapted by health care as a standard framework for conveying key information [21].
The provider then orders a dose that is not appropriate to the patient’s weight. The expected behavior is for the student to challenge the order. Challenging the order is based upon TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety. If the order is not challenged and the incorrect dose is given, the patient’s status deteriorates. Conversely if the order is challenged and corrected, using this interprofessional communication technique, the potential error is avoided. Here, the interprofessional team member can be a nurse practitioner, physician, or other provider. Students in this scenario learn not only how to improve their communication with other professionals but also learn the importance of working as a team in the health care profession in order to improve patient safety [22,23].
Challenges abound trying to organize and schedule members of different professions into a single simulated experience. Oftentimes students from one discipline outnumber others or exposure to patients in the clinical setting is not equal. Starting small (the availability of one or two providers) can be one way to have a successful interprofessional experience. This scope can expand as momentum grows. For example, one scenario includes medical students, pharmacy students, nurse practitioner, and nursing students. The scenario centers around a patient readmitted to the hospital for an inadvertent overdose of a prescribed medication. All members of the team interact with the patient and family. Using the simulation center during off hours allows accommodation of many students with diverse schedules and results in a rich opportunity for team building and learning.
During all simulation experiences, simulation team members work alongside the clinical faculty members who function as content experts. As in most educational simulations, students and faculty members participate in a debriefing session immediately following each scenario. During debriefing, students experience guided reflection. Students also reinforce positive aspects of the learning experience; faculty can help students’ link theory to practice, and students’ can think critically while applying the scenario to clinical practice [9]. The debriefing promotes improved student performance and enhanced clinical reasoning skills [21].
Students complete simulation evaluations that address the flow of the scenarios and provide feedback to facilitators. The majority of students find simulation an effective means of learning the skills appropriate to the age and developmental stages of the pediatric patient. Students have reported that while they do not have an opportunity to care for pediatric patients of all age groups in their clinical sites, simulation exposes them to scenarios that range from infants through adolescents. Students report that simulation gives them an opportunity to practice communication and medication skills. Students also report that simulation provides exposure to topics that are difficult, including bullying, leukemia, and sickle cell crisis. During one debriefing, the students who had played the role of family members/parents in the scenario remarked about how difficult it was to be the parent of a sick child and about how responsible they felt to advocate for their child’s care. They felt overwhelmed with the care needs of a sick child with such a complex illness, just as one might expect a parent would feel, but reported that they felt less anxious and more supported after receiving information from the nurse in the scenario and more prepared to care for their child’s chronic disease. Students felt that having been exposed to this type of simulation helped them to better understand what a parent experiences when their child is ill. They also thought that experiencing the different roles of parent, nurse, and sometimes child helps them to increase their knowledge and comfort level in pediatric clinical settings. Students identified difficulty having to balance the nursing needs of the infant during the simulation while needing to communicate effectively with both the infant and parents. They report feeling more prepared and confident to be able to handle these situations during their pediatric clinical rotation having had this opportunity to practice in simulation. Additionally, students appreciated practicing using SBAR and TeamSTEPPS during their pediatric scenarios and reported that it helped them build confidence and perform as an effective member of the interprofessional team.
Pediatric nursing simulations in this school of nursing program use both high and low fidelity scenarios to enhance communication skills within the context of the interprofessional team, family-centered care, and medication safety. Our students’ experiences are consistent with those reported by Megel and colleagues [5] who explored high-fidelity simulation in pediatrics using an infant manikin and found that students were more comfortable in their pediatric clinical experience if they had previously done a postoperative assessment with the infant manikin. The approach to simulation in our pediatric course emphasizes practice of communication skills with patients, families and the interprofessional team. Practicing all of these skills in the simulation environment is very helpful to effective and safe future practice. While other nurse educators have discussed the importance of communication in pediatrics [1,3] this critical skill receives an intentional focus in our course. We have also shown the value of “low fidelity” simulation as a way for students to gain confidence with skills specific to pediatrics and become familiar with equipment size and variability which is often intimidating.
Future Implications
Pediatric nurse educators must build on established knowledge of simulation effectiveness. Including simulation in the curriculum and giving students opportunities to learn through simulation will help educators identify what is effective in helping students to assimilate and apply knowledge in the clinical setting. As health care systems and delivery of care become increasingly complex, particularly in pediatrics where errors and risks are greater, simulation helps students transition to the role of the professional nurse. Students practice and learn from their mistakes and problem solve in a risk-free environment. High risk scenarios, not necessarily experienced by students or pediatric nurses in clinical settings, also warrant simulation and contribute to interprofessional team building activities and protocols for improving safety and communication techniques across disciplines. Traditional clinical experiences are difficult and competitive to obtain; therefore all students do not get a comprehensive clinical experience. This reality makes simulation an invaluable part of curriculum redesign and a way for students to meet the core outcomes in pediatric nursing education as well as fostering a culture of caring, family centered care and professionalism.
Laura A. Reese, BA in English and MA in English (to be completed summer 2015; Editorial assistance)


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