STEFANIE LA MANNA, PHD, MPH,ARNP,FNP-C DEIRDRE KRAUSE, PHD, ARNP, FNP-BC The Use of Standardized Patients to Facilitate Critical Thinking of the APRN Student in a Family Nurse Practitioner Program Academic Setting

Financial Disclosure We have no financial relationships to discuss and we will not discuss off label use and/or investigational use in our presentation

Acknowledgements Rosario Medina PhD, FNP-BC, ACNP, CNS Jennifer Stone, DNP, ARNP, FNP-BC Standardized Patients

Background With the increase number of chronic illness across all ages and the complexities of primary care management, advance practice nurses (APN) today are required to have higher levels of critical thinking, problem solving, and patient managed skills (Johnson, Hall, & Causey, 2014). Ultimate objective of higher education is to produce highly competent APN prepared to  improved access to health care  increase quality care  a healthier constituents of care (Aiken, et al., 2009)

Gap between Research and Practice Many nursing teaching methods are based on techniques that are out of date (text book) placing students out of touch or in concurrent with actual practice needs. Lack of controlled clinical practice has resulted in variant and unreliable clinical outcomes for student practice. Nursing education occurs in silos where students are separate from other health care professionals leaving them ill prepared to function in interdisciplinary roles. There is an increasing professional nursing gap between  Research  Education  Practice (Aiken, L.H. 2011).

Problem Statements Nurse educators often battle with whether advanced practice nursing students are adequately prepared for the real clinical setting. Standardized patients are underutilized in graduate nursing programs, especially in the family nurse practitioner academic setting. There is a lack of adequately PhD/ DNP prepared Nurse Practitioners in the academic arena to evaluate actual clinical sites. Clinical site acquisition has become a major problem in many nurse practitioner programs.

Significance to APRN Programs Inadequate and unmeasurable student outcomes  Inadequate amount of clinical sites- will continue to get worse  Competitors seeking similar sites  Sites being paid for being preceptor Lack of appropriate evaluation measures for critical thinking  Preceptors not having sufficient time to adequately evaluate student function Many schools have used the Sim Man but the scenarios still lack human spontaneous reactions. Programs do not have the resources for the appropriate numbers of PhD prepared educators.

Significance to Nursing Practice Students are not prepared for the real demands of clinical practice. Unprepared students are less marketable and less likely to stay at a given job due to increase frustration between what is taught and what actually happens in the clinical setting.

Future of Nursing Education The Robert Wood Johnson Foundation (RWJF)and The Institute of Medicine (IOM) are presently seeking for drastic change in the status of nursing education and practice (Aiken, L.H. 2011). Promote novel approaches to improve preparation for relevant practice (Cronewett, L., R. 2009, NLN, 2013).

Methods: Implementation of Standardized Patients Formative evaluation  Assessed strengths and weaknesses  Advanced health assessment; Primary care: Adult I  Pelvic and genitalia exams  Uncomplicated, acute illnesses found in primary care Summative evaluation  Assessed achievements and outcomes  Primary care: Adult II  Complex, chronic illnesses found in primary care  Adult and Geriatric

Methods Qualitative  Standardized patient’s provided feedback to students  Interpersonal Observational  Advanced health assessment  Faculty demonstrated, and students return demonstrated, male and female genitalia exams  Primary Care: Adult I and II  Scenarios provided to standardized patients  Students engaged in the role of either preceptor, APRN student, or family member  Verbal report on visit given to faculty (SOAP)  Round table discussions

Experience of the APRN Student “I think that observing the students with the patient actors at this point in the program gives the faculty an excellent opportunity to really gauge how the student is progressing.” “I really enjoyed the experience and think this is a very good idea. It gives the students the opportunity to be exposed to certain situations before performing in ‘real life.’ It helps us put the puzzle together and improve our critical thinking skills.”

Experience of the APRN Student “I thought today was great. In the clinical scenario there is not always time to really verbalize your thought process and get real time feedback. It felt good to show what and why I was thinking about a diagnosis and plan and get constructive feedback from my professor and patient actor.” “The experience with the male and female exams is one that I value and appreciate. In a profession as ours, nothing beats real hands on.”

Experience of the APRN Student “The standardized patients were very beneficial. They presented clients we don’t necessarily get to see in the clinical setting. It is also afforded us the opportunity to collaborate and present reason for our differential diagnosis.” “I can read the books, and they can explain what the os of a cervix should look like in null /multiparous female, or how a prostate should feel like, but the book can never give me the experience I felt, when I first visualized the os of a cervix, and felt the texture of a prostate.”

Experience of the APRN Student “Thank you so much for providing such a great opportunity to ‘practice’ on patients in a very relaxed environment. I think we learn so much from our peers and faculty.” “It is the best thing EVER. I have been in nursing for 13 years and I learned allot today. I wish we can do this more often. Thank you so much for giving me the opportunity. I feel this experience should be implemented in the APRN curriculum.

Standardized Patients as a Substitute for Clinical Site Evaluation “Having the opportunity to utilize patient actors in the lab to evaluate our competency in the clinical area is great.” “I think the idea of standardized patients are great, but not for clinical site evaluation. My peer was so stressed out that it was painful to watch her struggle.”

Outcomes Utilization of standardized patients in controlled clinical scenarios help  Meet the need for remediation of skills  Substitute clinical site evaluation when necessary  NP students develop critical thinking skills  Allows for on point evaluation of actions by  Student and peers  Clinical faculty  Standardized patients that give feedback for future improvement

Future Revisions and Implications Videotaping for review by student and faculty Structure experiences:  Advanced health assessment  Complete history and physicals on one SP  45 minutes allotted  Primary Care: Adult I  Acute illness: focused history and physical with diagnosis, and plan  30 minutes allotted

Future Revisions and Implications  Primary Care: Adult II  Chronic illness: History, physical, diagnosis/es, and plan (2 SP)  20 minutes allotted for each encounter  Practicum  Acute and chronic illness  6 exam rooms with standardized patients; student moving from room-to-room  20 minutes allotted for each encounter

Future Revisions and Implications Future: Both Adult One and Adult two will utilize GenX EMR system. Will foster confidence in the APRN student with the use of EMRs and the diagnostic reasoning in the adult patient.

Thank you

References Aiken, L.H. (2009). Education policy initiatives to address the nurse shortage. Health Affairs 28,(4), DOI: /hlthaff.28.4.w.646 Aiken, L.H. (2011). Nurses for the future. New England Journal of Medicine, 364; DOI: /NEJMp Cronenwett, L., R. (2009). Nursing education priorities for improving health and health care: The future of nursing: leading change, advancing health. National Academy of Science Retrieved NLN Board of governors (2013). A vision for doctoral preparation for nurse educators. NLN Vision Series. Retrieved