Abstract
Physical assessment of obese patients is an essential clinical skill for identifying the numerous health problems of obese patients and monitoring treatment effectiveness. Use of simulation mannequins facilitates teaching and learning of physical assessment. Available bariatric simulation mannequins have poor functional design, unrealistic appearance, and limited assessment functions. We developed a bariatric mannequin simulation system and an associated education curriculum of 7 case scenario and debriefing exercises focused on health problems experienced by individuals who are obese. An innovation of our mannequin is inclusion of programmable electronics that can be used with clinical tools that receive the electronic signals; together they provide ability to assess normal and abnormal signs of a wide variety of health problems. Ten nursing faculty and 51 nursing and medical students at a midwestern university evaluated the features and satisfaction of a prototype bariatric mannequin in separate simulation sessions using Likert-scaled questionnaires. Results showed that the majority of faculty (60%) and student (70%+) participants agreed/highly agreed that the bariatric mannequin was innovative, engaging, user-friendly, useful, and likely effective for teaching or learning. Satisfaction ratings of both groups were similar. Feedback from participants was incorporated into a final refined product that improved its realistic appearance.
Keywords: Simulation, mannequins, nursing education, obesity, bariatrics
The prevalence of obesity in the United States has become a major health concern, with over a third of adult Americans classified as obese.1 Obesity is closely linked to numerous chronic medical conditions such as hypertension, diabetes, obstructive sleep apnea, obesity hypoventilation syndrome,1–3 and skin problems such as pressure injury and moisture associated irritant contact dermatitis and intertrigo. These conditions require significant and often costly medical interventions, emphasizing the need for healthcare providers to remain current and skilled in bariatric assessments and treatments.3,4 In addition, obesity results in functional limitations in mobility, repositioning, and hygiene.5,6 Individuals who are obese can experience stigma and discrimination resulting in avoidance of healthcare and decreased health and well-being.7,8
Physical assessment of obese patients is an essential clinical skill for identifying and accurately diagnosing health problems early and monitoring effectiveness of treatments. However, physical assessment of obese patients presents unique challenges for clinicians. These patients have excess subcutaneous tissue, anatomical distortion, muffled heart, lung and bowel sounds, distant pulses, and reduced lung capacity in comparison to non-obese patients, which require specialized knowledge and experience for proper assessment.5,6
Simulated educational experiences have been shown to be effective in promoting knowledge acquisition and skill development of healthcare professionals.9–12 Simulation education, which commonly uses mannequin systems, provides a safe, dynamic, hands-on, and engaging educational approach for student learning.9.10 However, there are few bariatric mannequin products available on the market and those that do exist are inadequate. Limitations of current options include poor functional design, unrealistic appearance, and inability to represent the complex health status of obese patients. There is a need for more versatile, realistic and effective bariatric mannequin simulation systems to educate healthcare students and clinicians in caring for the increasing obese population.13−15
Preliminary work by our interdisciplinary team identified parameters for building a new bariatric mannequin simulation system that would be suitable for use in educational programs of healthcare providers. The team was comprised of nurse faculty investigators who are also educators, a three-person panel of advanced practice nursing and medical clinicians with expertise in care of obese patients, and product design engineers. The team discussed the need for a bariatric mannequin simulation system in nursing and medical educational curricula, experiences in the clinical setting, their ideas for the design of a bariatric mannequin system, as well as technical and financial considerations/limitations for system requirements from their practice/specialty perspectives. Recommendations for the design of the mannequin included realism in weight and appearance of skin folds, pannus, genitalia, and neck and limb circumferences. Considerations about user safety in moving and positioning a bariatric mannequin, availability of equipment (beds, chairs, and lifts) to support its weight, and storage space needed, and were also discussed. The team evaluated sample heart and respiratory/lung sounds for use with the mannequin and identified challenges of assessment such as edema grades, pulses, abdominal/intestinal distension, or skin rashes and other problems that would be beneficial to simulate. They identified clinical skills that would be useful to practice on a bariatric mannequin such as airway intubations, venipuncture, insertion of intravenous and urinary catheters and gastrointestinal tubes, skin/skinfold and wound care, cardio-pulmonary resuscitation, and patient transfer and repositioning. They reviewed and provided feedback about the engineering diagrams and prototypes that were developed. The study reported in this paper builds on our preliminary work.
The purpose of this paper is to report the results of a study whose aims were to 1) create an innovative bariatric mannequin simulation system, 2) develop an educational curriculum to accompany the bariatric mannequin simulation system, and 3) evaluate the bariatric mannequin simulation system using a sample of healthcare students and faculty.
Methods
Aim 1. Creation of a Bariatric Mannequin Simulation system
A bariatric mannequin simulation system was designed and developed by an interdisciplinary team comprised of product design engineers from two small businesses, an engineering research and design company, and a company that manufactures, markets, and distributes educational medical mannequins. Input from nursing and medical school faculty investigators and a clinician expert panel defined and guided the product requirements to align the desired features to clinical needs. The clinician panel was comprised of two advanced practice nurses (APRNs) and a physician who had experience caring for obese patients. One APRN was a family nurse practitioner and clinical faculty at a university school of nursing with cardiovascular clinical experience and the other was an adult gerontology acute care nurse practitioner certified in wound, ostomy, and continence care, and the physician is board certified in both family medicine and obesity medicine.
The team met several times during development of the product, reviewing the design, appearance, and functions of the bariatric mannequin in an iterative manner. This involved evaluating mechanical prototypes of the physical form-factor, weight, and appearance of the mannequin, reviewing realistic, pliable, adipose skin features to allow students to inspect underneath lifted skin folds and over regions on the mannequin, and assessing skin condition features (rashes and ulcers). Further, the team reviewed engineering developments which produced integrated electronics within the mannequin to provide programmable scenarios, configured via a mobile tablet application. The electronics using radio frequency identification (RFID) tags embedded in various locations of the mannequin body are capable of simulating a wide variety of normal and abnormal clinical signs present in diseases and chronic health conditions. The electronics control simulated biological signals within the mannequin and allow for interactive examination tools, including a stethoscope attachment and pulse oximeter that receive radio signals and blood pressure cuff, to sense their placements on key locations of the mannequin body. Applied pressure of these tools dynamically activates simulated biological signals such as heart, lung, and bowel sounds and blood pressure readings that the user can assess.
Aim 2
The faculty investigators and the clinical expert panel worked collaboratively to develop a simulation educational curriculum that would serve as a resource for use with the bariatric mannequin. They identified health problems that were common in patients with obesity as well as issues related to repositioning, transfer, and interpersonal communication to address in case scenarios. Each case scenario was designed according to the Healthcare Simulation Standards of Best Practice™ Simulation Design,16 including a patient summary, learning objectives, medical/health history, social history, presenting complaint, and an instructor’s guide for debriefing.
Aim 3
Design and Ethics Approval
The research study had an observational, evaluative design. The study received an Expedited review and approval by the university’s Institutional Review Board. All participants provided informed consent. All data collection forms had number codes instead of names and thus were deidentified for confidentiality.
Setting, Eligibility, and Recruitment
The setting of the study was a large, research-intensive public university in the upper midwestern United States. A convenience sample of adult students and faculty (18 years or older) in the nursing or medical schools of the university were eligible to participate. The School of Nursing has two prelicensure and two doctoral programs. The Bachelor of Science in Nursing (BSN) program is a traditional four-year undergraduate program and the Master’s in Nursing (MN) program is 15 months for students with a prior college degree. The doctoral programs are Doctor of Nursing Practice and a PhD program.
Recruitment strategies for students included verbal announcements about the study by research assistants or faculty investigators to in-person classes, written invitations in the general announcement section of course websites, email messages to student listservs, and word of mouth among students. Recruitment of faculty used announcements at faculty meetings, email messages to faculty listservs, and word of mouth.
Course schedules were reviewed and evaluation sessions were planned in between or soon after classes ended when students and faculty were on campus. Evaluation sessions included approximately four to six participants each. Pre-paid debit cards of $25 (i.e., Clincards) were offered to participants as recruitment incentives to compensate for their time and efforts. When evaluation sessions took place over the lunch hour, a box lunch was provided, and snacks (cookies and fruit) were offered at other sessions.
Data Collection Questionnaires
Several data collection questionnaires were developed by the research team based on a format used in our previous studies because established, appropriate tools are lacking. A student Demographics and Background questionnaire collected self-reported information about students’ demographic characteristics, amount of simulation education, knowledge of physical assessment, and clinical experience caring for obese patients. The Demographics and Background questionnaire for faculty asked about their demographics, experience in teaching with simulation and physical assessment, and experience caring for obese patients.
Questionnaires used for evaluating the bariatric mannequin simulation system had six scales for rating the realism, user-friendliness, engagement, likely effectiveness, likely usefulness, overall impression of the mannequin simulation system. There was a total of 22 questions and each used a five-point Likert scale with options of strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree. Questions about likely effectiveness and likely usefulness on student questionnaires focused on learning while those on faculty questionnaires focused on teaching. A seventh scale had nine questions to rate satisfaction with the mannequin’s features of realism, user-friendliness, engagement, likely effectiveness, likely usefulness, innovation, overall look or appearance of the product, and quality; this scale used a five-point Likert scale with options very satisfied, satisfied, neutral, dissatisfied, and very dissatisfied. There was an open-ended question for participants to tell us anything else they wanted us to know. Participants also completed the Satisfaction with Simulation Experience Scale (SSES).17 It measures satisfaction with simulation, is generic, and has been used in studies of nursing students.1 The SSES is an established 18-item scale with adequate construct validity and satisfactory reliability (Cronbach’s α=0.77).17 The scale has a 3-factor structure consisting of Debrief and Reflection (9 items), Clinical Reasoning (5 items) and Clinical Learning (4 items) sub-scales. Users rate their level of agreement with each SSES item on a five-point Likert scale ranging from strongly disagree to strongly agree.
Evaluation Session Procedures
One of the case scenarios featuring heart failure with reduced ejection fraction was adapted for the evaluation sessions. Separate evaluation sessions were held for students and faculty. Before the evaluation session, participants were asked to review a two-page educational brief explaining heart failure and its signs, symptoms and treatments to facilitate their participation in the simulation exercise.
Evaluation sessions lasted approximately 45–50 minutes. After participants checked in and completed their Demographics and Background questionnaire, they moved to a room set up as a clinic office where one of the faculty investigators summarized the purpose of the study and read a prebriefing script about the patient case. Participants were then instructed to assess the mannequin based on the case they heard as they would in a typical simulation learning experience. The mannequin, which was male, was seated in a wheelchair in the same room. Each participant was given an opportunity to interact with the mannequin and use the stethoscope tool to perform some part of a physical examination. At the end of the simulation, one of the faculty investigators facilitated a debriefing session. Participants then completed their evaluation forms and received their payment.
Data Analyses
Evaluation data collected from study participants were entered into SPSS software version 27.0 (IBM SPSS Statistics, Armonk, NY) and data were verified for completeness and accuracy. The SSES was scored using published scoring procedures resulting in the three sub-scale scores. Data were analyzed separately for student and faculty participants using descriptive statistics appropriate to the type of data and then tabulated. SPSS software version 27.0 (IBM SPSS Statistics, Armonk, NY) and SAS software version 9.4 (SAS Institute, Cary, NC, USA) were used for data analyses. Responses to the open-ended question were typed verbatim and analyzed by two independent research team members using an inductive/content analysis approach. The main idea and any sub-ideas were identified, number coded, and summarized. A third team member reviewed the results, and the three discussed and reached consensus about any differences.
Results
Aim 1
A full-body prototype bariatric mannequin system was successfully produced. Figure 1 depicts the first generation prototype mannequin system and the final Bariatric Nursing Manikin product that was ultimately developed. The evaluations reported in this paper utilized the prototype system that included some work-in-progress appearance features (e.g., apparent seams on connecting skin layers and limited posture positioning) so that improvements could be made based on the results. Feedback and suggested improvements from the study were incorporated into the final product. The completed Bariatric Nursing Manikin product represents a 350-pound male. It allows users to practice measurement of vital signs, patient transfer and lifting, range of motion exercises, perineal care, skin assessment, pressure injury and irritant contact dermatitis identification, and basic patient care skills.
Figure 1.
Initial prototype of mannequin (A), final Bariatric Nursing Manikin product (B), and close-ups of stethoscope attachment tool (C) and overlay of contact dermatitis skin problem (D)
Aim 2
Seven case scenarios were developed featuring the following clinical problems and issues: 1) peripheral artery disease with hypertension, 2) moderate heart failure with reduced ejection fraction, 3) chronic obstructive pulmonary disease, 4) preoperative evaluation for possible bariatric surgery, 5) incontinence, incontinence associated dermatitis, and intertrigo, 6) diabetic foot ulcer, and 7) safe repositioning, transfer, and respectful communication. The team included varying normal and abnormal signs to assess by auscultation and palpation in each case scenario. Five of the case scenarios (2, 3, 5–7 per above) targeted prelicensure nursing and medical students while the others (1 and 4) targeted students at an advanced practice level.
Aim 3
Sample
Of the 58 students who gave their informed consent to participate, 7 (12.1%) withdrew and did not participate citing time conflicts or not providing a reason. A total of 51 students, consisting of 45 nursing students (88.2%) and 6 medical students (11.8%) participated in the study. Ten faculty members, all from the School of Nursing, participated, and there were no withdrawals. There were 12 student and two faculty evaluation simulation sessions.
Characteristics of Student Participants
The characteristics of the student participants (n=51) are presented in Table 1. Most student participants (76.5%) were enrolled in pre-licensure nursing programs (BSN= 47.1% and MN = 29.4%). There were 5.9% doctoral nursing students and 11.8% medical student participants. The majority of student participants were female (78.4%) and white (78.4%). The race of other student participants was Asian (11.8%), Black, African American, or African (3.9%), and more than one race (5.9%); 3.9% were Hispanic/Latino ethnicity. Mean (sd) age of student participants was 25 (7.3) years.
Table 1.
Demographic Characteristics of Student and Faculty Participants
| Characteristic | Students (n=51) | Faculty (n=10) |
|---|---|---|
| Age (mean (sd)) | 25 (7.3) | 51 (14.0) |
|
| ||
| n (%) | ||
|
| ||
| Gender a | ||
| Male | 9 (17.6) | -- |
| Female | 40 (78.4) | 10 (100.0) |
| Non-binary | < 5 | -- |
| Race | ||
| White | 40 (78.4) | 9 (90.0) |
| Black, African American, African | 2 (3.9) | -- |
| Asian | 6 (11.8) | 1 (10.0) |
| More than one race | 3 (5.9) | -- |
| Hispanic/Latino Ethnicity | 2 (3.9) | 1 (10.0) |
| Nursing School | 10 (100) | |
| Pre-Licensure BSN Program | 24 (47.1) | |
| Pre-Licensure MNProgram | 15 (29.4) | |
| DNP Program | 3 (5.9) | |
| PhD Program | 3 (5.9) | |
| Nursing School | 6 (11.8) | |
| Years Teaching | ||
| 0–5 years | 5 (50.0) | |
| 6–10 years | 1 (10.0) | |
| 11–15 years | 1 (10.0) | |
| 16–20 years | 1 (10.0) | |
| 20+ years | 2 (20.0) | |
| Year in Program | ||
| 1st | 24 (47.1) | |
| 2nd | 9 (17.6) | |
| 3rd | 7 (13.7) | |
| 4th | 11 (21.6) | |
| Preferred Learning Method | ||
| Reading | 1 (2.0) | |
| Listening | 2 (3.9) | |
| Watching | 14 (27.5) | |
| Doing | 26 (51.0) | |
| More than 1 method | 8 (15.7) | |
| Knowledge about Physical Assessment | ||
| A Little | 7 (13.7) | |
| A Moderate Amount | 40 (78.4) | |
| A Lot | 4 (7.8) | |
| Amount of Simulation Education in General | ||
| None | -- | |
| A Little | 14 (27.5) | |
| A Moderate amount | 33 (64.7) | |
| A Lot | 4 (7.8) | |
| Amount of Simulation Education about Physical Assessment | ||
| None | -- | |
| A Little | 19 (37.3) | |
| A Moderate Amount | 29 (56.9) | |
| A Lot | 3 (5.9) | |
| Level of Experience Teaching Physical Assessment | ||
| Beginner | 4 (40.0) | |
| Intermediate | 4 (40.0) | |
| Expert | 2 (20.0) | |
| Amount of Teaching with Simulation in General | ||
| None | 1 (10.0) | |
| A Little | 5 (50.0) | |
| A Moderate Amount | 2 (20.0) | |
| A Lot | 2 (20.0) | |
| Amount of Teaching about Physical Assessment Using Simulation | ||
| None | 3 (30.0) | |
| A Little | 3 (30.0) | |
| A Moderate Amount | 2 (20.0) | |
| A Lot | 2 (20.0) | |
| Knowledge about Caring for Obese Adults | ||
| None | 5 (9.8) | -- |
| A Little | 29 (56.9) | 1 (10.0) |
| A Moderate Amount | 17 (33.3) | 7 (70.0) |
| A Lot | --- | 2 (20.0) |
| Level of Clinical Experience Caring for Obese Adults | ||
| Beginner | 37 (72.5) | |
| Intermediate | 11 (21.6) | |
| Expert | 3 (5.9) | |
Data from1 participant are missing.
The top three preferred learning methods of the student participants were Doing (51.0%), Watching (27.5%), and using More than one method (15.7%). The majority of student participants reported having a moderate amount of knowledge about physical assessment (78.4%). Most had a moderate amount of simulation education (64.7%) in general, and slightly more than half (56.9%) had a moderate amount of simulation education about physical assessment, 37.3% had a little amount, and 5.9% had a lot. None of the student participants reported having a lot of knowledge about caring for obese adults, 33.3% had a moderate amount of knowledge, 56.9% had a little, and 9.8% had no knowledge. Most of the student participants (72.5%) self-reported that they were at a beginner level of clinical experience caring for obese adults.
Characteristics of Faculty Participants
The characteristics of faculty participants (n=10) are presented in Table 1. All faculty members were female (100%) and primarily white (90%). There were 10% Asian and 10% Hispanic/Latino faculty participants. Mean (sd) age of faculty participants was 51 (14.0) years. Faculty participants varied in their experience teaching physical assessment with and without simulation. In terms of the level of experience teaching physical assessment, 40% each reported being at a beginner or intermediate level, and 20% were at an expert level. The percentage of faculty participants who had no experience teaching physical assessment with simulation was 30%, 30% had a little amount, 20% had a moderate amount, and 20% a lot. All of the faculty participants had some amount of knowledge about caring for obese adults with most (70.0%) reporting a moderate amount, 20% had a lot of knowledge, and 10% a little knowledge.
Evaluation by Student Participants
The evaluation scores of student participants for the bariatric mannequin simulation system are presented in Table 2. The vast majority (≥70%) of student participants agreed or strongly agreed with all evaluation questions about the bariatric mannequin simulator system’s Overall First Impression, Engagement, User-Friendliness, Realism, Likely Usefulness, Likely Effectiveness, and Innovation. Less than 5% of students disagreed or strongly disagreed with questions about these features of the system. Slightly more than half (52.9%) of student participants agreed or strongly agreed with the mannequin’s overall Look/Appearance, 31.4% were neutral, 15.7% disagreed.
Table 2.
Student Participants’ Evaluation and Satisfaction Scores(n = 51 unless otherwise noted)
| Bariatric Mannequin Simulation System Feature | Strongly Disagree | Disagree | Neither Agree nor Disagree | Agree | Strongly Agree |
|---|---|---|---|---|---|
|
| |||||
| n (%) of Student Participants | |||||
|
| |||||
| Overall Impression | |||||
| Positive first reaction | -- | -- | 5 (9.8) | 32 (62.7) | 14 (27.5) |
| Innovative | -- | -- | 1 (2.0) | 17 (33.3) | 33 (64.7) |
| Captures interest | -- | -- | 2 (3.9) | 11 (21.6) | 38 (74.5) |
| Liked overall look/ appearance | |||||
| -- | 8 (15.7) | 16 (31.4) | 23 (45.1) | 4 (7.8) | |
| Engagement | |||||
| Product is engaging | -- | -- | 1 (2.0) | 24 (47.1) | 26 (51.0) |
| Keeps my attention | -- | -- | 1 (2.0) | 22 (43.1) | 28 (54.9) |
| Opportunity to interact is at a good level | -- | 2 (3.9) | 4 (7.8) | 22 (43.1) | 23 (45.1) |
| Adds something new to simulation education | -- | -- | -- | 7 (13.7) | 44 (86.3) |
| User-Friendliness | |||||
| Easy to Use | -- | 2 (3.9) | 2 (3.9) | 27 (52.9) | 20 (39.2) |
| Realism | |||||
| Realistic | -- | 1 (2.0) | 13 (25.5) | 33 (64.7) | 4 (7.8) |
| Depicts reality accurately | -- | 1 (2.0) | 11 (21.6) | 32 (62.7) | 7 (13.7) |
| Depicts reality effectively | -- | -- | 6 (11.8) | 33 (64.7) | 12 (23.5) |
| Likely Effectiveness | |||||
| Will likely improve students’ knowledge | -- | -- | -- | 11 (21.6) | 40 (78.4) |
| Will likely improve students’ understanding | -- | -- | -- | 14 (27.5) | 37 (72.5) |
| Will likely improve students’ clinical skills | -- | -- | -- | 10 (19.6) | 41 (80.4) |
| Will likely improve students’ clinical decision making | -- | -- | 6 (11.8) | 14 (27.5) | 31 (60.8) |
| Will likely improve students’ confidence in caring for obese patients | -- | -- | 2 (3.9) | 12 (23.5) | 37 (72.5) |
| Likely Usefulness | |||||
| Will likely enhance learning | -- | -- | 1 (2.0) | 15 (29.4) | 35 (68.6) |
| Would seek courses using it | -- | -- | 10 (19.6) | 16 (31.4) | 25 (49.0) |
| Would recommend to others | -- | -- | 3 (5.9) | 20 (39.2) | 28 (54.9) |
| Relevant to healthcare education | -- | -- | -- | 9 (17.6) | 42 (82.4) |
| Relevant to caring for obese adults | -- | -- | -- | 8 (15.7) | 43 (84.3) |
| Satisfaction with Bariatric Mannequin Simulation System Feature | Very Dissatisfied | Dissatisfied | Neither Satisfied nor Dissatisfied | Satisfied | Very Satisfied |
|
| |||||
| Engagement | -- | -- | 5 (9.8) | 19 (37.3) | 27 (52.9) |
| User-Friendliness | -- | -- | 6 (11.8) | 26 (51.0) | 19 (37.3) |
| Realism | -- | 2 (3.9) | 14 (27.5) | 30 (58.8) | 5 (9.8) |
| Likely Usefulness | -- | -- | -- | 12 (23.5) | 39 (76.5) |
| Likely Effectiveness | -- | -- | 2 (3.9) | 17 (33.3) | 32 (62.7) |
| Innovation | -- | -- | 3 (5.9) | 14 (27.5) | 34 (66.7) |
| Look/Appearancea | -- | 7 (14.0) | 22 (44.0) | 19 (38.0) | 2 (4.0) |
| Quality | -- | 3 (5.9) | 12 (23.5) | 31 (60.8) | 5 (9.8) |
Data from 1 participant are missing.
The satisfaction of student participants with the bariatric mannequin simulation system was similarly high to their evaluations (Table 2). There were 70% or more students satisfied or very satisfied with all aspects of the bariatric mannequin simulation system except for its Look/Appearance. Approximately 40% of students were satisfied or very satisfied with the mannequin’s Look/Appearance, 44% were neutral, and 14% were dissatisfied. Student participants’ mean (sd) SSES scores indicate they were satisfied with the simulation experience: 39.1 (4.82) for Debrief and Reflection, 20.6 (2.95) for Clinical Reasoning, and 16.7 (2.48) for Clinical Learning.
Evaluation by Faculty Participants
Evaluation and satisfaction scores of faculty participants (n=10) are presented in Table 3. The majority (60%) of faculty participants agreed or strongly agreed with all evaluation questions about the bariatric mannequin simulator system’s Overall First Impression, Engagement, User-Friendliness, Likely Usefulness, Likely Effectiveness, and Innovation. For Look/Appearance of the bariatric mannequin, similar percentages of faculty participants, 40%, agreed/ strongly agreed and disagreed/strongly disagreed; 20% neither agreed nor disagreed. In terms of Realism, 50% of faculty participants agreed or strongly agreed, 20% neither agreed nor disagreed, and 30% disagreed.
Table 3.
Faculty Participants’ Evaluation and Satisfaction Scores(n=10 unless otherwise noted)
| Bariatric Mannequin Simulation System Features | Strongly Disagree | Disagree | Neither Agree nor Disagree | Agree | Strongly Agree |
|---|---|---|---|---|---|
|
| |||||
| n (%) of Faculty Participants | |||||
|
| |||||
| Overall Impression | |||||
| Positive first reaction | -- | 1 (10.0) | 2 (20.0) | 4 (40.0) | 3 (30.0) |
| Innovative | -- | -- | -- | 4 (40.0) | 6 (60.0) |
| Captures interest | -- | -- | -- | 5 (50.0) | 5 (50.0) |
| Liked overall look/ appearance | |||||
| 2 (20.0) | 2 (20.0) | 2 (20.0) | 3 (30.0) | 1 (10.0) | |
| Engagement | |||||
| Product is engaging | -- | -- | 2 (20.0) | 6 (60.0) | 2 (20.0) |
| Opportunity to interact is at a good level | -- | 1 (10.0) | 3 (30.0) | 4 (40.0) | 2 (20.0) |
| Adds something new to simulation education | -- | -- | -- | 4 (40.0) | 6 (60.0) |
| User-Friendliness | |||||
| Easy to use | -- | 1 (10.0) | 3 (30.0) | 4 (40.0) | 2 (20.0) |
| Realism | |||||
| Realistic | -- | 3 (30.0) | 2 (20.0) | 4 (40.0) | 1 (10.0) |
| Depicts reality accurately | -- | 2 (20.0) | 3 (30.0) | 4 (40.0) | 1 (10.0) |
| Depicts reality effectively | -- | 2 (20.0) | 3 (30.0) | 3 (30.0) | 2 (20.0) |
| Likely Effectiveness | |||||
| Will likely improve students’ knowledge | -- | -- | 1 (10.0) | 2 (20.0) | 7 (70.0) |
| Will likely improve students’ understanding | -- | -- | 1 (10.0) | 3 (30.0) | 6 (60.0) |
| Will likely improve students’ clinical skills | -- | -- | 1 (10.0) | 2 (20.0) | 7 (70.0) |
| Will likely improve students’ clinical decision making | -- | -- | 1 (10.0) | 2 (20.0) | 7 (70.0) |
| Will likely improve students’ confidence in caring for obese patients | -- | -- | -- | 2 (20.0) | 8 (80.0) |
| Likely Usefulness | |||||
| Will likely enhance teaching | -- | -- | -- | 4 (40.0) | 6 (60.0) |
| Meets a teaching need | -- | -- | -- | 4 (40.0) | 6 (60.0) |
| Will use product in courses | 1 (10.0) | -- | 3 (30.0) | 2 (20.0) | 4 (40.0) |
| Will recommend to other faculty | 1 (10.0) | -- | 1 (10.0) | 6 (60.0) | 2 (20.0) |
| Relevant to nursing education | -- | -- | 1 (10.0) | 2 (20.0) | 7 (70.0) |
| Relevant to caring for obese adults | -- | -- | -- | 3 (30.0) | 7 (70.0) |
| Satisfaction with Bariatric Mannequin Simulation System Features | Very Dissatisfied | Dissatisfied | Neither Satisfied nor Dissatisfied | Satisfied | Very Satisfied |
|
| |||||
| Engagement | 1 (10.0) | --- | 4 (40.0) | 4 (40.0) | 1 (10.0) |
| User-friendliness | --- | --- | 3 (30.0) | 6 (60.0) | 1 (10.0) |
| Realism | 1 (10.0) | 1 (10.0) | 3 (30.0) | 4 (40.0) | 1 (10.0) |
| Likely Usefulness | --- | 1 (10.0) | 1 (10.0) | 6 (60.0) | 2 (20.0) |
| Likely Effectiveness | --- | --- | 2 (20.0) | 5 (50.0) | 3 (30.0) |
| Innovation | --- | 2 (20.0) | 1 (10.0) | 5 (50.0) | 2 (20.0) |
| Look/Appearancea | 1 (11.1) | 4 (44.4) | 1 (11.1) | 2 (22.2) | 1 (11.1) |
| Quality | -- | 2 (20.0) | 2 (20.0) | 5 (50.0) | 1 (10.0) |
Data from 1 participant are missing
Regarding satisfaction with the bariatric mannequin simulation system’s features, 50% or more of faculty participants were satisfied or very satisfied with its Engagement, User-Friendliness, Realism, Likely Usefulness, Likely Effectiveness, and Innovation (Table 3). Approximately one-third (33%) of faculty were satisfied or very satisfied with the bariatric mannequin simulation system’s Look/Appearance, 11% were neither satisfied nor dissatisfied, and 56% were dissatisfied or very dissatisfied. The mean (sd) SSES scores of faculty participants show they were satisfied with the simulation experience: 40.1 (4.98) for Debrief and Reflection, 20.8 (3.62) for Clinical Reasoning, and 17.5 (1.96) for Clinical Learning.
Responses to Open-Ended Questions
There were four main ideas and several sub-ideas of the responses of student participants to the question about anything else that they want the investigators to know. These were 1) Skin (with three sub-ideas of Skin appearance, Texture, and Needs edema), 2) Mannequin Characteristics (with one sub-idea of Add/Improve features), 3) Usefulness (with one sub-idea of Mannequin positioning), and 4) Education Benefit (with three sub-ideas of Exposure to care of bariatric patients, Increases confidence, Important and great experience) (Table 4).
Table 4.
Student and Faculty Participants’ Responses to Open-Ended Question
| Main ideas and Sub-ideas of Student Participants’ | Evidence | Main ideas and Sub-ideas of Faculty Participants’ | Evidence |
|---|---|---|---|
| Skin • Skin appearance |
“Realistic skin was the best I have seen on a mannequin but additional body composition or fat deposits on arms, hands, and feet may make it more realistic.” |
Skin • Need for diverse skin tones/colors |
“Multiple skin color options are important.” |
| • Pitting edema | “Pitting edema would help.” | • Pitting edema | “Enable ability to simulate pitting edema” |
| • Texture | “I like the skin texture.” | ||
|
| |||
| Mannequin Characteristics • Add/Improve features |
“Include internal organs and bones to help palpate.” “The abdomen feels lumpy and not very realistic to a human abdomen.” |
Mannequin Characteristics • Add features |
“Add features: urinary cath, NG tube, IV placement, trach” |
| • Maneuverability | “Have handles on the core of the mannequin to better transport.” | ||
|
| |||
| Usefulness • Mannequin positioning |
“Might be best used if patient is in bed.” | Usefulness • Exposure to care of bariatric patients |
“It de-sensitizes students to a large body.” |
|
| |||
| Function of Tools | “Include more audio tags for cardiac and lung sounds that fit anatomical landmarks. Have tags for distal pulses (pedal) that can be listened through using a stethoscope to mimic a doppler.” | ||
|
| |||
| Educational Benefit • Exposure to care of bariatric patients |
“I think mannequin will be very beneficial for education. It will expose students to a more diverse patient population.” “I think this is very important and I’d like to see more of these simulations and patient-centered care about this population in our clinical. I think it should be used and incorporated!” “This is a great idea and will be useful in nursing education.” |
||
| • Increases confidence | “I like this idea a lot, it will be useful in helping students feel more confident in working with bariatric patients.” | ||
| • Important and great experience | “Overall, I was really impressed and engaged with this simulation. I think it would be extremely beneficial to students.” “I think this is a very necessary need in healthcare education and a really great tool!” |
||
Student participants described liking the appearance and texture of the skin of the mannequin. One suggested adding fat deposits to the arms, hands, and feet to make the mannequin look more realistic. Students desired the ability to palpate pitting edema on the extremities. Suggestions for other features to be added or improved were the inclusion of internal structures to simulate organs and bones to facilitate palpation during assessments and a more realistic feeling abdomen. Student participants gave positive feedback about the educational benefits of the bariatric mannequin simulation system. They viewed the mannequin as promoting diversity and patient-centered care. Interacting with the mannequin would increase student confidence in the care of this population of patients. They considered the bariatric mannequin simulation system an essential educational resource in preparing for their clinical experiences. They considered the bariatric mannequin innovative, a great idea, and important.
Responses of faculty participants to the open-ended question had three of the same main ideas as the student responses, although some of the sub-ideas differed, and one additional idea. These were 1) Skin (with one subtheme of Need for diverse skin tones/colors), 2) Mannequin Characteristics (with two sub-ideas of Add features and Maneuverability), 3) Function of tools, and 4) Educational Benefit (with one subtheme of Exposure to care of bariatric patients) (Table 4). The faculty participants desired diverse skin color tones for the mannequin and, similar to the students, the ability to palpate pitting edema. Suggestions for improvements included enhancing functionality with more audio tags for cardiac and lung sounds and simulating distal pulses, adding simulations for various catheters, and including handles for easier transport and positioning of the mannequin. They thought the bariatric mannequin simulation system was useful in assisting students to become more familiar with obese bodies.
Discussion
In this study, we successfully created a new and innovative bariatric mannequin simulation system. The evaluations of a majority of student and faculty participants who engaged in the test simulation session using the bariatric mannequin simulation system were positive. The mannequin simulation system was considered innovative, engaging, realistic, user-friendly, and likely useful and effective for teaching and learning. The electronics system of the mannequin and use of tools such as the stethoscope attachment provide users with a unique ability to gain experience auscultating normal and abnormal signs characteristic of a wide variety of health problems experienced by patients who are obese.
The participants in this study engaged with the simulation session and case scenario offered and comments indicated the experience was liked and was beneficial. Participants also gave feedback for continued development /improvement of the mannequin simulation system. Suggestions regarding adding functions such as ability to palpate pitting edema and pedal pulses and skills such as catheter/tube insertions, airway intubation mirrored and supported the ideas of our team in its initial planning. Further improvement of the look/appearance of the mannequin was also recommended.
Feedback from the evaluation sessions of this study was used to refine the initial prototype model for the final product. An advanced version of the bariatric mannequin is currently in development and incorporates additional features from the evaluators such as palpable pitting edema, pedal pulses, female gender, and darker skin pigmentation options. Additional simulated skills for urinary catheter insertion and airway intubation are planned. The advanced version is also planned to include adjustable BMI/weight features and enhanced joint articulation to enable higher-fidelity transfer training procedures by users.
In conclusion, given the increasing prevalence of obesity, this study addressed the need for a more robust and realistic bariatric simulation mannequin to support the education of nurses and other clinicians about physical assessment of patients who are obese. Based on positive evaluations of and satisfaction with the features of a prototype mannequin, we developed a final Bariatric Nursing Manikin product and a curricular resource of simulation case scenarios. An advanced mannequin that incorporates additional assessment opportunities based on feedback from study participants is under development.
Acknowledgements
The authors acknowledge Josh Thompson, MD, MPH, for his case study review and input.
Sources of Funding
This research was supported in part by funding from National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, under award numbers R43DK123905 and R44DK123905.
Footnotes
Conflicts of Interest
Authors from Innovative Design Labs and Realityworks have a financial interest in the Bariatric Mannequin created. The remaining authors have no conflicts of interest to declare.
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