Presentation on theme: "EVIDENCE-BASED PRACTICE: CURRENT RESEARCH OF SIMULATION-BASED EDUCATION JCCC SIMULATION CONFERENCE SEPTEMBER 17, 2010 Pamela R. Jeffries DNS, RN, FAAN,"— Presentation transcript:
1 EVIDENCE-BASED PRACTICE: CURRENT RESEARCH OF SIMULATION-BASED EDUCATION JCCC SIMULATION CONFERENCE SEPTEMBER 17, 2010Pamela R. Jeffries DNS, RN, FAAN, ANEFJohns Hopkins University School of Nursing
2 Objectives: The participant will be able to: State challenges concerning current clinical educationOffer resolution utilizing simulation methodology implementation
3 Current state of Clinical Nursing Education Errors correlated to new graduates inability to make clinical decisions(Smith & Crawford, 2002)New graduates do not meet their expectation for clinical judgment as identified by employment in clinical agencies(De Bueno, 2005)Accreditation agencies challenge educators to promote critical thinking (Long, 2004; NLN, 2003)
4 Current State -continued Teaching practices need to be evidence-based- educational research needed(NLN, 2005; IOM, 2001)Critical thinking and reflective skills of the practitioner are correlated with the quality of patient care(Conway, 1998; Paget, 2001)
5 Simulations Have Arrived… Where are we? Simulations in MedicineSimulations in NursingNext steps…..
6 Medical Research Integrative review by Issenberg et al., 2005: Providing feedback (47%)Repetitive practice (39%)Curriculum integration (25%)Range of task difficulty level (14%)Multiple learning strategies (10%)Capture clinical variation (10%)Controlled environment (9%)Individualized learning (9%)Defined outcomes (6%)Simulator validity for learning (3%)
7 Medical Research N=109 research articles Quality is weak. Based on research literature, can make statement that the use of high-fidelity patient simulation does “facilitate learning under the right conditions” (Issenberg et al., 2005, p. 10).
8 Nursing Research - HFPS (n=26) (Nehring, 2008) Since 2001, 26 nursing research studies related to high-fidelity patient simulation have been conducted.These studies have been conducted in the US (n=19), the UK (n=3), Sweden (n=1), Canada (n=1), China (n=1), and internationally (n=1).Nehring, W. (2008) U.S. Boards of Nursing and the Use of High Fidelity Patient Simulators in Nursing Education, Journal of Professional Nursing, 24(2),
9 Nursing ResearchMethods have included pretest-posttest (n=9), surveys (n=7), post-test only (n=4), focus group (n=2), observational and focus group (n=1), theory-driven description-observation- revision-review method (n=1), case study (n=1), and correlational (n=1).22 studies dealt with nursing education and 4 studies with team management.
10 Nursing Research Emphasis has been placed on: Competence (eg., clinical skills, basic knowledge) (n=7)ConfidenceSatisfactionUse of simulation as educational adjunct (n=9)Self-directed learning versus instructor-modeled learningDevelopment of rubric for clinical judgmentSimulation as substitution for clinical (n=2)Collaboration and teamwork (n=4)
11 NLN Study (multi-site 2003-2006) In this study, several areas were explored, however the major contributions to the science of nursing education in the area of simulations include:The theoretically-based Simulation Framework (Jeffries, Rizzolo, 2004)The Development of two instruments: The Simulation Design Scale and the EPSSIdentification of 5 key design features to include in the development of simulations
13 Best Practices in Simulation Simulation Design Features – ModelObjectives/focus of the simulations*Developing and maintaining realismProblem-solving componentsLearner Support*Debriefing/Guided Reflection
14 Objectives/information Learning objectives for the clinical scenario help to:Link the experience to the curriculumGuide the facilitation of the debriefing/experienceProvide structure to evaluate the simulation experience (Dreifuerst, 2009)Objectives need to be very specific when planning a simulation (Medley, 2005).
15 Objectives cont.Raemer (2003) recommends the use of both technical and non-technical objectives.Examples of technical objectives are the development of psychomotor skills and increased knowledge.Non-technical objectives include self confidence, satisfaction and critical thinking.
16 RealismRealism: Developing a simulation that can replicate a clinical experience – represents the reality without the constraints of a real-life clinical situation
17 Purpose of Realism:Realism has the potential to bridge the gap between classroom and clinical (Durham & Sherwood, 2008, Alfes, C. (2008).May facilitate the transfer of nursing skills to the clinical setting (Bradley, 2006)
18 Realism/FidelityCommon Findings in Simulations with students and translating simulation experience and knowledge into the clinical practice:Students do not translate “pretend” over into the clinical setting very well…educators need to be authentic in setting up the simulationsUntil students are immersed to perform an intervention, they do not know what “they don’t know” (e.g. standing orders)Even when students watch other students perform the simulation, it still “feels” different once they are immersed and having to make decisions.
19 Realism - continuedStudents have unrealistic expectations many times on what support, assistance and what they will and will not be doing when they begin functioning as a professional nurse. In simulations educators need to prepare students for the real world, complex clinical environment
20 Realism continuedAreas where we have found gaps in students expectations:Care of more than one patientUsing standing orders, protocolsBeing expected to “think on your feet.”Communicating appropriately with families and patientBelief that when a new drug is given on the unit post graduation, a manager will always be there to help
21 Fidelity/Realism: Making your Simulation Top-Notch
22 Provide Realism Dimensions of Realism (Beubien and Baker 2004): EnvironmentalEquipmentPsychological3 ways to think about reality (Rudolph, Simon, and Raemer (2007):PhysicalConceptualEmotional
23 Simulation as a Social Experience Lauken (2003) an Goffman (1974) state there are 3 ways to think about reality:PhysicalSemantical (theories, meaning of information)Phenomenal (emotions, beliefs, and self-awareness)Belief that an interaction between content and the way content is experienced needs to occur – believe that cognitive science has to exist with in a social environmentSimulation provides the experience of the phenomena of reality because it can describe different elements of the experience.(Elfrink, Nininger, Rohig, & Lee, 2009)
24 Framing: (Goffman, 1974)Concept of framing to support the notion of simulation as a social practiceFraming – cognitive structure that guides perception and provides representation of realityTwo types of Framing:Primary Framing: Helps to focus an individual on how to make sense of the simulationModulations: The account for individual’s orientation with the world (the shared responsibility of making simulations work)“Modulations have to be addressed to prevent negative learning.”
25 Considerations to reproduce reality: Incorporate as many realistic environmental aspects as possibleBe process-based, like clinical experiences are in realityEstablish validity of the scenariosInclude clinical realismMake students feel like they are immersed in the environment
26 Strategies to incorporate realism EquipmentReal-life patients, interactionIntroductory videoPersonal effects – realistic environmentPhysiological effectsIn-situ simulationUnfolding case simulations
27 EquipmentReal equipment that replicates what is used in the clinical environment is important, e.g. IV pumps, NG tubes, medications, IV pushes, etc.Simulators are more real-life, need to be sure the interaction replicates reality
28 Real Life- Patients, Interactions Teacher as the PatientInteracts with students in real-timeMasks-up; so real life, students don’t focus on the instructor as the patientWatch Cyril Smith Video
30 Introductory VideoA 5-minute videotape that visually sets the stage for the clinical simulation experience (5 minute video film – participants portraying patient and family members)(Alfes, C., 2008)Students state the introductory video helps to bring life to SimMan in the actual clinical simulationStudents also believed the video game them the chance to form a “plan of action and think through the nursing interventions before the simulation beganFaculty believe the video helps to visually introduce students to a pertinent clinical situation and realistic patient assignment
31 Personal Effects and Touches Students wear uniforms and use clinical forms and resources, similar to agency-based clinical experiencesThe clinical setting replicates reality, e.g.Care of patient in hospice, e.g. personal effects, quilt, family photos, soft music playing at bedside, etc.Interruptions during the care of patients, like realityMoulage (materials used to develop bruising, fruity-breath, etc.)Sounds, noises, smells are all part of the simulated environment
32 Physiological Effects A sense of emergency can be created if the student hears an emergency report, a deteriorating, lethal patient situationHave students to run to the event; have report provided away from the event so students adrenalin will increase like in an emergency situationEmotions can be triggered easily if the event appears realistic, e.g. pain in pain, family member distressed, saddened, etc.
33 In-Situ SimulationsIn-situ simulations: Simulations occurring in a real- life work settingExamples: in BLS in a neonatal unit; emergency situation occurring in an EDKneebone, et al, (2005) recreated real world pressure by conducting simulated scenarios within an authentic clinical spaceIn situ-simulations reproduce the condition of real practice
34 Unfolding Simulations/Cases Cases unfold at different times, in the same course, across the course, or across a nursing programThis type of case realistically simulates the real life patient interaction because learners experience the uncertainty and unpredictability of an actual, evolving clinical case (Karini, et., al., 2004).Examples:Patient admitted to E.D. – sepsisPatient on the unit – hypotensivePatient tranfered to ICUPatient discharge
35 Unfolding Cases – Teaching students differently
36 Learner SupportThe teacher is viewed as a facilitator of learning who structures learning experiences to allow students to construct knowledge for themselves, in contrast to a lecture driven, content delivery mode of instruction.Scaffolding supports the student initially, and the support is gradually withdrawn as the student actively constructs understanding in a way that makes meaning for them (Sudzina, 1997).
37 Learner SupportFive strategies can be used to assist student performance:modelingFeedbackInstructingQuestioningcognitive structuring.
38 Learner SupportLearning activities reflecting the complexity of real- world problems allow students to make meaning and develop a deeper understanding of realistic situationsThe real-world learning activities facilitate the individual student performance.
39 Problem-solving components Knowledge is actively constructed rather than transmitted to the learner.Von Glaserfeld (1996) describes two basic aspects of the constructivist model:Learning is a constructive activity that the students themselves must carry outThe task of the educator is not to dispense knowledge but to provide students with opportunities and incentives to build it up.
40 Problem-SolvingOpportunities should be created for students to determine, challenge, change, or add to existing beliefs and understandings through engagement in tasks that are structured to increase knowledge, skills, and problem solving
41 Debriefing/Guided Reflection Definition: The process whereby faculty and students reexamine the clinical encounter, fosters the development of clinical reasoning and judgment skills through reflective learning processesDebriefing is an essential element of simulation, however, practices vary greatly!
42 Debriefing continuedDebriefing provides opportunities to foster reflective learning, encompassing the ability to think-in-action as well as think-on-action (Schon, 1983)Debriefing offers a way to draw out student thinking and help students develop their complex decision-making skills (Decker, 2007)
43 Debriefing/Guided Reflection continued The importance of using reflective learning/guided reflection to teach students to apply what they have learned from one situation to the next in the context of critical thinking and decision making is well documented (Benner, et al, 1996, Chalykoff, 1993; Davies, 1995; Facione & Facione, 1996; Ironside, ; Tanner, 2006)The impact of different debriefing priorities on students’ clinical reasoning skills remains unclear and challenging (Gaba, & Howard, 2006)
44 SummaryMore research in the development, implementation, and evaluation of learning outcomes continues to be neededCreate your own educational research studies to contribute to the science of education in using simulation pedagogyStandards and competencies in this area are needed as educators continue to incorporate more simulations into the nursing curricula
45 SummarySimulation holds the promise to change faculty assumptions about how students learn and think and to become an essential teaching/assessment evaluation strategy in education of nurses.Effective teaching in clinical simulations has a powerful impact on student experiences and outcomes of a simulation exercise (Nehring, et al ; Henneman & Cunningham, 2005; Bremner, Aduddell, Bennett & VanGeest, 2006).