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Alamo Colleges Simulation in Nursing Education: Creating a Quality Simulation Yvette Baxter MSN, RN.

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1 Alamo Colleges Simulation in Nursing Education: Creating a Quality Simulation Yvette Baxter MSN, RN

2 Faculty Development in the Effective Use of Simulation Objectives:  Identify factors in the educational and practice environment which have contributed to the use of simulation in nursing education.  Identify advantages to incorporating simulation as a clinical teaching strategy.  Discuss strategies for maximizing simulation effectiveness and student learning outcomes.  Identify the key goals of debriefing  Identify the key goals of debriefing.

3 Academic and Healthcare Environment  Shortages of clinical faculty and clinical sites.  Limited exposure to high risk, low volume clinical events  Complexity of the healthcare environment  Emphasis on patient safety  Technological advances offering sophisticated and realistic clinical experiences in the laboratory setting  Need to better prepare new nurses for working in a complex and technologically rich health care environment

4 Clinical Gaps  IOM (2003): hospital leaders, health plans, and practice sites reported increasing skills deficits in new graduates reported  65-75% of new-to-practice nurses did not meet entry-level competencies for clinical judgment (Ulrich et al., 2010)  The Future of Nursing: Focus on Education (2011) – the current nursing educational system inadequate to prepare nurses with the necessary competencies to provide high-quality care in increasingly complex healthcare environment

5 Implications Medical Error:  Greater risk for errors in clinical practice Increased Turnover:  Gaps between preparation and practice requirements results in stress and increased potential to leave the field  The percentage of turnover of new graduates is estimated as 17.7% within one year, 33.4% within two years, and 46.3% by the third year (Cho, Lee, Mark, & Yun, 2012)

6 The Deficits Competencies in which new-to-practice nurses scored lowest included:  Interpretation of assessment data  Decision-making & application of nursing process  Identification of changes in patient status  Timely & appropriate follow-up  Initiative in management of care Saintsing, Gibson, and Pennington (2011)

7 Clinical Simulation  A technique, not a technology  Immersion of the learner with enough realism to suspend disbelief  Environment to develop knowledge, skills, and clinical reasoning  A concept- based learning experience

8   Self-confidence   Learn from mistakes without risk to patient safety   Practice high risk, low incidence patient events   Identify gaps in knowledge /skills   Diverse learning   Real time/immediate feedback   Promotes critical thinking and decision-making skills   Safety, teamwork, communication, collaborative learning Benefits of Simulation

9 Components for Creating a Quality Simulation   Faculty/Student Preparation   Scenario Selection, Writing, and Testing   Fidelity/Realism   Debriefing

10 Simulation Effectiveness “The patient simulation is only as effective as the faculty who are using it. The creativity, clinical knowledge, teaching expertise, and technological abilities of the faculty are highly influential in the effective use of patient simulation" (Durham and Alden, 2008, p. 3-237).

11 Faculty Preparation Requires:  Student-centered approach  Preparation and comfort with scenarios and equipment  Understanding of the goals/objectives  Creativity, flexibility, & recognition of learning opportunities  Participation in the design process/evaluation

12 Faculty Preparation  Understanding that mistakes will be made  Minimize competition  Small groups  Roles assignment and assumption of roles  Close observation of actions, interactions, and decisions  MINDSET!!!

13 Learner Preparation  Understanding of simulation guidelines, objectives, & means of evaluation  Establishment of confidentiality, trust, &consent  Pre-scenario study guide  Orientation to simulation environment  What is to be simulated  Once in the simulation, students should function as they would in the clinical environment

14 Clinical Scenario Defined “ The plan of an expected and potential course of events for a simulated clinical experience. The clinical scenario provides the context for the simulation and can vary in length and complexity, depending on the objectives ” (International Nursing Association for Clinical Simulation and Learning [INACSL], 2011).

15 Steps in Scenario Development   Selection of topic and template   Identification of learning objectives   Story Writing (determination of concepts, cues, and critical events)   Peer review/Validation   Pilot

16 Idea Generation   Course objectives   Identified practice gaps   Staff/student survey perceived learning needs/clinical challenges   Clinical experiences   Case studies   Legal cases Topic Selection

17   Pre-programmed/purchased   Created by faculty/educators   On-line pre-written scenarios   Books Source of Scenarios

18 Free On-line Resources   Healthy Simulation scenarios/ scenarios/   Kansas State Board of Nursing htm htm   Massachusetts Nursing Initiative- Simulation Scenario Library os.asp os.asp

19   Knowledge level of student   Goals and purpose of the simulation   Level of complexity and fidelity   Number of participants/length of time   Experience and comfort level of facilitator   Availability of content expert   Setting and equipment needed Considerations for Scenario Selection

20  Safety and identified concepts/competencies  Evidence based practice and standards of care  Institutional policies and procedures  References What Should be Incorporated in My Scenario?

21 Writing the Story Beginning:  Description of the patient, event, setting, participants  Information to be provided Middle:  Plot progression and contingencies  Expected actions & timelines  Cues  Flexibility of facilitator Ending:   Logical and realistic transition maximizes fidelity

22 Validation & Piloting Validation:  Evidence –based : current journals, clinical guidelines, and textbooks  Checked for accuracy and believability  Reviewed by content expert for validity and revised as needed Piloting:  Piloted with small group of targeted learners  Feedback enables scenario revision for maximum effectiveness  Information regarding timeline, areas where learners get derailed, or aspects of the scenario learners find confusing

23 Fidelity  The degree to which simulators and simulations mimic reality  Simulation experiences should be as realistic as possible  Realism of scenario, staging, props enhance the simulation experience

24 Realism “The realism of any simulation depends upon multiple factors, including the fidelity of the simulator, the environment, props, and the description of the scenario…as realism is enhanced, the effectiveness of the scenario as a learning tool is increased” (Durham & Alden, 2008, p. 3-234).

25 Staging

26 Staging

27 Debriefing: “a conversation among two or more people to review a simulated event or activity in which participants explore, analyze and synthesize their actions and thought processes, emotional states and other information to improve performance in real situations” (Center for Medical Simulation, 2009, p. 1).

28   Evaluate whether learning objectives met   Build on prior learning   Self-reflection/assessment   Communication/different perceptions/attitudes   Reinforce teaching points   Identify/ correct gaps in knowledge, skills, attitudes   Improve future performance Goals of Debriefing

29   Reaction – opportunity to decompress and discuss emotional response to the simulation experience   Analysis - provides a time for reflection, understanding, and discussion of what went well and what didn’t   Summary/Closure – a summary of the experience is provided and evaluation of the simulation as a learning experience Phases of the Debriefing Process

30 Role of Facilitator in Debriefing   Create a safe and trusting learning environment   Provide support   Permit opportunity for defusing emotions   Guide the reflective process   Provide feedback/observations   Assist in assimilating new knowledge

31 Texas Board of Nursing (BON) Position Statement on Simulation In 2010 the BON put forth a position statement to clarify the role and limitations of simulation in order to provide educators with guidelines for making simulation educationally sound and meaningful.

32 Texas Board of Nursing (BON) Position Statement on Sim ulation  Simulation provides a valuable adjunct to traditional clinical learning.  To be effective the simulation must challenge learners to use problem solving and critical thinking skills.  Each simulation experience should have clearly stated objectives that are presented to learners PRIOR to engaging in the experience.

33 Texas Board of Nursing (BON) Position Statement on Simulation  Learners are required to prepare for a clinical simulation experience in the same manner they would a hospital clinical experience.  An orientation to the simulation technology and environment is required.  The educator should act as a facilitator providing cues when needed, but not as an active participant.  Unless an end of life scenario, the simulation should end with a viable patient.

34 Acknowledgements The Alamo Colleges wishes to extend a special thanks to San Antonio College nursing students Lori Hannasch, Renee Howard, & Sylvia Muniz for lending their time and services in the making of this project!!!

35 Questions?

36 References  Ackermann, A.D. (2011, September 26). Standards of best practice: Simulation. International Nursing Association for Clinical Simulation and Learning. Retrieved from: 20Ackermann%20.pdf 20Ackermann%20.pdf 20Ackermann%20.pdf  Arafeh, J.M.R., Hansen, S.S., & Nichols, A. (2010). Debriefing in simulated-based learning. Facilitating a reflective discussion. The Journal of Perinatal and Neonatal Nursing, 24(4), 302-309.  Aschenbrenner, D.S., Milgrom, L.B., Settles,J. (2012). Designing simulation scenarios to promote learning. In P.R. Jeffries (Ed.). Simulation in nursing education: From conceptualization to evaluation (43-74). New York, NY: National League for Nursing  Buerhaus, P.I., Auerbach, D.I., & Staiger, D.O. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs, 28(4), w657-w668. doi: 10.1377/hlthaff.28.4.w657  Childs, J.C. & Sepples, S. (2006). Clinical teaching by simulation. Lessons learned from a complex patient care scenario. Nursing Education Perspectives, 27(3), 154-158. Cho, S.H., Lee, J.Y., Mark, B.A., & Yun, S.C. (2012). Turnover of new graduate nurses in their first job using survival analysis. Journal of Nursing Scholarship, 44(1), 63-70. doi: 10.1111/j.1547-5069.2011.01 Cohen, E.R., Feinglass, J., Barsuk, J.H., Barnard, C., O'Donnell, A., McGoghie, W.C., & Wayne, D.B. (2010). Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Society for Simulation in Healthcare, 5(2), 98-102. doi: 10.1097//sUG,0b013e3181bc8304 /

37 References  Dreifuerst, K.T., & Decker, S.I. (2012). Debriefing: An essential component for learning in simulation pedagogy. In P.R. Jeffries (Ed.). Simulation in nursing education: From conceptualization to evaluation (105-129). New York, NY: National League for Nursing   Duchscher, J.B. (2008). A process of becoming: The stages of new nursing graduate professional role transition. The Journal of Continuing Education in Nursing, 39(10), 441-450.  Durham, C.F., & Alden, K.R. (2008). Enhancing patient safety in nursing education through patient simulation. In R.G. Hughes (Ed), Patient safety and quality: An evidence-based handbook for nurses (AHRQ Publication No. 08-0043). Retrieved from:  Fanning, R.M., & Gaba, D.M. (2007). The role of debriefing in simulation-based learning. Society for Simulation in Healthcare, 2(2), 115-125. doi: 10.1097/SIH/0b013e3180315539   Friedman, M.I., Cooper, A.H., Click, E., & Fitzpatrick, J.J. (2011). Specialized new graduate RN critical care orientation: Retention and financial impact. Nursing Economics, 29(1), 7-14.  Giddens, J., Brady, D., Brown, P., Wright, M., Smith, D., & Harris, J. (2008). A new curriculum for a new era of nursing education. Nursing Education Perspectives, 29(4), 200-204.  Institute of Medicine (2003). Health professions education. A bridge to quality. Washington, D.C.: National Academy Press.

38 References  Institute of Medicine (2011). The future of nursing. Leading change, advancing health. Retrieved from:  The International Nursing Association for Clinical Simulation and Learning (2011). Scenario development [PowerPoint slides]. Retrieved from:  Jeffries, P.R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Educational Perspectives, 26(2), 96-103.  Jeffries, P.R., & Rizzolo, M.A. (2006). Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi- method study. National League for Nursing. Retrieved from:  Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds). (2000). To err is human: building a safer health care system. Retrieved from:  Massy, K. (2011). Identifying and analyzing professional practice gaps. The HIS Primary Care Provider, 36(3), 39-55. Retrieved from:

39 References  Pelayo, L.W. (2008). Responding to the nursing shortage – a new paradigm. Unpublished manuscript, Department of Nursing, Alamo Colleges, San Antonio, Texas   Rothgeb, M.K. (2008). Creating a nursing simulation laboratory: A literature review. Journal of Nursing Education, 47 911 0, 489-494.   Saintsing, D. Gibson, L.M., & Pennington, A.W. (2011). The novice nurse and clinical decision-making: How to avoid errors. Journal of Nursing Management, 19, 354-359. doi: 10.1111/j.1365-28344.2011.01248.x   Scheckel, M. (2009). Selecting learning experiences to achieve curriculum outcomes. In D.M. Billings & J.A. Halstead (Eds.), Teaching in nursing. A guide for faculty (pp.154-172). St. Louis, Missouri: Saunders Elsevier.   Sportsman, S., Bolton, C., Bradshaw, P., Close, D., Lee, M., Townley, N, & Watson, M.N. (2009). A regional simulation center partnership: Collaboration to improve staff and student competency. The Journal of Continuing Education in Nursing, 40(2), 67-73.  Texas Board of Nursing (2012). Texas Board of Nursing Position Statements. Retrieved from:

40 References  Ulrich, B., Krozek, C., Early, S., Ashlock, C.H., Africa, L.M., & Carman, M.L. (2010) Improving retention, confidence, and competence of new graduate nurses: Results from a 10- year longitudinal database. Nursing Economics, 28(6), 363-374.  Waxman, K. T. (2010). The development of evidence-based clinical simulation scenarios: Guidelines for nurse educators. Journal of Nursing Education, 49(1), 29-35. doi: 10.3928/01484834-20090916-07

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