1. Impact of Simulation on Nursing Education, Clinical Learning and Outcomes
Wendy Thomson, EdD, MSN, BSBA, RN, CNE, CHSE
University of South Florida
Director, Simulation Education
Director, Masters in Nursing Education Concentration

2. Disclosures Member of the INACSL Standards Committee 2015-2017
No other Disclosures

3. Objectives By the end of this session, you should be able to:
Identify the key findings in the National NCSBN Simulation Study
Interpret the findings of the NCSBN Simulation Study for your nursing program and nursing education
Explain how the INACSL Standards of Best Practice: Simulation is to be used within simulation programs
Discuss the potential implications of the NCSBN findings

4. Simulation
“ ...technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (Gaba, 2004, p. i2)

5. Why Simulation? Enormous amount of content and skills to be taught
Programs getting shorter
Decrease in clinical time
Limited clinical settings
Limited ability to engage in the role of the nurse
Increase in patient complexity
Disparity between “entry into practice” and “reality”

6. What do we know about simulation
Simulation based education shouldn’t be an extra-ordinary activity, added into an already overloaded curriculum.
Simulation must start at the beginning and be built into the normal training programs of various healthcare providers.
Lacking proof that this is a good thing to do.
Finally the NCSBN National simulation Study has results that we can use to justify what we have done and what we know already

7. NCSBN Simulation Study - 2013
Up to 50% simulation can be effectively substituted for traditional, business as usual, clinical experiences.
Up to 50% simulation can be effectively used in various programs, in different geographic locations, with good outcomes
Simulation usage doesn’t affect NCLEX pass rates

8. Caveats/Recommendations
Simulation usage can only be substituted for clinical when:
High Quality Simulation Scenarios are used
Faculty are dedicated and trained
Adequate numbers of simulation faculty to support learners
Debriefing methods are grounded in best educational practice
INACSL standards of best practice are followed
Equipment and supplies create a realistic environment

9. Other findings
50% group were stress inoculated so those participants had less stress in practice.
There was a statistically significant difference on the end of course ATI™ examinations between the groups, with the 50% group scoring better than the other two groups.
There was more failures in the control group, least failures in the 50%
However, not statistically significant

10. High Quality Simulation Scenarios
Scenarios followed NLN/Jeffries Framework Model
Ensures scenarios all had the same elements
Consistency
Published scenarios vs home grown?
Model is based on Chickering and Gamson which states:
Time on task, with a consistent approach and a lot of prompt feedback.

11. High Quality Simulation Scenarios
What does this mean for teaching and faculty?
Valid and reliable scenarios within your organization
Vet scenarios through a task force or committee
All scenarios should have the same components
Students know what they are getting into because they had it before
Consistency
Need training, can’t assume you know

12. Faculty are dedicated and trained
Dedicated faculty create consistent experiences
Outcomes can be measured
Mandatory Faculty training in facilitation and debriefing.
Select a debriefing method for your institution
Ask the faculty what method they use!
Ask how they know they are using it correctly!
Teach the debriefing method
By a SME

13. Faculty are dedicated and trained
Practice debriefing with real simulated simulation learning experiences
Evaluate debriefing via peer and expert evaluation
DASH rating tool >=7
Continuous monitoring of faculty debriefing skill competency
2x/semester

14. Faculty are dedicated and trained
Prevents “Diminishing Returns Phenomenon”
If we do the same thing too much we’ll start to feel burned out and may even start performing poorly.
Avoid grandfathering faculty.
Even the most experienced faculty/nurse/provider gets complacent
Ensure they follow your institutions way of debriefing

15. Debriefing methods are grounded in best educational practice
Select a debriefing method
Everyone should have a say but use more than plus/delta
Train the dedicated faculty on the debriefing method
Don’t assume a CEU offering or 1-3 conferences makes them competent!
Don’t grandfather anyone in by saying they have done this for a long time.
Baseline all your simulation faculty

16. Debriefing methods are grounded in best educational practice
Validate competency in skills of debriefing
DASH
Objective Structured Assessment of Debriefing (OSAD) (Paige, Arora, Fernandez, & Seymour, 2015)
Without continuous quality improvement, we can’t be sure faculty maintain the level of skill unless we retrain periodically.
Inter-rater reliability
Law of Diminishing Returns (also known as Diminishing Returns Phenomenon)
Validate each facilitator every semester or at least every academic year

17. Poor Debriefing (Silberman, 2007, p 70)
Clichéd conversations with no questioning or learning
Meandering discussion going wherever the most dominant people happen to take it
Paralysis by analysis with learning stagnating at the investigation stage
Post-mortems, producing a distorted negative bias that drains energy
Jumping to false conclusions by missing out on significant states
Future planning that is not well-grounded in what was learned from the experience.
Chaos & conflict with people being out of sequence with each other (while 1 person is talking about the future, another is still “in the exercise,: another is speaking her mind, another is excited about a personal insight and so on!)

18. INACSL Standards of Best Practice: Simulation are followed
Standard I – Terminology – Provide Consistency
Standard II – Professional Integrity of Participants
Standard III – Participant Objectives – Clear and Measurable
Standard IV – Facilitation – Multiple Methods
Standard V - Facilitator – Proficiency
Standard VI – Debriefing Process – Improve Practice Through Reflection
Standard VII - Participant Assessment and Evaluation
Standard ?? – Simulation Design
Standard ?? - IPE

19. Highlights of the Standards
Provide honest and clear feedback in an effective, respectful manner
Learners should receive/provide timely constructive feedback
Protect the scenario content
Measurable Objectives that address the domains of learning and be achievable based on the knowledge and level of the learner.
Facilitator has formal education/training in simulation-based learning
Debriefing is facilitated by someone competent in a structured debriefing framework and who observed the scenario
Use formative assessment and summative evaluation as appropriate

20. INACSL Standards of Best Practice: Simulation
First published in 2011,
Revised in 2013
2 new standards being released in 2015
Update coming soon
Very much aligns with the findings of the NCSBN Study

21. Equipment and supplies to create a realistic environment
Enough evidence to support high fidelity simulation
It isn’t about the manikin but the sights, sounds, and equipment that make the place real to a participant.
Elicits an emotional responses to what is happening.
Taps the senses like pretend cannot

22. Implications Dedicated Formerly trained faculty –
policy implications for BONs
Financial implications for institutions
Use of theory based debriefing methods
What do schools choose from?
Cost for training

23. Implications
Adequate numbers of simulation faculty to support the learners
Workload
Cost
Equipment and supplies to create a realistic environment
Space
What about Advanced Practice Education?
Can they substitute any clinical hours with Simulation based on the NCSBN findings?

24. Do we change everything based on study?
Is it simulation that forced the best learning and teaching practices?
Is it the infrastructure that forced the best learning and teaching practices?
Why was there no difference?
Anecdotal
Why were the participants equally clinically competent?
How controlled were the sites?
Each program had their own curriculum and got to choose where and when to integrate simulations.

25. What are the Next Steps?

26. Questions?

27. References
Gaba, D. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13 (Suppl 1), 2-10.
Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). Supplement: The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation,5(2), C1-S64.
International Nursing Association for Clinical Simulation and Learning. (2013, June). Standards of Best Practice: Simulation. Clinical Simulation in Nursing, 9(6S), S3-S11.
Silberman. M. (2007). The Handbook of Experiential Learning, San Francisco, CA: John Wiley & Sons.