1. Global Perspective for Integrating Simulation Across the Curriculum
Dr. Teresa Gore
SIM-One
2015 SIM EXPO
Simulation and Integration
Toronto, Canada
December 14, 2015

2. Teresa Gore, PhD, DNP, FNP-BC, NP-C, CHSE-A
Presenter
Teresa Gore, PhD, DNP, FNP-BC, NP-C, CHSE-A
Associate Professor
University of South Florida College of Nursing
INACSL President
Disclosure: Elsevier Simulation Learning System (SLS) scenario development

3. Overview
The body of evidence supporting the use of standards in Simulation education is growing. 
This presentation will introduce the standards and provide concrete examples for faculty to integrate the standards across nursing curriculum globally.

4. What is Simulation
“A pedagogy using one or more typologies to promote, improve, or validate a participant’s progression from novice to expert”
“Technique not technology to replace or amplify real experiences”
“An educational technique that allows interactive and at times immersive activity by recreating all or part of a clinical experience without exposing patients to the associated risks”
A pedagogy using one or more typologies to promote, improve, or validate a participant’s progression from novice to expert - CASN

5. Australia
Canada
China
Egypt
Europe
France
India
Mexico
Middle East
South America
Spain
Turkey
USA

6. GNSH Brazilian Association for Simulation in Healthcare
Association for Simulated Practice in Healthcare (ASPE)
Association for Standardized Patient Educators (ASPE)
Australian Society for Simulation in Healthcare (ASSH)
Canadian Network of Simulation in Healthcare (CNSH)
Nine Industry Providers
International Nursing Association for Clinical Simulation and Learning (INACSL)
International Pediatric Simulation Symposia (IPSS)
Japanese Society for Instructional Systems in Healthcare (JSISH)
London Deanery
Polish Society for Simulation in Healthcare (PSSH)
Royal College of Physicians and Surgeons of Canada (RCPSC)
Spanish Society for Simulation in Healthcare
Swiss Standardized Patient and Simulation Group
Society for Simulation in Healthcare (SSH)
Society in Europe for Simulation Applied to Medicine (SESAM)

7. Global

9. INACSL
Vision: INACSL is the global leader in transforming practice to impact patient safety through excellence in healthcare simulation.
Mission: Advancing the science of healthcare simulation

10. Canadian Representation
Nicole Harder
University of Manitoba
VP of Finance
Assistant Editor Clinical Simulation in Nursing
Colette Foisy-Doll
Grant MacEwan University
Awards and Nominations Chairperson
Leslie Graham
Durham College
Standards Committee
Running for VP of International Collaborative

11. INACSL Standards
INACSL Standards of Best Practice: SimulationSM
2011
2013
2015
2016

12. External Review American Academy of Pediatric Dentistry
American Nursing Association
Association for Simulated Practice in Healthcare
Australian College of Nursing
Australian Society for Simulation in Healthcare
British Columbia Institute of Technology School of Health Sciences
International Council of Nurses
International Federation of Dental Anesthesiology Societies
International Simulation and Gaming Association
National League for Nursing
Royal College of Physicians and Surgeons of Canada
Sigma Theta Tau International
Simulation Task Force of QTAR
Scottish Centre for Simulation and Clinical Health Factors
Society for Simulation in Healthcare
These are the 16 organizations that reviewed and provided feedback and suggested edits for the standards

13. Standards
1. Terminology
2. Professional Integrity
3. Participant Objectives
4. Facilitation Methods
5. Facilitator
6. Debriefing
7. Evaluation
Sim-IPE
Simulation Design

14. INACSL Standards of Best Practice: SimulationSM
Terminology

15. Consistent terminology provides guidance and clear communication and reflects shared values in simulation experiences, research, and publications. Knowledge and ideas are clearly communicated with consistent terminology to advance the science of simulation.
Consistency
Promotes consistency in publishing and research. We can all talk the same language
Rationale : Standardized terminology enhances understanding and communication among planners, participants, and others involved in simulation-based experiences. Terminology is
Outcome: Standardized terminology promotes consistency and understanding in education, practice, research, and publication. Standardized terminology also promotes consistency of experiences regardless of the simulation environment.

16. Professional Integrity
INACSL Standards of Best Practice: SimulationSM
Professional Integrity

17. It is essential to provide clear expectations for the attitudes and behaviors of simulation participants. Professional integrity related to confidentiality of the performances, scenario content, and participant experience is required during and after any simulation. Confidentiality is expected in live, recorded, or virtual simulation experiences.

18. Criterion 1. Protecting content of scenario and simulation
Criterion 2. Demonstrating professional and ethical behavior
Criterion 3. Receiving and providing constructive feedback
Example Criterion 2. Demonstrating professional and ethical behavior
Guideline: Participants are expected to demonstrate professional Integrity.
Guideline Statement: Participants should:
1. Provide honest and clear feedback in an effective, respectful manner.
2. Recognize unprofessional and unethical behavior during simulation and take steps to abate it.
3. Demonstrate mutual respect.

19. Participant Objectives
INACSL Standards of Best Practice: SimulationSM
Participant Objectives

20. All simulation-based learning experiences begin with development of clearly written participant objectives, which are available prior to the experience.
Criterion 1. Address domains of learning
Criterion 2. Correspond to participant’s knowledge level and experience
Criterion 3. Remain congruent with overall program outcomes

21. Criterion 4. Incorporate evidence-based practice
Criterion 5. Include viewing of client holistically
Criterion 6. Be achievable within an appropriate timeframe

22. Curriculum Overview
Typical
Innovative 57

23. INACSL Standards of Best Practice: SimulationSM
Facilitation

24. Multiple methods of facilitation are available, and use of a specific method is dependent on the learning needs of the participant(s) and the expected outcomes.
Criterion 1. Using facilitation methods congruent with simulation objectives
Criterion 2. Using facilitation methods congruent with expected outcomes

25. Pre-briefing
During Simulation
Debriefing

26. INACSL Standards of Best Practice: SimulationSM
Facilitator

27. A proficient facilitator is required to manage the complexity of all aspects of simulation. The facilitator has specific simulation education provided by formal coursework, continuing education offerings, and targeted work with an experienced mentor.
Criterion 1. Clearly communicates objectives and expected outcomes to participant(s)
Criterion 2. Creates a safe learning environment that supports and encourages active learning, repetitive practice, and reflection
Read the summary paragraph and each Criterion: Pick one criteria (or have the audience pick one they would like) to discuss-- read the guideline and give the bulleted examples from the actual publication– ask the audience for examples of how to implement or provide ways to implement from your facility if time allows – Ask if there are criteria they would like to discuss (can provide published bulleted information for these) or if there are any questions on this standard.

28. Criterion 3. Promotes and maintains fidelity
Criterion 4. Uses facilitation methods appropriate to participants’ level of learning and experience
Criterion 5. Assesses and evaluates the acquisition of knowledge, skills, attitudes, and behaviors
Criterion 6. Models professional integrity

29. Criterion 7. Fosters participant learning by providing appropriate support throughout the simulation activity, from preparation through reflection
Criterion 8: Establishes and obtains evaluation data regarding the effectiveness of the facilitator and the simulation experience
Criterion 9. Provides constructive feedback and facilitates debriefing with participants

30. INACSL Standards of Best Practice: SimulationSM
Debriefing

31. All simulation-based learning experiences should include a planned debriefing session aimed toward promoting reflective thinking.
Criterion 1. Facilitated by a person(s) competent in the process of debriefing
Criterion 2. Conducted in an environment that supports confidentiality, trust, open communication, self-analysis, and reflection

32. Criterion 3. Facilitated by a person(s) Who observes the simulated experience
Criterion 4. Based on a structured framework for debriefing
Criterion 5. Congruent with the participants’ objectives and outcomes of the simulation-based learning experience

33. How and why do you debrief? Plus – delta (can use delta sign)
Debriefing Methods
How and why do you debrief?
Plus – delta (can use delta sign)
Structured and Supported Debriefing Module using Gather, Analyze, and Summarize (GAS)
Debriefing for Meaningful Learning
Debriefing Assessment for Simulation in Healthcare
Debriefing Using Good Judgment
PEARLS
Now let’s explore some of the most common Healthcare simulation debriefing methods or frameworks
Plus – Delta is an adaptation of flight crew debriefing. This is set up in a 3 column written on a white board for participants to review. These columns are progressively filled in as the debriefing progresses. This is a very straight forward process. It is a reliable debriefing method that is easily mastered with minimal training
GAS is a debriefing method developed for the American Heart Association. This follows the Common Stages of Debriefing of reaction, analysis, and summary.
In the Gather phase participants provide their perspectives of the session. As the facilitator, you should be asking guided questions to promote effective dialogue
In the summary phase, facilitator leads in reviewing the simulated learning experience and examining the objective data. Actions can indicate the reasoning and motivation of the participant’s actions. This goes back to the get curious to understanding the actions of the participants.
Debriefing for Meaningful Learning Debriefing is a form of deliberate clinical teaching using reflection-in-action, reflection-on-action and reflection- beyond-action to teach clinical reasoning and thinking like a nurse. Debriefing is grounded in constructivism and problem-based learning theories and demonstrated positive student thinking and learning outcomes. The six phases for debriefing that guides the reflection of the participants are to: engage, explore, explain, elaborate, evaluate, and extend.
The issue arises when you only look at the outcomes. The facilitator must look at the action and the thinking at thee same time. As educators and facilitators we must look at making sure the participants are using the right thinking and the right action. If not patient safety issues can arise. Sometimes the right thinking can occur but the wrong action is taken or the wrong thinking but the right action. These can results in borderline patient outcomes . These are represented here as the yellow light and are signals that caution us of potential errors. The red light would be the wrong thinking and the wrong action and has a stronger chance of patient errors. Our goal is the green light which is the right thinking and the right action. This could equate to decreased chances of patient errors.
DASH is designed to assist in evaluating and developing debriefing skills based on evidence and theory about how people learn and change in experiential contexts. It evaluates the strategies and techniques used to conduct debriefings by examining concrete behaviors.
DASH is also designed to allow assessment of debriefings from a variety of disciplines and courses, varying numbers of participants, a wide range of educational objectives, and various physical and time constraints.
There are different DASH tools for students to evaluate the instructor/facilitator and trained rater evaluates the instructor/facilitator.
Debriefing with good judgment has three fundamental components
The first is Cognitive psychology-understand actions of participants based on the mental models. Actions can be seen, however, what leads or frames the participants use to why learner’s chose the actions they did.
The second is Declared Attitude or Stance – this is the genuine curiousity about the actions and why they were chosen. Non-judgmental supportive environment. This is the part that is the good judgment portion of the model.
This is then followed with inquiry. In inquiry the facilitator leads questions to the framing of their stance and uses paraphrasing.
“When I was observing your actions in the simulation, I noticed you did not raise the head of the bed for a patient that is short of breath that is a standard intervention for shortness of breath.” “I am curious what your treatment plan and priorities for this patient at that point?”
PEARLS is a mixed-method approach of debriefing that uses performance enhancement via augmented reflective learning in simulation. The facilitator select and apply the appropriate debriefing methodology using a decision support aid. PEARLS combines a learner self-assessment, facilitating focused discussion, and provides information by directed feedback using a scripted language to guide the debriefing.

34. INACSL Standards of Best Practice: SimulationSM
Evaluation

35. In a simulation-based experience, formative assessment or summative evaluation can be used
Criterion 1. Formative assessment
Criterion 2. Summative evaluation
Criterion 3. High-stakes evaluation

36. Adamson, K. A. , Kardong-Edgren, S. , & Willhaus, J. (2012)
Adamson, K. A., Kardong-Edgren, S., & Willhaus, J. (2012). An updated review of published simulation evaluation instruments. Clinical Simulation in Nursing, 9(9),
Kardong-Edgren, S., Adamson, K. A., & Fitzgerald, C. (2010). A review of currently published evaluation instruments for human patient simulation. Clinical Simulation in Nursing, 6(1), e25-e35. doi: /j.ecns

37. Sample Evaluations
CLECS
CCSI

38. Simulation-Enhanced interprofessional education (sim-IPE)
INACSL Standards of Best Practice: SimulationSM
Simulation-Enhanced interprofessional education (sim-IPE)

39. Criterion 3. Address Institutional and Local Issues
Sim-IPE occurs when participants and facilitators from two or more professions are engaged in a simulation health care experience to achieve shared or linked objectives and outcomes. The Sim-IPE is designed for the individuals involved to “learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p.31)
Criterion 1. Based on Theory
Criterion 2. Follow Best Practices in Simulation-Based and IPE
Criterion 3. Address Institutional and Local Issues
Criterion 4. Include an Evaluation Plan

42. INACSL Standards of Best Practice: SimulationSM
Simulation Design

43. Simulation-based experiences (SBEs) should be purposefully designed to meet identified objectives
Criterion 1. Needs Assessment
Criterion 2. Measurable Objectives
Criterion 3. Format of Simulation Based Experiences
Criterion 4. Clinical Scenario or Case
Criterion 5: Fidelity

44. Criterion 6: Facilitator/Facilitative Approach
Criterion 7: Briefing
Criterion 8: Debriefing and/or Feedback
Criterion 9: Evaluation
Criterion 10: Participant Preparation
Criterion 11: Pilot Testing of the SBE

45. Simulation Design
Needs Assessment
Measurable Objectives
Format of Simulation
Clinical Scenario or Case
Fidelity
Facilitator / Facilitative Approach
Briefing
Debriefing and / or Feedback
Evaluation
This can almost be seen as a checklist for success , if these are in place then it is more likely that there will be effective learning . These elements are based on adult educational theory and instructional design . Many of these elements have individually been discussed earlier some examples below – not exhaustive !
Needs assessment , Standard III, - What needs to be learnt? What is the best way and how?
2. Measurable Objectives, Standard III – This will guide the design of the simulation activity.
3. Format of simulation, Standard, III,– Based on the needs and objectives this will guide whether SP, Human Patient Simulators, Surgical , Ultrasound and virtual devices . Maybe hybrid simulation and location , a centre or point of care / in situ simulation .
4. Clinical Scenario or case - you need to provide context for the activity , what would they receive in real life ? Think about the back story , the clinical progression and cues that may be given , how the simulation activity will unfold , what should the learners do , what if they do not do what is expected , the end point
5.Fidelity Standard – need to create an environment that is perceived by the learners to be realistic enough that they can perform and thus learn , physical / conceptual and psychological fidelity.
6.Facilitator/Facilitative approach Standard VI
7.Briefing , - occurs ahead of the activity and helps create the fidelity and should include ground rules for safety . Think about creating a facilitators brief for standardization , equity and parity ,
8. Debriefing and/or feedback Standard VI
9. Evaluation, Standard VII,
10. Participant preparation, Standard II,
11. Test of the design - pilot all components not just the interactive part, the brief , all tools for assessment / evaluation

46. Effective Simulation-based Learning Design
Simulation Design
Effective Simulation-based Learning Design
UK by Matt Aldridge, President of INACSL Chapter Europe
Aldridge, M (2012) Developing Healthcare Skills through Simulation. London, SAGE.

47. Application
Arizona State Board of Nursing Advisory Opinion: Use of Simulation in Approved RN/LPN Programs
Incorporates a policy, general guidelines, requirements for simulation
Training requirements for facilitators
Canadian Association of Schools of Nursing (CASN)
The NCSBN published the findings of their randomized, controlled, large-scale, multi-site, longitudinal study with a follow-up component in These findings are impacting nursing education and how simulation is being used for pre-licensure nursing education. Ten schools were included with 5 associate degree and 5 baccalaureate degree. The results of this study revealed that up to 50% simulation can be used as a substitution for traditional clinical experiences across the prelicensure nursing curriculum without negative consequences to students. To achieve these results certain criterion should be incorporated into the simulation programs: The INACSL Standards of Best Practice: Simulation, high quality simulations, debriefing methods grounded in educational theory, and trained/dedicated simulation faculty.
In summary, both simulation and clinical placements facilitate learning in relation to practice outcome expectations. Simulation is ideally suited for practice situations that all students should experience as part of their preparation for practice; it provides opportunities to develop skills and abilities in relative isolation from other contingent variables. Clinical placements are essential for students to learn to respond within the context of a fluctuating external environment that impacts on caregiving, and in learning to provide care in a variety of time frames. (CASN, white paper draft 2015)

48. Simulation Guidelines
The NCSBN Simulation Guidelines are available at
Commitment from the institution
Appropriate facilities
Educational and technological resources and equipment
Qualified faculty and personnel
One year later in 2015, the NCSBN convened an expert panel to establish simulation guidelines based upon the NCSBN National Simulation Study and the INACSL Standards of Best Practice: Simulation. The guidelines are freely accessible at the web address listed. The guidelines address the institution’s commitment to the simulation program along with the need for appropriate facilities to conduct simulation. The need for educational and technological resources and equipment for simulation. The simulation must be conducted by qualified faculty and personnel that have and adhere to policies and procedures for simulation. Two checklist were also included: One for faculty preparation and the other for program preparation.

49. Resistance Buy-in Roger’s Diffusion of Innovation Theory Cost Mindset
Diffusion of innovations is a theory that seeks to explain how, why, and at what rate new ideas and technology spread through cultures
Cost
Mindset
Skills lab versus simulation

50. Simulation Fellowship
INACSL and CAE Healthcare
Fellowship based on the INACSL Standards of Best Practice: Simulation SM and the Essential of Simulation
Timeline
Webinar
Two-day immersive workshop
Mentorship online

51. INACSL-CAE Healthcare Simulation Fellowship
Formal education program for simulation-immersive kinesthetic learning
Educational theories
Development, practice, and validation of scenario development for high quality simulations
Facilitation methods and facilitator skills
Effective debriefing techniques
Evaluation methods
The INACSL Standards of Best Practice: Simulation SM and the Essentials of Simulation
Timeline
Webinar
Two-day immersive workshop
Mentorship online
To answer the question why is the Fellowship occurring now and why is it so important? The INACSL-CAE Healthcare Fellowship will assist Fellows in meeting the requirement of formal education program for simulation through immersive kinesthetic learning by incorporating
Educational theories
Development, practice, and validation of scenario development for high quality simulations
Facilitation methods and facilitator skills
Effective debriefing techniques
Evaluation methods
The Fellowship is based upon the INACSL Standards of Best Practice: Simulation SM and is a formal Simulation-Related Professional Development.
Now that we know why let’s review the history of simulation and the INACSL Standards of Best Practice along with the INACSL-CAE Healthcare Simulation Fellowship

52. Sim-ONE
SIM-one enables and supports research, development and innovation in the field of simulation for health professions education and health system improvement.
Keystones Certificate Course
MASCS Certificate Program
Meta-Leadership Program
Summer Simulation Institute
Grants
Scenario Repository

53. Please join us next year at the Gaylord Texan Resort!
INACSL 2016
Please join us next year at the Gaylord Texan Resort!
June 15-18, 2016
Grapevine, Texas

54. Contact Information
Teresa Gore
University of South Florida College of Nursing
INACSL President
       USF College of Nursing
12901 Bruce B. Downs Blvd, MDC 22
Tampa, Florida
Transforming Healthcare, Transforming Lives:
Creating the Nursing Leaders of Tomorrow and the Research
that Improves Health

55. References
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Lioce, L., Reed, C. C., Lemon, D., King, M. A., Martinez, P. A., Franklin, A. E., Boese, T., Decker, S., Sando, C. R., Gloe, D., Meakim, C., & Borum, J. C. (2013, June). Standards of Best Practice: Simulation Standard III: Participant Objectives. Clinical Simulation in Nursing, 9(6S), S15-S18.
Meakim, C., Boese, T., Decker, S., Franklin, A. E., Gloe, D., Lioce, L., Sando, C. R., & Borum, J. C. (2013, June). Standards of Best Practice: Simulation Standard I: Terminology. Clinical Simulation in Nursing, 9(6S), S3-S11.
Sando, C. R., Coggins, R. M., Meakim, C., Franklin, A. E., Gloe, D., Boese, T., Decker, S., Lioce, L., & Borum, J. C. (2013, June). Standards of Best Practice: Simulation Standard VII: Participant Assessment and Evaluation. Clinical Simulation in Nursing, 9(6S), S30-S32.

56. References
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57. References
NLN Board of Governors Vision Series (2015). Debriefing Across the Curriculum. Retrieved from
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