Integrating Simulation into Nursing Curriculum: Creative Solutions Laerdal SUN meeting Dallas Texas October 2009 Integrating Simulation into Nursing Curriculum: Creative Solutions A Mary Cato MSN, RN Oregon Health & Science University

Why integrate? How to integrate? Where to go for help

Value of simulation integration “The true value of simulation lies in its ability to offer experiences throughout the educational process that provide students with opportunities for repetition, pattern recognition, and faster decision making.” Doyle & Leighton, 2010

Issenberg 25% of studies cite integration of simulation-based exercises into the curriculum as an essential feature of their effective use. Simulation-based education should not be an extra-ordinary activity, but must be grounded in the ways learner performance is evaluated, and should be built into learners’ normal training schedule.

Effective medical learning stems from learner engagement in deliberate practice with clinical problems and devices in simulated settings in addition to patient care experience.

Why integrate simulation? 90% of nurse educators think their graduates are ready to safely practice 10% of hospital and health system executives think graduates are ready to safely practice What is it that accounts for this variation in perception? JONA November 2008

Where is improvement needed? Mainly NOT in “motor skills” New graduates often have little experience in: Delegation Taking “a full load” Utilizing resources (for themselves and their clients) Interprofessional communication Other ideas, from service, of what our new grads need to know?

Multiple domains Cognitive: mental skills (Knowledge) Affective: growth in feelings or emotional areas (Attitude) Psychomotor: manual or physical skills (Skills) -We can think about simulation as useful for learning in multiple domains -All three can be incorporated into simulation case. Beneficial to know where students are at in theory course, skills lab, and include that content into simulation scenario. Use of a realistic patient adds the affective domain. (need to deal with patient anger, or emotions at end-of-life, or frustration with member of the team, for instance.)

Bloom’s Taxonomy Original Terminology Revised Terminology Evaluation Synthesis Analysis Application Comprehension Knowledge Creating Evaluating Analyzing Applying Understanding Remembering Cognitive domain important to consider in curricular integration of simulation Thinking beyond the skills, what else can students practice/demonstrate in simulation? Remembering (1) Recalling information Recognising, listing, describing, retrieving, naming, findingNouns changed to verbs (thinking is active process) The knowledge category was renamed – remembering more accurately describes a category of thinking. Comprehension became understanding and synthesis was renamed creating in order to better reflect the nature of the thinking described by each category Understanding (2) Explaining ideas or concepts Interpreting, summarising, paraphrasing, classifying, explaining Applying (3) Using information in another familiar situation Implementing, carrying out, using, executing  Analysing (4) Breaking information into parts to explore understandings and relationships Comparing, organising, deconstructing, interrogating, finding  Evaluating (5) Justifying a decision or course of action Checking, hypothesising, critiquing, experimenting, judging  Creating (6) Generating new ideas, products, or ways of viewing things Designing, constructing, planning, producing, inventing     Bloom’s Taxonomy

Experiential Learning Because simulation is experiential learning, objectives can be higher level Creating and evaluating, for example, rather than simply understanding or remembering

Why integrate? How to integrate? Where to go for help

Determine Goal of Simulation Demonstrate Practice Evaluate “high fidelity” = highly realistic. Participants need to treat the manikin or standardized patient “as if” it were a real situation. Requires an engagement in the learning process.

Demonstration Classroom or lecture Skills lab Techniques of assessment Effects of a drug (use monitor) Role model communication Skills lab Demonstrate procedure Increase realism by doing procedure in context of patient care

Practice Utilize as clinical hours? Impact of increasing fidelity Able to provide context to situation Encourage use of clinical judgment, communication, resource management, “thinking on your feet,” teaching skills, management of emotional situations

Possibilities for practice High, mid, and low fidelity manikins Standardized patients and participants Role-playing Computer simulation Virtual reality

Why practice in simulation? Give students opportunities to make decisions Reinforce important concepts Teach and practice clinical judgment Practice professional communication Reflect on case

An Integrative Model of Clinical Judgment Noticing Interpreting Responding Reasoning Patterns Analytic Intuitive Narrative Expectations Context Background Relationship Action Initial Grasp Reflection on Action Outcomes Reflection on action and Clinical Learning Reflecting Tanner, CA (2006) Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, , 45(6), 204-211

Determine types of experiences Who are the client case exemplars? Common situations Highly prevalent nursing practice situations What students will most likely see in clinical High risk, low frequency situations Lack of clinical experiences Apply previously learned content “Spiral up” the curricular content Resources available Faculty & content experts Space & equipment

Leveling Scenario Objectives need to be attainable Tasks should be appropriate Consider “just manageable” situations – (the experience is challenging enough to move the learner to a higher level, but not so difficult that the learner becomes frustrated or discouraged) (Bransford, Brown and Cocking, 2000) Reflection on Practice is often triggered by a breakdown in clinical judgment Create Scenarios that are “Just Manageable Difficulty” Provide Coaching and Scaffolds Design Scenarios and Reflective Learning Activity that incorporate various kinds of knowledge that nurses use to make clinical judgments

When can the objectives be met? Student Prep During Simulation Debriefing Reflection on Learning “simulation encounter” may begin before simulation session. Provides multiple opportunities to meet objectives.

Foundations Training - CONFIDENTIAL Preparation Participant Handout Sent prior to simulation Policy/procedure review Skill review Role review Evidence-knowledge review Benefits Promotes self-directed learning Promotes accountability Increases confidence through preparation Identifies expectations Discuss the idea of preparing students vs. staff. Introduce the importance of orientation to simulation, how it fits in the curriculum, ground rules, expectations, and orientation to setting, manikin, etc. Describe hospital based orientation process. The focus in simulation shifts from the “sage on the stage” to one of students preparing for simulations as they would for clinical and through debriefing learning what they need to learn more about. Here the faculty may want to explore whether or not there are times when you might not want to allow for preparation in advance. © 2007 SimHealth Consultants, LLC. All Rights reserved. This Document may not be duplicated or distributed by any means.

During the Scenario Needing to think on your feet, communicate, use resources, set priorities, evaluate actions

During the Debriefing Deconstructing, reflecting, questioning, defending, supporting, advising, explaining, comforting and reassuring

Reflection on Learning Foundations Training - CONFIDENTIAL Reflection on Learning Occurs after the simulation session Reflective journaling Use of rubric Individual learning – availability of faculty outside of simulation session if needed © 2007 SimHealth Consultants, LLC. All Rights reserved. This Document may not be duplicated or distributed by any means.

Evaluation Formative vs summative or “high stakes” Clarity of objectives, what is being tested Participants need to know what the stakes are How will the results be communicated to the participants? Discuss conversations at INACSL, roundtable on “Using Simulation for High Stakes Testing.” Many discussions on both sides Can discuss this controversy over lunch or wine!

Consequences of Participation Foundations Training - CONFIDENTIAL Consequences of Participation Practice Deliberate Learning Evaluation You fail You pass A, A-, B+, B, B- Need to differentiate, but not always a clear distinction (at some level, you ARE evaluating, or judging) Participants need to know the stakes involved in participating in the scenario, and also in their participating in debriefing You won’t always know, as the debriefer, how participants will take the comments of others © 2007 SimHealth Consultants, LLC. All Rights reserved. This Document may not be duplicated or distributed by any means.

Why integrate? How to integrate? Where to go for help

Resources for faculty Organizations Courses INACSL SSiH NLN Workshops Apprenticeships Graduate courses

Sources for Scenarios Laerdal Nursing Scenarios SIRC (NLN/Laerdal Medical) has 2 samples in Designing & Developing a simulation course MedEdPORTAL (Association of American Medical Colleges) STORC OB Safety Initiative PNCI Increasing numbers available as schools are putting information online. Google search of nursing simulation scenarios revealed multiple sources through schools of nursing.

Sources for Scenarios: Publications “Real Nursing Simulations,” (2009) Pearson Education Inc. “Simulation Scenarios for Nurse Educators,” (2009) Campbell and Daley: Springer Publishing "High-Fidelity Patient Simulation and Nursing Education," (2009)Nehring and Lashley: Jones and Bartlett _Real Nursing Simulations, (has facilitators guide for faculty, website with prep and other activities for students) _Simulation Scenarios for Nurse Educators, step-by-step guide to designing and developing simulated scenarios, includes 17 exemplars of actual scenarios _will contain scenarios

Jeffries Simulation Framework Framework comprises 3 spheres. 1. faculty & student characteristics and educational practices 2. student outcomes (desired) 3. simulation design characteristics Nature of the simulation must be determined by the learning needs of the student. Jeffries Simulation Framework

Simulation Innovation Resource Center The SIRC Simulation Innovation Resource Center

SIRC Components: Template

Research Questions What do students need in real-world clinical practice and what can we simulate How much, How often When What aspects are most important for learning Does simulation make a difference to patient safety Does simulation improve patient care outcomes

Future of simulation Use of standardized patients Use of hybrid simulations Increased focus on management, delegation, and leadership Integration of Electronic Medical Record Interprofessional activities Graduate programs