Case scenario simulation in nursing education Presented by: Katy Gordon RN, MSN(c) Scholarly Project Ferris State University

Objectives Describe goals and objectives of scholarly project Describe how scholarly project supported by evidence-based practice and literature Describe graduate student personal and professional accountability

Objectives Describe analysis of outcomes supported by literature Describe adherence to legal , ethical, nursing, and organizational standards Describe recommendations for future use of case scenario simulation

Simulation in nursing education and Evidence-Based Practice Application and integration of skills, knowledge and critical thinking Facilitates development of student competence and confidence Involves experiential learning, adult learning, constructive learning, and reflective learning theories Fanning & Gaba, 2007; Grossman, Krom, & O’Connor, 2010; Jeffries, 2007; and Shinnick, Woo, & Mentes, 2011 Evidence-based data related to simulation in nursing education was acquired through the databases of CINAHL, OVID, and ERIC. Key words were used in the data search related to high fidelity simulation and nursing education. The purpose of the scholarly project was clarified. The goal of the scholarly project would be to design, implement, and evaluate a case scenario simulation. An outlined plan proposal was developed and approved by both Dr Candice Pickens and my FSU professor Mary Alkire. The project planning guide allowed me to follow a step-wise guide in order to successfully plan and complete the project in the subsequent semester at FSU Simulation allows students to think on their feet, not in their seat by providing the student an opportunity to apply and integrate the knowledge, skills, and critical thinking required for nursing practice Simulation also helps facilitate the development of competence and confidence in nursing skills and nursing reasoning that is situated in the context of its application to the patient Nursing is a practice profession. Using Benner’s novice to expert. One attains knowledge and applies that learned knowledge through stages. One begins at novice and advances to expert as they develop in their profession

Planning phase of Scholarly project Planning phase: Began in Fall of 2012. Dr. Candice Pickens approached me summer of 2012 regarding developing a simulation for NUR203 students. The intent of the project stemmed from the need to make curricular changes in the nursing program as a result of the NLNAC self-study and site visit (2012). Some restructuring of the curriculum was proposed in order to retain NLN accreditation. The Curriculum committee at MCC suggested expanding simulation across the curriculum as part of the revision. The planning phase was full of anticipation of what the final scholarly project would look like as an end project. Just as this pictures indicates, there are thousands of ideas that can be brought to life through simulation in nursing education. Choosing the right simulation takes place through careful planning and communication with stakeholders involved in the curriculum changes. Goals and objectives were planned as follows: Design, implement, and evaluate a case scenario simulation for advanced medical surgical nursing students at MCC. Review of course and curriculum objectives Case scenario to fit Defined Purpose/Intent of scholarly project

Goals and Objectives of scholarly project Design of case scenario simulation Implementation of case scenario simulation Evaluation of case scenario simulation Design of case scenario simulation: (took a lot of time/editing/mentoring/peer feedback) . Designing the case scenario simulation took up a lot of time for the project. Jeffries framework for simulation in nursing education was used when developing the simulation. INACSL standards for simulation (2011), and other literature related to simulation were also used when designing the case scenario simulation. The concepts of teacher as evaluator and facilitator, students as self-directed and motivated, educational practices that support active learning and diverse learning [auditory, kinesthetic, visual, tactile]. Simulation design characteristics which include objectives, fidelity, problem solving, student support, and reflective thinking , and expected student outcomes based on curriculum objectives specific to caring for client with cardiovascular disorder for NUR 203 didactic course were considered when developing the case scenario simulation. I started by looking at the course objectives, attending theory courses specific to cardiac content, and began looking through possible case scenario simulations to match-up with the course objectives. Ended up dove-tailing on the case scenario of Carl Shapiro. Evaluation of case scenario simulation: evaluation took place via pretest and posttest, student evaluation and feedback, peer feedback, and preceptor feedback. Any changes recommended will be considered with future use of this case scenario simulation

Design Phase of case scenario simulation Design of case scenario simulation: (took a lot of time/editing/mentoring/peer feedback) [simply talk about the simulation framework design characteristics. using the nursing education simulation framework proposed by Jeffries (2007) the concepts of teacher as evaluator and facilitator, students as self-directed and motivated, and theories that support active learning and diverse learning (auditory, kinesthetic, visual, and tactile) as collaborative educational practices need to be incorporated into the instruction. Simulation design characteristics which include objectives, fidelity, problem solving, student support, and reflective thinking , and expected student outcomes based on curriculum objectives were considered when developing a case scenario simulation. What did I want student to learn? (outcomes)Concepts that seem hard for students to grasp or that are difficult to teach in NUR 203 were considered when designing the simulated clinical experience. Dr. Pickens suggested a cardiac or neurological condition for the simulation. Consideration of what type of patient to simulate for the case scenario simulation also needed to consider the didactic course lay-out. With these factors considered, it was evident that I would be using a case scenario to reflect a cardiac patient with some type of worsening condition, which would allow me to effectively implement course content, concepts, and objectives. Objectives: (see design format) Fidelity: talk about simulation (hospital room with monitor, time on clock, patient chart, defibrillator, crash cart, ECG machine, etc.) Problem solving: Student support: through cuing as recommended by INACSL Debriefing: led by facilitator, immediately following simulation. Allows for reflective thinking. Back to objectives (met or unmet). What went good? What went bad? What would you do differently if repeating scenario? Now, talk about simulation: steps A - Z With this information in mind, I began brainstorming for a cardiac specific case scenario with course objectives in mind. I started by looking at the course objectives, attending theory courses specific to cardiac content, and began looking through possible case scenario simulations. Ended up dove-tailing on the case scenario of Carl Shapiro. Had Mr. Shapiro be admitted to ER/OBS area on NTG and HEP gtt, using ACS and HEP standing orders. ECG changes occurred, critical labs used as cues to represent infarct during simulation. Pt ECG changes to VF. Students have to use critical thinking skills and apply knowledge acquired in didactic course during the simulation. An RRT(code RN) is used for student cuing due to the complexity of the scenario. Medications (EPI and AMIO) and shocking of pt with correct joules with safety measures were integrated into the scenario. SBAR for communication integrated in simulation, as well as collaboration with peers Jeffries, 2007

Outcomes and objectives Simulation outcomes and objectives were correlated with course and curriculum outcomes and objectives for cardiac patient Outcome: Student(s) will care for a complex cardiac patient within the scope of nursing practice Objectives: outlined in simulation design

Design Characteristics Objectives Fidelity Problem Solving Student Support Debriefing

Implementation Phase of case scenario simulation Implementation of case scenario simulation: proposed simulation opportunity to enrolled NUR 203 was presented to didactic class on March 7, 2013. Explained benefits of case scenario simulation and opportunity to apply what has been learned in theory in a safe learning environment. 27 students signed up. Had to make some adjustments in how to implement with number of students who signed up. Improvised with observation room in room 2306 on 3/28 to accommodate staff and students. There were some time constraints due to : (content covered in class, faculty simulation lab hours, and number of students recommended by Jeffries). Progression of simulation was as follows: pretest, room orientation, shift-to shift report, simulation, debriefing, post-test, student evaluation. Project implemented one session on 3/28 (9 students in observation room) and three sessions allowing student, five at a time, to participate in actual simulation on 3/29

Evaluation phase of case scenario simulation Pretest and Post-test Debriefing Student feedback and evaluation Evaluation phase of case scenario simulation Pretest and posttest. Developed 10 test questions based on 2010 NCLEX-RN Detailed test plan (2010) and McDonalds (2007) development of test questions using the stem method. Test questions were developed at the application level and above. I also looked through NCLEX review books by Kaplan and Saunders to get a better understanding of test question development to reflect NCLEX test questions format. One of the intended student outcomes for the third goal of this project is to show improved NCLEX formatted posttest scores for students who participate in the high-fidelity simulation scenario. The pretest-posttest design will allow me to analyze if the teaching strategy of simulation in conjunction with didactic teaching is an effective outcome-based learning approach. Polit and Beck (2008) note pretest-posttest design allows one to collect data before and after an intervention. A pretest can also indicate student understanding of material before the simulation ( ). The simulated scenario is the intervention for the capstone project. Comparing the results of the pretest and posttest would allow me to analyze if the simulation helped improve critical thinking and overall understanding of the concepts in the simulation. Debriefing/Reflection: In order to evaluate the effectiveness of teaching, a debriefing session will occur with each teaching session in order to evaluate student outcomes related to the HFPS session. The debriefing session allows the student to reflect on the learning experience. Debriefing is where learning takes place for most students. Once successful facilitation of teaching in the ation lsimulab takes place, I will promptly guide the debriefing sessions for each HFPS session. Debriefing is an important component to evaluate student outcomes expected from the simulation teaching (Jeffries, 2007). Student feedback: Jeffries (2007) supports the use of attitude scales to measure student’s evaluation of the simulation as a teaching method. A Likert scale has been developed for participating students to measure the effectiveness of simulation as a teaching-learning experience. Jeffries suggests utilizing the Simulation Design Scale (SDS) to measure student learning outcomes in simulation. Components evaluated within the SDS include objectives, student support, problem solving, fidelity, and debriefing of the simulation learning experience (Jeffries, 2007). Preceptor feedback: continual throughout scholarly project. . An evaluation of the graduate student’s performance from Dr. Pickens is also an expected requirement for the capstone project. I have created statements using a Likert scale for Dr. Pickens to complete in order to evaluate the performance of the graduate student and scholarly project. The evaluator will be asked to measure the student’s performance based on a scale of strongly disagree (1), to strongly agree (7) According to Polit & Beck (2008), the respondent is asked to give their opinion regarding statement within the questionnaire in order to express their opinion. I have chosen to use a seven point Likert scale for the preceptor evaluation component of the capstone project. I have also interjected an area where the preceptor can give constructive feedback to me. I have provided adequate space for Dr. Pickens to write-in additional comments or concerns. Feedback is invaluable information that allows an individual to investigate how they can improve performance (Baker, 2010). I will use the evaluation tool to gain a better understanding of strengths and weaknesses as a nurse educator. The NLN (2005) suggest nurse educators act as mentors and engage in professional development activities. I will plan to attend professional development conferences related to the noted areas of weakness in the evaluation from Dr. Pickens.

Accountability = success of scholarly project Personal accountability Professional accountability Journaling Time log Adhered to proposed plans for scholarly project Communication Mentoring Change agent Personal Accountability: required from graduate course to keep reflective journaling throughout semester. A time log was also noted in the journal. I continuously reviewed the original project planning proposal guidelines to ensure objectives and goals were being met in a timely fashion for the launching of the scholarly project. Professional Accountability: Nurse educator competencies (Halstead, 2007) and the NLN scope and practice of nurse educators (2005) stresses communication and collaboration with peers, mentoring from faculty, particularly expert NE, and acting as change agent are desired characteristics of nurse educators. National League for Nursing, 2012

Analysis of Outcomes Design of Simulation Phase Implementation Phase Evaluation phase Planning Phase: In review of project planning guide proposal, all Goals and objectives were met on March 28th and 29th, 2013. using the project planning guide developed in Fall of 2012 with Dr. Pickens and professor from FSU approval. Design of Simulation: Course/Curriculum objectives for NUR 203 for appropriate case scenario Tentative curriculum changes with simulation lab in conjunction with didactic and clinical courses Jeffries Framework Learning Theories (experiential, constructive, and reflective) Standards of nursing care/practice Nursing and organizational standards: ANA, Joint Commission and NPSG (2013), INACSL Legal and ethical standards Implementation phase: Implemented the project on time as scheduled in planning phase. Steps to implementation were timed out through the semester in order for the case simulation to occur. Communication and mentoring from various faculty members and my preceptor were key to the success of the case scenario simulation. Last minute changes (observation room, amio, ECG lead changes to reflect discernable PVCs on monitor) were made as a result of a run-through simulation day as suggested by Jeffries (2007). I want to personally thank Karen Curtiss, Dr. Pickens, James, and Samantha in their support of this project. Evaluation phase: Pretest and Post-test: the use of pretest and posttest to analyze if the tests scores differed after the simulation. Pretest was given right before the simulation and post-test given after the debriefing phase. The results of the tests scores suggested . Debriefing Student evaluation: based on characteristics proposed by Jeffries (2007): objectives, student support, problem solving, constructive feedback through debriefing, and fidelity. Student evaluations provided insight on what could be done differently when this simulation is used in the future. Preceptor evaluation: Jeffries, 2007

Adherence to legal, Ethical, Nursing, and Organizational standards Legal standards Ethical standards Nursing standards Organizational standards

Legal and Ethical Standards Legal and ethical standards (nurses are the most trusted profession According to the annual Gallup poll, 85% of Americans rated nurses' honesty and ethical standards as "very high" or "high," The Joint Commission and Hospital NPSG (2013) list identification of patient and safe use of medicine as priority patient safety goals -The Institute of Medicine “recommends computer simulation training as one strategy to prevent errors in the clinical setting.” ([IOM], 2010). Incorporating medication administration into patient simulation scenarios offers numerous learning opportunities and benefits to students. Understanding of the rationale for medication use is enhanced as students are able to use critical thinking/judgment and analyze how medications fit into the treatment of selected conditions. They have an opportunity to identify the appropriate drugs, determine safe dosages, calculate dosages, properly identify the patient, administer medications by a variety of routes, observe for side effects, and evaluate the effectiveness of medications. The simulation presents a realistic simulated clinical setting with inherent distractions that may interfere with safe medication administration. For example, in the midst of activities surrounding a code situation, students are exposed to the reality of medication administration in an emergent situation and to the importance of providing the right patient with the right medication in the right dosage at the right time by the right route. Students can be taught to identify areas of potential error through use of effective communication and safety tools (Fowler-Durham, C., & Alden, C. R., 2008 ) -The teaching strategy of simulation has the potential to improve standards of practice, quality of care, patient safety and optimal patient outcomes when students learn and practice procedures and processes that are clinically effective in the practice setting., Simulation provides a safe learning environment for students to practice the skills, attitudes, and beliefs required for nursing practice (Pasci, 2008). Ethical considerations related to the teaching methods of simulation in nursing education include the principles of justice, autonomy, beneficence, and nonmaleficence (Jeffries, 2007). Jeffries, 2007; IOM 2010; and The Joint Commission, 2013

Nursing and organizational standards Nursing standards of practice and professional performance: Using the book Nursing: The Scope and Standards of Practice (2010), The following standards were considered and implemented in the scenario: Standards 1 – 16. ADPIE, Ethics, collaboration, communication, leadership, evidence-based practice and research, consultation NLN: supports the use of simulation to enhance interdisciplinary teamwork, patient safety, and best practices INACSL: simulation standards of terminology, professional integrity of participant, participant objectives, facilitation methods, simulation facilitator, the debriefing process, and evaluation of expected outcomes were considered when developing the case scenario simulation. American Nurses Association, 2010; Faragher, Boese, Decker, & Sando, 2011; and National League for Nursing, 2013

Evaluation of Project with recommendations Repeat of scenario Video recording of scenario for self-evaluation Use four-step process of simulation before implementing scenario in simulation lab Overall, project went as planned. Implementation phase of case scenario simulation was successful AEB post-test, objectives met with reflective/constructive feedback in debriefing process, and student evaluations. Repeat of scenario: Opportunity to repeat scenario improved overall performance of skills, and knowledge utilized during simulation (Sharon Maslovitz, MD, Gad Barkai, MD, Joseph B. Lessing, MD, Amitai Ziv, MD, and Ariel Many, MD, 2007). Abe Y, Kawahara C, Yamashina A, Tsuboi R. (2013) also encourages repeat of scenario, especially complex scenarios in order to allow students closure related to simulation learning experience. Video recording of scenario for self-evaluation: Allows student to self-evaluate performance and internalize overall concepts involved in simulated scenario The student may ask what content do I know, what do I need to keep on studying/practicing, and what do I need to improve “Retrain, recorrect, and reinforce skills required based on video feedback. Adds perspective on how you actually performed vs. how you “think” you performed (Fanning & Gaba, 2007). Confidentiality and consent issues would have to be considered before implementing this evaluation method. Student familiarity with equipment: This could be done through hands-on skills check-off or through demonstration in video. Hands-on approach may support more learner types. Four-step process of simulation before implementation of case scenario (Childs & Sepple s, 2006): CD-ROM/pre-test/group work Faculty guidance/content from station 1/instructor demonstration Group work/case studies Simulator mock scenario revolving around experience of station one through three Abe, Kawahara, Yamashina,& Tsuboi, 2013; Childs & Sepples, 2006; Fanning & Gaba, 2007; and Maslovitz, Barkai, Lessing, Ziv, & Many, 2007

Summary of Simulation Day A snap-shot of a scholarly project completed by Katy Gordon has been presented. Recall one of the first slides related to the planning stages of this project (recall how the picture was fuzzy and hard to view. I hope the pictures provided on this slide in particular give you a clear understanding of how the goals and objectives in order to design, implement, and evaluate a case scenario simulation for NUR 203 students were met. It is my intent to continue investigating simulation as a teaching-learning strategy in nursing education. This project has given me a better view of theories, framework, existing literature, as well as suggested areas to investigate related to simulation in nursing education. Thank you for allowing me to share my project from the planning stages to the evaluation phases. I I will now take any questions related to the scholarly project.

Questions

References Abe, Y., Kawahara, C., Yamashina, A., & Tsuboi, R. (2013). Repeated scenario simulation to improve competency in critical care: a new approach for nursing education. American Journal of Critical Care., 22(1), 33-40. doi: 10.4037/ajcc2013229. American Nurses Association (2010). Nursing: Scope and standards of practice (2nd ed.). Washington, D. C.: Nursesbooks.org Brown, D., & Chronister, C. (2009). The effect of simulation learning on critical thinking and self-confidence when incorporated into an electrocardiogram nursing course. Clinical Simulation in Nursing, 5(1), e45-e52. Childs, J. & Sepples, S. (2006). Clinical teaching by simulation: Lessons learned from a complex patient care scenario. Nursing Education Perspectives, 27(3), 154-158. Durham CF, Alden KR. Enhancing Patient Safety in Nursing Education Through Patient Simulation. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 51. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2628/ Fanning, R. M. & Gaba, D. M. The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125. Faragher, J. F., Boese, T., Decker, S., & Sando, C. (2011). Standards of best practice: Simulation. Clinical Simulation in Nursing, 7(4S), S1-S19 . Institute of Medicine (2010). The future of nursing: Focus on education. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Education%202010%20Brief.pdf Jeffries, P. (2007). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nursing Maslovitz, S., Barkai, G., Lessing, J., Ziv, A., & Many, A. (2007). Recurrent obstetric management mistakes identified by simulation. Obstetrics & Gynecology,9(6),1295-1300.

National League for Nursing (2005) National League for Nursing (2005). The scope and practice for academic nurse educators. New York, NY: National League for Nursing. National League for Nursing (2012). A Nursing Perspective on Simulation and Interprofessional Education (IPE): A report from the National League for Nursing’s Think Tank on using simulation as an enabling strategy for IPE. Retrieved from http://www.nln.org/facultyprograms/facultyresources/pdf/nursing_perspective_sim_education.pdf NCLEX-RN Detailed Test Plan (2010). 2010 NCLEX-RN Detailed test plan. Chicago, IL: National Council of State Boards of Nursing. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Rowles, C. J., & Russo, B. L. (2009). Strategies to promote critical thinking and active learning. In D. M. Billings & Halstead, J. A. (Eds.), Teaching in nursing: A guide for faculty (3rd ed., pp. 238-261). St. Louis, MO: Saunders Elsevier. The Joint Commission (2013). National patient safety goals. Retrieved from http://www.jointcommission.org/assets/1/6/2013_HAP_NPSG_final_10-23.pdf Witt, S., Borden, S., & York, N. L. (2010). Simulating rapid response in undergraduate critical care education. Dimensions of Critical Care Nursing. 29(1):33-39. doi: 10.1097/DCC.0b013e3181be4b70