I sort of remember nursing school

Another assignment that I figured would be nice to share here.

The book I am referencing is

Benner, P. E., Sutphen, M., Leonard, V., & Day, L. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass.

Educating Nurses was published 10 years after I graduated, yet my experience has similarities to the descriptions in the book.  In all honesty, it is tricky to reflect back on my undergrad without the bias of my own experience as a nurse educator. In fact, much of my motivation to study nursing education and become well versed in it was a result of my perception of my own educational experience- and my continued assessment of the state of nursing education while working as a full-time faculty in ADN and RN-BSN programs.

I went to nursing school at a private Baptist college in Texas., University of Mary-Hardin Baylor (UMHB). I was not Baptist, but it was the closest BSN program. I already had my AA in English and Music and when I decided to study nursing instead, I figured I should get my bachelors instead of another associate’s degree.

I took pre-req courses from a variety of community colleges- from Kentucky, Oklahoma, California and Texas. I was the ultimate transfer student. I took more than I needed because I did not what program I would apply to (or where I was going to live even- Army life) so I went in with a very solid foundation.  I think I only took one or two non-nursing classes at UMHB. Instead I had transcripts from 5 different schools. And I was a nontraditional student in that I was in my late 20s with two small children and my husband was active duty army.

So, with all that, my only goal in that program was to get done. I came in with a lot of pathophysiology knowledge (I used to read the Merck Manual as a teenager for fun) and a solid science- and liberal arts background. There was not as much of a crunch of content into our brains as things were more spread out over the curriculum. That’s in contrast to the ADN program I taught at- that concept that nursing education is additive is SO true, every year it seemed we added more material and never felt like we could let things go.  As a student in my BSN program, we did have mostly lecture (overheads not powerpoints!) and multiple choice exams. And usually one written assignment per semester. That was how the diadatic content was covered.

My favorite class was our senior leadership class, I think the instructor enjoyed teaching it also. She had an MBA and marched to her own drum. And it was not “life or death” content, so she could have fun with it- it was very much applied knowledge- teaching presentation (I made overhead slides!), a change project on our assigned units (mine was developing a policy about whose responsibility it was to change out full sharps containers). Overall there were other elements presented in the book that occurred in my program: team teaching, heavy emphasis on the NANDA diagnoses and all the crazy strict rules about how to write a nursing diagnosis, lots of sage on the stage style lecturing and the occasional game to make things interesting.

My clinical is even harder to recollect. I was not paying attention to how I was being taught and I was kind of on survival mode most of the time (my husband was deployed to Korea my entire senior year). How much my instructors took time to question me and help me find learning opportunities was completely lost on me. I showed up exhausted from staying up late, after my small children went to bed, making my drug cards and getting up way too early. I honestly cannot remember a single post conference. I have a blur of a few key moments- putting a foley in a small child, who they thought had Kawasaki disease and she had a terrible rash all over her peri area, yet no one guided me to consider NOT putting iodine on that raw tender skin. Now I know I could have used soap and water.  I got in big trouble taking a Dr. up on his invitation to observe a circumcision during my OB rotation- I still have no idea why it upset my instructor so much. That was one of those clinicals where our hands were tied and all we could do is observe anyhow! There was some bullying by faculty in that program for sure, but also some kind and compassionate instructors. I also struggled with feeling comfortable taking care of patients and asking them all the questions on our assessment paperwork. They were so tired, miserable and in pain. And I was supposed to ask them about their sex life? Finally, I have a distinct memory of working up a sweat while trying to put TED hose on a knee replacement patient. That was most likely because of the terrible, hot, impractical, polyester uniform, complete with purple apron, we had to wear.

I spent most of my clinicals feeling terrified and unsure of what I was doing. The instructors overall (with a few exceptions) were kind and supportive. I think some of my anxiety stemmed from the fact that while I had a great deal of knowledge, I had very little patient care skill or experience. And our lab experience was dismal to say the least. This was pre-simulators and we did not even have mannikins to practice on. The only hands on practicing we had was assessment on each other (in our sports bras, with the 2 boys in the class sent to another room) and injections – of saline into our thighs.  Everything else was talked about and we hoped to get a chance to see it in action and maybe try it out.  I went into nursing terrified of doing any skills… and eventually became a skills lab instructor. What a way to face my fears!

So reading Benner’s book, I mostly find myself going, “yup, seen that, did that, still do that” when they discuss some of the challenges in nursing education. I think my own experiences as a nursing student were what drove my obsession with giving my students a good solid lab experience, yet balanced by understanding I could teach them everything and allowing some things to fall away for other things to move in (for example no longer testing trach care in exchange for some informatics content).

To be Honest …

I am working on a concept analysis of prebriefing. It’s a thing you do as part of your research anyhow, and it’s for a class (of course). But I am getting a lot out of it. Much like my  last post that talked about my why for this topic, I am now seeing my what– as in what do I want to do in this topic?

I have said before, I want to lay the ground work for a framework for prebriefing, much like there is for debriefing (there are many, in fact). As I review this literature, I am beginning to form an idea, and I need to write it down here. Bear in mind, I am brainstorming, so I am not citing all the great minds who have come before me in this field. But I will say there are a few names who pop up regularly in prebriefing- and as a baby novice researcher, I’d like to connect with at some  point:

Donna S. McDermott, PhD, RN, CHSE

Karin Page-Cutrara, PhD RN

Jill Chamberlain, PhD RN

Anyhow back to me.

I think that while I might only be aiming to gather survey data about prebriefing (and participant preparation) practices in prelicensure nursing programs, I have a larger goal if I continue in research and in this field. I see that prebriefing is finally getting research attention. And while the INACSL Standards of Best Practice: SimulationSM continue to separate out the concepts of prebriefing and participant preparation, we need to move to a more integrated framework for the activities that take place before the simulation.

Once I collect data about what educators are actually doing in their simulations, I feel I can make the following proposal:

Best Practice is not just what everyone is doing,  but sometimes what everyone is doing (especially in a field that is young, yet well established like simulation) might be a good starting point. I think we need to develop a framework that is supported by the experts, learning theories and the reality of practice to structure the elements of prebriefing. It must be more than an orientation or a speech about “safe space” It should be in phases. Each phase addresses a learning domain.

The preparatory phase (cognitive domain) where learners prepare by learning about the the content they will encounter in the simulation. They may review pathophysiology or medications. Or develop concept maps or care plans for their simulated patients. They will be accountable for this prep work. This phase allows the learner to develop a foundation on which to build their learning in the scenario.

The orientation phase (psychomotor) which allows the learners to hands on experiment with equipment, or examine the space the simulation will occur and become familiar with it. In this phase, they may even review skills that may be required in the simulation whether it is auscultation of the mannikin or insertion of a foley catheter. This phase allows the learner to gain some comfort and eliminate distractions so they can focus on their higher level actions and decisions in the scenario.

The prebriefing phase (affective) where the facilitators reviews the expectations,  elements of psychological safety, fiction contract, the process of debriefing and other aspects that will provide a safe and respectful learning environment for the participants.  This phase is intended to help alleviate the learner’s anxiety going into the simulation and give them a sense of self-efficacy.

 

Yeah so, that’s my idea.

 

Mission Statement..but first an update

My life’s journey is to learn and grow so that I can make the world a better place by using my talents as a natural teacher to share knowledge and inspire others.

This blog has been neglected. It was created almost a year ago as part of an assignment for a course. The assignment was to create a teaching portfolio. I decided to create my own “blogfolio” that combined some permanent content – the portfolio, with updates that focused on my academic pursuits.

Well, fast forward a year. My resume has been updated and uploaded, but much of the  portfolio content does not apply to my current situation. I have transitioned from  academic nurse educator to clinical (hospital based) nurse educator. I have  moved back to the patient care setting, where I am the unit educator assigned to a surgical and an orthopedic unit.

I love being back in the hospital, I enjoy working with practicing nurses. I miss my students – although many former students are working as nurses at my facility, which is pretty great. I realized early on in this job that my talents and skills as an educator serve me in ways I took for granted in the academic setting. And in this new position, they are appreciated and supported.

I am still pursing my PhD although I have been thinking about options and other pathways that might serve me better (more in a future post, if I find time). I had a set back over the summer when I ruptured my achilles tendon and had surgery a month before I started my new position. I am back in classes- taking a class to explore my research method and a class on leadership (Organizational Foundation for Leading Change).

Which is what brings me back here today. To share something I am working on for my leadership class. My personal mission statement. While I have written nursing philosophies and a teaching philosophy, the personal mission statement was a bit of a new thing for me. I cheated a bit and used a website recommended by the instructors. It generated a series of statements which did not flow well or make sense to me. But they inspired me to put something together that did.

I now present to you my Personal Mission Statement:

My life’s journey is to learn and grow so that I can make the world a better place by using my talents as a natural teacher to share knowledge and inspire others. I thrive when I am working on something I am passionate about, and I want my life’s work to reflect my passions, while not letting myself get overwhelmed by my own personal goals and aspirations.  I strive to become a better listener who thinks about others first and facilitates growth and development in others. I want to learn to slow down, enjoy life and incorporate wisdom, charisma, a sense of the sacred and spiritual in to my purpose.

 

 

 

 

Taking a stab at my chapter one

I am taking a risk here, sharing my ideas and thoughts regarding my research- so if you for whatever reason, happen to care about this topic passionately… have plans to research it yourself – first I’d say, wow. Sorry. Second I’d say, PLEASE reach out and contact me. I’d rather find a way to collaborate instead of find myself at a loss for my topic (or see it presented at a conference). This is a big enough field, with enough “space” that we could share ideas and still get our work done! Again PLEASE email me and let’s talk about it. I would be happy to send you citations, suggestions and ideas!

Gotta get this boat to sail!

A few caveats! This is a first draft, I am focused on content rather than formatting, so there may be citation errors or awkward sentences, etc (I expect the same in my final draft too because… I’m only human!), so please don’t feel compelled to correct those! Also I am still trying to figure out what this chapter one business is all about. But I feel like publishing here makes me accountable to keep working on it! Also, if I had the time or the inclination, (and the html patience) I would link citations and such. But NAH.

I am taking a risk here, sharing my ideas and thoughts regarding my research- so if you, for whatever reason, happen to care about this topic passionately… have plans to research it yourself – first I’d say, wow. Sorry. Second I’d say, PLEASE reach out and contact me. I’d rather find a way to collaborate instead of find myself at a loss for my topic (or see it presented at a conference). This is a big enough field, with enough “space” that we could share ideas and still get our work done! Again PLEASE email me and let’s talk about it. I would be happy to send you citations, suggestions and ideas!

Finally, an update – I am currently stuck at home with a casted leg from the knee down. I managed to snap my achilles tendon taking a step (nothing exciting) and am recovering from surgical repair of the tendon. A couple of weeks of non-weight bearing on my RIGHT leg, then a couple months of cast and boot. It’s been 20 day since surgery and I’m finally feeling productive! So bear that in mind as you read:

CHAPTER ONE

THE INTRODUCTION

Description of Simulation

Simulation is the use of a “true to life setting” for the practice and performance of skills in healthcare (Society for Simulation in Healthcare, 2016). It is modeled on the training of pilots and other individuals who perform in high risk environments where there is a very narrow margin for error (Al-Elq, 2010). While there are many different ways to describe, define and use simulation in healthcare, the Society for Simulation in Healthcare identifies four major applications of simulation in healthcare: education, assessment, research, and health system integration in facilitating patient safety (Society for Simulation in Healthcare, 2016). In all of these, simulation is defined by what it does: provide a safe, realistically developed environment where the participants may engage in patient care, practice a skill, evaluate competency, test a process, demonstrate team dynamics and communication skills and research situations that occur in healthcare.

Simulation in nursing education has become a standardized part of many nursing schools and hospital training programs. In 2013, the International Association of Clinical Simulation and Learning published the first seven Standards of Best Practice: Simulation, adding two more standards in 2015 (Ackermann et al., 2013; Decker et al., 2015; Lioce et al., 2015). These standards came at crucial time with an increase in the use of simulation in nursing and the need for evidence based guidance. The goal of the standards is to “advance the science of simulation, share best practices, and provide evidence based guidelines for implementation and training” (The International Nursing Association for Clinical Simulation and Learning, 2015).

Prebriefing/Briefing in Simulation

It is in these Standards that the essential elements of simulation are found. The original seven Standards outlined the basic elements of simulation throughout. Overall the basic structure of a simulation scenario must include, among other elements, prebriefing or briefing

(Ackermann et al., 2013).The newest Standard, Simulation Standard IX: Simulation Design includes a more specific list of elements of simulation design, which also includes prebriefing/briefing (Lioce et al., 2015).

In the Standards and other simulation literature, prebriefing and briefing are interchangeable terms. This paper will refer to it as prebriefing. Simulation Standard I: Terminology defines prebriefing as:

An information or orientation session held prior to the start of a simulation-based learning experience in which instructions or preparatory information is given to the participants. The purpose of the prebriefing or briefing is to set the stage for a scenario and assist participants in achieving scenario objectives. Suggested activities in a prebriefing or briefing include an orientation to the equipment, environment, mannequin, roles, time allotment, objectives, and patient situation. (Ackermann et al., 2013, p. pp S3–S11).

According to the Standards, simulation prebrief is an essential element of simulation best practice. Simulation Standard IX: Simulation Design provides three guidelines for prebriefing:

Guideline 1: Briefing activities include the establishment of an environment of integrity, trust, and respect. Briefing includes identification of expectations for the participant(s) and the facilitator(s). This includes establishment of ground rules and a fiction contract.

Guideline 2: Briefing should include orientation of the participant(s) to the space, equipment, simulator, method of evaluation, roles (participants/facilitator/standardized patient), time allotment, broad and/or specific objectives, patient situation, and limitations.

Guideline 3: A written or recorded briefing plan standardizes the process and content for each scenario/case

(Lioce et al., 2015, p. pp 309–315)

 

Problem Statement

Prebriefing is an essential element of simulation, however the practice and content of prebrief varies widely. There is a paucity of research supported models for nursing faculty to use to guide the development of pedagogically sound prebriefing for simulation in pre-licensure programs.

Background and Significance

It has been almost 15 years since the Institutes of Medicine recommended the use of simulation in health care education to promote safe and competent nurses (Kohn, Corrigan, & Donaldson, 2000).  Simulation now is considered a viable option to supplement and replace clinical experiences in nursing education. It can be designed to provide consistent learning opportunities for groups of students in a way that the less predictable clinical setting cannot (Gates, Parr, & Hughen, 2011).

This is important because clinical sites are becoming increasingly difficult for nursing programs to secure (Ellis, 2013).  In 2010, a national survey conducted by the National League for Nursing questioned over 2,300 nursing programs across the United States and found that a major barrier to clinical learning for nursing students is “lack of quality clinical sites”  (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014; Ironside & McNelis, 2010). A 2010 National Council of State Boards of Nursing (NCSBN) survey found that many schools are turning to simulation as a way to provide students additional learning opportunities with 69% of schools surveyed reporting they used simulation to substitute for clinical learning experiences (Kardong-Edgren, Willhaus, Bennett, & Hayden, 2012).

The use of simulation as an adjunct or replacement for clinical hours is evidenced based. The results of a national, multi-site, longitudinal study of simulation, the NCSBN found that substituting simulation for up to 50% of  students’ traditional clinical experience in pre-licensure nursing programs was as effective as traditional clinical learning and did not affect National Council Licensure Examination (NCLEX) pass rates (Hayden et al., 2014).  Six months into  clinical practice, the study found that there was no significant differences in nursing practice between those groups of students  (Hayden et al., 2014).

As programs are moving to include simulation as a crucial component of their curriculum, faculty require guidelines based on solid pedagogy and evidence based practice that can be used to develop consistent simulation experiences for their students. Exploring the current practices of prebriefing among pre-licensure programs will help identify the gaps in practice and the development of such guidelines to assist simulation developers and programs to support student learning.

Aim and Research Questions

The aim of this research is to collect data regarding current simulation prebriefing practices in US pre-licensure nursing programs as a basis for developing a prebriefing framework for faculty to use when developing simulations.

This research seeks to answer the following questions:

  1. What is the current state of the science of pre-briefing in US pre-licensure nursing programs?
  2. What are the current pre-briefing/briefing practices in US pre-licensure nursing programs?
  3. How do they compare to the expert recommendations (DELPHI study?)
  4. What are the next steps necessary to establish pre-briefing standards?

NOTES: COMING SOON (maybe): preliminary design and theoretical framework

REFERENCES

Ackermann, A., Gore, T., Hewett, B., Harris, M. S., Lioce, L., Schnieder, R. S., … Martinez, P. a. (2013). Standards of Best Practice: Simulation. Clinical Simulation in Nursing, 9(6), ii–iii. http://doi.org/10.1016/j.ecns.2013.05.008

Al-Elq, A. H. (2010). Simulation-based medical teaching and learning. Journal of Family and Community Medicine, 17(1), 35–40. http://doi.org/10.4103/1319-1683.68787

Decker, S. I., Anderson, M., Boese, T., Epps, C., Mccarthy, J., Motola, I., … Scolaro, K. (2015). Standards of Best Practice : Simulation Standard VIII : Simulation-Enhanced Interprofessional Education ( Sim-IPE ). Clinical Simulation in Nursing, 11(6), 293–297. http://doi.org/10.1016/j.ecns.2015.03.010

Ellis, J. R. (2013). Washington State Nurses Association White Paper: Nursing Education in Washington State.

Gates, M. G., Parr, M. B., & Hughen, J. E. (2011). Enhancing Nursing Knowledge Using High-Fidelity Simulation. Journal of Nursing Education, 51(1), 9–15. http://doi.org/10.3928/01484834-20111116-01

Hayden, J., Smiley, R. a, Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). 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 Suppl), S1–S64. Retrieved from https://www.ncsbn.org/JNR_Simulation_Supplement.pdf

Ironside, P. M., & McNelis, A. M. (2010). Clinical Education in Prelicensure Nursing Programs : Findings from a National Survey. Nursing Education Perspectives, 31(4), 5–7.

Kardong-Edgren, S., Willhaus, J., Bennett, D., & Hayden, J. (2012). Results of the National Council of State Boards of Nursing National Simulation Survey: Part II. Clinical Simulation in Nursing, 8(4), e117–e123. http://doi.org/10.1016/j.ecns.2012.01.003

Kohn, L., Corrigan, J., & Donaldson, M. (2000). To err is human: Building a safe health system. Washington DC: National Academies Press. http://doi.org/10.1093/bja/aeq146

Lioce, L., Meakim, C. H., Fey, M. K., Chmil, J. V., Mariani, B., & Alinier, G. (2015). Standards of Best Practice: Simulation Standard IX: Simulation Design. Clinical Simulation in Nursing, 11(6), 309–315. http://doi.org/10.1016/j.ecns.2015.03.005

Society for Simulation in Healthcare. (2016). About Simulation. Retrieved July 20, 2016, from http://www.ssih.org/About-Simulation

The International Nursing Association for Clinical Simulation and Learning. (2015). Standards of Best Practice: Simulation. Retrieved July 20, 2016, from http://www.inacsl.org/i4a/pages/index.cfm?pageid=3407

Simulation in non-academic settings

Admittedly I have spent the last 7 years developing a simulation program in only one setting- academic. I have developed and implemented simulation for pre-licensure nurses in an ADN program. But in my years of learning and exploring, I have met with and learned from experts from all settings. Many in hospitals, at large universities with huge IPE programs, and even a few independent simulation companies. While my direct hands-on experience has been focused on students and their learning and application of new skills, I have been exposed to the many ways simulation can improve nursing, and not only nursing, but health care overall.  In fact, the certified healthcare simulation educator exam  is geared towards a variety of settings, and in my preparation for it, I had to open my mind to not only what works or is appropriate in my setting, but to also understand the universal “truths” of simulation in all settings.

Recently I endeavored to learn a little more about ways simulation is used in hospitals and healthcare systems. In my searches, I came across a very informative plenary speech from IMSH 2014 by Dr. Jennifer Arnold (link at the end of this post). At first I thought, she seems familiar- I remember seeing her at IMSH in 2016 and thinking then how I had seen her at other conferences (I notice the Sim Celebs at these things!) and that I’d seen her at other conferences. I don’t watch a lot of TV shows,  so I completely missed that she’s also a reality TV star! Once I found that out, I fell in total love with her- an  educated, eloquent and intelligent woman, representing simulation to the public was a great thing! Next time I see her at a conference, I plan to shake her hand and thank her!

That was my first time at IMSH- I’ve attended INACSL (very nursing focused) a few times and other nursing education focused NLN sponsored conferences, but this year was my first IMSH and it was amazing. It was a refreshing experience to interact and network with simulation experts from all sorts of disciplines and backgrounds.

Anyhow back to her speech- she explained the model they  developed at Texas Children’s Hospital to use simulation. It includes 5 areas that simulation can be applied:

  • Education
  • Competency and Assessment
  • Quality and Patient Safety Initiatives
  • Research and Development
  • Advocacy

In her speech she gives examples of each area and how they have developed simulations in response to a need presented to their center. Having a framework which the center’s mission is build upon is crucial. It keeps the simulation center focused on it’s mission, and creates criteria for appropriate use of resources and a structure for evaluation and program development.

In academia, we often find ourselves focused on specific learning outcomes and lose sight of the big picture of what those outcomes feed into. Our program is currently undergoing a curriculum revision and after the development of a new philosophy statement, we had to distill out program/educational outcomes for “what our students should look like” when they complete the program. That was a challenging but intriguing endeavor that produced 5 solid  outcomes that we can build our curriculum around. I think as the simulation “person”, I need to now integrate those outcomes into my simulation center mission (I am working on a policy and procedure manual for our newly renamed “Clinical Performance and Simulation Center”) so that the resources are used in a mindful fashion with program outcomes/goals in mind.  I think I might also develop a framework similiar to this.

I am using the SSIH Accreditation Standards to build the policy and procedure manual as they give a good framework for essential elements in a high functioning sim center. I plan to integrate the following standards into a mission/framework, along with the program philosophy and education outcomes:

Here is Dr. Arnold’s great speech: