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.

 

Why Pre-Briefing???

Pre-briefing is a crucial element of simulation which allows students to have a learning experience that is both valuable and retained.

I have been reflecting on my research interest. I had to do a discussion board posting in one of my classes that addresses my research phenomenon and concept. In that I reflected on what led to my interest in this topic. I realized is was borne out of my experiences with simulation. Observing the impact of preparation for simulation on students, and their response to the experience. Also, I am driven by my passion as an educator to shake up the traditional culture of nursing education which I have observed to be punitive and rarely student centered.  Simulation  is an opportunity for nursing education to move from behaviorist approaches to more constructivist and humanist approaches.

Pre-briefing is a crucial element of simulation which allows students to have a learning experience that is both valuable and retained. Much like care planning allows a nursing student the opportunity to prepare and plan out the interventions and care they will provide to their patients based on the patient’s own needs, a structured and comprehensive pre-briefing gives the nursing student the tools to interact in a simulation while focusing on the clinical decision making and clinical judgment aspects of nursing practice.  With good preparation, the use of clinical judgement and clinical decision making become the focus of the learning objectives of the scenario.

Simulation is the one safe environment where nursing students can bring together and act on the three domains of learning: cognitive, psychomotor and affective. For nursing students, traditionally cognitive learning occurs in their theory classes, memorizing lab values, symptoms of disease and medication side effects, assigning nursing interventions to disease and pathophysiology. Psychomotor learning happens in a skills lab setting, practicing invasive skills repeatedly on simple low fidelity manikins and task trainers. The clinical setting only affords the student the opportunity to observe clinical decision making, to shadow the clinical judgment of the nurse they follow. They have some opportunity to demonstrate what they have learned in theory class and lab, but the limitation of their role as students does not give them the freedom to make clinical decisions and follow through with their impact.  Only in simulation does the nursing student get to “practice nursing” in all its aspects. They bring the cognitive and psychomotor to a simulated patient while applying the affective learning domain to the clinical decisions and judgements they make in the simulation.

Because of the unique benefit of simulation to nursing students, it is crucial it is implemented in a way that is thoughtful and mindful of its effect on students. Anxious and uncertain students who feel ambushed by the experience miss out on a rich learning opportunity. Debrief in those situations focuses on their feelings about the simulation (fear, anxiety, embarrassment, and lack of confidence), not the process of clinical decision making, the rationale behind decisions and actions and the management of consequences. Their memory of sim lab will be negative and associated with stress, dread and anxiety. These are all barriers to the learning process, meeting the objectives of the scenario and retention of the intended learning outcomes.

Simulation is an experiential learning process and preparation is an essential element of that approach Preparing students in a mindful way, one that is clear about the objectives, goals and expectations of the scenario affords the student tools to approach the scenario focused on the clinical decision making process and their own use of clinical judgement. They come out feeling confident, able to apply the lessons learned in the scenario to their future practice and non-judgmentally reflective of their own behaviors.

This is based on my own observations as a simulation instructor/facilitator of over 7 years, my knowledge of the simulation literature, my understanding of teaching/learning theories and anecdotal evidence from simulation peers. My own teaching philosophy is grounded in the idea that nursing education is a transformational process for students. The educator is the facilitator of that process and has a powerful role in constructing learning opportunities that have a great effect on the growth and development of the student into a nurse. If done haphazardly or without consideration to the impact- especially in simulation- great harm can come to that student. Deep scars and trauma can be left behind, challenging the confidence, growth and positive transformation of that student. For this reason, I am researching the practices of pre-briefing in nursing education.  I feel it is crucial for a structured and theory based framework of the essential elements of pre-briefing be developed so nurse faculty can have guidance in implementing simulation based education. Pre-briefing is a critical element of simulation design and much like the focus on debriefing techniques and the safety of the simulation environment and the debrief, and I feel we must be just as careful, deliberate and structured in designing and implementing the pre-brief.

 

More on learning theories and nursing education.

Best practices in experiential learning.

Simulation based constructivist approach for education leaders.

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:

 

NLN Boise Simulation Conference 2016

Highlights of some sessions from Day Two!

DAY TWO:
Session: Innovative Strategies for Interactive Learning in a Nursing Clinical Learning Center

Presented by Jane Toon, DNP,RN; Carolyn Kirkendall, MSN, RN, CCRN; Stephanie Kemery, MSN, RN, CMSRN University of Indianapolis

Critical care based interactive learning stations. The goal was to address the fear of critical care setting and the patients which leads to a poor clinical experience as nurses don’t want  them near patients if the students look nervous.

They used faculty and grad students and alumni to facilitate the stations. It helped to have grad students and alumni- great resources for the students

The day consisted of 6 stations- each faculty facilitated, using Socratic questioning, 10 students per station. This was an all day event, 40 minutes per station, 2 objectives per station.

Sim critical care patient: set up a critical care assessment manikin- all things connected plus monitor with all wave forms. Other stations- sepsis,  EKG/rhythm strips, chest tubes, heart/lung sounds (vital sim),  mock code and drop calculations. This is not new material,  it’s reinforcement  of content. I like the idea of the assessment of the critical care patient, it’s a simple yet elegant way to teach the care of this kind of patient and something we could  use in our 6th quarter.

This is a great idea but so faculty intensive. It’s essential to a have experts. And one person who is circulating and making sure flow is working.

Session: Measuring Cognitive Load in Nursing Simulation 

Presented by Janye Josephsen, EdD, RN Bosie State University

Great  concepts, and I could see how this could connect with pre-briefing. Bringing students  into sim with no “schema” regarding what is happening can leave them overwhelmed by intrinsic and extraneous cognitive load and cannot get enough germane cognitive load.

I am excited to think about linking this kind of research with the current research/Delphi study that looks at pre-brief components recommended by certified simulation educators.  Cognitive load theory would be a great support for the need of solid pre-brief experience.

This presenter used video to show them (model) how to behave in the simulation. The idea is that giving these students a framework to build on before experiencing the simulation. Measured outcomes- pre and post knowledge survey and a cognitive load self report survey.

Presenters recommendation for reducing cognitive load for simulation:

  • pre-reading/activities (pretty standard for many simulations)
  • scaffolding/chunking (part of cognitive load theory)
  • self explanation effect (reflection on action- before the action!)
  • collective working memory (collaborative learning)

 

 

NLN Boise Simulation Conference 2016

A brief summary of my day one sessions at the NLN Boise Simulation Conference 2016

 

Day one:

Spent my morning at a session that introduced TeamSTEPPS facilitated by TeamSTEPPS trainers Tammye Erdmann MSEd, BScIT, RN, CHSE and Cathy Peterson, BSN, RN.

I have wanted to bring TeamSTEPPS into my lab classes and sim lab for a very long time, but I needed to learn more  about it and understand the components of it. I gained a great deal of knowledge about the processes. I think TeamSTEPPS would make a great framework for building simulation scenarios, too. The tools such as SBAR and I PASS THE BATON to set up the scenario and  patient information. Using the briefing model as a guide for developing the (pre-) brief for the students. TeamSTEPPS even has a debrief checklist.

So added to my to-do list for future development – planning/developing a communication scenario for first quarter students.

Dr. Kristina Thomas Dreifuerst RN, ANEF, CHSE: Afternoon presentation regarding debriefing across the curriculum. Great concepts. I have heard some of this before (at IMSH), but she presented more detailed guidance and examples of classroom discussion using a debriefing methodology rather than simply lecture and rapid fire questioning. Her emphasis is on Socratic questioning and the focus on why rather than what. (How is important too)

Dr. Suzie Kardong-Edgren RN, CNE, ANEF: Moving towards high stakes evaluation using simulation. This is  a hot and complex issue. Nursing faculty love to test students-sometimes too much IMHO. And skills testing is (IMHO again) a pretty big sacred cow. (funny coming from the lab instructor). While I agree we need to measure competency in nursing grads in some way BESIDES choose one of 4 answers, I don’t think the measure of a nurse is his or her ability to perform a skill while being evaluated is the pinnacle of nursing assessment.

High stakes testing in simulation can  be used in some ways for good-that is measuring how well a student can pick up changes in a patient’s status or perform the appropriate assessment. But in order to do it in a rigorous and consistent manner, the evidence, according to Dr. Edgren, shows that several elements are  necessary. A SHARED MENTAL MODEL among faculty is critical. But yet it’s the last thing most nursing programs have. You have hawks and doves  as evaluators- and the lack  of consistency can put a high stakes  evaluation program at risk. Getting all faculty on board for what the evaluation is measuring, how it is  measured and then moving on to establishing consistent  cut off scores is a lot of work.

The faculty need to review many videos to get a baseline for the “range of behaviors” and to establish cut off  scores.  In addition, it’s essential for there to be a large number of stations with different raters to ensure a balanced  evaluation.

This  process in the end needs to develop a “legally defensible model” because if a student’s nursing school career is based solely on high stakes simulation evaluation, then the program needs to be prepared for students to challenge the process- and there are litigators dedicated to helping these students out.

Personally, while I think done correctly this process could provide nursing with a valuable way to determine competency, I think that a competent nurse looks like a lot of different things in a lot of different settings. NCLEX is by no means the best measure of this but it’s what we have now. With the increase in delegation of tasks and skills -and considering that many of the skills we hold as so crucial to nurses to perform perfectly we now often rely on family members to perform in the home or UAPs in the clinical setting. Being a nurse is so much more than good sterile technique. In addition, many nursing skills take years to get “good at” with deliberate practice and experiencing variations in setting.

One school shared their process of using high stakes skills testing in their program because the students would be taught and tested on skills in the beginning of the program and then by their last quarter would  have skill decay, the practice partners were saying they had to “teach them everything again”. So they gave them a high stakes skills evaluation- meaning,  no chance for remediation or make up or retest- failure meant failure. (usually skills testing is performed until mastery is demonstrated).  That seemed like a dramatic response to that issue. Often the hospitals will say- “Oh we just want them to be able to think critically, we can teach them skills” and then turn around and complain “these new grads don’t know how to do any skills”…. but it’s all a symptom of a critical issue in nursing ed- filing the gap between what the schools are capable of (especially with the challenges of getting enough clinical placements for students, the lack  of good learning experiences for students once they at the clinical  sites and the overwhelming amount of information we need to dump into  the student’s heads in such a short time) and what the practice partners/hospitals expect from students. The advent of residency programs has greatly supported this transition (and were mostly developed in response to the high attrition rate of new nurses who leave  nursing completely in the first year), but not all hospitals can provide that. This is an issue that won’t go away soon and I think simulation will play larger role in resolving it.

 

 

 

 

 

Reflective Journal Entry After Visiting a Sim Lab

As part of my faculty role practicum, I wrote a reflective journal entry about meeting with a dedicated simulation faculty at a local university.

 

Write a one page reflective summary of experience, using the Gibb’s Reflective Cycle Model (description, feelings, evaluation, analysis, conclusion, action plan) (Gibbs, 1988).

Description:

My visit to the Clinical Performance Lab (CPL) allowed me to sit in and observe 3 simulations with undergraduate students. It was a new simulation for the program, developed by a master’s student. Along with the sim faculty, another faculty – content expert in pediatrics was facilitating the scenario.

In addition to observing the simulation, I was able to interview the sim faculty extensively about her role, her pre-briefing and de-briefing practices and all things simulation.

Often other faculty are very proficient in simulation and the  sim faculty allows them to run debrief and other aspects of the simulations. But there are some faculty who are simply not familiar with the best practices of simulation and debriefing methods or just do not have enough time and experience in simulation, in which case then, they serve as content experts to support her in facilitation. It is sim faculty’s expertise, as evidenced by  certification (CHSE) in simulation and the role as dedicated simulation faculty that allows her to make those determinations.

We talked about the pre-briefing practices at the CPL for a while also. Students will receive materials from their course instructor, some very basic and others more complex, however they are working to revise and standardize simulation preparation. As simulation is considered a clinical day, students should be as prepared for it in the same way. The onsite pre-brief consists mostly of an orientation to the simulation and scenario. The sim faculty will informally tailor the presentation depending on the experience level of the student and the type of scenario.

I  also discovered that a method of managing lots of students- presenting unfolding scenarios for a clinical group split in two as I do  is something they do there as well.

Feelings: I always love meeting and talking with other simulation faculty. We are a unique bunch of people, who are passionate about simulation and who teach in an innovative way. We share a universal set of values about the benefits of simulation and learning in a simulation setting. As a result of this experience, I came away with a strong sense of validation regarding my own beliefs and practices in simulation. My approach is consistent with that of the experts- and now with my own CHSE I am technically an expert also. I learned that even though I operate in a small, restricted simulation setting right now, I am doing as much as possible to maintain the standards of best practice.

I was able to explore this simulation center model and gain some insights that I can transfer to BC as we work to expand and grow our own simulation center. It was very clear to me that having the equipment and physical space is only part of requirements. Having a strong simulation team –with administrative, technical and operations support along with faculty who support the program policies is necessary to provide a stable and sustainable simulation center for students. I face a lot of challenges in my role at BC and while faculty support the idea of me becoming a simulation expert/director there, our resources and capabilities as provided by the college are limiting and may restrict our growth. Seeing how much this instituion supports its CPL and simulation programs shows me what can be possible if the mission of the institution supports the use of innovative teaching and learning methods like simulation.

Evaluation:

The practicum experience was rich for me. Again, being able to connect with like-minded folks on a very personal level is rewarding. I have attended tons of conferences and there are opportunities there to network and connect, but the directed experience of the practicum allowed me to focus on my needs and gain deeper insights.

In dicussion, I found that my pre-brief practice is very similar to what they do at the CPL. I learned more about other aspects of preparation for students, including assignments and the guidelines and sim lab policy.

Analysis:

My overall impression of the experience for me was validating. I confirmed that my practices at BC are consistent with those of an expert simulation faculty. I was able to also gain some ideas for approaching simulation and also share some of my own practices and methods. While our programs are very different in size and resource, students  still gain a great deal  in the simulations we offer. I mentioned to that since I am just a “one woman show” there at BC, we only are able to offer a few simulation experiences for students, to which the sim faculty said something like, “It’s better to do just a couple high quality scenarios than a bunch of poorly done simulations”.

Conclusion:

I feel it was a strong, hands-on, personalized learning experience for me. It’s tricky to explore a faculty role as this class requires, as I am already in one. So being able to step into the world of someone who serves in a dedicated simulation faculty role was nice. I wear many hats at BC and  I realized that if the college could figure out a way to support me as a dedicated simulation faculty, the program would benefit enormously.

Action plan:

I plan to integrate some of the ideas I got from my practicum experience into my program at BC. I learned about some useful evaluation tools which I hope to start using at BC. I plan to continue to advocate for my role as simulation faculty and the need for more support in our sim lab.

 

Gibbs Reflective Cycle

 

Regulation and Requirements in Simulation

Schools of nursing will be forced to bring their programs in line as simulation is defined by standardized best practices and regulatory requirements.

Description of the Issue

The use of simulation in nursing programs has evolved significantly in the last ten years and the research now supports it as a valid substitute for the traditional clinical learning experience (Jeffries, 2015). The National Council of State Boards of Nursing (NCSBN) national, multi-site, longitudinal simulation study 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 or clinical practice (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). These findings led to the NCSBN recommendations for simulation programs, supported by The INACSL Standards of Best Practice: Simulation, and the NLN Vision Statement on Simulation in Nursing Education (Ackermann et al., 2013; Alexander et al., 2014; NLN Board of Governors, 2015). These publications are now being used by many state boards of nursing and other governing bodies as guidelines for best practices in simulation in schools of nursing (Hayden, Smiley, & Gross, 2014).

Clinical sites are difficult to secure and often lack opportunities for students to participate in much more than basic tasks (Ironside, McNelis, & Ebright, 2014). It is a challenge for students to get the rich learning experiences in these settings they require to become safe and competent nurses. 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” (Ironside & McNelis, 2010).  This situation has not improved much and increasingly nursing programs are looking to simulation as a way to provide students clinical experiences (Richardson & Claman, 2014).  The Guidelines established by the NCSBN study have great implications for nursing programs as programs will be required to be compliant with regulations of state boards of nursing and accrediting bodies in order to provide robust, evidence based simulation experiences to replace clinical learning.

Summary of the Literature

The most current data regarding national requirements by state boards of nursing comes from Hayden et al., (2014) in their descriptive survey of the current simulation regulatory environment.  They found that within the United States, 8 states do not allow registered nurse education programs to use simulation to replace clinical hours (Hayden, Smiley, & Gross, 2014). California, Vermont and Virginia specifically allow 25% of the clinical hours to be in simulation (Hayden, Smiley, & Gross, 2014). Florida recently increased its allowance to 50% (Rutherford-Hemming, Lioce, Kardong-Edgren, Jeffries, & Sittner, 2016).  The remaining U.S. states either have no specific amounts allowed or indicated they are planning to establish regulations (Hayden, Smiley, & Gross, 2014; Rutherford-Hemming et al., 2016).

In addition to guidance regarding amount of simulation, there are 14 U.S. Boards of Nursing have formal requirements or advisory statements for the use of simulation in registered nurse education programs. (Hayden, Smiley, & Gross, 2014).  Examples from states such as Virginia, Arizona and Washington provide specific advisory requirements which reflect both the INACSL standards and the NCSBN recommendations  (Arizona State Board of Nursing, 2015; Virginia Board of Nursing, 2013; Washington State Nursing Care Quality Assurance Commission, 2015).  For example, Arizona states, “Programs that use simulation in place of actual patient care need to do so using INACSL Standards” (Arizona State Board of Nursing, 2015). Virginia is less direct but does provide specific required components of simulation and faculty preparation that are similar to the INACSL Standards, such as clear objectives, pre-briefing/orientation and training requirements for the faculty facilitator conducting debriefing  (Ackermann et al., 2013; Virginia Board of Nursing, 2013).  The unpublished draft Washington State Administrative Code regarding simulation circulated via the CNEWS listserv lists criteria that are similar to the NCSBN recommended program and faculty preparation checklists (Alexander et al., 2014; Washington State Nursing Care Quality Assurance Commission, 2015).

Perspectives of the Issue from Education and Practice

The NCSBN guidelines were developed based on the requirements of the NCSBN study sites and, as Suzie Kardon-Egren recently stated, “Very few United States programs have the trained faculty and standardization to provide the same level of simulation used in the study” (Rutherford-Hemming et al., 2016, p. 3).  The challenge is that State Boards of Nursing are not telling programs how to meet the requirements. More states will be adopting similar requirements for simulation and nursing education program will have to carefully evaluate their plans to use simulation.  Reflecting on the NCSBN guidelines, the concern is how will programs and faculty obtain the financial and human resources necessary to meet these requirements.

Implications for nurse education

Going forward, nursing education programs will have to either revise their current simulation practices or develop new ones that meet their state requirements. As Lori Lioce stated, “Implications from the NCSBN study support and require changes in daily operations and structure of health care simulation education programs”(Rutherford-Hemming et al., 2016). This effects a large number of programs, in 2010 87% of schools of nursing used simulation in their programs and that number has been steadily growing (Fey & Jenkins, 2015; Hayden, 2010).  Major areas for programs to address are based on the NCSBN Guidelines and focus on faculty and program preparation (Alexander et al., 2014).

Faculty Preparation

The lack of properly prepared educators is considered a barrier to the expansion of the use of simulation curriculum (McNeill, Parker, Nadeau, Pelayo, & Cook, 2012). Often the training faculty receive is focused on the technology, rather than the methodology and pedagogy of simulation (Waxman & Miller, 2014). Jeffries et al (2013) recommend the creation of a faculty development program that extends beyond a single session of training and includes hands on experiences with simulation along with continued professional development opportunities. Standardized training programs such as the NLN SIRC (http://sirc.nln.org/) are now available in addition to certification as a Certified Healthcare Simulation Educator. These can be used by nursing programs to prepare their faculty and demonstrate their level of expertise (National League for Nursing, 2015; Society for Simulation in Healthcare, 2016).

Once properly trained, faculty need to meet the other requirements of the Guidelines, such as the use of standardized, theory-based debriefing (Fey & Jenkins, 2015). Faculty will also have to work together to develop or revise simulation programs that provide “active learning, repetitive practice, and reflection” and scenarios with clear objectives and outcomes (Alexander et al., 2014, p. 41). Faculty will also develop and implement a plan for evaluation of all aspects of the simulation program, including the effectiveness of the facilitators and the simulation experiences (Alexander et al., 2014).

Program Preparation

Administrators of schools of nursing need to be prepared to provide the resources necessary, including financial, human and material, to support the Guidelines (Alexander et al., 2014). The needs of faculty and the program must be provided by institutional resources, such as funding for training and time for the development of curriculum.

Programs need leadership that understand the need for long range planning that supports the growth of simulation at their institution (Alexander et al., 2014). Nursing programs often have the equipment (simulator) to run simulations, but it was obtained through non-sustained funding like grants and donations. Programs also need sustainable income to support staff salaries, training, and equipment upkeep plus the supplies necessary to simulate a “realistic patient environment” (Alexander et al., 2014).  This is a major issue for many programs. In an international study of simulation centers, dedicated funding and adequate staffing (specifically dedicated simulation technicians) are found to be top strengths and, when lacking, they are seen as barriers to growth (Qayumi et al., 2014).  One strategy is to pool resources through the development of state consortiums and interdisciplinary simulation centers (Jeffries et al., 2013; Lujan et al., 2011; The Forum of State Nursing Workforce Centers, 2012).

Potential research areas

It is necessary to continue to pursue rigorous research of the use of simulation in nursing programs in order to support the resources needed for high quality standardized simulation. Information regarding how schools of nursing respond to their Boards of Nursing simulation requirements, including strategies they are using to meet the requirements, can guide simulation program development. As most published standards require evaluation processes in simulation programs, research that explores how nursing programs evaluate their use of resources, faculty and student performance, and simulation effectiveness can also provide guidance. Research that compares learning in clinical and simulation environments more directly lends support to funding to state mandated requirements for simulation in nursing programs (Leighton, 2015).

Studies need to demonstrate the return on investment of simulation in ways such as improved patient outcomes and safety in order to support the resource demands of simulation (Rutherford-Hemming et al., 2016).  While there is already evidence that faculty preparation influences simulation effectiveness, continued research needs to expand and examine correlations between faculty qualifications and certifications, and the student outcomes, such as NCLEX pass rates and clinical performance in order to support the amount of resources necessary to adequately train faculty(Fey & Jenkins, 2015).

Conclusion

Schools of nursing will be forced to bring their programs in line as simulation is defined by standardized best practices and regulatory requirements. While the NCSBN Guidelines seem very reasonable, a deeper look reveals the challenges that programs will face implementing them. The need for institutions and administration to support faculty as they work to develop simulation programs that meet these requirements is crucial. Sustainable models that include maintained funding, continued professional development and embedded evaluation are no longer optional for schools that plan to use simulation to replace clinical hours. As one participant at the 2015 INACSL Conference NCSBN Study forum stated, “…the option to use simulation today will become a mandate for simulation in the future”, so will the use of best practices in simulation be a mandate for the future of nursing education (Rutherford-Hemming et al., 2016).

 

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