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).

 


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

Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-edgren, S. S., … Tillman, C. (2014). NCSBN Simulation Guidelines for Prelicensure Nursing Programs. Journal of Nursing Regulation, 6(3), 39–42. http://doi.org/10.1016/S2155-8256(15)30783-3

Arizona State Board of Nursing. (2015). Advisory opinion: Education use of simulation in approved RN/LPN programs.

Fey, M. K., & Jenkins, L. S. (2015). Debriefing Practices in Nursing Education Programs: Results from a National Study. Nursing Education Perspectives, 36(6), 361–366. http://doi.org/10.5480/14-1520

Hayden, J. (2010). Use of Simulation in Nursing Education: National Survey Results. Journal of Nursing Regulation, 1(3), 52–57. http://doi.org/10.1016/S2155-8256(15)30335-5

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

Hayden, J., Smiley, R., & Gross, L. (2014). Simulation in Nursing Education: Current Regulations and Practices. Journal of Nursing Regulation, 5(February), 25–30. http://doi.org/10.1016/S2155-8256(15)30084-3

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.

Ironside, P. M., Mcnelis, A. M., & Ebright, P. (2014). Clinical education in nursing : Rethinking learning in practice settings. Nursing Outlook, 62(3), 185–191. http://doi.org/10.1016/j.outlook.2013.12.004

Jeffries, P. R. (2015). Signs of Maturity…Simulations are growing and getting more attention. Nursing Education Perspectives, 36(6), 358–359. http://doi.org/10.1016/S2155-8256(15)30062-4

Jeffries, P. R., Battin, J., Franklin, M., Savage, R., Yowler, H., Sims, C., … Dorsey, L. (2013). Creating a professional development plan for a simulation consortium. Clinical Simulation in Nursing, 9(6), e183–e189. http://doi.org/10.1016/j.ecns.2012.02.003

Leighton, K. (2015). Development of the clinical learning environment comparison survey. Clinical Simulation in Nursing, 11(1), 44–51. http://doi.org/10.1016/j.ecns.2014.11.002

Lujan, J., Stout, R., Meager, G., Ballesteros, P., Cruz, M. S., & Estrada, I. (2011). Partnering to maximize simulation-based learning: Nursing regional interdisciplinary simulation centers. Journal of Professional Nursing, 27(6), 41–45. http://doi.org/10.1016/j.profnurs.2011.07.001

National League for Nursing. (2015). Simulation Innovation Resource Center. Retrieved July 21, 2015, from http://sirc.nln.org/

NLN Board of Governors. (2015). A vision for teaching with simulation. NLN Vision Series, (April).

Qayumi, K., Pachev, G., Zheng, B., Ziv, A., Koval, V., Badiei, S., & Cheng, A. (2014). Status of simulation in health care education: an international survey. Advances in Medical Education and Practice, 5, 457–67. http://doi.org/10.2147/AMEP.S65451

Richardson, K. J., & Claman, F. (2014). High-Fidelity Simulation in Nursing Education : A Change in Clinical Practice. Nursing Education Perspectives, 35(2), 125–128.

Rutherford-Hemming, T., Lioce, L., Kardong-Edgren, S. “Suzie,” Jeffries, P. R., & Sittner, B. (2016). After the National Council of State Boards of Nursing Simulation Study—Recommendations and Next Steps. Clinical Simulation in Nursing, 12(1), 2–7. http://doi.org/http://dx.doi.org/10.1016/j.ecns.2015.10.010

Society for Simulation in Healthcare. (2016). About CHSE. Retrieved January 1, 2016, from http://www.ssih.org/Certification/CHSE

The Forum of State Nursing Workforce Centers. (2012). Use of high-fidelity simulation in nursing education: Four state stories.

Virginia Board of Nursing. (2013). Use of Simulation in Nursing Education.

Washington State Nursing Care Quality Assurance Commission. (2015). Unpublished Draft of WAC 246-840-534.

Topic Proposal

I have to write an educational issues paper for one of my classes this semester at WSU. Here’s my topic proposal:

The National Council of State Boards of Nursing (NCSBN) study, a national, multi-site, longitudinal study of simulation, 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 lead 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 being used by state boards of nursing and other governing bodies as a framework for simulation programs at schools of nursing. As a result simulation is growing to be a complex, potentially regulated method of teaching that will influence nursing students programs across the nation. My proposed topic will be a review of criteria and standards that nursing programs can use to develop robust, evidence based simulation programs that will be compliant with potential regulations and requirements of state boards and accrediting bodies.

In thinking about this topic and my approach to the issue, I think that one thing that really drives the “issue” part of it is the ability for schools of nursing to meet the various criteria that state and national agencies are setting forth. Robust, effective simulation requires extensive preparation, training of personnel, technological support, equipment resources and solid theory based teaching-learning understanding that many community colleges are not equipped to meet. And it’s community colleges that are feeling the squeeze for clinical sites the most.

 

 

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

Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-edgren, S. S., … Tillman, C. (2014). NCSBN Simulation Guidelines for Prelicensure Nursing Programs. Journal of Nursing Regulation, 6(3), 39–42. http://doi.org/10.1016/S2155-8256(15)30783-3

Hayden, J. K., 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

NLN Board of Governors. (2015). A Vision for Teaching with Simulation. NLN Vision Series, (April).

Thoughts on Feedback

Self-reflection is key for the learner in simulation and nursing. As a simulation facilitator, I also must engage reflective practice. 

 

I have started reading Feedback in Higher and Professional Education  edited by David Boud and Elizabeth Molloy. Before I dropped it in the tub (because that’s where all the best reading happens) I had already begun to think about feedback differently.

First of all, when an educator grades and provides “feedback” to an assignment, it is a very one-way process. Optimal feedback is a conversation. In the world of adult learning theory, contructivism and heutagogy, it should be learner centered and directed. Of course learners do not always know what they do not know-that is in many ways, the goal of the educator as guide/mentor/facilitator. So when giving feedback, I think, even on assignments, the educator must first reflect on what the learner needs, not on what the educator thinks they need. Or assumes.

In simulation, debriefing is meant to be a self-reflective  process, driven by the learner. But it can be difficult for those of us used to being the “teacher” in the room to allow the student to elicit the specific feedback he or she feels they need. I struggle with it often. I do try to ensure that by the end of the session, the key learning objectives have been met and any misinformation, or grievous errors clarified. But I will admit I tend to let the minutae go so that students will absorb the feedback they are open to. I am going to try to adapt my technique to be more mindful of that perspective and see how that changes the effectiveness of my debriefing.

 

 

Goals, continuing…

The last post was very focused in response to an assignment requirement, however things happen and life makes you look at the future differently.
I wrote those goals with the assumption that I would continue on in academia. I hope to continue in nursing education in some form or shape. But often my tunnel vision keeps me from seeing all the opportunities out there for me to shape and support the nursing profession, using the skills and talents I have.

My skills and talents include the ability to teach, teach well, I think. To support and mentor others. To embrace innovation and find ways to integrate it into my practice- that’s obvious through my simulation interests and development of informatics curriculum. I think I am a pretty good leader- that is I am very self-reflective (I have been told some times, “too self-reflective!”) and aspire to a servant-leadership approach at my best. I have to take the time to reflect on these and other strengths occasionally and be open to all the different ways I can use these skills and talents.

I will admit I am looking forward to a sunnier climate in the future. But who knows where the future will take me.

I recently updated this site (even more) with some examples of my simulation academic work. Mostly “homework” I feel pretty good about. Enjoy.

 

My goals…5 years

This “blogfolio” was created as a result of an assignment in my faculty role seminar class. One requirement of the assignment is to include scholarly and service goals. So let me talk a little about my 5 year goals.

It’s hard to look at the 5 year plan of your life when you are buried deep in the work of getting through PhD course work, plus working a full time teaching gig and serving in a leadership position at the college.  But I do have some ideas about where I want to see myself in those areas.

As far as my scholarly goals, I intend to be finished with my PhD and its research by 2018. I am still not sure what my research will look like, but there are 3 things I want to look at- to survey programs around the country to see what their practices are regarding pre-briefing, development of a framework and pilot testing it. Once I finish my PhD,  I anticipate a transition into a different teaching setting. I may have to then develop more concrete research goals depending on the type of institution I wind up at. I hope to continue my trajectory in simulation research, nursing education research and be part of the establishment of standards and best practice in regards to pre-briefing.

My lifelong dream is to write to disseminate and bring research to nursing education practice.  Before I ever thought of becoming a nurse, I was an English major. I loved to write and realized at one point, I could write in any profession. As a result, I hope to see myself published in ways that are not just research based journals, but in ways like this blog and perhaps even in a column in a journal. I hope to have opportunities to present material at conferences as I go along in my pathway.

My service goals include increased presence in organizations that support nursing education, simulation and technology in nursing education. Once my life becomes more manageable, I would like to pursue leadership positions in these organizations. I would like to continue to be involved in textbook review and eventually be involved in writing some chapters.

My life 5 year plan includes personal goals, too. I hope to see myself relocated to a new location- with more sunshine and closer to the ocean. I would also like spend the year after my PhD is finished to train to climb Mt Rainier. Well, to Camp Muir. With a guide.  Another personal goal is to hike the Pacific Crest Trail with my husband.

Preparing a 3 hour lecture for undergraduate students.

Many of my blog posts are just class assignments I felt pretty good about and want to share. This one is a discussion board response to the prompts in italics for my faculty role seminar class.

What suggestions do you have for effective lecture preparation (you can share your own experience if you want):

My first response would be “Don’t do it!” Lecturing is a very effective delivery method of content and some research shows students benefit from the lecture approach with higher achievement test scores in some settings (Schwerdt & Wuppermann, 2011). On the other hand, most proponents of adult learning theory will tell you that lecture in the “sage on the stage” model, is not as effective with the adult learner, especially if delivered in a 3 hour block as this discussion prompt requests (Lowe, 2011).  The adult learner is able to “pay attention” in about 20 minute blocks which presents challenges when, as we in nursing often have to do, there is a large amount of information that must be presented- as in this case, within 3 hours (Lowe, 2011).

So what is the solution and the advice to the novice educator? Continue reading “Preparing a 3 hour lecture for undergraduate students.”