Healthcare Simulation Week 2020! Reflections of a simulationist.

When I discovered simulation, I was first intrigued by the technology, l’ll admit. And the overall coolness of it… but it led me on a path that transformed what teaching means to me… and to the learner.

I went into teaching at first… I thought… because I like to hear myself talk. OK, not exactly but, you know, I wanted to share all my knowledge. Translate information, facts and the skills of being a nurse through me and to students. I envisioned myself as the wise, honored teacher. The Sage on the Stage… those were the teachers I learned from in my life, those I respected and emulated.

But then, I discovered simulation.  I was first intrigued by the technology, l’ll admit. And the overall coolness of it… but it led me on a path that transformed what teaching means to me… and to the learner.

My first simulation experience was as an observer… I actually- literally stumbled onto it… I was at the training center for Madigan Army Medical Center (now known as the Charles A. Andersen Simulation Center) earning my ACLS instructor certification. I was working as a floor nurse at MAMC at the time, and just beginning to nurture the teacher within.

My first exposure to simulation- I stumbled into a room with this going on!

While I was in class, I was distracted by loud noises from another room… shouting, moaning,  explosions. I slipped out of my classroom and wandered the halls until I found the source of the commotion. A dimly lit room, camo nets hanging from the ceiling, darkness punctuated by strobe light flashes, the sound of mortar explosions and someone groaning in pain. I look down to see a man on the ground, covered in blood, the source of the groans. It took a minute for me to realize he wasn’t real… that I’d stumbled into a well crafted battle injury scenario training space.

I thought to myself, “wow! What a way to learn”… to be immersed in the reality of a situation (to learn later that’s fidelity) in a place where mistakes and  learning have no risk and cause no harm (to learn later that’s psychological safety) with the opportunity to reflect on actions taken and how to improve (to learn later that’s debriefing).  I was hooked!

I went back to my ACLS class and inadvertently created and ran my very first sim scenario. I had to teach the asystole algorithm.  So I created a scenario with a witnessed asystole patient, who the learners go on to discover was DNR after they initiated resuscitation… it was fun to see the progression of the scenario (I got to use a Sim Man too!). And have a meaningful discussion about the challenges of this algorithm and the ethics of resuscitation. 

Fast forward many years from that day. I’ve run hundreds of simulations, in a variety of fidelity levels, in all sorts of settings, with the complete gamut of technologies and I have taught hundreds of nurses and health care providers.

And I no longer want to be that Sage on the Stage. I will admit, I am finding myself doing a lot of webinars and other types of presentations still have me up there, speaking and sharing ideas. But still, my goal is to awaken knowledge in others, not pour my vast amount of wisdom unto their heads. As a simulationist, I guide learners through experiences that allow them to determine their own learning. There’s a whole host of learning theories and teaching methods this approach supports from constructivism to heutogogy. But what reinforces it to me is seeing the results. Seeing learners gain insight and awareness during a robust and learner-focused debriefing.  I have come to realize my skill as a sim facilitator and debriefer is critical to guiding them to creation of knowledge and hitting those crucial levels in learning taxonomy through experiential learning.

Bloom’s Taxonomy AND Vygotsky’s Zone of Proximal Development to explain the importance of preparation for simulation. How nerdy is that?!

I now am privileged to be in a leadership position and supporting a program that provides simulation experiences to learners. I am also training up the next generation of simulationists. Simulation is still fun to me, though. I love creating real life scenarios,  making the environment realistic, helping learners suspend disbelief and seeing them get caught up in the excitement of a challenging patient care situation, a communication challenge, a team based intervention or disaster scenario.  When I see the wheels turning in their heads, the self-reflection turned on and,  in that psychologically safe environment, the ability to learn from doing things right AND making mistakes, I am inspired by them!

Me, presenting a webinar about how we are bringing students back to the Simulation Center during the pandemic.

I became a nurse, like many have before me, to “help” others. That extended to my teaching, to “teach” others. I have learned, though, we help others the best by not doing for them or “to” them… but doing with them. The path to healing belongs to the patient and the path to learning, to the learner. As a nurse I have had the honor to walk alongside folks on their path to wellness,  and now, as a teacher,  I am privileged to guide learners through immersion experiences from which they emerge as safe, competent healthcare providers.

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.