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Chapter 29

Simulation in Healthcare Education

Introduction to Simulation

What is simulation?

A pedagogy using one or more typologies to promote, improve, and/or validate a participant’s progression from novice to expert. (pg S6)

Simulated Clinical Experience: Includes prebriefing, the clinical scenario, and debriefing. It is the engagement part of a clinical scenario. (pg S6)

Clinical Scenario: Is the plan of an expected and potential course of events for a simulated clinical experience. It provides the context for a simulation and can vary in length and complexity, depending on the objectives. (pg S5)

Time honored; used in health sciences education for decades

“One or more typologies to promote, improve, and/or validate a participant’s progression from novice to expert

Aligns with experiential learning theory (necessary to apply knowledge in the classroom)

Designing the clinical scenario should include: participant preparation; prebriefing, patient information describing the situation; student learning objectives; environmental conditions; related equipment and props and resources to increase the realism of the experience; roles, expectations, and/or limitations of each role for the participants; debriefing process; a progression outlined including a beginning and an ending; a debriefing process; and evaluation criteria.

Types of Simulations

Case studies

Computer models (second life)

Standardized patients

Part-task trainers

Medium-to-high fidelity patient simulators

Written case studies used for year

Second Life is a virtual learning environment.

Standardized patients involves using live actors to play the role of the patient. This is very realistic, but we cannot practice invasive psychomotor skills on these actors.

Part Task Trainers represent anatomical parts of the human body and are utilized for skill acquisition.

Full-body mannequins are labeled as either medium- or high-fidelity mannequins. Learners practice their skills; mannequins can be programmed to respond as a human would. They have blinking eyes, rising chests, heart sounds, lung sounds, etc.

Fidelity

Level of realism

Variety of dimensions

Physical factors (e.g., environment, equipment)

Psychological factors (e.g., emotions, beliefs)

Social factors (e.g., motivation, goals)

Culture of the group

Degree of openness and trust; “modes of thinking”

Fidelity describes the level of realism.

Humans (standardized patients) are very realistic, but also involve cost for scheduling and training, and there is risk when performing procedures on live actors.

Ways to create fidelity: add physical factors, psychological factors, social factors, or cultural aspects.

Benefits

Practice in a safe environment

Simulation can enhance

Knowledge

Competence

Self-efficacy

Confidence

Deliberate practice

Mastery learning

Standardized educational experiences

Much evidence to support that simulation can enhance knowledge, competency, self-efficacy, and confidence.

Allows learners to practice in safe environment without harm to patients.

Allows opportunities for deliberate practice: practicing a skill again and again until it is perfected.

Creates standardized learning experiences so that all learners can be exposed to a low-occurrence but high-risk situation.

Simulation Program Evaluation

Kirkpatrick’s Model

Level 1: Reaction

Level 2: Learning

Level 3: Behavior

Level 4: Organizational impact

Kirkpatrick identified four levels of outcomes that can be measured with respect to training programs.

Level 1: reaction “Was the learner satisfied with the simulation experience?”

Level 2: Learning: “Did the learner score higher on cognitive tests after the simulation experience?”

Level 3: Behavior: “Did the learner perform better on the clinical unit after the simulation experience?”

Level 4: Organizational Impact: “Was there improvement in patient outcomes after the simulation experience?”

Challenges and Opportunities

Cost

Technology

Faculty development

Faculty or administrative buy-in

Cost ranges from $45,000 – $125,000 for high-fidelity mannequins.

Standardized patients need to be reimbursed for their time.

Costs related to AV equipment, moulage supplies, staff for simulation lab.

Technology is complex and can be difficult to operate.

Change Efforts Applied to Simulation

Kotter’s eight steps (Figure 29-4)

Create a sense of urgency.

Develop a guiding coalition.

Develop the vision.

Communicate the vision.

Empower stakeholders to act on the vision.

Create short-term wins.

Consolidate improvements.

Institutionalize new approaches.

Essentially, simulation is a CHANGE in the way that we are teaching. By trying to implement simulation within a currently established curriculum or educational program, we are try to make a ’change movement.’

John Kotter’s 8 Steps to Leading Change can be used as a framework to help simulation educators and facilitators implement this new teaching methodology within their current curriculum or educational programs.

Use Figure 29-4 as a guide – this figure gives specific tips to help simulation educators/facilitators.

Experiential Learning Theory

Knowles Adult Learning Theory

Adult learners are self-directed, learn from experience, are problem-centered, and need rationalization for learning.

Kolb’s Theory

Is the ability to transfer knowledge from theory into practice.

Waldner and Olson applied Benner’s stages of learning with the experiential learning with simulation.

Consider the appropriate terms andragogy versus pedagogy.

Andragogy: self-directed, past experiences build on present situations, application of knowledge is connected with the application and is problem centered, readiness to learn and need to know the rationale

Pedagogy: the science or profession of teaching

Which is more applicable to nursing and you personally?

Situated Cognition

Is applied to the use of simulation.

For students to envision themselves successfully integrating into a new role, practicing the role in a realistic environment will assist with role identification, mental visualization for performing in the role, and bridging the gap from didactic to practice.

Participating and acting in a specific simulation case can lead to generalization of the information to apply to new situations.

Situated Cognition applies to learning domains: Ask participants to provide examples.

Psychomotor: focuses on the precision of performing a skill or assessment.

Cognitive: application with thinking (perform, identify, maintain, communication, prioritize, and provide).

Affective: emotion of reflective thinking by responding to and prioritizing patient care.

Lasater Interactive Model of Clinical Judgment Development

Four areas of clinical judgment are:

Noticing

Interpreting

Responding

Reflecting

How does this apply to simulation?

Noticing 2. interpreting 3. responding 4. reflecting.

Application to simulation: noticing and assessing the patient, interpreting the findings and developing a plan of care and interventions, and reflecting during the debriefing process.

National League for Nursing Jeffries Simulation Framework

Conceptual framework

Developed to design, implement, and evaluate simulation experiences

Triadic relationship of students, faculty, and educational practices

Five possible outcomes: Increased knowledge, skill performance, learner satisfaction, critical thinking abilities, and self-confidence of participants

Triadic relationship of teacher, student, and educational practices:

Student: Knowing the participants--Standard 3

Teacher: Being a competent facilitator--Standard 5

Educational Practices: Active, experiential learning practices (andragogy)

Gaba’s Eleven Dimensions of Simulation

Purpose and aim

Participants

Number

Disciplines involved

Interprofessional teamwork

Experience level

Roles

Objectives for knowledge, skills, and behaviors

Chronological and developmental age of the patient

Technology required

Environment or site of simulation

Active participation of simulation

Feedback method

As we discuss in the next section with Standards of Best Practice: Simulation, are these models/frameworks and the Standards of Best Practice: Simulation congruent?

Standards of Best Practice: Simulation

Development process

First seven standards

Terminology

Professional integrity

Participants’ objectives

Facilitation methods

Facilitator

Debriefing process

Evaluation of outcomes

Development Process: International Nursing Association for Clinical Simulation and Learning (INACSL) Board of Directors 2009-2011 developed the Standards at the request of the membership and needs analysis. After initial drafts the Standards were reviewed by an invited content specialist, then sent to the membership. Currently the Standards committee is working on updating the standards and developing guidelines.

Click on the link and discuss each standard

Simulation Phases

Preparation phase

Familiarize students with situation, assessments, and expectations.

Simulation phase

Focus on objectives; is based on experience level

Facilitation

Which type (instructor, student, a combination)?

Debriefing and feedback

Reflect and clarify actions and concepts

Evaluation

Cognitive, psychomotor, and affective domain

When you are designing a simulation scenario, these are the major phases to focus on.

Application of Simulation to Education

Much evidence is in undergraduate education.

Increased knowledge, confidence

Increased competence, self-efficacy

Improved patient outcomes

Less evidence is in graduate education.

Look to research findings of other healthcare disciplines.

It is important to look outside of graduate nursing education for research related to simulation, particularly outcomes. Simulation has been used in other healthcare specialties for many years—anesthesia has been using simulation for over 20 years! Research in other areas can easily be extrapolated to graduate healthcare education.

Journal editors will no longer publish articles only about student satisfaction with high-fidelity simulation as that is a prevalent response. However, there continues to be a need to determine if learning is transferred to practice.

Interprofessional Education and Simulation

Identified need for interprofessional education (IPE)

Interprofessional Educational Collaborative (IPEC) developed core competencies

Collaboration among multiple associations

Core competencies for interprofessional collaborative practice

The Interprofessional Educational Collaborative (IPEC) composed of:

American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools of Public Health.

Table 27.5 outlines each competency, its focus, application for simulation, and opportunities for IPE.

Charges of the Institute of Medicine

Institute of Medicine (IOM)

Incorporates evidence-based practices into patient care.

Offers translational research.

Offers more interprofessional educational opportunities.

Needs to continue to develop these opportunities.

IOM reports have been widely read, quoted, and studied since their releases in the early 2000s. The reports documented the extent of medical error in the US and outlined some methods to use to prevent the errors.

Most errors are preventable.

Changing educational design could lead to improved patient care.

IPE—2010 survey, only about half of the respondents provided any IPE. Of the programs providing IPE experiences, only a few institutions stated this practice was utilized more than occasionally in the simulation The logistics of scheduling multiple disciplines for simulation is one of the major obstacles for IPE experience. For graduate school students, IPE simulations are an excellent way to learn how to function and adapt practices to achieve the best outcomes.

New Educational Strategies

Situation-Background-Assessment-Recommendation (SBAR) Communication Tool

Simulation scenarios

Informatics

1) SBAR—use of a common communication tool between nurses and physicians

2) Simulation Scenarios—

Practice skills/techniques

Assessment

Therapeutic communication

Interprofessional collaboration

Reflection on actions and inactions

Incorporation of evidence

3) Informatics--point of care access of information by handheld devices or computers, the electronic medical record, and electronic health record. If the interprofessional members of the health care team have access to all of the information about a patient, this could assist in delivery of health care for more holistic treatment, potentially decreasing harm to the patient.

Future Directions

Improved technology

Gaming

Importance of standards with any modality

Simulation educators need to continue to work with vendors to increase the fidelity and usability of various forms of simulation.

Gaming is an emerging method of learning through the use of gaming through computers or in the virtual environment.

Standards of best practice will continue to be studied, tested, and revised. Guidelines will be developed to help faculty more easily put the Standards to use.

Chapter 29

Simulation in Healthcare Education