EVIDENCE-BASED PRACTICE: CURRENT RESEARCH OF SIMULATION-BASED EDUCATIONJCCC SIMULATION CONFERENCESEPTEMBER 17, 2010

Pamela R. Jeffries DNS, RN, FAAN, ANEFJohns Hopkins University School of Nursing

Objectives: The participant will be able to:

State challenges concerning current clinical education

Offer resolution utilizing simulation methodology implementation

Current state of Clinical Nursing Education

Errors correlated to new graduates inability to make clinical decisions (Smith & Crawford, 2002)

New graduates do not meet their expectation for clinical judgment as identified by employment in clinical agencies (De Bueno, 2005)

Accreditation agencies challenge educators to promote critical thinking (Long, 2004; NLN, 2003)

Current State -continued

Teaching practices need to be evidence-based- educational research needed(NLN, 2005; IOM, 2001)

Critical thinking and reflective skills of the practitioner are correlated with the quality of patient care

(Conway, 1998; Paget, 2001)

Simulations Have Arrived…Where are we?

Simulations in Medicine

Simulations in Nursing

Next steps…..

Medical Research Integrative review by Issenberg et al., 2005:

Providing feedback (47%) Repetitive practice (39%) Curriculum integration (25%) Range of task difficulty level (14%) Multiple learning strategies (10%) Capture clinical variation (10%) Controlled environment (9%) Individualized learning (9%) Defined outcomes (6%) Simulator validity for learning (3%)

Medical Research

N=109 research articles Quality is weak. Based on research literature, can make

statement that the use of high-fidelity patient simulation does “facilitate learning under the right conditions” (Issenberg et al., 2005, p. 10).

Nursing Research - HFPS (n=26)(Nehring, 2008)

Since 2001, 26 nursing research studies related to high-fidelity patient simulation have been conducted.

These studies have been conducted in the US (n=19), the UK (n=3), Sweden (n=1), Canada (n=1), China (n=1), and internationally (n=1).

Nehring, W. (2008) U.S. Boards of Nursing and the Use of High Fidelity Patient Simulators in Nursing Education, Journal of Professional Nursing,

24(2), 109-117.

Nursing Research

Methods have included pretest-posttest (n=9), surveys (n=7), post-test only (n=4), focus group (n=2), observational and focus group (n=1), theory-driven description-observation-revision-review method (n=1), case study (n=1), and correlational (n=1).

22 studies dealt with nursing education and 4 studies with team management.

Nursing Research

Emphasis has been placed on: Competence (eg., clinical skills, basic

knowledge) (n=7) Confidence Satisfaction Use of simulation as educational adjunct

(n=9) Self-directed learning versus instructor-

modeled learning Development of rubric for clinical judgment Simulation as substitution for clinical (n=2) Collaboration and teamwork (n=4)

NLN Study (multi-site 2003-2006)

In this study, several areas were explored, however the major contributions to the science of nursing education in the area of simulations include:

The theoretically-based Simulation Framework (Jeffries, Rizzolo, 2004)

The Development of two instruments: The Simulation Design Scale and the EPSS

Identification of 5 key design features to include in the development of simulations

DESIGN DESIGN CHARACTERISTICS CHARACTERISTICS and SIMULATION and SIMULATION (intervention)(intervention) Objectives

Fidelity

Problem-solving

Student Support

Reflection

OUTCOMESOUTCOMES• Learning (Knowledge)• Skill performance• Learner satisfaction• Critical-thinking• Self-confidence

Simulation FrameworkSimulation Framework

Demographics

Active learning Feedback Student/ faculty interaction

Collaboration High expectations Diverse learning Time on task

Program

Level

Age

Jeffries & Rizzolo, 2004

Best Practices in Simulation

Simulation Design Features – Model Objectives/focus of the simulations *Developing and maintaining realism Problem-solving components Learner Support *Debriefing/Guided Reflection

Objectives/information

Learning objectives for the clinical scenario help to: Link the experience to the curriculum Guide the facilitation of the

debriefing/experience Provide structure to evaluate the simulation

experience (Dreifuerst, 2009)

Objectives need to be very specific when planning a simulation (Medley, 2005).

Objectives cont.

Raemer (2003) recommends the use of both technical and non-technical objectives.

Examples of technical objectives are the development of psychomotor skills and increased knowledge.

Non-technical objectives include self confidence, satisfaction and critical thinking.

Realism

Realism: Developing a simulation that can replicate a clinical experience – represents the reality without the constraints of a real-life clinical situation

Purpose of Realism:

Realism has the potential to bridge the gap between classroom and clinical (Durham & Sherwood, 2008, Alfes, C. (2008).

May facilitate the transfer of nursing skills to the clinical setting (Bradley, 2006)

Realism/Fidelity

Common Findings in Simulations with students and translating simulation experience and knowledge into the clinical practice:

1. Students do not translate “pretend” over into the clinical setting very well…educators need to be authentic in setting up the simulations

2. Until students are immersed to perform an intervention, they do not know what “they don’t know” (e.g. standing orders)

3. Even when students watch other students perform the simulation, it still “feels” different once they are immersed and having to make decisions.

Realism - continued

Students have unrealistic expectations many times on what support, assistance and what they will and will not be doing when they begin functioning as a professional nurse. In simulations educators need to prepare students for the real world, complex clinical environment

Realism continued

Areas where we have found gaps in students expectations: Care of more than one patient Using standing orders, protocols Being expected to “think on your feet.” Communicating appropriately with families

and patient Belief that when a new drug is given on the

unit post graduation, a manager will always be there to help

Fidelity/Realism: Making your Simulation Top-Notch

Provide Realism

Dimensions of Realism (Beubien and Baker 2004):

Environmental Equipment Psychological

3 ways to think about reality (Rudolph, Simon, and Raemer (2007):

Physical Conceptual Emotional

Simulation as a Social Experience Lauken (2003) an Goffman (1974) state there are 3 ways to

think about reality: Physical Semantical (theories, meaning of information) Phenomenal (emotions, beliefs, and self-awareness)

Belief that an interaction between content and the way content is experienced needs to occur – believe that cognitive science has to exist with in a social environment

Simulation provides the experience of the phenomena of reality because it can describe different elements of the experience.

(Elfrink, Nininger, Rohig, & Lee, 2009)

Framing: (Goffman, 1974)

Concept of framing to support the notion of simulation as a social practice

Framing – cognitive structure that guides perception and provides representation of reality Two types of Framing:

Primary Framing: Helps to focus an individual on how to make sense of the simulation

Modulations: The account for individual’s orientation with the world (the shared responsibility of making simulations work)

“Modulations have to be addressed to prevent negative learning.”

Considerations to reproduce reality: Incorporate as many realistic

environmental aspects as possible Be process-based, like clinical

experiences are in reality Establish validity of the scenarios Include clinical realism Make students feel like they are

immersed in the environment

Strategies to incorporate realism Equipment Real-life patients, interaction Introductory video Personal effects – realistic environment Physiological effects In-situ simulation Unfolding case simulations

Equipment

Real equipment that replicates what is used in the clinical environment is important, e.g. IV pumps, NG tubes, medications, IV pushes, etc.

Simulators are more real-life, need to be sure the interaction replicates reality

Real Life- Patients, Interactions Teacher as the

Patient Interacts with

students in real-time

Masks-up; so real life, students don’t focus on the instructor as the patient

Watch Cyril Smith Video

Instructor as standardized patient

Introductory Video

A 5-minute videotape that visually sets the stage for the clinical simulation experience (5 minute video film – participants portraying patient and family members)

(Alfes, C., 2008) Students state the introductory video helps to

bring life to SimMan in the actual clinical simulation

Students also believed the video game them the chance to form a “plan of action and think through the nursing interventions before the simulation began

Faculty believe the video helps to visually introduce students to a pertinent clinical situation and realistic patient assignment

Personal Effects and Touches Students wear uniforms and use clinical forms

and resources, similar to agency-based clinical experiences

The clinical setting replicates reality, e.g. Care of patient in hospice, e.g. personal effects,

quilt, family photos, soft music playing at bedside, etc.

Interruptions during the care of patients, like reality Moulage (materials used to develop bruising, fruity-

breath, etc.) Sounds, noises, smells are all part of the simulated

environment

Physiological Effects

A sense of emergency can be created if the student hears an emergency report, a deteriorating, lethal patient situation

Have students to run to the event; have report provided away from the event so students adrenalin will increase like in an emergency situation

Emotions can be triggered easily if the event appears realistic, e.g. pain in pain, family member distressed, saddened, etc.

In-Situ Simulations

In-situ simulations: Simulations occurring in a real-life work setting

Examples: in BLS in a neonatal unit; emergency situation occurring in an ED

Kneebone, et al, (2005) recreated real world pressure by conducting simulated scenarios within an authentic clinical space

In situ-simulations reproduce the condition of real practice

Unfolding Simulations/Cases Cases unfold at different times, in the same

course, across the course, or across a nursing program

This type of case realistically simulates the real life patient interaction because learners experience the uncertainty and unpredictability of an actual, evolving clinical case (Karini, et., al., 2004).

Examples: Patient admitted to E.D. – sepsis Patient on the unit – hypotensive Patient tranfered to ICU Patient discharge

Unfolding Cases – Teaching students differently

Learner Support

The teacher is viewed as a facilitator of learning who structures learning experiences to allow students to construct knowledge for themselves, in contrast to a lecture driven, content delivery mode of instruction.

Scaffolding supports the student initially, and the support is gradually withdrawn as the student actively constructs understanding in a way that makes meaning for them (Sudzina, 1997).

Learner Support

Five strategies can be used to assist student performance: modeling Feedback Instructing Questioning cognitive structuring.

Learner Support

Learning activities reflecting the complexity of real-world problems allow students to make meaning and develop a deeper understanding of realistic situations

The real-world learning activities facilitate the individual student performance.

Problem-solving components Knowledge is actively constructed rather

than transmitted to the learner. Von Glaserfeld (1996) describes two

basic aspects of the constructivist model: Learning is a constructive activity that the

students themselves must carry out The task of the educator is not to dispense

knowledge but to provide students with opportunities and incentives to build it up.

Problem-Solving

Opportunities should be created for students to determine, challenge, change, or add to existing beliefs and understandings through engagement in tasks that are structured to increase knowledge, skills, and problem solving

Debriefing/Guided ReflectionDefinition: The process whereby faculty

and students reexamine the clinical encounter, fosters the development of clinical reasoning and judgment skills through reflective learning processes

Debriefing is an essential element of simulation, however, practices vary greatly!

Debriefing continued

Debriefing provides opportunities to foster reflective learning, encompassing the ability to think-in-action as well as think-on-action (Schon, 1983)

Debriefing offers a way to draw out student thinking and help students develop their complex decision-making skills (Decker, 2007)

Debriefing/Guided Reflection continued

The importance of using reflective learning/guided reflection to teach students to apply what they have learned from one situation to the next in the context of critical thinking and decision making is well documented (Benner, et al, 1996, Chalykoff, 1993; Davies, 1995; Facione & Facione, 1996; Ironside, 29003; Tanner, 2006)

The impact of different debriefing priorities on students’ clinical reasoning skills remains unclear and challenging (Gaba, & Howard, 2006)

Summary

More research in the development, implementation, and evaluation of learning outcomes continues to be needed

Create your own educational research studies to contribute to the science of education in using simulation pedagogy

Standards and competencies in this area are needed as educators continue to incorporate more simulations into the nursing curricula

Summary

Simulation holds the promise to change faculty assumptions about how students learn and think and to become an essential teaching/assessment evaluation strategy in education of nurses.

Effective teaching in clinical simulations has a powerful impact on student experiences and outcomes of a simulation exercise (Nehring, et al. 2002; Henneman & Cunningham, 2005; Bremner, Aduddell, Bennett & VanGeest, 2006).

Questions: pjeffri2@son.jhmi.edu