best practices in simulation education
TRANSCRIPT
Best Practices in Best Practices in Best Practices in Best Practices in Simulation EducationSimulation Education
Sharon Decker, RN, Ph.D., CCRN, ACNS-BC, ANEFProfessor and Director of Clinical SimulationsProfessor and Director of Clinical SimulationsCovenant Health System Endowed Chair in
Simulation and Nursing EducationProject Director: F. Marie Hall SimLife CenterT T h U i it H lth S i C tTexas Tech University Health Sciences Center
ObjectivesObjectivesjj
• Identify best practices in providing Identify best practices in providing effective simulation education.
• Review models and constructs guiding course developmentp
• No disclosuresNo disclosures
Adult Learning PrinciplesAdult Learning Principlesg pg p• Diverse Learning Styles
• Visual (realism, fidelity of the environment)
Auditory (verbal responses)• Auditory (verbal responses)
• Tactile (demonstrate)• Tactile (demonstrate)
• Kinesthetic (handling equipment)( g q p )
Adult Learning PrinciplesAdult Learning Principlesg pg p• Constructivism
Learning = process of constructing meaning
Educator functions as a collaborative facilitatorI l d i ti l l i Includes experiential learning
Active engagementActive engagementReflective thought
Philosophic FrameworkPhilosophic FrameworkPhilosophic FrameworkPhilosophic Framework
• Kolb (1984)o b ( 98 )•Learning enhanced through a synergistic transaction between l d h ilearner and the environment
• Bandura (1977)•Learning enhanced – self-confidence promoted with active learning
Philosophic FrameworkPhilosophic FrameworkPhilosophic FrameworkPhilosophic Framework• Dewey (1910, 1916)
•Learning is dependent upon •Learning is dependent upon integration of experience with reflection and of theory with ypractice
• SchÖn (1987)•Learning promoted through the use of a “reflective practicum”of a reflective practicum –learning environment realistic in which faculty act as coachy
Simulation as an Simulation as an Educational StrategyEducational StrategyEducational StrategyEducational Strategy
• Requires faculty to:
- develop new t i competencies
b k k- be risk takers
Best PracticesBest Practices• Outcomes dependent on
Planning
• Structure/design • Questioning / cueing
C iti• Critique• Evidence Based• Practice• Practice
Hawkins, Todd, & Manz, 2008Jeffries & Rizzalo 2007Jeffries & Rizzalo, 2007
Best PracticesBest PracticesAppropriate personnel
Developing the case scenarioC itiq ing the case scena io Critiquing the case scenario Preparing the roomManaging the simulatorManaging the simulatorCritiquing the learnersConducting debriefing / guided reflectionConducting debriefing / guided reflectionModifying the case scenario
Best PracticesBest PracticesFaculty Buy-In• Faculty development
• Orientation to simulation/simulators
• Active participation- Planning scenarios- Observation of student performance
Best PracticesBest PracticesLearners Buy-In
• Orientation
• Repeated experiences
• Introduce early in the curriculumy
Best practicesBest practicesppComponents of simulation promoting l ilearning
• Feedback• Repetitive practice• Curriculum integration• Effective use of difficulty• Multiple learning strategies
Best PracticesBest PracticesIntegration through-out the Curricula
• Develop a curriculum mapIdentif lea ning o tcomes to be • Identify learning outcomes to be facilitated by simulation
• Determine placement within curriculum• Determine placement within curriculum• Match with theoretical content• Conduct and gather outcomesConduct and gather outcomes• Modify
Concepts/Included in all Concepts/Included in all iiscenariosscenarios
Concept Melnyk, 2008
Hodge, et al, 2008
Decker, et al., 20072008 2008 2007
Patient Safety √ √
Communication √ √ √
Resource Management √
Situation Awareness/Prioritization √ √
Therapeutic Interventions √ √
Assessment √ √
Critical thinking √ √
Others?Others?
Models and ConstructsModels and Constructs• Framework for single session
- 90 minutes • Rapid sequence of 3 related simulations • Intermixed with two focused teaching sessions • Concluded with 15 min Reflective Session
- 94% felt exercise should be routine part of curriculum
McMahon Monaghan Falchuk Gordon & Alexander 2005McMahon, Monaghan, Falchuk, Gordon, & Alexander, 2005
Models and ConstructsModels and Constructs• Framework for clinical day (TTUHSC)
- 3 Scenarios• Concept Mapping or Cause & Effect Diagramming
20 i t bl k- 20 minutes blocks• Concept map – Cause & Effect
DiagrammingDiagramming• Simulated scenario• Concept map – integrationp p g• Debriefing (Alpha and Delta)
Student CommentsStudent Comments
• “… educational and made me critically think”
• “The scenarios really opened my eyes…”
• “I enjoyed doing our concept maps j y g p ptogether…because I’m a visual learning and seeing the pathophysiology and how it correlates with the signs and symptoms helps me understand the disease process…”p
“Cause and Effect”Root Impression Outcome Treatment
MI diti Raised HOBDecreased AnxietyMI-, myocarditis, cardiomyopathies-decreased contractility
Renal failure,
Confusion, fatigue
Cyanosis
Pulmonary vascular congestion
O2 @ 3L/NC
Increased O2 satsDecreased anxietyDecreased confusionD d i
y
Decreassed Confusion
Increased O2 sat
Decreased cyanosis
,excess IV fluids, mitral valvular disease-increased preload and decreased contractility
g
Dyspnea
Cough
Frothy sputum
Rales
Decreased cyanosis
Digoxin
Increased contractilityd di
Increased contractility
Increased cardiac output
Decreased HR
d i
Increased peripheral resistance-increased afterload
S3 gallop
Decreased cardiac output
cardiomegaly
Increased cardiac outputDecreased HRDecreased edemaIncreased urine
Lasix
Increased urine production
Decreased reabsorption of water
Increased urine outputafterload
Decreased urine output
Edema
Lasix
Decreased reabsorption of waterLoss of K+Increased urine outputDecreased edema
Decreased Edema
Decreased edema
Simulation ModelSimulation Model(Modified for TTUHSC)(Modified for TTUHSC)(Modified for TTUHSC)(Modified for TTUHSC)
Reflective thinking
Jefferies (2007)
Questioning
Guided Reflection
Jefferies (2007)
Decker (2007)
Correlation of Correlation of Critical and Reflective ThinkingCritical and Reflective ThinkingCritical and Reflective ThinkingCritical and Reflective Thinking
Stages of Reflective ThinkingCritical Reflectors
Assimilated experiential knowledgep g“I felt from past simulations we need to work together. That is how I approach other simulations and clinical situations now.”
Verbalized a positive mind-set“I think we could have done better…we should have really looked at the vital signs…”have really looked at the vital signs…
ReflectorsSome integration of experiential knowledge
“I think we’ve kind of had to somewhat prioritize ourI think we ve kind of had to somewhat prioritize our actions…”
Verbalized an improved mind-set“I don’t feel like I’m totally there yet ”I don t feel like I m totally there yet.
Non-ReflectorsDemonstrated no evidence of reflection
Verbalized a negative mind setVerbalized a negative mind-set“I felt like I was trying but felt even though I thought I was making the right decisions it never seemed to work ”
Debriefing ModelsDebriefing Modelsgg
• Plus - DeltaPlus Delta
Plus – Delta –
Behaviors to improve on
Include both what and
Examples of good behaviors
Include both what and how
Structured and Supported ModelModel
• Gather• Gather the data• Ask probing questions
• Analyze
• Summarize
Debriefing ModelsDebriefing Modelsgg
• Advocacy Inquiry• Advocacy – Inquiry• “I noticed ….”
• “I’m concerned…”
• “I was wondering…”
Gibbs (1988)
DescriptionWhat happened?
Action PlanIf it arose
would you do?
G bbs ( 988)Reflective Cycle
Conclusionwhat else could you
FeelingsWhat were yourcould you
have done?
ythinking & feeling?
EvaluationAnalysis EvaluationWhat was good &
bad aboutthe experience?
AnalysisWhat sense can
you make ofthe situation?
Driscoll, 2000The WHAT Model Of Reflection
Experience
WHAT?Describe the event
p
Purposeful reflection
New learningSO WHAT?
Analysis the event
New learning
Discover what learning emerges from the
reflection
NOW WHAT?Proposed action
reflection
Johns, 1995, 1996Johns, 1995, 1996(Based on Carper’s Ways of Knowing)(Based on Carper’s Ways of Knowing)(Based on Carper s Ways of Knowing)(Based on Carper s Ways of Knowing)
• Aesthetics “learning and knowing self” grasping, interpreting, envisioning and responding”
• Describe what influenced your ti d i th i actions during the scenario.
P l “ d t di l d i d • Personal “understanding personal dynamics and the ability to cope with the situation”
• Discuss your satisfaction with your • Discuss your satisfaction with your actions during this scenario.
Johns, Johns, • Ethics “knowing what is right and wrong and being
committed to take action on this basis”
Describe how your personal values and beliefs influenced your actions during this experienceduring this experience.
• Empirics “identifying and acknowledging lack of p y g g gknowledge”
Describe the knowledge and skills you Describe the knowledge and skills you have that influenced your decision making during this experience.
Johns, Johns, • Reflexivity “resolve the contradictions
between what the practitioner’s aim to achieve and actual practice, with the intent p ,to achieve more desirable and effective practice”
Describe situations you have experienced as a student nurse that influenced your decision that influenced your decision making during this experience.
Describe how this experience could have been handled differently.y
Decker’sDecker’s (Based on Johns Work)(Based on Johns Work)
1 Talk to me about the problem your patient was 1. Talk to me about the problem your patient was having
2. What was your main goal during this simulation?3. Tell me what influenced your actions during the y g
scenario.4. Talk to me about how this experience made you
feel and how satisfied you are with the actions you initiated?initiated?
5. Talk to me about how your personal values and beliefs influenced your actions during this experience.
6 T lk t b t th k l d d kill 6. Talk to me about the knowledge and skills you have that helped you provide patient care during this simulated experience.
7. Talk to me about experiences you have had that p yinfluenced what you did during this scenario.
8. What would you do different if we went back into the patient’s room and repeated the scenario right now?now?
Factors Identified by Student Groups as Affecting Critical and Reflective Thinking During a Simulated Learning Experience
Factors Identified Percent of Groups a
P l R t St 50%Personal Response to Stress 50%Perceived Self-Confidence 25%Skill C t 25%Skills Competence 25%Urgency of Task 17.8%E i ti l K l d 17 8%Experiential Knowledge 17.8%Theoretical Knowledge 14.3%P t ti l L l I li ti 10 7%Potential Legal Implications 10.7%a (N=28)
Decker, 2007,
Additional Factors Additional Factors IdentifiedIdentified
• Tunnel vision (fixations) • Tunnel vision (fixations), • Resistant to change,
Defensi e attit de • Defensive attitude, • Poor communication skills,
I bilit t i t • Inability to access appropriate resources both technical and human, and and
• Cultural background.Decker, 2007,
Shift ReportMedical Records
2 MinutesFirst-Line Prompt
-Vague
-1 Minute-Second-Line Prompt
- More Specificf--Repeat if Needed
Problem Identified(Focused
Assessment)Required Inter –
disciplinary
Larew, C., Lessan, S., Spunt, D., Foster, D., & Covington, B. (2006). Innovations in clinical simulation: Application of Benner's theory in an i i i i l i [El i i ] N i Ed i P i 27(1) 16 21
disciplinary Communication
interactive patient care simulation [Electronic version]. Nursing Education Perspectives. 27(1), 16‐21.
Kneebone, R., Scott, W., Darzi, A., & Horrocks, M. (2004). Simulation and clinical practice: strengthening the relationship [Electronic version] Medical Education 38(10) 1095-1102 relationship [Electronic version]. Medical Education, 38(10), 1095-1102.
Bligh, J., & Bleakley, A. (2006). Distributing menus to hungry learners: Can learning by simulation become i l ti f l i ? M di l T h 28(7) 606 613simulation of learning?. Medical Teacher, 28(7), 606-613.
Best PracticesBest Practices• Inter-professional Simulations
- Team Training and Patient Safety
The Joint Commission, 2008“Studies show that well functioning teams make fewer mistakes than do individuals.”
Teamwork TrainingTeamwork Traininggg
• Knowledge• Skills• Attitude• Didactic – knowledge
and attitude• Experiential Learning with guided
feedback – knowledge, skills, & attitudeg , ,
Teamwork Training: Teamwork Training: Spectrum of ActivitiesSpectrum of ActivitiesSpectrum of ActivitiesSpectrum of Activities
Verbal exercises Problem-based Learning
Role playing Case-based Learning
Simulation Simulation-based Learning
Simultaneously make decisions, perform procedures, and i i h binteract with team members
Links previous work experience
Promotes understanding of different roles
Facilitates reflective thinking
Teamwork TrainingTeamwork TrainingggApproaches
“Single Discipline” Training“Others” played by actors or faculty
“Combined-Team” Training“Team” learns together
Teamwork Training: Teamwork Training: MetaMeta analysesanalysesMetaMeta--analysesanalyses
• Critical principlesId tif iti l t i (KSA)• Identify critical competencies (KSA)
• Emphasize teamwork over tasksDesi ed o tcomes sho ld g ide the • Desired outcomes should guide the process
• Provide guided active learning• Provide guided active learning• Mirror the work environment (simulation)• Feedback – relevant and timelyFeedback relevant and timely• Evaluate the outcomes• Reinforce Salas DiazGranados Weaver King 2008)Salas, DiazGranados, Weaver, King, 2008)
ModelsModels• Curriculum - 4 sessions over 4 weeks
• 20 students• Small group format
• Exchange perspectives - socialization• Role playing - Discussion
h d f l• One time visit with patient and family• Discussion related to visit
G D b i fi• Group Debriefing
Results: Increased in perceived role understandingFineberg, Wenger, Forrow, 2004Fineberg, Wenger, Forrow, 2004
“Highest” Degree of Competence
Competency related to
Technical Skills
Requires Knowledge, Recognition, Assessment,Recognition, Assessment, Prioritization, & Application of Experience & Judgment.
Cognitive Basis
Simulation Training, Research, and Technology Simulation Training, Research, and Technology g, , gyg, , gyUtilization System clinical performance pyramid. Utilization System clinical performance pyramid.
Binstadt, E. S., Walls, R. M., White, B. A., Nadel, E. S., Takayesu, J. K, Barker, T. D., et. al. (2007). A comprehensive medical simulation education curriculum for emergency medicine residents. Annals of Emergency
d ( )Medicine, 49(4), 495-504.
Overview of the Overview of the Simulation ModuleSimulation Module for Assessment of Resident for Assessment of Resident Targeted Event Responses (SMARTER) processes for training Targeted Event Responses (SMARTER) processes for training
teamwork in EM. Adapted from Rosen et al.teamwork in EM. Adapted from Rosen et al.1616 EMEM == emergency emergency teamwork in EM. Adapted from Rosen et al.teamwork in EM. Adapted from Rosen et al. EMEM emergency emergency medicine; KSAsmedicine; KSAs == knowledge, skills, and attitudes.knowledge, skills, and attitudes.
Shapiro, M. J., Gardner, R., Godwin, S. A., Jay, G. D., Lindquist, D. G., Salisbury, M. L., et al. (2008). Defining team performance for simulation-based training: methodology, metrics, and opportunities for emergency medicine Academic Emergency Medicine 15 1088 1097 medicine. Academic Emergency Medicine, 15, 1088-1097.
Overview of event‐based approach to training (EBAT) process for teamwork training in emergency medicine (EM). KSA = knowledge, skills, and attitudes.g y ( ) g , ,
Rosen, M. A., Salas, E., Wu, T. S., Salvatore, S., Lazzara, E. H., Lyons, R., et al. (2008). Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine residents. Academic
dEmergency Medicine, 15, 1190-1198.
Best PracticesBest Practices• Licensure
- Patient based MCQ- Computer based case simulations- Standardized Patients- Life-size integrated simulators- Virtual Realityy
Best PracticesBest Practices• Competency Assessment
- Joint Commission
- Licensure
- Certifications
Best PracticesBest Practices
• Research needed to address:• Research needed to address:Determine who should be assessed
D t i h t t t l h ld b Determine what assessment tools should be used
Identify core competenciesIdentify core competencies
Develop and validate “appropriate testing scenariosscenarios