icamira facilitator's resource manual · and procedural skills to healthcare professionals ......

Simulation Workshop Program

Facilitator Guide

Table of Contents

Facilitator Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

About Simulation Techniques . . . . . . . . . . . . . . . . . . . . . . . . .1

Simulation Workshop Overview . . . . . . . . . . . . . . . . . . . 3

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Simulation Workshop Planning . . . . . . . . . . . . . . . . . . . . . . . .4

Equipment, Resources & Planning . . . . . . . . . . . . . . . . . . 8

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

SP Scenario Resources & Equipment . . . . . . . . . . . . . . . . . . . . .8

Facilitator Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Facilitator Instructions . . . . . . . . . . . . . . . . . . . . . . . . .10

Sample Workshop Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Workshop Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1© 2010, Mount Sinai Hospital, Toronto, Canada

Facilitator Welcome

Welcome to the Facilitator Guide for the Simulation Workshop Program. This guide has been prepared to assist you in the delivery of this workshop. It outlines the purpose of the workshop, and provides a description and the learning objectives for participants. The guide outlines detailed steps on how to organize the workshop.

This guide should be used in partnership with the Introduction Guide . All of the facilitator resources and participant handouts can be found in the Resources section of the manual.

About Simulation TechniquesSimulation is a technique that replaces or amplifies real patient experiences with guided, artificially contrived experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner(16)*. Simulation training is an established teaching technique in medicine, surgery, nursing and allied health(17).

Standardized patient (SP) simulations have proven successful in teaching general communication skills, behaviour management, symptom assessment, and technical and procedural skills to healthcare professionals(18-22).

Evidence suggests that simulations facilitate learning because they:

f foster opportunities to provide immediate performance feedback;

f offer repetitive practice;

f provide a range of difficulty;

f offer opportunities for integrating multiple learning strategies;

f capture clinical variation;

f provide individualized learning; and,

f allow for the measurement of specific performance outcomes(23).

* ReferencesarefoundattheendoftheResourcesSection.

Introduction Guide


iCAMIRA Facilitator’s Resource Manual

2 © 2010, Mount Sinai Hospital, Toronto, Canada

As part of the iCAMIRA education intervention, the University of Toronto’s Standardized Patient Program facilitated the development of generic medical/surgical patient scenarios for the Simulation Workshop. The scenarios were informed by clinical experts and members from Mount Sinai Hospital’s Patient Advisors Group.

Standardized Patients (SPs) were used to play the patient roles in the scenarios. SPs are professional actors who work with the University of Toronto Standardized Patient Program to play a variety of roles that facilitate experiential learning of healthcare professionals.

There are fees associated with the development of scenarios, training SPs for the role and SP time during the actual workshop. If you plan to use SPs from the University of Toronto program, connect with them 3-4 months in advance of your start date to discuss your program needs. Their contact information can be found at: http://www.spp.utoronto.ca.

IMPORTANT !

If you do not have access to standardized patients, the

workshop can be developed using role-playing

techniques with staff.

http://www.spp.utoronto.ca


Simulation Workshop Overview

Figure 1: Overview of the Education Program

PurposeThe simulation workshop provides participants with an opportunity to apply the knowledge obtained in the eLearning module through experiential case scenarios. Participants will have repeated practice engaging the patient, scoring the standardized assessment tool, and will receive feedback from the SP(s).

DescriptionThe workshop consists of three main sections: introduction/overview; four patient scenarios; and participant debrief. The workshop is designed to be 4 hours in length. Four generic patient scenarios from medical and surgical settings have been developed and SPs were trained to play the patient roles. The aim of the workshop is for participants to engage the patient and to practice using the Observer Rating Scale for Patient Anxiety. This is done in pairs, so participants have four opportunities to practice using the tool and observe a colleague using the tool.

Simulation WorkshopProgram

FacilitatedDiscussion Program

EvaluationAnxietyAssessment

Independent Learner

Program

OrganizationalReadiness

eLearningModule

Learning ObjectivesThe learning objectives for the Simulated Workshop Program are:

1. Recognize symptoms of low, moderate and high anxiety through assessment of SPs using the anxiety assessment tool.

2. Utilize feedback from SPs to reflect upon effective and non-effective verbal and non-verbal communication techniques for engaging patients.

3. Discuss interventions that help manage patient anxiety.




Simulation Workshop PlanningThe iCAMIRA educational intervention was an organizational initiative targeted to approximately 400 participants. The workshops required a minimum of 8 participants with a maximum of 20. The same four scenarios ran on two separate tracks, with a total of 8 SPs per workshop. The following sections in this guide, which details the simulation workshop, are based on the planning and implementation experience of the iCAMIRA project. The workshop does not require the use of SPs and can be implemented using role-playing techniques. The timelines, materials and resources will vary depending on the magnitude of your planned program.

8 Weeks prior to the workshop

� Determine the date, time and location for the workshop

� Book rooms based on your maximum registration number

� Book SPs

� Prepare promotional materials and registration process

� Promote the workshop

� Provide eLearning module instructions to registered participants


� If you develop your own scenarios and use SPs, meet with the SP coordinator to draft scenarios

� Send promotional reminders about the workshop

� Send reminders about the eLearning module to registered participants

� Gather/book equipment that is required for scenarios

� Order linens: each SP requires 2 gowns, a top and bottom sheet, and a pillow case


� Print facilitator workshop resources, including:

– Checklist for Simulation Workshop

– Case Scenarios with Scoring Legend

– Simulation Workshop Facilitator Tool

1 - Case Scenarios with Scoring Legend

8 - Simulation Workshop Facilitator Tool

1 - Checklist for Simulation Workshop


� Print Scenario Stems or laminate them if you are providing more than one workshop

� Print participant materials:

– iCAMIRA Participant Evaluation Form

– Observer Rating Scale for Patient Anxiety ( 4 copies per participant )

� Confirm eLearning module completion by participants and send a reminder email to those who have not yet completed the module

� Order catering for the workshop (optional); consider dietary needs of participants and SPs

3 Days to 1 week prior to the workshop

� Send an email reminder to participants, providing workshop instructions and directions to the workshop location

� If registration does not meet minimum numbers, cancel room bookings, catering, SPs and send a cancellation email to registered participants and managers

1 Day prior to the workshop

� Confirm the catering order (retain info for catering order, contact for inquiries)

� Confirm the equipment and room bookings (retain info for contact in case of problems)

� Print signs for directions to the workshop location

� Review the facilitator guide, and facilitator and participant materials

� Print the registration roster

Facilitator TipsIn your communications with participants, be sure to include a note about the workshop being “scent free”. Participants are mindful of this in the workplace and not necessarily for workshops. Remind them that the SPs are essentially patients, some of whom may have perfume allergies.

2 - iCAMIRA Participant Evaluation Form

5 - Observer Rating Scale for Patient Anxiety

7 - Scenario Stems for Simulation Workshop




Day of the workshop

Before the workshop (arrive at least an hour early)

� Post signs for directions to the workshop

� Set up chairs in the main room in a manner that will facilitate discussion

� Set up the equipment and linens in the SP exam rooms

� Tape each scenario stem to the appropriate room door

� Set up the registration/sign in area

� Receive catering

End of the workshop

� Hand out the participant certificates (if required)

� Remind the participants to gather all of their belongings

� Clean up any remaining materials

� Strip linens in the scenario rooms and gather/put away equipment

� Check all rooms for participant belongings

� Take down the signs for directions to the workshop

Facilitator TipsA Checklist for Simulation Workshop is provided for you. It is a helpful tool to use to ensure that you have made all the necessary arrangements and have all of your resources and handouts for the workshop.

Facilitator TipsIf you are using SPs, ensure that the scenario rooms are prepared with linens, gowns and any medical equipment necessary to make the scenario realistic.

Be prepared for participants who show up without having completed their eLearning module. The iCAMIRA project made no exceptions for participants who did not complete the eLearning module, as its completion is critical to participants being fully able to take part in the workshop.

Decide on a cut-off time for late arrivals. Consider turning away participants who arrive after the start of the first scenario rotation. It is challenging to integrate them and may be disruptive to the other participants and SPs.


Post workshop

� Email the group of participants to notify them if any belongings were left behind

� Update your participant tracking system, confirming the names of participants who attended the workshop and those who did not

� Provide an electronic copy of the confirmed participants to the managers (if required)

� Send out ‘thank yous’ as required

� Write the workshop summary report (if required); summarize how the workshop went and note any tips or suggestions for running future workshops (this is an opportunity to refine the process of planning, implementing and evaluating the workshop)




Equipment, Resources & Planning

Equipment � Presentation room large enough

to accommodate all participants for the group discussion

� Chairs (1 per participant, facilitator and SP)

� Box of pens

� Name tags

� Masking tape

� Catering (optional)

SP Scenario Resources & Equipment The following resources and equipment are recommended if you are using the scenarios included in this guide:

� 4-8 Exam/hospital ward type rooms with bed and chair for scenarios

� 4 IV poles

� 4 saline solutions

� 2 newspapers

� 2 rolls of kling

� Paper surgical tape

� 2 NG tubes

� 2 stopwatches

� 2 sets of scenario stems

Facilitator TipsIf you are using SPs, provide a separate room for them to meet and debrief. They prefer not to mingle with the participants until after the scenario rotations are completed.

If you are using SPs, they require beverages, and if it is an early morning workshop, a continental breakfast is appreciated.


Facilitator Resources A copy of the following resources can be found in the Resources section of this manual.

� Planning Resources

– Checklist for Simulation Workshop

– iCAMIRA Poster

– iCAMIRA Registration (sample email/poster)

– Incomplete eLearning Module (sample email)

– Preparing for Simulation Workshop (sample email)

� Implementation Resources

– Case Scenarios with Scoring Legend

– iCAMIRA Participant Evaluation Form

– Observer Rating Scale for Patient Anxiety (4 per participant)

– Simulation Workshop Facilitator Tool

– Scenario Stems for Simulation Workshop

1 - Checklist for Simulation Workshop

2 - iCAMIRA Poster3 - iCAMIRA Registration4 - Incomplete eLearning

Module5 - Preparing for

Simulation Workshop

1 - Case Scenarios with Scoring Legend


5 - Observer Rating Scale for Patient Anxiety

7 - Scenario Stems for Simulation Workshop





Facilitator Instructions

Sample Workshop Agenda

8:00 – 8:15 am8:15 –10:30 am10:30 –10:45 am10:45 –11:50 am 11:50 –12:00 pm

Introduction/OverviewSP ScenariosBreakDebrief Wrap-up and Evaluation

Workshop OverviewThe workshop will last approximately 4 hours in length, depending on participation levels during the program debrief. There is some flexibility in the agenda time, but the scenarios and debrief should be more heavily weighted. Figure 2 provides an overview of the Simulation Workshop Program.

Figure 2: Overview of the Simulation Workshop Program

Welcome, Introductions and Workshop Overview

Scenarios (30 mins each)

Debrief and Surveys

(15 min)

(2.5 hrs)

(1 hr)

Read stem (1 min)Warning knock (at 5 mins)Knock for switch (at 7 mins)Knock for feedback (at 7 mins)Tool feedback (4 mins)SP feedback (10 mins)End scenario (at 29 mins)Move to next scenario (1 min)

T r a c k 1

Scenario1

Scenario2

Scenario3

Scenario4

Reset

T r a c k 2

Scenario1

Scenario2

Scenario3

Scenario4

Reset


Introduction/Overview (15 minutes)

� Use the Simulation Workshop Facilitator Tool.

� Participants who have little or no experience with role-playing may be anxious about the process. Check-in with the group and help to normalize their experience. Emphasize that the workshop is not evaluative and that participants should have fun and enjoy the process.

� It helps to keep the introduction/orientation brief. Because of the participants’ anxiety, they often don’t take in a lot of the explanation regarding the scenario rotations. The facilitator usually needs to go over the scenario rotations again once participants are at the scenario room doors.

� Ensure that each participant has four anxiety assessment tools and a pen/pencil for scoring the SPs anxiety in each scenario. It’s helpful if participants write the name of the SP on each assessment tool, as it reminds them ‘who is who’ during the debrief. They can also use the back of these sheets to jot notes during the discussion.

� Point out the location(s) of the washrooms.

� Ask participant to bring their valuables with them when leaving the main room.

� Let participants know that they will have a 15 minute break between the scenarios and debrief.

Scenarios (120-140 minutes)

Participants rotate through the four scenario stations where they interact with the SP, practice their anxiety assessment skills using the tool, and receive feedback from the SPs. The feedback is around how the SP felt about the experience “in the moment” regarding the healthcare professional’s engagement and communication process. The time allocation for the scenario rotations is broken down in the following steps:

f Each station lasts 30 minutes in total. The estimated 30 minutes for each scenario is based on a group of up to 16 participants. If there are 17 to 20 participants, build in a rest station and shorten each scenario to 25 minutes. Additional time may also need to be built in for travel between stations if the rooms are not close to each other.

f Participants have 1 minute to read the stem on the door, and are then asked by the facilitator to enter the room.

f The facilitator will knock on the door at 5 minute mark of the interview (‘warning’ knock). The facilitator will then knock on the door at the 7 minute mark to have participants switch roles.





f Restarting the timer, the facilitator will knock at the 5 minute mark. At 7 minute mark, he/she will knock again, open the door and say “feedback”. Participants will have 4 minutes to discuss the scoring and items of the tool with each other, and then move into feedback from the SPs for 10 minutes.

f At the 29 minute mark, the facilitator will open the door again and give participants 1 minute to wrap up. At 30 minutes, the facilitator opens the door and encourages participants to move on.

Break (15 minutes)

Debrief (60-65 minutes)

Scoring the Scenarios (15 minutes)

Begin the debrief with the scoring of the four scenarios using the Observer Rating Scale for Patient Anxiety. This provides an opportunity to:

� address any discrepancies in the use of and scoring of the tool;

� provide messages about the advantages of using an anxiety assessment tool; and

� allow for the discussion of any challenges of implementing the tool in the clinical context.

Facilitator TipsIf you are running two tracks of scenarios, each track requires a facilitator. Each facilitator requires a stopwatch in order to keep the rotations on time.

Facilitator TipsThe anxiety assessment scoring tools are based on the scenarios that were created for the iCAMIRA project. If you choose to use the scenarios included with this guide, the scoring of the tool may vary depending on your interpretation and implementation of each scenario.

It may be helpful to view the scenarios on the DVD and their associated anxiety tool scoring (this can be found in the Facilitated Discussion Program: Facilitator Guide. The DVD clips were based on the same scenarios as those for

the Simulation Workshop Program. Notice that the anxiety tool scoring is slightly different for the scenarios in the DVD as compared to the Simulation Workshop Program. This is a result of slightly different interpretations for the same scenario.

Facilitated Discussion Program


Participant Debrief & Discussion ( 45-50 minutes)

Ask participants to discuss their experiences with each of the scenarios. If using SPs, ask a SP from each scenario to participate in the discussion and provide feedback about his/her experience.

Sample discussion points for each scenario are provided at the end of the four scenarios.

Sample discussion questions:

f What went well?

f What were some of the challenges?

f What feedback did participants receive from the SP that might be helpful in their practice?

f What strategies did participants use to engage the SP? (e.g., information seeking, open or closed ended questions, touch, humour, use of personal space, or non-verbal communication)

f What strategies were effective in decreasing the patient’s anxiety?

f What strategies were ineffective in decreasing the patient’s anxiety?

f How did participants handle not being able to provide the SP with all the information he/she wanted? What was the SPs experience of this?




Scenario 1: Rose Hatfield

Rose has a low level of anxiety. She has fears about the potential results of the MRI and is not displaying a great deal of anxiety. Her concentration is good and there is not a lot of overt tension, except for some tearfulness when talking about her mother. The difficulty sleeping appears to be because of the tubes. However, it would be important to ask Rose if there is anything else keeping her awake, and whether her sleep has only been disturbed since coming into the hospital. Obtaining this information will help to clarify whether the sleep problems are related to fears and worries, or just a result of the hospital environment.

Rose responds well to open-ended questions. She is the “nice-pleasant” patient who won’t necessarily volunteer a lot of information, but if you take the time to engage her and keep asking open-ended questions, she will divulge more information about herself. On the surface, her main concern is the MRI result. By picking up on cues from Rose, the healthcare professional (HCP) can

probe with more open-ended questions and get to the real source of Rose’s worry. Some HCPs are concerned about probing too much, or asking too many questions. Take your cues from the patient. He/she will let you know if the questions are too intrusive or if he/she doesn’t want to talk.

Like Rose, many of our patients want answers to questions about their diagnosis, treatment, results, etc. There are many times when we don’t have the information or can’t convey the information because of the scope of our role. It’s perfectly okay to say that you don’t have the results. As a HCP, you’re not expected to have all the answers. Though you may not have the answer the patient is looking for, there is a lot of information you do have about how long things take, the process for procedures and results, etc. We sometimes take these things for granted because we live and breathe them every day. Remember however, that for the patient, hospital procedures and routines are unfamiliar, and this often gives rise to fears, anxieties and worries.


Scenario 2: Phil Archer

Phil is a gentleman who doesn’t open up easily. He’s not a big conversationalist! Because of this, there may be a tendency for HCPs to “write Phil off” and forget about him, thinking that he doesn’t want to engage. In fact, he does have a moderate level of anxiety and fears about losing his foot.

Moving from open-ended questions to more close-ended or directive questions allows Phil to engage. For patient’s like Phil, there are two important points to remember:

1. They need more time to open up and engage which means that as a HCP you will need to return several times to engage with Phil in order to develop some rapport

2. Closed or directive type questions will be more effective

Patients like Phil have a lot bottled up and going on in their head. It’s often very hard for them to answer global, open-ended questions. They have difficulties focusing on any one problem or concern.

So as HCPs, we need to help focus, or direct their thinking. This becomes even more pertinent when the patient is anxious or worried. It may seem counter-intuitive because as HCPs we’re taught to ask open-ended questions. It’s generally a good rule of thumb to start with open-ended questions, and to also have other communication strategies in our toolbox when the open-ended approach doesn’t work.

It can also be helpful to Phil, if the HCP reflects back to Phil what he/she is observing (e.g., the lack of eye contact and fidgeting). When patients are anxious or worried, they are often not aware of their behaviour. Reflecting on a patient’s behaviour also acknowledges for the patient that you are paying attention.

So the next time you encounter a Phil-type patient, don’t “write them off” because of their apparent lack of engagement. There’s often a lot going on for these patients. It just takes a little more time and patience on our part to find it out.




Scenario 3: Amanda Cooper

With Amanda, it is important for staff to recognize the signs of high anxiety and to actually manage, rather than assess the anxiety. This includes using techniques like supportive listening and providing reassurance (e.g., that the team is not hiding anything and trying to figure out what is wrong with her). Conveying a non-verbal stance that you are going to stay and not run out the room is important to building trust with Amanda.

Amanda provides all the answers to the anxiety assessment without the HCP needing to ask a lot of questions. Her level of anxiety is clearly high, as are her fears of a brain tumor and dying. She tells the HCP that she isn’t sleeping. Though she isn’t crying, pacing or restless, there is a certain tension in her body posture. Assessing concentration with Amanda is a bit more difficult as it is easy to mistake her constant focus on the brain tumor

and dying as an inability to remember information given to her. Given a supportive and calm approach, Amanda is able to concentrate on the information and understand the difference between a stroke and a TIA.

The challenge for HCPs is to find a way to tolerate Amanda’s affect. If the HCP just keeps leaving the room, Amanda’s anxiety will not be addressed and in fact will continue to increase which leads to her constantly ringing the call bell.

It’s tempting to label patients like Amanda as histrionic or “over-the-top” and to view them as “difficult or needy”. HCPs need to recognize the patient’s distress and find ways to manage their own discomfort with the patient’s affect. Use your colleagues for support, have a care plan for consistency and be aware of your own triggers.


Scenario 4: Derek Lewis

Try to put yourself in Derek’s position for a moment. Most 20 something’s are leading very active lives and don’t have too many worries. Derek is facing his mortality. He is a 22 year old male, so don’t expect that he’s going to come right out and say he’s scared…but he is. All of his questions around the surgery, the pain and what happens afterwards, are an invitation for the HCP to engage with Derek. Engaging with Derek around his questions will help to build rapport and trust. He is overwhelmed and alone in the city. He is desperately wanting to talk with someone, but remember, he is a 22 year old male! As HCPs, we need to recognize that he’s not going to be the one to initiate the conversation.

Derek’s reference to his condition being like Terry Fox’s is silently asking that question that he’s afraid to ask. “Does that mean I’m going to die too?” As the HCP, the reference to Terry Fox provides an opportunity to ask Derek directly if he is afraid of dying which then gives Derek the space to have the conversation if he so chooses. It also allows for a conversation about how medicine has advanced since Terry Fox’s time and to ask Derek is he would like more information from his doctor regarding prognosis. The combination of caring and

taking the time to discuss death as well as providing factual information will help to manage Derek’s anxiety.

The other key point for this scenario is around providing Derek with reassurance regarding the healthcare team. He is angry and feels his family doctor may have missed something. It’s important to not get caught up in that discussion. You weren’t there and so don’t really know what happened. Provide support to Derek and focus on the present by conveying confidence in your colleagues and reassuring him that he has a great team. Genuineness is very important when engaging with Derek. If you are in a position where you don’t have confidence in your colleagues, then don’t say so. You could simply say to Derek that you’ll pass his concerns about “something being missed” on to his doctor.

Derek is a young man facing a possible leg amputation and maybe even death. The reaction of HCPs to Derek’s situation is often one of sadness and feeling badly for the situation he is facing. Sometimes, there is also fear and discomfort on the part of the HCP regarding conversations around death and dying. In order to be an effective care provider, it’s important that HCPs manage their emotions and use their colleagues for support.




Summary of Key Discussion Points for Scenarios

� Engaging your patients and developing rapport helps them feel cared for and will help decrease their anxiety.

� Engaging your patients and developing rapport improves the patient care experience and gives you more job satisfaction.

� Recall from the scenarios that it really didn’t take a lot more time to engage and do a good job of assessing the patient’s anxiety. Remember that an extra minute can make a big difference in decreasing your patient’s anxiety and actually save you a lot of “responding to call-bell” time in the end.

� Be aware of “cues” from the patient and don’t be afraid to ask questions, rather than trying to guess what the cues mean. The cues may be verbal or non-verbal.

� Each patient is different. Use the different communication techniques you’ve learned to connect with your patient.

� The anxiety assessment tool provides you and your colleagues with a common language with which to communicate about patient anxiety. It’s a subjective tool, so not everyone will have exactly the same score. What’s important are the low, moderate and high categories. It’s these categories that determine the appropriate interventions.

Evaluation (5-10 minutes)

f Have participants complete the iCAMIRA Participant Evaluation Form.



References

1. Sherbourne, C.D., et al. (1994). Prevalence of comorbid anxiety disorders in primary care outpatients. Archives of Family Medicine, 5(1), 27-34.

2. Stoudemire, A. (1996). Psychiatry in medical practice. Implications for the education of primary care physicians in the era of managed care: Part 1. Psychosomatics, 37(6), 502-508.

3. Bohachick, P. (1984). Progressive relaxation training in cardiac rehabilitation: Effect on perceptions of challenges, control, competition and collaboration in Ontario’s evolving healthcare system. Healthc Q., 8(3), 36-47.

4. Lawlis, G.F., et al. ( 1985). Reduction of postoperative pain parameters by pre-surgical relaxation instructions for spinal pain patients. Spine, 10(7), 649-651.

5. Frazier, S.K., et al. (2002). Management of anxiety after acute myocardial infarction. Heart and Lung: The Journal of Acute and Critical Care, 31(6), 411-420.

6. Saravay, S., et al. (1996). Four-year follow-up of the influence of psychological comorbidity on medical rehospitalisation. American Journal of Psychiatry, 153(3), 397-403.

7. Walker, F.B., et al. (1987). Anxiety and depression among medical and surgical patients nearing hospital discharge. Journal of General Internal Medicine, 2(2):99-101.

8. Simon, E.P., et al. (1995). Delivery of home care services after discharge: what really happens. Health and Social Work, 20(1):5-14.

9. Creed, F., et al. (2002). Depression and anxiety impair health-related quality of life and are associated with increased costs in general medical inpatients. Psychosomatics, 43(4):302-309.

10.Moser, D.K. (2002). Psychosocial factors and their association with clinical outcomes in patients with heart failure: Why clinicians do not seem to care. European Journal of Cardiovascular Nursing, 1(3):183-8.

11. Burman, M.E., et al. (2005). Treatment practices and barriers for depression and anxiety by primary care advanced practice nurses in Wyoming. Journal of the American Academy of Nurse Practitioners, 17(9):370-80.

References



12.Sheldon, L.K., et al. (2008). Putting evidence into practice: evidence-based interventions for anxiety. Clinical Journal of Oncology Nursing, 12(5):789-97.

13.Brown, A.D., et al. (2008). Comparing patient reports about hospital care across a Canadian-US border. International Journal of Quality in Healthcare, 20(2), 95-104.

14.Maunder, R.G. (2009). [Observer Rating Scale for Patient Anxiety]. Unpublished raw data.

15.Hamilton, M. (1959). The measurement of anxiety states by rating. British Journal of Medical Psychology, 32, 50-55.

16.Gaba, D.M. (2004). The future vision of simulation in healthcare. Quality Safe Healthcare, 13 (Suppl 1);i2-i10.

17.Nishisaki, A., et al. (2007). Does patient simulation improve patient safety, self-efficacy, operational performance and patient safety. Anesthesiology Clinics, 25:225-236.

18. Johnson, J.A., et al. (1996). Effectiveness of standardized patient instruction. Journal of Dentistry Education, 60(3):262-66.

19.Estrada, C.A., et al. (1997). Positive affect facilitates integration of information and decreases anchoring in reasoning among physicians, Organizational Behaviour and Human Performance, 72:117–135.

20.Blue, A.V., et al. (1998). The effectiveness of the structured clinical instruction module. American Journal of Surgery, 176(1):67-70.

21.Madan, A.K., et al. (1998). Comparison of simulated patient and didactic methods of teaching HIV risk assessment to medical residents. American Journal of Prevention Medicine, 15(2):114-9.

22.Aspegren, K. (1999). How to get the best physicians? Admission procedure and education must cooperate. Lakartidningen, 96(36):3742-3.

23. Isenberg, S.B., et al. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27:10-28.

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