Impact of Simulation on Nursing Education, Clinical Learning and OutcomesWENDY THOMSON, EDD, MSN, BSBA, RN, CNE, CHSE

UNIVERSITY OF SOUTH FLORIDA

DIRECTOR, SIMULATION EDUCATION

DIRECTOR, MASTERS IN NURSING EDUCATION CONCENTRATION

Disclosures

Member of the INACSL Standards Committee 2015-2017

No other Disclosures

Objectives

By the end of this session, you should be able to:

1. Identify the key findings in the National NCSBN Simulation Study

2. Interpret the findings of the NCSBN Simulation Study for your nursing program and nursing education

3. Explain how the INACSL Standards of Best Practice: Simulation is to be used within simulation programs

4. Discuss the potential implications of the NCSBN findings

Simulation

“ ...technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (Gaba, 2004, p. i2)

Why Simulation?

Enormous amount of content and skills to be taught

Programs getting shorter

Decrease in clinical time

Limited clinical settings

Limited ability to engage in the role of the nurse

Increase in patient complexity

Disparity between “entry into practice” and “reality”

What do we know about simulation

Simulation based education shouldn’t be an extra-ordinary activity, added into an already overloaded curriculum.

Simulation must start at the beginning and be built into the normal training programs of various healthcare providers.

Lacking proof that this is a good thing to do.

Finally the NCSBN National simulation Study has results that we can use to justify what we have done and what we know already

NCSBN Simulation Study - 2013

Up to 50% simulation can be effectively substituted for traditional, business as usual, clinical experiences.

Up to 50% simulation can be effectively used in various programs, in different geographic locations, with good outcomes

Simulation usage doesn’t affect NCLEX pass rates

Caveats/Recommendations

Simulation usage can only be substituted for clinical when:

High Quality Simulation Scenarios are usedFaculty are dedicated and trained

Adequate numbers of simulation faculty to support learners

Debriefing methods are grounded in best educational practice

INACSL standards of best practice are followedEquipment and supplies create a realistic environment

Other findings

50% group were stress inoculated so those participants had less stress in practice.

There was a statistically significant difference on the end of course ATI™ examinations between the groups, with the 50% group scoring better than the other two groups.

There was more failures in the control group, least failures in the 50%

However, not statistically significant

High Quality Simulation Scenarios

Scenarios followed NLN/Jeffries Framework Model

Ensures scenarios all had the same elements

Consistency

Published scenarios vs home grown?

Model is based on Chickering and Gamson which states:

Time on task, with a consistent approach and a lot of prompt feedback.

High Quality Simulation Scenarios

What does this mean for teaching and faculty? Valid and reliable scenarios within your organization

Vet scenarios through a task force or committee

All scenarios should have the same components Students know what they are getting into because they

had it before Consistency

Need training, can’t assume you know

Faculty are dedicated and trained

Dedicated faculty create consistent experiencesOutcomes can be measured

Mandatory Faculty training in facilitation and debriefing.Select a debriefing method for your institution

Ask the faculty what method they use!Ask how they know they are using it correctly!

Teach the debriefing method By a SME

Faculty are dedicated and trained

Practice debriefing with real simulated simulation learning experiences

Evaluate debriefing via peer and expert evaluationDASH rating tool >=7

Continuous monitoring of faculty debriefing skill competency2x/semester

Faculty are dedicated and trained

Prevents “Diminishing Returns Phenomenon”If we do the same thing too much we’ll start to feel burned

out and may even start performing poorly.

Avoid grandfathering faculty. Even the most experienced faculty/nurse/provider gets

complacent Ensure they follow your institutions way of debriefing

Debriefing methods are grounded in best educational practice

Select a debriefing method Everyone should have a say but use more than plus/delta

Train the dedicated faculty on the debriefing method Don’t assume a CEU offering or 1-3 conferences makes them

competent!

Don’t grandfather anyone in by saying they have done this for a long time.

Baseline all your simulation faculty

Debriefing methods are grounded in best educational practice

Validate competency in skills of debriefing DASH

Objective Structured Assessment of Debriefing (OSAD) (Paige, Arora, Fernandez, & Seymour, 2015)

Without continuous quality improvement, we can’t be sure faculty maintain the level of skill unless we retrain periodically.

Inter-rater reliability

Law of Diminishing Returns (also known as Diminishing Returns Phenomenon)

Validate each facilitator every semester or at least every academic year

Poor Debriefing (Silberman, 2007, p 70)

Clichéd conversations with no questioning or learning

Meandering discussion going wherever the most dominant people happen to take it

Paralysis by analysis with learning stagnating at the investigation stage

Post-mortems, producing a distorted negative bias that drains energy

Jumping to false conclusions by missing out on significant states

Future planning that is not well-grounded in what was learned from the experience.

Chaos & conflict with people being out of sequence with each other (while 1 person is talking about the future, another is still “in the exercise,: another is speaking her mind, another is excited about a personal insight and so on!)

INACSL Standards of Best Practice: Simulation are followed

Standard I – Terminology – Provide Consistency

Standard II – Professional Integrity of Participants

Standard III – Participant Objectives – Clear and Measurable

Standard IV – Facilitation – Multiple Methods

Standard V - Facilitator – Proficiency

Standard VI – Debriefing Process – Improve Practice Through Reflection

Standard VII - Participant Assessment and Evaluation

Standard ?? – Simulation Design

Standard ?? - IPE

Highlights of the Standards

Provide honest and clear feedback in an effective, respectful manner

Learners should receive/provide timely constructive feedback

Protect the scenario content

Measurable Objectives that address the domains of learning and be achievable based on the knowledge and level of the learner.

Facilitator has formal education/training in simulation-based learning

Debriefing is facilitated by someone competent in a structured debriefing framework and who observed the scenario

Use formative assessment and summative evaluation as appropriate

INACSL Standards of Best Practice: Simulation

First published in 2011,

Revised in 2013

2 new standards being released in 2015

Update coming soon

Very much aligns with the findings of the NCSBN Study

Equipment and supplies to create a realistic environment

Enough evidence to support high fidelity simulation It isn’t about the manikin but the sights, sounds, and

equipment that make the place real to a participant.

Elicits an emotional responses to what is happening. Taps the senses like pretend cannot

Implications

Dedicated Formerly trained faculty – policy implications for BONs Financial implications for institutions

Use of theory based debriefing methodsWhat do schools choose from?Cost for training

Implications

Adequate numbers of simulation faculty to support the learners Workload

Cost

Equipment and supplies to create a realistic environment Space

Cost

What about Advanced Practice Education? Can they substitute any clinical hours with Simulation based on the NCSBN

findings?

Do we change everything based on study?

Is it simulation that forced the best learning and teaching practices?

Is it the infrastructure that forced the best learning and teaching practices?

Why was there no difference?

Anecdotal

Why were the participants equally clinically competent?

How controlled were the sites?

Each program had their own curriculum and got to choose where and when to integrate simulations.

What are the Next Steps?

Questions?

References

Gaba, D. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13 (Suppl 1), 2-10.

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). Supplement: The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation,5(2), C1-S64.

International Nursing Association for Clinical Simulation and Learning. (2013, June). Standards of Best Practice: Simulation. Clinical Simulation in Nursing, 9(6S), S3-S11.

Silberman. M. (2007). The Handbook of Experiential Learning, San Francisco, CA: John Wiley & Sons.