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