PAMELA R. JEFFRIES DNS, RN, FAAN,ANEFASSOCIATE DEAN FOR ACADEMIC AFFAIRS

JOHNS HOPKINS UNIVERSITY SCHOOL OF NURSING

CLINICAL SIMULATIONS IN HEALTHCARE CONFERENCE – MAY 19, 2010TULSA, OKLAHOMA

The Future of Simulation: Innovations and Possibilities

Objectives of this session: The participant will be able to:

1. Discuss changes occurring in nursing education and the use of clinical simulations

2. Describe the essential tools and skills nurse educators need to incorporate simulations into the teaching-learning process

3. Explore future possibilities nurse educators can embrace using simulations

Clinical Simulations: a potential solution for clinical practice and enhancement

There is currently a widespread movement to use simulations of all types in nursing education as a teaching-strategy and/or as an evaluation mechanism.

Why is there a sudden increase in this innovative strategy?

How do educators know if this mechanism is providing the learning outcomes needed to prepare the graduate for real-time nursing practice?

Increased Need for Simulations: Why do educators want to use them?

Decreasing number of clinical sites for practice Nurse educator shortage Decision-making/problem-solving skills needed Cost-effective clinical education needed Gap between academia and practice New model of education needed (e.g. technology, realism,

diagnostic reasoning skills)

Why do educators want to use them?

IOM (2004) challenges health educators to expand technologies and support innovations

NLN has challenged educators to be innovative in our educational practices

New graduates must be prepared for the demand of healthcare and increased complexity – need for rapid decision making

Simulations use continued

Concept of patient safety increasing – use of simulation as a safety concepts

National Council of State Board of Nursing – predicts the future of clinical education in nursing will include the increased use of simulations

Higher education paradigm shift from teaching to learning paradigms

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 articlesQuality 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)

Nursing Research

In the past 40+ years, nursing educators have conducted similar studies involving case studies, computerized patients, standardized patients, and have achieved similar results.

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 CHARACTERISTICCHARACTERISTICS S 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

Changes/Issues in Nursing Education

Regulatory Boards – watchfully monitoring – providing research funding

Faculty skill sets changing

Partnerships and Collaborations

Need for better prepared students exiting nursing programs

Regulatory Boards watchfully monitoring and calling for multi-site research

Innovations in Nursing Education and Clinical

Numerous questions center on the use of simulation in nursing education. How it can be used effectively and its role in clinical development of students is of major importance and of interest to both regulators and educators alike. In collaboration with Rush University, NCSBN embarked on a pilot project to evaluate the value and validity of simulation as an educational strategy. Results indicated further study is needed in this area and our research agenda includes a large-scale, multi-site study.

National Council of State Board of Nursing (NCSBN), www.ncsbn.org

Faculty Skill Sets Changing and Required

Changes in teaching – student-centered approaches

High tech- must include technology into clinical and classroom teaching

Must be creative, innovative – keep students engaged

High quality, real skills, high expectations of our students

Partnerships and Collaborations

EcO 15 – 10 county consortium on improving healthcare – focus: developing regional sim centers and providing faculty development

SPRING program – JHI and the new graduates

IU SON and Clarian Health – partners to improve care

Need to “bridge the gap” between education and practice

A gap exists between the academic preparation of nursing students and the needs of the clinical agency

There is a growing concern among the frontline hospital leaders about the new graduates

Clinical education is not currently working using only the traditional models we have used for decades

The Nurse Executive center of the Advisory Board (2008)

Survey taken 2008

Of 135 nurse executives – 10% who responded to the survey stated new graduates were fully prepared for practice while 89.9% of the 362 nursing school leaders agreed

A large preparation-practice gap exists!

The Nursing Executive Center of The Advisory Board Company (2008)

Practice-Readiness defined in 6 general areas

Clinical knowledge

Technical skills

Critical Thinking

Communication

Professionalism

Management of responsibilities

Next Steps

Most of these competencies are directly related to ways students gain clinical experiences in the nursing program

The report identified a “collaborative/partnering” (academe and practice) would help the gap

Can the clinical model redesign also include simulations to help facilitate these practice-ready general areas?

The Evolution of the “new” Educator

Today

Facilitators of learningInnovative, creativeTechnology-savvy or

willing to learnFocus: student-

centered learningProviding students

with “real-world” experiences and examples

Knowledge workers, creators, and designers

Future Possibilities

The future is bright for the use of simulations in nursing education!

Simulation centers are being built all around the world

Funding dollars are being provided to build simulation centers and to use technology

Stimulus monies – some were earmarked for simulation!

Stimulus Call for Simulation Center Design

NIH Announces Availability of Funding for Simulation in $1bn Stimulus Bill

Posted: 03-31-2009 The National Institutes of Health (NIH) has announced that

simulation facilities for training health care providers and researchers will be eligible for funding from the $1 billion Congress appropriated in the stimulus bill (The Recovery Act) to NIH for grants and contracts to construct, repair, or renovate existing research facilities.

NIH's inclusion of simulation centers as being eligible for this funding will provide a tremendous opportunity for the development of new simulation centers, as well as the enhancement of existing centers. 

Future Possibilities

Uses of Simulation Expanding in Education

The evolution of “the simulation technology”

Teaching environments/possibilities

The learner

Future Uses and Activities where Simulations are Involved

Research in simulations increasing – e.g. Advanced Practice Nurses multi-site study

Unfolding cases

Simulations included in large Foundation and partnership grants

Integrating simulations into patient and caregiver teaching/health promotion and prevention

Mastery Learning - Features1. Baseline (e.g., diagnostic testing)

2. Clear learning objectives, units ordered by difficulty

3. Educational activities (e.g., deliberate skills practice) focused on objectives

4. Minimum passing mastery standard (MPS) for each unit

5. Formative testing → mastery of each unit

6. Advancement if performance ≥ MPS

7. Continued practice or study until MPS is reached

Multicenter Study Effectiveness of Harvey Nurses

Curriculum

Multicenter Study Effectiveness of Harvey Nurses

Curriculum

Pretest• Knowledge - MCQ• Skills – Checklist• Confidence - Survey

Training Intervention• Pre-Self Study Program• Instructor Guided Sessions• Learner Practice w/Feedback• Self Study Program• Learner Training Logbook

Posttest• Knowledge - MCQ• Skills – Checklist• Confidence – Survey• Instructor Satisfaction

AdvancementMPS Achieved

No

Multicenter Study Effectiveness of Harvey Nurses Curriculum

Mastery Learning – benchmarks setDeliberate Practice – repetitive practice/feedbackCurricular Integration – part of existing coursesAdaptive Learning – small group/self

learning/remediationClinical Variation – 10 clinical cases

Evidence-based Training

Unfolding Cases – Teaching students differently

Grant funding sources calling for simulations

Hartford Foundation partners with the NLN

Simulations incorporated into the grant – develop and implement simulations focused on caring for the aged in the grant

Special series comingAACN Essentials

mandating geriatrics in curriculum

Hartford Foundation Funding to foster geriatric nursing using simulations

John A. Hartford Foundation Funds New Three-Year Project"Fostering Geriatrics in Pre-licensure Nursing Education, Phase II"

Laerdal Medical to Contribute $187K for New Simulation Design for Geriatric Care FOR IMMEDIATE RELEASE

New York, NY — April 8, 2009 — Following a successful Hartford Foundation-funded project to foster geriatrics education among associate degree, pre-licensure nursing students at the Community College of Philadelphia (CCP), the National League for Nursing and Laerdal Medical Corporation have joined forces with the college to extend this preparation to students in all pre-licensure RN programs: associate, baccalaureate, and diploma. This next phase, supported again by a generous grant of nearly $700,000 from the John A. Hartford Foundation, will build on the work done through "Fostering Geriatrics in Associate Degree Nursing Education," funded by Hartford in 2007-08.

NLN Web site – http:/www.nln.org

Using simulations to teach patients and & caregivers

NIH R01 Grants calling for innovation

How can simulations/technology be incorporated into these types of research

Obama’s challenge equipment grants….many, many focused on innovation and health information technology

Use of Technology

The Simulation Technology and the Future

Evolution of the simulators

Robotics?Shift from the majority

of clinical practicum and teaching to teaching clinical in a simulated environment so students can be learn and practice problem-solving, decision-making, and critical thinking

Virtual Simulation and Patient Care

The student or learner

What do they look like in the future?

High technology skillsNeed rapid information

and retrievalDesire real-life

application, everything else is irrelevant

The Globals – Generation linked to each other Borderless environment Embrace a wider stage Bring a global perspective to everything! Desire intercultural dialogues and

lessons

Our students

Simulation has emerged!Simulation has emerged! The future of simulationsThe future of simulations

The future for clinical is promising!

Over time, more evidence will be disseminated on the use, implementation, and best practices of incorporating clinical simulation into a nursing curriculum.

Summary

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.

One approach for Gateway to change in nursing education is the incorporation of clinical simulations in nursing curricula.

If not on board, get on board to use this amazing technology!

Goal for using simulations: Optimal Student Learning for High Quality Patient Care

Questions: pjeffri2@son.jhmi.edu