A CLEAR Approach for the Novice Simulation Facilitator

Teaching and Learning in Nursing xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Teaching and Learning in Nursing journal homepage: www.jtln.org

A CLEAR Approach for the Novice Simulation Facilitator Michelle Curley Moulton a,⁎, Laura Lucas b, Gail Monaghan b, Sandra M. Swoboda b,c a b c

University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201, USA Johns Hopkins University School of Nursing, 525 North Wolfe Street, Baltimore, MD 21205, USA Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA

a r t i c l e

i n f o

Article history: Accepted 18 November 2016 Available online xxxx Keywords: Novice facilitator INACSL Best Practice Standards℠ Simulation Debriefing challenges Experiential learning

a b s t r a c t Facilitating a simulated clinical experience for prelicensure nursing students requires skills. Frequently, the experience is planned, presented, and debriefed by an educator assigned as the facilitator. The International Nursing Association for Clinical Simulation and Learning (INACSL) Best Practice Standards℠ provide the goals for all simulation experiences. This article identifies challenges frequently experienced by the novice facilitator in meeting the standards. A table with the acronym CLEAR has been developed to identify challenges and strategies to assist the novice facilitator to meet the INACSL Best Practice Standards: Simulation Standard V: Facilitator℠ recommendations. The strategies provide the facilitator innovative ways to promote successful simulation learning experiences. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

The use of simulation in health care education is a valuable teaching strategy that provides experiential learning opportunities. A simulation scenario immerses the learner in a clinical scenario that is followed by debriefing by a facilitator. The role of the facilitator is fundamental to the success of the experience and the debriefing of the learner. Knowing how to operationalize and deliver the facilitator role and responsibilities can be challenging for a novice. The purpose of this article is to provide suggestions, direction, and guidance to the novice simulation facilitator through the use of an original acronym CLEAR. The acronym utilizes the evidence-based recommendations from the International Nursing Association for Clinical Simulation and Learning (INACSL) Best Practice Standards℠. INACSL is an organization that works to inform and disseminate evidence-based healthcare simulation practices with the intent of improving patient safety (INACSL, 2015). Background The evidence-based recommendations for the novice simulation facilitator are derived from the INACSL Best Practice Standards: Simulation Standard V: Facilitator (Boese et al., 2013). The recommendations include ways to gain knowledge of the simulation teaching/learning pedagogy, develop skills to prepare for the facilitator role, and explore

qualities that embody a successful simulation facilitator. Standards of best practice provide guidelines, clarity, and a framework to ensure quality and consistency in simulation experiences for students (Alexander et al., 2015). The International Nursing Association for Clinical Simulation and Learning (INACSL) Best Practice Standards help to equalize and balance the experience for participants by using evidence-based criteria for success and detail preparations necessary to assist learners in achieving desired outcomes. Standards provide a methodology to evaluate learner outcomes and decrease variation in simulation education (Rutherford-Hemming, Lioce, & Durham, 2015). A few assumptions are posited by the authors. The first assumption is that training and approaches to facilitating simulation vary among organizations and programs (Casey, Roberts, & Salaman, 1992; Hallmark, 2015). The aim of this article is to establish a single voice and a first step for novice simulation facilitators to expand simulation knowledge and interest; it is not an exhaustive review of facilitation methods. Second, intended audiences are novice simulation facilitators. To define novice, the authors turn to Benner's seminal work, “From Novice to Expert (1982)”, whereas “novice” is simply a person with no experience. To expand the scope of this work, the authors expanded the definition to include simulation facilitators with less than 1-year experience in debriefing techniques.

This work was supported, in part, by the Who Will Care? Fund for Nurse Education administered by the Maryland Healthcare Education Institute, an affiliate of the Maryland Hospital Association.

Definition of Facilitator and Differentiation Between “Facilitator” and “Debriefer”

⁎ Corresponding author. Tel.: +1 443 614 7910. E-mail addresses: [email protected], [email protected] (M.C. Moulton), [email protected] (L. Lucas), [email protected] (G. Monaghan), [email protected] (S. Swoboda).

According to the “INACSL Standards of Best Practice: Simulation Standard I: Terminology℠,” a facilitator is defined as “an individual who provides guidance, support, and structure during simulation-

http://dx.doi.org/10.1016/j.teln.2016.11.003 1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Moulton, M.C., et al., A CLEAR Approach for the Novice Simulation Facilitator, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.003

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M.C. Moulton et al. / Teaching and Learning in Nursing xxx (2016) xxx–xxx

based learning experiences” (Meakim et al., 2013, p. S6). In addition, Lekalakala-Mokgele and Du Rand (2005) define facilitation as a “method and strategy that occurs throughout (before, during, and after) simulation-based learning experiences in which a person helps to bring about an outcome(s) by providing unobtrusive guidance” (Meakim et al., 2013, p. S6). Together, the two terms describe the continuous process in which a designated person conducts and guides the simulation experience from beginning to end. This differs from what this article terms as debriefer or someone who is solely managing the deliberate process of dialog and reflection following a simulated scenario. Fanning and Gaba (2007) identify the elements of the debriefing process and note that, while elements may be done informally or even independently by the participants, it is the skilled role of the facilitator that will help move participants through the elements. While a facilitator often conducts the debriefing as an imbedded piece of the entire experience, it is important to note the facilitator's more robust role in planning, implementing, and evaluating the simulation experience with and for learners. The work of facilitating a simulation experience far exceeds a task that can be learned or delivered “on the fly.” Much of nursing and medical education is learned in this way; do one, see one, teach one method of learning on one's feet (Coughlin, McElroy, & Patrick, 2010), but learner-centered and experiential learning pedagogy, such as simulation, is expanding this approach. The depth and detail of the facilitator standard is evidence that an intentional, detailed,

and mentored learning process for the novice simulation facilitator is necessary. In summary, if it is in the best interest that simulation participants learn in the spirit of experiential and reflective principles, so should the novice simulation facilitator. As previously introduced, the acronym CLEAR was developed for the purpose of incorporating the INACSL Best Practice Standards into simulation facilitation. This was designed to offer guidance to the novice facilitator to identify the standard and recall mechanisms to support the standard while debriefing a learning experience. The acronym stands for “C” communication and constructive feedback; “L” learning partnerships and leader; “E” environment and ensure fidelity; “A” accommodation and assessment/evaluation; and “R” reflection. The CLEAR approach (Table 1) offers initial steps for the novice simulation facilitator to develop knowledge, skills, and attitudes. Conceptual Framework: Martin Buber's Theory One of the most challenging, yet rewarding, aspects of facilitating simulation is transforming the traditional teaching role to one of a side-by-side partnership with the learners. This notion of creating a learning partnership can be founded by the I and Thou book written by Martin Buber in 1923 and then expanded to include educational context by Robert Young in 1992. The author discusses the relationship in which people “see the world.” The seminal work goes on to explain that one can make observations of the world from an “I and

Table 1 CLEAR Recommendations for the Novice Simulation Facilitator

C

L

E

A

R

Characteristic

Challenges

Strategy

Communication Criterion 1

“What” to communicate “How” to communicate

Share simulation objectives with learners Establish learner-focused discussion format Maintain an open posture; monitor nonverbal cues

Constructive Feedback Criterion 9

Accepting and responding with constructive feedback

Role model being open to constructive feedback Utilize an evidence-based debriefing method to structure and guide feedback

Leadership Criterion 6

How to prepare for simulation.

Review simulation objectives and related content Be aware of common themes/“issues” Be prepared to discuss ethical issues

Learning Partnership Criterion 7

How to partner with learners and maintain teacher-learner relationship How to engage with learners during simulation.

Be patient with all mistakes Express curiosity and respect for students Preobserve the simulation with another facilitator

Environment Criterion 2/3

How to decrease learner anxiety or fear of making mistakes

Establish a safe learning environment View mistakes as triggers for learning Inquire with curiosity

How to help learners “overcome the fakeness” of simulated environment

Allow time for hands-on interaction (manikin) Attention to details to create clinical realism Minimize interruptions

Facilitate teaching based on assumed learner's knowledge.

Use open-ended questions or phrases to open discussion: “Talk about the situation when…” “How might you approach…?” “Help me understand more about…” “Share your thinking when....?”

How to adjust the simulation to meet the learners' expressed needs.

Use active listening skills Guide discussions per learners' responses Accommodate to varied learning styles

Assessment and Evaluation Criterion 5

What to talk about in debriefing

Promote discussion of observed actions in context with objectives/desired outcome Observe learners' knowledge, skills, attitudes to guide facilitator's debriefing points Use learner's initial reactions or expressed feelings to guide a few debriefing points

Reflection Criterion 8

How to encourage reflective thinking

Ask learners for a take away message. Allow time to complete a formal evaluation Reflect on learners' feedback and revise the experience as needed Role model reflection with an open-minded approach to “gray” areas

Accommodation Criterion 4

Please cite this article as: Moulton, M.C., et al., A CLEAR Approach for the Novice Simulation Facilitator, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.003

M.C. Moulton et al. / Teaching and Learning in Nursing xxx (2016) xxx–xxx

It” perspective that explains how one sees the world before him or her, independently. However, more meaning and understanding may be gleaned from an “I and Thou” perspective, in which one works to understand how others may see the world and then, together, how the world or “It” is perceived (Buber, 1958). This conceptual model can be used to explain how the simulation facilitator works to stand beside the learner and, together, make observations of the simulation experience or “It” phenomenon (Fig. 1). The facilitator standard recommendations put forth by the INACSL Best Practice Standards consistently describe various ways the facilitator can and should partner with the learner to understand the simulated learning experience, from beginning to end. This theme will be further explored throughout this work.

respect is shared equally among all participants and the facilitator. This helps the learner invest in the experience and creates a sense of ownership with the learning experience. The simulation's learning objectives, both in technical and critical thinking skills, should be shared with learners. Having the students verbalize objectives will provide an opportunity for questions and further clarifications (RutherfordHemming et al., 2015). Last, communicating the logistical expectations (i.e., schedule, breaks, and format) with learners in the beginning helps the facilitator create an environment that is transparent and trustworthy. The manner in which a facilitator communicates is critical. There are two important ways a facilitator communicates: nonverbally and verbally. How a facilitator communicates nonverbally includes a facilitator's active listening and expressed awareness of learners' nonverbal cues. Knowing how to display purposeful nonverbal communication can be challenging for a novice simulation facilitator. Maintaining an open posture helps to place the learner at ease as each enters into simulation. An open posture includes eye contact, leaning forward, and open arms (Mehrabian, 1969). This helps to imply that the simulation facilitator is actively listening and emotionally available to the learner. How a facilitator communicates verbally includes using clear language to describe specific simulation events to the learners during debriefing (Wickers, 2010). The facilitator's attention to detail during simulation observation is essential to provide specific constructive feedback during debriefing. For example, while observing simulation, the facilitator can identify behaviors that then can be shared with the learners for discussion and exploration during debriefing (Rosen, Salas, Silvestri, Wu, & Lazzara, 2008). This helps the facilitator to be specific and clear with learners regarding key discussion points. In addition, communicating the relevant debriefing points helps to initiate the reflection process necessary to assist the learner obtaining deeper learning. Communication skills require practice, and simulations provide the safe environment to improve over time (Jeffries, 2014).

INACSL Standards for the Facilitator The INACSL Best Practice Standards were developed, revised, and enacted in 2011 by a task force that consisted of a board of directors and INACSL members (Sando, Faragher, Boese, & Decker, 2011). The INACSL Best Practice Standards: Simulation Standard V: Facilitator include nine criteria that outline the knowledge, skills, and attitudes of a successful facilitator. To guide the recommendations within, the criteria were summarized and categorized using the “CLEAR” acronym as follows. The discussion provides a description of the acronym, identifies potential challenges that a novice simulation facilitator may face, and offers strategies for success (Table 1). “C” Communication and Constructive Feedback Communication INACSL Standards of Best Practice: Facilitator Criterion 1: “Clearly communicates the objectives and expected outcomes to the participant(s).” The content or “what” a facilitator communicates helps set the tone for any simulation and has an enormous effect and impact on learners. Some of the most important communication with learners is initiated at the beginning of each simulation. Two important communication points are the establishment of psychological safety and sharing the learning objectives. For example, promoting psychological safety is done in part by articulating the need for confidentiality and demonstrating respect for peers and faculty (Sittner et al., 2015). In addition, communicating the expectation of mutual

Constructive Feedback INACSL Standards of Best Practice: Facilitator Criterion 9: “Provides constructive feedback and facilitates debriefing with the participants.” Debriefing is a critical component of simulation and serves as the method in which to deliver feedback and initiate dialog with learners. There are many ways to structure debriefing, using different methods to guide the learning conversation. When choosing a

Simulation Experience “It”

Teaching & Learning

Facilitator

Learner COMMUNICATION

“I”

3

“Thou”

Fig. 1. Martin Buber's concept of “I, It & Thou” applied to the simulation experience with facilitator and learner.

Please cite this article as: Moulton, M.C., et al., A CLEAR Approach for the Novice Simulation Facilitator, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.003

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structure for example, a facilitator can consider the use of video to play a portion of the recording for students (Chronister & Brown, 2012). This helps bring the learners directly to critical points of inquiry and assists the facilitator in encouraging reflection. When choosing a method to guide the learning conversation, a facilitator has several choices. A small sample of debriefing methods to explore are Debriefing for Meaningful Learning (Dreifuerst, 2012), Debriefing with Good Judgment (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007), and Promoting Excellence and Reflective Learning in Simulation (PEARLS) (Eppich & Cheng, 2015). While the many options for debriefing methods can be overwhelming, it is most important to incorporate an evidence-based method. The facilitator must be familiar with the method used to guide the learner and receive formal training with feedback to encourage success with students (Decker et al., 2013). According to Rutherford-Hemming et al. (2015), it is important to keep the facilitation methods focused on the learner and to avoid defaulting to a traditional teacher-centered debriefing format. Formal training in how to lead a debriefing conversation with a specific debriefing method can avoid this potential pitfall. One way a facilitator can offer constructive feedback is in the use of the advocacy–inquiry format (Rudolph et al., 2007). This style of feedback recommends the facilitator to identify and offer an observation of the learner. In addition, the facilitator asks a curious question to reveal the rationale behind the learner's action, for example: “So, Damon, I noticed that you stepped away from the patient to find the bag mask apparatus as the vital signs were deteriorating. I was thinking there were possible alternative means to oxygenate the patient (advocacy). So I'm curious: how were you seeing the situation at that time? (inquiry)” (Rudolph et al., 2007, p. 371). This form of communication, when done in a safe environment, is effective to encourage, support, and investigate the leaner's thought process (Rudolph et al., 2007). Constructive feedback in the form of debriefing values both the insight of the learner and the expertise of the facilitator without creating a sense of defensiveness, embarrassment, criticism, fear, or blame (Mayville, 2011).

The facilitator is in a unique position to influence and manage all aspects of simulation. This will include the art of being able to partner with the learner to elicit reflective learning that will affect the learners' ability to apply changes to future practice. It is important for the facilitator to be able to observe, assess, guide, and support a participant's learning during the debriefing time. The facilitator encourages learning in the form of repetitive practice, talking, writing, and relating to past experiences. Based on a participant's actions or lack of actions during a simulation, the facilitator maintains the learning partnership with positivity.

“L” Learning Partnership and Leader

INACSL Standards of Best Practice: Facilitator Criterion 2: “Creates a safe learning environment that supports and encourages active learning, repetitive practice, and reflection.” This criterion highlights the role of the facilitator in creating an environment that supports and encourages active learning, practice, and reflection. Creating a safe learning environment for simulation participants is critical to allow learners the space and opportunity to think, perform, reflect, and share their experiences during simulation. For example, the simulated environment often requires “behind the scenes” observers including faculty, supervisors, and/or peers. Often, learners perceive faculty or peers as having punitive judgment or power that creates a sense of vulnerability. Vulnerability can tamper the learner's readiness to take the learning risks necessary to make simulation successful. In addition, the debriefing discussion following the simulated event often brings forth learner mistakes or knowledge gaps that can be visible to everyone involved in the discussion. To help learners feel comfortable engaging with the open observation and discussion format, facilitators should create a safe learning environment and a sense of trust (Neill & Wotton, 2011). Establishing trust can include stating a few key points: keeping the simulation peer performances and debriefing discussions confidential, explaining expectations of both facilitator and learners, and describing the debriefing process (Fanning & Gaba, 2007). More specifically, it is important to impart on learners that mistakes in simulation are triggers for learning discussions in the debriefing. Being explicit and transparent about the facilitator's approach to addressing simulation performance can help learners feel more at ease. Ideally, these discussion points should occur before the simulated events occur and are maintained throughout the entire experience (Fanning & Gaba, 2007).

Learning Partnership INACSL Standards of Best Practice: Facilitator Criterion 7: “Foster participant learning by providing appropriate support throughout the simulation activity, from preparation through reflection.” This criterion addresses the importance of a facilitator supporting the learner throughout the entire simulation experience. Providing continual learner support is a way to help the participant achieve optimal learning. An example is teaching a child how to ride a bike using training wheels initially and then lessening the physical support as the child becomes more independent and confident in the skill. One way this can be achieved is through the creation of a learning partnership. A learning partnership can be established using the Martin Buber's theory as support for how the simulation facilitator and learners can collaborate to evaluate the outcomes of the simulation activity together. This learning partnership expresses itself most centrally and is beneficial during the time of debriefing. During debriefing, the facilitator shares observed learner “mistakes” for the sake of uncovering and closing performance gaps that can be applied to real-world patient care. The importance of the learning partnership is how the learning occurs in the safety of the simulated environment. The safety of the simulated environment is much like the training wheels of the beginner bike rider mentioned earlier. The facilitator assists the learner with identifying aspects of the simulation that could have been changed to promote better patient outcomes and meet the objectives (Boese et al., 2013). Much of this will be accomplished through inquiry and dialog.

Leader INACSL Standards of Best Practice: Facilitator Criterion 6: “Models professional integrity.” The facilitator as the leader prepares for all aspects of the simulation and reviews the content related to the objectives. By doing so, the facilitator may be able to anticipate some common reactions by learners. For example, a simulation scenario with objectives focusing on end-of-life nursing care can anticipate a high likelihood for a personally emotional response by a learner. Being prepared on how to handle a participant's emotional response helps the facilitator gather resources for continued support in advance. An example of continued support for learners can be referrals to campus student support centers like counseling and stress management services. According to criterion six, the facilitator models professional integrity (Boese et al., 2013). The actions of the facilitator influences the learners' outcomes. The behaviors attributed to a successful facilitator include being positive, enthusiastic, flexible and resourceful, organized, and prepared for managing the simulation (Boese et al., 2013). Last, the facilitator promotes a calm environment to build trust, share his or her expertise, and be mindful of issues regarding diversity, inclusive of ethical or cultural sensitivity (Boese et al., 2013). “E” Environment and Ensure Fidelity

Please cite this article as: Moulton, M.C., et al., A CLEAR Approach for the Novice Simulation Facilitator, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.003

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To support learners, one conceptual model presented by Rudolph, Simon, Dufresne, and Raemer (2006) encourages the instructor or simulation facilitator to use a stance of “curiosity and respect” when engaging with learners. To do this, participants are asked curious questions intended to uncover the rationales or mental models that lead to the observable actions during the simulation event. Sharing the stance of curiosity and respect with learners prior to the start helps create the side-by-side learning partnership of understanding the series of events, rather than just stating facts and assumed solutions.

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discussion. The use of open-ended questions in debriefing elicits the learners' understanding and response to the scenario. For example, begin a debriefing session with the following question: “What are your initial reactions to the simulation?”. This question will often bring to the surface the challenges and clinical problems the learners were presented with during the simulated event. Facilitators can take note of some of the themes that resonated among participants during this opening assessment. “R” Reflection

Ensure Fidelity Reflection INACSL Standards of Best Practice: Facilitator Criterion 3: “Promotes and maintains fidelity.” This criterion addresses the facilitator's role in establishing and maintaining fidelity or “realism” of the simulation. The simulation environment inherently asks the learner to negotiate what is real versus what is simulated. This may lead to learner confusion. An early systematic review of the literature-identified simulation with high realism was preferred by learners and allowed for better transferability to the real clinical setting (Issenberg, Mcgaghie, Petrusa, Lee Gordon, & Scalese, 2005). The facilitator helps establish high-fidelity simulation for learners by ensuring that the environment closely mimics that of the real clinical setting. This requires attention to details and innovation. Maintaining a high-level realism is also the facilitator's responsibility. This is achieved by informing the learners of the manikin and technology functions prior to the start of the simulated experience. Simulation resources (i.e., electronic/ paper patient charts, medications, hemodynamic monitors, etc.) should also be shared with learners prior to beginning their learning experience. Providing a hands-on opportunity to listen to manikin lung sounds and feel pulses, for example, can help the learners gain an increased sense of comfort and familiarity to help them through the simulation event. “A” - Accommodation and Assessment/Evaluation Accommodation INACSL Standards of Best Practice Facilitator Criterion 4: “Uses facilitation methods appropriate to the participants' level of learning and experience.” This criterion asks the facilitators to use methods that accommodate the participants' level of learning and experience. Learners come to simulation with varied learning styles, knowledge, and skill levels. In order to accommodate the variety, facilitators need to be flexible and willing to change the direction of the learning experience as needed. One way to accommodate to learners' needs is to use open-ended questions during debriefing when trying to gain learners' insight into their actions (Table 1). Once the learners begin to share their experience, the facilitator's job is to use active listening skills and be ready to respond based solely on the learner's response. This type of accommodation may require the facilitator to acknowledge and remove any preconceived biases or expectations and truly respond to what is heard. Open questioning and active listening help guide an enriching group discussion that is reflective of actual learner knowledge gaps versus teaching from an agenda or checklist. Assessment/Evaluation INACSL Standards of Best Practice Facilitator Criterion 5: “Assesses and evaluates the acquisition of knowledge, skills, attitudes, and behaviors.” The facilitator is expected to assess and evaluate the acquisition of knowledge, skills, attitudes, and behaviors. The most direct way to do this is to create a list of objectives and defined observable behaviors. These observable behaviors guide not only the facilitator's observation during the simulated event but also the debriefing

INACSL Standards of Best Practice Facilitator Criterion 8: “Establishes and Obtains Evaluation Data Regarding the Effectiveness of the Facilitator and the Simulation Experience.” Reflective learning includes the process of reflection that requires an honest self-assessment combined with open communication to identify the “how” and “why” of a participant's actions, which led to a specific outcome (Mayville, 2011). Learning is impacted by one's ability to consciously integrate experiences with skills, attitudes, implications of an action, and preexisting knowledge. There may be new perspectives and interpretations after the process of reflective thinking. While reflective thinking does not happen intrinsically, an effective facilitator assists and guides a learner to use reflective thinking in an effective manner (Decker et al., 2013). It is useful for the facilitator to model reflective thinking in a way that provides each participant time to reflect on their own experiences and to be able to identify a discovery point or “take away” from this experience (Durham, Cato, & Lasater, 2014). Debriefing has been identified as a reflective phase of the simulation process. During this time, feedback is constructive, and the facilitator allows time and encourages the participant to self-evaluate and critique (Boese et al., 2013). Reflective learning has been credited with fostering the development of clinical judgment and clinical reasoning when guided by an effective facilitator (Decker et al., 2013; Ironside & Jeffries, 2010; Mariani, Cantrell, Meakim, Prieto, & Dreifuerst, 2013). Reflective learning is the responsibility not only of the learner but also of the facilitator. Conclusion The role of facilitator is essential in achieving learner success during the experiential learning experience of simulation. A novice facilitator is often challenged when newly engaging with simulation pedagogy, but support is available and has been offered within. The theoretical application of “I and Thou” (Fig. 1) supports the importance of creating a faculty–learner partnership and embodies the INACSL Standards of Best Practice: Simulation Standard: Facilitator. The evidence-based recommendations of the INACSL Standards of Best Practice further offer a solid foundation and resource for successful simulation teaching/learning strategy. Last, experienced simulation facilitators shared lessons learned that reflect the real-time experiential learning that novice facilitators experience, similar to that of the learners in simulation. As research and new methods to facilitating increase, educators' attention to standards guiding simulation must increase as well. To assist in this process, the CLEAR table is a tool to assist in preparation and performance for simulation, according to industry standards. As simulation in nursing progresses, it is important to keep this learner-focus experience CLEAR. Acknowledgments This work was supported in part by the Who Will Care? Fund for Nurse Education administered by the Maryland Healthcare Education Institute, an affiliate of the Maryland Hospital Association. We

Please cite this article as: Moulton, M.C., et al., A CLEAR Approach for the Novice Simulation Facilitator, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.003

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Please cite this article as: Moulton, M.C., et al., A CLEAR Approach for the Novice Simulation Facilitator, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.11.003