Handling Strong Emotions Before, During, and After Simulated Clinical Experiences

Clinical Simulation in Nursing (2016) 12, 37-43

www.elsevier.com/locate/ecsn

Review Article

Handling Strong Emotions Before, During, and After Simulated Clinical Experiences Katherine J. Janzen, RN, MN, ONC(C)*, Shelley Jeske, RN, MN, CHSE, Heather MacLean, RN, MN, Giuliana Harvey, RN, MN, Penny Nickle, BN, MEd, Leanne Norenna, RN, BScN, MN, Murray Holtby, RN, PhD, BTh, Heather McLellan, RN, BN, MDE, CFRN School of Nursing and Midwifery, Faculty of Health, Community and Education, Mount Royal University, Calgary, Alberta, Canada T3E 6K6 KEYWORDS psychological harm; simulated clinical experiences; psychological safety; facilitators; prebrief; scenario; debrief; nursing simulation; emotions in simulation

Abstract: Psychological harm is a complex phenomenon which becomes even more complex and problematic in simulated clinical experiences (SCEs). Currently, there exists only one published protocol that addresses policies and procedures to mediate psychological harm during simulated clinical experiences. In this article, the phenomenon of psychological safety and psychological harm is explored. By synthesizing the results of a literature search, actions that could be taken before, during, and after the debrief are outlined. With the literature acting as a springboard for further discussion, suggestions are provided by a think tank of novice to expert facilitators that may assist simulation teams to mediate and intervene when psychological harm occurs with students. Cite this article: Janzen, K. J., Jeske, S., MacLean, H., Harvey, G., Nickle, P., Norenna, L., Holtby, M., & McLellan, H. (2016, February). Handling strong emotions before, during, and after simulated clinical experiences. Clinical Simulation in Nursing, 12(2), 37-43. http://dx.doi.org/10.1016/j.ecns.2015.12.004. Ó 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Simulation has long been a mainstay in medical education and is increasingly becoming an essential part of nursing education (Jeffries & Rogers, 2007; Benner, Sutphen, Leonard, & Day, 2010; Paige, Arora, Fernandez, & Seymour, 2015, Truog & Meyer, 2013). Benner et al. (2010) have called for simulated clinical experiences (SCEs) as a means for educating nurses which is beneficial for student learning overall. Simulation is an extremely effective mode of teaching (Paige et al., 2015), it also has been shown to enhance

* Corresponding author: [email protected] (K. J. Janzen).

knowledge gained from SCEs anywhere from 7 to 9 weeks after SCE (Ross et al., 2013) to up to a year after the experience (Hubert, Duwat, Deransy, Mahjoub, & Dupont, 2014). Learning is additionally enhanced when emotional content is added into simulation scenarios as it impacts affective changes in students (Corvetto & Taekman, 2013). Simulation has been shown to be effective in replacing from 13% to 50% of clinical hours for nursing students since 2007 (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014; Larue, Pepin, & Allard, 2015). With this knowledge, SCEs could be considered a strong pedagogy to incorporate into nursing education.

1876-1399/$ - see front matter Ó 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.ecns.2015.12.004

When the Debrief Time Runs Out Although debriefing is considered to be the most essential factor for effective learning (Levett-Jones & Lapkin, 2014; Paige et al., 2015) during a SCE, the prebriefing is highly influential on the debriefing outcomes in terms of experiential learning, reflection, and future application (Rudolph, Raemer, & Simon, 2014). Key Points Rudolph et al. (2014)  Psychological harm explain that in prebriefing, can occur in highly objectives are clarified, the immersive and environment is outlined, emotionally charged roles are delineated, confiSCEs. dentiality is emphasized,  An awareness of the and expectations are made cues that demonstrate explicit. Furthermore, prepsychological harm briefing sets the stage for is a precursor to the student engagement as it prevention and manhelps to develop trusting agement if psychorelationships. logical harm. Preparation during the  Policy and procedure prebrief additionally indevelopment is essencludes a process of creating tial to assist students an agreement on the part of whose psychological the student and the facilitaintegrity becomes tor(s) (Rudolph et al., compromised before, 2014). There is a need for during or after the destudents to establish a ‘‘ficbriefing process. tion contract’’ in which they acknowledge and accept they will actively care for a ‘‘real’’ (although simulated) patient during the scenario and that they will actively participate in a ‘‘fictional environment’’ (p. 341). This fictional environment, created by facilitator(s), engages students in an atmosphere of realism. In addition, Rudolph et al. (2014) emphasize that facilitator(s) are strongly expected to focus on logistical details and communicating and embodying a commitment of mutual respect for all participants which additionally values all participant’s perspectives. After the scenario is concluded, a debriefing session takes place where a discussion is facilitated by trained facilitator(s). In the postsimulation debrief, the students have an opportunity to not only reflect on the scenario but also discuss what went well and what did not (Rudolph et al., 2014). In this atmosphere, sense making is paired with application of lessons learned for prospective clinical experiences. This sense making contributes to learning that persists long past the simulation experience (Fanning & Gaba, 2007). Paige et al. (2015) identify three key roles of the facilitator during the debriefing process: ‘‘making it safe, making it stick, and making it last’’ (p. 127). In terms of making SCEs safe, the role of facilitator(s) includes academic safety (Ganley & Linnard-Palmer, 2012) and psychological safety (Gaba, 2013; Truog & Meyer, 2013). The purpose of this article was to explore psychological

38 safety in SCE and to identify strategies to assist students whose psychological integrity becomes compromised before, during or after the debriefing process.

Background The SCE facilitators group in a mid-sized university in Western Canada met to discuss the inherent challenges and ongoing potential of psychological harm in SCEs. Physical and emotional manifestations of psychological harm were observed in a few students who had recently attended SCEs. For example, a confrontation scenario with an angry family member generated post-traumatic stress in a student that was triggered by the memory of her father. Questions arose pertaining to how psychological safety could be extended before, through, and after the debriefing process when students are visibly physically or emotionally triggered by past events in their lives and/or remain troubled beyond the debriefing session. In addition, what safety measures could be put into place operationally? Both novice and experienced facilitators took part in the discussion. One team member held Certified Healthcare Simulation Educator status with 8 years experience. The remainder of the team had from 1 to 5 years experience in facilitating simulation and various levels of simulation development expertise. All team members were nurses and educators. The purpose of the meeting was to create a think tank and generate potential solutions to prevent or at least mediate in situations where psychological harm was ascertained to have occurred. Recommendations were derived from six pages of notes taken at the meeting by one of the authors. The notes were analyzed for themes and then categorized into recommendations. This article represents the outcomes of the categorization and the literature review that ensued.

Literature Review Psychological harm is defined as ‘‘harm that can manifest itself through worry (warranted or unwarranted), feeling upset or depressed, embarrassed, shameful or guilty, and/or result in the loss of self-confidence’’ (University of Virginia, 2012, para 2). There is a paucity of research surrounding psychological harm occurring in students in SCEs (Corvetto & Taekman, 2013). Ferguson et al. (2014) emphasize that there is no known literature available which offers validated experiences. Willhaus, Averette, Gates, Jackson, and Windgael (2014) cite only two formally reported severe anxiety reactions in the literature (Macy & Schrader, 2008; Oberleitner, Broussard, & Bourque, 2011). Over the course of delivering SCEs in our center, our outcomes mirror the literatureda small number of reactions cause large concern for how we best manage these cases. Psychological safety is a complex phenomenon. Although Ganley and Linnard-Palmer (2012) describe pp 37-43  Clinical Simulation in Nursing  Volume 12  Issue 2

When the Debrief Time Runs Out academic safety and psychological safety as interchangeable terms, we posit that these are separate entities. Academic safety is compromised when students fear ‘‘academic failure, negative judgment by their faculty and peers’’ while psychological safety refers to freedom from embarrassment, and loss of integrity (p. e2). Academic safety has ties to performative safety, which entails freedom from adverse consequences to self-perception, social standing, or career path (p. e2). The foundations of psychological safety are trust and safety (Gaba, 2013). Safety refers to both psychological and environmental safety where ‘‘a safe learning environment [is] one in which [learners] are not ridiculed, or embarrassed by their mistakes. able to function without debilitating anxiety and not afraid to fail’’ (Ganley & Linnard-Palmer, 2012, p. e4). Furthermore, there is no judgment when mistakes are made, but rather the mistakes are seen as learning opportunities. A safe environment is one which is conducive to learning where students ask questions, experience healthy anxiety, increase their confidence, and has the potential to excel in a constructive manner (p. e4). Psychological safety can be influenced not only by fatigue and illness but also by prescription medications and ‘‘other vagaries of life’’ (Gaba, 2013, p. 6). Low selfconfidence can also influence psychological safety resulting in greater stress than that is normally experienced by students before and during the SCE (Leigh, 2008). SmithStoner (2009) suggests that psychological safety can be further impaired by pediophobia (fear of dolls) and students that may be resistant to participating in SCEs. A safe learning milieu necessitates psychological and emotionally balanced conditions that offer an empowering experience for all students (Ganley & Linnard-Palmer, 2012). Truog and Meyer (2013) pose the question of whether a SCE exposes learners to psychological harm. Certainly, the SCE can evoke high anxiety among learners which is well documented in the literature (Cato, 2013; Corvetto & Taekman, 2013; Ferguson et al., 2014; Leigh, 2008; Smith-Stoner, 2009). For those students who are proficient at masking their emotionsdvulnerability, weakness, shame, or distressdmay become by-products of SCEs and not recognized by the facilitator (Truog & Myers, 2013). Conversely, some students are openly triggered by the events of SCEs and experience a multitude of emotions either during the prebriefing scenario or the debriefing especially if an element of deception is employed in the simulation scenario (Gaba, 2013; Truog & Myers, 2013). Willhaus et al. (2014) cite, ‘‘uncontrolled crying, a sense of impending doom or danger, fear of loss of control, loss of consciousness, rapid heart rate, chest pain, sweating, shortness of breath, nausea, dizziness, trouble swallowing [and] allergic reaction’’ as some of the reactions that can occur with increased or uncontrolled stress in SCEs (p. 234). Although there is significant evidence supporting the benefits of effective debriefing, there is great variance in the time frame that is suggested for this component of the SCE. Jeffries and Rizzolo (2006) cite a 20-minute time limit,

39 whereas Der Sahakian et al. (2015) emphasize that 45 minutes should be taken for the debriefing. Cato (2013) suggests that debriefing normally last two times the length of the SCE scenario. What happens to students who are still visibly triggered or emotionally upset when the debriefing ends? Ferguson et al. (2014) suggest that SCEs can mimic a ‘‘pulling away’’ versus engagement or a ‘‘fight or flight’’ response evoking anger or withdrawal. For example, a student might leave an SCE when an emotional trigger becomes too much to bear. This may be not much different than a clinical situation. Thus, students may become very withdrawn or on the other hand be outwardly or inwardly troubled. The International Nursing Association for Clinical Simulation and Learning describes best practices for nursing simulation. The Simulation Design Standard (Lioce et al., 2015) discusses prebriefing activities which promote a respectful, trusting learning environment and expectations for all participants including the facilitator. Lioce et al. (2015) also emphasize the importance of adequate facilitator preparation which for our purposes within this article should include consideration and awareness of psychological guidelines where possible. At present, no formalized protocol exists describing steps to be taken surrounding potential distressing events (Willhaus et al., 2014) other than creating a safe environment (The INACSL Board of Directors, 2011a; 2011b). Willhaus et al. (2014) have created the only known sample policy for the identification and proactive planning for inadvertent stress responses in SCEs. Cato (2013) used the model of Palethorpe and Wilson’s (2011) (that has been utilized in industry) to create the Comfort-StretchPanic Model in Simulation (Table). The model of Cato (2013) emphasizes that there are three zones that students can experience in an SCE. The first zone, comfort, reflects student disengagement and an emphasis on the experience not being ‘‘real.’’ The second zone, stretch, finds students fully engaged with an optimal level of stress and challenge which facilitates learning and application to the realities of the clinical setting. The final zone, panic, results in student distress which impairs cognitive learning capacity. Rudolph et al. (2014) suggest that the prevention of psychological harm begins during the prebriefing and continues through the scenario and debriefing when a ‘‘safe container’’ is established (p. 339). Furthermore, it is emphasized that interpersonal risk may still be experienced by students despite establishing an atmosphere of psychological safety (Rudolph et al., 2014). The goal is ‘‘creating a setting where learners feel safe enough to embrace feeling uncomfortable’’ (p. 340). When learners move from being uncomfortable to experiencing psychological harm, it is imperative that new strategies be put in action. The first step to addressing psychological harm would be recognition of students who remain distressed and where the students align with the behaviors within the model of pp 37-43  Clinical Simulation in Nursing  Volume 12  Issue 2

When the Debrief Time Runs Out Table

40

Comfort-Stretch-Panic Model in Simulation

Comfort Zone  Little challenge present  Involvement is minimal  Any learning is considered to be by chance (Palethorpe & Wilson, 2011) Student Responses  This is fake so I can try whatever I want.  Who cares if I mess up?  It’s just a mannequindit’s not real.

Impact on Learning  This has not helped my learning in clinical

Stretch Zone

Panic Zone

 Learners presented with some stress  Motivated to optimal performance  Challenging conditions (Palethorpe & Wilson, 2011) Student Responses

 Challenge or stress becomes too great  Learning is severely impaired  Decrease in efficiency (Palethorpe & Wilson, 2011) Student Responses

 I appreciate the aspects of unknown  It’s good preparation for learning how to deal with feelings  If I do a lot of prep, I feel not totally confident, but better  I think it is good to anticipate what could go wrong  I can learn from other’s mistakes Impact on Learning  I learn from other people’s mistakes  I can explain what was on my mind and walk through it. I like the ‘‘after part’’  If I have to operate under pressure, I find it easier to reflect back on those experiences in a powerful way that might affect my ability to do those skills later on  Our groups have been pretty good at giving constructive feedback  The facilitator broke it all down into what went well and what did not. I liked that.

 I went to call somebody and could not even see the numbers on the phone  I’m sweaty  I cried  I cannot handle this  I’m freaking out  This is triggering another past situation in my life  I’m totally overwhelmed Impact on Learning  I lose what I prepared for my mind goes blank and my heart starts beating really fast  I did vitals and forgot them  I called a minute later and could not remember what the respirations were  I did not know what to do. I felt I was about to do the wrong thing  I panicked and just shut down

Adapted from Cato (2013); used with permission.

Cato (2013). As Cato explains, distress impairs students’ cognitive abilities, and students simply are unable to learn when in a panic zone. To move students from the panic zone to the stretch zone involves coaching in relation to student skills and fostering support from their peers. Cato suggests sharing the model with nursing students during initial orientation to SCEs or at the beginning of each prebrief. It is suggested that there will be input at the end of the debriefing by the student’s clinical instructor as an additional postdebriefing session as a means of promoting a sense of recovery in students who experience anxiety. Gaba (2013) offers a list of suggestions that may help facilitators and those who develop SCEs:  ‘‘[Facilitators] must think hard about the ethical and psychological aspects of what they are doing both in advance and in the moment.  [Facilitators] should design and conduct SCEs in ways that take into account the vulnerabilities [of the students].  During prebriefing the [facilitators] should discuss and disclose relevant psychologically challenging

components of simulation scenarios when it is possible to do so without adversely affecting the learning objectives.  During debriefing [facilitators] should disclose any deception or scripting of scenario outcome or confederate behavior, so that learners may understand what transpired and why the scenario was conducted as it was.  [Facilitators] for scenarios that are likely to evoke strong emotions and psychological response from participants should be highly experienced and prepared to deal with the issues raised. For example, taking into account some of the potential triggers generated during a scenario, and recognizing that an awareness or sensitivity to evoke a psychological response exists within a SCE.  [Facilitators] should consider routine follow-up with all participants after such simulations are conducted and certainly follow-up if there is any indication of a significant psychological impact from the experience. [Facilitators] should consider establishing referral linkages with professionals who can evaluate and treat individuals who are troubled by the simulation.’’ (p. 6) pp 37-43  Clinical Simulation in Nursing  Volume 12  Issue 2

When the Debrief Time Runs Out Corvetto and Taekman (2013) and Willhaus et al. (2014) offer additional suggestions which echo those of Gaba (2013). They recommend the provision of counseling services, establishment of a safety plan for students who are identified at high risk for self harm, and the inclusion of psychology faculty from nursing or other disciplines in sessions that are likely to provoke strong emotions or psychological harm. Der Sahakian et al. (2015) describe that unproductive debriefing occurs when SCE participants sense that a complication has hampered the process of learning. Complications, such as psychological harm or distress, can be resolved partially by ‘‘decontextualizing’’ the participant’s experiences during the debriefing session (p. 203). This involves psychological safety in sharing, exploring, and expressing emotions (p. 204).

Facilitator Discussion Results Students encountering SCEs can be challenged in many ways prior, during, and after SCE. Before participating in an SCE, the simulation students may feel that something is going to happen to them. Leigh (2008) supports this citing a ‘‘feeling of foreboding’’ occurring among students (p. 7). Alternately, the scenario may be known ahead of time despite the best of efforts to maintain confidentiality. This may result in feelings of complete control versus no control. There may be, however, value in both SCE situations. Given this, is the ‘‘surprise factor’’ a necessary element in SCEs? As a facilitation team, we have not come to a consensus on this question, we do believe that it is dependent on (a) the level of learners, (b) the intended learning outcomes, and (c) a determination of whether the scenario has an objective of recognizing a condition or situation. Students who are in programs that have extremely high standards for admission, such as undergraduate nursing programs, may find themselves in situations where they feel like they have failed in SCEs. This may be the first time the students do not succeed in their educational pursuits. Students may take this sense of failure personally if the outcomes were less than positive for them. Students may see their actions as ‘‘right’’ or ‘‘wrong’’ rather than following an algorithm. Part of debriefing in these situations may involve constructing the SCE scenario to assist students in developing a deeper understanding of their decision-making and the intents of the scenario. Other students may view SCEs as a ‘‘game’’ where the goal is to get to the next level. This may result in disparate anger due to feelings of SCEs being a ‘‘no win’ situation. Although at some institutions, all students have the opportunity to be active participants within a scenario, many SCE scenarios are comprised of those who provide direct patient care during the scenario and those who remain observers of the direct patient care delivered by

41 their peers. We surmise that the potential for differences in levels of engagement in students results in further questions for exploration. Are active participants more affected psychologically and thus experience more psychological harm than observers? Do observers experience psychological harm through transference and counter transference from their peers who are active participants? With this in mind, setting the stage in the prebrief and identifying roles and vulnerabilities of students becomes even more important as stress and cognitive load can be considerable in SCEs (Rudolph et al., 2014). More research is needed to understand these processes in regards to psychological harm. Rudolph et al. (2014) note that it is much easier to decipher what needs to occur as an SCE unfolds when looking from the outside in, but it is much harder looking from the inside out. Likewise, it is much easier for facilitators to see what needs to be done once outside the debrief than inside when thinking on one’s feet and with no protocols to follow. This leads to a possible rethinking about how the SCE is performed. The following constitutes a list of potential actions that were identified that could be taken in debriefing to modulate experiences of psychological harm. Many of these suggestions have inherent strengths and challenges for implementation, but are important to consider.  Being aware of what cues demonstrate psychological harm.  Encourage emphasis on not only caring for self but also how to care for self after SCEs. This would include student and facilitator self-care as facilitators may experience a degree of psychological harm because of a student’s strong emotions.  Consider the inclusion of clinical instructors in the room with the students. This may help students mimic the calm, organized behavior of the clinical instructor. The clinical instructor’s role should carefully be defined to create a balance that elicits a sense of safety for students. Keeping learning and performance separate is integral in creating safe spaces for students when interacting with their clinical instructors.  Engage in SCE debriefing with a cofacilitator at all times to ensure additional support for the identification and management of psychological/physical harm.  Consult with risk management services within the college or university to draft policies surrounding SCE and psychological safety.  Normalize situations of stress (especially if such situations are an expectation for a professional career). The prevention of dysfunctional stress begins with the recognition that nursing is a stressful profession (Bailey & Clarke, 2013). Capp and Williams (2012) have demonstrated that a preawareness of stressproducing situations that can and do occur in nursing can be protective for nursing students. pp 37-43  Clinical Simulation in Nursing  Volume 12  Issue 2

When the Debrief Time Runs Out  Have an ‘‘alternate facilitator plan’’ where the phone number and location of an additional facilitator are available (‘‘on call’’ facilitator) to assist with students experiencing psychological harm and/or remaining learners. This is supported by Willhaus et al. (2014).  Provide resources for handling psychological harm to students in the prebriefing portion of SCE such as counseling services and health services within the university or college.  Incorporate Comfort-Stretch-Panic Model for Simulation by Cato (2013) as a departure point for discussion with students in both prebriefing and debriefing.  Ensure that urgent/emergency contact information is readily available for facilitators/staff if a student needs immediate medical or psychological attention (e.g., security services, emergency services).

Conclusion In this article, the authors explored psychological harm which has a potential to occur in highly immersive and emotionally charged SCEs. Through investigating the literature that surrounds psychological harm and further discussion, suggestions to assist faculty in the prevention and management of psychological harm in students were presented. More research is needed to describe and explore this important phenomenon and interventions to mediate it. As debriefing is considered to be the most important element of SCEs, there should be transparency and an increased focus on some of the psychological aspects of SCEs in debriefing. This can include being more mindful about stressors and triggers of students who may inadvertently experience psychological harm as a result of their SCE experience. This ultimately begins with the establishment of a ‘‘safe space’’ in prebriefing which sets up the scenario for successful outcomes with students. Although not every student will experience psychological harm, attention and education regarding psychological harm can further enhance the safety and trust of students who engage in SCEs.

Acknowledgments The authors would like to thank Dr. Mary L. Cato for graciously allowing us to adapt her Comfort-Stretch-Panic Model for use in this article.

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42 Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Capp, S. J., & Williams, M. G. (2012). Promoting student success and well-being: A stress management course. Holistic Nursing Practice, 26(5), 272-276. http://dx.doi.org/10.1097/HNP.0b013e318263f32a. Cato, M. L. (2013). Nursing student anxiety in simulation settings: A mixed methods study. (Doctoral dissertation, Portland State University), pp. 1-185, Retrieved from http://cpedinitiative.org/files/Cato.pdf. Corvetto, M. A., & Taekman, J. M. (2013). To die or not to die? A review of simulated death. Simulation in Healthcare, 8(1), 8-12. http: //dx.doi.org/10.1097/SIH0b013e3182689aff. Der Sahakian, G., Alinier, G., Savoldelli, G., Oriot, D., Jaffrelot, M., & Lecomte, F. (2015). Setting conditions for productive debriefing. Simulation & Gaming, 46(2), 197-208. http://dx.doi.org/10.1177/ 1046878115576105. Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125. Ferguson, E., Buttery, A., Miles, G., Tatalia, C., Clarke, D. D., Lonsdale, A. J., ., & Lawrence, C. (2014). The temporal rating of emergency non-technical skills (TRENT) index for self and others: Psychometric properties and emotional responses. BMC Medical Education, 14(1), 240-251. http://dx.doi.org/10.1186/s12909-014-0240-y. Gaba, D. M. (2013). Simulations that are challenging to the psyche of participants: How much should we worry and about what? Simulation in Healthcare, 8(1), 4-7. http://dx.doi.org/10.1097/SIH.0b013e18264a6f. Ganley, B. J., & Linnard-Palmer, L. (2012). Academic safety during nursing simulation: Perceptions of nursing students and faculty. Clinical Simulation in Nursing, 8(2), e49-e57. http://dx.doi.org/10.1016/ j.ecns.2010.06.004. 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. Retrieved from http://atireallife. com/wp-content/uploads/2014/08/JNR_Simulation_Supplement.pdf. Hubert, V., Duwat, A., Deransy, R., Mahjoub, Y., & Dupont, H. (2014). Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology, 120(4), 999-1008. http://dx.doi.org/10. 1097/ALN.0000000000000138. Jeffries, P., & Rizzolo, M. (2006). Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi- method study. New York: National League for Nursing. Jeffries, P. R., & Rogers, K. J. (2007). Theoretical framework for simulation design. In P. R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing 21-33).  (2015). Simulation in preparation or subLarue, C., Pepin, J., & Allard, E. stitution for clinical placement: A systematic review of the literature. Journal of Nursing Education and Practice, 5(9), 132. http: //dx.doi.org/10.5430/jnep.v5n9p132. Leigh, G. T. (2008). High-fidelity patient simulation and nursing students’ self-efficacy: A review of the literature. International Journal of Nursing Education Scholarship, 5(1), 1-17, Retrieved from http://www.degruyter.com/view/j/ijnes.2008.5.issue-1/ijnes.2008.5.1.1613%20/ijnes. 2008.5.1.1613.xml. Levett-Jones, T., & Lapkin, S. (2014). A systematic review of the effectiveness of simulation debriefing in health professional education. Nurse Education Today, 34(6), e58-e63. Lioce, L., Meakim, C. H., Fey, M. K., Chmil, J. V., Mariani, B., & Alinier, G. (2015). Standards of best practice: Simulation standard IX: Simulation design. Clinical Simulation in Nursing, 11(6), 309-315. http://dx.doi.org/10.1016/j.ecns.2015.03.005. Macy, R., & Schrader, V. (2008). Pediophobia: A new challenge facing nursing faculty in clinical teaching by simulation. Clinical Simulation in Nursing, 4(3), e89-e91.

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When the Debrief Time Runs Out Oberleitner, M. G., Broussard, A. B., & Bourque, J. (2011). An unintended consequence of simulation: A case report. Clinical Simulation in Nursing, 7(2), e35-e40. Paige, J. T., Arora, S., Fernandez, G., & Seymour, N. (2015). Debriefing 101: Training faculty to promote learning in simulation-based training. The American Journal of Surgery, 209(1), 126-131. http://dxdoi.org/10. 1016.j.amjsurg.2014.05.034. Palethorpe, R., & Wilson, J. P. (2011). Learning in the panic zone: Strategies for managing learner anxiety. Journal of European Industrial Training, 35(5), 420-438. http://dx.doi.org/10.1108/0309059111113 8008. Ross, A. J., Anderson, J. E., Kodate, N., Thomas, L., Thompson, K., Thomas, B., ., & Jaye, P. (2013). Simulation training for improving compassionate care of older people: An independent evaluation of an innovative program for interprofessional education. BMJ Quality and Safety, 22(6), 495-505. Rudolph, J. W., Raemer, D. B., & Simon, R. (2014). Establishing a safe container for learning in simulation. Simulation in Healthcare, 9(6), 339-349. http://dx.doi.org/10.1097/SIH.0000000000000047.

43 Smith-Stoner, M. (2009). Using high-fidelity simulation to educate nursing students about end- of-life care. Nursing Education Perspectives, 30(2), 115-120. http://dx.doi.org/10.1136/bmjqs-2012-000954. The INACSL Board of Directors. (2011a). Standard V: Simulation facilitator. Clinical Simulation in Nursing, 7(45), s14-s15. http: //dx.doi.org/10.1016/j.ecns.2011.05.009. The INACSL Board of Directors. (2011b). Standard VI: The debriefing process. Clinical Simulation in Nursing, 7(45), s16-s17. http: //dx.doi.org/10.1016/j.ecns.2011.05.010. Truog, R. D., & Meyer, E. C. (2013). Deception and death in medical simulation. Simulation in Healthcare, 8(1), 1-3. http://dx.doi.org/10. 1079/ISH.0b013e182689fc2. University of Virginia. (2012). Types of harm. Retrieved from http:// www.virginia.edu/vpr/irb/sbs/resources_guide_risk_define_types. html. Willhaus, J., Averette, M., Gates, M., Jackson, J., & Windgael, S. (2014). Proactive policy planning for unexpected student distress during simulation. Nurse Educator, 39(5), 232-235. http://dx.doi.org/10. 1097/NNE.000000000000062.

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