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How can nurse educators perform patient simulation efficiently?
Teaching and Learning in Nursing (2016) 11, 8–14
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How can nurse educators perform patient simulation efficiently?1,2 Michael D. Aldridge MSN, RN, CNE⁎ Concordia University Texas, Austin, TX 78726, USA University of Northern Colorado, Greeley, CO 80639, USA KEYWORDS: Simulations education; Simulations administration; Simulations utilization; Education, nursing; Faculty, nursing education
Abstract Simulation use in nursing programs has increased dramatically, and the benefits of simulation have now been demonstrated in multiple studies. However, simulation is a time-consuming teaching method. This article provides recommendations for performing simulation activities efficiently, including faculty training and support, in-class simulation, scenario and manikin choice, equipment organization, simulation mapping in the curriculum, and preprogrammed scenario use. Implementing these recommendations may help faculty members use simulation both effectively and efficiently. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Evidence is accumulating that patient simulation is a teaching methodology that is both effective and popular among both students and faculty members. As a result, nursing faculty members are using simulation with increasing frequency. However, faculty frequently state concerns about the time investment required to create and implement these simulations. In some settings, the time needed to carry out simulation could be a barrier to faculty using simulation. This article will provide an overview of simulator use and its effectiveness and then provide recommendations for implementing simulation activities within nursing curricula in a time-efficient manner.
1. How Do Nursing Programs Use Simulation? The use of simulators in nursing schools has been steadily increasing and has typically focused on high-fidelity patient 1
Funding: not applicable Conflict of Interest: The author declares no conflict of interest. ⁎ Corresponding author. Tel.: +1 512 313 5518. E-mail address: [email protected]
2
simulators (HFPSs). An HFPS is considered to be a computerized full-body manikin that provides real-time physiological changes (Nehring & Lashley, 2010). A medium-fidelity simulator is a full-body manikin that may allow students to perform procedures or hear breath sounds but lacks the ability for the chest to rise (Nehring & Lashley, 2010). In addition, many schools use low-fidelity simulators, also known as task trainers, to help students learn to perform nursing skills. An example of a task trainer is a disjointed arm for learning venipuncture. Anecdotal descriptions of HFPS use in nursing programs began appearing in the nursing literature in 2001 (Nehring, Ellis, & Lashley, 2001), and studies reported rapid adoption of the technology. A 2007 study of 78 nursing programs revealed that 60 of those schools used simulators in core nursing classes, and 24 used HFPS (Katz, Peifer, & Armstrong, 2010). This study also found that of the schools not using HFPS, approximately 70% planned to purchase high-fidelity simulators. Later studies continued to document increased simulator use in nursing programs. A large representative study conducted in 2010 of 1,060 nursing programs indicated
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Patient simulation that 87% of the programs used medium- or high-fidelity simulation, and the majority of programs reported that simulation was used in five or more courses (Hayden, 2010). The author concluded that these data signified both an overall growth in HFPS as well as diffusion of simulation throughout the curriculum. In a recent survey of 139 nursing programs, 126 of the respondents indicated that simulation was used in the nursing curriculum, with the majority (94 respondents) indicating that simulation was used to replace traditional clinical hours (Davis, Kimble, & Gunby, 2014). These data clearly demonstrate the rapid growth of HFPS over the last 15 years. Although simulator use has increased over time, there appears to be wide variation in how extensively these simulators are used within the curriculum, with some schools using them fairly minimally and others using them extensively. For example, Hayden (2010) noted the median number of simulations in a program as 13, with a range of 1 to 233. In that study, HFPS was used most often in foundations courses and medical/surgical nursing courses.
2. Is Simulation Effective? Evidence of the effectiveness of simulation as a teaching modality is increasing. A recent meta-analysis of 20 studies of simulation in nursing education found that participants who received simulation had better learning outcomes than the control groups (Shin, Park, & Kim, 2015). Specifically, simulation was most effective in meeting identified learning objectives when the learners were evaluated during the simulation, when psychomotor skills were included, when the simulations emphasized clinical situations, and when the simulators were high fidelity rather than low fidelity (Shin et al., 2015). Some nursing faculty members have questioned whether simulation can effectively substitute for traditional clinical education in the acute care setting (Miller & Bull, 2013). Recently the National Council for State Boards of Nursing released their findings from a 2-year multisite longitudinal study that was designed to determine if a percentage of clinical hours could be replaced effectively by simulation (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Three groups of students were studied: a control group that received no more than 10% of clinical time in simulation, an intervention group that spent 25% of clinical time in simulation, and another intervention group that spent 50% of clinical time in simulation. Outcome measures included nursing knowledge assessed through standardized Assessment Technologies, Inc. examinations, clinical competency with an evaluation rubric, and National Council Licensure Examination, Registered Nurse (NCLEX-RN®) pass rates (Hayden et al., 2014). The study found equivalent outcomes in all three groups, indicating that up to 50% of simulation time could be effectively substituted for traditional clinical experiences (Hayden et al., 2014). However, nursing faculty members need to be aware that very specific conditions were used to achieve these results. In the study, a dedicated team of nursing faculty members who
9 were trained in simulation methods led the simulations, while clinical faculty members attended the simulations with their clinical groups to serve as content experts (Zulkosky, Husson, Kamerer, & Fetter, 2014). Faculty members were trained to use an educationally sound debriefing model, Debriefing for Meaningful Learning, and had their debriefing skills evaluated during the study (Hayden et al., 2014). In short, best practices in simulation were used in order to achieve these results. In an editorial, Kardong-Edgren (2015) points out that many nursing programs lack the conditions in their own simulation programs to match those used in the National Council for State Boards of Nursing study. In addition to the conditions described in the study, nursing faculty members can refer to the International Nursing Association for Clinical Simulation in Learning's Standards of Best Practice when considering how to most effectively carry out simulation. For example, the recently released standard about simulation design provides an overview of how to design a simulation from conception to evaluation (Lioce et al., 2015). It is also a useful reference for faculty members needing to demonstrate the complexity of incorporating simulation into a nursing program. In response to these accumulating studies, the National League for Nursing recently issued a vision statement for teaching with simulation (National League for Nursing, 2015). This document calls on nursing faculty members to integrate simulation into the curriculum using the best simulation practices. In addition, leaders of nursing schools are called upon to provide budgetary support for simulation equipment, facilities, and faculty development in simulation.
3. What Are Common Barriers to Simulation Use? Although HFPS use has increased dramatically, many barriers remain. The initial costs of purchasing high-fidelity simulators are considerable, with some models costing as much as $60,000 (Nehring & Lashley, 2010). Additional costs such as maintenance contracts, repair costs, beds for the manikins, and computer equipment can escalate the cost of simulation (Brost, Thiemann, & Dunn, 2008). If the school is converting classroom space into a simulation laboratory, there may be additional construction costs such as installing headwalls, sinks, and medical gases. In addition, schools must have space to store the simulator and the funds to purchase consumable supplies. Nursing faculty members have identified barriers of integrating HFPS as a lack of time for simulation development, lack of support, and lack of appropriate equipment for specific simulation goals (Adamson, 2010). Specifically, many schools spend significant amounts of money on the initial investment for a simulation program but comparatively little money for faculty support and development (Adamson, 2010). Other studies have found that, until recently, faculty members have been reticent to adopt HFPS because there has not been strong evidence that it provides
10 superior learning outcomes (Miller & Bull, 2013). In addition, some faculty members are unsure how to manage the logistics of incorporating simulation in larger nursing programs (Miller & Bull, 2013). For example, if a simulation is designed for five students, determining how to expose 150 students to the simulation is a logistical challenge. Despite these barriers, there are strategies to overcome them. A common model for the initial purchase of simulator equipment is through a grant (Nehring & Lashley, 2010). Once funds are secured, getting bids from multiple vendors as well as input from educators currently using those simulators is highly advisable (Brost et al., 2008). Programs also need to obtain equipment to support the realism of the simulation laboratory, such as beds, headwalls, overbed tables, IV poles, and pumps. Rather than purchase this equipment new, consider getting bids from refurbished medical equipment vendors. Some clinical partners may also be willing to donate equipment they no longer need (Brost et al., 2008). In addition, the cost of disposable supplies can be high. Some programs purchase these supplies for students by charging a laboratory fee, while other programs contract with a supply vendor and have the students directly purchase a kit containing the supplies. Supply vendors will work with a nursing program to customize the supply kit to meet the program's needs.
4. How Time-Consuming Is Simulation? It is well established that HFPS is time consuming in the beginning. Numerous articles cite the significant time investment required to develop a simulation program (Adamson, 2010; Davis et al., 2014; Katz et al., 2010; King, Moseley, Hindenlang, & Kuritz, 2008; Nehring & Lashley, 2004). However, these studies are based upon surveys of faculty opinions about barriers to HFPS and did not attempt to quantify the time required. One study (Jones & Hegge, 2008) reported on data collected in 2005 from a single nursing school in which faculty members were surveyed to determine their perceptions of how much time it would require for them to plan, implement, and evaluate the use of HFPS into their nursing courses. The faculty members in this study perceived that they would need between 0.25 and 1 full-time equivalent release time for one semester in order to bring HFPS into their courses. To date, no other studies have been identified that attempted to quantify the time investment for HFPS. Quantifying the time needed to perform HFPS using best practices could provide nursing faculty data to support teaching time release for facilitating simulation. This is an area largely unexplored and remains an opportunity for further research. At this point, specific data are lacking in the literature, but there seems to be agreement that simulation is a time-intensive endeavor.
M.D. Aldridge Table 1
Recommendations for Performing Simulations Efficiently
Determine critical information faculty members need to know to perform simulation, such as simulator operation, scenario variation, and debriefing techniques. Provide adequate time and support for faculty members to learn simulation, and do not expect them to use simulation until training is complete. Plan simulation activities with other faculty members who teach those students to allow for flexibility with scheduling. Use simulation in the classroom setting to expose greater numbers of students to the scenario. Design simple scenarios first and, then, advance to more complex scenarios. Use lower fidelity manikins when possible because high-fidelity manikins are labor intensive to program and use. Organize simulator equipment and supplies into boxes for each simulation. Map out simulation activities across the curriculum to prevent duplication. Use preprogrammed scenarios whenever possible. It is usually more efficient to adapt a preprogrammed scenario than to write one from scratch. Hire a simulation specialist to support faculty member development and use of simulation. This person should have at least part-time workload release.
5. Performing Patient Simulation Activities Efficiently There is ample evidence that nursing faculty members are using simulation more often and that it is an effective teaching method. However, simulation is time consuming. The literature does offer several ideas about how to implement and use simulation effectively so that faculty members are using their time efficiently. Table 1 summarizes these recommendations for quick reference.
5.1. Provide Simulation Support and Training for Faculty Members The literature is consistent in stating that it takes significant time for faculty to develop competence in using simulation (Nehring, Wexler, Hughes, & Greenwell, 2013). Although the time investment to use simulation is substantial, it can be minimized when faculty members receive adequate support and training in how to use simulation. In a seminal article about developing simulation programs, the authors emphasize the importance of faculty development time and state that there are different levels of faculty expertise needed to carry out simulation (Seropian, Brown, Gavilanes, & Driggers, 2004). The most efficient use of time is to concentrate expertise into a few faculty members who become simulation specialists (Seropian et al., 2004). These specialists become well versed over many years in all aspects of simulation development and operations, while the majority of faculty members learn the basics of how to use the simulators to conduct simulation and how to debrief students after the simulation. Faculty members should not be expected to run a simulation until they have received training in the teaching method (Jones & Hegge, 2008; Seropian et al., 2004).
Patient simulation
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Table 2 Observation Checklist for a Hypothetical Simulation Involving an Infant With Hyperkalemia Action
Yes, No, Comments done not done
Receives report from Emergency Department nurse Performs assessment of baby Attaches baby to monitor Notes peaked T-waves on monitor Analyzes laboratory results (notes potassium level) Prioritizes medications correctly (calcium, kayexalate) Administers medications safely (6 R's) Communicates effectively with mother
Unfortunately, there are few guidelines describing the minimal skills and knowledge that faculty members need in order to use simulation effectively (Faz, Van Sell, & Sheriff, 2014), and training programs are inconsistent among nursing schools. A literature review of 25 studies about faculty development for simulation identified the following competencies that require faculty proficiency: skill in running the equipment, the ability to meet objectives when simulations vary with different groups of students, debriefing techniques, and evaluation of scenarios for future changes (Nehring et al., 2013). There are many resources available for faculty members to learn how to teach using simulation, including graduate coursework, journal articles, books, webinars, conferences, formal on-site training, and informal training (Faz et al., 2014). One study found that the majority of faculty members preferred acquiring skills in simulation through practice with feedback from others who were skilled in simulation teaching methods (Anderson, Bond, Holmes, & Cason, 2012). These recommendations can guide programs in determining when to begin faculty development, what content to include, and what training methods to use. It is not necessary, nor is it a good use of their time, for most faculty members to try to become experts in simulation. Rather, all faculty members should become competent in simulation teaching methods while receiving support from a smaller number of faculty members who have developed expertise in simulation.
5.2. Decide How to Manage the Logistics of Simulation The logistics of running simulations for large groups of students can be overwhelming to faculty members who have not used it before. One center reports on its experience in conducting HFPS for a cohort of 375 first year nursing students (Rochester et al., 2012). These authors discuss how they managed logistics for this cohort by planning for the
simulation before the semester began. They scheduled an entire week out of the semester for simulation, required clinical faculty to assist, and used staggered start times and multiple rooms. By using these strategies, they were able to rotate up to 100 students through the simulation experience each day in groups of five. The faculty involved also conducted a focus group of a representative group of students, and data indicated that the simulation was effective in terms of nursing role development and thinking in real time (Rochester et al., 2012). This example illustrates the point that quality HFPS is possible with prior planning and well-trained faculty members.
5.3. Bring Simulators Into the Classroom Another approach to using simulation is to bring the simulator into the classroom. The simplest method is to run a simulation that relates to the content being discussed that day with a small group of students while the others observe. For example, during an adult health nursing class about neurological injuries, an in-class simulation could be done to demonstrate neurological assessment, nursing interventions, and medication administration. These teaching points would all connect directly to the material being taught during that class but would also give the students context for the information. For example, Hooper, Shaw, and Zamzam (2015) recognized that it was time intensive for one faculty member to facilitate a simulation with four students and instead opted to bring several simulations into the classroom setting. They accomplished this by having the students prepare for two simulations each week and then selected a group of students to actively participate in the simulation in the laboratory while the other students observed the activities via a live video stream into the classroom. During the course of the simulations, all students were able to actively participate. One caveat to using in-class simulation is that the faculty member must make sure that the students not participating directly are actively observing in order to get benefit from the experience. Developing observation checklists for students not participating in the simulation and engaging them in discussion could provide an incentive for them to be active observers. Table 2 provides an example of an observation checklist for a hypothetical simulation involving an infant with hyperkalemia. A variation of in-class simulation (Norman, Thompson, & Missildine, 2013) is to segment the in-class simulation into 2-minute sections and have small groups of students complete each section. For example, one group completes the assessment, the next group communicates findings to the provider, another group completes the intervention, and a final group evaluates the intervention. Faculty members using this technique found that all 52 students in the lecture course were able to participate in some aspect of the 70-minute simulation experience (Norman et al., 2013). The authors estimated that, if the simulation had been run in a
12 traditional laboratory setting with small groups of students, it would have taken 19.5 hours to engage all 52 students, so the potential time savings in using simulation in the classroom are significant.
5.4. Start With Simple Simulations Simulation can be done on many levels, and it is not necessary to make the simulation extremely complicated, have the patient deteriorate rapidly, or have the patient suffer a cardiac arrest. These complex scenarios are very time consuming to create, set up, and run. It may be a better use of time to begin with less complex scenarios that simply reinforce the content being taught (Seropian et al., 2004). For example, a brief simulation that emphasizes hand washing and administering medications safely can be very effective because those objectives are critical parts of the nursing curriculum.
5.5. Use the Right Simulator for the Job During the planning phase of a simulation, faculty members should initially define the objectives of the simulation. Then an attempt should be made to match the simulator to the objectives. For example, if the objective of the simulation was for students to detect a change in cardiac rhythm and then assess the patient, a high-fidelity simulator would likely provide the most fidelity. On the other hand, if the objective was to detect that a patient was having chest pain and, then, to administer medication, a lower fidelity simulator might be used. Setting up and programming high-fidelity simulators is more complicated and time intensive than using lower fidelity simulators. Therefore, the best use of time is to use lower fidelity manikins when possible.
5.6. Organize Equipment for Each Simulation Into Boxes One technique for saving time when setting up a simulation is to have everything that is needed for the set up organized into boxes. Plastic tubs that can be labeled and easily stacked or placed on shelves work well. For example, a box for a simulation about dehydration could contain the patient's armband, Foley catheter bag, wig, and intravenous line tubing. Include a checklist of supplies found in other areas, such as supply carts, that are also used in the simulation. Put items used to increase fidelity such as a fall risk sign or pictures of the patient's family in the box too. Place any documents used during the simulation in the box, including forms used for charting. When everything is in one place, set up time is reduced, and all items needed for the simulation are present.
5.7. Map Out Simulation Activities Across the Curriculum It is useful to get an understanding of how simulation is used in the entire nursing curriculum in order to prevent
M.D. Aldridge duplication of activities. For example, faculty could find that simulations involving cardiac arrest are being done in three different courses, while simulations involving postoperative nursing care are being done only once. It is useful to have simulations that reinforce basic nursing care as well as scenarios that students typically cannot actively participate in during clinical courses, such as a rapidly changing patient status. In addition, consideration should be given to situations where patient simulation has been shown to provide good learning outcomes, such as recognition of the deteriorating patient (Bell-Gordon, Gigliotti, & Mitchell, 2014; Buykx et al., 2012). Having a wide variety of simulations throughout the nursing curriculum is desirable.
5.8. Use Available Resources Writing scenarios is extremely time consuming because of the research that is involved to make the scenario evidence based and the backstory complete. Determining laboratory values, imaging studies, medication dosages, psychosocial history, and assessment findings and creating the patient chart take significant amounts of time. Therefore, the best use of faculty time is to use preprogrammed scenarios whenever possible (Faz et al., 2014). One study indicated that 67% of nursing programs purchase scenarios (Hayden, 2010). There are a number of sources for scenarios, including some that are free and others that can be purchased. It is often more efficient to adapt a preprogrammed scenario than to write one from scratch. Table 3 lists Web sites and organizations that offer free simulations for nursing faculty members.
5.9. Hire a Simulation Specialist A common recommendation to save faculty time is to hire a simulation specialist (Nehring et al., 2013). This person is recognized as a simulation champion and expert who assists other faculty members with simulation design and implementation. This person may have some workload release from teaching. Two surveys of nursing schools found that 75% had a simulation coordinator (Davis et al., 2014; Nehring & Lashley, 2004), and that position had at least a part-time workload release (Nehring & Lashley, 2004). A common method for validating expertise is through certification. The Society for Simulation in Healthcare (SSH) has a certification available to nurse educators that validates expertise in simulation education. In order to obtain certification as a certified health care simulation educator, an applicant must participate in health care simulation in an educational role in the undergraduate, graduate, allied health, or health care setting; have earned a bachelor's degree or equivalent experience; and have 2 years of continued use of simulation in health care education, research, or administration (SSH, 2015). After validating the educator's application and references, the educator must pass a 115-question multiple-choice examination that is taken at a testing center. Results are available immediately at the conclusion
Patient simulation Table 3
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Web Sites and Organizations that Offer Free Simulations
Organization
Web site a
Kansas Board of Nursing
http://www.ksbn.org/education/Scenario/ SimulationScenarioLibrary.htm
Description
-16 simulations with charting documents -Varying complexity -Peer reviewed Montgomery College http://cms.montgomerycollege.edu/nursingsims/ -10 scenarios -Contain videos, simulation guides, and documents Massachusetts Nursing Initiative http://www.mass.edu/currentinit/Nursing/Sim/ -6 adult and 2 pediatric scenarios Welcome.asp -Free registration required Center for Health Sciences Interprofessional http://collaborate.uw.edu/educators-toolkit/heet-v- -13 scenarios, adult and pediatric Education, Research, and Practice (University nursing-simulation-scenarios-and-supporting-Varying levels of complexity of Washington) documents.html -Includes debriefing guide University of South Dakota http://www.usd.edu/health-sciences/nursing/ -30 scenarios simulation-scenarios -Organized by concepts -Includes preclass work and chart components a
Web site addresses were current as of May 2015. Please read the terms of use for each organization's simulation library.
of the examination, and the certification is good for 3 years (SSH, 2015).
6. Conclusion In summary, patient simulation is an effective yet time-consuming teaching strategy. As evidence mounts demonstrating the benefits of simulation, the burdens of implementing it must also be considered. Faculty members describe significant barriers to using simulation, including time constraints, lack of support, and concerns about how to implement it. Strategies for dealing with these concerns have been described in the literature. By using these strategies, it is possible for nursing faculty to perform simulation efficiently.
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14 review.International Journal of Health Sciences Education, 1(1) (Available at: http://dc.etsu.edu/ijhse/vol1/iss1/4). Norman, J., Thompson, S., & Missildine, K. (2013). The 2-minute drills: Incorporating simulation into a large lecture format. Clinical Simulation in Nursing, 9, e433−e436, http://dx.doi.org/10.1016/j.ecns.2012.08.004. Rochester, S., Kelly, M., Disler, R., White, H., Forber, J., & Matiuk, S. (2012). Providing simulation experiences for large cohorts of 1st year nursing students: Evaluating quality and impact. Collegian, 19, 117−124, http://dx.doi.org/10.1016/j.colegn.2012.05.004. Seropian, M. A., Brown, K., Gavilanes, J. S., & Driggers, B. (2004). An approach to simulation program development. Journal of Nursing Education, 43, 170−174.
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How can nurse educators perform patient simulation efficiently?1,2 Michael D. Aldridge MSN, RN, CNE⁎ Concordia University Texas, Austin, TX 78726, USA University of Northern Colorado, Greeley, CO 80639, USA KEYWORDS: Simulations education; Simulations administration; Simulations utilization; Education, nursing; Faculty, nursing education
Abstract Simulation use in nursing programs has increased dramatically, and the benefits of simulation have now been demonstrated in multiple studies. However, simulation is a time-consuming teaching method. This article provides recommendations for performing simulation activities efficiently, including faculty training and support, in-class simulation, scenario and manikin choice, equipment organization, simulation mapping in the curriculum, and preprogrammed scenario use. Implementing these recommendations may help faculty members use simulation both effectively and efficiently. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Evidence is accumulating that patient simulation is a teaching methodology that is both effective and popular among both students and faculty members. As a result, nursing faculty members are using simulation with increasing frequency. However, faculty frequently state concerns about the time investment required to create and implement these simulations. In some settings, the time needed to carry out simulation could be a barrier to faculty using simulation. This article will provide an overview of simulator use and its effectiveness and then provide recommendations for implementing simulation activities within nursing curricula in a time-efficient manner.
1. How Do Nursing Programs Use Simulation? The use of simulators in nursing schools has been steadily increasing and has typically focused on high-fidelity patient 1
Funding: not applicable Conflict of Interest: The author declares no conflict of interest. ⁎ Corresponding author. Tel.: +1 512 313 5518. E-mail address: [email protected]
2
simulators (HFPSs). An HFPS is considered to be a computerized full-body manikin that provides real-time physiological changes (Nehring & Lashley, 2010). A medium-fidelity simulator is a full-body manikin that may allow students to perform procedures or hear breath sounds but lacks the ability for the chest to rise (Nehring & Lashley, 2010). In addition, many schools use low-fidelity simulators, also known as task trainers, to help students learn to perform nursing skills. An example of a task trainer is a disjointed arm for learning venipuncture. Anecdotal descriptions of HFPS use in nursing programs began appearing in the nursing literature in 2001 (Nehring, Ellis, & Lashley, 2001), and studies reported rapid adoption of the technology. A 2007 study of 78 nursing programs revealed that 60 of those schools used simulators in core nursing classes, and 24 used HFPS (Katz, Peifer, & Armstrong, 2010). This study also found that of the schools not using HFPS, approximately 70% planned to purchase high-fidelity simulators. Later studies continued to document increased simulator use in nursing programs. A large representative study conducted in 2010 of 1,060 nursing programs indicated
http://dx.doi.org/10.1016/j.teln.2015.09.001 1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Patient simulation that 87% of the programs used medium- or high-fidelity simulation, and the majority of programs reported that simulation was used in five or more courses (Hayden, 2010). The author concluded that these data signified both an overall growth in HFPS as well as diffusion of simulation throughout the curriculum. In a recent survey of 139 nursing programs, 126 of the respondents indicated that simulation was used in the nursing curriculum, with the majority (94 respondents) indicating that simulation was used to replace traditional clinical hours (Davis, Kimble, & Gunby, 2014). These data clearly demonstrate the rapid growth of HFPS over the last 15 years. Although simulator use has increased over time, there appears to be wide variation in how extensively these simulators are used within the curriculum, with some schools using them fairly minimally and others using them extensively. For example, Hayden (2010) noted the median number of simulations in a program as 13, with a range of 1 to 233. In that study, HFPS was used most often in foundations courses and medical/surgical nursing courses.
2. Is Simulation Effective? Evidence of the effectiveness of simulation as a teaching modality is increasing. A recent meta-analysis of 20 studies of simulation in nursing education found that participants who received simulation had better learning outcomes than the control groups (Shin, Park, & Kim, 2015). Specifically, simulation was most effective in meeting identified learning objectives when the learners were evaluated during the simulation, when psychomotor skills were included, when the simulations emphasized clinical situations, and when the simulators were high fidelity rather than low fidelity (Shin et al., 2015). Some nursing faculty members have questioned whether simulation can effectively substitute for traditional clinical education in the acute care setting (Miller & Bull, 2013). Recently the National Council for State Boards of Nursing released their findings from a 2-year multisite longitudinal study that was designed to determine if a percentage of clinical hours could be replaced effectively by simulation (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Three groups of students were studied: a control group that received no more than 10% of clinical time in simulation, an intervention group that spent 25% of clinical time in simulation, and another intervention group that spent 50% of clinical time in simulation. Outcome measures included nursing knowledge assessed through standardized Assessment Technologies, Inc. examinations, clinical competency with an evaluation rubric, and National Council Licensure Examination, Registered Nurse (NCLEX-RN®) pass rates (Hayden et al., 2014). The study found equivalent outcomes in all three groups, indicating that up to 50% of simulation time could be effectively substituted for traditional clinical experiences (Hayden et al., 2014). However, nursing faculty members need to be aware that very specific conditions were used to achieve these results. In the study, a dedicated team of nursing faculty members who
9 were trained in simulation methods led the simulations, while clinical faculty members attended the simulations with their clinical groups to serve as content experts (Zulkosky, Husson, Kamerer, & Fetter, 2014). Faculty members were trained to use an educationally sound debriefing model, Debriefing for Meaningful Learning, and had their debriefing skills evaluated during the study (Hayden et al., 2014). In short, best practices in simulation were used in order to achieve these results. In an editorial, Kardong-Edgren (2015) points out that many nursing programs lack the conditions in their own simulation programs to match those used in the National Council for State Boards of Nursing study. In addition to the conditions described in the study, nursing faculty members can refer to the International Nursing Association for Clinical Simulation in Learning's Standards of Best Practice when considering how to most effectively carry out simulation. For example, the recently released standard about simulation design provides an overview of how to design a simulation from conception to evaluation (Lioce et al., 2015). It is also a useful reference for faculty members needing to demonstrate the complexity of incorporating simulation into a nursing program. In response to these accumulating studies, the National League for Nursing recently issued a vision statement for teaching with simulation (National League for Nursing, 2015). This document calls on nursing faculty members to integrate simulation into the curriculum using the best simulation practices. In addition, leaders of nursing schools are called upon to provide budgetary support for simulation equipment, facilities, and faculty development in simulation.
3. What Are Common Barriers to Simulation Use? Although HFPS use has increased dramatically, many barriers remain. The initial costs of purchasing high-fidelity simulators are considerable, with some models costing as much as $60,000 (Nehring & Lashley, 2010). Additional costs such as maintenance contracts, repair costs, beds for the manikins, and computer equipment can escalate the cost of simulation (Brost, Thiemann, & Dunn, 2008). If the school is converting classroom space into a simulation laboratory, there may be additional construction costs such as installing headwalls, sinks, and medical gases. In addition, schools must have space to store the simulator and the funds to purchase consumable supplies. Nursing faculty members have identified barriers of integrating HFPS as a lack of time for simulation development, lack of support, and lack of appropriate equipment for specific simulation goals (Adamson, 2010). Specifically, many schools spend significant amounts of money on the initial investment for a simulation program but comparatively little money for faculty support and development (Adamson, 2010). Other studies have found that, until recently, faculty members have been reticent to adopt HFPS because there has not been strong evidence that it provides
10 superior learning outcomes (Miller & Bull, 2013). In addition, some faculty members are unsure how to manage the logistics of incorporating simulation in larger nursing programs (Miller & Bull, 2013). For example, if a simulation is designed for five students, determining how to expose 150 students to the simulation is a logistical challenge. Despite these barriers, there are strategies to overcome them. A common model for the initial purchase of simulator equipment is through a grant (Nehring & Lashley, 2010). Once funds are secured, getting bids from multiple vendors as well as input from educators currently using those simulators is highly advisable (Brost et al., 2008). Programs also need to obtain equipment to support the realism of the simulation laboratory, such as beds, headwalls, overbed tables, IV poles, and pumps. Rather than purchase this equipment new, consider getting bids from refurbished medical equipment vendors. Some clinical partners may also be willing to donate equipment they no longer need (Brost et al., 2008). In addition, the cost of disposable supplies can be high. Some programs purchase these supplies for students by charging a laboratory fee, while other programs contract with a supply vendor and have the students directly purchase a kit containing the supplies. Supply vendors will work with a nursing program to customize the supply kit to meet the program's needs.
4. How Time-Consuming Is Simulation? It is well established that HFPS is time consuming in the beginning. Numerous articles cite the significant time investment required to develop a simulation program (Adamson, 2010; Davis et al., 2014; Katz et al., 2010; King, Moseley, Hindenlang, & Kuritz, 2008; Nehring & Lashley, 2004). However, these studies are based upon surveys of faculty opinions about barriers to HFPS and did not attempt to quantify the time required. One study (Jones & Hegge, 2008) reported on data collected in 2005 from a single nursing school in which faculty members were surveyed to determine their perceptions of how much time it would require for them to plan, implement, and evaluate the use of HFPS into their nursing courses. The faculty members in this study perceived that they would need between 0.25 and 1 full-time equivalent release time for one semester in order to bring HFPS into their courses. To date, no other studies have been identified that attempted to quantify the time investment for HFPS. Quantifying the time needed to perform HFPS using best practices could provide nursing faculty data to support teaching time release for facilitating simulation. This is an area largely unexplored and remains an opportunity for further research. At this point, specific data are lacking in the literature, but there seems to be agreement that simulation is a time-intensive endeavor.
M.D. Aldridge Table 1
Recommendations for Performing Simulations Efficiently
Determine critical information faculty members need to know to perform simulation, such as simulator operation, scenario variation, and debriefing techniques. Provide adequate time and support for faculty members to learn simulation, and do not expect them to use simulation until training is complete. Plan simulation activities with other faculty members who teach those students to allow for flexibility with scheduling. Use simulation in the classroom setting to expose greater numbers of students to the scenario. Design simple scenarios first and, then, advance to more complex scenarios. Use lower fidelity manikins when possible because high-fidelity manikins are labor intensive to program and use. Organize simulator equipment and supplies into boxes for each simulation. Map out simulation activities across the curriculum to prevent duplication. Use preprogrammed scenarios whenever possible. It is usually more efficient to adapt a preprogrammed scenario than to write one from scratch. Hire a simulation specialist to support faculty member development and use of simulation. This person should have at least part-time workload release.
5. Performing Patient Simulation Activities Efficiently There is ample evidence that nursing faculty members are using simulation more often and that it is an effective teaching method. However, simulation is time consuming. The literature does offer several ideas about how to implement and use simulation effectively so that faculty members are using their time efficiently. Table 1 summarizes these recommendations for quick reference.
5.1. Provide Simulation Support and Training for Faculty Members The literature is consistent in stating that it takes significant time for faculty to develop competence in using simulation (Nehring, Wexler, Hughes, & Greenwell, 2013). Although the time investment to use simulation is substantial, it can be minimized when faculty members receive adequate support and training in how to use simulation. In a seminal article about developing simulation programs, the authors emphasize the importance of faculty development time and state that there are different levels of faculty expertise needed to carry out simulation (Seropian, Brown, Gavilanes, & Driggers, 2004). The most efficient use of time is to concentrate expertise into a few faculty members who become simulation specialists (Seropian et al., 2004). These specialists become well versed over many years in all aspects of simulation development and operations, while the majority of faculty members learn the basics of how to use the simulators to conduct simulation and how to debrief students after the simulation. Faculty members should not be expected to run a simulation until they have received training in the teaching method (Jones & Hegge, 2008; Seropian et al., 2004).
Patient simulation
11
Table 2 Observation Checklist for a Hypothetical Simulation Involving an Infant With Hyperkalemia Action
Yes, No, Comments done not done
Receives report from Emergency Department nurse Performs assessment of baby Attaches baby to monitor Notes peaked T-waves on monitor Analyzes laboratory results (notes potassium level) Prioritizes medications correctly (calcium, kayexalate) Administers medications safely (6 R's) Communicates effectively with mother
Unfortunately, there are few guidelines describing the minimal skills and knowledge that faculty members need in order to use simulation effectively (Faz, Van Sell, & Sheriff, 2014), and training programs are inconsistent among nursing schools. A literature review of 25 studies about faculty development for simulation identified the following competencies that require faculty proficiency: skill in running the equipment, the ability to meet objectives when simulations vary with different groups of students, debriefing techniques, and evaluation of scenarios for future changes (Nehring et al., 2013). There are many resources available for faculty members to learn how to teach using simulation, including graduate coursework, journal articles, books, webinars, conferences, formal on-site training, and informal training (Faz et al., 2014). One study found that the majority of faculty members preferred acquiring skills in simulation through practice with feedback from others who were skilled in simulation teaching methods (Anderson, Bond, Holmes, & Cason, 2012). These recommendations can guide programs in determining when to begin faculty development, what content to include, and what training methods to use. It is not necessary, nor is it a good use of their time, for most faculty members to try to become experts in simulation. Rather, all faculty members should become competent in simulation teaching methods while receiving support from a smaller number of faculty members who have developed expertise in simulation.
5.2. Decide How to Manage the Logistics of Simulation The logistics of running simulations for large groups of students can be overwhelming to faculty members who have not used it before. One center reports on its experience in conducting HFPS for a cohort of 375 first year nursing students (Rochester et al., 2012). These authors discuss how they managed logistics for this cohort by planning for the
simulation before the semester began. They scheduled an entire week out of the semester for simulation, required clinical faculty to assist, and used staggered start times and multiple rooms. By using these strategies, they were able to rotate up to 100 students through the simulation experience each day in groups of five. The faculty involved also conducted a focus group of a representative group of students, and data indicated that the simulation was effective in terms of nursing role development and thinking in real time (Rochester et al., 2012). This example illustrates the point that quality HFPS is possible with prior planning and well-trained faculty members.
5.3. Bring Simulators Into the Classroom Another approach to using simulation is to bring the simulator into the classroom. The simplest method is to run a simulation that relates to the content being discussed that day with a small group of students while the others observe. For example, during an adult health nursing class about neurological injuries, an in-class simulation could be done to demonstrate neurological assessment, nursing interventions, and medication administration. These teaching points would all connect directly to the material being taught during that class but would also give the students context for the information. For example, Hooper, Shaw, and Zamzam (2015) recognized that it was time intensive for one faculty member to facilitate a simulation with four students and instead opted to bring several simulations into the classroom setting. They accomplished this by having the students prepare for two simulations each week and then selected a group of students to actively participate in the simulation in the laboratory while the other students observed the activities via a live video stream into the classroom. During the course of the simulations, all students were able to actively participate. One caveat to using in-class simulation is that the faculty member must make sure that the students not participating directly are actively observing in order to get benefit from the experience. Developing observation checklists for students not participating in the simulation and engaging them in discussion could provide an incentive for them to be active observers. Table 2 provides an example of an observation checklist for a hypothetical simulation involving an infant with hyperkalemia. A variation of in-class simulation (Norman, Thompson, & Missildine, 2013) is to segment the in-class simulation into 2-minute sections and have small groups of students complete each section. For example, one group completes the assessment, the next group communicates findings to the provider, another group completes the intervention, and a final group evaluates the intervention. Faculty members using this technique found that all 52 students in the lecture course were able to participate in some aspect of the 70-minute simulation experience (Norman et al., 2013). The authors estimated that, if the simulation had been run in a
12 traditional laboratory setting with small groups of students, it would have taken 19.5 hours to engage all 52 students, so the potential time savings in using simulation in the classroom are significant.
5.4. Start With Simple Simulations Simulation can be done on many levels, and it is not necessary to make the simulation extremely complicated, have the patient deteriorate rapidly, or have the patient suffer a cardiac arrest. These complex scenarios are very time consuming to create, set up, and run. It may be a better use of time to begin with less complex scenarios that simply reinforce the content being taught (Seropian et al., 2004). For example, a brief simulation that emphasizes hand washing and administering medications safely can be very effective because those objectives are critical parts of the nursing curriculum.
5.5. Use the Right Simulator for the Job During the planning phase of a simulation, faculty members should initially define the objectives of the simulation. Then an attempt should be made to match the simulator to the objectives. For example, if the objective of the simulation was for students to detect a change in cardiac rhythm and then assess the patient, a high-fidelity simulator would likely provide the most fidelity. On the other hand, if the objective was to detect that a patient was having chest pain and, then, to administer medication, a lower fidelity simulator might be used. Setting up and programming high-fidelity simulators is more complicated and time intensive than using lower fidelity simulators. Therefore, the best use of time is to use lower fidelity manikins when possible.
5.6. Organize Equipment for Each Simulation Into Boxes One technique for saving time when setting up a simulation is to have everything that is needed for the set up organized into boxes. Plastic tubs that can be labeled and easily stacked or placed on shelves work well. For example, a box for a simulation about dehydration could contain the patient's armband, Foley catheter bag, wig, and intravenous line tubing. Include a checklist of supplies found in other areas, such as supply carts, that are also used in the simulation. Put items used to increase fidelity such as a fall risk sign or pictures of the patient's family in the box too. Place any documents used during the simulation in the box, including forms used for charting. When everything is in one place, set up time is reduced, and all items needed for the simulation are present.
5.7. Map Out Simulation Activities Across the Curriculum It is useful to get an understanding of how simulation is used in the entire nursing curriculum in order to prevent
M.D. Aldridge duplication of activities. For example, faculty could find that simulations involving cardiac arrest are being done in three different courses, while simulations involving postoperative nursing care are being done only once. It is useful to have simulations that reinforce basic nursing care as well as scenarios that students typically cannot actively participate in during clinical courses, such as a rapidly changing patient status. In addition, consideration should be given to situations where patient simulation has been shown to provide good learning outcomes, such as recognition of the deteriorating patient (Bell-Gordon, Gigliotti, & Mitchell, 2014; Buykx et al., 2012). Having a wide variety of simulations throughout the nursing curriculum is desirable.
5.8. Use Available Resources Writing scenarios is extremely time consuming because of the research that is involved to make the scenario evidence based and the backstory complete. Determining laboratory values, imaging studies, medication dosages, psychosocial history, and assessment findings and creating the patient chart take significant amounts of time. Therefore, the best use of faculty time is to use preprogrammed scenarios whenever possible (Faz et al., 2014). One study indicated that 67% of nursing programs purchase scenarios (Hayden, 2010). There are a number of sources for scenarios, including some that are free and others that can be purchased. It is often more efficient to adapt a preprogrammed scenario than to write one from scratch. Table 3 lists Web sites and organizations that offer free simulations for nursing faculty members.
5.9. Hire a Simulation Specialist A common recommendation to save faculty time is to hire a simulation specialist (Nehring et al., 2013). This person is recognized as a simulation champion and expert who assists other faculty members with simulation design and implementation. This person may have some workload release from teaching. Two surveys of nursing schools found that 75% had a simulation coordinator (Davis et al., 2014; Nehring & Lashley, 2004), and that position had at least a part-time workload release (Nehring & Lashley, 2004). A common method for validating expertise is through certification. The Society for Simulation in Healthcare (SSH) has a certification available to nurse educators that validates expertise in simulation education. In order to obtain certification as a certified health care simulation educator, an applicant must participate in health care simulation in an educational role in the undergraduate, graduate, allied health, or health care setting; have earned a bachelor's degree or equivalent experience; and have 2 years of continued use of simulation in health care education, research, or administration (SSH, 2015). After validating the educator's application and references, the educator must pass a 115-question multiple-choice examination that is taken at a testing center. Results are available immediately at the conclusion
Patient simulation Table 3
13
Web Sites and Organizations that Offer Free Simulations
Organization
Web site a
Kansas Board of Nursing
http://www.ksbn.org/education/Scenario/ SimulationScenarioLibrary.htm
Description
-16 simulations with charting documents -Varying complexity -Peer reviewed Montgomery College http://cms.montgomerycollege.edu/nursingsims/ -10 scenarios -Contain videos, simulation guides, and documents Massachusetts Nursing Initiative http://www.mass.edu/currentinit/Nursing/Sim/ -6 adult and 2 pediatric scenarios Welcome.asp -Free registration required Center for Health Sciences Interprofessional http://collaborate.uw.edu/educators-toolkit/heet-v- -13 scenarios, adult and pediatric Education, Research, and Practice (University nursing-simulation-scenarios-and-supporting-Varying levels of complexity of Washington) documents.html -Includes debriefing guide University of South Dakota http://www.usd.edu/health-sciences/nursing/ -30 scenarios simulation-scenarios -Organized by concepts -Includes preclass work and chart components a
Web site addresses were current as of May 2015. Please read the terms of use for each organization's simulation library.
of the examination, and the certification is good for 3 years (SSH, 2015).
6. Conclusion In summary, patient simulation is an effective yet time-consuming teaching strategy. As evidence mounts demonstrating the benefits of simulation, the burdens of implementing it must also be considered. Faculty members describe significant barriers to using simulation, including time constraints, lack of support, and concerns about how to implement it. Strategies for dealing with these concerns have been described in the literature. By using these strategies, it is possible for nursing faculty to perform simulation efficiently.
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