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Jeffries Simulation Framework State of the Science Project: Participant Construct
Clinical Simulation in Nursing (2014) 10, 363-372
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NLN/Jeffries Simulation Framework State of the Science Project: Participant Construct Carol F. Durham, EdD, RN, ANEF, FAANa,*, Mary L. Cato, EdD, RNb, Kathie Lasater, EdD, RN, ANEFc a
Clinical Professor and Director, Education-Innovation-Simulation Learning Environment, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7460, USA b Assistant Professor, Oregon Health & Science University School of Nursing, Portland, OR 97239, USA c Professor, Oregon Health & Science University School of Nursing, Portland, OR 97239, USA KEYWORDS NLN/Jeffries Simulation Framework; student; simulation participant; participant characteristics; construct; interprofessional simulation; simulation; construct model for simulation participant
Abstract Background: The initial Jeffries Simulation Framework was developed by Jeffries and Rogers in 2007 to guide the evolving simulation-based education. This framework identified five constructs: student, teacher, educational practices, simulation design characteristics, and outcomes. In 2011, the International Nursing Association for Clinical Simulation and Learning assembled a panel of simulation experts to review the literature to establish evidence for each of the framework constructs. This report summarizes the findings of the research about the simulation student construct and the rationale for expanding the label from student to participant. Method: A database was used to collate literature citations and findings to identify who participates in simulation and their associated characteristics. Preliminary findings were presented at the 2012 International Nursing Association for Clinical Simulation and Learning (INACSL) annual conference and feedback from attendees was solicited. The team then summarized the findings and considered the attendee comments. Results: Findings from the literature suggest that the construct be changed from student to participant. This article used current literature and expertise to expand the original participant descriptors to four elements: demographics, roles/responsibilities, attributes, and values. The paper further presents characteristics for each element. Conclusion: It was notable that the participants in simulation were seldom the focus of the literature. Early on, it became evident that there was no consistency about what the participants in the simulation were called or what their roles were. The broadening of the term from student to participant allowed for the inclusion of the range of individuals involved in simulation. Standardization of terminology will provide more consistency, improving descriptions, and reporting of simulation activities in the literature. Cite this article: Durham, C. F., Cato, M. L., & Lasater, K. (2014, July). NLN/Jeffries Simulation Framework State of the Science Project: Participant construct. Clinical Simulation in Nursing, 10(7), 363-372. http:// dx.doi.org/10.1016/j.ecns.2014.04.002. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
* Corresponding author: [email protected] (C. F. Durham). 1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2014.04.002
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The growth of simulation as a learning activity in health care professions has exploded in the past decade. Research focused on simulation as experiential pedagogy in health care has gone from nonexistent to prolific. Early in nursing education’ use of simulation, a framework for approaching simulation as a model for education was Key Points developed. The NLN/Jeff Supported by the literries Simulation Framework ature, the word partici(NLN/JSF) was an outcome pant replaces student of the first large, multisite to more accurately nursing study supported by reflect who particithe NLN and Laerdal pates in simulation. Medical (Jeffries, 2007). Elements of roles/reMany subsequent studies sponsibilities, attrihave used one, two, or all butes, values, and five constructs of the origdemographics replace inal framework to guide the original particithe expanding body of pants elements of research. The five conprogram, level, and structs included (a) student, age, which are pre(b) teacher, (c) educational sented in the model. practices, (d) simulation Exemplar charactdesign characteristics, and eristics delineate de(e) outcomes. scriptors for each In summer of 2011, the element. International Nursing Association for Clinical Simulation and Learning (INACSL) assembled five international project teams of nursing educators to examine the simulation research literature to uncover evidence that could (a) support the framework’s validity as a theory and/or (b) refine the NLN/JSF. At this initial meeting of the team, it was clear that our charge included finding a new name for the construct as student was judged inadequate by those involved in the project. The team presented preliminary findings at the 2012 11th Annual International Nursing Simulation/Learning Resource Centers Conference where nurse educators and practitioners from around the world provided their perspectives and feedback. The purpose of this article was to report the findings of a search for current evidence, including the literature, expert perspectives of the authors, and attendees at the INACSL annual conference, about the student construct. Concurrent with the growth of research is the recognition of a broader scope of uses for simulation, which translates to a wider range of those engaged in simulation than was initially the case. Hence, the Student Construct Team began the literature search with the recognition that the term student was too narrow and needed to be changed. The NLN/JSF student construct was initially defined by only three descriptors: program, level, and age with no further descriptions. The possibility of a broader term for the construct brought acknowledgment that additional or
replacement descriptors would better describe those involved in simulation.
Literature Search Process Team members investigated the literature using the terms simulation, student, learner, and/or participant. Each team member consulted a librarian and used multiple databases, including CINAHL, ERIC, PsychINFO, and Medline. Research articles were the primary focus, but systematic reviews and other nonresearch articles, such as expert opinions, were also included. Complex issues arose from the comprehensive search. For example, the simulation literature was not necessarily focused on nursing or health care simulation but included literature from other types of simulation, such as aviation. The nursing and health care literature used multiple terms for simulation, including human patient simulation, highfidelity simulation, nursing simulation, and health care simulation (Gore, Hunt, Parker, & Raines, 2010; Leigh, 2008; Smith-Stoner, 2009; Zavertnik, Huff, & Munro 2010). For example, the National Council of State Boards of Nursing offers the following definitions for prelicensure nursing programs: 1. High-fidelity simulation Patient care scenario that uses a standardized patient or a full-body patient simulator that can be programmed to respond to affective and psychomotor changes, such as breathing chest action. Examples of highfidelity manikins include SimManÒ, METIman, and NoelleÒ with Newborn HalÒ. 2. Medium-fidelity simulation Patient care scenario that uses a full-body simulator with installed human qualities such as breath sounds without chest rise. An example of a medium-fidelity manikin is VitalSimÔ. 3. Task trainers Part of a manikin designed for a specific psychomotor skill, for example, an arm for IV insertion practice (Hayden, 2010, p. 53). Literature, including standardized patients or actors as well as manikins and task trainers, was examined. In searching the literature, it was apparent that researchers were doing relevant simulation research with not only undergraduate nursing students but also graduate students, practicing nurses, interprofessional teams, and other nonnursing practitioners (Bambini, Washburn, & Perkins, 2009; Blum, Borglund, & Parcells, 2010; Chappy, Jambunatian, & Marnock, 2010; Fountain & Alfred, 2009; Parsh, 2010). Because we were searching for a new construct label to define who was involved in simulation, we determined that an integrative review (Whittemore & Knafl, 2005) was
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impractical and limited the possibilities. Additionally, there are five English language journals devoted specifically to simulation and numerous health care education journals that have liberally published simulation research. The team determined to expand the NLN/JSF construct from student to participant, which allowed the inclusion of multiple relevant data sources. Student was limiting to the model because it referred to only one of the multiple participants involved and necessary to actualize a simulation. Replacing the term student with participant provided inclusion of all involved in the simulated learning including the educator, facilitator, embedded actors, and others providing support roles and or facilitation. The team’s early decision to use participant was further affirmed when the second edition of Simulation in Nursing Education (Jeffries, 2012) changed the Student Construct to Participant Construct (Figure 1). During the literature search, we found that authors’ experiences as simulation experts guided the team and resulted in different perspectives and directions for the search. The search continued until the team discovered overlap and redundancy in the literature. An Excel analysis worksheet was used to compile and organize the publication findings. Categories included relevant concept being studied, sample size, study design, type of learner, type of simulation, instruments used, significant findings, and comments on the study. What finally emerged was a model,
Figure 2
Figure 1 The National League for Nursing/Jeffries Simulation Framework. From Jeffries, 2012 (p. 37). The figure is included with permission of the National League of Nursing, Washington, DC.
describing a broader range of simulation participant characteristics that informed a more comprehensive development of the participant construct within the NLN/JSF (Figure 2).
Model of simulation participant construct with elements and associated characteristics.
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Overview of Model The Student Construct Team quickly discovered that the descriptors from the initial model (program, level, and age) were limited, reflecting the simulation research literature at the time of the original model’ development (Jeffries, 2007). Based on the evidence, the team added the following elements: demographics, roles and responsibilities, attributes, and values along with characteristics for each. These elements and characteristics, although not exhaustive, were culled from the literature and expert simulation users to illustrate the multifaceted elements found in participants. They may overlap in an effort to explain the complexity of the participant in simulation. Researchers or educators may expand these characteristics depending on the focus of their work. The new participant construct model more completely captured the multiple descriptors of a participant (Figure 2).
Linking the Model to Known Evidence and Other Ways of Knowing Although this model was not intended to be all-inclusive, it allows the reader to understand the complexities associated in simulation. As the field of health care simulation continues to advance, characteristics of participants will be ever evolving. The remainder of the article describes and links the four elements to evidence from the literature and/ or the expertise of those engaged in simulation.
Demographics The model reconceptualized and expanded the demographics element to include not only program and age but also gender, culture/ethnicity, learner, and interprofessional practice, regardless of the participant’s other roles. Prior experience in health care may be an important variable although it could be argued experience does not assure comfort or skill in simulation; however, as it was suggested by Jeffries and Rogers (2007), it was included as a demographic characteristic. Within the demographic characteristic of program, we included curriculum since simulation is offered in nonacademic settings. The expansion allowed for consideration of transition to practice/orientation, professional prelicensure, advanced practice, and competency/certification. The level of the participant was subsumed under program/ curriculum (Figure 2).
Roles/Responsibilities While the element roles/responsibilities seemed straightforward, the nomenclature was found to be complex. Health care provider included a list of those who deliver health
care to patients/clients: nurse, physician, pharmacist, student, and others and set the stage for interprofessional simulation in which the participant may function both as an individual and as a member of a team. Additional roles emerged that are often used to either provide meaningful learning experiences for multiple participants, such as observer or those who augment the realism of the clinical case, including participants playing the role of significant other, and support staff, such as unit secretary. An embedded participant (also known as scenario guide, scenario role player, or confederate) was defined as a role assigned in a simulation encounter to help guide the scenario. The guidance may be influential as positive, negative, or neutral or as a distracter, depending on the objective(s), the level of the participants, and the scenario. Although the embedded participant’s role is part of the situation, the underlying purpose of the role may not be revealed to the participants in the scenario or simulation (INACSL) (Meakim et. al, 2013, p. s6). The term confederate was used as a synonym for embedded actor (Meakim et. al, 2013, p. s5); however it has generated much debate in simulation communities as use of confederate may evoke negative connotations. Facilitator is defined as ‘‘an individual who provides guidance, support, and structure during simulation-based learning experiences’’ (Meakim et. al, 2013, p. s6). Teacher was defined as ‘‘one who uses a system of directed and deliberate actions and activities for the purpose of inducing learning’’ (Meakim et. al, 2013, p. s9). In this model, we found it helpful to couple teacher with facilitator. Others was listed to allow flexibility for the evolution of simulation and to more broadly include the interprofessional practitioners in simulated experiences to mimic clinical experiences such as social work, physical therapy, dentistry, and legal (Figure 2).
Attributes Participants’ individual attributes affect their learning in simulation. Their previous life experiences, including loss of a loved one and/or other encounters with the health care system, may surface when they are immersed in a simulation. Oftentimes, educators are so focused on the teaching and learning outcomes, they do not consider the nuances of the participant. The attributes element of the model captured the participant’s preparation, considered learning styles, motivation/perception, and included the less-considered but important characteristics of selfefficacy, safe environment, vulnerability, and anxiety. Preparation for Simulation Depending on the purpose of a simulation session, preparation for participants may include readings or other information. Facilitators may provide preparatory materials to improve participants’ performance and reinforce course
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content (Alden & Durham, 2012). When simulation occurs in a practice environment, preparation before simulation was less often used because practicing nurses have less time and inclination to prepare outside of their work hours and generally have more experience and knowledge. In addition to assigned readings, participants may benefit from reading and reviewing patient histories, pathophysiology, laboratory results, medications, assessment instruments, and technical skills descriptions before simulation. This preparatory work occurred frequently in academic settings. However, preparation may not always improve performance. In one study, Gantt (2013) examined the effect of preparation on performance and anxiety and found that preparation for simulation decreased anxiety levels but was related to decreased scores on an evaluative performance rubric. Learning Styles Simulation engages all the senses, much like clinical experience, and provides opportunity for participants to engage on a variety of levels of learning. Adult learners have different learning styles. These can be identified using a simple test, such as the Kolb’s Learning Style Inventory (1984), to determine whether one is an auditory, visual, or kinesthetic learner. Simulation engages four different learning styles: through active experimentation, that is doing, and concrete experience, that is, feeling what it is like to be in the situation the scenario presents. In preparing for the experience, one is likely to do some abstract conceptualization of what the experience will be like, and for those watching the simulation, and during the debriefing, there is opportunity for reflective observation. Although useful for participants to be aware of their own learning styles, it would be challenging and undesirable for simulation facilitators to alter simulation activities to suit each participant. The utility lies in participants’ own understanding and ability to work with their strengths in adapting to the learning environment. ‘‘Teaching to what the student prefers provides for a positive social learning environment and a positive student experience, but it does not necessarily challenge the student’s thinking’’ (Kaakinen & Arwood, 2009, p. 14). Simulation allows the participant to stretch and engage in all four of Kolb’s learning preferences. Participants are allowed ‘‘to go beyond knowing to advance to synthesis and application of knowledge as they assess, plan, implement, and evaluate’’ their patient care (Durham & Alden, 2008, p.5). Motivation/Perception Participants’ motivation for participation may affect the outcome. DeCarlo, Collingridge, Grant, and Ventre (2008) examined barriers to practicing nurses’ participation in simulation training. Nurses identified several concerns that limited their engagement in simulation: being videotaped, lack of previous exposure to simulation, and an unwillingness to see simulation as the real thing. In addition,
the unit in which they worked affected perceptions toward simulation use. Cordeau (2010) analyzed nursing students’ reflections on simulation and identified that students valued the simulation for the learning, including understanding cues provided by patients and being able to reflect on their own actions. Walton, Chute, and Ball (2011) found that simulation helped students appreciate the role of the nurse, take the role seriously, and ‘‘transfer their skills and knowledge to clinical practice while gaining confidence’’ (p. 309). The motivation to participate in simulation is unique for nursing students in an academic program. Often, simulation counts as clinical hours; students participate in simulation just as they care for patients in clinical settings. In some cases, simulation performance, or at least attendance and participation, may be part of a student’s grade. An acceptance of simulation as a learning strategy is often a natural outcome when simulation is integrated into a curriculum. For participants to fully benefit from the learning environment in simulation, they must be open to viewing the simulated patient as ‘‘real,’’ or at least real enough to elicit authentic health care provider responses. Simulation facilitators ask participants to ‘‘suspend disbelief,’’ and treat the simulated patient as they would, a real patient. However, because a perfect representation of a clinical environment and patient is difficult to create, participants may find it challenging to suspend disbelief. Dieckmann, Gaba and Rall (2007) focused on the value of simulation as ‘‘social practice,’’ which they defined as ‘‘a contextual event in space and time, conducted for one or more purposes, in which people interact in a goal-oriented fashion with each other, with technical artifacts (the simulator), and with the environment (including relevant devices)’’ (p. 184). For students to benefit from this ‘‘social practice,’’ they need to accept that the simulated event may lack certain aspects of a real situation. Instead of suspending disbelief, participants may only need to agree to accept the learning that occurs in the simulated situation, whether it seems completely real or not. Self-Efficacy Studies about self-efficacy, confidence, and self-confidence related positive outcomes in simulation. Researchers reported that with an increase in self-efficacy or confidence, participants demonstrated improvement in critical thinking and leadership skills, learning from mistakes, identification of gaps in knowledge, and ability to handle the unexpected (Leigh, 2008). In several studies, simulation implemented before a clinical day helped increase participants’ confidence as they entered a clinical setting, specifically in mental health, pediatric, and obstetric settings (Crider & McNiesh, 2011; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; Schoening, Sittner, & Todd, 2006). Lasater, Johnson, Ravert and Rink (2014) found promise in the impact of an expert nurse role model on students’
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confidence as it related to clinical judgment development. Bambini et al. (2009) also found an increase in selfefficacy among students who had participated in a simulation experience before clinical, but they cautioned that, ‘‘while self-efficacy is important, further research should be directed toward using simulated experiences to evaluate a student’s ability to transfer theoretical knowledge into a contextual experience’’ (p. 82). In other words, selfefficacy alone does not translate to safe patient care and improved outcomes in practice. Engaging in simulated experiences brings awareness of what one does not know because the nuances surrounding health care are many. Preparation and debriefing may illuminate knowledge gaps that might never be discovered in the classroom or even the clinical setting (Lasater, 2007). It is the combination of preparing, doing, observing, and discussing that may well shine the light on a heretofore undiscovered gap, allowing additional learning to enhance patient safety. Although participants may report that their performance or their confidence increased because of simulation, studies show that self-assessment is not necessarily the optimal method for determining actual skill level nor is there necessarily a relationship between confidence and competence. Baxter and Norman (2011) reported negative correlations between nursing student self-assessments and observed structured clinical examination ratings, and they suggest the practice of self-assessment be reconsidered. Paul (2010) reported similar findings in a study of nursing students’ self-assessment of their cardiopulmonary resuscitation (CPR) skills. Calhoun, Rider, Meyer, Lamiani, and Truog (2009) used a multirater assessment in a study of physicians in family meeting simulations and found that the participants both under- and over-appraised their own performance, although they found this valuable information in terms of feedback and promoting insight into practice. Other studies found no relationship between confidence and clinical performance (Liaw, Scherpbier, Rethans, & Klainin-Yobas, 2012; Sadosty et al., 2011).
develop critical thinking skills. Crider and McNiesh, (2011), Megel et al. (2012), Schoening et al., (2006), and Szpak and Kameg (2013) identified the safe or nonthreatening environment of simulation as helpful in preparing students for the potentially stressful clinical environments of pediatric, psychiatric, and obstetric nursing. Ganley and Linnard-Palmer (2010) studied academic safety in simulation and found that students wanted a supportive climate ‘‘where they could learn without fear of failure’’ (p. e50).
Safe Environment Although simulation has often been promoted as a ‘‘safe place to practice,’’ participants and facilitators may not define safety in the same way. Although simulation allows practice for safe care of the simulated patient, participants may not necessarily feel that simulation is safe for them as participants. In his work on adult learning, or andragogy, Knowles, Holton, & Swanson (2005) cited certain characteristics of a safe environment that support learning. These include ‘‘physical comfort, mutual trust and respect, mutual helpfulness, freedom of expression, and acceptance of differences’’ (p. 93). Facilitators could apply all these concepts in designing safe learning activities in simulation. Several benefits of ‘‘safe’’ or ‘‘nonthreatening’’ learning environments have been identified. Kaddoura (2010) reported that a nonthreatening environment in simulation helped students
Anxiety Anxiety was defined as ‘‘painful or apprehensive uneasiness of mind usually over an impending or anticipated ill,’’ and ‘‘an abnormal and overwhelming sense of apprehension and fear often marked by physiological signs (as sweating, tension, and increased pulse),’’ according to Merriam-Webster. Whether simulation is used for practice or evaluation, participants often describe intense feelings of anxiety, usually related to being observed or judged by others. By its very nature, simulation is frequently an activity during which observation is an important aspect of learning (Seropian, Brown, Driggers & Gavilanes, 2004), and helping participants manage anxiety can be critical. Learners in simulation may be anxiously waiting for an adverse event to occur, or anxiety may stem from previously negative experiences in simulation.
Vulnerability Vulnerability is closely related to self-efficacy and the concept of safe environment in simulation. Participants who are observed or videotaped during simulation report feeling uncomfortable and exposed according to DeCarlo et al. (2008). Respect, faculty and peer support, and feedback are necessary for an environment to be considered ‘‘safe’’ by the learners. Psychological safety for participants in simulation occurs when the participant ‘‘is able to behave or perform without fear of negative consequences to self-image, social standing, or career trajectory’’ (Ganley & Linnard-Palmer, 2010, p. 2). Participants often complain that the cameras and the knowledge that they are being observed and critiqued affect their ability to perform adequately in a simulation. Myrick and Parker (2012) reported that students felt fear, anxiety, and stage fright when watched by others. It is common for participants to state that they would have responded differently in ‘‘real life’’ than they would in a simulation, which is a difficult concept to study. However, in clinical settings, they will continue to be watched whether by a preceptor, the patient’s family or the patient. Clapper (2010) believes that students may fear being ‘‘unveiled as a fraud’’ (p. e12). Newer nursing students, especially, may feel like imposters as they provide nursing care to a simulated patient who truly needs a ‘‘nurse’’ to intervene. As Beischel (2013) explained, ‘‘when a student performs in front of others, erroneous answers and faulty execution of nursing interventions are apparent to all’’ (p. 228).
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Anxiety is not necessarily a detriment to learning, and in fact, may facilitate learning by increasing motivation and duplicating the anxiety that is often felt in ‘‘real’’ clinical environments (Jo€els, Pu, Wieger, Oitzl & Krugers, 2006; Zoladz & Diamond, 2009). If participants are unmotivated or experience no stress at all, they may not take the activity seriously and benefit from the simulation (Cato, 2013). An optimal level of anxiety has been described as one in which learners are presented with some stress or challenge which motivates them to strive for optimal performance (Palethorpe & Wilson, 2011). Several studies (Gore et al., 2010; Megel, et al, 2012; Szpak & Kameg, 2013) found that a simulation experience before clinical decreased student anxiety, which can be a barrier to learning when they enter the clinical area. Lasater (2007) and Cato (2013) found that affirmation and awareness of learning can make the anxiety involved in the simulation worthwhile.
Values
while putting together some aspects of the situation they may not have thought of or encountered before. This may well occur in the debriefing experience when peer participants, including the facilitator, talk about the scenario and how it unfolded. In this way, participants receive feedback very close to the time of the action. Timely Feedback Because participants engage in scenarios as either active participants or observers, timely feedback from peer participants as well as the facilitator(s) is possible and beneficial. There is not a focus in simulation literature on delivering timely feedback, although one study identified that participants were anxious for and valued feedback from peers and facilitators, so they could better learn from their simulation experiences (Lasater, 2007). In contrast, Myrick and Parker found active observers/peers may be somewhat judgmental and their critique could ‘‘cognitively overwhelm’’ (2012, p. 371) novice learners. Feedback from both peers and facilitators may be subsumed in the debriefing process. Simulation scenarios are often condensed versions of real-life clinical situations. As such, Oermann and Gaberson (2014) highlighted the importance of clear feedback for formative evaluation; in the context of a debriefing, it is crucial to avoid participant trauma in the form destructive feedback (Hertel & Millis, 2002).
Participants see simulation as an adding value to their learning, that is, they come to simulation, anticipating achieving these values. A question that arose in our search was, ‘‘are these values the same as outcomes (added value) or values that participants bring to simulation?’’ When educators describe the use of simulation, they often speak of the value-added learning for the participants. However, only a few of these are captured in the literature. The team used their expertise and experience as well as that of other simulation educators to expand the values element of the model and to capture the values the participant has about simulation. Participants are engaged in active learning to make connections and apply their knowledge. Ideally in simulation, participants receive timely feedback, practice professional behaviors, allowing them to understand where they have met the standards of care and when there are knowledge gaps. This immediate feedback affirms their application of knowledge, skills, and attitudes around the delivery of quality and safe patient-centered care, including patient advocacy. Active learning includes opportunities for participants to be immersed in collaborative learning in a safe environment allowing for reflective practice (Figure 2).
Application of Professional Behaviors Simulation is designed to mimic reality, so many programs require participants to dress as they would in a similar clinical setting to enhance the reality and create a professional environment. Simulation also offers participants an opportunity to practice professional behaviors during scenarios, such as leadership, communication, and teamwork (Lewis, Strachan, & Smith, 2012; Simones et al., 2010). As interprofessional education becomes more common, particularly in simulation, these opportunities will expand to learn about professional roles of other health care professions (WHO, 2010) and collaborate more effectively with them Titzer, Swenty, & Hoehn (2012). Even within professional peer groups, there is value in learning collaboratively based on disparities of contexts of care, patient assignments, and time in the profession.
Reflective Practice/Affirmation of Knowledge, Skills, and Attitudes Reflective practice is inherent in well-designed simulation experiences (Alden & Durham, 2012). Simulation is likely to bring discovery for the participant about some aspect of the situation that was unknown before the intensive handson experience. In one study, nursing students engaged in their first experiences in simulation identified that simulation helped them to integrate their learning from a variety of modalities, including classroom, clinical, reading, and skills laboratory (Lasater, 2007). Participants may gain insight that their actions are appropriate or even excellent
Patient-Centered Care/Delivery of Quality and Safe Care/Patient Advocacy Health care training has always held the delivery of quality and safe patient care as a prime tenet. Simulation provides a strategy to not only teach about quality and care but a chance to observe and refine the learner’s application of those concepts. Since the Institute of Medicine (1999) report and the Quality and Safety Education for Nurses (Cronenwett et al., 2007), the imperative to integrate patient-centered care into simulation was highlighted. Participants can be taught and are expected to be patient advocates to enhance the quality and safety of their health care.
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Simulation allows participants to practice these skills, rehearse the language they will use, and experience how they can improve care structures when they keep their focus on the patient as the center of care.
interprofessional teamwork, communication, and collaboration (teamstepps.ahrq.gov).
Conclusion Active Learning Simulation creates a space for active or experiential learning. Clapper (2010) explained the value of ‘‘the learner becoming actively involved in the experience and reflecting on the experience during as well as after’’ (p. e10). This describes what occurs in a typical simulation case followed by debriefing. Knowing and doing are two different things, and when participants are immersed in a simulated clinical experience, they have to apply what they know. This active learning provides them with the opportunity to rehearse their professional skills and to identify knowledge gaps. The participant can practice psychomotor skills as well as clinical judgment, communication, teamwork, and collaboration within an environment that proves them timely feedback. Collaborative Learning Through collaborative learning, participants are afforded the opportunity to learn with other professionals, benefiting from a range of perspectives. Although this is potentially a source of some anxiety (Myrick & Parker, 2012), it may well be a motivator or catalyst for participants to thoroughly prepare for the experience. By engaging peer observers in the debriefing process, groups of participants gain an enhanced repertoire of possible actions and ideas for their practice (Lasater, 2007; Seropian et al., 2004). An expanded means of collaborative learning connects learners in interprofessional education, defined as ‘‘students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes’’ (WHO, 2010, p. 13). Based on Institute of Medicine studies (IOM, 1999; 2001; 2003), lack of interprofessional communication and teamwork are threats to patient safety, primarily in acute care settings. Learning side-by-side in multiple settings, including simulation, participants gain a deeper understanding of roles and responsibilities as well as have the opportunity to practice communication and teamwork in difficult, complex, or complex patient care situations (Bambini et al., 2009; Durham & Alden, 2012). The growing body of literature focused on interprofessional simulation education supports students’ desire and ability to learn in teams (Baker et al., 2008; Ker, Mole, & Bradley, 2003; Luctkar-Flude et al., 2010; Reese, Jeffries, & Engum, 2010). One study identified that although participants liked communicating and collaborating, there was some reluctance to speak freely in the interprofessional group (Lucktar-Fludee et al., 2010). National initiatives such as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) can be incorporated into simulation to provide effective strategies for
In the short time since the NLN/JSF was first published, much about simulation and its use as an educational strategy has changed. Initially, health care simulation was primarily limited to students. The original model was much more focused on the elements of the simulation than it was on the characteristics of the student. Best practices derived from the initial NLN/Laerdal study have shaped and enhanced the Participant Construct model presented in this article. Burgeoning health care simulation research since the introduction of the NLN/JSF Model has informed much of what we know about simulation participants and their responses to it. Simulation’s uses within health care have also proliferated to the extent that even the newest version of the model recognizes that not all who engage in simulation are students. Hence, the term participant more broadly captures the larger and more diverse cadres of players in simulation. Our team sought to use the research available to more intricately describe characteristics of participants in four elementsddemographics, roles/responsibilities, attributes, and valuesdusing evidence from the literature.
Acknowledgments The overall project was partially funded by a National League for Nursing (NLN) Education Research grant (Patricia Ravert as Principal Investigator), and each team member received a small stipend to assist with travel expenses. No commercial financial support was received for this study. C.D., M.C., and K.L. received travel and meal funding from National League for Nursing and the International Nursing Association for Clinical Simulation and Learning (INACSL) for this work. C.D., M.C. and K.L. received no commercial financial support. C.D. is the President of INACSL and K.L. is an early researcher of simulation as pedagogy in nursing education. INACSL has been a supporter of the examination of the National League for Nursing/Jeffries Simulation Framework. The role of C.D., M.C., and K.L. in the development of this manuscript included (a) acquisition of review data, analysis, and interpretation of data and (b) drafting and revision of the manuscript.
References Alden, K. R., & Durham, C. F. (2012). Integrating reflection in simulation: Structure, content, and process. In G. Sherwood, & S. H. Deutsch (Eds.),
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Lasater, K., Johnson, E. A., Ravert, P., & Rink, D. (2014). Role modeling clinical judgment for an unfolding older adult simulation. Journal of Nursing Education, 53(5), 257-264. http://dx.doi.org/10.3928/014 84834-20140414-01. Leigh, G. T. (2008). High-fidelity patient simulation and nursing student’s self-efficacy: A review of the literature. International Journal of Nursing Education Scholarship, 5(1), 37. http://dx.doi.org/10.2202/1548923X.1613. Lewis, R., Strachan, A., & Smith, M. M. (2012). Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. The Open Nursing Journal, 6, 82-89. http://dx.doi.org/10.2174/1874434601206010082. Liaw, S. Y., Scherpbier, A., Rethans, J. J., & Klainin-Yobas, P. (2012). Assessment for simulation learning outcomes: A comparison of knowledge and self-reported confidence with observed clinical performance. Nurse Education Today, 32(6), e35-e39. Luctkar-Flude, M., Baker, C., Pulling, C., McGraw, R., Dagnone, D., Medves, J., & Turner-Kelly, C. (2010). Evaluating an undergraduate interprofessional simulation-based educational module: Communication, teamwork, and confidence performing cardiac resuscitation skills. Advances in Medical Education and Practice, 1, 59-66. http: //dx.doi.org/10.2147/AMEP.S14100. Meakim, C., Bose, T., Decker, S., Franklin, A. E., Gloe, D., Lioce, L., . Borum, J. C. (2013). Standards of best practice: Simulation. Standard I: Terminology. International Nursing Association for Clinical Simulation and Learning (INACSL). Clinical Simulation in Nursing, 9(6S), s3-s11. http://dx.doi.org/10.1016/j.ecns.2013.0.008. Megel, M. E., Black, J., Clark, L., Carstens, P., Jenkins, L., Promes, J., . Goodman, T. (2012). Effect of high-fidelity simulation on pediatric nursing students’ anxiety. Clinical Simulation in Nursing, 8(9), e419e428. http://dx.doi.org/10.1016/j.ecns.2011.03.00. Oermann, M. H., & Gaberson, K. B. (2014). Evaluation and testing in nursing education (4th ed.). New York: Springer Publishing. 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/10.1108/03090591111138008. Myrick, F., & Patrick, B. C. (2012). The pedagogical ebb and flow of human patient simulation: Empowering through a process of fading support. Journal of Nursing Education, 51(7), 365-372. Parsh, B. (2010). Characteristics of effective simulated clinical experience instructors: Interviews with undergraduate students. Journal of Nursing Education, 49(10), 569-572. http://dx.doi.org/10.3928/01484834-2010 0730-04. Paul, F. (2010). An exploration of student nurses’ thoughts and experiences of using a video-recording to assess their performance of cardiopulmonary resuscitation (CPR) during a mock objective structured clinical examination (OSCE). Nursing Education in Practice, 10(5), 285-290.
Reese, C. E., Jeffries, P. R., & Engum, S. A. (2010). Using simulations to develop nursing and medical student collaboration. Nurse Education Perspectives, 31(1), 33-37, Retrieved from http://go.galegroup.com/ ps/i.do?id¼GALE%7CA219831328&v¼2.1&u¼unc_main&it¼r&p¼ AONE&sw¼w. Sadosty, A. T., Bellolio, M. F., Laack, T. A., Luke, A., Weaver, A., & Goyal, D. G. (2011). Simulation-based emergency medicine resident self-assessment. Journal of Emergency Medicine, 41(6), 679-685. http: //dx.doi.org/10.1016/j.jermed.2011.05.041. Schoening, A. M., Sittner, B. J., & Todd, M. J. (2006). Simulated clinical experience nursing students’ perceptions and the educators’ role. Nurse Educator, 31(6), 253-258. Seropian, M., Brown, K., Driggers, B., & Gavilanes, J. (2004). Simulation: Not just a manikin. Journal of Nursing Education, 43(4), 164-169. Simones, J., Wilcox, J., Scott, K., Goeden, D., Copley, D., Doetkott, R., & Kippley, M. (2010). Collaborative simulation project to teach scope of practice. Journal of Nursing Education, 49(4), 190-197. Smith-Stoner, M. (2009). Web-based broadcast of simulations: Expanded access to learning. Nurse Educator, 34(6), 266-270. Szpak, J. L., & Kameg, K. M. (2013). Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clinical Simulation in Nursing, 9(1), e13-e19. http://dx.doi.org/10.1016/j.ecns. 2011.07.003. Titzer, J. L., Swenty, C. F., & Hoehn, W. G. (2012). An interprofessional simulation promoting collaboration and problem solving among nursing and allied health professional students. Clinical Simulation in Nursing, 8(8), e325-e333. http://dx.doi.org/10.1016/j.ecns.2011.01.001. Walton, J., Chute, E., & Ball, L. (2011). Negotiating the role of the professional nurse: The pedagogy of simulation: A grounded theory study. Journal of Professional Nursing, 27(5), 299-310. http://dx.doi.org/10. 1016/j.profnurs.2011.04.005. Whittemore, R., & Knafl, K. (2005). The integrated review: Updated methodology. Journal of Advanced Nursing, 52(5), 546-553. http: //dx.doi.org/10.1111/j.1365-2648.2005.03621.x. World Health Organization (WHO). (2010). Framework for action on interprofessional education & collaborative practice. Geneva: World Health Organization. Retrieved from http://whqlibdoc.who.int/hq/2010/ WHO_HRH_HPN_10.3_eng.pdf. Zavertnik, J. E., Huff, T. A., & Munro, C. L. (2010). Innovative approach to teaching communication skills to nursing students. Journal of Nursing Education, 49(2), 65-71. http://dx.doi.org/10.3928/01484834-2009091806. Zoladz, P., & Diamond, D. (2009). Linear and non-linear dose-response functions reveal a hormetic relationship between stress and learning. Dose-Response, 7, 132-148. http://dx.doi.org/10.2203/dose-response. 08-015.Zoladz.
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Featured Article
NLN/Jeffries Simulation Framework State of the Science Project: Participant Construct Carol F. Durham, EdD, RN, ANEF, FAANa,*, Mary L. Cato, EdD, RNb, Kathie Lasater, EdD, RN, ANEFc a
Clinical Professor and Director, Education-Innovation-Simulation Learning Environment, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7460, USA b Assistant Professor, Oregon Health & Science University School of Nursing, Portland, OR 97239, USA c Professor, Oregon Health & Science University School of Nursing, Portland, OR 97239, USA KEYWORDS NLN/Jeffries Simulation Framework; student; simulation participant; participant characteristics; construct; interprofessional simulation; simulation; construct model for simulation participant
Abstract Background: The initial Jeffries Simulation Framework was developed by Jeffries and Rogers in 2007 to guide the evolving simulation-based education. This framework identified five constructs: student, teacher, educational practices, simulation design characteristics, and outcomes. In 2011, the International Nursing Association for Clinical Simulation and Learning assembled a panel of simulation experts to review the literature to establish evidence for each of the framework constructs. This report summarizes the findings of the research about the simulation student construct and the rationale for expanding the label from student to participant. Method: A database was used to collate literature citations and findings to identify who participates in simulation and their associated characteristics. Preliminary findings were presented at the 2012 International Nursing Association for Clinical Simulation and Learning (INACSL) annual conference and feedback from attendees was solicited. The team then summarized the findings and considered the attendee comments. Results: Findings from the literature suggest that the construct be changed from student to participant. This article used current literature and expertise to expand the original participant descriptors to four elements: demographics, roles/responsibilities, attributes, and values. The paper further presents characteristics for each element. Conclusion: It was notable that the participants in simulation were seldom the focus of the literature. Early on, it became evident that there was no consistency about what the participants in the simulation were called or what their roles were. The broadening of the term from student to participant allowed for the inclusion of the range of individuals involved in simulation. Standardization of terminology will provide more consistency, improving descriptions, and reporting of simulation activities in the literature. Cite this article: Durham, C. F., Cato, M. L., & Lasater, K. (2014, July). NLN/Jeffries Simulation Framework State of the Science Project: Participant construct. Clinical Simulation in Nursing, 10(7), 363-372. http:// dx.doi.org/10.1016/j.ecns.2014.04.002. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
* Corresponding author: [email protected] (C. F. Durham). 1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2014.04.002
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The growth of simulation as a learning activity in health care professions has exploded in the past decade. Research focused on simulation as experiential pedagogy in health care has gone from nonexistent to prolific. Early in nursing education’ use of simulation, a framework for approaching simulation as a model for education was Key Points developed. The NLN/Jeff Supported by the literries Simulation Framework ature, the word partici(NLN/JSF) was an outcome pant replaces student of the first large, multisite to more accurately nursing study supported by reflect who particithe NLN and Laerdal pates in simulation. Medical (Jeffries, 2007). Elements of roles/reMany subsequent studies sponsibilities, attrihave used one, two, or all butes, values, and five constructs of the origdemographics replace inal framework to guide the original particithe expanding body of pants elements of research. The five conprogram, level, and structs included (a) student, age, which are pre(b) teacher, (c) educational sented in the model. practices, (d) simulation Exemplar charactdesign characteristics, and eristics delineate de(e) outcomes. scriptors for each In summer of 2011, the element. International Nursing Association for Clinical Simulation and Learning (INACSL) assembled five international project teams of nursing educators to examine the simulation research literature to uncover evidence that could (a) support the framework’s validity as a theory and/or (b) refine the NLN/JSF. At this initial meeting of the team, it was clear that our charge included finding a new name for the construct as student was judged inadequate by those involved in the project. The team presented preliminary findings at the 2012 11th Annual International Nursing Simulation/Learning Resource Centers Conference where nurse educators and practitioners from around the world provided their perspectives and feedback. The purpose of this article was to report the findings of a search for current evidence, including the literature, expert perspectives of the authors, and attendees at the INACSL annual conference, about the student construct. Concurrent with the growth of research is the recognition of a broader scope of uses for simulation, which translates to a wider range of those engaged in simulation than was initially the case. Hence, the Student Construct Team began the literature search with the recognition that the term student was too narrow and needed to be changed. The NLN/JSF student construct was initially defined by only three descriptors: program, level, and age with no further descriptions. The possibility of a broader term for the construct brought acknowledgment that additional or
replacement descriptors would better describe those involved in simulation.
Literature Search Process Team members investigated the literature using the terms simulation, student, learner, and/or participant. Each team member consulted a librarian and used multiple databases, including CINAHL, ERIC, PsychINFO, and Medline. Research articles were the primary focus, but systematic reviews and other nonresearch articles, such as expert opinions, were also included. Complex issues arose from the comprehensive search. For example, the simulation literature was not necessarily focused on nursing or health care simulation but included literature from other types of simulation, such as aviation. The nursing and health care literature used multiple terms for simulation, including human patient simulation, highfidelity simulation, nursing simulation, and health care simulation (Gore, Hunt, Parker, & Raines, 2010; Leigh, 2008; Smith-Stoner, 2009; Zavertnik, Huff, & Munro 2010). For example, the National Council of State Boards of Nursing offers the following definitions for prelicensure nursing programs: 1. High-fidelity simulation Patient care scenario that uses a standardized patient or a full-body patient simulator that can be programmed to respond to affective and psychomotor changes, such as breathing chest action. Examples of highfidelity manikins include SimManÒ, METIman, and NoelleÒ with Newborn HalÒ. 2. Medium-fidelity simulation Patient care scenario that uses a full-body simulator with installed human qualities such as breath sounds without chest rise. An example of a medium-fidelity manikin is VitalSimÔ. 3. Task trainers Part of a manikin designed for a specific psychomotor skill, for example, an arm for IV insertion practice (Hayden, 2010, p. 53). Literature, including standardized patients or actors as well as manikins and task trainers, was examined. In searching the literature, it was apparent that researchers were doing relevant simulation research with not only undergraduate nursing students but also graduate students, practicing nurses, interprofessional teams, and other nonnursing practitioners (Bambini, Washburn, & Perkins, 2009; Blum, Borglund, & Parcells, 2010; Chappy, Jambunatian, & Marnock, 2010; Fountain & Alfred, 2009; Parsh, 2010). Because we were searching for a new construct label to define who was involved in simulation, we determined that an integrative review (Whittemore & Knafl, 2005) was
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impractical and limited the possibilities. Additionally, there are five English language journals devoted specifically to simulation and numerous health care education journals that have liberally published simulation research. The team determined to expand the NLN/JSF construct from student to participant, which allowed the inclusion of multiple relevant data sources. Student was limiting to the model because it referred to only one of the multiple participants involved and necessary to actualize a simulation. Replacing the term student with participant provided inclusion of all involved in the simulated learning including the educator, facilitator, embedded actors, and others providing support roles and or facilitation. The team’s early decision to use participant was further affirmed when the second edition of Simulation in Nursing Education (Jeffries, 2012) changed the Student Construct to Participant Construct (Figure 1). During the literature search, we found that authors’ experiences as simulation experts guided the team and resulted in different perspectives and directions for the search. The search continued until the team discovered overlap and redundancy in the literature. An Excel analysis worksheet was used to compile and organize the publication findings. Categories included relevant concept being studied, sample size, study design, type of learner, type of simulation, instruments used, significant findings, and comments on the study. What finally emerged was a model,
Figure 2
Figure 1 The National League for Nursing/Jeffries Simulation Framework. From Jeffries, 2012 (p. 37). The figure is included with permission of the National League of Nursing, Washington, DC.
describing a broader range of simulation participant characteristics that informed a more comprehensive development of the participant construct within the NLN/JSF (Figure 2).
Model of simulation participant construct with elements and associated characteristics.
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Overview of Model The Student Construct Team quickly discovered that the descriptors from the initial model (program, level, and age) were limited, reflecting the simulation research literature at the time of the original model’ development (Jeffries, 2007). Based on the evidence, the team added the following elements: demographics, roles and responsibilities, attributes, and values along with characteristics for each. These elements and characteristics, although not exhaustive, were culled from the literature and expert simulation users to illustrate the multifaceted elements found in participants. They may overlap in an effort to explain the complexity of the participant in simulation. Researchers or educators may expand these characteristics depending on the focus of their work. The new participant construct model more completely captured the multiple descriptors of a participant (Figure 2).
Linking the Model to Known Evidence and Other Ways of Knowing Although this model was not intended to be all-inclusive, it allows the reader to understand the complexities associated in simulation. As the field of health care simulation continues to advance, characteristics of participants will be ever evolving. The remainder of the article describes and links the four elements to evidence from the literature and/ or the expertise of those engaged in simulation.
Demographics The model reconceptualized and expanded the demographics element to include not only program and age but also gender, culture/ethnicity, learner, and interprofessional practice, regardless of the participant’s other roles. Prior experience in health care may be an important variable although it could be argued experience does not assure comfort or skill in simulation; however, as it was suggested by Jeffries and Rogers (2007), it was included as a demographic characteristic. Within the demographic characteristic of program, we included curriculum since simulation is offered in nonacademic settings. The expansion allowed for consideration of transition to practice/orientation, professional prelicensure, advanced practice, and competency/certification. The level of the participant was subsumed under program/ curriculum (Figure 2).
Roles/Responsibilities While the element roles/responsibilities seemed straightforward, the nomenclature was found to be complex. Health care provider included a list of those who deliver health
care to patients/clients: nurse, physician, pharmacist, student, and others and set the stage for interprofessional simulation in which the participant may function both as an individual and as a member of a team. Additional roles emerged that are often used to either provide meaningful learning experiences for multiple participants, such as observer or those who augment the realism of the clinical case, including participants playing the role of significant other, and support staff, such as unit secretary. An embedded participant (also known as scenario guide, scenario role player, or confederate) was defined as a role assigned in a simulation encounter to help guide the scenario. The guidance may be influential as positive, negative, or neutral or as a distracter, depending on the objective(s), the level of the participants, and the scenario. Although the embedded participant’s role is part of the situation, the underlying purpose of the role may not be revealed to the participants in the scenario or simulation (INACSL) (Meakim et. al, 2013, p. s6). The term confederate was used as a synonym for embedded actor (Meakim et. al, 2013, p. s5); however it has generated much debate in simulation communities as use of confederate may evoke negative connotations. Facilitator is defined as ‘‘an individual who provides guidance, support, and structure during simulation-based learning experiences’’ (Meakim et. al, 2013, p. s6). Teacher was defined as ‘‘one who uses a system of directed and deliberate actions and activities for the purpose of inducing learning’’ (Meakim et. al, 2013, p. s9). In this model, we found it helpful to couple teacher with facilitator. Others was listed to allow flexibility for the evolution of simulation and to more broadly include the interprofessional practitioners in simulated experiences to mimic clinical experiences such as social work, physical therapy, dentistry, and legal (Figure 2).
Attributes Participants’ individual attributes affect their learning in simulation. Their previous life experiences, including loss of a loved one and/or other encounters with the health care system, may surface when they are immersed in a simulation. Oftentimes, educators are so focused on the teaching and learning outcomes, they do not consider the nuances of the participant. The attributes element of the model captured the participant’s preparation, considered learning styles, motivation/perception, and included the less-considered but important characteristics of selfefficacy, safe environment, vulnerability, and anxiety. Preparation for Simulation Depending on the purpose of a simulation session, preparation for participants may include readings or other information. Facilitators may provide preparatory materials to improve participants’ performance and reinforce course
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content (Alden & Durham, 2012). When simulation occurs in a practice environment, preparation before simulation was less often used because practicing nurses have less time and inclination to prepare outside of their work hours and generally have more experience and knowledge. In addition to assigned readings, participants may benefit from reading and reviewing patient histories, pathophysiology, laboratory results, medications, assessment instruments, and technical skills descriptions before simulation. This preparatory work occurred frequently in academic settings. However, preparation may not always improve performance. In one study, Gantt (2013) examined the effect of preparation on performance and anxiety and found that preparation for simulation decreased anxiety levels but was related to decreased scores on an evaluative performance rubric. Learning Styles Simulation engages all the senses, much like clinical experience, and provides opportunity for participants to engage on a variety of levels of learning. Adult learners have different learning styles. These can be identified using a simple test, such as the Kolb’s Learning Style Inventory (1984), to determine whether one is an auditory, visual, or kinesthetic learner. Simulation engages four different learning styles: through active experimentation, that is doing, and concrete experience, that is, feeling what it is like to be in the situation the scenario presents. In preparing for the experience, one is likely to do some abstract conceptualization of what the experience will be like, and for those watching the simulation, and during the debriefing, there is opportunity for reflective observation. Although useful for participants to be aware of their own learning styles, it would be challenging and undesirable for simulation facilitators to alter simulation activities to suit each participant. The utility lies in participants’ own understanding and ability to work with their strengths in adapting to the learning environment. ‘‘Teaching to what the student prefers provides for a positive social learning environment and a positive student experience, but it does not necessarily challenge the student’s thinking’’ (Kaakinen & Arwood, 2009, p. 14). Simulation allows the participant to stretch and engage in all four of Kolb’s learning preferences. Participants are allowed ‘‘to go beyond knowing to advance to synthesis and application of knowledge as they assess, plan, implement, and evaluate’’ their patient care (Durham & Alden, 2008, p.5). Motivation/Perception Participants’ motivation for participation may affect the outcome. DeCarlo, Collingridge, Grant, and Ventre (2008) examined barriers to practicing nurses’ participation in simulation training. Nurses identified several concerns that limited their engagement in simulation: being videotaped, lack of previous exposure to simulation, and an unwillingness to see simulation as the real thing. In addition,
the unit in which they worked affected perceptions toward simulation use. Cordeau (2010) analyzed nursing students’ reflections on simulation and identified that students valued the simulation for the learning, including understanding cues provided by patients and being able to reflect on their own actions. Walton, Chute, and Ball (2011) found that simulation helped students appreciate the role of the nurse, take the role seriously, and ‘‘transfer their skills and knowledge to clinical practice while gaining confidence’’ (p. 309). The motivation to participate in simulation is unique for nursing students in an academic program. Often, simulation counts as clinical hours; students participate in simulation just as they care for patients in clinical settings. In some cases, simulation performance, or at least attendance and participation, may be part of a student’s grade. An acceptance of simulation as a learning strategy is often a natural outcome when simulation is integrated into a curriculum. For participants to fully benefit from the learning environment in simulation, they must be open to viewing the simulated patient as ‘‘real,’’ or at least real enough to elicit authentic health care provider responses. Simulation facilitators ask participants to ‘‘suspend disbelief,’’ and treat the simulated patient as they would, a real patient. However, because a perfect representation of a clinical environment and patient is difficult to create, participants may find it challenging to suspend disbelief. Dieckmann, Gaba and Rall (2007) focused on the value of simulation as ‘‘social practice,’’ which they defined as ‘‘a contextual event in space and time, conducted for one or more purposes, in which people interact in a goal-oriented fashion with each other, with technical artifacts (the simulator), and with the environment (including relevant devices)’’ (p. 184). For students to benefit from this ‘‘social practice,’’ they need to accept that the simulated event may lack certain aspects of a real situation. Instead of suspending disbelief, participants may only need to agree to accept the learning that occurs in the simulated situation, whether it seems completely real or not. Self-Efficacy Studies about self-efficacy, confidence, and self-confidence related positive outcomes in simulation. Researchers reported that with an increase in self-efficacy or confidence, participants demonstrated improvement in critical thinking and leadership skills, learning from mistakes, identification of gaps in knowledge, and ability to handle the unexpected (Leigh, 2008). In several studies, simulation implemented before a clinical day helped increase participants’ confidence as they entered a clinical setting, specifically in mental health, pediatric, and obstetric settings (Crider & McNiesh, 2011; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; Schoening, Sittner, & Todd, 2006). Lasater, Johnson, Ravert and Rink (2014) found promise in the impact of an expert nurse role model on students’
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confidence as it related to clinical judgment development. Bambini et al. (2009) also found an increase in selfefficacy among students who had participated in a simulation experience before clinical, but they cautioned that, ‘‘while self-efficacy is important, further research should be directed toward using simulated experiences to evaluate a student’s ability to transfer theoretical knowledge into a contextual experience’’ (p. 82). In other words, selfefficacy alone does not translate to safe patient care and improved outcomes in practice. Engaging in simulated experiences brings awareness of what one does not know because the nuances surrounding health care are many. Preparation and debriefing may illuminate knowledge gaps that might never be discovered in the classroom or even the clinical setting (Lasater, 2007). It is the combination of preparing, doing, observing, and discussing that may well shine the light on a heretofore undiscovered gap, allowing additional learning to enhance patient safety. Although participants may report that their performance or their confidence increased because of simulation, studies show that self-assessment is not necessarily the optimal method for determining actual skill level nor is there necessarily a relationship between confidence and competence. Baxter and Norman (2011) reported negative correlations between nursing student self-assessments and observed structured clinical examination ratings, and they suggest the practice of self-assessment be reconsidered. Paul (2010) reported similar findings in a study of nursing students’ self-assessment of their cardiopulmonary resuscitation (CPR) skills. Calhoun, Rider, Meyer, Lamiani, and Truog (2009) used a multirater assessment in a study of physicians in family meeting simulations and found that the participants both under- and over-appraised their own performance, although they found this valuable information in terms of feedback and promoting insight into practice. Other studies found no relationship between confidence and clinical performance (Liaw, Scherpbier, Rethans, & Klainin-Yobas, 2012; Sadosty et al., 2011).
develop critical thinking skills. Crider and McNiesh, (2011), Megel et al. (2012), Schoening et al., (2006), and Szpak and Kameg (2013) identified the safe or nonthreatening environment of simulation as helpful in preparing students for the potentially stressful clinical environments of pediatric, psychiatric, and obstetric nursing. Ganley and Linnard-Palmer (2010) studied academic safety in simulation and found that students wanted a supportive climate ‘‘where they could learn without fear of failure’’ (p. e50).
Safe Environment Although simulation has often been promoted as a ‘‘safe place to practice,’’ participants and facilitators may not define safety in the same way. Although simulation allows practice for safe care of the simulated patient, participants may not necessarily feel that simulation is safe for them as participants. In his work on adult learning, or andragogy, Knowles, Holton, & Swanson (2005) cited certain characteristics of a safe environment that support learning. These include ‘‘physical comfort, mutual trust and respect, mutual helpfulness, freedom of expression, and acceptance of differences’’ (p. 93). Facilitators could apply all these concepts in designing safe learning activities in simulation. Several benefits of ‘‘safe’’ or ‘‘nonthreatening’’ learning environments have been identified. Kaddoura (2010) reported that a nonthreatening environment in simulation helped students
Anxiety Anxiety was defined as ‘‘painful or apprehensive uneasiness of mind usually over an impending or anticipated ill,’’ and ‘‘an abnormal and overwhelming sense of apprehension and fear often marked by physiological signs (as sweating, tension, and increased pulse),’’ according to Merriam-Webster. Whether simulation is used for practice or evaluation, participants often describe intense feelings of anxiety, usually related to being observed or judged by others. By its very nature, simulation is frequently an activity during which observation is an important aspect of learning (Seropian, Brown, Driggers & Gavilanes, 2004), and helping participants manage anxiety can be critical. Learners in simulation may be anxiously waiting for an adverse event to occur, or anxiety may stem from previously negative experiences in simulation.
Vulnerability Vulnerability is closely related to self-efficacy and the concept of safe environment in simulation. Participants who are observed or videotaped during simulation report feeling uncomfortable and exposed according to DeCarlo et al. (2008). Respect, faculty and peer support, and feedback are necessary for an environment to be considered ‘‘safe’’ by the learners. Psychological safety for participants in simulation occurs when the participant ‘‘is able to behave or perform without fear of negative consequences to self-image, social standing, or career trajectory’’ (Ganley & Linnard-Palmer, 2010, p. 2). Participants often complain that the cameras and the knowledge that they are being observed and critiqued affect their ability to perform adequately in a simulation. Myrick and Parker (2012) reported that students felt fear, anxiety, and stage fright when watched by others. It is common for participants to state that they would have responded differently in ‘‘real life’’ than they would in a simulation, which is a difficult concept to study. However, in clinical settings, they will continue to be watched whether by a preceptor, the patient’s family or the patient. Clapper (2010) believes that students may fear being ‘‘unveiled as a fraud’’ (p. e12). Newer nursing students, especially, may feel like imposters as they provide nursing care to a simulated patient who truly needs a ‘‘nurse’’ to intervene. As Beischel (2013) explained, ‘‘when a student performs in front of others, erroneous answers and faulty execution of nursing interventions are apparent to all’’ (p. 228).
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Anxiety is not necessarily a detriment to learning, and in fact, may facilitate learning by increasing motivation and duplicating the anxiety that is often felt in ‘‘real’’ clinical environments (Jo€els, Pu, Wieger, Oitzl & Krugers, 2006; Zoladz & Diamond, 2009). If participants are unmotivated or experience no stress at all, they may not take the activity seriously and benefit from the simulation (Cato, 2013). An optimal level of anxiety has been described as one in which learners are presented with some stress or challenge which motivates them to strive for optimal performance (Palethorpe & Wilson, 2011). Several studies (Gore et al., 2010; Megel, et al, 2012; Szpak & Kameg, 2013) found that a simulation experience before clinical decreased student anxiety, which can be a barrier to learning when they enter the clinical area. Lasater (2007) and Cato (2013) found that affirmation and awareness of learning can make the anxiety involved in the simulation worthwhile.
Values
while putting together some aspects of the situation they may not have thought of or encountered before. This may well occur in the debriefing experience when peer participants, including the facilitator, talk about the scenario and how it unfolded. In this way, participants receive feedback very close to the time of the action. Timely Feedback Because participants engage in scenarios as either active participants or observers, timely feedback from peer participants as well as the facilitator(s) is possible and beneficial. There is not a focus in simulation literature on delivering timely feedback, although one study identified that participants were anxious for and valued feedback from peers and facilitators, so they could better learn from their simulation experiences (Lasater, 2007). In contrast, Myrick and Parker found active observers/peers may be somewhat judgmental and their critique could ‘‘cognitively overwhelm’’ (2012, p. 371) novice learners. Feedback from both peers and facilitators may be subsumed in the debriefing process. Simulation scenarios are often condensed versions of real-life clinical situations. As such, Oermann and Gaberson (2014) highlighted the importance of clear feedback for formative evaluation; in the context of a debriefing, it is crucial to avoid participant trauma in the form destructive feedback (Hertel & Millis, 2002).
Participants see simulation as an adding value to their learning, that is, they come to simulation, anticipating achieving these values. A question that arose in our search was, ‘‘are these values the same as outcomes (added value) or values that participants bring to simulation?’’ When educators describe the use of simulation, they often speak of the value-added learning for the participants. However, only a few of these are captured in the literature. The team used their expertise and experience as well as that of other simulation educators to expand the values element of the model and to capture the values the participant has about simulation. Participants are engaged in active learning to make connections and apply their knowledge. Ideally in simulation, participants receive timely feedback, practice professional behaviors, allowing them to understand where they have met the standards of care and when there are knowledge gaps. This immediate feedback affirms their application of knowledge, skills, and attitudes around the delivery of quality and safe patient-centered care, including patient advocacy. Active learning includes opportunities for participants to be immersed in collaborative learning in a safe environment allowing for reflective practice (Figure 2).
Application of Professional Behaviors Simulation is designed to mimic reality, so many programs require participants to dress as they would in a similar clinical setting to enhance the reality and create a professional environment. Simulation also offers participants an opportunity to practice professional behaviors during scenarios, such as leadership, communication, and teamwork (Lewis, Strachan, & Smith, 2012; Simones et al., 2010). As interprofessional education becomes more common, particularly in simulation, these opportunities will expand to learn about professional roles of other health care professions (WHO, 2010) and collaborate more effectively with them Titzer, Swenty, & Hoehn (2012). Even within professional peer groups, there is value in learning collaboratively based on disparities of contexts of care, patient assignments, and time in the profession.
Reflective Practice/Affirmation of Knowledge, Skills, and Attitudes Reflective practice is inherent in well-designed simulation experiences (Alden & Durham, 2012). Simulation is likely to bring discovery for the participant about some aspect of the situation that was unknown before the intensive handson experience. In one study, nursing students engaged in their first experiences in simulation identified that simulation helped them to integrate their learning from a variety of modalities, including classroom, clinical, reading, and skills laboratory (Lasater, 2007). Participants may gain insight that their actions are appropriate or even excellent
Patient-Centered Care/Delivery of Quality and Safe Care/Patient Advocacy Health care training has always held the delivery of quality and safe patient care as a prime tenet. Simulation provides a strategy to not only teach about quality and care but a chance to observe and refine the learner’s application of those concepts. Since the Institute of Medicine (1999) report and the Quality and Safety Education for Nurses (Cronenwett et al., 2007), the imperative to integrate patient-centered care into simulation was highlighted. Participants can be taught and are expected to be patient advocates to enhance the quality and safety of their health care.
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Simulation allows participants to practice these skills, rehearse the language they will use, and experience how they can improve care structures when they keep their focus on the patient as the center of care.
interprofessional teamwork, communication, and collaboration (teamstepps.ahrq.gov).
Conclusion Active Learning Simulation creates a space for active or experiential learning. Clapper (2010) explained the value of ‘‘the learner becoming actively involved in the experience and reflecting on the experience during as well as after’’ (p. e10). This describes what occurs in a typical simulation case followed by debriefing. Knowing and doing are two different things, and when participants are immersed in a simulated clinical experience, they have to apply what they know. This active learning provides them with the opportunity to rehearse their professional skills and to identify knowledge gaps. The participant can practice psychomotor skills as well as clinical judgment, communication, teamwork, and collaboration within an environment that proves them timely feedback. Collaborative Learning Through collaborative learning, participants are afforded the opportunity to learn with other professionals, benefiting from a range of perspectives. Although this is potentially a source of some anxiety (Myrick & Parker, 2012), it may well be a motivator or catalyst for participants to thoroughly prepare for the experience. By engaging peer observers in the debriefing process, groups of participants gain an enhanced repertoire of possible actions and ideas for their practice (Lasater, 2007; Seropian et al., 2004). An expanded means of collaborative learning connects learners in interprofessional education, defined as ‘‘students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes’’ (WHO, 2010, p. 13). Based on Institute of Medicine studies (IOM, 1999; 2001; 2003), lack of interprofessional communication and teamwork are threats to patient safety, primarily in acute care settings. Learning side-by-side in multiple settings, including simulation, participants gain a deeper understanding of roles and responsibilities as well as have the opportunity to practice communication and teamwork in difficult, complex, or complex patient care situations (Bambini et al., 2009; Durham & Alden, 2012). The growing body of literature focused on interprofessional simulation education supports students’ desire and ability to learn in teams (Baker et al., 2008; Ker, Mole, & Bradley, 2003; Luctkar-Flude et al., 2010; Reese, Jeffries, & Engum, 2010). One study identified that although participants liked communicating and collaborating, there was some reluctance to speak freely in the interprofessional group (Lucktar-Fludee et al., 2010). National initiatives such as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) can be incorporated into simulation to provide effective strategies for
In the short time since the NLN/JSF was first published, much about simulation and its use as an educational strategy has changed. Initially, health care simulation was primarily limited to students. The original model was much more focused on the elements of the simulation than it was on the characteristics of the student. Best practices derived from the initial NLN/Laerdal study have shaped and enhanced the Participant Construct model presented in this article. Burgeoning health care simulation research since the introduction of the NLN/JSF Model has informed much of what we know about simulation participants and their responses to it. Simulation’s uses within health care have also proliferated to the extent that even the newest version of the model recognizes that not all who engage in simulation are students. Hence, the term participant more broadly captures the larger and more diverse cadres of players in simulation. Our team sought to use the research available to more intricately describe characteristics of participants in four elementsddemographics, roles/responsibilities, attributes, and valuesdusing evidence from the literature.
Acknowledgments The overall project was partially funded by a National League for Nursing (NLN) Education Research grant (Patricia Ravert as Principal Investigator), and each team member received a small stipend to assist with travel expenses. No commercial financial support was received for this study. C.D., M.C., and K.L. received travel and meal funding from National League for Nursing and the International Nursing Association for Clinical Simulation and Learning (INACSL) for this work. C.D., M.C. and K.L. received no commercial financial support. C.D. is the President of INACSL and K.L. is an early researcher of simulation as pedagogy in nursing education. INACSL has been a supporter of the examination of the National League for Nursing/Jeffries Simulation Framework. The role of C.D., M.C., and K.L. in the development of this manuscript included (a) acquisition of review data, analysis, and interpretation of data and (b) drafting and revision of the manuscript.
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