- Email: [email protected]
Simple simulation technology
Teaching and Learning in Nursing (2013) 8, 70–74
www.jtln.org
Tim J. Bristol PhD, RN, CNE, ANEF Karin Sherrill, MSN, RN, CNE, ANEF
Simple simulation technology The increased use of simulation in nursing education is sweeping the country. The integration of this active learning strategy has been born out of necessity from the lack of clinical experiences for our students in health care organizations. Adoption of simulation is different for each program. A number of programs do not have adequate funding, whereas other schools of nursing have invested heavily in equipment, scenarios, and specially trained faculty. Regardless, many schools continue to have a difficult time integrating simulation into the curriculum. Expanding the use of simulation does not have to be complex. It can be accomplished simply with basic tools and thinking outside the box. For many educators, simulation is considered the use of high-fidelity manikins. According to Pamela Jefferies (2012), simulation is far more than just high-fidelity learning. “Typically, a simulation involves a student or group of students providing care for a patient who is represented by a manikin, an actor or a standardized patient (SP), depending on the clinical situation.” This use of “low tech” or “low fidelity” simulation can be as effective as integrating high-fidelity manikins. Other educators are conducting simulation with handheld computers as a means of bringing clinical to class. Schlairet (2012) effectively used handheld computers to help students manage care plans in simulated clinical experiences. She noted that the students were not only developing clinical reasoning skills but also developing reflection skills while meeting professional competencies. The value of simulation is in the learning experience, not in the equipment. The origination of learning activities needs to be founded upon course objectives and anticipated outcomes. A common course objective in a theory or clinical course may include “utilize the nursing process to implement clinical reasoning and critical thinking skills.” Using the active learning strategy of simulation, this course competency can be better accomplished by having students apply the principles of the nursing process. Here are some examples of how to meet this course objective using simple simulation technology.
1. Low fidelity and highly effective High-fidelity manikins are not always required to make a simulation effective. Using a static manikin can become very realistic given the right conditions. With wireless speakers (less than US$50), faculty can have audio coming from the static manikin. Well-placed post-it sticky notes can often serve as a means of communicating an abnormal assessment finding (crackles heard here, 3 + dorsalis pedis pulse (see Fig. 1), 1 cm × 1 cm fixed, hard, tender, etc.). Creating a realistic environment is the key to earning buy-in from students. Providing a realistic report, requiring students to prioritize their care, offering a patient complaint of “oh, I hurt so much, please give me something for pain,” and role modeling professionalism will allow this low-fidelity scenario to become a highly effective learning environment.
2. Low-fidelity electronic health records When a nursing program cannot afford an educational electronic health record, have students type into a Word document or Excel spreadsheet on a tablet or laptop at the bedside. A simple Word document can be developed into a Word Form that the students can complete independently, submit to their instructor via e-mail, or exchange with a friend to evaluate for accuracy. Although this is not as realistic as an electronic health record, it requires the student to reflect upon their care, organize their thoughts, and develop the skills of documentation. Note: the support section of office.microsoft.com provides updated information on creating forms.
3. Low-fidelity medication administration We all wish we had a real Pyxis or AccuDose for our students during simulation. But for many of us that is often a low-priority item on the budget wish list. There is a low-cost, low-tech way to accomplish the concepts of medication
1557-3087/$ – see front matter © 2013 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.teln.2013.01.002
Simple simulation technology
71 shape of a baseball). A curve ball card may say “your patient's temperature is 101 degrees” or “your patient is having a grand mal seizure.” These simple triggers require the student to reevaluate their plan of care, switch gears, and use their critical reasoning skills. You can also text a curve ball to a student group, increasing the use of technology.
6. Interprofessional simulation
Fig. 1
Dorsalis pedis pulse data with sticky note.
administration. For less than US$100, purchase a medication cart or multiple drawer carts from a hardware store. Place an older laptop or tablet computer on top and create a PowerPoint with hyperlinks or an Excel spreadsheet that guides and directs students to the proper drawer of the cart where they remove the medications (see Fig. 2). Offering a hyperlink within the program to Web resources for medication administration supports competencies related to informatics such as “appreciate the value of clinical decision support tools.” Here is a sample offered by a school of nursing. It can be downloaded and revised to meet your school's needs. PowerPoint sample download (http://tinyurl.com/ medadmindrawer).
4. Run a multipatient simulation day Running a multipatient, multistudent simulation can be confusing for the instructor but educational for the student. Use your multibed laboratory (static manikins work great) to create multiple patient scenarios. Begin your day by offering report for the “ward” of patients. It is important to allow students time to organize their day, prioritizing their care, looking up their medications, and determining which patient needs to be assessed first. Once the day begins, student will assess, give medications, hang intravenous (IV) solutions, interact with family (can be SPs or fellow students), call the health care provider, prepare patients for procedures, and perform admission and/or discharge teaching. Often, students find that this is the first time they are totally responsible for the patient care, and many ah-ha moments take place.
5. Throw them a curve ball Curve balls are a great way to stimulate critical thinking in your students in the laboratory setting. A curve ball is a premade index card that can be handed to the student during skills practice, simulation, or clinical (our cards are in the
Interprofessional collaborative practice (ICP) is a growing pedagogy that is important for simulation education. The joint effort of the Interprofessional Education Collaborative recently created core competencies for ICP (http://www. aacn.nche.edu/education-resources/ipecreport.pdf). Having nursing students “play” a respiratory therapist or social worker can be ineffective because many students do not understand the scope of practice for that profession. A more realistic way of developing teamwork and collaboration is by creating simulations that include multiple disciplines. Imagine the value of nursing students caring for a simulated patient alongside a respiratory, pharmacy, and nursing assistant student. The richness of this learning opportunity is valuable in so many ways. However, logistically working out this scenario can be difficult. The University of Kansas Medical Center is composed of the school of medicine, the school of nursing, and the school of health professions. These three schools have coordinated a simulation scenario for a pediatric patient simulation, which includes the medical, pharmacy, and nursing schools using the electronic health record. Medical student(s) write orders, the pharmacy students evaluate and validate the orders, and the nursing students complete the orders in the simulation laboratory. The case contains opportunities for students to practice communication skills with pediatric patients and parents, learn to enter and verify orders, find and implement existing treatment guidelines, and explore complex ethical/ legal issues. Debriefing takes place with all three groups of students simultaneously via a Webcam.
7. Video recording and review The Internet is an abundant resource for videos demonstrating clinical performance. Some videos are better than others. Choosing the right video requires a bit of forethought on how the video will help the students meet course learning objectives. Find a video clip that students can review at home, posting an on-line reflection of their thoughts and concerns in the discussion forum. To integrate Quality and Safety Education for Nurses (2012) Institute, pose questions to students that would require them to address concepts of safety, patient-centered care, or evidence-based practice. The learners could be directed to identify a strength or a weakness in the performance of the nurse on the video.
72
Sample low-fidelity medication administration system.
T. J. Bristol, K. Sherrill
Fig. 2
Simple simulation technology To make this evaluation more personal, have students' video record themselves in simulation and self-reflect on their performance. The same may be done for small groups of students. Low-cost video cameras (e.g., camcorders, “flip cams,” etc.) are usually adequate to capture the performance in these situations. For optimal positioning of the camera, consider securing them to the top of an iv pole. Many smart telephones also have video capabilities. Keep in mind that video postings of student performance should only be shared with student permission and be in a secured area of a course management system (e.g., Blackboard, eCollege, Angel, etc.). Many schools use public locations to share videos (iTunesU, YouTube, Teachertube, etc.); however, faculty should discuss this with their school's registrar or marketing department to ensure that this is not a violation of the Family Educational Rights and Privacy Act.
8. Debrief on-line A group of senior students several years ago unintentionally “killed” their patient in simulation. The emotion of knowing they had done harm to a child was emotionally distressing. Debriefing that day was focused on the emotion of the situation rather than learning from the mistakes made. After class that day, students continued the discussion online using their course management system. The instructor posed three questions to the students: (a) If you could change your actions, what would you have done differently? (b) How did your personal values and beliefs impact your nursing decisions? and (c) How will this experience change your future nursing practice? The rich discussion that followed allowed students to selfreflect on how to improve quality and safety in the process of providing care. The following week in postclinical, the instructor asked the question: “In what ways did you change your actions today in clinical as a result of what happened last week in simulation?” The responses were amazing. Online debriefing can be used to continue a simulation discussion, expand upon a debriefing discussion, or clarify misinformation discussed during debriefing. Requiring students to research a condition and post an evidencebased article supporting their practice reinforces the concepts of safe, evidence-based practice. Extending the debriefing discussion on-line can also help when there is a concern that low-fidelity simulation may not have been “real enough” for the learners. Through the extended on-line discussion, students are given the chance to dig deeper and pull out meaning that may not have been readily evident in the low-fidelity simulation.
9. Simulate a root cause analysis on-line Common practice in acute care facilities is the use of root cause analysis after a sentinel event. This process helps
73 identify the what, how, and why of an incidence and creates a plan to prevent recurrence. This form of quality improvement looks at the components of people, equipment, policy, and procedures to determine areas of process breakdown. Do you ever have a poor performance in the simulation laboratory? After debriefing, have the students break into small groups and post their root cause analysis on the course discussion board? Compare the group discussions; did all groups arrive at the same conclusions?
10. Case management simulation recording Present the class with the challenge of simulating a patient case management meeting. Each student needs to role play a professional of the multidisciplinary team. Consider a culturally diverse client who is preteen, newly diagnosed with diabetes mellitus. The team may include the patient and their family, cultural leader, nurse, social worker, school teacher, pharmacist, dietitian, diabetic nurse educator, and health care provider. The scenario should be video recorded and posted to the course management system for discussion and evaluation. Ask each student to evaluate the simulation with certain guidelines in mind (e.g., www.qsen.org; NCLEX® Client Needs; AACN Essentials, etc.).
11. Move simulation into the classroom Some schools have the ability to place their manikin on a gurney and move it to the classroom. Using the high-fidelity manikin in the classroom can be challenging and hence the need for low fidelity. The low-fidelity manikin will usually not require the compressor, command module, electricity, and others. Bringing simulation to class has many advantages related to teaching clinical reasoning skills. When discussing the assessment findings of a patient with respiratory distress, role play for students how to organize care to minimize worsening the patient's situation. Ask students to participate by performing prioritized interventions. If you cannot move a manikin to the classroom, don a hospital gown and begin speaking to the class in first person. “Someone help me, my chest hurts and I'm all sweaty” can engage a classroom more quickly than a PowerPoint of bullet points on a myocardial infarction.
12. Grand rounds On some campuses, simulation rooms sit dormant during a portion of the day. Begin weekly grand rounds. Grand rounds, as practiced in hospitals for many years, allow students to come into the simulation environment as if they are entering a hospital unit. The instructor leads the group by giving a short case history and poses questions to the group about teaching needs, dietary needs, critical laboratory values, and others. Prompting by the “patient” is also
74 beneficial in guiding and directing the group when they have difficulty answering the instructor's questions. This focused learning works well to expand collaboration of various student groups and works great as an introduction to the simulation. Oftentimes, the senior students may be the leaders of the grand rounds, much as how a chief resident would fill this role in a clinical setting. The less-experienced students learn from the more-experienced ones, building teamwork and collaboration skills (Sherrill, 2012).
T. J. Bristol, K. Sherrill can help students synthesize high-level content. And simple technology such as low-cost wireless speakers, camcorders, and PowerPoint presentations can add enough realism to help students develop clinical reasoning skills. Tim J. Bristol PhD, RN, CNE, ANEF Karin Sherrill MSN, RN, CNE, ANEF E-mail address: [email protected]
References 13. Clinical reasoning is crucial Simulation helps the students learn through experiencing complex concepts first hand. This learning strategy requires the use of imagination on the part of the learner and the faculty. Think of ways to make the learning a hands-on experience with little or no technology involved. The role play with students in control of the learning experience can be very effective. Using sticky notes on the static manikin
Jeffries, P. (2012). Simulation in nursing education, from conceptualization to evaluation, 2nd ed. New York: National League for Nursing. Quality and Safety Education for Nurses Institute. (2012). Competencies: Pre-licensure KSAs Cleveland, Oh: Author Retrieved from http://qsen. org/competencies/pre-licensure-ksas/. Schlairet, M. C. (2012). PDA-assisted simulated clinical experiences in undergraduate nursing education: A pilot study. Nursing Education Perspectives, 33(6), 391−394. Sherrill, K. (2012). Using nursing grand rounds to enforce Quality and Safety Education for Nurses competencies. Teaching and Learning in Nursing, 7(3), 118−120.
www.jtln.org
Tim J. Bristol PhD, RN, CNE, ANEF Karin Sherrill, MSN, RN, CNE, ANEF
Simple simulation technology The increased use of simulation in nursing education is sweeping the country. The integration of this active learning strategy has been born out of necessity from the lack of clinical experiences for our students in health care organizations. Adoption of simulation is different for each program. A number of programs do not have adequate funding, whereas other schools of nursing have invested heavily in equipment, scenarios, and specially trained faculty. Regardless, many schools continue to have a difficult time integrating simulation into the curriculum. Expanding the use of simulation does not have to be complex. It can be accomplished simply with basic tools and thinking outside the box. For many educators, simulation is considered the use of high-fidelity manikins. According to Pamela Jefferies (2012), simulation is far more than just high-fidelity learning. “Typically, a simulation involves a student or group of students providing care for a patient who is represented by a manikin, an actor or a standardized patient (SP), depending on the clinical situation.” This use of “low tech” or “low fidelity” simulation can be as effective as integrating high-fidelity manikins. Other educators are conducting simulation with handheld computers as a means of bringing clinical to class. Schlairet (2012) effectively used handheld computers to help students manage care plans in simulated clinical experiences. She noted that the students were not only developing clinical reasoning skills but also developing reflection skills while meeting professional competencies. The value of simulation is in the learning experience, not in the equipment. The origination of learning activities needs to be founded upon course objectives and anticipated outcomes. A common course objective in a theory or clinical course may include “utilize the nursing process to implement clinical reasoning and critical thinking skills.” Using the active learning strategy of simulation, this course competency can be better accomplished by having students apply the principles of the nursing process. Here are some examples of how to meet this course objective using simple simulation technology.
1. Low fidelity and highly effective High-fidelity manikins are not always required to make a simulation effective. Using a static manikin can become very realistic given the right conditions. With wireless speakers (less than US$50), faculty can have audio coming from the static manikin. Well-placed post-it sticky notes can often serve as a means of communicating an abnormal assessment finding (crackles heard here, 3 + dorsalis pedis pulse (see Fig. 1), 1 cm × 1 cm fixed, hard, tender, etc.). Creating a realistic environment is the key to earning buy-in from students. Providing a realistic report, requiring students to prioritize their care, offering a patient complaint of “oh, I hurt so much, please give me something for pain,” and role modeling professionalism will allow this low-fidelity scenario to become a highly effective learning environment.
2. Low-fidelity electronic health records When a nursing program cannot afford an educational electronic health record, have students type into a Word document or Excel spreadsheet on a tablet or laptop at the bedside. A simple Word document can be developed into a Word Form that the students can complete independently, submit to their instructor via e-mail, or exchange with a friend to evaluate for accuracy. Although this is not as realistic as an electronic health record, it requires the student to reflect upon their care, organize their thoughts, and develop the skills of documentation. Note: the support section of office.microsoft.com provides updated information on creating forms.
3. Low-fidelity medication administration We all wish we had a real Pyxis or AccuDose for our students during simulation. But for many of us that is often a low-priority item on the budget wish list. There is a low-cost, low-tech way to accomplish the concepts of medication
1557-3087/$ – see front matter © 2013 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.teln.2013.01.002
Simple simulation technology
71 shape of a baseball). A curve ball card may say “your patient's temperature is 101 degrees” or “your patient is having a grand mal seizure.” These simple triggers require the student to reevaluate their plan of care, switch gears, and use their critical reasoning skills. You can also text a curve ball to a student group, increasing the use of technology.
6. Interprofessional simulation
Fig. 1
Dorsalis pedis pulse data with sticky note.
administration. For less than US$100, purchase a medication cart or multiple drawer carts from a hardware store. Place an older laptop or tablet computer on top and create a PowerPoint with hyperlinks or an Excel spreadsheet that guides and directs students to the proper drawer of the cart where they remove the medications (see Fig. 2). Offering a hyperlink within the program to Web resources for medication administration supports competencies related to informatics such as “appreciate the value of clinical decision support tools.” Here is a sample offered by a school of nursing. It can be downloaded and revised to meet your school's needs. PowerPoint sample download (http://tinyurl.com/ medadmindrawer).
4. Run a multipatient simulation day Running a multipatient, multistudent simulation can be confusing for the instructor but educational for the student. Use your multibed laboratory (static manikins work great) to create multiple patient scenarios. Begin your day by offering report for the “ward” of patients. It is important to allow students time to organize their day, prioritizing their care, looking up their medications, and determining which patient needs to be assessed first. Once the day begins, student will assess, give medications, hang intravenous (IV) solutions, interact with family (can be SPs or fellow students), call the health care provider, prepare patients for procedures, and perform admission and/or discharge teaching. Often, students find that this is the first time they are totally responsible for the patient care, and many ah-ha moments take place.
5. Throw them a curve ball Curve balls are a great way to stimulate critical thinking in your students in the laboratory setting. A curve ball is a premade index card that can be handed to the student during skills practice, simulation, or clinical (our cards are in the
Interprofessional collaborative practice (ICP) is a growing pedagogy that is important for simulation education. The joint effort of the Interprofessional Education Collaborative recently created core competencies for ICP (http://www. aacn.nche.edu/education-resources/ipecreport.pdf). Having nursing students “play” a respiratory therapist or social worker can be ineffective because many students do not understand the scope of practice for that profession. A more realistic way of developing teamwork and collaboration is by creating simulations that include multiple disciplines. Imagine the value of nursing students caring for a simulated patient alongside a respiratory, pharmacy, and nursing assistant student. The richness of this learning opportunity is valuable in so many ways. However, logistically working out this scenario can be difficult. The University of Kansas Medical Center is composed of the school of medicine, the school of nursing, and the school of health professions. These three schools have coordinated a simulation scenario for a pediatric patient simulation, which includes the medical, pharmacy, and nursing schools using the electronic health record. Medical student(s) write orders, the pharmacy students evaluate and validate the orders, and the nursing students complete the orders in the simulation laboratory. The case contains opportunities for students to practice communication skills with pediatric patients and parents, learn to enter and verify orders, find and implement existing treatment guidelines, and explore complex ethical/ legal issues. Debriefing takes place with all three groups of students simultaneously via a Webcam.
7. Video recording and review The Internet is an abundant resource for videos demonstrating clinical performance. Some videos are better than others. Choosing the right video requires a bit of forethought on how the video will help the students meet course learning objectives. Find a video clip that students can review at home, posting an on-line reflection of their thoughts and concerns in the discussion forum. To integrate Quality and Safety Education for Nurses (2012) Institute, pose questions to students that would require them to address concepts of safety, patient-centered care, or evidence-based practice. The learners could be directed to identify a strength or a weakness in the performance of the nurse on the video.
72
Sample low-fidelity medication administration system.
T. J. Bristol, K. Sherrill
Fig. 2
Simple simulation technology To make this evaluation more personal, have students' video record themselves in simulation and self-reflect on their performance. The same may be done for small groups of students. Low-cost video cameras (e.g., camcorders, “flip cams,” etc.) are usually adequate to capture the performance in these situations. For optimal positioning of the camera, consider securing them to the top of an iv pole. Many smart telephones also have video capabilities. Keep in mind that video postings of student performance should only be shared with student permission and be in a secured area of a course management system (e.g., Blackboard, eCollege, Angel, etc.). Many schools use public locations to share videos (iTunesU, YouTube, Teachertube, etc.); however, faculty should discuss this with their school's registrar or marketing department to ensure that this is not a violation of the Family Educational Rights and Privacy Act.
8. Debrief on-line A group of senior students several years ago unintentionally “killed” their patient in simulation. The emotion of knowing they had done harm to a child was emotionally distressing. Debriefing that day was focused on the emotion of the situation rather than learning from the mistakes made. After class that day, students continued the discussion online using their course management system. The instructor posed three questions to the students: (a) If you could change your actions, what would you have done differently? (b) How did your personal values and beliefs impact your nursing decisions? and (c) How will this experience change your future nursing practice? The rich discussion that followed allowed students to selfreflect on how to improve quality and safety in the process of providing care. The following week in postclinical, the instructor asked the question: “In what ways did you change your actions today in clinical as a result of what happened last week in simulation?” The responses were amazing. Online debriefing can be used to continue a simulation discussion, expand upon a debriefing discussion, or clarify misinformation discussed during debriefing. Requiring students to research a condition and post an evidencebased article supporting their practice reinforces the concepts of safe, evidence-based practice. Extending the debriefing discussion on-line can also help when there is a concern that low-fidelity simulation may not have been “real enough” for the learners. Through the extended on-line discussion, students are given the chance to dig deeper and pull out meaning that may not have been readily evident in the low-fidelity simulation.
9. Simulate a root cause analysis on-line Common practice in acute care facilities is the use of root cause analysis after a sentinel event. This process helps
73 identify the what, how, and why of an incidence and creates a plan to prevent recurrence. This form of quality improvement looks at the components of people, equipment, policy, and procedures to determine areas of process breakdown. Do you ever have a poor performance in the simulation laboratory? After debriefing, have the students break into small groups and post their root cause analysis on the course discussion board? Compare the group discussions; did all groups arrive at the same conclusions?
10. Case management simulation recording Present the class with the challenge of simulating a patient case management meeting. Each student needs to role play a professional of the multidisciplinary team. Consider a culturally diverse client who is preteen, newly diagnosed with diabetes mellitus. The team may include the patient and their family, cultural leader, nurse, social worker, school teacher, pharmacist, dietitian, diabetic nurse educator, and health care provider. The scenario should be video recorded and posted to the course management system for discussion and evaluation. Ask each student to evaluate the simulation with certain guidelines in mind (e.g., www.qsen.org; NCLEX® Client Needs; AACN Essentials, etc.).
11. Move simulation into the classroom Some schools have the ability to place their manikin on a gurney and move it to the classroom. Using the high-fidelity manikin in the classroom can be challenging and hence the need for low fidelity. The low-fidelity manikin will usually not require the compressor, command module, electricity, and others. Bringing simulation to class has many advantages related to teaching clinical reasoning skills. When discussing the assessment findings of a patient with respiratory distress, role play for students how to organize care to minimize worsening the patient's situation. Ask students to participate by performing prioritized interventions. If you cannot move a manikin to the classroom, don a hospital gown and begin speaking to the class in first person. “Someone help me, my chest hurts and I'm all sweaty” can engage a classroom more quickly than a PowerPoint of bullet points on a myocardial infarction.
12. Grand rounds On some campuses, simulation rooms sit dormant during a portion of the day. Begin weekly grand rounds. Grand rounds, as practiced in hospitals for many years, allow students to come into the simulation environment as if they are entering a hospital unit. The instructor leads the group by giving a short case history and poses questions to the group about teaching needs, dietary needs, critical laboratory values, and others. Prompting by the “patient” is also
74 beneficial in guiding and directing the group when they have difficulty answering the instructor's questions. This focused learning works well to expand collaboration of various student groups and works great as an introduction to the simulation. Oftentimes, the senior students may be the leaders of the grand rounds, much as how a chief resident would fill this role in a clinical setting. The less-experienced students learn from the more-experienced ones, building teamwork and collaboration skills (Sherrill, 2012).
T. J. Bristol, K. Sherrill can help students synthesize high-level content. And simple technology such as low-cost wireless speakers, camcorders, and PowerPoint presentations can add enough realism to help students develop clinical reasoning skills. Tim J. Bristol PhD, RN, CNE, ANEF Karin Sherrill MSN, RN, CNE, ANEF E-mail address: [email protected]
References 13. Clinical reasoning is crucial Simulation helps the students learn through experiencing complex concepts first hand. This learning strategy requires the use of imagination on the part of the learner and the faculty. Think of ways to make the learning a hands-on experience with little or no technology involved. The role play with students in control of the learning experience can be very effective. Using sticky notes on the static manikin
Jeffries, P. (2012). Simulation in nursing education, from conceptualization to evaluation, 2nd ed. New York: National League for Nursing. Quality and Safety Education for Nurses Institute. (2012). Competencies: Pre-licensure KSAs Cleveland, Oh: Author Retrieved from http://qsen. org/competencies/pre-licensure-ksas/. Schlairet, M. C. (2012). PDA-assisted simulated clinical experiences in undergraduate nursing education: A pilot study. Nursing Education Perspectives, 33(6), 391−394. Sherrill, K. (2012). Using nursing grand rounds to enforce Quality and Safety Education for Nurses competencies. Teaching and Learning in Nursing, 7(3), 118−120.