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Jeffries Simulation Framework: State of the Science
Clinical Simulation in Nursing (2013)
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e1-e8
www.elsevier.com/locate/ecsn
Review Article
The Educational Practices Construct of the National League of NursingeJeffries Simulation Framework: State of the Science Beth Fentress Hallmark, PhD, RNa,*, Cynthia M. Thomas, EdD, RNC, CDONAb, Laura Gantt, RN, PhD, CEN, NE-BCc a
Belmont University, College of Health Sciences and Nursing, Nashville, TN 37212, USA Ball State University School of Nursing, Muncie IN, 47306, USA c East Carolina University College of Nursing, Greenville, NC 27858, USA b
KEYWORDS simulation; Jeffries framework; educational practices; facultyestudent interaction; active learning; collaboration; high expectations; diverse learning; feedback; time on task
Abstract: In June 2011 three independent nurse researchers were charged with the task of reviewing the NLN-Jeffries (2007) Simulation Framework, specifically, the educational practices construct. This was done in an effort to define and enhance the major constructs to advance the science of simulation in nursing practice. The educational practices construct has seven components including: faculty-student interaction, active learning, collaboration, high expectations, diverse learning, feedback, and time on task. An initial extensive literature review was conducted followed by a presentation of the findings at the 2012 International Nursing Simulation/Learning Resource Centers Conference in San Antonio, Texas. Based on audience feedback a second literature review was completed, however there were no new significant findings. The discoveries revealed a lack of consistency or absences in the use of the educational practices terminology in the current literature. This review article details the findings of the literature review for the educational practices construct and suggestions for moving forward with the NLN-Jeffries (2007) Simulation Framework towards a theory. Cite this article: Hallmark, B. F., Thomas, C. M., & Gantt, L. (2013, -). The Educational Practices Construct of the National League of NursingeJeffries Simulation Framework: State of the Science. Clinical Simulation in Nursing, Vol(X), e1-e8. http://dx.doi.org/10.1016/j.ecns.2013.04.006. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Introduction This article is the result of a project beginning in June 2011 through January 2013 involving five groups of volunteer researchers who were assigned the tasks of researching and analyzing the recently named * Corresponding author: [email protected] (B. F. Hallmark).
NLNeJeffries Simulation Framework for simulation development, design, practices, characteristics, and outcomes. The NLNeJeffries Simulation Framework has been used in nursing education to monitor the creation of human patient simulation scenarios and to function as a theoretical framework for continued research on the implementation of simulation (Wilson & Hagler, 2012; Young & Shellenbarger, 2012). The work was partially
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2013.04.006
Educational Practices Construct of the NLN/Jeffries Simulation Framework supported by a 2011 grant provided by the National League of Nursing (NLN) to evaluate the potential growth of the NLNeJeffries Simulation Framework. The groups comprised national and international members, and the group members physically met at conference gatherings and conducted Internet and teleconference Key Points meetings as work progressed. There were five The review of literamajor constructs identified ture revealed that facfrom the Jeffries (2005) ulty-student interactions framework: teacher, student, affects retention and educational practices, simuconfidence. lation design characteristics, The term high expecand outcomes. Each group tations was rarely adwas assigned a specific condressed in the literature. struct in which to conduct The terms feedback the analysis, disseminate and debriefing are used the findings at the 11th Aninterchangeably but are nual International Nursing not the same. Simulation/Learning Resource Center Conference sponsored by the International Nursing Association of Clinical Simulation and Learning (INACSL) held in June 2012 in San Antonio, Texas, reviewed comments from conference participants, conducted additional investigation based on conference participant feedback, and wrote and submitted the findings. The review was developed with the consideration that the work should attempt to identify alternative and consistent terminology and clear definitions for conducting research studies on simulation activities and provide a framework for submitting such findings for publication. This article details the work of the educational practices construct component of the NLNeJeffries Simulation Framework.
Methods The educational practices construct has seven components, including facultyestudent interaction, active learning, collaboration, high expectations, diverse learning, feedback, and time on task, as suggested by Chickering and Gamson (1987). Jeffries and Rogers (2007) included these principles in the framework. The three independent researchers assigned to the educational practices group equally divided the seven principles among the group with the exception of diverse learning, which all members researched. Each educational practice group member independently researched and analyzed the assigned principles using a variety of Internet search engines spanning from 1987 to 2012, such as WebFeat (a federated search engine that included Ovid, Cumulative Index to Nursing and Allied Health Literature, ProQuest, PubMed, MEDLINE, and Google). During the yearlong process, the initial findings were shared with group members and subsequently formed into a podium
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presentation for the 2012 INACSL conference. An extensive literature review by the three independent researchers revealed a lack of consistency in the use of the educational practices terminology or that terminology was not identified in the current literature. This article represents the results of the initial literature review, the conference audience feedback, and further review of the literature based on the feedback for the educational practices construct.
Findings Three independent nurse researchers reviewed and analyzed existing literature on the seven principles of educational practicedfacultyestudent interaction, active learning, collaboration, high expectations, diverse learning, feedback, and time on taskdto determine commonalities that might support the move of the 2005 NLNeJeffries Simulation Framework to a theory. The results indicate that specific terms are used interchangeably with other terms, some words may be outdated, selected terms need to be better defined for current practice use, and many terms were not found in the current literature.
FacultyeStudent Interaction The first element of the educational practices is facultye student interaction. Thirty-six articles were located and reviewed; 12 articles had relevant information related to this project. It was initially imperative to define the actual term interaction. Wagner (1994, p. 9) defined interaction as the ‘‘reciprocal events that require at least two objects and two actions/interactions occur when these objects and events mutually influence one another.’’ The interaction that occurs in simulation education is fundamental to the pedagogy. The National Survey of Student Engagement, a national database that describes best practices associated with student engagement and learning, describes faculty and student interaction as a ‘‘benchmark’’ of effective practice that correlates with positive educational outcomes. Tanner’ s work (2010, p. 351) work identified the need for more research on the ‘‘interaction between faculty and students to support learning (e.g., questioning and guiding).’’ Although there has not been a plethora of health care simulation research that identified facultyestudent interaction specifically, other educational literature emphasized its importance. Kata (2009) examined online learning and facultyestudent interaction. Kata’s literature review revealed that facultyestudent interaction affects retention and confidence and provides for deeper learning experiences for the students, improved rates of course completion related to the feelings of support, and improved motivation to complete the course of study. Gibson (2009) proposed that for facultyestudent interaction to have a positive influence on the learner, the faculty must relate to the student in the student’s world of technology. pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
Educational Practices Construct of the NLN/Jeffries Simulation Framework Business literature was also surveyed related to how it might better inform the concept of facultyestudent interaction. Of great interest and application to health care simulation was the publication by Russell-Bennett, Rundle-Thiele, and Kuhn (2010). Using a simulated marketplace, the analysis reported that the simulation exercise ‘‘encourages more active learning and collaboration, is more academically challenging, and permits more studentefaculty interaction than a traditional lecturebased course’’ (Russell-Bennett et al., 2010, p. 253). In the marketing education literature, Peltier, Hay, and Drago (2005, p. 252) examined the development of student’s reflective behaviors, finding that facultyestudent interaction was a vital component in the growth and cultivation of ‘‘higher order reflective thinking.’’ In addition, these authors published a second work in 2006 that supports the importance of facultyestudent interaction, stated that ‘‘higher order reflection will only occur when all individuals in the learning community are motivated by and feel comfortable with their instructor’’ (Peltier, Hay, & Drago, 2006, p. 7). In addition to supporting reflection, the authors emphasized that facultyestudent interaction allows the learner to examine feelings such as doubt and uncertainty and how personal learning exposes them to contradictions in their and others’ previously held ideas. Limbach and Waugh (2011, p. 9059) support the idea that facultyestudent interaction develops ‘‘higher level’’ thinking and stressed that as faculty encourage student interaction, they must be ‘‘highly skilled questioners’’ in facilitating the student response. In a study that examined how to effectively replace clinical experiences with simulation activities, Parsh (2010) highlighted the idea that what the learners want is for the faculty to collaborate and support them as they learn and make critical decisions. The students also stated they valued the faculty guiding them during the simulation and providing time for students to be independent. The simulation literature and literature from other disciplines draws attention to the important role that facultyestudent interaction has in student learning; and thus analysis supports the importance of facultyestudent interaction in a framework to describe simulation research, design, and implementation.
Active Learning Chickering and Gamson (1987) were clear about the role of active learning in education: Learning is not a spectator sport. Students do not learn much just sitting in classes listening to teachers, memorizing pre-packaged assignments, and spitting out answers. They must talk about what they are learning, write about it, relate it to past experiences, and apply it to their daily lives. They must make what they learn part of themselves. (p. 1)
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Reviewed literature related to active learning included 25 articles from across disciplines with positive findings to support active learning’s application as a component of simulation education. Active learning has become more important as workplaces are more complex and critical thinking is more important; employers expect their employees to possess the ability to learn on the job and be self-directed (Bell & Kozlowski, 2008; Jeffries, 2005). The use of active learning as a teaching strategy helps facilitate this readiness. ‘‘Moreover, interactive learning also motivates learners and useful to improve learning in complex domains’’ (Chen, Hong, Sung, & Chang, 2011, p. 276). Simulation, through active learning principles, engages students while they are ‘‘immersed’’ in a situation of decision making and patient care (Ruggenberg, 2008). Shinnick, Woo, & Mentes (2010) noted that as nurse educators make every effort to encourage active learning, simulation helps provide a pedagogy that engages students in the events of learning. The use of simulation technology, and associated educational practices, is an active learning strategy that ‘‘helps learners engage in the authenticity, reflection and knowledge construction activities to achieve a higher level of cognition’’ (Chen et al., 2011, p. 269).
Collaborative Learning Chickering and Gamson (1987) believed that learning is enhanced when it involves a team approach, is collaborative, not competitive, and not done in isolation. Collaborative learning was referred to as ‘‘participants working together to resolve problems in a situation and share in the decision making process’’ (Chickering & Gamson, 1987, p. 99). Collaborative learning may take place within a school of nursing with different levels of students, among students within a learning environment, and across disciplines. A systematic search was conducted to determine if collaborative learning was documented in the literature; over 45 simulation articles were located. The initial results indicated that the actual terms collaboration and collaborative learning were rarely found in the reviews, however, a subsequent search revealed more information in disciplines outside nursing. This was a surprising finding because nurses are frequently engaged in collaboration with other health care providers and rarely work in isolation. It is plausible nurse authors or researchers neglect to report collaboration because it is almost always present in health care and frequently included in student simulation learning activities. The term cooperative learning refers to a greatly structured small group technique of students working together on tasks requiring interdependent goals and rewards (Slavin, 1990; Smith, 1989; Smith & MacGregor, 1992; Webb, 1989). Cooperative learning was found in relation to computer learning and could be used interchangeably or in addition to collaborative learning in the computer literature. pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
Educational Practices Construct of the NLN/Jeffries Simulation Framework Tan, Gallo, Jacobs, and Lee (1999) described cooperative learning as a range of concepts and techniques for enhancing the value of studentestudent interaction. Damon and Phelps (1989) identified the terms peer tutoring, cooperative learning, and peer collaboration. Lave and Wenger (1991) and Rogoff and Lave (1984) postulated that peer interaction provides learners with insight into the other learner’s needs and focus, and it is the greatest way to explain things, benefiting from a new way to approach thinking. Nussbaum, Alvarez, McFarland, Gomez, Claro, and Radovic (2009) commented that collaboration and group accomplishment are not necessarily achieved by assigning students to groups then telling them to work together. Collaboration and group assignment are best when the selected tasks are appropriate to the capabilities of the individual learners and to the collaboration process and structured in a manner that promotes successful cooperation. Howard, Englert, Kameg, and Perozzi (2011) created simulation activities that promoted collaboration among faculty throughout the curriculum and traditional undergraduate and accelerated nursing students. Bultas and Hassler (2010) reported collaborative efforts among different nursing faculty to create a simulation experience, while McGaghie, Issenberg, Petrusa, and Scalese (2010) described a collaborative teamwork approach with medical students. Learning is enhanced when it represents a team effort rather than as a solo race. Effective learning, like good work, is collaborative and social, not competitive and isolated. Working with others often escalates involvement in learning. Having one’s own ideas and responding to others’ reactions improve thinking and deepen understanding. However, it is important that clear, concise goals and objectives are present and are matched to the level of student learning for successful collaboration to take place.
High Expectations It is generally accepted that faculty have an expectation of students to perform well during a simulated activity. Jeffries (2005) explained that faculty should have high expectations for student performance and in doing so students may meet or exceed expectations. Students should also establish goals that will help them achieve the course or simulation objectives and pursue advice from faculty to ensure high performance. A systematic review was completed to determine if the term high expectations was documented in the literature or if faculty and students had established expectations for simulated activities. Over 46 published simulation articles were reviewed. The actual term high expectations was rarely addressed in the literature. In most articles the idea of high expectations was implied and dependent on faculty and student expectations for the experience and the student learning styles. Shearer and Davidhizar (2003) stated that for a simulation to be successful faculty must establish clear objectives and
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guidelines and provide an explanation about the simulation and their expectations of student performance during the simulation to students. Jeffries and Rogers (2007) explained that well-designed simulations establish high standards for students and provide provisions for the students to be successful. More recently, Sharpnack (2012) used low-fidelity simulations with sophomore nursing students and found that students perceived the simulation to be realistic and had high positive expectations for collaborative learning and team building.
Diverse Learning Chickering and Gamson (1987) defined diverse learning as various students with diverse abilities and learning styles in need of different learning opportunities. Jeffries (2005) pointed out that students have different learning needs and expectations, and Shearer and Davidhizar (2003) defined diversity as a value for learning. Students today include the traditional college-aged learners, first-time adult learners, and second-degree students. Students can vary in age, sex, life experiences, learning styles, and expectations. Students also have different socioeconomic statuses, ethnic backgrounds, values for learning, and preferences for working alone or within a group. Another aspect to consider is that some study findings in the social sciences have indicated that men are more knowledgeable, spend more time, have more interest, and play digitalsimulated games more frequently than women. Information may be of importance to nursing education simulation experiences because women still represent the majority of nursing students (Cassell, 1998; Lucas & Sherry, 2004; Wright et al., 2001). In addition, English as a second language students have an increased desire to learn when engaged in simulated activities (Simulations in Language Teaching, n.d.). The effect of these differences on learning, particularly simulation learning, is the focus of the framework.
Time on Task Although Chickering and Gamson (1987) did not offer a specific definition, their usage of the term served as the basis for time on task in the NLNeJeffries Simulation Framework. Time on task is equated with effective time management by students and with the expectations set by faculty and institutions related to time periods established for learning. Fifteen articles were initially located. The dates included for the article search were 1987 through 2012. This range was chosen because of Chickering and Gamson’s (1987) original work on the topic. Only eight articles met inclusion criteria for the first round of concept analysis. Little substantive work related to time on task has been undertaken since Chickering and Gamson’s (1987) mention of the importance of this concept in best practices for education. pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
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Although there appears to be a dearth of information in the literature on time on task, there is evidence of potentially related concepts. Bland, Topping, and Wood (2010) discussed the critical need for learning to use time well. Shearer and Davidhizar (2003) discussed how scenario timeframes must allow time for students to ‘‘warm up’’ to roles and must be tailored to objectives. Simulations are seen as offering a measured approach to task completion and can be adjusted to speed up or slow down time to facilitate student learning. A great deal of discussion is ongoing in recent literature and on simulation organization Listservs about the appropriate length of time for students to be in simulation scenarios of different types. Because simulation scenarios use multiple types of media, including auditory, visual, and other forms of input, cognitive overload may result because of the demands on all types of learner processing. Mayer and Moreno (2003) suggested segmenting, or breaking down material into bite-sized segments, as one solution to cognitive overload. This would imply that limiting the length of a simulation and its associated objectives may be best, especially since a focused debriefing or feedback session should follow the simulation. A term commonly found in the current literature that may have overlapping attributes with time on task is deliberate practice. Certainly, as noted by Walton, Chute, and Ball (2011), repetitive practice is part of the trial and error of becoming a professional. However, it must also be noted that according to Ericsson, Charness, Feltovich, and Hoffman (2006), expert performance is about more than just practicing; it involves practice that is specifically focused on improvement (Duvivier, Muijtens, Moulaert, van der Vleuten, & Scherpbier, 2011). Three additional articles were located and reviewed based on specific suggestions from the conference participants; however, no other relevant evidence was found to contribute to this concept analysis of time on task, but more directly to deliberate practice (see discussion).
Nursing Association of Clinical Simulation and Learning (INACSL, 2011), feedback is defined as one-way communication given to a participant from a facilitator, simulator, or other participants in an effort to improve performance. Fortunately, authors and simulation organizations have begun to define what feedback is and is not. However, there are still many researchers who do not define or outline what feedback is within a simulation study or article. What is known from the literature about simulation and feedback is that it is (a) best when specific to a person and action (Lasater, 2007; Zigmont, Kappus, & Sudikoff, 2011); (b) when balanced, covering both positive and negative aspects (Cant & Cooper, 2011); (c) when structured and handled skillfully (Cushing, Abbott, Lothian, Hall, & Westwood, 2011); (d) time-consuming when done well (Calhoun, Rider, Peterson, & Meyer, 2010); and (e) most effective from a ‘‘live’’ instructor, rather than a computer, manikin, or program (Mikkelsen, Reime, & Harris, 2008; Porte, Xeroulis, Reznik, & Dubrowski, 2007). Although some authors use the terms feedback and debriefing interchangeably, the definitions are clearly not the same. Debriefing may encompass feedback to learners; debriefing is the conversation in which feedback takes place (Eppich, 2011). Because debriefing is included as a simulation design characteristic in the NLNeJeffries Simulation Framework, it seems likely the terms are not synonymous within the framework. Literature about debriefing supports it being more of a reframing, reexamining, and reflective process as compared with feedback; debriefing is more likely than feedback to explore emotions and to come from many sources within a scenario, such as other participants, the facilitator, and the simulator itself (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007; Rudolph, Simon, Raemer, & Eppich, 2008).
Feedback
Chickering and Gamson’s (1987) educational practices were thoroughly investigated in this literature review. There continues to be questions about the terminology and consistency of findings in the literature related to this construct within the framework; however, the NLNeJeffries Simulation Framework applies these practices to simulation effectively. The presentations at the INACSL-sponsored conference provided an audience and expert feedback. This time allowed for new ideas to be examined and provided researchers the opportunity to respond through more detailed literature review. The authors have recommended further investigation surrounding the work. Literature from education experts and national surveys supports the importance of faculty student interaction. Active learning is used interchangeably with constructivism, hands-on learning, and experiential learning. The literature supports active learning as an important concept
Chickering and Gamson (1987) did not clearly define the term feedback as it is as an educational practice constructs within the framework. Twenty-four articles were initially located. Only four of the 24 articles were found to be irrelevant to the analysis; 20 articles were included in the first round of concept analysis. In addition, seven articles on debriefing were reviewed for the purpose of clarifying differences and similarities with the term feedback. There are a number of definitions for the term feedback within the literature as they relate to training and education. Van de Ridder, Stokking, McGahie, and Ten Cate (2008) defined feedback as ‘‘specific information about the comparison between the trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance’’ (p. 93). For purposes of best practices in simulation in the standards published by the International
Discussion
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Educational Practices Construct of the NLN/Jeffries Simulation Framework related to student understanding. Simulation is a prime example of active learning. The debate related to terminology will be decided as more experts examine the differences in these terms. The idea of collaboration is not new to nursing; learning, however, in collaborative ways such as simulation may be a new concept to many; but the collaboration among health care providers cannot be ignored. The continued push for interprofessional education demands that health care professionals understand one another’s role, improve communication, and provide safe, quality care to patients, and this may be accomplished through the use of well-orchestrated simulated activities (AACN, 2012; Barnsteiner, Disch, Hall, Mayer, & Moore, 2007). Nursing education is rigorous. Students are expected to work hard and be prepared. The use of simulation is no exception. The current literature in nursing education supports that faculty will continue to have high expectations. However, do students have the same high expectations as the faculty regarding simulated activities? Postreview and the presentation at the 2012 International Nursing Simulation/Learning Resource Centers Conference brought this question for future consideration. Diverse learning is defined in many ways and the framework is no exception. Simulation research is in its infancy, and future investigations can focus on actually defining diverse learning and standardizing the items that are reported in the area of diversity and their effect on educational outcomes. The review findings indicated that although there is information on diverse learning in many published articles, it is not well defined, and the terms diverse learning and diversity seem to be used interchangeably. When information on diverse learning was provided, the focus was on the student population’s diversity such as age, sex, and ethnic background as a value for learning and socioeconomic status (Jeffries, 2005; Shearer & Davidhizar, 2003). Also lacking was how different student learning styles were addressed within the simulation activities. Information about the diversity of the faculty, teaching styles, age range, educational background, and simulation experience was not found and may be an area for future research. Much research remains to be done to determine whether time on task is a concept that should be included within the NLNeJeffries Simulation Framework. It may be the case that the term time on task is simply outdated and could be changed to another term, such as deliberate practice. However, there seems to be some differences between these concepts that require further clarification. Because less research has been completed on time on task, a qualitative analysis of the concept might allow for a further definition of the term, as well as examination of potential similarities to other terms. Moving forward in testing of relationships of concepts within the NLNeJeffries Simulation Framework, it may be helpful to determine whether time on task can be measured such that a connection between time on task
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and performance can be quantified. Researchers have already shown that deliberate practice improves performance (Ericsson, 2004; Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; Oermann et al., 2011), but areas such as the relationship between deliberate practice and competency need further investigation. Future research on feedback could seek to clarify a great many ambiguities around the term. For example, is group or individual feedback best? Simulations most often involve more than one learner. Learners receive feedback from multiple sources when in a group, including the simulator or program, instructor, and other students, but they may prefer individualized feedback in lieu of or in addition to these other forms. Since best practices in feedback are not entirely known, and it may be the case that feedback within the NLNeJeffries Simulation Framework should be replaced with debriefing, which has been studied extensively (Cant & Cooper, 2011; Rudolph et al., 2008; Zigmont et al., 2011). However, current literature does not support the terms being one and the same in definition or practice.
Recommendations Future research in the areas of faculty interaction could focus on how facultyestudent interaction, specifically in simulation exercises, affects student performance and confidence. When considering the future direction for use of the term active learning, it is recommended that we continue using the term interchangeably with terms such as experiential learning while further investigating the effect of such learning activities on desired student outcomes. Although it appears that collaborative learning has been used in the past to represent collaboration among different people and disciplines, using the term in the concept of simulation is new and presents challenging approaches. Therefore, collaborative learning should be examined further in terms of clarifying how the framework is using the idea of collaborative learning. As pointed out, faculty generally have high expectations for student learning in the realm of simulation activities, yet questions are being raised such as: (a) Should the high expectations of faculty be different from students’ expectations? (b) Should the definition be the same for academic simulations and professional nurse competencies? It is recommended that further discussion and research be conducted to address these questions. Although the term time on task has been used in the NLNeJeffries Simulation Framework, questions about the term’s relevance to current simulation and education trends may have made the term outdated. A consensus will need to be reached as to the continued use of the term time on task or the use of a more updated or appropriate term to describe this realm of simulation. Diverse learning is not well defined in the literature, it is not how the term applies in simulation. A well-defined term for simulation use would help educators and researchers pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
Educational Practices Construct of the NLN/Jeffries Simulation Framework alike to use the term more consistently while providing valuable information for readers. Feedback has been used interchangeable with debriefing, yet we know the terms are different as to how and when they are used. Perhaps continued work should be done to define feedback and debriefing and how and when these terms should be applied during a simulation exercise. Much work is still needed to create a more cohesive use of terminology when educators are creating and implementing simulation scenarios and when sharing the information with others.
Conclusion The identification of pedagogically sound educational practices to support simulation is well defined in the framework. There continue to be questions regarding the language used to describe the use of some of the practices; research must continue to support the clarification of these ideas and terminology while supporting the use of such practices.
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Duvivier, R. J., Muijtens, A. M., Moulaert, V., van der Vleuten, C., & Scherpbier, A. (2011). The role of deliberate practice in the acquisition of clinical skills. BMC Medical Education, 11(101), 1-7, Retrieved May 6, 2013, from. http://www.biomedcentral.com/1472-6920/ 11/101. Eppich, W. (2011). An introduction to simulation and basics of debriefing competent simulation instructors are the key to successful simulationbased training (SBT). Proceedings from IMSH ’11: Essentials of simulation-based education. San Diego, CA. Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine, 79(10), S70-S81. Ericsson, A. K., Charness, N., Feltovich, P., & Hoffman, R. R. (2006). Cambridge handbook on expertise and expert performance. Cambridge, UK: Cambridge University Press. Gibson, S. E. (2009). Intergenerational communication in the classroom: recommendations fo successful teacher-student relationships. Nursing Education Perspectives, 1, 7-39. Howard, V. M., Englert, N., Kameg, K., & Perozzi, K. (2011). Integration of simulation across the undergraduate curriculum: student and faculty perspectives. Clinical Simulation in Nursing, 7(1), e1-e11. http: //dx.doi.org/10.1016/j.ecns.2009.10.004. International Nursing Association for Clinical Simulation and Learning (INACSL). Board of directors. (2011). Standards of best practice: Terminology. Clinical Simulation in Learning, 7, s3-s7. http: //dx.doi.org/10.1016/j.ecns.2011.05.005. Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Gordon, D. L., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10-28. Jeffries, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103. Jeffries, P., & Rogers, K. J. (2007). Simulation standards theoretical framework for simulation design. In P. R. Jeffries (Ed.), Simulation in Nursing Education: From Conceptualization to Evaluation (pp. 21-33). New York, New York. National League of Nursing. Kata, M. L. (2009). Online student cohort’s experiences of interaction: A comparison of online and traditional student cohorts’ experience of interaction that affect learning and persistence. Rochester, Michigan: Dissertation, Oakland University. Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students’ experience. Journal of Nursing Education, 46(6), 269-276. Lave, J., & Wenger, E. (1991). Situated learning. Cambridge, Engl.: Cambridge University Press. Limbach, B., & Waugh, W. (2011). Developing higher level thinking. Journal of Instructional Pedagogies, OC09057-OC09060. Retrieved May 6, 2013, from http://www.aabri.com/OC09manuscripts/OC09060.pdf Lucas, K., & Sherry, J. L. (2004). Sex differences in video game play: A communication-based explanation. Communication Research, 31(5), 499-523. Mayer, R. E., & Moreno, R. (2003). Nine ways to reduce cognitive load in multimedia learning. Educational Psychologist, 38(1), 43-52. Mikkelsen, J., Reime, M. H., & Harris, A. (2008). Nursing students’ learning of managing cross-infectionsdScenario-based simulation training versus study groups. Nurse Education Today, 28, 664-671. Nussbaum, M., Alvarez, C., McFarland, A., Gomez, F., Claro, S., & Radovic, D. (2009). Technology as small group face to face collaboration scaffolding. Computers & Education, 52, 147-153. Oermann, M. H., Kardong-Edgren, S., Odom-Mayer, T., Hallmark, B. F., Hurd, D., Rogers, N., . & Smart, D. A. (2011). Deliberate practice of motor skills in nursing education: CPR as exemplar. Nursing Education Perspectives, 32(5), 311-315. Parsh, B. (2010). Characteristics of effective simulated clinical experience instructors: Interviews with undergraduate students. Journal of Nursing Education, 10, 569-572.
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Educational Practices Construct of the NLN/Jeffries Simulation Framework Peltier, J., Hay, A., & Drago, W. (2005). The reflective learning continuum: Reflection on reflections. Journal of Marketing Education, 3, 250-263. Peltier, J., Hay, A., & Drago, W. (2006). Reflecting on reflection: Scale extension and a comparison of undergraduate business students in United States and United Kingdom. Journal of Marketing Education, 28(1), 5-16. Porte, M. C., Xeroulis, G., Reznick, R. K., & Dubrowski, A. (2007). Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. American Journal of Surgery, 193, 105-110. Rogoff, B., & Lave, J. (1984). Everyday cognition: Its development in social context. Cambridge, MA: Harvard University Press. Rudolph, J. W., Simon, R., Raemer, D. B., & Eppich, W. J. (2008). Debriefing as formative assessment: Closing performance gaps in medical education. Academic Emergency Medicine, 15, 1010-1016. Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: Combining rigorous feedback with genuine inquiry. Anesthesiology Clinics, 25, 361-376. Ruggenberg, S. (2008). The effect of simulated clinical experience on knowledge, near transfer and far transfer in nursing education. San Francisco: Dissertation, University of San Francisco. Russell-Bennett, R., Rundle-Thiele, S. R., & Kuhn, K. (2010). Engaging marketing students: Student operated businesses in a simulated world. Journal of Marketing Education, 3, 253-263. Sharpnack, P. A. (2012). Using low-fidelity simulations with sophomore nursing students in baccalaureate nursing program. Nursing Education Perspectives. Retrieved May 6, 2013, from. http://www.readperiodicals. com/201207/2736870181.html#b. Shearer, R., & Davidhizar, R. (2003). Using role play to develop cultural competence. Journal of Nursing Education, 42(6), 273-276. Shinnick, M. A., Woo, M. A., & Mentes, J. C. (2010). Human patient simulation: state of the science in prelicensure nursing education. Journal of Nursing Education, 2, 65-67. Simulations in Language Teaching. Randall’s ESL Cyber Listening. Simulations: A tool for testing ‘‘virtual reality’’ in the language classroom. Retrieved May 6, 2013, from www.esl-lab.com/research/simul.htm Slavin, R. E. (1990). Cooperative learning: Theory, research, and practice. Englewood Cliffs, NJ: Prentice-Hall.
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Smith, K. A. (1989). The craft of teaching cooperative learning: An active learning strategy. Proceedings of the 1989 Annual Convention of the American Society for Engineering Education. Smith, B. L., & MacGregor, J. T. (1992). What is collaborative learning? In A. Goodsell, M. Maher, & V. Tinto (Eds.), Collaborative learning: A sourcebook for higher education (pp. 9-22) University Park, PA: National Center on Postsecondary Teaching Learning, and Assessment. Tan, G., Gallo, P. B., Jacobs, G. M., & Lee, C. K.-E. (1999). Using cooperative learning to integrate thinking and information technology in a content based writing lesson. Internet TESL Journal, 8. Retrieved May 6, 2013, from. http://iteslj.org/Techniques/Tan-Cooperative.html. Tanner, C. (2010). Transforming prelicensure nursing education: preparing the new nurse to meet emerging health care needs. Nursing Education Perspectives, 31(6), 347-353. Van de Ridder, J. M. M., Stokking, K. M., McGahie, W. C., & ten Cate, O. T. J. (2008). Medical education, 42, 189-197. Wagner, M. (1994). In support of a functional definition of interaction. American Journal of Distance Education, 8(2), 6-29. Walton, J., Chute, E., & Ball, L. (2011). Negotiating the role of professional nurse: A response to the National Education Commission report ‘‘Prisoners of Time.’’ Journal of Professional Nursing, 27(5), 299-310. Webb, N. M. (1989). Peer interaction and learning in small groups. International Journal of Educational Research, 13(1), 21-39. Wilson, R. D., & Hagler, D. (2012). Through the lens of instructional design: appraisal of the Jeffries/National League for Nursing Simulation Framework for use in acute care. Journal of Continuing Education for Nurses, 43(9), 428-432. Wright, J. C., Huston, A. C., Vandewater, E. A., Bickham, D. S., Scantlin, R. M., Kotler, J. A., . & Lee, J. (2001). American children’s use of electronic media in 1997: A national survey. Applied Developmental Psychology, 22(1), 31-47. Young, P. K., & Shellenbarger, T. (2012). Interpreting the NLN Jeffries framework in the context of nurse educator preparation. Journal of Nursing Education, 51(8), 422-428. Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). The 3D model of debriefing, defusing, discovering, and deepening. Seminars in Perinatology, 35(2), 52-58.
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Review Article
The Educational Practices Construct of the National League of NursingeJeffries Simulation Framework: State of the Science Beth Fentress Hallmark, PhD, RNa,*, Cynthia M. Thomas, EdD, RNC, CDONAb, Laura Gantt, RN, PhD, CEN, NE-BCc a
Belmont University, College of Health Sciences and Nursing, Nashville, TN 37212, USA Ball State University School of Nursing, Muncie IN, 47306, USA c East Carolina University College of Nursing, Greenville, NC 27858, USA b
KEYWORDS simulation; Jeffries framework; educational practices; facultyestudent interaction; active learning; collaboration; high expectations; diverse learning; feedback; time on task
Abstract: In June 2011 three independent nurse researchers were charged with the task of reviewing the NLN-Jeffries (2007) Simulation Framework, specifically, the educational practices construct. This was done in an effort to define and enhance the major constructs to advance the science of simulation in nursing practice. The educational practices construct has seven components including: faculty-student interaction, active learning, collaboration, high expectations, diverse learning, feedback, and time on task. An initial extensive literature review was conducted followed by a presentation of the findings at the 2012 International Nursing Simulation/Learning Resource Centers Conference in San Antonio, Texas. Based on audience feedback a second literature review was completed, however there were no new significant findings. The discoveries revealed a lack of consistency or absences in the use of the educational practices terminology in the current literature. This review article details the findings of the literature review for the educational practices construct and suggestions for moving forward with the NLN-Jeffries (2007) Simulation Framework towards a theory. Cite this article: Hallmark, B. F., Thomas, C. M., & Gantt, L. (2013, -). The Educational Practices Construct of the National League of NursingeJeffries Simulation Framework: State of the Science. Clinical Simulation in Nursing, Vol(X), e1-e8. http://dx.doi.org/10.1016/j.ecns.2013.04.006. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Introduction This article is the result of a project beginning in June 2011 through January 2013 involving five groups of volunteer researchers who were assigned the tasks of researching and analyzing the recently named * Corresponding author: [email protected] (B. F. Hallmark).
NLNeJeffries Simulation Framework for simulation development, design, practices, characteristics, and outcomes. The NLNeJeffries Simulation Framework has been used in nursing education to monitor the creation of human patient simulation scenarios and to function as a theoretical framework for continued research on the implementation of simulation (Wilson & Hagler, 2012; Young & Shellenbarger, 2012). The work was partially
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2013.04.006
Educational Practices Construct of the NLN/Jeffries Simulation Framework supported by a 2011 grant provided by the National League of Nursing (NLN) to evaluate the potential growth of the NLNeJeffries Simulation Framework. The groups comprised national and international members, and the group members physically met at conference gatherings and conducted Internet and teleconference Key Points meetings as work progressed. There were five The review of literamajor constructs identified ture revealed that facfrom the Jeffries (2005) ulty-student interactions framework: teacher, student, affects retention and educational practices, simuconfidence. lation design characteristics, The term high expecand outcomes. Each group tations was rarely adwas assigned a specific condressed in the literature. struct in which to conduct The terms feedback the analysis, disseminate and debriefing are used the findings at the 11th Aninterchangeably but are nual International Nursing not the same. Simulation/Learning Resource Center Conference sponsored by the International Nursing Association of Clinical Simulation and Learning (INACSL) held in June 2012 in San Antonio, Texas, reviewed comments from conference participants, conducted additional investigation based on conference participant feedback, and wrote and submitted the findings. The review was developed with the consideration that the work should attempt to identify alternative and consistent terminology and clear definitions for conducting research studies on simulation activities and provide a framework for submitting such findings for publication. This article details the work of the educational practices construct component of the NLNeJeffries Simulation Framework.
Methods The educational practices construct has seven components, including facultyestudent interaction, active learning, collaboration, high expectations, diverse learning, feedback, and time on task, as suggested by Chickering and Gamson (1987). Jeffries and Rogers (2007) included these principles in the framework. The three independent researchers assigned to the educational practices group equally divided the seven principles among the group with the exception of diverse learning, which all members researched. Each educational practice group member independently researched and analyzed the assigned principles using a variety of Internet search engines spanning from 1987 to 2012, such as WebFeat (a federated search engine that included Ovid, Cumulative Index to Nursing and Allied Health Literature, ProQuest, PubMed, MEDLINE, and Google). During the yearlong process, the initial findings were shared with group members and subsequently formed into a podium
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presentation for the 2012 INACSL conference. An extensive literature review by the three independent researchers revealed a lack of consistency in the use of the educational practices terminology or that terminology was not identified in the current literature. This article represents the results of the initial literature review, the conference audience feedback, and further review of the literature based on the feedback for the educational practices construct.
Findings Three independent nurse researchers reviewed and analyzed existing literature on the seven principles of educational practicedfacultyestudent interaction, active learning, collaboration, high expectations, diverse learning, feedback, and time on taskdto determine commonalities that might support the move of the 2005 NLNeJeffries Simulation Framework to a theory. The results indicate that specific terms are used interchangeably with other terms, some words may be outdated, selected terms need to be better defined for current practice use, and many terms were not found in the current literature.
FacultyeStudent Interaction The first element of the educational practices is facultye student interaction. Thirty-six articles were located and reviewed; 12 articles had relevant information related to this project. It was initially imperative to define the actual term interaction. Wagner (1994, p. 9) defined interaction as the ‘‘reciprocal events that require at least two objects and two actions/interactions occur when these objects and events mutually influence one another.’’ The interaction that occurs in simulation education is fundamental to the pedagogy. The National Survey of Student Engagement, a national database that describes best practices associated with student engagement and learning, describes faculty and student interaction as a ‘‘benchmark’’ of effective practice that correlates with positive educational outcomes. Tanner’ s work (2010, p. 351) work identified the need for more research on the ‘‘interaction between faculty and students to support learning (e.g., questioning and guiding).’’ Although there has not been a plethora of health care simulation research that identified facultyestudent interaction specifically, other educational literature emphasized its importance. Kata (2009) examined online learning and facultyestudent interaction. Kata’s literature review revealed that facultyestudent interaction affects retention and confidence and provides for deeper learning experiences for the students, improved rates of course completion related to the feelings of support, and improved motivation to complete the course of study. Gibson (2009) proposed that for facultyestudent interaction to have a positive influence on the learner, the faculty must relate to the student in the student’s world of technology. pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
Educational Practices Construct of the NLN/Jeffries Simulation Framework Business literature was also surveyed related to how it might better inform the concept of facultyestudent interaction. Of great interest and application to health care simulation was the publication by Russell-Bennett, Rundle-Thiele, and Kuhn (2010). Using a simulated marketplace, the analysis reported that the simulation exercise ‘‘encourages more active learning and collaboration, is more academically challenging, and permits more studentefaculty interaction than a traditional lecturebased course’’ (Russell-Bennett et al., 2010, p. 253). In the marketing education literature, Peltier, Hay, and Drago (2005, p. 252) examined the development of student’s reflective behaviors, finding that facultyestudent interaction was a vital component in the growth and cultivation of ‘‘higher order reflective thinking.’’ In addition, these authors published a second work in 2006 that supports the importance of facultyestudent interaction, stated that ‘‘higher order reflection will only occur when all individuals in the learning community are motivated by and feel comfortable with their instructor’’ (Peltier, Hay, & Drago, 2006, p. 7). In addition to supporting reflection, the authors emphasized that facultyestudent interaction allows the learner to examine feelings such as doubt and uncertainty and how personal learning exposes them to contradictions in their and others’ previously held ideas. Limbach and Waugh (2011, p. 9059) support the idea that facultyestudent interaction develops ‘‘higher level’’ thinking and stressed that as faculty encourage student interaction, they must be ‘‘highly skilled questioners’’ in facilitating the student response. In a study that examined how to effectively replace clinical experiences with simulation activities, Parsh (2010) highlighted the idea that what the learners want is for the faculty to collaborate and support them as they learn and make critical decisions. The students also stated they valued the faculty guiding them during the simulation and providing time for students to be independent. The simulation literature and literature from other disciplines draws attention to the important role that facultyestudent interaction has in student learning; and thus analysis supports the importance of facultyestudent interaction in a framework to describe simulation research, design, and implementation.
Active Learning Chickering and Gamson (1987) were clear about the role of active learning in education: Learning is not a spectator sport. Students do not learn much just sitting in classes listening to teachers, memorizing pre-packaged assignments, and spitting out answers. They must talk about what they are learning, write about it, relate it to past experiences, and apply it to their daily lives. They must make what they learn part of themselves. (p. 1)
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Reviewed literature related to active learning included 25 articles from across disciplines with positive findings to support active learning’s application as a component of simulation education. Active learning has become more important as workplaces are more complex and critical thinking is more important; employers expect their employees to possess the ability to learn on the job and be self-directed (Bell & Kozlowski, 2008; Jeffries, 2005). The use of active learning as a teaching strategy helps facilitate this readiness. ‘‘Moreover, interactive learning also motivates learners and useful to improve learning in complex domains’’ (Chen, Hong, Sung, & Chang, 2011, p. 276). Simulation, through active learning principles, engages students while they are ‘‘immersed’’ in a situation of decision making and patient care (Ruggenberg, 2008). Shinnick, Woo, & Mentes (2010) noted that as nurse educators make every effort to encourage active learning, simulation helps provide a pedagogy that engages students in the events of learning. The use of simulation technology, and associated educational practices, is an active learning strategy that ‘‘helps learners engage in the authenticity, reflection and knowledge construction activities to achieve a higher level of cognition’’ (Chen et al., 2011, p. 269).
Collaborative Learning Chickering and Gamson (1987) believed that learning is enhanced when it involves a team approach, is collaborative, not competitive, and not done in isolation. Collaborative learning was referred to as ‘‘participants working together to resolve problems in a situation and share in the decision making process’’ (Chickering & Gamson, 1987, p. 99). Collaborative learning may take place within a school of nursing with different levels of students, among students within a learning environment, and across disciplines. A systematic search was conducted to determine if collaborative learning was documented in the literature; over 45 simulation articles were located. The initial results indicated that the actual terms collaboration and collaborative learning were rarely found in the reviews, however, a subsequent search revealed more information in disciplines outside nursing. This was a surprising finding because nurses are frequently engaged in collaboration with other health care providers and rarely work in isolation. It is plausible nurse authors or researchers neglect to report collaboration because it is almost always present in health care and frequently included in student simulation learning activities. The term cooperative learning refers to a greatly structured small group technique of students working together on tasks requiring interdependent goals and rewards (Slavin, 1990; Smith, 1989; Smith & MacGregor, 1992; Webb, 1989). Cooperative learning was found in relation to computer learning and could be used interchangeably or in addition to collaborative learning in the computer literature. pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
Educational Practices Construct of the NLN/Jeffries Simulation Framework Tan, Gallo, Jacobs, and Lee (1999) described cooperative learning as a range of concepts and techniques for enhancing the value of studentestudent interaction. Damon and Phelps (1989) identified the terms peer tutoring, cooperative learning, and peer collaboration. Lave and Wenger (1991) and Rogoff and Lave (1984) postulated that peer interaction provides learners with insight into the other learner’s needs and focus, and it is the greatest way to explain things, benefiting from a new way to approach thinking. Nussbaum, Alvarez, McFarland, Gomez, Claro, and Radovic (2009) commented that collaboration and group accomplishment are not necessarily achieved by assigning students to groups then telling them to work together. Collaboration and group assignment are best when the selected tasks are appropriate to the capabilities of the individual learners and to the collaboration process and structured in a manner that promotes successful cooperation. Howard, Englert, Kameg, and Perozzi (2011) created simulation activities that promoted collaboration among faculty throughout the curriculum and traditional undergraduate and accelerated nursing students. Bultas and Hassler (2010) reported collaborative efforts among different nursing faculty to create a simulation experience, while McGaghie, Issenberg, Petrusa, and Scalese (2010) described a collaborative teamwork approach with medical students. Learning is enhanced when it represents a team effort rather than as a solo race. Effective learning, like good work, is collaborative and social, not competitive and isolated. Working with others often escalates involvement in learning. Having one’s own ideas and responding to others’ reactions improve thinking and deepen understanding. However, it is important that clear, concise goals and objectives are present and are matched to the level of student learning for successful collaboration to take place.
High Expectations It is generally accepted that faculty have an expectation of students to perform well during a simulated activity. Jeffries (2005) explained that faculty should have high expectations for student performance and in doing so students may meet or exceed expectations. Students should also establish goals that will help them achieve the course or simulation objectives and pursue advice from faculty to ensure high performance. A systematic review was completed to determine if the term high expectations was documented in the literature or if faculty and students had established expectations for simulated activities. Over 46 published simulation articles were reviewed. The actual term high expectations was rarely addressed in the literature. In most articles the idea of high expectations was implied and dependent on faculty and student expectations for the experience and the student learning styles. Shearer and Davidhizar (2003) stated that for a simulation to be successful faculty must establish clear objectives and
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guidelines and provide an explanation about the simulation and their expectations of student performance during the simulation to students. Jeffries and Rogers (2007) explained that well-designed simulations establish high standards for students and provide provisions for the students to be successful. More recently, Sharpnack (2012) used low-fidelity simulations with sophomore nursing students and found that students perceived the simulation to be realistic and had high positive expectations for collaborative learning and team building.
Diverse Learning Chickering and Gamson (1987) defined diverse learning as various students with diverse abilities and learning styles in need of different learning opportunities. Jeffries (2005) pointed out that students have different learning needs and expectations, and Shearer and Davidhizar (2003) defined diversity as a value for learning. Students today include the traditional college-aged learners, first-time adult learners, and second-degree students. Students can vary in age, sex, life experiences, learning styles, and expectations. Students also have different socioeconomic statuses, ethnic backgrounds, values for learning, and preferences for working alone or within a group. Another aspect to consider is that some study findings in the social sciences have indicated that men are more knowledgeable, spend more time, have more interest, and play digitalsimulated games more frequently than women. Information may be of importance to nursing education simulation experiences because women still represent the majority of nursing students (Cassell, 1998; Lucas & Sherry, 2004; Wright et al., 2001). In addition, English as a second language students have an increased desire to learn when engaged in simulated activities (Simulations in Language Teaching, n.d.). The effect of these differences on learning, particularly simulation learning, is the focus of the framework.
Time on Task Although Chickering and Gamson (1987) did not offer a specific definition, their usage of the term served as the basis for time on task in the NLNeJeffries Simulation Framework. Time on task is equated with effective time management by students and with the expectations set by faculty and institutions related to time periods established for learning. Fifteen articles were initially located. The dates included for the article search were 1987 through 2012. This range was chosen because of Chickering and Gamson’s (1987) original work on the topic. Only eight articles met inclusion criteria for the first round of concept analysis. Little substantive work related to time on task has been undertaken since Chickering and Gamson’s (1987) mention of the importance of this concept in best practices for education. pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
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Although there appears to be a dearth of information in the literature on time on task, there is evidence of potentially related concepts. Bland, Topping, and Wood (2010) discussed the critical need for learning to use time well. Shearer and Davidhizar (2003) discussed how scenario timeframes must allow time for students to ‘‘warm up’’ to roles and must be tailored to objectives. Simulations are seen as offering a measured approach to task completion and can be adjusted to speed up or slow down time to facilitate student learning. A great deal of discussion is ongoing in recent literature and on simulation organization Listservs about the appropriate length of time for students to be in simulation scenarios of different types. Because simulation scenarios use multiple types of media, including auditory, visual, and other forms of input, cognitive overload may result because of the demands on all types of learner processing. Mayer and Moreno (2003) suggested segmenting, or breaking down material into bite-sized segments, as one solution to cognitive overload. This would imply that limiting the length of a simulation and its associated objectives may be best, especially since a focused debriefing or feedback session should follow the simulation. A term commonly found in the current literature that may have overlapping attributes with time on task is deliberate practice. Certainly, as noted by Walton, Chute, and Ball (2011), repetitive practice is part of the trial and error of becoming a professional. However, it must also be noted that according to Ericsson, Charness, Feltovich, and Hoffman (2006), expert performance is about more than just practicing; it involves practice that is specifically focused on improvement (Duvivier, Muijtens, Moulaert, van der Vleuten, & Scherpbier, 2011). Three additional articles were located and reviewed based on specific suggestions from the conference participants; however, no other relevant evidence was found to contribute to this concept analysis of time on task, but more directly to deliberate practice (see discussion).
Nursing Association of Clinical Simulation and Learning (INACSL, 2011), feedback is defined as one-way communication given to a participant from a facilitator, simulator, or other participants in an effort to improve performance. Fortunately, authors and simulation organizations have begun to define what feedback is and is not. However, there are still many researchers who do not define or outline what feedback is within a simulation study or article. What is known from the literature about simulation and feedback is that it is (a) best when specific to a person and action (Lasater, 2007; Zigmont, Kappus, & Sudikoff, 2011); (b) when balanced, covering both positive and negative aspects (Cant & Cooper, 2011); (c) when structured and handled skillfully (Cushing, Abbott, Lothian, Hall, & Westwood, 2011); (d) time-consuming when done well (Calhoun, Rider, Peterson, & Meyer, 2010); and (e) most effective from a ‘‘live’’ instructor, rather than a computer, manikin, or program (Mikkelsen, Reime, & Harris, 2008; Porte, Xeroulis, Reznik, & Dubrowski, 2007). Although some authors use the terms feedback and debriefing interchangeably, the definitions are clearly not the same. Debriefing may encompass feedback to learners; debriefing is the conversation in which feedback takes place (Eppich, 2011). Because debriefing is included as a simulation design characteristic in the NLNeJeffries Simulation Framework, it seems likely the terms are not synonymous within the framework. Literature about debriefing supports it being more of a reframing, reexamining, and reflective process as compared with feedback; debriefing is more likely than feedback to explore emotions and to come from many sources within a scenario, such as other participants, the facilitator, and the simulator itself (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007; Rudolph, Simon, Raemer, & Eppich, 2008).
Feedback
Chickering and Gamson’s (1987) educational practices were thoroughly investigated in this literature review. There continues to be questions about the terminology and consistency of findings in the literature related to this construct within the framework; however, the NLNeJeffries Simulation Framework applies these practices to simulation effectively. The presentations at the INACSL-sponsored conference provided an audience and expert feedback. This time allowed for new ideas to be examined and provided researchers the opportunity to respond through more detailed literature review. The authors have recommended further investigation surrounding the work. Literature from education experts and national surveys supports the importance of faculty student interaction. Active learning is used interchangeably with constructivism, hands-on learning, and experiential learning. The literature supports active learning as an important concept
Chickering and Gamson (1987) did not clearly define the term feedback as it is as an educational practice constructs within the framework. Twenty-four articles were initially located. Only four of the 24 articles were found to be irrelevant to the analysis; 20 articles were included in the first round of concept analysis. In addition, seven articles on debriefing were reviewed for the purpose of clarifying differences and similarities with the term feedback. There are a number of definitions for the term feedback within the literature as they relate to training and education. Van de Ridder, Stokking, McGahie, and Ten Cate (2008) defined feedback as ‘‘specific information about the comparison between the trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance’’ (p. 93). For purposes of best practices in simulation in the standards published by the International
Discussion
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Educational Practices Construct of the NLN/Jeffries Simulation Framework related to student understanding. Simulation is a prime example of active learning. The debate related to terminology will be decided as more experts examine the differences in these terms. The idea of collaboration is not new to nursing; learning, however, in collaborative ways such as simulation may be a new concept to many; but the collaboration among health care providers cannot be ignored. The continued push for interprofessional education demands that health care professionals understand one another’s role, improve communication, and provide safe, quality care to patients, and this may be accomplished through the use of well-orchestrated simulated activities (AACN, 2012; Barnsteiner, Disch, Hall, Mayer, & Moore, 2007). Nursing education is rigorous. Students are expected to work hard and be prepared. The use of simulation is no exception. The current literature in nursing education supports that faculty will continue to have high expectations. However, do students have the same high expectations as the faculty regarding simulated activities? Postreview and the presentation at the 2012 International Nursing Simulation/Learning Resource Centers Conference brought this question for future consideration. Diverse learning is defined in many ways and the framework is no exception. Simulation research is in its infancy, and future investigations can focus on actually defining diverse learning and standardizing the items that are reported in the area of diversity and their effect on educational outcomes. The review findings indicated that although there is information on diverse learning in many published articles, it is not well defined, and the terms diverse learning and diversity seem to be used interchangeably. When information on diverse learning was provided, the focus was on the student population’s diversity such as age, sex, and ethnic background as a value for learning and socioeconomic status (Jeffries, 2005; Shearer & Davidhizar, 2003). Also lacking was how different student learning styles were addressed within the simulation activities. Information about the diversity of the faculty, teaching styles, age range, educational background, and simulation experience was not found and may be an area for future research. Much research remains to be done to determine whether time on task is a concept that should be included within the NLNeJeffries Simulation Framework. It may be the case that the term time on task is simply outdated and could be changed to another term, such as deliberate practice. However, there seems to be some differences between these concepts that require further clarification. Because less research has been completed on time on task, a qualitative analysis of the concept might allow for a further definition of the term, as well as examination of potential similarities to other terms. Moving forward in testing of relationships of concepts within the NLNeJeffries Simulation Framework, it may be helpful to determine whether time on task can be measured such that a connection between time on task
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and performance can be quantified. Researchers have already shown that deliberate practice improves performance (Ericsson, 2004; Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; Oermann et al., 2011), but areas such as the relationship between deliberate practice and competency need further investigation. Future research on feedback could seek to clarify a great many ambiguities around the term. For example, is group or individual feedback best? Simulations most often involve more than one learner. Learners receive feedback from multiple sources when in a group, including the simulator or program, instructor, and other students, but they may prefer individualized feedback in lieu of or in addition to these other forms. Since best practices in feedback are not entirely known, and it may be the case that feedback within the NLNeJeffries Simulation Framework should be replaced with debriefing, which has been studied extensively (Cant & Cooper, 2011; Rudolph et al., 2008; Zigmont et al., 2011). However, current literature does not support the terms being one and the same in definition or practice.
Recommendations Future research in the areas of faculty interaction could focus on how facultyestudent interaction, specifically in simulation exercises, affects student performance and confidence. When considering the future direction for use of the term active learning, it is recommended that we continue using the term interchangeably with terms such as experiential learning while further investigating the effect of such learning activities on desired student outcomes. Although it appears that collaborative learning has been used in the past to represent collaboration among different people and disciplines, using the term in the concept of simulation is new and presents challenging approaches. Therefore, collaborative learning should be examined further in terms of clarifying how the framework is using the idea of collaborative learning. As pointed out, faculty generally have high expectations for student learning in the realm of simulation activities, yet questions are being raised such as: (a) Should the high expectations of faculty be different from students’ expectations? (b) Should the definition be the same for academic simulations and professional nurse competencies? It is recommended that further discussion and research be conducted to address these questions. Although the term time on task has been used in the NLNeJeffries Simulation Framework, questions about the term’s relevance to current simulation and education trends may have made the term outdated. A consensus will need to be reached as to the continued use of the term time on task or the use of a more updated or appropriate term to describe this realm of simulation. Diverse learning is not well defined in the literature, it is not how the term applies in simulation. A well-defined term for simulation use would help educators and researchers pp e1-e8 Clinical Simulation in Nursing Volume Vol Issue X
Educational Practices Construct of the NLN/Jeffries Simulation Framework alike to use the term more consistently while providing valuable information for readers. Feedback has been used interchangeable with debriefing, yet we know the terms are different as to how and when they are used. Perhaps continued work should be done to define feedback and debriefing and how and when these terms should be applied during a simulation exercise. Much work is still needed to create a more cohesive use of terminology when educators are creating and implementing simulation scenarios and when sharing the information with others.
Conclusion The identification of pedagogically sound educational practices to support simulation is well defined in the framework. There continue to be questions regarding the language used to describe the use of some of the practices; research must continue to support the clarification of these ideas and terminology while supporting the use of such practices.
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