- Email: [email protected]
The Feasibility and Use of Simulation to Assess Parent Learning
Clinical Simulation in Nursing (2020) 38, 23-26
www.elsevier.com/locate/ecsn
Research Brief
The Feasibility and Use of Simulation to Assess Parent Learning Michelle Whalen, DNP, RN, NNP-BC, CNE*, Michelle L. Aebersold, PhD, RN, CHSE, FAAN, Kathryn Nelson, DNP, RN, CPNP-AC/PC, Deborah M. Rooney, PhD University of Michigan, School of Nursing, Ann Arbor, MI 48109-2003, USA KEYWORDS simulation; pediatric; caregiver; parent education; tracheostomy
Abstract: Children dependent on long-term mechanical ventilation after discharge from an acute care center are at high risk for readmissions, morbidity, and mortality directly related to the care they receive in the home environment. Parents are inadequately prepared to provide the level of care needed in the home setting before their child’s discharge home. The primary goal of the Parental Airway Assessment with Simulation program was to assess parent learning and confidence in managing these children in the home setting after discharge. The Simulation Model for Improved Learner and Health Outcomes framed this assessment program’s development, implementation, and evaluation which focused on artificial airway management. The evaluation of parent discharge education was quantified at multiple intervals with parent(s) acting as their own controls. This program implemented a multistep simulation-based assessment intervention over a 6-8 weeks which included a home visit after discharge. After program completion, parents showed a 22% increase in self-reported confidence in caring for their technology-dependent child after discharge using an administered pre-post family assessment survey. At the end of the program, parents showed significant improvement in clinical skills with a demonstrated increase across all four tracheostomy skill assessments. Cite this article: Whalen, M., Aebersold, M. L., Nelson, K., & Rooney, D. M. (2020, January). The feasibility and use of simulation to assess parent learning. Clinical Simulation in Nursing, 38(C), 23-26. https://doi.org/ 10.1016/j.ecns.2019.10.003. Ó 2019 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
The population of children dependent on tracheostomy placement and long-term mechanical ventilation is increasing exponentially as the quality of pediatric trauma services, pediatric and neonatal intensive care services, and
* Corresponding author: [email protected] (M. Whalen).
overall pediatric medical management continues to evolve. Because of these improvements, the number of children successfully discharged home with tracheostomies continues to increase as medical advances improve the overall health and longevity of children with significant respiratory insufficiency (Cohen et al., 2011; Edwards, O’Toole, & Wallis, 2004; Kun, Edwards, Ward, & Keens, 2012).
1876-1399/$ - see front matter Ó 2019 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2019.10.003
Simulation to Assess Parent Learning Children requiring tracheostomies are medically fragile, have complicated physiology, and are at an increased risk for repeated acute illness and hospitalization. These complex children demand that parents carry out interventions at home that had been previously been provided by specially trained pediatric registered nurses and respiratory therKey Points apists. Families are not pre Simulation is underpared for the direct care used in the training their child requires and and assessment of peoften are provided discharge diatric caregivers. education and training using Simulation is a viable modalities that are outdated modality to assess (Cohen et al., 2011; Tofil parent clinical skills et al., 2013; Toly, Musil, & before discharge. Carl, 2012a,b). Studies Simulation-based have demonstrated that the discharge education quality of care a child reprovides opportuceives in the home is nities to evaluate directly linked to their parent skills. long-term health outcomes; therefore, suboptimal home care equates to suboptimal long-term outcomes (Edwards, Kun, & Keens, 2010; Kun et al., 2012). Parent discharge teaching continues to be reliant on videos and equipment demonstrations on static airway models with limited constructive feedback or quantitative assessment of skills (Tofil et al., 2013; Toly et al., 2012a,b). Parents need to be able to practice the skills required to care for these children in an environment that is controlled, forgiving, and immersive to truly prepare for a discharge home (Tofil et al., 2013; Toly et al., 2012a,b). The goal of this multistep simulation-based pilot program was to assess and measure parent clinical skills in preparation to care for their child with a tracheostomy after discharge using evidence-driven practices and clinical skill repetition.
Sample The target goal for sample inclusion was a total of six to ten families. In all, a total of eight parents were enrolled in this pilot program. Fifteen total families were referred through pediatric subspecialty services with enrollment criteria identified as being a child younger than eighteen years with primary tracheostomy placement, English speaking, and available for multiple education sessions, including a home visit after discharge. Those excluded from the study included two patients older than 18 years, two children with tracheostomies previously, a child entering hospice care for an evolving congenital syndrome, a child who passed away shortly after tracheostomy placement, and a family who would not be geographically available for a home visit after discharge.
24 As the skill focus was specifically addressing tracheostomy skills, mechanical ventilators as a mode of respiratory support did not factor into inclusion or exclusion criteria. The patients included in the study encompassed both a mix of ventilator-dependent children and children requiring only a tracheostomy with a humidified oxygen mask. Six of the children were ventilator dependent and two of the children were only tracheostomy dependent. Coincidentally, all patients referred and subsequently enrolled were infants.
Methods This was a pilot program with a descriptive quantitative design established to assess parent tracheostomy skills over time after sequential simulation sessions. The institutional review board at the organization reviewed the submitted program protocol and granted approval. Families who were referred were contacted within ten days of the surgical placement of the tracheostomy to capitalize on early educational opportunities yet be respectful of the change in their child’s health status after tracheostomy. Parents were provided program information at time of consent and those agreeing to take part in the study were then given a general overview of the program. Once consented, the parents were given laminated resource cards that outlined the skills being evaluated in easy to follow steps supported with illustrations. The program was titled Parent Airway Assessment with Simulation and consisted of sequential simulation sessions with quantified skill attainment scores over a 4- to 8-week time frame. To effectively assess the parent’s tracheostomy clinical skills, four Parent Airway Assessment with Simulation skill checklists were developed. The four checklists included general tracheostomy care, tracheostomy suctioning, tracheostomy securement, and tracheostomy changes. Informed in entirety by an extensive literature search, the skill checklists had evidence-based practice standards represented in each step to ensure that parents were taught the most current method of pediatric tracheostomy care during their simulation sessions. The checklists were reviewed for accuracy and distributed to a mixed team of ten pediatric intensive care providers to confirm their validity and reliability. All four checklists were independently evaluated by this team during a four-week period of simulated skill sessions that used a standardized scenario and a low-fidelity infant simulator. Test/retest reliability was measured over the course of multiple sessions with the content experts to ensure that the four checklists established consistent results when used for skill assessment. Validity of the checklists was established by using a content validity index (CVI). A CVI is a commonly accepted method of measuring the content validity of a tool and has been applied to simulation scenarios (Rutherford-Hemming, pp 23-26 Clinical Simulation in Nursing Volume 38
Simulation to Assess Parent Learning 2015). For the assessment of the skills checklists, the clinical experts were asked to rate the relevance of each of the items on each of the four skill checklists using a four-point relevancy scale. The CVI values ranged from 0.5 to 1.0; items with a CVI > 0.8 were retained as written on the checklist. Items with a CVI calculated at less than or equal to 0.8 were reworded, clarified, and re-evaluated to ensure that the tool, as developed, had the capability to measure the parent’s skills during simulation. The individual item CVIs ranged from 0.8 to 1.0 with the average CVI for the four tools ranging from 0.9 to 1.0 suggesting high inter-rater agreement of the checklists.
Results Simulation education is based on adult learning theory and is a proven educational technique in a clinical learning that has demonstrated success in improving skills (Tofil et al., 2013). A benefit of simulation is that it affords the facilitator an opportunity to assess a clinical skill provider in real time and within the context of a realistic scenario to evaluate psychomotor skills and clinical thinking. Parents enrolled in the program were supported and provided with a focused assessment of their newly acquired clinical skills and advanced discharge preparation through resource card distribution, multiple simulation sessions, and engaged debriefing over a 4- to 8-week period that included five points of contact throughout the program duration. Over the course of the program, all families enrolled were exposed to multiple simulation sessions and demonstrated significant increases in skill levels across all content assessed with a p value ¼ .006. The Pearson correlation value for skill acquisition across all four skills was r ¼ 0.92, indicating a robust positive correlation between simulation-based parent education and successful skill performance. Increases for all four skills examined trach care, trach suctioning, trach securement, and trach changes, were measured using separate t test evaluations indicating a Pearson’s r coefficient level of 0.75 to 0.94. There was a statistically significant increase in mean score increases across all four skills assessed that increased incrementally over time with a positive correlation demonstrated between the first simulation session and the applied intervention in the final simulation session in the family’s home setting.
Discussion Children who are tracheostomy dependent are at risk for complications and after their discharge, the medical team caring for these patients expects the parents to assume and replicate the care their child received in the acute care setting in the home setting. Despite vast innovations in health care education delivery, parent discharge education has not been uniformly updated with changing technologies nor does it use adult learning theory to its fullest
25 potential. The underlying goal of this pilot program was to assess parent learning using simulation-based modalities that supplemented existing discharge education delivery. Research supports the idea that effectively training the caregivers of these high-risk children will positively affect health care outcomes after discharge (Merchant, 2012; Tofil et al., 2013; Toly et al., 2014). Using simulation to assess parent learning, to predict next steps, and to move beyond task or skill demonstrations to higher level thinking processes, such as problem solving, would also then be expected to improve the health of the child in the home environment. Throughout this process, parents demonstrated an increase in skill acquisition in conjunction with anticipatory preparation for what could come next in caring for their child. This observation, noted across all groups, necessitates greater exploration in future studies to fully elicit the perceived benefits of simulation beyond simple skill demonstrations. This study had several limitations making it difficult to cleanly interpret obtained results. Applying simulation as both an assessment tool and an educational adjunct occurred concurrently with the existing discharge education program for these children and was not a stand-alone program which could skew results because of institutional limitations. Owing to the concurrent nature of this assessment program with an already established educational program, it was difficult to determine if adding simulation alone was responsible for the increases in parent skill level or if just the addition of more educational opportunities and the application of new technologies had positive implications for parent learning. In the future, interfacing this assessment program with current discharge education delivery could yield data uncompromised by other initiatives so that clearer conclusions could be drawn.
Conclusion In pediatrics where emergencies are thankfully infrequent, quick responses can affect patient outcomes and decide the remaining life course for the affected child. Simulation offers multiple opportunities to hone and assess clinical skills, evaluate critical thinking, and cement learning during debrief to improve responses for the next planned patient encounter. This pilot program demonstrated that using simulation as a teaching modality in the instruction of pediatric primary caregivers is beneficial with endless opportunities. Parents, home health providers, and extended support persons caring for a child with complex, technological dependence should be afforded the same opportunity for education as the individuals caring for the child in an inpatient setting. Striving to reconcile simulation training with improved patient outcomes as a primary focus should be an underlying goal of future research. As simulation training continues to expand its reach into the changing world of health care, health care providers need pp 23-26 Clinical Simulation in Nursing Volume 38
Simulation to Assess Parent Learning to understand and embrace the utility and function of an environment in which skills, knowledge, and improved care can safely be integrated into discharge education to insure discharge readiness.
References Cohen, E., Kuo, D. Z., Agrawal, R., Berry, J., Bhagat, S. K., Simon, T. D., & Srivastava, R. (2011). Children with medical complexity: An emerging population for clinical and research initiatives. Pediatrics, 127(3), 529-538. https://doi.org/10.1542/peds.2010-0910. Edwards, J. D., Kun, S. S., & Keens, T. G. (2010). Outcomes and causes of death in children on home mechanical ventilation via tracheostomy: An institutional and literature review. Journal of Pediatrics, 157(6), 955959. https://doi.org/10.1016/j.jpeds.2010.06.012. Edwards, E. A., O’Toole, M., & Wallis, C. (2004). Sending children home on tracheostomy dependent ventilation: Pitfalls and outcomes. Archives of Disease in Childhood, 89(3), 251-255. Kun, S. S., Edwards, J. D., Ward, S. L., & Keens, T. G. (2012). Hospital readmissions for newly discharged pediatric home mechanical ventilation patients. Pediatric Pulmonology, 47(4).
26 Merchant, D. C. (2012). Does high-fidelity simulation improve clinical outcomes? Journal for Nurses in Staff Development: JNSD: Official Journal of the National Nursing Staff Development Organization, 28(1), E1-E8. https://doi.org/10.1097/NND.0b013e318240a728, quiz E9-E10 Rutherford-Hemming, T. (2015). Determining content validity and reporting a content validity index for simulation scenarios. Nursing Education Perspectives (National League for Nursing), 36(6), 389-393. https://doi. org/10.5480/15-1640. Tofil, N. M., Rutledge, C., Zinkan, J. L., Youngblood, A. Q., Stone, J., Peterson, D. T., & White, M. L. (2013). Ventilator caregiver education through the use of high-fidelity pediatric simulators: A pilot study. Clinical Pediatrics, 52(11), 1038-1043. https://doi.org/10.1177/000992 2813505901. Toly, V., Musil, C. M., & Carl, J. C. (2012a). A longitudinal study of families with technology-dependent children. Research in Nursing & Health, 35(1), 40-54. https://doi.org/10.1002/nur.21454. Toly, V. B., Musil, C. M., & Carl, J. C. (2012b). Families with children who are technology dependent: Normalization and family functioning. Western Journal of Nursing Research, 34(1), 52-71. https://doi.org/10. 1177/0193945910389623. Toly, V. B., Musil, C. M., & Zauszniewski, J. A. (2014). Resourcefulness training intervention: A promising approach to improve mental health of mothers with technology-dependent children. Applied Nursing Research, 27(1), 87-90. https://doi.org/10.1016/j.apnr.2013.11.003.
pp 23-26 Clinical Simulation in Nursing Volume 38
www.elsevier.com/locate/ecsn
Research Brief
The Feasibility and Use of Simulation to Assess Parent Learning Michelle Whalen, DNP, RN, NNP-BC, CNE*, Michelle L. Aebersold, PhD, RN, CHSE, FAAN, Kathryn Nelson, DNP, RN, CPNP-AC/PC, Deborah M. Rooney, PhD University of Michigan, School of Nursing, Ann Arbor, MI 48109-2003, USA KEYWORDS simulation; pediatric; caregiver; parent education; tracheostomy
Abstract: Children dependent on long-term mechanical ventilation after discharge from an acute care center are at high risk for readmissions, morbidity, and mortality directly related to the care they receive in the home environment. Parents are inadequately prepared to provide the level of care needed in the home setting before their child’s discharge home. The primary goal of the Parental Airway Assessment with Simulation program was to assess parent learning and confidence in managing these children in the home setting after discharge. The Simulation Model for Improved Learner and Health Outcomes framed this assessment program’s development, implementation, and evaluation which focused on artificial airway management. The evaluation of parent discharge education was quantified at multiple intervals with parent(s) acting as their own controls. This program implemented a multistep simulation-based assessment intervention over a 6-8 weeks which included a home visit after discharge. After program completion, parents showed a 22% increase in self-reported confidence in caring for their technology-dependent child after discharge using an administered pre-post family assessment survey. At the end of the program, parents showed significant improvement in clinical skills with a demonstrated increase across all four tracheostomy skill assessments. Cite this article: Whalen, M., Aebersold, M. L., Nelson, K., & Rooney, D. M. (2020, January). The feasibility and use of simulation to assess parent learning. Clinical Simulation in Nursing, 38(C), 23-26. https://doi.org/ 10.1016/j.ecns.2019.10.003. Ó 2019 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
The population of children dependent on tracheostomy placement and long-term mechanical ventilation is increasing exponentially as the quality of pediatric trauma services, pediatric and neonatal intensive care services, and
* Corresponding author: [email protected] (M. Whalen).
overall pediatric medical management continues to evolve. Because of these improvements, the number of children successfully discharged home with tracheostomies continues to increase as medical advances improve the overall health and longevity of children with significant respiratory insufficiency (Cohen et al., 2011; Edwards, O’Toole, & Wallis, 2004; Kun, Edwards, Ward, & Keens, 2012).
1876-1399/$ - see front matter Ó 2019 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2019.10.003
Simulation to Assess Parent Learning Children requiring tracheostomies are medically fragile, have complicated physiology, and are at an increased risk for repeated acute illness and hospitalization. These complex children demand that parents carry out interventions at home that had been previously been provided by specially trained pediatric registered nurses and respiratory therKey Points apists. Families are not pre Simulation is underpared for the direct care used in the training their child requires and and assessment of peoften are provided discharge diatric caregivers. education and training using Simulation is a viable modalities that are outdated modality to assess (Cohen et al., 2011; Tofil parent clinical skills et al., 2013; Toly, Musil, & before discharge. Carl, 2012a,b). Studies Simulation-based have demonstrated that the discharge education quality of care a child reprovides opportuceives in the home is nities to evaluate directly linked to their parent skills. long-term health outcomes; therefore, suboptimal home care equates to suboptimal long-term outcomes (Edwards, Kun, & Keens, 2010; Kun et al., 2012). Parent discharge teaching continues to be reliant on videos and equipment demonstrations on static airway models with limited constructive feedback or quantitative assessment of skills (Tofil et al., 2013; Toly et al., 2012a,b). Parents need to be able to practice the skills required to care for these children in an environment that is controlled, forgiving, and immersive to truly prepare for a discharge home (Tofil et al., 2013; Toly et al., 2012a,b). The goal of this multistep simulation-based pilot program was to assess and measure parent clinical skills in preparation to care for their child with a tracheostomy after discharge using evidence-driven practices and clinical skill repetition.
Sample The target goal for sample inclusion was a total of six to ten families. In all, a total of eight parents were enrolled in this pilot program. Fifteen total families were referred through pediatric subspecialty services with enrollment criteria identified as being a child younger than eighteen years with primary tracheostomy placement, English speaking, and available for multiple education sessions, including a home visit after discharge. Those excluded from the study included two patients older than 18 years, two children with tracheostomies previously, a child entering hospice care for an evolving congenital syndrome, a child who passed away shortly after tracheostomy placement, and a family who would not be geographically available for a home visit after discharge.
24 As the skill focus was specifically addressing tracheostomy skills, mechanical ventilators as a mode of respiratory support did not factor into inclusion or exclusion criteria. The patients included in the study encompassed both a mix of ventilator-dependent children and children requiring only a tracheostomy with a humidified oxygen mask. Six of the children were ventilator dependent and two of the children were only tracheostomy dependent. Coincidentally, all patients referred and subsequently enrolled were infants.
Methods This was a pilot program with a descriptive quantitative design established to assess parent tracheostomy skills over time after sequential simulation sessions. The institutional review board at the organization reviewed the submitted program protocol and granted approval. Families who were referred were contacted within ten days of the surgical placement of the tracheostomy to capitalize on early educational opportunities yet be respectful of the change in their child’s health status after tracheostomy. Parents were provided program information at time of consent and those agreeing to take part in the study were then given a general overview of the program. Once consented, the parents were given laminated resource cards that outlined the skills being evaluated in easy to follow steps supported with illustrations. The program was titled Parent Airway Assessment with Simulation and consisted of sequential simulation sessions with quantified skill attainment scores over a 4- to 8-week time frame. To effectively assess the parent’s tracheostomy clinical skills, four Parent Airway Assessment with Simulation skill checklists were developed. The four checklists included general tracheostomy care, tracheostomy suctioning, tracheostomy securement, and tracheostomy changes. Informed in entirety by an extensive literature search, the skill checklists had evidence-based practice standards represented in each step to ensure that parents were taught the most current method of pediatric tracheostomy care during their simulation sessions. The checklists were reviewed for accuracy and distributed to a mixed team of ten pediatric intensive care providers to confirm their validity and reliability. All four checklists were independently evaluated by this team during a four-week period of simulated skill sessions that used a standardized scenario and a low-fidelity infant simulator. Test/retest reliability was measured over the course of multiple sessions with the content experts to ensure that the four checklists established consistent results when used for skill assessment. Validity of the checklists was established by using a content validity index (CVI). A CVI is a commonly accepted method of measuring the content validity of a tool and has been applied to simulation scenarios (Rutherford-Hemming, pp 23-26 Clinical Simulation in Nursing Volume 38
Simulation to Assess Parent Learning 2015). For the assessment of the skills checklists, the clinical experts were asked to rate the relevance of each of the items on each of the four skill checklists using a four-point relevancy scale. The CVI values ranged from 0.5 to 1.0; items with a CVI > 0.8 were retained as written on the checklist. Items with a CVI calculated at less than or equal to 0.8 were reworded, clarified, and re-evaluated to ensure that the tool, as developed, had the capability to measure the parent’s skills during simulation. The individual item CVIs ranged from 0.8 to 1.0 with the average CVI for the four tools ranging from 0.9 to 1.0 suggesting high inter-rater agreement of the checklists.
Results Simulation education is based on adult learning theory and is a proven educational technique in a clinical learning that has demonstrated success in improving skills (Tofil et al., 2013). A benefit of simulation is that it affords the facilitator an opportunity to assess a clinical skill provider in real time and within the context of a realistic scenario to evaluate psychomotor skills and clinical thinking. Parents enrolled in the program were supported and provided with a focused assessment of their newly acquired clinical skills and advanced discharge preparation through resource card distribution, multiple simulation sessions, and engaged debriefing over a 4- to 8-week period that included five points of contact throughout the program duration. Over the course of the program, all families enrolled were exposed to multiple simulation sessions and demonstrated significant increases in skill levels across all content assessed with a p value ¼ .006. The Pearson correlation value for skill acquisition across all four skills was r ¼ 0.92, indicating a robust positive correlation between simulation-based parent education and successful skill performance. Increases for all four skills examined trach care, trach suctioning, trach securement, and trach changes, were measured using separate t test evaluations indicating a Pearson’s r coefficient level of 0.75 to 0.94. There was a statistically significant increase in mean score increases across all four skills assessed that increased incrementally over time with a positive correlation demonstrated between the first simulation session and the applied intervention in the final simulation session in the family’s home setting.
Discussion Children who are tracheostomy dependent are at risk for complications and after their discharge, the medical team caring for these patients expects the parents to assume and replicate the care their child received in the acute care setting in the home setting. Despite vast innovations in health care education delivery, parent discharge education has not been uniformly updated with changing technologies nor does it use adult learning theory to its fullest
25 potential. The underlying goal of this pilot program was to assess parent learning using simulation-based modalities that supplemented existing discharge education delivery. Research supports the idea that effectively training the caregivers of these high-risk children will positively affect health care outcomes after discharge (Merchant, 2012; Tofil et al., 2013; Toly et al., 2014). Using simulation to assess parent learning, to predict next steps, and to move beyond task or skill demonstrations to higher level thinking processes, such as problem solving, would also then be expected to improve the health of the child in the home environment. Throughout this process, parents demonstrated an increase in skill acquisition in conjunction with anticipatory preparation for what could come next in caring for their child. This observation, noted across all groups, necessitates greater exploration in future studies to fully elicit the perceived benefits of simulation beyond simple skill demonstrations. This study had several limitations making it difficult to cleanly interpret obtained results. Applying simulation as both an assessment tool and an educational adjunct occurred concurrently with the existing discharge education program for these children and was not a stand-alone program which could skew results because of institutional limitations. Owing to the concurrent nature of this assessment program with an already established educational program, it was difficult to determine if adding simulation alone was responsible for the increases in parent skill level or if just the addition of more educational opportunities and the application of new technologies had positive implications for parent learning. In the future, interfacing this assessment program with current discharge education delivery could yield data uncompromised by other initiatives so that clearer conclusions could be drawn.
Conclusion In pediatrics where emergencies are thankfully infrequent, quick responses can affect patient outcomes and decide the remaining life course for the affected child. Simulation offers multiple opportunities to hone and assess clinical skills, evaluate critical thinking, and cement learning during debrief to improve responses for the next planned patient encounter. This pilot program demonstrated that using simulation as a teaching modality in the instruction of pediatric primary caregivers is beneficial with endless opportunities. Parents, home health providers, and extended support persons caring for a child with complex, technological dependence should be afforded the same opportunity for education as the individuals caring for the child in an inpatient setting. Striving to reconcile simulation training with improved patient outcomes as a primary focus should be an underlying goal of future research. As simulation training continues to expand its reach into the changing world of health care, health care providers need pp 23-26 Clinical Simulation in Nursing Volume 38
Simulation to Assess Parent Learning to understand and embrace the utility and function of an environment in which skills, knowledge, and improved care can safely be integrated into discharge education to insure discharge readiness.
References Cohen, E., Kuo, D. Z., Agrawal, R., Berry, J., Bhagat, S. K., Simon, T. D., & Srivastava, R. (2011). Children with medical complexity: An emerging population for clinical and research initiatives. Pediatrics, 127(3), 529-538. https://doi.org/10.1542/peds.2010-0910. Edwards, J. D., Kun, S. S., & Keens, T. G. (2010). Outcomes and causes of death in children on home mechanical ventilation via tracheostomy: An institutional and literature review. Journal of Pediatrics, 157(6), 955959. https://doi.org/10.1016/j.jpeds.2010.06.012. Edwards, E. A., O’Toole, M., & Wallis, C. (2004). Sending children home on tracheostomy dependent ventilation: Pitfalls and outcomes. Archives of Disease in Childhood, 89(3), 251-255. Kun, S. S., Edwards, J. D., Ward, S. L., & Keens, T. G. (2012). Hospital readmissions for newly discharged pediatric home mechanical ventilation patients. Pediatric Pulmonology, 47(4).
26 Merchant, D. C. (2012). Does high-fidelity simulation improve clinical outcomes? Journal for Nurses in Staff Development: JNSD: Official Journal of the National Nursing Staff Development Organization, 28(1), E1-E8. https://doi.org/10.1097/NND.0b013e318240a728, quiz E9-E10 Rutherford-Hemming, T. (2015). Determining content validity and reporting a content validity index for simulation scenarios. Nursing Education Perspectives (National League for Nursing), 36(6), 389-393. https://doi. org/10.5480/15-1640. Tofil, N. M., Rutledge, C., Zinkan, J. L., Youngblood, A. Q., Stone, J., Peterson, D. T., & White, M. L. (2013). Ventilator caregiver education through the use of high-fidelity pediatric simulators: A pilot study. Clinical Pediatrics, 52(11), 1038-1043. https://doi.org/10.1177/000992 2813505901. Toly, V., Musil, C. M., & Carl, J. C. (2012a). A longitudinal study of families with technology-dependent children. Research in Nursing & Health, 35(1), 40-54. https://doi.org/10.1002/nur.21454. Toly, V. B., Musil, C. M., & Carl, J. C. (2012b). Families with children who are technology dependent: Normalization and family functioning. Western Journal of Nursing Research, 34(1), 52-71. https://doi.org/10. 1177/0193945910389623. Toly, V. B., Musil, C. M., & Zauszniewski, J. A. (2014). Resourcefulness training intervention: A promising approach to improve mental health of mothers with technology-dependent children. Applied Nursing Research, 27(1), 87-90. https://doi.org/10.1016/j.apnr.2013.11.003.
pp 23-26 Clinical Simulation in Nursing Volume 38