655CHAPTER 56
Final Words of Wisdom on Simulation
BACKGROUND TO THE THIRD EDITION
Since the writing of the first and second edition, as our simulation journey continues, we are stunned and amazed—never did we believe the book would be on the best seller list, translated into Korean, or become such an essential resource for so many. For this edition we reached out to our faithful readers through the International Nursing Association for Clinical Simulation and Learning (INACSL) and the national American Association of Colleges of Nursing (AACN) deans and directors list serves to contact national leaders in simulation and lab directors and coordinators for nursing education. With thanks to our SurveyMonkey® guru, Colleen Cox, at Western Connecticut State University (WCSU), we were able to assess the usefulness of the book in addition to this group’s perception of the gaps that needed to be filled in the second edition. The national survey demonstrated that readers found the following most useful: ideas for building a lab, specialty scenarios, leveled scenarios, including increased complexity, objectives that matched National League for Nursing (NLN) and AACN categories, and details for running scenarios. Secondly, debriefing guidelines and evaluation checklists were most useful. The second question on the survey asked what areas would be most helpful—participants identified advanced practice scenarios with an emphasis on nurse practitioners (NPs), interprofessional team building scenarios, and identified that new scenarios were needed at all levels: undergraduate, graduate, and doctorate. We also found that participants identified the following types of scenarios as most needed: assessment, communication, interprofessional, competency evaluation, and cultural awareness as well as including patients of various ages, gender, and ethnicity.
Other areas of importance that we assessed included the use of web applications (iPhone, iPad, social media) and participants only showed interest in the iPad and in the incorporation of electronic health records. Similar to the National Council of State Boards of Nursing (NCSBN) surveys (Hayden, 2010; Kardong-Edgren, Willhaus, Bennett, & Hayden, 2012), our participants reported the importance of simulation, the integration into their curriculum, but participants classified only 50% of the faculty as champions. We feel that this “50%” is encouraging, given that 10 years ago most nursing faculty probably would have reported less than 10% as champions in the use of simulation. Participants believed that an expanded version of the book would assist faculty to become more comfortable with the use of simulation and with the integration of innovative educational pedagogy into their nursing programs. As we suspected, although survey participants identified using preprogrammed scenarios, it appears that faculty who have developed expertise in simulation prefer to develop their own scenarios. To that end, this book was revised to assist faculty to continue to do just that!
Much has changed in the last 5 years and research on simulation has proliferated not just in nursing. The NCSBN studies (Hayden, 2010; Kardong-Edgren et al., 2012) demonstrated that schools of nursing are using simulations in very different ways and there is no uniform 656methodology A study in Canada provided an inventory on the use of simulated clinical learning experiences and evaluation of their effectiveness (Garrett, Van der Wal, Tench, & Fretier, 2007). Conclusions were that the simulated clinical learning offered advantages, such as a safe environment, especially in high-risk procedures; exposure to rare but complicated events; the manipulation of opportunities for care; the provision of feedback in a timely manner; the ability to standardize, repeat, evaluate, and assess performances; and to organize and practice team behavior (Garrett et al., 2007, p. 2). A lack of standardization of terminology, issues of cost and access to equipment, and minimal actual replacement of clinical hours by simulation were part of key findings. In addition, cost-benefit analyses have not been done to demonstrate the effectiveness of particular approaches (Garrett et al., 2007).
INSIGHTS GLEANED
We learn so much about the creativity and innovation of simulation in nursing education as we work with authors nationally and internationally in various areas where simulation is being used. The authors who submitted chapters are truly engaging in the pedagogy of simulation, paving the path toward the future where simulation becomes a standard in the transformation of health care professional education. The introduction of the book sets the stage for all the changes that have occurred and the Framework for Simulation Learning has been moved to the second chapter to set the stage for descriptions of integrating simulation throughout the pedagogy (Chapter 4), innovative approaches to faculty development including international and interprofessional perspectives from teaching intensive and research intensive sites (Chapter 5), and the description of building a learning resource center has taken into consideration many changes that have occurred from when the coeditors began (Chapter 6). This third edition benefits from the updated version of our contributors Meakim and Rockstraw description in Chapter 7 of a detailed simulation center that incorporates the highest level of technology. We endeavored in the first edition to present basic scenarios with a focus on prelicensure nursing education, with only a few chapters offering multiple scenarios. In contrast, the second edition presented more complex undergraduate scenarios: and discipline-specific chapters as well as Home care blending cultural sensitivity and scenarios written according to Quality and Safety Education for Nurses (QSEN) competencies. This third edition continues the practice of significant additions in specialties, the advanced practice, master’s, and doctoral level scenarios as well as the interdisciplinary and interprofessional scenarios. This continues to reflect the trends globally where undergraduate simulation has expanded to the graduate level. Because of increasing focus on interprofessional education, Part III of this new edition provides 16 interdisciplinary and interprofessional scenarios of varying complexity and from the United States and Canada. Finally, Part IV describes the continuing maturity level of simulation by providing insight to learning to write like a nurse during simulation, how to publish your simulation work, and how to assess your expertise by outlining certification and accreditation programs internationally.
TRENDS AND GAPS
Still a pervading issue is the configuration of simulation labs and the role of who staffs the labs and who oversees and has responsibility for simulation. In relationship to the configuration of the labs, learning resource centers, there is still a lot of variation nationally and internationally from distinct rooms to complete learning resource centers, which may consist of full floors or actual buildings to interdisciplinary regional resource centers. We are still challenged in defining the role of simulation directors. Although masters-prepared nurses as simulation lab managers are ideal, there still exist many spunky and resourceful baccalaureate-prepared nurses who manage the responsibilities of the lab, including equipment maintenance, setup and running of simulations, and scheduling day-to-day activities. For true integration and curricular development using simulation in nursing programs, doctorally prepared faculty in the role of directing and overseeing 657the learning resource center are ideal. In order for us to truly achieve a simulation-focused pedagogy throughout the curriculum, doctorally prepared faculty will need to be engaged in the work of the learning resource center. This role could include overseeing lab managers and staff for the day-to-day running of activities; curricular development and integration of simulation-focused pedagogy; faculty development and skill enhancement in the use and development of simulation scenarios; research on the effectiveness of simulation and innovative educational techniques to enhance health care professional education; outreach to the community to develop partnerships for the running of the center and its use for regional training; and competency-based continuing education for health care professionals.
Another trend is the increased rigor of “Simulation Based Research” (SBR) and quality to enhance moving forward the science of simulation within nursing and health care. Better research will be done when simulation scenarios are developed in a consistent manner using evidence-based best practice standards for the clinical situation as well as for the development of the scenario (INACSL, 2016). Increasing the use of theory-based research to study simulation is also a key factor to increasing the rigor and efficacy of nursing research in this area (Kaakinen & Arwood, 2009; Rourke, Schmidt, & Garga, 2010) as well as looking beyond self-efficacy (Kardong-Edgren, 2013) and faculty and student satisfaction. The next phase of research in simulation needs to demonstrate that knowledge transfer, retention, and behavior modification result as a direct outcome of simulation education, whether for prelicensure nursing students or interprofessional teams in situ, and that these changes result in increased patient safety and improved patient outcomes and quality of care. Part of rigorous research includes using valid and reliable tools. An evaluation of simulation tools was done (Kardong-Edgren, Adamson, & Fitzgerald, 2010) and presently INACSL provides a repository of instruments used in simulation research on their website (INACSL, 2015).
Faculty Buy-In, Professional Development, and Time Management
We were hoping that in the elapsed time between the editions of this book we would see more faculty buy-in and professional development and allotment of time for simulation integration, but these issues are still a challenge. Here we feel we should address the issue of the national crisis of faculty shortages, which impact faculty workload. Adamson (2010), DaRosa et al. (2011), and Schneider Sarver, Senczakowicz, and Slovensky (2010) discuss these issues as barriers to the full integration of simulation. Although there is no replacement for full administrative support for simulation, at the university level, such as exists at Davenport University, we still have to find ways to enable faculty to meet this goal. We still contend that simulation is a vehicle for the faculty to achieve the goal of working smarter, not harder, with good student outcomes and increased faculty and student self-efficacy and satisfaction. As we have suspected since the inception of simulation in nursing, research is now demonstrating the benefits in increased self-confidence, problem solving, and the importance of debriefing (Alfers, 2011; Reese, Jeffries, & Engum, 2010).
In addition to getting faculty buy-in, supporting new faculty in their role and the learning curve involved in taking on tenure track positions not to mention learning about the integration of innovative technology and experiential learning methods such as simulation. There is a difference in the level of respect for the Scholarship of Teaching and Learning, and although the U.S. Health Resources and Service Administration (HRSA) funds provide support for educational program development and research, similar resources are not easily available in Canada. One of the major shifts since the writing of the second edition has been the increased rigor in the science of simulation. The INACSL Best Practice Standards: SimulationSM (INACSL, 2016), the NCSBN Simulation Guidelines for Prelicensure Nursing Programs (Alexander et al., 2015) and the increase in integrative and systematic reviews of simulation research are providing more consistent and standardized ways to support the provision of the highest quality learning experiences possible.
We are pleased to see that work is being done on an interprofessional collaboration to match the Interprofessional Education Collaborative Expert Panel (IPEC, 2011a, 2011b). This 658is a tremendous use of simulation for the enhancement of collaborative teamwork in areas to increase patient safety and satisfaction and addresses the QSEN competencies (Gantt & Webb-Corbett, 2010; Ironside, Jeffries, & Martin, 2009; Morello et al., 2013; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013; Thomas & Galla, 2013), including medication safety (Berdot et al., 2016; Härkänen, Voutilainen, Turunen, & Vehviläinen-Julkunen, 2016; Sears, Goldsworthy, & Goodman, 2010). Other research has been done on enhanced interprofessional communication between nursing students and medical students (Reising, Carr, O’Shea, & King, 2011; Scherer, Myers, O’Connor, & Haskins, 2013), as well as between nursing students at various levels (Leonard, Shuhaibar, & Chen, 2010). Systematic reviews of interprofessional simulations include: emergency situations (Murphy, Curtis, & McCloughen, 2016), intensive care (O’Leary, Nash, & Lewis, 2015; Watts et al., 2014), and with standardized patients (Koo, Idzik, Hammersla, & Windemuth, 2013).
On the horizon, we see the use of simulation to educate nurses in the care of veterans (Anthony, Carter, Freundl, Nelson, & Wadlington, 2012) and publications documenting the experiences of veteran nurses (Scannell-Desch & Doherty, 2012). Schools of nursing are using simulation and other innovative technologies to teach students about posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) so they can better treat veterans who are coming home from war as part of the Joining Forces Initiative. Dr. Campbell was thrilled to present the first edition of this book to First Lady Michelle Obama in support of the Joining Forces Initiative.
We are pleased to see that additional work is being done in end-of-life care (Gillan, Jeong, & van der Riet, 2014; Leighton & Dubas, 2009) and simulation to enhance cultural awareness (Grossman, Mager, Opheim, & Torbjornsen, 2012; Haas, Seckman, & Rea, 2010; Ozkara San, 2015; Roberts, Warda, Garbutt, & Curry, 2014; Rock, Schaar, & Swenty, 2012), as prescribed in our Framework for Simulation Learning in Nursing Model (Daley & Campbell, 2009). We now have research documenting that simulation increases knowledge and skills at the graduate level, increases self-confidence in students and nurse educators, and the benefits of simulation as a method of teaching (Jeffries et al., 2011).
When academic metrics were used to measure psychomotor skills in students, no differences were found on standardized examinations between teaching using simulation or traditional methods (Sportsman, Schumacher, & Hamilton, 2011). The researchers felt that their study provided initial evidence of the impact of simulation on academic success. More studies are necessary in this area. Another study revealed documentation of gaps in critical thinking and problem recognition by students during simulation, for example not reporting essential information and a need for further research in this area (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009). This study demonstrates how essential the integration of simulation experiences are with traditional clinical experiences. As reflected in the Framework for Simulation Learning in Nursing Model (Daley & Campbell, 2009), through debriefing and concept mapping faculty can see how students develop in their thinking, acting, and reflecting like a nurse.
Setting the Priorities Increased Interest in Interdisciplinary Education, Team Building, Communication, and Safety—Knowledge Transfer, Retention, Behavior Change
As aptly stated by Brewer (2011) “HPS use has not yet developed to its fullest potential” (p. 317). There is much work to be done. We, the editors of this book, would like to challenge nurse educators (and nurse researchers) to continue to persevere and go beyond simple assessment of confidence and attitudes, and begin the work of metric-based assessment of outcomes to continue the work to make simulation measureable! We believe the priorities for simulation in nursing education should be to continue to work toward full integration of simulation throughout all levels of nursing education. Furthermore, we believe that simulation is a means for meeting the demand for interprofessional and interdisciplinary educational opportunities (Institute of Medicine [IOM], 2011) and is rich in research opportunities.
659LOOKING TOWARD THE FUTURE
There are many changes on the horizon, which mean that nursing faculty need themselves to be constantly vigilant, creative, fearless, and passionate. With increasing faculty shortages and health care practitioner shortages, especially nurses, new ways of delivering nursing programs must be envisioned. Better collaboration between practice partners and educators needs to happen. Use of more technology for flipped classrooms, virtual simulation, and online clinics and learning opportunities will become a reality. More sensitive simulators providing sensory feedback to guide health professionals’ assessment and skill in techniques already exist (e.g., pelvic, prostate, breast examination or catheter or intravenous insertions; Laufer et al., 2016). This text has provided a summary of the many advantages of using simulation to educate nurses, interprofessional teams, and has focused on both technical and nontechnical skills. The scenarios provided are written using the INACSL Best Practice Standards SimulationSM (INACSL, 2016) and the authors describe the integration in their curriculums, the effect on students, and the lessons they have learned. In addition, the scenarios outline objectives and essentials from AACN or the NCLEX-RN® Blueprint so that the faculty using the scenarios can decide where they best fit to meet the student competency needs and abilities. In addition, many of the scenarios describe ways to level the experiences such that they can be used with novice students or those more advanced. Many of the scenarios in the text are at a level that would be easily translated for use in clinical settings to maintain staff competency and allow for practice of team-building skills.
Overall, the authors of the chapters in this book recognize the barriers they face, especially when it comes to the use and research of simulation, for example the lack of time, workload, and fear of technology. Yet, similar to research findings, they felt enabled when they were provided professional development and training, felt that administration was supportive and had a dedicated simulation coordinator (Al-Ghareeb & Cooper, 2016). In conclusion, we look forward to a day when simulation in nursing education is a commonplace and “a given” as part of nursing education. We have already experienced great growth over the time that the third edition of this text has evolved and look back and say “Remember when simulation meant sticking an orange with a needle, and there were no human patient simulators?” Even more now we believe simulation will prove the key to the future of nursing education that is well-grounded in safety, excellence, and reflection.
REFERENCES
Adamson, K. (2010, May). Integrating human patient simulation into associate degree nursing curricula: Faculty experiences, barriers, and facilitators. Clinical Simulation in Nursing, 6, e75–e81.
Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-Edgren, S. S., … Tillman, C. (2015). NCSBN simulation guidelines for prelicensure nursing programs. Journal of Nursing Regulation, 6(3), 39–42. doi:10.1016/S2155-8256(15)30783-3
Alfers, C. M. (2011). Evaluating the use of simulation with beginning nursing students. Journal of Nursing Education, 50(2), 89–93.
Al-Ghareeb, A. Z., & Cooper, S. J. (2016). Barriers and enablers to the use of high-fidelity patient simulation manikins in nurse education: An integrative review. Nurse Education Today, 36, 281–286.
Anthony, M., Carter, J., Freundl, M., Nelson, V., & Wadlington, L. (2012, April). Using simulation to teach veteran-centered care. Clinical Simulation in Nursing, 8(4), e145–e150.
Berdot, S., Roudot, M., Schramm, C., Katsahian, S., Durieux, P., & Sabatier, B. (2016). Interventions to reduce nurses’ medication administration errors in inpatient settings: A systematic review and meta-analysis. International Journal of Nursing Studies, 53, 342–350.
Brewer, E. P. (2011). Successful techniques for using human patient simulation in nursing education. Journal of Nursing Scholarship, 43(3), 311–317.
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