19CHAPTER 3
Integrating Simulation-Focused Pedagogy Into Curriculum
This chapter describes how simulation fits the needs for 21st-century nursing education. Aspects that are covered include the changing needs for nursing education in a technologically complex environment, how to succeed when incorporating simulation, the importance of the faculty role in embedding simulation throughout the nursing curriculum, meeting the challenges of clinical placement, and specific challenges and benefits to integrating simulation into the curriculum with an evidence-based practice focus.
SIMULATION: THE MISSING PIECE
Historically, education at all levels has emphasized critical thinking as a standard. Students now arrive on campus with the basic skills to learn through critical thinking. However, distinct to this generation of learners is the ability to use and adapt readily to the rapid technological advances seen since the turn of the century. Although they primarily use this technology as a source of entertainment and creativity, these students often arrive knowing more about technology than their teachers and expecting nontraditional teaching methods that incorporate technology at every turn. As always, the challenge on college campuses is for faculty to stay abreast, if not ahead of, a typical undergraduate’s technology-laden learning needs in addition to facilitating the higher level of critical thinking expected of college graduates. Simulation provides the missing piece for nursing education through harnessing each student’s enthusiasm for technology into an interactive and valuable learning experience in which to engage in critical thinking (Radhakrishnan, Roche, & Cunningham, 2007).
The past 20 years have seen major advancements in technology available in nursing education, and most faculty and nursing programs have recognized the need for incorporating technology into the way they are teaching. Technology-equipped classrooms are the norm, enabled to have the capability to use streamlined video, have in-classroom web access, and use web-based learning platforms in each class. Students are also encouraged to “Google.” Virtual hospitals have appeared online, interactive nursing case studies are readily available, and we now have the ability to stream actual patient data in real time into remote classrooms for analysis. In addition, high-technology products have become available for students to learn nursing in lifelike patient encounters. Most recent, with the creation of high-fidelity human patient simulators (HPSs), there is an opportunity to take simulation to a higher interactive level within the bounds of practice and safety before actual patient interactions. This technology is within reach of most nursing programs from the traditionally basic level to the most cutting edge.
However, navigating the simulation maze, obtaining and renovating space, and, most important, obtaining faculty buy-in and promoting ownership of simulation within the curriculum 20have not proved to be a smooth transition. At present, the need for more complicated scenarios has evolved as patients have become sicker and staff nurses have been required to provide more complex care. Nursing faculty who are feeling the responsibility of arriving at hospitals with competently trained students have identified the need to practice complex care before clinical experiences. Simulation meets this need.
The traditional approach to the use of simulation in nursing curricula is to develop independent modules that students must complete and be assessed on before entering the clinical areas. Traditionally, low-fidelity simulations on static manikins have been delivered by lab personnel under the direction of faculty. These scenarios are easily set up, require low-maintenance materials, and allow for easy evaluation. These methods have a long history of proven success in task training and may or may not involve individual nursing faculty input. However, task-based modules, such as catheterization, do not require the same level of complexity, critical thinking, communication, and use of nursing skills as a scenario that integrates all these areas.
In contrast, the simulations provided in this book come from competent clinical and seasoned faculty members who have been actively integrating simulation into every course taught. This feature brings a new level of curricular sophistication and provides an example for others on how the methods they are using to teach already can be incorporated with a simulation-focused pedagogy. Throughout the text, the term simulation-focused pedagogy is used to describe a method of using simulation and scenarios to integrate content and multiple concepts in all areas of nursing care to provide an interactive environment by which students are held accountable to use the information they are learning. Simulation integrates theoretical didactic components with critical thinking to enact nursing behaviors in a safe, efficient, ethical manner or as an end-point (capstone) measure of competencies. Although assimilating simulation-focused pedagogy has become a worthy and essential curricular goal, most nursing educators have struggled to find ways to integrate simulation throughout each program’s curriculum.
Early literature had emphasized purely medical and surgical uses for simulation; however, we feel strongly that simulation crosses all clinical areas of nursing curricula and is applicable in all areas. All faculty members are capable of being involved in the development, implementation, and evaluation of scenarios to meet their curricular goals. The scenarios presented provide a wide breadth of simulation scenarios for all levels of undergraduate and graduate nursing curricula, as well as new interprofessional scenarios.
ESSENTIAL TOOL KIT FOR SUCCESS: PERSISTENCE, VISION, AND PATIENCE
Many of us have arrived at simulation in one of these two ways: (a) as a dream for how things should be done with little or no financing or (b) as a well-financed initiative with no schematics for implementation of something designated as the “simulation lab.” However, as one arrives at simulation, the realization occurs quickly that its implementation is a daunting task. Many levels arise for implementation, and hidden costs and factors are continually discovered. Yet, once implemented, the results are amazing.
Our joint experience is that persistence in pursuing the implementation of simulation is invaluable. One faculty member described this as a “dogged” and an unrelenting pursuit! Whether the vision has been dictated or created individually, it is this vision that helps to navigate the many obstacles and to meet the challenges that arise head on. Patiently reiterating the need, returning to key people to explain the rationale and vision, and writing and rewriting plans and strategies have been required throughout the experience. Key to this persistence have been the support, encouragement, and faith of the faculty.
FACULTY FACTOR
21Building a foundation for the integration of simulation throughout the curriculum must take into account the faculty factor. Although most who are leading the way for the integration of simulation are comfortable with the technology, many nursing faculty groups reflect varying levels of technology training and usage of technology in their classes. High-fidelity simulation requires more than a basic understanding of computers. Most simulation companies who were initially willing to train faculty as needed are now charging for this service, necessitating a “train the trainers” type of initiative. This often forces a decision to find an expert or two who, in addition to a usual faculty load, is also responsible for training the entire faculty on how to use the simulators—a very daunting task. Finding time for individual or group training is essential but can be difficult to manage given the faculty shortages and already-busy workload of nursing faculty. As not all nursing programs have lab personnel, often individual faculty must be trained to run their own simulations. However, promoting ownership and individual buy-in within a faculty member’s program or course and group simulation initiatives often eases the transition to integrating simulation into individual courses. Given the atmosphere of academic freedom, some strategies to encourage and inspire hesitant faculty may include inviting them to observe a scenario or role-play one of the parts; having an “open door” policy for interested faculty to discuss their ideas, outline templates, and receive coaching in simulation; retreats to strategize about methods to embed simulation and technology throughout the curriculum; and innovative ideas for faculty professional development (see Chapter 4).
If an enthusiastic early adopter is identified, it is imperative that faculty who are novices in simulation have the opportunity to feel supported in exploring innovative teaching models that incorporate state-of-the-art simulation. A junior colleague of ours has shared the following:
As educators providing instruction via high-tech simulation, we can provide today’s students with a safe and controlled environment in which to learn. What became increasingly apparent to me in my first experience as a clinical coordinator at a highly respected (simulation and learning) laboratory was what we were providing our students and what we were practicing in our department were two different concepts. Despite having a “Safe Zone” sticker on my office door for students to know they would be free from bullying, discrimination, and shaming while in my office, the same could not be said for how my departmental colleagues were treating each other. Simulation shaming is a term to explain the environment created within the department that disrupts the ability to provide the best experience for our students. Within my own department, it amazed me how destructive this practice can be, not only to the staff itself but to the ability to provide the highest quality of instruction to the students. This caused those part-time staff members to feel as though their contributions were not as important as those who were addressed professionally and therefore (the staff) were less likely to contribute. In institutions where simulation shaming is both practiced and unimpeded, an environment is created that not only circumvents accountability but has the potential to marginalize valuable opportunities for our students. One could argue that if we expect our students to be accountable for their performance, respect the differences of both colleagues and patients, and speak kindly, we must expect the same from ourselves. (C. Kraft, personal communication, November 12, 2016)
For instance, we worry that junior faculty and lab staff’s contribution to simulation may not be represented in authorship—we need to ensure that junior faculty are supported and recognized in their contributions and inspired to continue to develop their simulation and teaching expertise. As a discipline, we are known for “eating our young,” which has been conceptualized as vertical violence and bullying, and we recognize this as one of the many concerns in retaining nurses in practice and education. We can no longer tolerate this behavior, given the shortages we are facing and the intellect wasted. As the use of simulation accelerates, we ask all nursing 22educators to maintain the highest levels of professional integrity and face their fears to support new ways of thinking, teaching, and practicing this profession we love (International Nursing Association for Clinical Simulation and Learning [INACSL], 2016).
CLINICAL EXPERIENCE VERSUS SIMULATION
The need for simulated nursing experiences has been reinforced by the scarcity of clinical placement sites. Program enrollments have increased the large numbers of students needing clinical experiences and a nursing shortage that requires adequate staffing to handle students has created stress for both academic institutions and hospitals alike. This situation has sparked much discussion about how much clinical time should be replaced with simulation or whether simulation should ever replace clinical time at all. Although most nursing programs are deciding this issue individually, each program has required hours for program completion by individual state boards of nursing and in Canada, by provincial Colleges of Nurse Regulators. In one state, a brainstorming session of the statewide deans and directors was held early in this new era of simulation and, in general, it was suggested that no more than 10% of clinical time would be used for simulation. Other states have made arrangements for incorporating simulation into calculated clinical time. The National Council of State Boards of Nursing (NCSBN) position paper of 2005 reported that boards addressed two major issues: (a) the increased use of technology for nursing education clinical experiences and (b) the use of clinical sites and learning centers. Although nursing education experiences should represent the full life span with actual patients, they may include innovative teaching strategies that complement clinical, like simulation, but should not entirely replace clinical. In reality, with practice time in the simulation lab, students may enter the clinical sites at a higher cognitive and skill level with increased confidence, and therefore get more out of the experience (Bremner, Aduddell, Bennett, & VanGeest, 2006; Murray, Grant, Howarth, & Leigh, 2008; NCSBN, 2005; Nehring, 2008). This finding was supported by a study conducted by the NCSBN and results were released in 2014, stating:
It was found that up to 50 percent simulation was effectively substituted for traditional clinical experience in all core courses across the prelicensure nursing curriculum under conditions comparable to those described in the study. Additionally, the use of up to 50 percent simulation did not affect NCLEX pass rates. (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014, p. S38)
These findings confirm the validity of the efficacy of substituting simulation for clinical time in well-chosen educational experiences (Hayden et al., 2014).
A frequently used method of integrating simulation as a complement to clinical experience is doing simulations early in the semester. Nursing faculty are often unfamiliar with a new group of students and need to assess their competency level before placing them with actual patients. The use of simulated scenarios can help prepare students for the higher level of patient care required in a new semester. Faculty can then move forward into the semester having assessed strengths, weaknesses, and areas in need of improvement.
Another method of implementing simulation within a semester is transforming what currently exists in the form of weekly task-oriented modules to simulation scenarios. Traditionally used to demonstrate competency on one static task, simulations transform a static task into an engaging and realistic patient interaction involving communication, safety precautions, and the need to react to changing physiologic conditions. In addition, when hospitals have the available resources (e.g., high-fidelity HPSs), clinical faculty may choose to incorporate a simulation into a postconference session to share an important learning experience with the whole group, reinforce important aspects of care, and debrief to assist the students in recognizing alternative scenarios for providing care and assessing and evaluating patient reaction to the plan of care and actual nursing interventions.
23Simulation has also been used for clinical remediation when a student is struggling in clinical (Bremner et al., 2006; Haskvitz & Koop, 2004; Kuiper, Heinrich, Matthias, Graham, & Kotwall, 2008). A student can be assigned time in the lab with a simulator to reprocess a difficult clinical situation, to practice a skill that she or he was unable to perform in clinical, and/or to recreate an actual patient situation that a student needs to process more slowly in order to understand. Providing an opportunity in which students can process in a safe environment often increases a student’s confidence in actual patient interactions. From an assessment standpoint, if a student is not safe and not meeting the objectives in clinical, simulation can help both the faculty and student pinpoint deficits in critical thinking and decision making.
Faculties have also found simulations to be useful as an end-point assessment of knowledge learned. Simulation testing can be used at the close of the semester as a final competency assessment or as a program assessment before graduation. Hospitals have now begun testing minimum competencies of both new graduates and new hires using simulators and scenarios. End-point simulation testing has better prepared new graduates for this challenge.
FORMAL CURRICULAR CHANGE VERSUS INTEGRATION INTO THE EXISTING CURRICULUM
We have heard many faculty members discuss the fact that adding simulation would require a major and formal change in their program curriculum. We respectfully disagree. Simulation is, simply, a learning tool. We have been using simulation since the practice of teaching nursing began. We used each other in nursing school to learn our assessments, practiced static skills on static manikins, and gave injections to oranges. Certainly, computerized simulation is at a different level, but we have found that, other than adding or rewording some course objectives or retooling a practice module to a technology-enhanced module, there has not been a need to rewrite the curriculum. In addition, we now see graduate-level courses on technology-based learning that may include simulation. Most programs have been able to seamlessly add simulation as a within-course learning experience.
ESTABLISHING THE FIT ACROSS THE CURRICULUM
The goal of simulation has been to enhance critical thinking and decision making at all levels of a nursing curriculum through realistic interactions with a simulated patient. Simulation can be implemented in every course, although some aspects of this implementation depend on the availability of faculty who are able to join in the scenario (possibly running the simulation equipment, being a disconcerted family member, or even being the voice of the patient). At a second-year or program-entry level, uses for simulation include physical assessment within the first medical–surgical course and in studying pharmacology. In learning physical assessment, students can use simulation to assess body sounds, locate landmarks, and run and rerun system assessments as needed for enhancing learning. In a lower level medical–surgical course, students can interact with the simulated patient before meeting patients and practice communication techniques. An instructor may decide to introduce a difficult patient scenario to a novice nursing student so that strategies for success can be practiced before meeting an actual challenging patient. Simulation has been used in teaching pharmacology to bring home the seriousness of prioritizing a patient’s safety in medication administration (Seropian, Dillman, Lasater, & Gavilanes, 2007). Using a high-fidelity HPS, an instructor has the capacity to show real-time effects of a medication as it is administered. Within a scenario, the instructor can show the positive effects as well as the side effects of certain medications, while demonstrating the physiologic impact of that medication in specific disease categories.
In midlevel curriculum or at the third-year level, simulation can be used in the application of the nursing process throughout the life span. Simulation scenarios can be developed in chronic and 24acute medical–surgical care, family care, care of mother and baby, pediatrics, geriatrics, home care, and psychiatric care. These scenarios can be tailored to involve multiple students and faculty enacting various family and professional roles in order to demonstrate the complexity of holistic care.
At the senior level, simulation is effective in teaching the application of the nursing process in complex and emergency nursing care (Childs & Sepples, 2006; Comer, 2005). Although it is impractical and unethical to wait until an actual patient situation becomes an emergency, student responses to emergency and life-threatening scenarios can be assessed through the use of simulation. These scenarios can be run or programmed to have multiple outcomes depending on the students’ actions within the scenario. Many dispute the ethics of letting a simulator flatline in a scenario, simulations that test a student’s knowledge in resuscitation, either alone or in a team, have been reported to be important learning experiences for students who are able to practice their first code on a simulated patient. Although students verbalize disappointment when the outcome is not positive, they are very enthusiastic about running and rerunning the scenario until a positive outcome is achieved. This experience is unique to the high-fidelity simulators. In contrast, if a positive outcome is not achieved, students are provided the opportunity to practice good communication skills with family members and broach topics of organ donation, spirituality, and proper protocol for pronouncement of death and management of the body. Even though these are perceived as challenging situations to enact, graduates often identify such situations as areas in which they wish there had been more instruction while in nursing school so that they would be properly prepared for their real-life experiences as a nurse.
Although most scenarios are generated by faculty for use in their own courses, simulations have also been developed by students, as suggested by Larew, Lessans, Spunt, Foster, and Covington (2006). At all levels of the curriculum, students can be encouraged to use actual patient data to build their own scenario for their own learning as well as for demonstration purposes for the class (see Chapter 44 for an example of student-generated senior scenarios). One university professor is using student-developed studies in the pediatric clinical rotation. As it is often challenging to find high-acuity pediatric patients on a consistent basis in any clinical setting, this professor instructs the students to generate a complex scenario as a replacement or supplement to actual patients cared for. Students then demonstrate for the class and submit a paper summary for grading. The person who specializes in simulation works with the students to familiarize them with the medium-fidelity HPS as part of the project, but learning the ins and outs of running the technology is part of the learning experience.
As another example, in a women’s health course, students in groups are responsible for presenting specific case scenarios on key areas, such as ectopic pregnancy and preterm labor. They are given some basic guidelines of information but are responsible for researching the clinical condition, identifying the nurse’s role, and coming up with an appropriate care plan. This method can involve role play or the use of simulated patients, and their peers are more engaged when involved in this style of interactive learning. From here, the faculty goes on to incorporate content-appropriate material and reinforce the important points that all the students can relate back to with the benefit of a concrete “scenario.”
EVIDENCE-BASED PRACTICE
An essential component to integrating simulation throughout the curriculum is the inclusion of evidence-based practice. Scenarios should include reference lists of research studies and standards of care used (Childs, Sepples, & Chambers, 2007). The students should also have access to resources before, during, and after simulations, for finding additional information needed to complete or understand the scenario. Just as is true in nursing care of real patients, students should be using only the latest research in the implementation of care on the simulated patient. Students may be asked in advance to pull standards of care and research before simulations. They may have access to the web through the classroom computer or a tablet. In addition, many programs have set up simulation websites for use by the students and faculty in learning more 25about the simulation process and for quick access to important websites as references. For faculty, it is helpful if a scenario references the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan categories (NCSBN, 2015) and/or accreditation bodies, such as the American Association of Colleges of Nursing (AACN; 2008, 2011) and its Essentials documents and current revisions, for curricular reference points.
As mentioned in Chapter 1, INACSL Standards of Best Practice: Simulation (2013) added Standard VIII: Interprofessional Education (Decker et al., 2015). Health care professional programs are including competencies for accreditation and regulation and expecting students to learn together. Simulation provides a unique opportunity for interprofessional education and practice and demonstrated enhanced learning and skill performance, and research supports its usefulness (Bambini, Washburn, & Perkins, 2009; Koo, Idzik, Hammersla, & Windemuth, 2013; Murphy, Curtis, & McCloughen, 2016; Watts et al., 2014). Chapter 5 of this book incorporates an innovative approach to faculty development for interprofessional simulation and Part III includes 16 scenarios for interprofessional education.
BENEFITS ACROSS THE CURRICULUM
The benefits of integrating simulation throughout the curriculum are immediately evident: students respond enthusiastically to the technology but, more important, are able to accurately diagnose and intervene in nursing problems beyond faculty expectations. Because of the breadth of programming of the medium- and high-fidelity HPSs, faculty no longer have to search for actual patients with all heart, lung, and abdominal problems and abnormal sounds. This allows for the recognition of an assessment factor already learned before actual patient care, significantly increasing the likelihood of accurate assessment while caring for actual patients. In addition, students can be exposed to more conditions in a more controlled environment at a more rapid pace. Simulation takes on a life of its own, thus becoming “real” to the students.
In conclusion, this chapter has emphasized the importance of integrating a simulation-focused pedagogy throughout the curriculum to best meet the needs of your program. In order to help with curriculum mapping using scenarios in this text, the authors of the scenarios have been asked to identify the objectives, competencies, and/or essentials that are accomplished by their scenario. Given that the NCLEX-RN exam is the licensing exam in both the United States and Canada, some authors have also included information to map the scenario by the NCLEX-RN exam test plan, wherever feasible (NCSBN, 2015). Our goal with this text was to incorporate the expertise of nursing faculty, practitioners, and interprofessional colleagues to provide as much information as possible for the smooth integration of simulation and experiential learning in nursing programs around the globe.
REFERENCES
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf
American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing for professional nursing practice. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf
Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives, 30(2), 79–82.
Bremner, M. N., Aduddell, K., Bennett, D. N., & VanGeest, J. B. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educator, 31(4), 170–174.
Childs, J. C., & Sepples, S. B. (2006). Lessons learned from a complex patient care scenario. Nursing Education Perspectives, 27(3), 154–158.
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