3CHAPTER 1
Simulation-Focused Pedagogy for Nursing Education
THE CHALLENGE OF TEACHING IN THE 21ST CENTURY
This book is written on the basis of our personal experiences with audiences of nursing faculty regionally, nationally, and internationally who have expressed frustration, consternation, anxiety, and bewilderment about “where to start” with simulation, especially with human patient simulators (HPSs). We have been privileged to be present at the start of simulation, with the inherent frustration of explaining to administration and fellow faculty the potential and vision that this innovative learning experience can provide for nursing students.
It is our hope that the simulation scenarios and other valuable information included in this text provide nurse educators with a place to start—a template for the creation of their own broad and relevant experiences in the classroom and in clinical settings. It is paramount that we share our passion for the process and our strong belief that all faculty can contribute, at whatever level of simulation, to this process. Yes, there are gaps and challenges expressed in the literature; yes, faculty struggles to meet the new demands of this technology within the realm of faculty shortages and workload. Yet, the potential benefits to faculty and students are clear, especially by enhancing critical thinking beyond protocol and critical pathways. Often, it is an astute, expert nurse who, in noting subtle changes in a patient, enacts the kind of care that saves the patient’s life. Nurses are the front-line providers of care.
Simulation is presented by allowing for reflection on all aspects of care. The built-in debriefing period, which encourages reflection on thoughts, actions, and outcomes, also leads to better transfer of knowledge to practice and more versatile thinking processes for future application individually, in groups, and across interprofessional teams with a focus on patient-centered care. In addition, the faculty role of mentor and facilitator in this process combines faculty expertise with student innovation. It is a learning process for all, which improves methods of teaching and learning overall.
ROLE OF SIMULATION IN NURSING EDUCATION
So many changes have occurred since the first edition of this book. The scenarios and information have been shared globally and Dr. Campbell’s Academia.edu website, which contains some of the text has been viewed 4,558 times and downloaded 302 times since 2012. One of the biggest changes for simulation in nursing is that the International Nursing Association for Clinical Simulation and Learning (INACSL) has taken the lead in defining best practices, referenced as INACSL Standards of Best Practice: SimulationSM (INACSL, 2013/2016) and which includes: Standard I: Terminology 4(Meakim et al., 2013), Standard II: Professional Integrity of Participants (Gloe et al., 2013), Standard III: Participant Objectives (Lioce et al., 2013), Standard IV: Facilitation (Franklin et al., 2013), Standard V: Facilitator (Boese et al., 2013), Standard VI: The Debriefing Process (Decker et al., 2013), Standard VII: Participant Assessment and Evaluation (Sando et al., 2013), Standard VIII: Interprofessional Education (Decker et al., 2015), and Standard IX: Simulation Design (Lioce et al., 2015). During the writing, these standards were updated and can be found on the INACSL website (INACSL, 2013/2016). Dr. Campbell was invited to review the revisions and give input as an individual contributor. Other areas promising an increasing consistency in simulation programs include the NCSBN’s Simulation Guidelines for Prelicensure Nursing Program (Alexander et al., 2015), while Cheng and colleagues (2016) have consolidated the reporting guidelines for health simulation research by extending the Consolidated Standards of Reporting Trials (CONSORT) and STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statements. The intention of these guidelines and best practices is not to squelch the innovative potential that nursing faculty bring to simulation, but rather to provide credibility in reporting the effect of simulation in nursing education and research. As the coeditors know well, nursing faculty are often teaching “on the fly.” Although it is helpful to have standards and guidelines, we don’t want to underestimate the refreshing expertise nurses bring that encourages creativity and innovation in nursing faculty. In hindsight, the chapter template and scenarios provided in the first edition of this text actually took into consideration most of the areas that are today identified as best practices.
Initially, many nurse educators and researchers were at the forefront in recognizing simulation as a valuable tool for gaining knowledge (Alinier, Hunt, & Gordon, 2003; Childs & Sepples, 2006; Henneman & Cunningham, 2005; Jeffries, 2005; Roberts & McGowan, 2004). Although beyond our wildest dreams and expectations, considerable research, including multiple systematic reviews, integrated reviews of the literature, and carefully designed randomized-controlled studies (Adamson, 2015; Keers, Williams, Cooke, Walsh, & Ashcroft, 2014), are now setting the standard for high-level research in simulation, demonstrating the impact of this innovative method of teaching. In addition, the scholarship of teaching and learning has gained increased respect as the importance of demonstrating the efficacy of various methods of teaching to transfer knowledge and change behavior was recognized. This is especially important in the clinically based application of nursing science. Finally, the incorporation of interprofessional simulations for team training and patient safety are recognized as equally important and need to be considered in every nursing education program (Malt, 2015).
The availability of high-fidelity technology at a reasonable cost, and the availability of funds to purchase this equipment, has resulted in its widespread acquisition across the globe. Although some faculty have reported to us that, on delivery, these HPSs may remain in a box, unused. Other faculty, who have had the benefit of preassembly and attending 1- to 2-day workshops, need encouragement and inspiration to fully implement simulation within their individual courses and throughout their curriculum. When attending simulation conferences, it appears that everyone is incorporating and using simulation (or has bought the equipment). But when you talk to faculty, they are confused, overwhelmed, and frustrated with trying to write and implement scenarios into their individual courses.
One only needs to watch a group of students in a simulation to fully appreciate its teaching and learning potentialities at hand. After all, simulation prompts positive results. Although initially, the research for assessment and evaluation for nursing education fell behind the medical literature, currently, evidence exists that simulation results in better outcomes and improved performance (Cook et al., 2011, 2013), and more reliable and valid instruments are available for use to test and incorporate simulation (Kardong-Edgren, Adamson, & Fitzgerald, 2010), including this repository of instruments used in simulation research: www.inacsl.org/i4a/pages/index.cfm?pageID=3496. Early on, in a study of the use of clinical laboratories in Victoria, Australia (with site visits, interviews, and curricula review), researchers found that use of the laboratories was based on past experience, tradition, and resources rather than evidence (Wellard, Woolf, & Gleeson, 2007). Research on simulation in nursing is ongoing, and has matured to the stage where new meta-analyses and reviews of the literature continue to support the use of simulation for the education of health professionals. Early in this research trajectory, the benefits of simulation were well documented by the National League for Nursing (NLN)/Laerdal simulation study 5(Jeffries & Rizolo, 2006), and current evidence has suggested that substituting simulation for clinical practice results in similar outcomes to traditional education for prelicensure nursing students (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014).
On a broader level, an administration’s procurement of the money for providing the necessary resources (faculty development, equipment purchase, building renovations, faculty time, etc.) does not transfer immediately into less faculty workload. In contrast, it often requires more investment of time and resources up front to get to the “work smarter, not harder” phase. One strategy has been to assign already overburdened lab directors with the “task” of incorporating simulation for faculty. Whether in static modules as testing before entering clinical, skill-based task training, or endpoint competency testing, the actual development and running of the scenarios is parceled out to lab staff, information technology personnel, and others. As this process may not directly involve faculty, their valuable educational and clinical expertise is more often overlooked. Another strategy allows for individual faculty to initiate simulation within their own teaching load in single courses. Faculty find this process time-consuming and complex when starting without the help or guidance of those more experienced in simulation (Nehring & Lashley, 2004). Currently, to meet this faculty knowledge gap, simulation training and/or certification has become more commonplace, for example, through the Society for Simulation in Health Care (ssih.org/certification). In addition, multiple workshops are available through conferences (www.inacsl.org), and nursing programs are including courses and certificates in advanced innovative educational methodologies, including simulation. See Chapter 54 for more information about simulation certification and accreditation.
We feel that simulation offers an innovative approach that complements and easily integrates into the existing nursing curricula, addressing the needs of a new generation of nurses and a society with increasingly complex health care needs. In order to fully appreciate the incorporation of simulation and the driving forces behind this movement, one needs to recognize that the challenges include understanding issues facing nursing education, the influence of technology on theoretical and conceptual aspects of nursing education, learning in the digital culture, and the challenge of suspending disbelief to make simulations real. In order for a transfer of knowledge to occur, the student’s role in the simulation needs to be as authentic as possible.
Some of the issues facing nursing education include the increased acuity level of patients, the nursing faculty and staff shortages, limited clinical sites, and the shifting role of the nurse. Quality and safety of patient care have become a major societal focus driving the increased accountability of nursing faculty and students to provide safe, effective, knowledgeable nurses who can function in a highly complex health care environment. Nurses are expected to demonstrate leadership skills in the coordination of patient care and safety, and even in the role of overseeing interprofessional teams that provide multifaceted care. Increasingly, nurses are expected to use their knowledge to transform health care delivery. Simulation provides an environment for the teaching and learning of interprofessional collaboration through scenarios embedded with communication, safety, delegation, critical thinking, and other important nursing program outcomes where novice nursing students can practice in a safe environment (Berndt, 2014; Fisher & King, 2013; Haskvitz & Koop, 2004; Jeffries, 2005; Jose & Dufrene, 2014; Keers et al., 2014; Radhakrishnan, Roche, & Cunningham, 2007; Zhang, Thompson, & Miller, 2011). Finally, the challenge of assessment and evaluation of student performance can go beyond skill-based assessment to include nontechnical skills, such as communication and conflict resolution, as well as more summative processes such as student growth over time, development of critical thinking, and socialization into professional nursing practice.
THEORETICAL AND CONCEPTUAL ISSUES IN NURSING EDUCATION
When viewed as a learning tool, simulation aligns well with the theoretical and conceptual foundations of nursing education. Models and frameworks have been proposed and used to help 6conceptualize the role of simulation in nursing education. One such model describes a simulation protocol that was formulated by the University of Maryland School of Nursing (Larew, Lessans, Spunt, Foster, & Covington, 2006). This protocol, based on the work of Benner (1984), uses a cue-based system with escalating prompts to move students through recognition to assessment to intervention to problem resolution. Recommendations to highlight one problem at a time, allowing the scenarios to be student directed with time for processing in the pacing of the scenario, laid the foundation for further development of simulation frameworks. Jeffries and Rodgers (2007) proposed a theoretical framework for simulation from “insights gained from theoretical and empirical literature” (p. 22) on simulation in nursing and related disciplines. This eclectic approach to formulating simulation frameworks provides the basis for a holistic, flexible, and multifaceted method of integrating simulation into nursing education.
In addition to those seminal works cited earlier (Jeffries & Rodgers, 2007; Larew et al., 2006), we have considered the work of Tanner (2006) in our conceptualization of simulation. Tanner’s model of clinical judgment is relevant in simulation because a large part of it involves clinical judgment and decision making. His description of aspects of the process includes noticing, interpreting, responding, and reflecting. This model emphasizes expectations of the situation that may be implicit or explicit. A particular emphasis on reflection finds support in the recent literature, which highlights reflection as an essential element in the improvement of clinical reasoning (Tanner, 2006). In simulation, an equivalent concept is debriefing, which should include Tanner’s reflection-on-action as a synthesis of experiential knowledge resulting in the formulation of best practices. In a clinical situation, nursing students often observe and are unable to enact interventions independently. In simulation, reflection on interventions can result in a second try in a safe environment, where improved outcomes are immediately evident.
Fink (2003), another driving force in our simulation-focused pedagogy, discussed the creation of significant learning experiences. On the basis of education research, he has compiled six major dimensions to “formulate significant learning goals” (p. 75). In considering these learning goals, we have identified areas that demonstrate how simulation complements nursing education to meet program goals and outcomes. For example, the goals include (a) foundational knowledge (nursing content), (b) application (enactment of the scenario allows for use of knowledge and skills in a safe environment), (c) integration (synthesizing the science of nursing with knowledge from all disciplines—in conjunction with critical thinking, this dimension incorporates decision making and priority setting), (d) human dimension (interacting with themselves and others to form a view of who they are as nursing professionals, including opportunities for collaboration), (e) caring (the art of nursing), and (f) learning how to learn (empowering students for professional lifelong learning). The debriefing component of simulation pedagogy allows for an integration of all six major dimensions of Fink’s learning goals.
Of interest in simulation is social ecological theory (Stokols, 1996). This framework examines individual experiences and culture brought to social situations and how they impact behavioral outcomes. The social determinants of health (Wilkinson & Marmot, 2003), developed by the World Health Organization’s European division in the 1990s, incorporate social ecological theory and continue to be imbedded as a foundation for Healthy People 2020 (U.S. Department of Health and Human Services, 2000). These theoretical cores should be directly linked to simulations as they are being developed.
For example, a common challenge for nurses working in inpatient environments is the decontextualization of the patient. By this, we mean that care is being provided without an understanding of the social and physical environment or the behavioral motivators related to health of the individual patient. The result can be that patient teaching and other nursing activities done in the institution do not match the reality of the patient’s home environment. In home health care, nurses often need to reteach the patient and/or caregiver to fit the care plan to the resources available.
In simulation, not only is the context of the patient important, but educators must consider the cultural predispositions that students bring into the learning environment, which may affect behavior and the outcome of the scenario. The same is almost true within the culture of a nursing floor or unit. Clinical judgments made may be influenced by these multiple factors and need 7to be considered in the culturally sensitive care of real patients. In addition, simulations can be manipulated such that the patients being cared for have a variety of cultural backgrounds, needs (including special needs of patients with disabilities or chronic and/or terminal diseases), experiences, and diverse social and environmental support systems. Including these factors enhances the simulation and learning experience for students and increases the “realness” of the scenario.
Related nursing concepts in simulation are vigilance and failure to rescue. As nursing educators, vigilance is one of the most important yet difficult concepts to teach to nursing students (Almerud, Alapack, Fridlund, & Ekebergh, 2007; Jacobs, Apatov, & Glei, 2007; Meyer & Lavin, 2005). Although introduced early in assessment courses, the evolution of vigilance as an essential function of a nurse is amenable to practice and refinement during simulation. Once taught in this setting, students become aware of the value of maintaining vigilance in actual health care settings. A consequence of failed vigilance is failure to rescue. Although unethical to practice in the clinical setting, a student who experiences failure to rescue in a simulation can follow through with reflective debriefing, reformulate a plan, carry out the new plan, and then successfully maintain vigilance. Students have reported, “never forgetting” the opportunity to “redo.” Once again, this experience adds to the development of the student’s vision of the impact of maintaining excellence in nursing care.
From the student’s perspective, there have been reports that conceptualizing the scenario through the lens of the nursing process while in the midst of a simulation is extremely helpful in producing positive outcomes. It has been frequently observed in our teaching that students, in the excitement of enacting a scenario, jump past focused assessments and begin performing interventions without data to support their decisions. Gentle coaching and reminders by the instructors alleviate this tendency.
In theorizing about technology in simulation, one may want to consider that, beyond technological fidelity, there are actually three levels of fidelity: environmental, equipment, and psychological (Fritz, Gray, & Flanagan, 2007).
• Environmental fidelity: “The realism of the environment in which the simulation takes place” (Fritz et al., 2007, p. 2).
• Equipment fidelity: “Hardware and/or software realism of the simulator” (Fritz et al., 2007, p. 2).
• Psychological fidelity: “The degree to which the trainee perceives the simulation to be a believable representation of the reality it is duplicating” (Fritz et al., 2007, p. 2).
In nursing, we have incorporated these fidelities by making simulation as real as possible—a suspension of disbelief—so that the student interacts and participates more fully. The way space is structured to look and feel like a clinical unit, with necessary equipment, sets the scene for the simulation. In addition, events need to flow smoothly (e.g., responses from “patients” and “families”) so that the student acknowledges his or her role in meeting patient needs.
There are three goals or levels of enacting a reality-based simulation:
1. For students: The simulation must be believable. They must take on the role of the “nurse” and feel the responsibility for the care, assessment, and delegation necessary to meet the needs of this “real” patient. If the patient takes a turn for the worse, can students believe that their actions (or inactions) may lead to an adverse outcome for the patient (maybe even death)? In reality, we would not want them to have a life-threatening experience with a real patient in clinical; however, simulation provides a safe environment to learn skills necessary for the prevention of adverse outcomes. It is necessary to “suspend reality” and allow the students to embrace their role and act confidently with the necessary clinical reasoning to accomplish their objectives. The debriefing component of the simulation is much richer if the students self-reflect from a perspective that their actions and decisions really made a difference in the outcome of care.
2. For faculty: Simulation must also be believable for faculty in the sense that they can accomplish this and meet their educational goals via simulation; it is feasible, possible, and fun. From learning theory and brain theory, faculty are encouraging the use of the right and left brain, which has been demonstrated to better embed the experience, and make the substance of what is learned more accessible or easily retrieved for use in future, varied, patient encounters (Seigel, 2007). Faculty need to feel supported in their integration and use of simulation in their courses and they need to receive the resources necessary (time, equipment, information technology [IT] support) to effectively accomplish their goals.
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