409CHAPTER 35
Using Simulation to Enhance Emotional Intelligence in Nurse Anesthesia Students
Nurse anesthesia programs are faced with the critical challenge of preparing students to practice safely and effectively in the demanding and emotionally charged perioperative environment. The nursing literature has begun to recognize the importance of noncognitive factors, such as emotional intelligence (EI), on clinical performance and decision making. This chapter will focus on the use of targeted simulation as a tool to enhance EI of student registered nurse anesthetists.
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
The integration of simulation technology into nurse anesthesia education has become a common practice. Although low-fidelity simulators and static manikins have been used for decades to teach basic psychomotor and critical decision-making skills, the addition of high-fidelity simulation (HFS) has enabled educators to tackle more complex concepts and clinical situations than ever before. Students are encouraged to use increasingly complex critical decision-making skills in the management of patients in the perioperative period. In addition, the program is able to expose students to a wider range of clinical situations, many of which are rarely encountered in clinical practice, but in which experience in management is essential to practice. HFS is incorporated throughout the anesthesia curriculum, beginning in the students’ clinical orientation and across all five clinical practicums in order to facilitate the progression from novice to independent anesthesia care providers. Students are exposed to the theoretical concepts in their didactic courses and are then given the opportunity to apply them in the safety of the simulation environment.
Although most anesthesia simulation has focused on developing clinical expertise, program faculty have recognized the importance of noncognitive factors, such as EI, on student success and patient outcomes. EI is defined as the ability to reason with and about emotions (Mayer & Salovey, 1997). It includes a set of skills that allows a person to more fully appreciate and adapt to the context of a situation by combining feelings with thinking, and can be described as four related but distinct abilities: (a) perceiving emotions, (b) using emotions, (c) understanding emotions, and (d) managing emotions (Mayer & Salovey, 1997). This chapter focuses specifically on the first EI domain: perceiving emotions.
410B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The Fairfield University Egan School of Nursing and Health Sciences (SON) will be moving into a new building and state-of-the-art simulation center on the Fairfield University campus in the fall of 2017. This facility has been designed to foster the development of psychomotor, cognitive, and affective clinical skills in the students enrolled in both the graduate and undergraduate programs. It will be equipped with two fully functional anesthesia simulation locations designed to allow for the implementation of high-fidelity simulation across the life span (newborn to geriatric) and health care continuum. Students have access to Laerdal’s SimBaby and 3G SimMan, as well as CAE Healthcare’s iStan (http://caehealthcare.com/images/uploads/brochures/iStan-brochure.pdf) high-fidelity simulators. Simulation space is also available to serve as a preoperative holding area, postanesthesia care unit (PACU), and intensive care unit in order to run scenarios in other locations where anesthesia care providers are required to manage patients. The simulation rooms will share a control room that will be capable of recording and transmitting in real time running scenarios to adjacent classrooms in order to facilitate effective observation and debriefing. In order to enhance the fidelity of the EI simulation curriculum, students participating in the university’s standardized patient initiative will be used.
In addition to the HFS rooms, independent skills labs have been designed to house the low-fidelity simulators and static trainers, which can also be used to enhance the fidelity and supplement learning within the HFS environment. A stand-alone 20-bed graduate health assessment lab with integrated audiovisual capabilities for recording and debriefing will be available for use.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The primary objective of this scenario is to enhance EI skills in entry-level nurse anesthesia students preparing at either the master’s or doctoral level. Nurse anesthesia programs are charged with the vital task of preparing students to competently practice in the challenging and emotionally draining perioperative setting. To meet this challenge, educators have focused on the students’ ability to meet competencies by presenting theoretical content and ensuring skill acquisition (American Association of Colleges of Nursing [AACN], 2011). Such a focus relies on cognitive thought. However, noncognitive factors, such as EI, are also thought to improve student outcomes (Beauvais, Brady, O’Shea, & Griffin, 2011; Beauvais, Denisco, & Stewart, 2014; Beauvais, Stewart, Denisco, & Beauvais, 2014; Collins, 2013). The concept of EI caught the attention of nursing scholars as some believe EI is at the heart of nursing care (Freshwater & Stickley, 2004). Nursing is a profession that requires the ability to cope with a wide range of human emotions (Freshwater & Stickley, 2004). Nurses are expected to manage their emotional lives while interpreting other people’s emotional state (Cadman & Brewer, 2001). In turn, that information is used to make critical decisions.
Thus, the simulation experience outlined in this chapter is designed to incorporate and foster the development of EI skills for nurse anesthesia students. This scenario is intended to enhance the student’s ability to:
1. Perceive emotions
2. Use emotions
3. Understand emotions
4. Manage emotions
Nurse anesthesia students who deal with emotionally charged situations could certainly benefit from such exposure. The scenario presented in this chapter is envisioned for anesthesia 411students in the first year of the anesthesia program, but can be modified for use in undergraduate and graduate programs across disciplines. Other scenarios used to enhance EI skills have been developed for the middle and end of the anesthesia program.
D. INTRODUCTION OF SCENARIO
Setting the Scene
This scenario takes place in the endoscopy suite of a medical facility. A 65-year-old male presents for a colonoscopy under general anesthesia. He has a past medical history that is significant for hypertension (HTN), obstructive sleep apnea (OSA), obesity (body mass index [BMI]: 40), and active gastroesophageal reflux disease (GERD). He is on metoprolol 25 mg twice a day (BID) and uses a continuous positive airway pressure (CPAP) machine at home. You are very concerned about the potential for airway obstruction and aspiration if you anesthetize the patient so you decide to place a secure airway endotracheal tube [ETT]). The patient is placed on the procedure table and attached to standard monitoring equipment, including EKG, blood pressure (BP) cuff, pulse oximeter, and end-tidal carbon dioxide monitoring. The endoscopist enters the suite and on discussion with him regarding the anesthetic plan he or she becomes irate and starts yelling that the patient does not need to be intubated and he or she will do the procedure without anesthesia if you attempt to intubate the patient. The scenario begins when the student must determine how to proceed.
Technology Used
This scenario can be run using either a high-fidelity human patient simulator (HPS) or, if desired, a standardized patient, which would have the advantage of increasing the fidelity because the focus of the scenario is on perceiving emotions. If standardized patients are used it will also be necessary to provide adequate training to ensure that appropriate patient characteristics and actions are displayed during the scenario.
Access to patient records, either in electronic or paper format, should be provided. As most facilities have transitioned to electronic records, access to an electronic format during the simulation would offer greater scenario realism and allow participants (anesthesia and nurses) to chart information as would be appropriate during an actual procedure. Audiotaped recordings of sounds commonly heard in the environment where anesthesia is administered should be incorporated into the scenario to simulate the hectic environment of an endoscopy suite. Finally, audiovisual capabilities are required to allow for recording and debriefing of the scenario. If recording is planned, it is necessary to obtain written permission either at the start of the simulation session or, ideally, on entrance into the training program. A blanket release can be obtained and used to cover all simulation sessions in which a student participates during his or her educational experience.
Objectives
Students who successfully complete this scenario exercise will have demonstrated their ability regarding the following four skills:
1. Understand the first EI domain: perceiving emotions
2. Recognize his or her own feeling as they relate to the situation
3. Understand the feelings of others
4. Identify verbal and nonverbal manifestations of emotions
Successful completion of this simulation activity would also allow the student to meet several of the American Association of Colleges of Nursing’s Essentials of Master’s Education in Nursing (AACN, 2011), including:
Essential I: Background for Practice From Sciences and Humanities, Objectives 1, 3 to 5
Essential II: Organizational and Systems Leadership, Objectives 1 and 2
Essential IV: Translating and Integrating Scholarship Into Practice, Objective 4
Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes, Objectives 3 and 4
Essential IX: Master’s Level Nursing Practice, Objectives 1 to 4
This scenario addresses the following Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006):
Essential I: Scientific Underpinnings for Practice, Objectives 1 to 3
Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Leadership, Objectives 1 to 3
Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes, Objectives 1 and 2
Essential VIII: Advanced Nursing Practice, Objectives 1 to 4
Description of Participants
A minimum of four participants will be required to run the scenario. The role of the endoscopist should be played by an actor who is provided with a description of the scenario and a short script so that he or she can effectively portray the physician. Unknown to all other participants, the endoscopist is irate because the last time he or she had a patient who was intubated for a procedure the endoscopist was delayed by an hour and had to cancel office hours. Therefore, unless the anesthesia students’ specifically try to identify the reasons for his or her refusal, the endoscopist will continue to hold this position. If the students attempt to identify the underlying reason for his annoyance, then the endoscopist may become amenable to a discussion of the merits of endotracheal intubation in this patient.
The patient can either be portrayed by a standardized patient or high-fidelity simulator, but regardless it is important that the patient reacts to the communication exchange with increasing anxiety. Two students are required to portray the anesthetists assigned to care for the patient during the colonoscopy. If other students are available, one can be scripted into the scenario to play the role of the endoscopy nurse. This individual may be included to carry out tasks as directed by the gastroenterologist.
E. RUNNING OF THE SCENARIO
Before running the scenario, all students must have completed the didactic component required to effectively participate in the simulation. Before the date of simulation, students are provided with an article outlining EI and are then given the opportunity to discuss it as part of the prebriefing with the facilitators. This scenario is run with two faculty facilitators who are present for the briefing and debriefing. During the actual simulation, one facilitator stays with the students observing the simulation via live videostream and the other facilitator provides the voice of Mr. Jones (patient). Students come to the classroom to be briefed with a general description of the scenario. Two students are randomly chosen to participate in the simulation while the other students are tasked with observing the scenario via live videostream in a nearby classroom. The equipment necessary for running the scenario is available in the simulation room. An actor plays the endoscopist in the scenario.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Perceiving Emotions During the Anesthetic Management of a Patient Presenting for Colonoscopy
413Scenario Level
This scenario is designed to run with students enrolled in nurse anesthesia programs at the master’s or doctoral level
Focus Area
Nurse anesthesia students in the first year of the program
Scenario Description
Mr. Jones is a 65-year-old male who presents for colonoscopy under general anesthesia. He has a past medical history that is significant for HTN, OSA, obesity (BMI of 40), and active GERD. He is on metoprolol 25 mg BID and uses a CPAP machine at home. You are very concerned about the potential for airway obstruction and aspiration if you anesthetize the patient so you decide to place a secure airway ETT. On discussion with the endoscopist, he becomes irate and starts yelling that the patient does not need to be intubated and he will do the procedure without anesthesia if you attempt to intubate the patient. How do you proceed?
Scenario Objective
At the completion of the scenario the participant will:
1. Understand the importance of perceiving emotions in interprofessional collaboration and conflict resolution
2. Recognize his or her own feeling as they relate to the individual situation
3. Understand the feelings of others
4. Identify verbal and nonverbal manifestations of emotions as they affect communication
Setting the Scene
Equipment Needed
High- (or low)-fidelity simulator; procedure table; standard monitoring equipment, including BP, EKG, pulse oximetry, and end-tidal carbon dioxide measurement; nasal cannula; auxiliary oxygen; medications, including propofol, succinylcholine, ephedrine, and phenylephrine; emergency airway equipment; video-recording device
Simulator Level
High-fidelity simulation
Participants Needed
Four participants required: Two anesthesia care providers (student role), endoscopist (actor), patient (standardized patient or high-fidelity simulator), endoscopy nurse (student) if available
Scenario Implementation
Initial Settings for High-Fidelity Simulator or Patient Monitor
BP: 149/86 mmHg, heart rate (HR): 76 beats/minute, respiratory rate (RR): 18 breaths/minute, SaO2: 99% (vital signs will gradually rise as patient becomes more anxious during endoscopist/anesthesia care provider exchange).
414Required Student Assessments and Actions
Because of the nature of the scenario, assessment of students’ ability to meet objectives is determined during the debriefing process through critical reflection and ability to accurately recognize their feelings/emotions, recognize the feelings/emotions of the endoscopist and the patient, and identify verbal and nonverbal manifestations of the feelings/emotions. However, the student is assessed on carry out the following actions:
1. Completes a comprehensive anesthesia history and physical, including airway assessment
2. Explains anesthetic plan of care to the patient
3. Attaches standard monitors and supplemental oxygen
4. Communicates anesthetic plan of care to endoscopist
5. Acknowledges endoscopist’s concerns and communicates rationale for plan
6. Attempts to identify underlying issues for endoscopist’s emotions
7. Recognizes impact of communication on the patient’s emotional state
Evaluation Criteria
__Student is able to recognize how he or she feels in the scenario.
__Student understands how and why the endoscopist feels the way he or she does in the scenario.
__Student recognizes both the verbal and nonverbal manifestations of emotions in all involved parties.
__Reflective journal is evaluated.
Checklist of Interventions and Assessments
Exhibit 35.1 contains the checklist used to evaluate students in the scenario.
415G. DEBRIEFING GUIDELINES
An essential element of simulation involves debriefing the experience to encourage reflective practice (Decker et al., 2013; Lavoie, Pepin, & Boyer, 2013). Fairfield University SON uses the Standards of Best Practice: Simulation Standard VI: The Debriefing Process (Decker et al., 2013). As such, debriefing is led by faculty who are competent in the process and happens in a safe learning environment. The faculty facilitator watches the simulation and employs a structured framework to debrief while focusing on the stated outcomes and objectives (Decker et al., 2013). For the purposes of this simulation, the ability-based model of EI conceptualized by psychologists Jack Mayer and Peter Salovey (1997) is used. Their four-branch model defines EI as the ability to reason with and about emotions. EI combines feelings with thinking and can be described as four related but distinct abilities: (a) perceiving emotions, (b) using emotions, (c) understanding emotions, and (d) managing emotions (Mayer & Salovey, 1997). As a result, during the debriefing, students are asked to reflect on all four branches of EI. General debriefing questions are provided as follows for each of the branches.
Branch 1: Perceiving Emotions
• What were you feeling during the scenario?
• What do you think the other people in the scenario were feeling?
Goal: The ability to learn to identify and label specific feelings in yourself and others, ability to clearly and directly communicate and discuss these emotions
Branch 2: Using Emotions
• How did your feelings guide you to what is important to think about?
• How did you use your feelings to help you with decisions that were appropriate for you and others involved?
Goal: The ability to use your feelings constructively
Branch 3: Understanding Emotions
• What was the purpose of the emotion you felt?
• What was the purpose of the emotion expressed by others in the scenario?
• What was the relationship between emotions? How and why did they change from one to another?
• How did emotions lead to the behavior in yourself and others?
• What was the relationship between thoughts and feelings?
• What were the causes of your emotion and what is the relationship to your human psychological needs, especially your unmet emotional needs?
Goal: The ability to understand the meaning of emotions and how they can change
Branch 4: Managing Emotions
• How were you able to turn negative emotions into positive learning and growing opportunities?
• How were you able to help others identify and benefit from their emotions?
Goal: The ability to manage emotions for personal and social growth
416H. SUGGESTIONS/KEY FEATURES TO REPLICATE OR IMPROVE
The health care literature has demonstrated that high levels of EI are associated with improved problem solving and decision making (McQueen, 2004; Moyer & Wittmann-Price, 2008). For nurse anesthetists in particular, EI may help in preparing students for roles, which will necessitate them working in teams and managing conflict (Collins, 2013). Therefore, the incorporation of simulation to promote the development of EI has the potential to have a significant impact on nursing performance and academic success. However, the use of simulation to enhance EI is in its infancy and there is limited information to define the “ideal” curriculum. The key features of EI can be addressed in any HFS as human interaction does not take place independent of emotion. In fact, when engaged in critical thinking and decision making, emotions help to shape what individuals think about and how they think about it. Therefore, it is recommended that when appropriate, questions targeting students’ ability to perceive emotions, use emotions, understand emotions, and manage emotions be incorporated into HFS wherever possible.
I. RECOMMENDATIONS FOR FURTHER USE
Although the scenario provided in this chapter focuses on the nurse anesthesia student in the first year of the program, we would recommend that scenarios such as these be incorporated throughout the program to foster the enhancement of EI skills. We would suggest that four scenarios be incorporated into the program. Each scenario would address all four branches of EI: perceiving emotions, using emotions, understanding emotions, and emotional management. Debriefing questions touch on all areas but one branch would be highlighted during each debriefing session and then in the reflective journaling follow-up.
J. HOW SIMULATION-BASED PEDAGOGY HAS CONTRIBUTED TO IMPROVED STUDENT OUTCOMES
A comprehensive simulation curriculum has become an expected component of a nurse anesthesia program. Students enjoy using simulation as a learning tool because it provides them with the opportunity to develop strong psychomotor, cognitive and affective skills in a safe, nonthreatening environment. With the integration of an EI curriculum, students can now learn to manage and use their emotions to obtain positive outcomes in the perioperative setting. Students are able to see both the positive and negative consequences of their actions on the decision-making process. As a result, they tend to have a better understanding of the impact of emotions on their decisions and the decisions of others. Therefore, they tend to rate their overall educational experiences more positively and request more simulation in their programs.
Given the positive correlations between EI and student outcomes, many scholars, such as Collins (2013), have proposed that nursing education should consistently incorporate EI skills development into the nursing curriculum at all levels. Given the potential significance to nursing education outcomes and assuming simulation positively influences EI in nurse anesthetist students, nursing education will have identified a sustainable, powerful teaching strategy that could potentially increase the performance and success of nurse anesthesia students. The possibilities are limited only by the imagination of educators developing simulation scenarios for integration in nursing education.
417K. EXPERT RECOMMENDATIONS AND WORDS OF WISDOM
Overall, the scenario worked very well and received positive evaluations from students. Aside from offering additional EI scenarios throughout the nursing anesthesia program, our other recommendation would be to provide more information presimulation. We found the students were superficially familiar with the term emotional intelligence. However, the experience might be enhanced if students are asked to complete some preliminary exercises to ensure they understand the basic concepts before beginning the scenario. For example, during a presimulation for EI branch one (identify emotions) students could be asked to reflect whether they attend to emotions or whether they consider this piece of information irrelevant. Considering that emotions can be read through facial expressions and interpreted through body language and tone of voice, we would recommend that faculty create some presimulation exercises to see whether students can identify the emotional cues and whether they are accurate in their interpretation.
L. EVALUATION OF BEST PRACTICE STANDARDS AND USE OF CREDENTIALED SIMULATION FACULTY
Fairfield University SON has initiated the process of becoming a Society for Simulation Health Care (SSH) Accredited Program. We are using the International Nursing Association for Clinical Simulation and Learning (INACSL) standards as a framework to confirm that our faculty have the knowledge, skills, and abilities to facilitate quality health care simulation activities (INACSL, 2013/2016). In order to promote faculty expertise in simulation, Fairfield University has encouraged faculty to receive simulation training and to sit for the certification examination. All faculty members who facilitate simulation-based experiences (SBE) have been formally trained through CAE Healthcare and Laerdal via live and webinar-based workshops on simulation pedagogy. In addition, the director of simulation for the SON is fully trained via INACSL and is currently serving as a National League for Nursing (NLN) Fellow. Faculty have been afforded the opportunity to attend simulation conferences. To help reach as many faculty members as possible, the SON has hosted debriefing and facilitation training programs that have specifically targeted the integration of the INACSL best practice standards into the simulation curriculum across programs. Fairfield University SON views simulation as a valuable method to link classroom learning to real-life clinical experiences.
INACSL Standard IX: Simulation Design, has been used as the specific framework for the development, implementation, and evaluation of simulation scenarios across nursing programs and clinical specialties (2013/2016). Within the nursing anesthesia program, specific aims and measurable objectives that correspond to the student’s level of knowledge and experience, and that build on previous mastery of concepts and skills, are identified as the basis for individual SBE development. Faculty members are then embedded in the scenarios to provide support and guidance as needed in order promote attainment of course objectives. Scenarios are recorded with the permission of participants so that they can be used as part of the debriefing process to guide discussion, examine best practices, and promote critical reflection among participants. Overwhelming, both the students embedded in the scenarios and those watching the simulcasts find the experiences have a positive impact on their learning and success in the clinical arena because they provide students with the opportunity to test their critical thinking and examine the impact of their decision making in a safe learning environment.
REFERENCES
American Association of Colleges of Nursing. (2006). Essentials of doctoral education for advanced nursing practice. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf
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