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Copy of Simulation 101

Presented by Dr. Terry Larsen
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Terry Larsen

on 28 May 2013

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Transcript of Copy of Simulation 101

Terry Larsen, PHD, RN, CNS Introduction to Conducting Simulation
PART III DEBRIEFING
PART IV Simulation 101
A formal workshop, course, class, or other activity that uses a substantial component of simulation as a technique

“ Building a simulation center

Building a successful simulation
program” SIMULATION PROGRAM Simulation
A technique that uses a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions (Simulation Committee, 2007) DEFINITIONS
The report identified a “collaborative/partnering”
(academia and practice)
would help close the gap NEXT STEPS BRN (Ca) is allowing up to 25% for human patient simulation (HPS) simulation for pre-licensure nursing student’s clinicals
Diverse nursing student population(Lasater, 2007) CHANGING PARADIGMS Medical education
Nursing education
Certification training
Continuing education training
Staff development
Allied health education USE OF SIMULATION Task trainers
Standardized Patients
Computer simulations
Low Fidelity simulators
High Fidelity simulators
Virtual Reality (Second life, My Neighborhood) TYPES OF SIMULATION Simulation
Used as a strategy, not a technology

Simulators
Types of equipment that replicate a task environment with sufficient realism to serve a desired purpose.
www. ahrq.gov SIMULATION VS. SIMULATOR The physical, contextual, and emotional realism that allows persons to experience a simulation as if they were operating in an actual healthcare activity.
( SSH Simulation Committee, 2007) FIDELITY = REALISM Common misconceptions

Over-purchased equipment

Lack of training

Expensive skills lab WHAT IS SIMULATION? 1. Terminology
2. Professional Integrity of Participant
3. Participant Objectives
4. Facilitation Methods
5. Simulation Facilitator
6. The Debriefing Process
7. Evaluation of Expected Outcomes INACSL STANDARDS (2011) Clinical knowledge
Technical skills
Critical Thinking
Communication
Professionalism
Management of responsibilities PRACTICE-READINESS Clinical education is not currently working using only the traditional models we have used for decades NEED TO “BRIDGE THE GAP” Student preparation for practice survey : 89%: A large preparation-practice gap exists!


The Nursing Executive Center of The Advisory Board Company (2008) THE NURSE EXECUTIVE CENTER OF THE ADVISORY BOARD (2008)
Regulatory Boards – watchfully monitoring – providing research funding
Faculty skill sets changing
Partnerships and collaborations
Need for better prepared students exiting nursing programs CHANGES/ISSUES IN NURSING EDUCATION
Accreditation agencies challenge educators to promote critical thinking (Long, 2004; NLN, 2003) CURRENT STATE OF CLINICAL NURSING EDUCATION Decreasing number of clinical sites for practice
Nurse educator shortage
Decision-making/problem-solving skills needed
Cost-effective clinical education needed
Gap between academia and practice
New model of education needed (e.g. technology, realism, diagnostic reasoning skills) WHY DO EDUCATORS WANT TO USE SIMULATION? National Council of State Board of Nursing – predicts the future of clinical education in nursing will include the increased use of simulations SIMULATIONS USE There is currently a widespread movement to use simulations of all types in nursing education as a teaching-strategy and/or as an evaluation mechanism. A POTENTIAL CLINICAL EDUCATION ENHANCEMENT IOM (2004) challenges health educators to expand technologies and support innovations
NLN has challenged educators to be innovative in our educational practices(2003)
New graduates must be prepared for the demand of healthcare and increased complexity – need for rapid decision making
Higher education paradigm shift from teaching to learning paradigms WHY DO EDUCATORS WANT TO USE SIMULATION Discuss changes occurring in nursing education and the use of clinical simulations
Explain the rising surge of simulation into nursing education
Describe common simulation definitions
Discuss common misconceptions surrounding simulation
Identify leading international simulation societies driving new standards for teaching and research with simulation teaching methodology. OBJECTIVES OF THIS SESSION:
THE PARTICIPANT WILL BE ABLE TO: At the end of this group of simulation modules(4 sessions) the faculty will be able to…..

Build a challenging and safe learning environment
Prepare, build, conduct and debrief engaging simulation scenarios COURSE OBJECTIVES International Nursing Association for Clinical Simulation and Learning (INACSAL) published new standards 2011.
Society for Simulation in Healthcare (SSH) Credentialing
Simulation Center Accreditation (SSH)
Agency for Healthcare Research (AHRQ)
Quality Safety Education Nursing (QSEN)
National League of Nursing (NLN)
California Simulation Association (CSA) NEW STANDARDS BEING SET High tech- must include technology into clinical and classroom teaching

Must be creative, innovative – keep students engaged

High quality, real skills, high expectations of our students

FACULTY SKILL SETS CHANGING AND REQUIRED Patient Safety
Demand for higher quality of care CHANGING PARADIGMS World War II
Training pilots
Astronauts
Medical education
Nursing education HISTORICAL PERSPECTIVES PART I Adult learners:
Are independent and self directed
Have rich experiences
Value relevant learning
Prefer problem-centered approaches to learning
Are more motivated by internal drivers and external ones
ANDRAGOGY: FIVE ASSUMPTIONS Learning is most effective when the interaction takes place in an authentic environment working on real-world activities. SITUATED COGNITION Helps students to achieve outcomes
Provides students with “high risk”, “low frequency” clinical experiences
Increases student’s clinical confidence
The rising call for “in-situ” simulation SIMULATION-BASED SKILLS ACQUISITION RETENTION OF LEARNING Describe how adult learning principles, experience, reflective practice, and emotions influence learning in Simulation-Based Education (SBE)
Describe how learning theories are used to engage students with experiential learning
Apply theoretical principles of simulation to specific course objectives COURSE OBJECTIVES Founded on adult learning principles
Promotes practice as a team
Efficiency in a new era
Accelerates the expertise curve
Patient safety: practice without risk
Early exposure and competence
Education on demand
Mitigates time and chance SIMULATION-BASED EDUCATION Create a safe yet challenging learning environment
Help learners diagnose their own learning needs and develop a plan to meet their objectives
Help learners evaluate their own learning-critical reflection USING ANDRAGOGY TO TEACH EFFECTIVELY “ Tags” all of the experiential learning bases
Is emotionally compelling
Anchors knowledge
Allows for “unfreezing” that promotes new knowledge, skills and attitudes. EMOTIONAL LEARNING IS SO POWERFUL JOHN DEWEY: Experiential Learning
KURT LEWIN: Change Theory
DAVID KOLB: Experiential Learning
CHRIS ARGYRIS; DONALD SCHON: Action Science
NASA/FAA SIMULATION
DAVID GABA; JEFFREY COOPER
EMOTIONAL LEARNING THEORETICAL INFLUENCES ON SBE BUILDING EXPERTISE THEORETICAL AND PEDAGOGICAL FOUNDATIONS OF SIMULATION
PART II Deliberate Practice EXPERIENTIAL LEARNING Task with a well-defined goal
Motivation to improve
Feedback
Opportunity for repetitive practice and gradual refinements of performance DELIBERATE PRACTICE EXPERIENTIAL LEARNING To help develop reflective practitioners
To educate superb clinicians
To enhance patient safety
To save patient’s lives WHY WE ARE HERE….
WE WILL LEARN TOGETHER FACILITATION I WILL TEACH YOU INSTRUCTION We will do our best to create a realistic environment
We ask you to do your best to participate as if things were real
Learners will do things differently than they would in a real setting.
Do not hurt the actors ENGAGING IN A SIMULATED CONTEXT Realistic factors to make learning seem real
Design scenarios from the simple to the complex based on
The needs of the program, level of student, course objectives
Problem solving, decision based case studies
Low level of uncertainty FEEL AUTHENTIC Teach students to think on their feet
Control the clinical environment ensuring adequate case exposure with in a limited period of time
Faculty must create realistic scenarios to create proactive decision making and experience the outcomes from those decisions
If the learner is prepared for the experience, learning is enhanced PREPARATION ENHANCES LEARNING Create simulation scenarios from real-life clinical situations
Discuss sources available to generate ideas for scenario development.
Identify resource and tools needed for scenario development
Describe the process of simulation development OBJECTIVES Ask for confidentiality (Las Vegas principle)
Actions and remarks of participants
Case details

Appeal to participants to reflect on their actions thinking during debriefing
Ask them to think deeply about their practice, assumptions and knowledge
Insist that participants be polite, respectful and curious about other’s actions and remarks SET GROUND RULES ON PARTICIPATION, CONFIDENTIALITY, RESPECTFULNESS Be fair about simulation’s strengths and weaknesses

Don’t over or undersell
Admit weaknesses and focus on the strengths in terms of what needs to be accomplished

Don’t try to convince participants the simulation is more real than they’re willing to make it

Discuss the roots of cases
QI, litigation, faculty experience AGREE ON THE FICTION CONTRACT Introduce simulation (handouts)
Explain simulation specific techniques
Unusual events, time warps, pause and discuss, deliberate practice
Discuss research protocols and obtain permission
Announce whether there will be visitors
Discuss care and comfort issues
Schedule, restroom facilities, food, transportation, etc ORIENT TO THE ENVIRONMENT Because learners will be in new situations:

This may feel awkward
They may feel surprised
They will zig when you wish you had zagged


They may feel safe here and uncertain there SAFETY CONSIDERATIONS We believe that each individual participating in activities at the West Coast Learning Simulation Centers is intelligent, capable, cares about doing their best, and wants to improve.



(Adapted from the Harvard MCS with permission 2012) THE BASIC ASSUMPTION Introduce self-background and expertise

Reveal your expertise
Reveal your stories and experience
Introduce participants – background, experience, level
Provide course learning objectives PROVIDE FOR PERSONAL COMFORT AND BUILD TRUST (CONTINUED) Set up room beforehand (1hr)
Ensure physical comfort of participants
Arrange furniture thoughtfully
Post names of instructors and participants
Check room: markers, erasers, coffee, snacks, etc.
Ensure the room looks like valued guests are expected.
Greet participants. Show an interest in them and an appreciation for them coming PROVIDE FOR PERSONAL COMFORT AND BUILD TRUST
Four areas to consider

1. Provide for personal comfort and build trust
2. Orient to environment
3. Agree on a fiction contract
4. Agree on participation, confidentiality, respectfulness WE ARE SETTING THE CONTEXT FOR LEARNING… Why simulation is being used
What it will accomplish
What is involved in participating in simulation
Guidelines for behavior
Create a collegial learning environment STUDENT ORIENTATION SHOULD INCLUDE SMART
Specific
Measurable
Achievable
Relevant
Timely STEP 1: CREATE OBJECTIVES Based on objectives
Consider adult learning principles
Identify potential obstacles, constraints, etc.
Realistic time frames for presentation
Focus on process and content
Learning activities and tools support objectives TRAINING DESIGN Prepare for the time investment
Complexity
Resources
Stakeholder involvement & availability

Identify timelines
Faculty expectations TIME INVESTMENT Introduction to Conducting Simulation PART III Ask for buy-in to the fiction contract

“We’re going to work hard to make the simulation seem as realistic as we can – For your part, see if you can focus on solving the problems presented - is that OK?”

State that participants will probably conduct themselves differently in simulation than they do in the real clinical environment. AGREE ON THE FICTION CONTRACT Knows the purpose of Learning
Feel supported
Responsible for learning
Understand relevance
Active learning
Internal motivation to learn THE LEARNER Enhance the realism of the scenario


Ensure the scenario replicates the student’s clinical experiences SUBJECT MATTER EXPERTS Case studies
Journal articles
Risk management
Legal cases
Clinical experiences
Care Plans RESOURCES FOR SCENARIO IDEAS Review course objectives
Theory content
Essential experiences learner needs
Psychomotor skills RESOURCES FOR SCENARIO IDEAS Onda, E (2011). Situated Cognition: Its relationship to simulation in nursing education. Clinical Simulation in Nursing. e1-e8.
Overstreet, M (2008). The use of simulation technology in the education of nursing students. NursClin N Am 43 593-603.
Waxman, K.T. (2010). The development of Evidence-based clinical simulation scenarios: Guidelines for Nurse Educators. Journal of Nursing Education. 49,(1). 29-35. Association of Standardized Patient Educators www.aspeducators.org
International Nursing Association for Clinical Simulation and Learning (INACSL) http://www.inacsl.org/
Gaumard Scientific http://www.gaumard.com/
Laerdal Simulation User Network http://simulation.laerdal.com/
National League for Nursing http://sirc.nln.org
Meti (Medical Education Technologies Institute)http://www.meti.com/index.html
Society for Simulation in Healthcare (SSH)http://www.ssih.org/public/ RESOURCES DASH. Retrieved December 13, 2012 from http://www.harvardmedsim.org/_media/DASH-SV%20Short,%20Sept2010,%20Final.pdf
Overstreet, M.(2010). Ee-chats: the seven components of nursing debriefing. Continuing Education of Nurses. 41(12), 538-539. doi: 10.3928/00220124-20101122-05
Rudolf, J.W., Simon, R., Dufresnes, R.L, Raemer, D.B. (2006). There’s no such thing as “nonjudgmental debriefing: a theory and method for debriefing with good judgment. Simulations in Healthcare 191): 49-55. REFERENCES http://www.harvardmedsim.org/_media/DASH-SV%20Short,%20Sept2010,%20Final.pdf DEBRIEFING ASSESSMENT FOR SIMULATION IN HEALTHCARE (DASH) STUDENT VERSION© Genuine question in order to elicit student’s thought processes

i.e.. “I am wondering, would you like to tell us what was going through your mind at the time when ………” INQUIRY
Allow short amount of time for personal, quite, student self reflection before starting debriefing

Start with the positive actions and interventions that occurred

Allow for venting of feelings brought on by the experience

Reinforce positive aspects of the experience

Provide an opportunity to discuss proper interventions and actions GETTING STARTED



Part IV DEBRIEFING Harder,B. Nicole (2009). Evolution of simulation use in health care education. Clinical Simulation in Nursing. 5, e169-e172.
Holcome, E, Rizzolo, M., Sachdeva, A.K., Rosenber, M., Ziv, A. (2011). Simulation-Based Assessment and the Regulation of Healthcare Professionals. Society for Simulation in Healthcare. 6(7), Supplement.S59-S62.
Jeffries, P.R. (2005). A framework for designing, implementing and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26, 960103.
Rudolph, J.W., Simon, R., Rivard, P., Dufresne, R.L., Raemer, D.B. (2007 ). Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry. Anesthesiology Clinics, Volume 25, Issue 2, Pages 361-376 REFERENCE 1. Get in touch with your emotions
2. Set your stance
3. Pair advocacy and inquiry

“I noticed that when the patient’s blood pressure dropped you ..………”
ADVOCACY- INQUIRY Attitude is crucial

Be non-judgmental and kind

Stick to the learning objectives

THE DEBRIEFING MOLECULE Availability of quite, comfortable space for reflection (2 times longer than sim time)
Prepare structured guidelines, questions to guide debriefing with students
Provide a structured method for peer review with small amount of teacher
Allow for input
Allow for students to reflect and verbalize
Bring all students together, away from lab DEBRIEFING Three things to establish prior to debriefing

Confidentiality

Basic Assumption

Fiction Contract PRE-BRIEF Guide by asking questions in order to facilitate discussion
To help students link their simulation experience to behaviors and events with what is familiar in the real world FACILITATORS Makes meaning of the experience

Stimulates learner’s reflection and communication of events

Explore emotions
Enhances learning by reframing events
Transfer learning to a higher level of thinking DEBRIEFING DEBRIEFING-DEFINED Involves cognitive, affective and behavioral components

Active participation vs. passive listening


Immediate application to real life


It is self-directed LEARNING IS MORE EFFECTIVE WHEN Articulate non-judgmental debriefing techniques


http://tlc.discovery.com/videos/the-little-couple-debriefing.html OBJECTIVES
SUMMARIZES WHAT WAS LEARNED AND TRANSLATE INTO PRINCIPLES TO IMPROVE PRACTICE
i.e. “These are the things you told me you need to work on………………………………

i.e.“The take home points include (change in practice)………………. Example 2
Jason, I can’t believe it took you 90 seconds to notice he was desaturating!
Inquiry: What was this patient’s pulse when you went to look for the bag-mask? Example 1
Jason, I noticed that you stepped away form the patient to find the bag-mask apparatus as the vital signs were deteriorating. I was thinking there possibly were alternative means to oxygenate the patient.
Inquiry: So, I’m curious: how were you seeing the situation at the time? ADVOCACY/INQUIRY
Rudolf, JW, et al., (2006) “Debriefing with good judgment” Conduct with care and respect

Non-threatening, nonjudgmental

Confidentiality RULES OF CONDUCT Identifies what the learning needs are-
Plus - indicates what went well
Deltas - how the learner would change the learning situation for next time
“Close the performance gap” – Best practices PLUS-DELTA Desired Actions Actual Actions Bridge the performance gap
The difference between the desired and the actual levels of performance. GOAL OF DEBRIEFING Deliberate
Practice Certification Healthcare Simulation Educator
CHSE Society for Simulation in Healthcare (SSH) has developed and accredited the first Simulation Educator certification this year. DEBRIEFING STAGE Beginning - (emotional reactions) How do you feel now?

Middle - (analysis, understanding, generalization to px)
Advocacy-Inquiry technique

End - (summarize) Statements/Observations
Take home points Mikasa, A.W., Cicero, T.R., Adamson, K. A. Outcome-based evaluation tool to evaluate student performance in high-fidelity simulation. Clinical Simulation in Nursing . El-37. doi:10.10.1016/j.ecns.2012.06.001.
Overstreet, M (2008). The use of simulation technology in the education of nursing students. NursClin N Am 43 593-603.
Waxman, K.T. (2010). The development of Evidence-based clinical simulation scenarios: Guidelines for Nurse Educators. Journal of Nursing Education. 49,(1). 29-35. Association of Standardized Patient Educators www.aspeducators.org
International Nursing Association for Clinical Simulation and Learning (INACSL) http://www.inacsl.org/
Gaumard Scientific http://www.gaumard.com/
Laerdal Simulation User Network http://simulation.laerdal.com/
National League for Nursing http://sirc.nln.org
Meti (Medical Education Technologies Institute)http://www.meti.com/index.html
Society for Simulation in Healthcare (SSH)http://www.ssih.org/public/ RESOURCES Professional development
Developing research proposals
Securing funding
Utilizing available resources
Evaluating outcomes
Data collection
Reporting out IMPLICATIONS FOR FACULTY Cognitive
Standardized Exams
Course Exams
Psychomotor
Checklists
Global Rating Scales
Affective
Confidence
Self-efficacy
Satisfaction TYPES OF TOOLS State ways to achieve best results r/t simulation evaluation

Describe challenges and opportunities r/t simulation evaluation EVALUATION COURSE EVALUATION Holcome, E, Rizzolo, M., Sachdeva, A.K., Rosenber, M., Ziv, A. (2011). Simulation-Based Assessment and the Regulation of Healthcare Professionals. Society for Simulation in Healthcare. 6(7), Supplement.S59-S62 Jeffries, P.R. (2005). A framework for designing, implementing and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26, 960103.
Rudolph, J.W., Simon, R., Rivard, P., Dufresne, R.L., Raemer, D.B. (2007 ). Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry. Anesthesiology Clinics, Volume 25, Issue 2, Pages 361-376
Onda, E (2011). Situated Cognition: Its relationship to simulation in nursing education. Clinical Simulation in Nursing. e1-e8. REFERENCES Kardong-Edgren, S., Adamson, K. Fitzgerald, C. (2010). A review of currently published evaluation instruments for human patient simulation. Clinical Simulation in Nursing. 6, e25-e35. doi:10.1016/jecns.2009.08.004.
Kardong-Edgren, S., Hanberg, A.D., Keenan, C,m Ackerman, An., Chambers, K. (2011). A discussion of high-stakes testing: an extension of a 2009 INACSL conference roundtable. Clinical Simulation in Nursing. 7, e19-e24. doi: 10.1016/j.ecns.2010.02.002.
Harder,B. Nicole (2009). Evolution of simulation use in health care education. Clinical Simulation in Nursing. 5, e169-e172.
Herm, S. Scott, K., & Copley (2007). “Sim” sational revelations. Clinical Simulation in Nursing Education. 3 325-e30. doi10.1016/j.acns2009.05.036 REFERENCE DASH. Retrieved December 13, 2012 from http://www.harvardmedsim.org/_media/DASH-SV%20Short,%20Sept2010,%20Final.pdf
Overstreet, M.(2010). Ee-chats: the seven components of nursing debriefing. Continuing Education of Nurses. 41(12), 538-539. doi: 10.3928/00220124-20101122-05
Rudolf, J.W., Simon, R., Dufresnes, R.L, Raemer, D.B. (2006). There’s no such thing as “nonjudgmental debriefing: a theory and method for debriefing with good judgment. Simulations in Healthcare 191): 49-55. REFERENCES

Evaluates all 3 domains of learning
Met/Not Met


“More rigorous than traditional tools Valerie Howard EdD MSN RN(2012) HERM TOOL Utilize the best evidence
Concern with inter-rater reliability
Quality improvement of the learner’s experience CHOOSING AN EVALUATION METHOD Standardized
Correlate
To the level of fidelity
Learning objectives
Consider prompting levels
Pre-determined parameters for terminating scenario prior to completion
Include learner self-assessment of performance TO ACHIEVE BEST RESULTS Evaluation criteria and methods explained in advance
Previously tested instruments
Reliability and validity established BEST RESULTS RECOMMENDATIONS NLN
Simulation Design Scale
Educational Practice Questionnaire
Student Satisfaction and Confidence in Learning
METI Simulation Effectiveness Tool (SET)
Lasater Clinical Judgment Rubric
Creighton Simulation Evaluation Tool
ANTS VALIDATED TOOLS Cognitive, affective and psychomotor

Knowledge, skills and attitudes r/t (QSEN Competencies for example)
Patient safety
Teamwork/Collaboration
Evidence-based Practice
Quality improvement
Informatics THREE DOMAINS OF LEARNING Develop objectives for learner to guide evaluation activities
Evaluate
Instructor/Facilitator
Quality of Simulation Experience
Learner satisfaction STANDARD VII http://www.harvardmedsim.org/_media/DASH-SV%20Short,%20Sept2010,%20Final.pdf DEBRIEFING ASSESSMENT FOR SIMULATION IN HEALTHCARE (DASH) STUDENT VERSION© Evaluation
Part V http://www.youtube.com/watch?v=Z9C0yVgTcbs http://www.wingclips.com/movie-clips/paul-blart-mall-cop/police-boot-camp http://www.wingclips.com/movie-clips/imagine-that/how-to-sing http://www.uci.edu/features/2010/09/feature_medsim_100928.php http://movieclips.com/ukKJv-apollo-13-movie-square-peg-in-a-round-hole/
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