Taking Your First StepsSimulation IntegrationBeth Fentress Hallmark, PhD, RN

Belmont University College of Health Sciences

Introduction:

• Beth Hallmark, PhD, RN– Belmont University– Director of Simulation, Gordon E. Inman

College of Health Sciences and Nursing– Laerdal Center of Educational Excellence– Director Tennessee Simulation Alliance

Objectives:

• Identify the benefits, challenges and emerging trends in the use of simulation

• Identify what is driving simulation education• Discover ways to integrate simulation into

nursing curriculum• Identify courses where simulation may help

you reach curricular objectives.• Verbalize training resources for your school

Belmont UniversityNashville, Tennessee

• 7,000 + students

College of Health Sciences

Inter-professional Education• Nursing

– Accelerated, Fast track and Traditional BSN– FNP, DNP

• Social Work (BSW)• Physical Therapy (DOT)• Occupational Therapy (DPT/MSOT)• Pharm D

Belmont’s Integration:

• May 2006 – Gordon E. Inman College of Health Sciences and Nursing

• August 2006 – Simulation Coordinator named

• Spring 2007 – Faculty development activities

• Fall 2010 McWhorter Center• Established one physical space for COHS

Belmont UniversityNashville, Tennessee

• 2- Eight bed Adult Health laboratories• 8 bed “Acute care” lab• 6 bed Peds lab• 8 bed Health Assessment/OB lab• 4 Inter-professional private patient rooms

Inman Center

• 77,000 square feet• Designed to house Nursing,

Occupational Therapy, and Social Work• Conference Center on 4th floor• Planning for building began Spring

2004• Groundbreaking October 2004, moved

in May 18, 2006

Adult Health Nursing Lab•Functioning headwalls (compressed air/suction)•Lift equipment•“Storage” converted to “clean utility room” – materials management

McWhorter Hall

• Designed to house Pharmacy, PT, (Chem labs)

• 90,000 square feet• Retail Pharmacy• Health Services Clinic• 4 Sim Rooms/SP

and mannequins

MISSION & VISION

Mission of the Health Care Simulation Center is to provide high quality experiential education through innovative simulation based teaching and inter-professional collaboration to enhance clinical reasoning and safe practices in health care.

Vision for the Future: National Leaders in interprofessional healthcare simulation.

Belmont’s SON Goals

• Prepare the novice nurse for clinical practice

• Link Concepts & Critical Thinking to Practice

• Progressive Complexity• Theoretical Support

Why Integrate Simulation?

• The true value of simulation lies in its ability to offer experiences throughout the educational process that provide students with opportunities for:

• Repetition

• pattern recognition, and

• faster decision making.”

Doyle & Leighton, 2010

Why Integrate Simulation?

Bridging the gap between education and practice

• “90% of nurse educators think their graduates are ready to safely practice VS. 10% of hospital administrators”

• JONA , November 2008

Transition from student to RN

Research shows new grads experience:• Fear• Lack of confidence• Communication deficits • Complex decision making• Contradictory information• Issues working with peers

Dyess, S., & Sherman, R.. (2009). The first year of practice: New graduate nurses' transition and learning needs. The Journal of Continuing Education in Nursing, 40(9), 403-10. doi: 1864764661.

New Graduates say:

• They feel uncomfortable with:– IV skills– Physical Assessment– Care of the dying patient– Caring for patients with changing care

needs

– Marshburn, D., Engelke, M., & Swanson, M.. (2009). Relationships of New Nurses' Perceptions and Measured Performance-Based Clinical Competence. The Journal of Continuing Education in Nursing, 40(9), 426-32.  Retrieved November 2, 2009, from ProQuest Medical Library. (Document ID: 1864764651).

Practice Partners Say:

Students • Fail to perform relevant nursing actions

relating to specific disease states• Lack the ability to prioritize• Give incomplete or irrelevant

information to PCP• Have difficulty giving rationale for

nursing actions• Do not know laboratory values• Burns, P., & Poster, E.. (2008). Competency Development in New Registered Nurse Graduates: Closing the Gap Between Education and

Practice. The Journal of Continuing Education in Nursing, 39(2), 67-73.  Retrieved November 2, 2009, from ProQuest Medical Library. (Document ID: 1423354581).

Simulation Training

• Adult Learner: self direction

• “High fidelity team simulation combined with reflective debriefing teaches learners to monitor and question their mental models and practice behaviors”

• “Vivid experiences in simulation stimulates the ‘need to know’ that motivates adult learner”

Experiential Learning and Simulation

The Shifting Paradigm

OLD• Didactic• See one do one• Silos• Practice on patients• Learn from mistakes

on LIVE patients

NEW• Self-directed• Practice to pre-defined

standards or competency using simulators

• Learn from your mistakes on SIMULATED patients

• Team Training• Reflection

Risk Management

• Most serious medical errors are committed by

competent, caring people doing what other competent, caring people would do.”

-Donald M. Berwick, MD, MPP

Not just about the people, it is about the design:

System, medical devices, procedures, polices• Human Factors: safeguard in the design• “making it difficult for people to do the wrong

thing”

• Environmental

• Organizational

• Individual

• Team

• Patient Related

Factors that increase risk of error

Root Cause Information for Medication Error Events Reviewed by The Joint Commission(Resulting in death or permanent loss of function) 2004 through 2011 (N=333)

• The majority of events have multiple root causes• Medication Use 292• Leadership 248• Communication 242• Human Factors 239• Assessment 138• Information Management 127• Physical Environment 63• Continuum of Care 33• Care Planning 32• Patient Education

• Realistic Learning Experience

• Medical issues

• Legal issues

• Patient relation issues

• Ethical issues• Identification of Potential System Failures• Repair System Failures• Test New Systems• Team Simulation• Employee Satisfaction and Retention• Student and Patient Satisfaction• Risk Reduction• $$$$$$ Savings

Advantages to using simulation

• “Training multidisciplinary teams using simulation is an effective strategy for reducing surgical errors counts”

• Helmreich & Merritt, 1998

• “Simulation-based training in team coordination process has been found to be an effective tool for improving team coordination process in high performance teams in the Navy”

• Cannon-Bowers & Salas, 1998

How can you use simulation?

• Crisis Management• Flexibility• Use factual knowledge• Critical thinking• Team interaction

• Response time• Communication Skills• Planning• Strategy • Multiple Decisions• Collaboration

• Clinical time• State by State regulations in nursing education• Lab time• Orientation• In situ• Remediation

• What areas do you have difficulties in clinical placement? OB? PEDS? PYSCH?

• EMR/MEDS?• High Risk Lo Volume incidents

Where can you use simulation?

Why do we plan?

• “If simulation is instituted in a curriculum prior to completion of evaluation planning, the potential for pedagogic improvement may be jeopardized”.

• Schlairet, 2011.

Why Integrate Simulation?

• Deliberate practice • Healthcare Technologies• Team training• Quality and safety• Delegation• Therapeutic communication/Inter-

professional • Clinical Judgment/Decision-Making

What can simulation do?

• Help promote teamwork and collaboration• Foster effective and safe communications• Delegation• Safe practices/Quality Improvement• Cultural awareness• Evidence based practice• Patient centered care

Advantages of Simulation

• Safe practice arena• Hands on• Exposure to rare/high risk events• Practice cognitive and psychomotor skills• Transfer to clinical setting• Immediate feedback• Reflective learning

Where to start?

• Seropian et al. (2004) recommended eight steps to institute a simulation program: – Develop a vision to show what is to be achieved, who will

be involved, and how the laboratory will be used.– Generate a business plan to outline initial and annual fiscal

obligations.– Identify and seek support from stakeholders.– Construct the facility or laboratory, as defined in the vision

and the business plan, including the equipment purchase.– Provide training for all individuals who will be involved.– Develop the curriculum.– Faculty training. – Determine policies and procedures.

– Collect Data!

Vision/Mission/Goals

• Spend time working on this before you jump in head first to simulation..if you did not do it in this order..BACK UP!

Business Plan

• Sustainability• Planning• Show ROI• Budget 3, 5 years out• Staffing

Other

• Maintain a working lab group to create change.• Strengthen partnerships with local medical

centers• Develop relationships with vendors• Provide consistent and timely communications

between the lab group, faculty and administration.

• Maintain records to identify areas of needed improvement

• Hire faculty and staff that are qualified to support our vision

Other

• Manage the financial resources to provide the most sophisticated equipment available.

• Develop simulation within every course in the curriculum.

• Benchmark through electronic resources and by developing relationships with experts in the field.

• Inventory management• Maintenance of Capital equipment.

Stakeholders!

• Who?• Why?• Where ?• What can they do for you?• What can you do for them?

Curriculum Development

• PLAN• PLAN • PLAN!!

Lab/Simulation Committee

– Lab Committee/simulation group– Lab coordinator– Champions– Share with faculty new standards (ie:

SBAR, QSEN)– Map skills throughout curriculum (“lets do

blood now”)– Develop a written plan– Mission and vision– Goals

Learning Domains

• Cognitive: “involves knowledge and the development of intellectual skills. This includes the recall or recognition of specific facts, procedural patterns, and concepts that serve in the development of intellectual abilities and skills”

• In Nursing Education; what falls in the cognitive domain?

http://www.nwlink.com/~donclark/hrd/bloom.html

Learning Domains

• Affective: “manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes”.

• In Nursing education what falls in the affective domain?

http://www.nwlink.com/~donclark/hrd/bloom.html

Learning Domains

• Psychomotor: “includes physical movement, coordination, and use of the motor-skill areas. Development of these skills requires practice and is measured in terms of speed, precision, distance, procedures, or techniques in execution”.

• What falls in the psychomotor domain?

http://www.nwlink.com/~donclark/hrd/bloom.html

Traditional Nursing Education

• Didactic• Lab• Clinical• Orientation at workplace• CEUs

New Strategies

• Simulation as a Teaching Strategy• Simulation as an Evaluation Tool• High stakes?

Types of Simulation

• Case Study• Role-playing• Standardized patients• Partial vs. Complex Task Trainers

– Static and Computerized • Integrated Simulators (HPS)• Virtual Simulation/Online

Types of Simulators

Fidelity

Low Fidelity: Task Trainers.

Medium Fidelity: non-responsive in terms of physiological signs but can have heart and lung sounds, etc.

High Fidelity: physiologically responsive to students actions or lack of action.

Simulation: Theory

• Active Learning• Reflective Thinking• Constructivism

Curricular Changes

• Examine where simulation naturally fits– Outline a plan based on each semester

• Build simulations upon one another• Simple to complex• Students need exposure early in the

program• Use for remediation and clinical

makeup

Connecting the dots in courses:

• Labs• Didactic• Courses in same semester• How can we “marry” the content and

reiterate in simulation?• How can we re-frame the content we

are teaching in labs and didactic within simulation?

Standards

Identify your programs outcomes based on standards.– BSN Essentials– QSEN– IOM– Joint Commission– NCLEX– Core Competencies for Interprofessional

Collaborative Practice

How do I overcome:

• Faculty Resistance– Time– Resources

• Technology assistance, equipment

– Pay– Administrative Assistance– Skills– Scheduling

What do I need?

• CHAMPION• Administrative Buy In• Money: Grants• Staff• Space• Faculty Development Plan• Policies • Mission Vision• Stakeholders

What do I need?

Champion• One or two people who are interested

in this new pedagogy.• Train the champions then bring back

info to the rest of faculty• Champion can send information to

others in form of literature and conference ideas

• Lead simulation committee/group

What do I need?

• Administrative Buy In How to accomplish this?

• Bring in experts/consultants• Take them with you to meetings• Share with them what you learn at

conferences• Show them student evaluations• Demonstrate how simulation works• Peer pressure

What do I need? MONEY…..

MONEY…..• Grants • State • Federal• Local community organizations• National Private Funding groups

What do I need?

Staff• Simulation Director• Faculty: Simulation Committee Group• Technical Support: IT and Network

specialist• Supply specialist• Scheduling

What do I need?

Space• STORAGE, STORAGE, and still

MORE STORAGE!!• Preparation Area• Simulation Labs• Partitions?• Observation/Control Room• Debriefing room

What do I need?

Faculty Development Plan• Conferences• Lunch and Learn• SIRC.NLN.org• List serves

– INACSL– SSiH

• NLN• AACN• Invite them to play a part

Components to a Simulation

• Student Preparation• Objectives• Report• Actual Simulation• Debriefing• Evaluation

Student Preparation

• How does a student prepare for a simulation?

• Do you give them the case prior to the simulation?

• What are the objectives of the simulations?

• Formative or Summative• Case Study versus procedural prep

Objectives

• Need to fit with curricular objectives and course objectives

• Case by case • General safety and communication• So many more

Report

• One example of integration• Students need to learn how to receive

and give report• Use SBAR or other communication

rubrics• Ask practice partners for the system

they use

Simulation

• Scenarios– Pre programmed – Make it your own

• Validate with practice partners• Faculty script/training • Reality: suspend• Fiction Contract

Debriefing

• Reflection• TRAIN faculty/method• Learner uses previous knowledge to

build upon• Bad Habits develop if not addressed• Video taping

• DASH model for training faculty

Evaluation

• MUST be based on your objectives!• Remember to link your simulation

objectives to your course..to your program..to the college..etc

• Formative or Summative Evaluation• Evaluation rubric

Where can you use clinical sims?

What can we examine in acute care?

• Patient Safety• Team• Communication

Nursing Education

• Confidence• Self-Efficacy• Skills• Communication• Test scores

• NLN: High Stakes• NCSBN: Clinical Replacement

• Your curricular objectives should dictate what simulators, what information and what simulation you need

• Team simulation• Skills are a small percentage of the training• Process oriented simulation• Leadership is essential• Effective communication is a must component• Education should be universal, pro-active and non-

punitive• ?HIGH STAKES?

Examine Curriculum

• Clinical Skills integrated in a summative simulation

• Sterile procedure: foley, dressing change

• Medication administration: insulin, Flu, pain med

• Vitals/assessment• Clamp NG

Introduction to Nursing

• Severe dehydration• Bowel Obstruction• IV fluid bolus• Oxygen• Zofran

Adult Health One

• Post Partum bleed• Antepartum: Hyperemesis, PIH, pre-

term labor• Mega Sim Scenario: Doctors office

early labor delivery code and postpartum

Obstetrics

• Depression• Schizophrenia: Neuroleptic Malignant

Syndrome• Alcohol withdrawal

Psychiatric

PEDS

• Respiratory• ALL• Skills

Adult Health Two

• End of Life• Codes• Blood

Leadership

• Delegation• Nurse practice Act

Other Disciplines

• OT and PT lines acute care• Pharm medication dosage

• Interprofessional

• Nursing Education• Medical Education

Literature review

Support: Find a Network

• Tennessee Simulation Alliance (www.tnsim.org)

• INACSL (www.inacsl.org)• SSiH (www.SSiH.org)• NLN SIRC (www.sirc.nln.org)• Simulation Users Network (SUN)

Questions?