The Future of Simulation: Innovations and Possibilities

1. The Future of Simulation: Innovations and Possibilities Pamela R. Jeffries DNS, RN, FAAN,ANEF Associate Dean for Academic Affairs Johns Hopkins University School of Nursing Clinical Simulations in Healthcare Conference – May 19, 2010 Tulsa, Oklahoma

2. Objectives of this session: The participant will be able to: Discuss changes occurring in nursing education and the use of clinical simulations Describe the essential tools and skills nurse educators need to incorporate simulations into the teaching-learning process Explore future possibilities nurse educators can embrace using simulations

3. Clinical Simulations: a potential solution for clinical practice and enhancement 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. Why is there a sudden increase in this innovative strategy? How do educators know if this mechanism is providing the learning outcomes needed to prepare the graduate for real-time nursing practice?

4. Increased Need for Simulations: Why do educators want to use them? 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)

5. Why do educators want to use them? IOM (2004) challenges health educators to expand technologies and support innovations NLN has challenged educators to be innovative in our educational practices New graduates must be prepared for the demand of healthcare and increased complexity – need for rapid decision making

6. Simulations use continued Concept of patient safety increasing – use of simulation as a safety concepts National Council of State Board of Nursing – predicts the future of clinical education in nursing will include the increased use of simulations Higher education paradigm shift from teaching to learning paradigms

7. Current state of Clinical Nursing Education • Errors correlated to new graduates inability to make clinical decisions (Smith & Crawford, 2002) • New graduates do not meet their expectation for clinical judgment as identified by employment in clinical agencies (De Bueno, 2005) • Accreditation agencies challenge educators to promote critical thinking (Long, 2004; NLN, 2003)

8. Current State -continued • Teaching practices need to be evidence-based- educational research needed (NLN, 2005; IOM, 2001) • Critical thinking and reflective skills of the practitioner are correlated with the quality of patient care (Conway, 1998; Paget, 2001)

9. Simulations Have Arrived…Where are we? Simulations in Medicine Simulations in Nursing Next steps…..

10. Medical Research • Integrative review by Issenberg et al., 2005: • Providing feedback (47%) • Repetitive practice (39%) • Curriculum integration (25%) • Range of task difficulty level (14%) • Multiple learning strategies (10%) • Capture clinical variation (10%) • Controlled environment (9%) • Individualized learning (9%) • Defined outcomes (6%) • Simulator validity for learning (3%)

11. Medical Research • N=109 research articles • Quality is weak. • Based on research literature, can make statement that the use of high-fidelity patient simulation does “facilitate learning under the right conditions” (Issenberg et al., 2005, p. 10).

12. Nursing Research - HFPS (n=26)(Nehring, 2008) • Since 2001, 26 nursing research studies related to high-fidelity patient simulation have been conducted. • These studies have been conducted in the US (n=19), the UK (n=3), Sweden (n=1), Canada (n=1), China (n=1), and internationally (n=1). Nehring, W. (2008) U.S. Boards of Nursing and the Use of High Fidelity Patient Simulators in Nursing Education, Journal of Professional Nursing, 24(2), 109-117.

13. Nursing Research • Methods have included pretest-posttest (n=9), surveys (n=7), post-test only (n=4), focus group (n=2), observational and focus group (n=1), theory-driven description-observation-revision-review method (n=1), case study (n=1), and correlational (n=1). • 22 studies dealt with nursing education and 4 studies with team management.

14. Nursing Research Emphasis has been placed on: • Competence (eg., clinical skills, basic knowledge) (n=7) • Confidence • Satisfaction • Use of simulation as educational adjunct (n=9) • Self-directed learning versus instructor-modeled learning • Development of rubric for clinical judgment • Simulation as substitution for clinical (n=2) • Collaboration and teamwork (n=4)

15. Nursing Research • In the past 40+ years, nursing educators have conducted similar studies involving case studies, computerized patients, standardized patients, and have achieved similar results.

16. NLN Study (multi-site 2003-2006) In this study, several areas were explored, however the major contributions to the science of nursing education in the area of simulations include: The theoretically-based Simulation Framework (Jeffries, Rizzolo, 2004) The Development of two instruments: The Simulation Design Scale and the EPSS Identification of 5 key design features to include in the development of simulations

17. OUTCOMES • Learning (Knowledge) • Skill performance • Learner satisfaction • Critical-thinking • Self-confidence TEACHER STUDENT • Program • Level • Age • Demographics • DESIGN CHARACTERISTICS and SIMULATION (intervention) • Objectives • Fidelity • Problem-solving • Student Support • Reflection • Active learning • Feedback • Student/ faculty interaction • Collaboration • High expectations • Diverse learning • Time on task EDUCATIONAL PRACTICES Simulation Framework Jeffries & Rizzolo, 2004

18. Changes/Issues in Nursing Education Regulatory Boards – watchfully monitoring – providing research funding Faculty skill sets changing Partnerships and Collaborations Need for better prepared students exiting nursing programs

19. Regulatory Boards watchfully monitoring and calling for multi-site research Innovations in Nursing Education and Clinical Numerous questions center on the use of simulation in nursing education. How it can be used effectively and its role in clinical development of students is of major importance and of interest to both regulators and educators alike. In collaboration with Rush University, NCSBN embarked on a pilot project to evaluate the value and validity of simulation as an educational strategy. Results indicated further study is needed in this area and our research agenda includes a large-scale, multi-site study. National Council of State Board of Nursing (NCSBN), www.ncsbn.org

20. Faculty Skill Sets Changing and Required Changes in teaching – student-centered approaches 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

21. Partnerships and Collaborations EcO 15 – 10 county consortium on improving healthcare – focus: developing regional sim centers and providing faculty development SPRING program – JHI and the new graduates IU SON and Clarian Health – partners to improve care

22. Need to “bridge the gap” between education and practice A gap exists between the academic preparation of nursing students and the needs of the clinical agency There is a growing concern among the frontline hospital leaders about the new graduates Clinical education is not currently working using only the traditional models we have used for decades

23. The Nurse Executive center of the Advisory Board (2008) Survey taken 2008 Of 135 nurse executives – 10% who responded to the survey stated new graduates were fully prepared for practice while 89.9% of the 362 nursing school leaders agreed A large preparation-practice gap exists! The Nursing Executive Center of The Advisory Board Company (2008)

24. Practice-Readiness defined in 6 general areas Clinical knowledge Technical skills Critical Thinking Communication Professionalism Management of responsibilities

25. Next Steps Most of these competencies are directly related to ways students gain clinical experiences in the nursing program The report identified a “collaborative/partnering” (academe and practice) would help the gap Can the clinical model redesign also include simulations to help facilitate these practice-ready general areas?

26. The Evolution of the “new” Educator

27. Today Facilitators of learning Innovative, creative Technology-savvy or willing to learn Focus: student-centered learning Providing students with “real-world” experiences and examples Knowledge workers, creators, and designers

28. Future Possibilities The future is bright for the use of simulations in nursing education! Simulation centers are being built all around the world Funding dollars are being provided to build simulation centers and to use technology Stimulus monies – some were earmarked for simulation!

29. Stimulus Call for Simulation Center Design NIH Announces Availability of Funding for Simulation in $1bn Stimulus Bill Posted: 03-31-2009 The National Institutes of Health (NIH) has announced that simulation facilities for training health care providers and researchers will be eligible for funding from the $1 billion Congress appropriated in the stimulus bill (The Recovery Act) to NIH for grants and contracts to construct, repair, or renovate existing research facilities. NIH's inclusion of simulation centers as being eligible for this funding will provide a tremendous opportunity for the development of new simulation centers, as well as the enhancement of existing centers. 

30. Future Possibilities • Uses of Simulation Expanding in Education • The evolution of “the simulation technology” • Teaching environments/possibilities • The learner

31. Future Uses and Activities where Simulations are Involved Research in simulations increasing – e.g. Advanced Practice Nurses multi-site study Unfolding cases Simulations included in large Foundation and partnership grants Integrating simulations into patient and caregiver teaching/health promotion and prevention

32. Multicenter Study Effectiveness of Harvey Nurses Curriculum Mastery Learning - Features • Baseline (e.g., diagnostic testing) • Clear learning objectives, units ordered by difficulty • Educational activities (e.g., deliberate skills practice) focused on objectives • Minimum passing mastery standard (MPS) for each unit • Formative testing → mastery of each unit • Advancement if performance ≥ MPS • Continued practice or study until MPS is reached

33. Multicenter Study Effectiveness of Harvey Nurses Curriculum • Training Intervention • Pre-Self Study Program • Instructor Guided Sessions • Learner Practice w/Feedback • Self Study Program • Learner Training Logbook • Pretest • Knowledge - MCQ • Skills – Checklist • Confidence - Survey No • Posttest • Knowledge - MCQ • Skills – Checklist • Confidence – Survey • Instructor Satisfaction MPS Achieved Advancement

34. Multicenter Study Effectiveness of Harvey Nurses Curriculum Evidence-based Training • Mastery Learning – benchmarks set • Deliberate Practice – repetitive practice/feedback • Curricular Integration – part of existing courses • Adaptive Learning – small group/self learning/remediation • Clinical Variation – 10 clinical cases

35. Unfolding Cases – Teaching students differently

36. Grant funding sources calling for simulations Hartford Foundation partners with the NLN Simulations incorporated into the grant – develop and implement simulations focused on caring for the aged in the grant Special series coming AACN Essentials mandating geriatrics in curriculum

37. Hartford Foundation Funding to foster geriatric nursing using simulations John A. Hartford Foundation Funds New Three-Year Project"Fostering Geriatrics in Pre-licensure Nursing Education, Phase II" Laerdal Medical to Contribute $187K for New Simulation Design for Geriatric Care FOR IMMEDIATE RELEASE New York, NY — April 8, 2009 — Following a successful Hartford Foundation-funded project to foster geriatrics education among associate degree, pre-licensure nursing students at the Community College of Philadelphia (CCP), the National League for Nursing and Laerdal Medical Corporation have joined forces with the college to extend this preparation to students in all pre-licensure RN programs: associate, baccalaureate, and diploma. This next phase, supported again by a generous grant of nearly $700,000 from the John A. Hartford Foundation, will build on the work done through "Fostering Geriatrics in Associate Degree Nursing Education," funded by Hartford in 2007-08. NLN Web site – http:/www.nln.org

38. Using simulations to teach patients and & caregivers NIH R01 Grants calling for innovation How can simulations/technology be incorporated into these types of research Obama’s challenge equipment grants….many, many focused on innovation and health information technology Use of Technology

39. The Simulation Technology and the Future Evolution of the simulators Robotics? Shift from the majority of clinical practicum and teaching to teaching clinical in a simulated environment so students can be learn and practice problem-solving, decision-making, and critical thinking

40. Virtual Simulation and Patient Care

41. The student or learner What do they look like in the future? High technology skills Need rapid information and retrieval Desire real-life application, everything else is irrelevant The Globals – Generation linked to each other Borderless environment Embrace a wider stage Bring a global perspective to everything! Desire intercultural dialogues and lessons Our students

42. Summary Simulation has emerged! The future of simulations The future for clinical is promising! Over time, more evidence will be disseminated on the use, implementation, and best practices of incorporating clinical simulation into a nursing curriculum.

43. Summary Simulation holds the promise to change faculty assumptions about how students learn and think and to become an essential teaching/assessment evaluation strategy in education of nurses. One approach for Gateway to change in nursing education is the incorporation of clinical simulations in nursing curricula. If not on board, get on board to use this amazing technology!

44. Goal for using simulations: Optimal Student Learning for High Quality Patient Care

45. Questions: pjeffri2@son.jhmi.edu