Overview

Simulation is growing in popularity in nursing and healthcare educational systems across the country. Its use is driven by the demand to educate healthcare professionals for the growing national nursing shortage, the need to practice skills without harming live patients, and the increasing ease of its usage and availability. The technology is popular among the younger, technologically savvy generations and appreciated by the older. Simulation has a variety of applications. Some examples include to increase knowledge and skill retention for rare and high-risk medical situations and to improve team dynamics and performance in ad hoc teams, such as code blue responses. It offers a unique, controlled, learner-focused educational environment that can mimic real-life situations and experiences. Being used by educators, faculty, and residency programs, simulation is a valuable learning tool that appeals to visual, kinesthetic, and auditory learners. There are a variety of simulation tools that can be employed to make an exceptional educational experience. This course explores the history of simulation use, uses for it, how to use simulation as a learning tool, effectively creating a simulation scenario to meet educational goals, and proper debriefing tactics for simulation educational sessions.

Education Category: Management
Release Date: 05/01/2018
Expiration Date: 04/30/2021

Audience

This course is designed for healthcare educators in the academic and staff development sectors. This includes nursing, medical, and allied health programs. It may also have application to healthcare workers exploring new ways to practice, test, and learn new skills related to their job requirements.

Accreditations & Approvals

In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program. AACN Synergy CERP Category C.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through November 21, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2019; South Carolina, Provider #50-2405.

Course Objective

The purpose of this course is to provide healthcare educators with the information necessary to design and implement a simulation curriculum to create a rewarding, effective, and interactive learning environment for participants. These sessions will lead to greater skill retention, safer practitioners, and increased confidence and competence in healthcare workers.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Describe the adaption of the history of simulation use into the healthcare industry.
  2. Name applications of simulation as a healthcare learning tool.
  3. Identify how to use learning domains when creating a simulation learning scenario.
  4. Apply simulation learning activities to specific student population educational needs.
  5. Identify components of planning a debriefing session.
  6. Describe the role of the educator in a debriefing session.
  7. Outline tips for a successful debriefing session.

Faculty

Jessica Kamerer, EdD, MSN, RNC-NICU,, has worked training healthcare providers using simulation methods since 2006. She has experience utilizing simulation in academic and staff development environments. She works with college faculty, residency programs, and hospital educators to develop simulation-based educational programs. Programs range from medical student education in programs such as the family practice residency, nursing and respiratory care programs, to staff development, policy testing, and competency trainings. Her undergraduate degree from Indiana University of Pennsylvania is a Bachelor of Science in Nursing and her Master's degree from Walden University is a Master of Science in Nursing, specializing in education. Her Master's degree capstone project focus was research utilizing simulation to increase the effectiveness of graduate nurse orientation in critical care units. Her Doctorate of Education degree with a concentration in organizational leadership is from Nova Southeastern University. As an expert, Mrs. Kamerer provides trainings on learner-centered teaching pedagogies including simulation, as well as consults on development of simulation curriculums, research, and grant writing. Her medical background includes emergency medicine, mental health, and neonatal intensive care. She has a specialist RNC certification as a neonatal intensive care nurse. Mrs. Kamerer has been published and presented locally, nationally, and internationally on a variety of topics related to simulation, innovative teaching strategies, and neonatal medicine. She is currently a nursing faculty member and Director of Online Nursing Programs at Robert Morris University.

Faculty Disclosure

Contributing faculty, Jessica Kamerer, EdD, MSN, RNC-NICU,, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Jane C. Norman, RN, MSN, CNE, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

Technical Requirements

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#31212: Teaching Healthcare Professionals Using Simulation

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INTRODUCTION

Simulation is not a new concept to education. In its earliest uses, it was role-playing or skill demonstration on models. Many nurses gave their first intramuscular injections on oranges. Though low-tech versions, they were still a type of simulation. Great educators know that learner-centered education is a key component to student engagement and knowledge retention. When coupled with an immersive learning environment in which students can practice hands-on learning, it is a recipe for success. Simulation learning has come to have many definitions. The National Council of State Boards of Nursing (NCSBN) defines simulation as, "activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision making, and critical thinking through techniques such as role playing and the use of devices such as interactive videos or mannequins" [1]. Simulation is a teaching practice and a tool, not just a technology. With any educational practice or tool, a good educator will start with the content to be taught and then determine which technologies will best enable learning [2]. For medical education students, simulation often is the best technology to utilize given that it allows realistic and immediate feedback for participants without risking patient harm.

Simulation is growing in popularity in nursing and healthcare educational systems across the country. A 2010 survey of 1,060 nursing programs across the United States reported that 87% were using simulation in their curriculum [3]. The benefits of simulation are widely accepted, as it offers the opportunity to practice repeatedly and safely [4]. Its use is driven by the demand for educated healthcare professionals resulting from the growing national nursing shortage, the need to practice skills without harming live patients, and the increasing ease of its usage and availability. Competition by healthcare schools nationwide for clinical sites has resulted in the use of simulation as a model for clinical supplementation. The technology is popular among the technologically savvy younger generations and is appreciated by others. Simulation can be used for teaching new skills, testing competency, and improving team dynamics. It offers a unique, controlled, learner-focused educational environment that can mimic real-life situations and experiences. A 2014 NCSBN study showed that replacing up to 50% of clinical hours with simulation in prelicensure nursing education achieved comparable student outcomes (e.g., clinical competency, pass rates) to traditional clinical experiences in nursing education (i.e., simulation used in less than 10% of clinical hours) [43].

Virtual simulations (i.e., video game-like interactive computer programs) have now grown in popularity, with 65% of nursing programs using virtual simulation according to a 2016 national survey [44]. Although this technology will undoubtedly become nearly ubiquitous in the near future, it remains to be proven to what extent virtual simulation can replace clinical hours or live simulation. One provider of virtual simulation claims that their products improve clinical competency, content knowledge, critical thinking, and self-confidence equivalent to traditional live-action simulation [45]. Those who have studied the effectiveness of virtual simulation seem to concur. They emphasize that this technology may be able to imitate real-world, high-risk scenarios better than clinical hours because the intensity of life and death scenarios can be played out fully in virtual reality, and the low cost of virtual simulation may provide a more widespread opportunity for nursing students to think critically and build confidence.

Being used by nurse educators, faculty, and residency programs, simulation is a valuable learning tool that appeals to visual, kinesthetic, and auditory learners. Simulation is considered a more interactive learning strategy than traditional lecture methods [5]. Few other teaching modalities can claim this, and students often learn well in these educational experiences. There are a variety of simulation tools that can be employed to make an exceptional educational experience. This course explores the history of simulation use, uses of simulation, how to use simulation as a learning tool, effectively creating a simulation scenario to meet educational goals, and proper debriefing tactics for simulation educational sessions.

HISTORY OF SIMULATION

Simulation had been adopted in many professions before it took hold in health care. The most well-known early use of simulation was by the aviation industry. It was instituted in pilot training beginning in the 1970s, after recognition of the devastation human error in this context could bring to the public [6,7]. The impetus of this change was the sentinel event of the tragic airport disaster in 1977 at Tenerife in the Canary Islands. This well-publicized aviation incident was the result of a breakdown in communication and flight crew errors that led to two Boeing 747 passenger crafts colliding on the runway, killing 583 passengers. It remains to this day the deadliest aviation accident in history. The incident received worldwide attention, and the airline ultimately claimed responsibility, paying millions in restitution to victims' families. Still used in a variety of trainings today, re-enactment videos and hundreds of articles regarding the incident have been published. In 1979, investigators for the National Transportation Safety Board reported that at the time, human error was the cause of 60% to 80% of aviation accidents [6]. In the 1990s, Crew Resource Management programs blossomed [7]. These programs focused on interdisciplinary communication, team building, and simulation of crisis events to improve flight crew performance and lessen aviation errors that could potentially lead to civilian deaths or injuries [8].

The U.S. military also adopted the use of simulation as an effective means of training soldiers. Simulation is still used today for military medical personnel to teach or maintain skills for a variety of tasks, but most notably for high-acuity, low-circumstance situations. However, its use is not just health care related; simulation has been used for years in the military to teach everything from gun safety to military strategy with war games. The military uses a variety of simulation modalities, creating some of the most advanced virtual simulations and computer learning in the world. This is important, as simulation should mimic reality as much as possible to foster experiential learning in a realistic environment [9]. Although it is a very useful tool, the military also realizes there is only so much one can learn from electronic means. Some skills require tactile and psychomotor practice to perfect what a virtual world cannot replicate.

With the increase of military reserve unit personnel in the last few decades, advanced medical simulation exercises have been utilized to maintain skills when not in active duty. Some military units will even partner with civilian simulation centers to provide these trainings if their resources are scarce or unavailable [10]. Using simulation to maintain skills of reserve military members while they are not in active duty ensures they will be prepared if called into active duty. An underprepared medic is of no use to anyone in battle, during which skills can often mean the difference between life and death.

Many industries have found uses for simulation to increase productivity and even sales. One of the most famous innovators of simulation was Walt Disney, who strongly believed in the need to simulate in order to innovate, even from the start of his career [11].

Although aviation and military industries have been using simulation for decades, medical schools have also adopted its use, and nursing and other allied healthcare schools have followed [12]. As the technology has grown to meet the needs of medical industries and become more cost effective, user friendly, and realistic, it has come to be very common to see schools and hospitals using simulation to train healthcare professionals. Publicity has also brought simulation equipment to the masses. Potential healthcare students consider universities' and colleges' available simulation equipment when choosing a school. Today's learners live in a technology-rich environment, and today's healthcare market demands the use of technology in their training. Educators must meet these demands by learning to integrate this technology into their practice.

Technology is used by students in their everyday life. Even if students can text and search the Internet, they may not be prepared for the types of technology they will be expected to use when they graduate. Computerized charting, point-of-care information capturing devices, monitors, smart pumps, and accessing or viewing online medical test results are just some of things they will be expected to do. Simulation may be used as a way to bring these students up to par when they enter the workforce [13]. Traditional case studies, reading assignments, and course lectures can only take students so far; educators must adapt their practices to address these modern needs.

Training and education in healthcare professions can be flexible; it can be easily adapted to meet the needs of the learners and improve performance either for the schools or organizations [14]. Simulation was originally considered a way to teach skills to medical students. As technology and teaching methods have grown, its uses have also grown. It is now used to teach and develop procedures, develop critical thinking, crisis training, multidisciplinary team development, and communication skills. With mannequins so advanced they can react to medications, blink, bleed, talk, and respond to interventions, educators are beginning to question whether it is ethical to teach students on live patients. Interest in simulation-based education has also been heightened in risk management departments, where the use of simulation to train staff is touted as both a cost-saving and life-saving tool. The benefits of simulation can be difficult to identify, because they are hard to assess. Instead of direct outcomes, more vague influences may need to be observed, such as increased effectiveness of health care and reduced medical errors [15].

Today, there are many forms of simulation. The most well-known simulation tool is the human patient simulator, a full-body mannequin model that may have various levels of technology. The technology is classified as fidelity, with ranges on a continuum from low to high according to the degree to which they most closely represent reality [16]. There are also task trainers, virtual or flat-screen simulation, and standardized patients. However, as the most popular form of healthcare simulation, the human patient simulator will be the focus of this course.

APPLICATIONS

Innovation and simulation have found their place in various arenas in the healthcare realm. Simulation focuses on active learning, with a purpose of building learner confidence and enhancing clinical judgment [17]. The ultimate goal of the educator when using simulation should be to create a learner-centered educational experience to foster optimal educational outcomes. Simulation-based education has a wide variety of applications in health care, including academics, staff development, competency maintenance, and team development.

ACADEMICS

When used as a teaching method and not just a piece of technology, simulation can be invaluable in educating students. It is difficult to use simulation to replace physical contact with live patients, but it can make student and faculty time in actual clinical environments more valuable and cost-effective [1]. It creates a learner-centered environment whereby students can take on the role of the healthcare provider, allowing students an avenue to practice skills within their potential scope of practice (instead of under the limitations of a student). Students can face situations they will need to manage as new practitioners in an environment where they can make mistakes and see the consequences without risking patient harm [18]. When taught in the hospital setting, students have to function as students, with limited scope and responsibilities. When used in a lab, simulation allows students to act out scenarios to learn about specific procedures and case presentations.

Creating realistic, student-driven simulations can increase critical-thinking skills and knowledge retention. However, these scenarios can prove difficult for educators who are more accustomed to teacher-centered, traditional, lecture-style instructional methods [19]. However, when used as an immersive learning environment, simulation scenarios require minimal faculty involvement limited to facilitation. In these scenarios, students are provided the opportunity to link didactic material to the clinical environment without the fear or anxiety of possibly inflicting patient harm. Students also have the luxury of having instant feedback to their interventions and actions.

When used as an adjunct to traditional lecture courses, simulation can keep students engaged in the classroom. Bringing a mannequin to the classroom can bring case studies to life, providing a means for demonstrating procedures, physiologic responses, or case presentations. For example, instead of having students read and listen to a lecture about bacterial meningitis, a hands-on option could be added. A simulation exercise coupled with this lecture content could show students the characteristic rash, how the acute illness can rapidly progress if untreated, and a demonstration of positioning for a lumbar puncture procedure or possibly even intubation for airway management. Instead of appealing to one type of learner (the auditory style), the lesson would also engage the active and visual learners to make a richer learning experience for everyone.

Simulation can also be used as a supplement for clinical experiences. With student enrollments increasing to meet the demands of projected shortages, clinical site competition between schools is growing, making it difficult for faculty to provide everyday clinical experience for students. Days with a dearth of patients, surgeries, or experiences do occur, most commonly in specialty areas like pediatrics or maternity. Simulation can be a solution to these situations, allowing for a productive use of resources instead of wasted down time.

Simulation may also be a way for clinical instructors to evaluate the level of performance of their students. Often, instructors can only be with one student at a time, running from one student to the next to pass medications, help interpret charts, answer questions, and possibly assist with procedures. Simulation allows instructors to work with and evaluate multiple students instead of only one at a time.

Watching students during a simulation exercise can provide a wealth of knowledge to educators. They can see which of their students understand content, which need practice with communication skills, which step up to the leadership role, and which need remediation. Educators can evaluate students in a standardized environment. For example, students may be assessed on their ability to perform a pediatric physical assessment without the participation of parents, an uncooperative child, or clinical area activity (i.e., distractions), unless the instructor designs these factors into the experience.

STAFF DEVELOPMENT

Educators in staff development are also increasing the use of simulation as a means of working with licensed healthcare professionals. From physicians in residency programs to graduate nurses, the flexibility and personalization of this teaching modality has appeal to most everyone. The most commonly used application in this area is for training purposes, to teach new skills or reinforce previously learned ones. The skills can be task-focused for the beginner-level learners, and complexity can be increased with the level of knowledge of the learner. For example, the instructor may be interested in teaching staff how to perform a breast exam on female patients. This very personal task is relatively simple to perform, but it can be intimating to students due to the importance of doing it right to detect breast cancer and the intimate nature of the patient contact. The students can be presented the methods and then given breast exam task trainer models on which to practice. When they can demonstrate proper completion of the breast exam on the models, a level of complexity can be added. The task trainer can next be applied to a person or a mannequin. This adds a more personal element and can help students overcome the social anxiety that may be associated with the exam. Students would have to also practice communication skills when interacting with the "patient" as well. For the most advanced students, the model could even contain a lump, which would then require the student to deliver bad news and treatment options to the patient. Tying the emotional aspect to the clinical knowledge in these exercises creates a memorable learning experience and can help with knowledge retention and transference into clinical practice.

Remediation is another application for staff development. There are times when staff require additional practice or another chance to catch on to a procedure, skill, or task. Simulation can be a way to put individuals in a safe learning environment, so remediation can be most effective. Instead of capitalizing on those negative thoughts and singling a staff member out to demonstrate a specific skill, simulation can be used to put them into a clinical setting and recreate their comfort zone, helping them to relax and perform at their optimal level.

EVALUATION METHODS

Simulation as an evaluation method can be used in many facets of healthcare education. The value of using simulation for evaluation is being increasingly appreciated, as traditional methods of testing (such as observation and oral exams) are limited in their ability to distinguish between adequate and inadequate clinical performance [20]. For example, the Objective Structured Clinical Examination (OSCE) medical and nurse practitioner students pass in order to obtain licensure is incorporating more simulation in place of real patients. OSCEs may even have a place in other health profession's licensing exams in the future.

On a simpler scale, simulation can be used for individual courses. It provides a unique opportunity for instructors to create a clinical environment conducive to testing without the variability of real-life circumstances. Simulation can be used as a tool to test simple skills such as Foley catheter insertion or more complex concepts such as shift report or hand-off communication.

However, using simulation as an evaluation method is not without its downside. There is a risk that using simulation this way will ruin the safe learning environment created for education. It is important to be upfront with learners about the goals of the experience. When students know what is expected of them, they can feel prepared and act accordingly. When they come with one expectation (the experience is for learning) and are asked to complete another (an examination), they may feel that they were not informed or allowed the opportunity to be prepared. In addition, the technology can be distracting for some learners, who may focus entirely on the mode of simulation and ignore the patient.

COMPETENCY MAINTENANCE AND TESTING

Many professionals complete tests in order to validate their level of performance and to continue clinical practice. This can be specialty-specific skills, such as how to work certain equipment or complete certain documentation methods, or it can be renewal of certifications required to work, such as advanced cardiac life support (ACLS), pediatric advanced life support (PALS), or neonatal resuscitation. Whatever they may be, organizations are required to show their staff have displayed the skills necessary to safely practice.

The traditional method of evaluating these designated competencies is skill demonstration stations. Using this model, staff demonstrate their designated requirements to a validator, who would then sign them off to the organization as safe to continue to practice. This can be time-consuming and labor-intensive and is not the most effective means of completing competency validation. Staff usually also have the option of being signed off on the skill when performing patient care, but this can be dangerous and may take unnecessary risks.

Simulation can be used in place of or in conjunction with demonstration stations to help evaluate staff and develop professional knowledge, skills, and attitudes while protecting patients [21]. Creating a simulation that incorporates the essential elements of competency can be a more effective means of testing. Small teams could participate and be evaluated, and teams could include various disciplines. This would allow individual skills to be tested, as required, and would promote team building and communication skills.

TEAM DEVELOPMENT

Using simulation for team training shows promise in impacting knowledge, attitudes, and behaviors of a team's skills [22]. The goal is to produce efficient healthcare teams that optimize the use of people, resources, and communication to create a safer care environment for patients. In aviation, these team-building simulations were called crew resource management; the adaptation in health care is commonly termed crisis resource management (CRM).

CRM has become a training methodology to develop healthcare professionals who can efficiently work within a team to perform in high-stress, life-threatening situations by applying concepts of leadership, communication, assertiveness, decision making, and team performance [23]. Emphasis in CRM courses is placed on behavioral skills, such as communication, leadership, and situational awareness [24]. Within healthcare organizations, professionals have often become accustomed to working in silos; nurses work well with nurses, respiratory therapists work well with respiratory therapists, and physicians work well with physicians. When members of these various disciplines are pulled together, it can be confusing to determine who takes the lead, how to communicate effectively, or how to understand each other's scope of practice. Problems in the interdisciplinary team are enough of a problem when they happen during a less risky task, such as transporting a patient to a new room. But when team breakdown and communication difficulties occur in an ad hoc crisis group, such as a cardiac arrest team, this disconnect can lead to sentinel events and poor patient outcomes. CRM is geared to address these concerns.

Most CRM trainings consist of different parts. The first is a didactic portion that covers the background and principles of CRM. Then, there is trainee participation in a simulation scenario, whereby they manage a crisis event. This is followed by a debriefing of all the participants, during which a critical analysis of the simulation event and self-reflection of their performance is completed, often utilizing video debriefing [23]. The participants should be multidisciplinary, including for example, nurses, physicians, and respiratory therapists. Having representatives from various disciplines fosters collaboration, understanding, and communication among the team.

In order to facilitate better communication, some healthcare organizations have adopted the SBAR technique for communicating information among healthcare professionals of various disciplines. The acronym SBAR refers to four steps in effective conveyance of patient information [42]:

  • Situation: Identify oneself, the patient, and the current problem

  • Background: Relay pertinent background information

  • Assessment: Clearly describe the current assessment of the situation

  • Recommendation: Outline any recommendations for safe and appropriate care

Simulation scenarios may be used to gauge a team's communication techniques and adherence to the SBAR standard.

Derivatives of CRM and SBAR courses have been created for team training. The Agency for Healthcare Research and Quality has established the TeamSTEPPS program, a three-phase teamwork system that is evidence-based and aimed at improving patient safety by improving communication and teamwork skills among healthcare professionals [25]. Other trainings exist, but the basis is the same: improve patient safety by teaching healthcare professionals how to work effectively in a team.

CREATING A SIMULATION SCENARIO

Producing an effective learning environment with technology is a challenge [26]. Hayden reports that among 1,060 nursing school respondents, 78% have faculty members who write their own simulation scenarios, but of those, only 30% have received any training on how to do so [3]. For many just starting to use simulation, the most difficult step is getting started. Many companies and even some text book publishers are beginning to sell prepackaged simulation scenarios with varying levels of complexity. These can be convenient to use, but as educators start to do more teaching with simulation, these generic, premade scenarios are not likely to meet all their needs. This section will discuss factors educators should consider when creating their own learning experiences with a simulation scenario.

The very first step is to establish the goals. These goals will determine the complexity and the type of scenario that should be created. For example, is the goal for the students to practice taking vital signs while distracted by patient questioning or is it to know when to call a physician for orders? Maybe the goal is more complex, such as teaching how to prioritize patient care needs or to develop and utilize critical-thinking skills. After the goals are defined, then the scenario can be formulated.

RESOURCES

When the goals have been set, the topic or content to be covered must be selected. This can be overwhelming if a large amount of content is being taught. Most often, the content of a simulation stems from a disease process. For example, the simulation content might be on postpartum hemorrhage, exacerbation of congestive heart failure, or care of a pediatric patient with an asthma attack. There may be an abundance of resources available when choosing a simulation topic, but they may need to be looked at from a new perspective. Possible resources include case studies, real experiences, course content students seem to struggle with understanding, test scores, or exam blueprints.

Many healthcare teachers already rely on case studies to teach content, and these can be adapted easily into a simulation. Consider using a simulator to show physiologic changes instead of having students read about them. Use test scores to identify students' weak areas or topics that require supplemental instruction; students may historically seem to have trouble comprehending a certain set of material. This material can be provided in a simulation activity that will appeal to more learning styles and possibly close the gap between comprehending the didactic material and applying it to a clinical situation or the gap between classroom instruction and the unpredictability of clinical areas [27].

WRITING OBJECTIVES

When goals have been set and content chosen, it is then time to create measurable objectives. It is vitally important to write clear, specific, and measurable objectives, as successful simulations rely on carefully planned scenarios with clear learning goals and objectives [28]. Objectives will guide the instructors and the participants. This is a great time to determine if the simulation is going to be used for learning, remediation, or educational purposes. As discussed, being upfront about the purpose of the session will keep students on task, focused, and in a learning-centered consciousness while participating.

Clear objectives are also very important if the person writing the scenario will be different than the person running it. For example, some institutions have faculty who write a scenario for a course, and the learning activity will be used by all students and taught by other clinical instructors. In order to maintain as much consistency as possible for the students between the clinical groups, the objectives must be clear and specific, so all faculty and participants are held to the same standards.

Learning objectives should also have a time frame. They should specify if learners are expected to meet the target(s) during the simulation scenario, prior to arriving for the simulation activity, or in the debriefing session afterwards. Objectives should also be specific. If students are expected to complete a cardiac assessment, explain what that means. Is it expected they listen to heart sounds in all fields, attach the patient to a monitor and interpret their electrocardiogram rhythm, and/or obtain a history of all related illness and medications? Definitions may vary among faculty members, so being specific will clarify discrepancies. Lastly, make sure the objectives are measurable. These are all important things to be considered; examples of properly written learning objectives will be provided later in this course.

APPLYING LEARNING DOMAINS

Learning occurs best when it can be applied to multiple learning domains. The affective, cognitive, and psychomotor learning domains are important because they address the types and styles of learning among students. The affective domain applies to attitudes, beliefs, values, feelings, and emotions. Learning in this domain occurs when students relate their feelings or emotions to the content they are learning. Many faculty members find it difficult to address this domain when instructing, as traditional, faculty-centered education for large numbers of students often does not directly relate to feelings, emotions, or values. The cognitive domain includes knowledge, comprehension, application, analysis, synthesis, and evaluation. Conventional lecture-style courses typically apply to the cognitive domain, as their purpose is to transfer knowledge from the professor to the students. Finally, the psychomotor domain relates to motors skills, including both gross and fine. It encompasses the physical doing of things or the demonstration of skills [29]. Demonstration requires the student to perform or physically do the skill in the objective directed to address the psychomotor domain. For example, teaching a child to tie his or her shoelaces is a type of psychomotor learning. Examples of objectives as they apply to each of the learning domains include:

  • Cognitive: Students will correctly prioritize physician orders and patient care for completion. This includes when to complete an assessment and contact the physician and organizing orders for completion by priority.

  • Affective: Students will actively discuss their feelings and concerns of the simulation experience in a debriefing session related to knowledge application, physiology, and medication administration.

  • Psychomotor: Students will correctly demonstrate how to insert a Foley catheter while maintaining sterile technique in the simulation exercise.

The verbs of each objective are directly related to the associated learning domain.

Students who learn best in the cognitive domain may not comprehend material when it is only addressed in the psychomotor format. This is important to consider when designing any learning session, so all domains are used to help multiple learners increase their comprehension. The simulation modality can appeal to all three learning domains. Students must recall knowledge (cognitive) to perform the appropriate interventions to care for a patient (psychomotor) that will then be discussed in the debriefing session (affective).

CREATING CONTENT

The next step in creating a simulation scenario is to write the content. An easy method to begin is the creation of an outline. The major headings of the outline should answer the following questions:

  • How should students find the scenario?

  • What stages should the scenario proceed through?

  • What should happen if students do things correctly or incorrectly?

  • How will the scenario end?

This outline will tell the person managing the simulation how it should be set up (I), how the simulator should be programmed (II), how they should adjust simulator settings based on the student performance (III), and when to end the session (IV).

There are simulation scenario templates available from publishers and organizations and in the literature. For example, the National League for Nursing's (NLN's) Simulation Innovation Resource Center (SIRC) has free, downloadable templates available on their website (http://sirc.nln.org). Exploring these templates may be helpful in finding a format that is easiest to understand, adapt, and work from when managing and writing scenarios. The templates often include areas to create supportive documents and information for students, such as physician orders or test results.

Create the Environment

Setting up the simulation will determine how students will find the simulator when they arrive. For example, if the session is about a patient who falls at home, the students might find the simulator dressed in street clothes on the floor. Or if the scenario is about an intensive care unit (ICU) patient who is having an acute myocardial infarction, the simulator should be dressed in a hospital gown, lying in a hospital bed, attached to a monitor, in a room set up to look like it is in an ICU. How the simulation is prepared will provide clues to the participants as to how to get started and the guidelines they are expected to apply. If they are acting as home care nurses for the first example, they will have different resources and skills than the nurses in the second scenario caring for the ICU patient. Establishing the scenario also includes creating the patient history and determining how it will be relayed to participants. A report could be given verbally, or a faux patient chart could be created and placed in the room for review.

Identify Stages

Next, it is important to determine the stages of the simulation according to the progression of the illness for the case; this is usually done by following the normal presentation of the disease on which the scenario is based. Each time there is a change in the patient status, a new section of the outline should begin, and these sections will become stages for the scenario. Each stage should include assessment findings, such as lung, heart, and bowel sounds. For example, a scenario about a patient having a myocardial infarction could include three basic stages: presentation, worsening of symptoms needing intervention, and recovery after proper interventions have been instituted. The vital signs should be listed for each change in status/stage as well. It is also helpful to list the interventions students are expected to complete and how much time should be spent on each stage.

Reactivity

The third part consists of reacting to the student's performance. A good amount of improvising will be necessary while managing the scenario, but it is vital to plan ahead as much as possible when writing a simulation. The simulator should know how to react if the students do what is expected or if they do not perform as intended. The simulator should "respond" to the participants' interventions by changes in vital signs or by giving verbal feedback as the patient. Consider using the simulator as a cuing mechanism to guide students as well. For example, if the expected behavior is to apply oxygen to the patient but the students are not doing so, oxygen saturations may decline in response to their lack of intervention and/or the patient may complain of increasing shortness of breath. Other signals that can be worked in are calls or visits from "ancillary staff" (actors/faculty members pretending to be healthcare team members) to cue students. For example, if a scenario requires students to interpret lab results before it progresses, someone could call in as the physician and ask for a patient status update, including the lab findings. This would trigger students to interpret the lab test(s) without the faculty having to interrupt the learning process.

Wrap Up

The final part of writing a scenario outline is to consider how it should end. Wrapping up the simulation is important, and how it is done matters to learners. It can be worked into the exercise or stopped when notification is given by the instructor running the activity. If it is worked into the exercise, make sure it is clear the point is to end the simulation. For example, if the end of the scenario is just when all the expected interventions have been completed, participants will not know when to end; because they are not privileged to know what all the expected behaviors are, they will keep performing until informed to stop. An alternative is to make the case end in a way that is conducive to real life, such as needing to give report to the next shift via hand-off communication or the patient transporter arrives to take the simulator to an ordered test or for a procedure. Either verbally telling or working the end of the scenario into the simulation is acceptable, as long as it is clear when the activity is to be concluded.

Evaluation of Appropriateness and Realism

It is very important when creating simulation curriculum to consider if the scenario is appropriate. This includes making sure the activity meets the needs of the learners and is at a level at which they can be successful when they participate. Questions to consider are: Does it fit the level of student? Does it need to be simplified? Does it need to be more difficult? Does it need more subtle or obvious cues? Remember the learning goals and objectives and relate them to the student population. It is easy to get carried away and want to include many things in the scenario. This can lead to making the simulation too complex or the objectives unachievable. Remember the time frame of the scenario and only include an attainable amount of items that can be completed.

The level of the learner should dictate the complexity of the experience. Scenarios should address the learning objectives, but also be written to the level of the learner [30]. If participants are first-year nursing students, the scenario must contain more basic concepts, with many or obvious cues. For more experienced learners, such as for a staff development course, the concepts should be more complex, with subtle cues to invoke communication and foster critical thinking among participants. Distracters can also be used for higher level students. Distracters refer to items worked into the scenario that students must manage in order to be successful. For example, a radio could be playing loudly, and students would be expected to manage the noise (turning the radio down or off) so communication is clearly heard and understood between participants.

It can be very beneficial to consider having peers review a new scenario before implementing it. They can offer advice regarding whether the simulation meets the objectives, is appropriate to the learners' skill level, and can be understood or requires clarification.

After a simulation is written, it should be evaluated for "realness." The overall goal of using simulation is to provide a realistic, safe learning environment for healthcare students to practice their skills. When creating the experience, consider how to make it more realistic for participants. Using props is one way to add realism, and this can include things like a patient chart, an identification band, and patient belongings in the room. Having the students call a person to get needed services, results, or equipment is also more realistic. Giving them a live person to talk to, instead of just requesting items and having them arrive, forces students to communicate professionally and allows them to experience the importance of being clear about their requests to get what they need. Giving the simulator a voice also adds a level of realism to the case. Learners may find it awkward at first to talk directly to a plastic mannequin, but as they get involved and the mannequin answers back, it gets easier.

The experiential learning aspect of simulation calls for participants to understand that their actions have reactions. There must be a correlation between how they perform in the scenario and how the patient responds in order for proper learning to occur. A suitable way to achieve this is to have the simulator's vital signs or status change based on how the students perform. When a role-playing nurse administers nitroglycerine, the myocardial infarction patient should voice some relief from pain and his or her blood pressure should improve. If it is what is expected to happen in real life, the student should experience it in the simulation.

Moulage is also an excellent way to add realism to a scenario. Moulage refers to the application of makeup or decals to create mock versions of disease or injuries in simulations. An example could be creating a necrotic pressure ulcer on the sacrum of a bed-ridden patient. Moulage can also utilize props, room set-up, or faux body fluids to simulate diseases. This can create a sense of realism for the activity and help to suspend the disbelief of the participants. Moulage should be added to scenarios whenever possible and kept in the context of the learning exercise. If it is used too much, however, it can be more of a distraction than a help to students. It is also important to investigate what materials are safe to be used on simulators before being applied, as many mannequins and models have skin that is easily stainable.

SCENARIO OUTLINE EXAMPLE

The following is an example of an outline for a simulated learning experience. The case is designed for nursing students learning how to manage a patient during a postpartum hemorrhage.

Title: Postpartum Hemorrhage Simulation

  1. How should students find the scenario?

    1. Room: Postpartum care unit room

    2. Simulator: Female, in hospital gown with fundus module on abdomen

    3. Moulage: Approximately 500 cc of faux blood on dressing (e.g., Peri-Pad), underwear, and bed sheets

    4. History: Patient J is a woman, 23 years of age, gravida 1 para 1, 2 hours status post spontaneous vaginal delivery of male weighing 9 lbs 7 oz, with no significant past medical history.

  2. What stages should the scenario proceed through?

    1. Stage 1: Initial presentation

      1. Vital signs: Heart rate 100 beats per minute, blood pressure 92/60 mm Hg, respirations 22 breaths per minute

      2. Assessment: Patient anxious, diaphoretic, and uncomfortable. Fundus boggy on palpation. Complains of feeling "wet."

      3. Expected interventions: Complete assessment, contact healthcare provider to report a patient status change, and obtain orders for treatment

      4. Time frame: 10 minutes

    2. Stage 2: Progressing hemorrhage

      1. Vital signs: Heart rate 130 beats per minute, blood pressure 84/50 mm Hg, respirations 28 breaths per minute

      2. Assessment: Patient becomes disoriented and has difficulty breathing.

      3. Expected interventions: Implement healthcare providers orders:

        • Perform continuous fundal massage

        • Administer 500 mL normal saline solution with 30 Units oxytocin IV to run at 150 mL/hour

        • Give methylergonovine 0.2 mg IM injection

        • Administer oxygen via nasal cannula at 2 liters

        • Obtain a complete blood cell count, type, and screen

        • Administer misoprostol 600 mcg rectally

      4. Time frame: 10 minutes

    3. Stage 3: Stabilization and recovering after orders implemented

      1. Vital signs: Heart rate 90 beats per minute, blood pressure 104/60 mm Hg, respirations 18 breaths per minute

      2. Assessment: Fundus becomes firm; patient's breathing and vital signs stabilize.

      3. Expected interventions: Monitor patient until stable.

      4. Time frame: 10 minutes

  3. What should happen if students do things correctly or incorrectly?

    1. Stage 1: If done correctly, progress to stage 2. If done incorrectly, have patient vital signs decline and patient complains more of being anxious, dizzy, and very wet.

    2. Stage 2: If done correctly, progress to stage 3. If done incorrectly, have patient become unresponsive until interventions are initiated.

    3. Stage 3: If done correctly, end simulation. If done incorrectly, have patient question about their blood pressure and bleeding until patient is assessed.

  4. How will the scenario end?

    1. Option 1: Verbally tell participants simulation has ended.

    2. Option 2: Have physician arrive and request update on patient. After given, inform participants their shift is over.

CONCLUSION

Welcoming the use of simulation as an educational tool into one's teaching practice can be rewarding for educators and their students. Its increased usage in many fields and the growing research on effective methods leading to improved learning outcomes gives credit to this modality. The learner-centered approach gives real-life applicability to clinical problems that can produce opportunities for participants to analyze, apply, and synthesize new and previously learned content [41]. However, these methods can be challenging to learn and master. When first starting out, educators may find it helpful to shadow or mentor with another faculty member proficient in these methods. Using simulation is a teaching practice with a wide array of applicability in healthcare education and staff development. Educators can adopt published scenarios or create their own. When coupled with an effective, learner-driven, reflective debriefing session, the educational rewards can be monumental for all involved.

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