Curriculum Development: Where Does Simulation Fit (Models and Approaches)

1. Curriculum Development: Where Does Simulation Fit (Models and Approaches) JCCC Simulation Conference September 17-18, 2010 Pamela R. Jeffries PhD, RN, FAAN, ANEF

2. Objectives: The participant will be able to: • Describe different simulation models that can be incorporated into your teaching • Discuss the deliberative practice curriculum model to use in simulations • Identify various other types of simulations to incorporate in the nursing curriculum

3. Models of Simulations • SCAPES • Deliberative Practice Model • Unfolding Case Model

4. Uses for Different Types of Simulations For Different Teaching Areas (SCAPES) • S = Skills Training • C = Communication Skills • A = Assessment of skills and critical behaviors • P = Problem-solving, decision-making • E = Exemplary Teaching the Teacher • S = Simulated Teamwork and collaborative learning

5. S= Skills Training • Part-task training devices, such as IV arms and haptic (forced feedback) IV trainers are used in simulations for psychomotor skills with the learner able to practice a skill repeatedly before performing it on a real patient. • The part-task trainers typically ensure a satisfactory rate of achievement of objectives and benefit to the participant. • Studies have shown that these task trainers do instruct the participants on the psychomotor skill and that the skill set is transferred to the real-patient environment (Engum& Jeffries, 2002; Hovancsek& Horn, 2004).

6. Part-task training - Skills • Part-task training devices, such as IV arms and haptic (forced feedback) IV trainers are used in simulations for psychomotor skills with the learner able to practice a skill repeatedly before performing it on a real patient. • The part-task trainers typically ensure a satisfactory rate of achievement of objectives and benefit to the participant. • Studies have shown that these task trainers do instruct the participants on the psychomotor skill and that the skill set is transferred to the real-patient environment (Engum& Jeffries, 2002; Hovancsek& Horn, 2004).

7. Traditional Learning Method Computer Virtual Reality Learning Method

8. C = Communication Skills • Students can learn to communicate and gain confidence in talking with family members and parents before going to the pediatric clinical setting • Students learn how to communicate with a grieving family member in an end-of-life scenario

9. A – assessment Skills • Students can use various types of patient simulators to learn and practice their assessment skills. • Full head-to-toe assessment can be done in addition to specific auscultation skills, e.g cardiac and respiratory sounds

10. P = Problem Solving and Decision-Making using Scenario-based Simulation • Students are immersed in a 20 minute simulation followed by a 20 minute debriefing with a focus and objectives directed toward caring for a post-thoracotomy patient and what to do when the patient has tachypnea and chest pain

11. E = Exemplary Teaching the Teacher • A new clinical model at JHU SO is the PEP unit, where staff nurses become the instructors for the students; faculty now precept and work with faculty • Simulations are set-up to teach faculty how to ‘deal with a difficult student’ and other types of activities an educator may confront

12. S= Simulated Team work and Interdisciplinary/Intraprofessional activities • Simulations are ideal to promote interdisciplinary collaboration among different groups of healthcare professionals • An example of an interdisciplinary scenario with a physician and nursing student working with a deteriorating patient

13. Teamwork Collaboration • Team skills such as a mega code, ACLS training, and other types of scenarios that are team-based can be done in a simulated environment using high-fidelity simulations. • Example AHA grant – training teams for ACLS

14. Simulations in-situ

15. Virtual Simulation and Patient Care

16. Deliberative Practice Curriculum • Cardiovascular assessment skills including auscultation are deficient among nurses today • Effective instructional methods are needed • Prior studies have shown that simulation technology and deliberate, repetitive practice resulted in a large and significant improvement in the recognition of simulated heart sounds and findings of actual human sounds (Issenberg, 2002).

17. A multi-site study to test deliberative practice of cardiovascular skills • A multi-site study was created to develop, implement, and evaluate outcomes from a cardiovascular assessment curriculum for Advanced Practice Nurses at 4 different institutions • 2 Project Directors – • Dr. Pam Jeffries – Johns Hopkins University SON • Dr. Barry Issenberg – Gordon Medical Research Center in Miami

18. Deliberate Practice Curriculum Features • Highly motivated learners • Engaged with well-defined objectives • Approved level of difficulty • Focused, repetitive practice • Rigorous, precise educational measures • Trainer monitors learning experiences • Advance to another task, once completed (Ericsson & Lehmann, 1996, pp. 278-279)

19. Goal in Deliberate Practice Constant skill, knowledge, or professional improvement, not just status quo. A. Ericsson 2007

20. Mastery Learning Goal: All learners accomplish all educational objectives without variation 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

21. Best Evidence Training Using Simulation • 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 Key Features of BEME Review of Simulation Issenberg, et al 2005

22. Methodology • Phase I – Curriculum Development Composition and Description • Phase II – Curriculum Evaluation – pilot tests • Phase III – Multi-site Study at 4 sites

23. Phase I - Curriculum Development Multi-center Collaboration • Univ of Miami Gordon Center • Michael Gordon • Joan Baker • Johns Hopkins Univ • Pam Jeffries • Florida International Univ • Jeff Groom • Lucie Dlugasch • Indiana Univ • Julie Settles • Texas Tech Health Sciences • Sharon Decker • Univ of Pittsburgh • Michael Beach • John O’Donnell

24. Instructional Tools - Harvey,The Cardiopulomonary Patient Simualtor Pulses Venous & Arterial Chest Wall Auscultatory Findings Cardiac Pulmonary

25. Instructional Tools - Introductory Program • Case-based • PowerPoint Format • Reviews Basics of Cardiopulmonary Assessment • Correlates bedside findings with cardiac anatomy and physiology

26. Instructional Tools - Nurses Learner Manual • Case-based • Basic Material • Vital signs • Heart/lung sounds • Recognize normal • Detect abnormal • Advanced material • Identify extra heart sounds • Identify murmurs • Diagnose cardiac, lung conditions

27. Instructional Tools – Instructor Guide • Operational Guide • Identify Learner Needs • Use in Different Contexts • Integrating into Curriculum • Assessment Methods • Research Opportunities

28. Instructional ToolsSelf-learning Multimedia Program • One hour learning module • Covers 12 most essential heart sounds & murmurs • Video-based instruction • Case-based with practice and testing sections Animations correlate with pathophysiology

29. Outcome Measures • Cognitive Knowledge • 31 item multiple choice exam • Skills Demonstration • 13 item skills check-list validated by 5 content experts • Self-efficacy • 3 item scale • Student satisfaction • 3 item scale • Instructor satisfaction and confidence • 8-item scale • Student training log

30. Research Questions • Can APNs perform accurate, cardiovascular assessment after completing the Harvey curriculum? 2. Is there a significant difference in nursing skill performance and clinical diagnostic reasoning pre-post testing? 3. Do students perceive improved self-confidence in their cardiovascular and clinical reasoning skills?

31. Research Questions (cont.) 4. Are students satisfied with instruction? 5. Are nurse educators satisfied and confident with the instruction? 6. What percent of students require remediation to obtain benchmarks set?

32. Phase II Curriculum EvaluationPilot Study • 2 sites conducted small pilot studies • Required students to assess selected findings • Significant data results obtained in pilot • Teaching assessed and findings applied to Phase III – multi-site study Pretest Posttest

33. Phase III - Current Study (Cohort) • Time Frame: January – June, 2009 • Institutions: • Florida International University • Indiana University • Texas Tech Health Sciences • University of Pittsburgh • Course: • Advanced pathophysiology or assessment of NP program

34. Study Design • Pretest • Knowledge - MCQ • Skills – Checklist • Confidence - Survey • Training Intervention • Pre-Self Study Program • Instructor Guided Sessions • Learner Practice w/Feedback • Self Study Program • Learner Training Logbook Advancement Remediation • Posttest • Knowledge - MCQ • Skills – Checklist • Confidence – Survey • Instructor Satisfaction MPS Achieved MPS Not Achieved

35. Results – Research Questions #1 & 2 Knowledge Can APNs perform accurate cardiovascular assessments after completing the Harvey curriculum? Is there a significant difference in nursing skill performance and clinical diagnostic reasoning pre-post testing? Pretest Posttest Skills Findings Technique Pretest Posttest

36. Research Questions #3 & 4 Do students perceive improved self-confidence in their cardiovascular and clinical reasoning skills? 1 – strongly disagree 5 – strongly agree * (p<.05) Are students satisfied with the instructional method using the Harvey simulator and curriculum? 1 – strongly disagree 5 – strongly agree

37. Research Question #5 Are nurse educators satisfied and confident with the instruction? 1 – strongly disagree 5 – strongly agree 1 – strongly disagree 5 – strongly agree

38. Research Question #6 What percent of students needed remediation to obtain benchmarks set? 11% of the learners required remediation (4 of 36 students)

39. Conclusion Educational intervention using simulation technology that engages learners in deliberative practice of clinical skills produces significant improvement and are highly rated by learners and instructors

40. Nursing Implications • Institute more deliberate practice into the nursing curriculum • Utilize the patient simulators for hands-on experiences • Students can learn from a variety of methods, e.g. deliberative practice, CD ROM, instructors face-to-face, therefore educators need to be encouraged to utilize different approaches to your teaching

41. Another Simulation Model/Approach Unfolding Cases • Using geriatric content as an exemplar • ACES – NLN work www.nln.org/ACES

42. STAGES Pamela Jeffries, PhD, RN, FAAN, ANEF, Project Director Teri Boese, MSN, RN Mary L. Cato, MSN, RN Jeanne Cleary, MA, RN Cynthia Reese, PhD, RN, CNE

43. Unfolding Simulation Cases STAGES Template for Unfolding Cases Monologue 1 Monologue 2 Simulation Scenarios Finish the Story Instructor Toolkit

44. Cases include: Complexity Missing information Varied settings Family dynamics/role strain Common syndromes of aging Differences in responses of older adults to illness Assessing risk/benefit in context of respect for individual’s preferences/values Evidence-based practice/use of validated tools Multidisciplinary team approach

45. Monologue Hello, my name is Millie. I live in Minnesota in the same house for the last 50 years. Harold and I raised Dina here and we had many good years together as a family. Harold passed last year. He was 91 you know, and I miss him terribly. I think about him every day. Snuggles, my cat, keeps me company. Location: Physician’s Office

46. Dina dropped me off and left me here. I’m not sure where I am or why I’m here. Why can’t I remember? They tell me I have an infection, but I don’t have a fever and I feel ok. Where is Dina? I haven’t seen her in maybe 6 years…. Location: Hospital

47. Simulation Cases Scenario 1 Assessment, appropriate use of assessment tools, communication Scenario 2 Falls risk assessment, conflict between patient and daughter Scenario 3 Functional assessment, discharge teaching, referrals

48. Free download http://sirc.nln.org

49. Instructor Tool Kit Ideas for how to use monologues Suggested for questions/guidelines for Class discussion Small group discussions Web-based discussion/assignments Reflective journaling Links to appropriate “How to Try This” tools