Taking Your First Steps

1. Taking Your First Steps Simulation Integration Beth Fentress Hallmark, PhD, RN Belmont University College of Health Sciences

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. McWhorter Hall Designed to house Pharmacy, PT, (Chem labs) 90,000 square feet Retail Pharmacy Health Services Clinic 4 Sim Rooms/SP and mannequins

10. 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.

11. Belmont’s SON Goals • Prepare the novice nurse for clinical practice • Link Concepts & Critical Thinking to Practice • Progressive Complexity • Theoretical Support

12. 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

13. 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

14. 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.

15. 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).

16. 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).

17. Simulation Training

18. Experiential Learning and Simulation • 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”

19. 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

20. 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”

21. Factors that increase risk of error • Environmental • Organizational • Individual • Team • Patient Related

22. 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

23. Advantages to using simulation • 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

24. “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

25. How can you use simulation? Crisis Management Flexibility Use factual knowledge Critical thinking Team interaction Response time Communication Skills Planning Strategy Multiple Decisions Collaboration

26. Where can you use simulation? • 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

27. 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.

28. Why Integrate Simulation? • Deliberate practice • Healthcare Technologies • Team training • Quality and safety • Delegation • Therapeutic communication/Inter-professional • Clinical Judgment/Decision-Making

29. 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

30. 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

31. 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!

32. 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!

33. Business Plan • Sustainability • Planning • Show ROI • Budget 3, 5 years out • Staffing

34. 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

35. 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.

36. Stakeholders! • Who? • Why? • Where ? • What can they do for you? • What can you do for them?

37. Curriculum Development • PLAN • PLAN • PLAN!!

38. 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

39. 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

40. 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

41. 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

42. Traditional Nursing Education • Didactic • Lab • Clinical • Orientation at workplace • CEUs

43. New Strategies • Simulation as a Teaching Strategy • Simulation as an Evaluation Tool • High stakes?

44. Types of Simulation • Case Study • Role-playing • Standardized patients • Partial vs. Complex Task Trainers • Static and Computerized • Integrated Simulators (HPS) • Virtual Simulation/Online

45. 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.

46. Simulation: Theory • Active Learning • Reflective Thinking • Constructivism

48. 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

49. 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?

50. Standards Identify your programs outcomes based on standards. • BSN Essentials • QSEN • IOM • Joint Commission • NCLEX • Core Competencies for Interprofessional Collaborative Practice