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 University Nashville, 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 University Nashville, 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 4 th 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. Adult Learner: self direction “High fidelity team simulation combined with reflective debriefing teaches learners to monitor and question their mental models and practice behaviors” “Vivid experiences in simulation stimulates the ‘need to know’ that motivates adult learner” Experiential Learning and Simulation

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

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. Realistic Learning Experience Medical issues Legal issues Patient relation issues Ethical issues Identification of Potential System Failures Repair System Failures Test New Systems Team Simulation Employee Satisfaction and Retention Student and Patient Satisfaction Risk Reduction $$$$$$ Savings Advantages to using simulation

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. Clinical time State by State regulations in nursing education Lab time Orientation In situ Remediation What areas do you have difficulties in clinical placement? OB? PEDS? PYSCH? EMR/MEDS? High Risk Lo Volume incidents Where can you use simulation?

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!!

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

51. How do I overcome: Faculty Resistance –Time –Resources Technology assistance, equipment –Pay –Administrative Assistance –Skills –Scheduling

52. What do I need? CHAMPION Administrative Buy In Money: Grants Staff Space Faculty Development Plan Policies Mission Vision Stakeholders

53. What do I need? Champion One or two people who are interested in this new pedagogy. Train the champions then bring back info to the rest of faculty Champion can send information to others in form of literature and conference ideas Lead simulation committee/group

54. What do I need? Administrative Buy In How to accomplish this? Bring in experts/consultants Take them with you to meetings Share with them what you learn at conferences Show them student evaluations Demonstrate how simulation works Peer pressure

55. What do I need? MONEY….. MONEY….. Grants State Federal Local community organizations National Private Funding groups

56. What do I need? Staff Simulation Director Faculty: Simulation Committee Group Technical Support: IT and Network specialist Supply specialist Scheduling

57. What do I need? Space STORAGE, STORAGE, and still MORE STORAGE!! Preparation Area Simulation Labs Partitions? Observation/Control Room Debriefing room

58. What do I need? Faculty Development Plan Conferences Lunch and Learn SIRC.NLN.org List serves –INACSL –SSiH NLN AACN Invite them to play a part

59. Components to a Simulation Student Preparation Objectives Report Actual Simulation Debriefing Evaluation

60. Student Preparation How does a student prepare for a simulation? Do you give them the case prior to the simulation? What are the objectives of the simulations? Formative or Summative Case Study versus procedural prep

61. Objectives Need to fit with curricular objectives and course objectives Case by case General safety and communication So many more

62. Report One example of integration Students need to learn how to receive and give report Use SBAR or other communication rubrics Ask practice partners for the system they use

63. Simulation Scenarios –Pre programmed –Make it your own Validate with practice partners Faculty script/training Reality: suspend Fiction Contract

64. Debriefing Reflection TRAIN faculty/method Learner uses previous knowledge to build upon Bad Habits develop if not addressed Video taping DASH model for training faculty

65. Evaluation MUST be based on your objectives! Remember to link your simulation objectives to your course..to your program..to the college..etc Formative or Summative Evaluation Evaluation rubric

66. Where can you use clinical sims?

67. What can we examine in acute care? Patient Safety Team Communication

68. Nursing Education Confidence Self-Efficacy Skills Communication Test scores NLN: High Stakes NCSBN: Clinical Replacement

69. Your curricular objectives should dictate what simulators, what information and what simulation you need Team simulation Skills are a small percentage of the training Process oriented simulation Leadership is essential Effective communication is a must component Education should be universal, pro-active and non-punitive ?HIGH STAKES? Examine Curriculum

70. Clinical Skills integrated in a summative simulation Sterile procedure: foley, dressing change Medication administration: insulin, Flu, pain med Vitals/assessment Clamp NG Introduction to Nursing

71. Severe dehydration Bowel Obstruction IV fluid bolus Oxygen Zofran Adult Health One

72. Post Partum bleed Antepartum: Hyperemesis, PIH, pre- term labor Mega Sim Scenario: Doctors office early labor delivery code and postpartum Obstetrics

73. Depression Schizophrenia: Neuroleptic Malignant Syndrome Alcohol withdrawal Psychiatric

74. PEDS Respiratory ALL Skills

75. Adult Health Two End of Life Codes Blood

76. Leadership Delegation Nurse practice Act

77. Other Disciplines OT and PT lines acute care Pharm medication dosage Interprofessional

78. Nursing Education Medical Education Literature review

79. Support: Find a Network Tennessee Simulation Alliance (www.tnsim.org) INACSL (www.inacsl.org) SSiH (www.SSiH.org)www.SSiH.org NLN SIRC (www.sirc.nln.org)www.sirc.nln.org Simulation Users Network (SUN)

80. Questions?