Transcript Taking Your First Steps

Taking Your First Steps
Simulation Integration
Beth Fentress Hallmark, PhD, RN
Belmont University College of Health Sciences
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
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
Belmont University
Nashville, Tennessee
• 7,000 + students
College of Health Sciences
Inter-professional Education
• Nursing
– Accelerated, Fast track and Traditional BSN
– FNP, DNP
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Social Work (BSW)
Physical Therapy (DOT)
Occupational Therapy (DPT/MSOT)
Pharm D
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
Belmont University
Nashville, Tennessee
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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
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
Adult Health
Nursing Lab
•Functioning
headwalls
(compressed
air/suction)
•Lift equipment
•“Storage”
converted to “clean
utility room” –
materials
management
McWhorter Hall
• Designed to house Pharmacy, PT,
(Chem labs)
• 90,000 square feet
• Retail Pharmacy
• Health Services Clinic
• 4 Sim Rooms/SP
and mannequins
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.
Belmont’s SON Goals
• Prepare the novice nurse for clinical
practice
• Link Concepts & Critical Thinking to
Practice
• Progressive Complexity
• Theoretical Support
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.”
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
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.
New Graduates say:
• They feel uncomfortable with:
– IV skills
– Physical Assessment
– Care of the dying patient
– Caring for patients with changing care
needs
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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).
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
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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).
Simulation
Training
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”
The Shifting Paradigm
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OLD
NEW
Didactic
See one do one
Silos
Practice on patients
Learn from mistakes on
LIVE patients
• Self-directed
• Practice to pre-defined
standards or competency
using simulators
• Learn from your mistakes
on SIMULATED patients
• Team Training
• Reflection
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”
Factors that increase risk of error
• Environmental
• Organizational
• Individual
• Team
• Patient Related
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)
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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
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
• “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
How can you use simulation?
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Crisis Management
Flexibility
Use factual knowledge
Critical thinking
Team interaction
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Response time
Communication Skills
Planning
Strategy
Multiple Decisions
Collaboration
Where can you use simulation?
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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
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.
Why Integrate Simulation?
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Deliberate practice
Healthcare Technologies
Team training
Quality and safety
Delegation
Therapeutic communication/Interprofessional
• Clinical Judgment/Decision-Making
What can simulation do?
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Help promote teamwork and collaboration
Foster effective and safe communications
Delegation
Safe practices/Quality Improvement
Cultural awareness
Evidence based practice
Patient centered care
Advantages of Simulation
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Safe practice arena
Hands on
Exposure to rare/high risk events
Practice cognitive and psychomotor skills
Transfer to clinical setting
Immediate feedback
Reflective learning
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!
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!
Business Plan
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Sustainability
Planning
Show ROI
Budget 3, 5 years out
Staffing
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
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.
Stakeholders!
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Who?
Why?
Where ?
What can they do for you?
What can you do for them?
Curriculum Development
• PLAN
• PLAN
• PLAN!!
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
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
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
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
Traditional Nursing Education
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Didactic
Lab
Clinical
Orientation at workplace
CEUs
New Strategies
• Simulation as a Teaching Strategy
• Simulation as an Evaluation Tool
• High stakes?
Types of Simulation
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Case Study
Role-playing
Standardized patients
Partial vs. Complex Task Trainers
– Static and Computerized
• Integrated Simulators (HPS)
• Virtual Simulation/Online
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.
Simulation: Theory
• Active Learning
• Reflective Thinking
• Constructivism
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
Connecting the dots in courses:
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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?
Standards
Identify your programs outcomes based
on standards.
– BSN Essentials
– QSEN
– IOM
– Joint Commission
– NCLEX
– Core Competencies for Interprofessional
Collaborative Practice
How do I overcome:
• Faculty Resistance
– Time
– Resources
• Technology assistance, equipment
– Pay
– Administrative Assistance
– Skills
– Scheduling
What do I need?
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CHAMPION
Administrative Buy In
Money: Grants
Staff
Space
Faculty Development Plan
Policies
Mission Vision
Stakeholders
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
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
What do I need? MONEY…..
MONEY…..
• Grants
• State
• Federal
• Local community organizations
• National Private Funding groups
What do I need?
Staff
• Simulation Director
• Faculty: Simulation Committee Group
• Technical Support: IT and Network
specialist
• Supply specialist
• Scheduling
What do I need?
Space
• STORAGE, STORAGE, and still
MORE STORAGE!!
• Preparation Area
• Simulation Labs
• Partitions?
• Observation/Control Room
• Debriefing room
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
Components to a Simulation
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Student Preparation
Objectives
Report
Actual Simulation
Debriefing
Evaluation
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
Objectives
• Need to fit with curricular objectives
and course objectives
• Case by case
• General safety and communication
• So many more
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
Simulation
• Scenarios
– Pre programmed
– Make it your own
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Validate with practice partners
Faculty script/training
Reality: suspend
Fiction Contract
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
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
Where can you use clinical sims?
What can we examine in acute care?
• Patient Safety
• Team
• Communication
Nursing Education
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Confidence
Self-Efficacy
Skills
Communication
Test scores
• NLN: High Stakes
• NCSBN: Clinical Replacement
Examine Curriculum
• Your curricular objectives should dictate
what simulators, what information and what
simulation you need
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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?
Introduction to Nursing
• Clinical Skills integrated in a summative
simulation
• Sterile procedure: foley, dressing
change
• Medication administration: insulin, Flu,
pain med
• Vitals/assessment
• Clamp NG
Adult Health One
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Severe dehydration
Bowel Obstruction
IV fluid bolus
Oxygen
Zofran
Obstetrics
• Post Partum bleed
• Antepartum: Hyperemesis, PIH, preterm labor
• Mega Sim Scenario: Doctors office
early labor delivery code and
postpartum
Psychiatric
• Depression
• Schizophrenia: Neuroleptic Malignant
Syndrome
• Alcohol withdrawal
PEDS
• Respiratory
• ALL
• Skills
Adult Health Two
• End of Life
• Codes
• Blood
Leadership
• Delegation
• Nurse practice Act
Other Disciplines
• OT and PT lines acute care
• Pharm medication dosage
• Interprofessional
Literature review
• Nursing Education
• Medical Education
Support: Find a Network
• Tennessee Simulation Alliance
(www.tnsim.org)
• INACSL (www.inacsl.org)
• SSiH (www.SSiH.org)
• NLN SIRC (www.sirc.nln.org)
• Simulation Users Network (SUN)
Questions?