Overview of Simulation

Overview of Simulation

Hsing-Mei Chen, PhD, RNAssistant Professor, Department of Nursing,

College of MedicineNational Cheng kung University, Taiwan

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Education Achievement in 21th Century

• A transition from training to education for higher level of decision making

• Surface to deep thinking• Independent thinker• Multi-professional links (inter-professional

education)• Evidence based practice

Simon Cooper, PhD, RN

Original of Simulation

• 16th century, mannequins (referred to as “phantoms”) were developed to teach obstetrical skills and reduce high maternal and infant mortality rates.

• Airline industry training: pilot and flight crews• Anesthesia education• First simulator in health education in 1960s– Resusci Anne– Harvey for cardiology training

(Simul Healthcare 2006;1: 252–256)

Havey for cardiology training

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Current Situation

• A movement toward making simulations a part of the clinical practicum, either as a clinical substitute or as an adjunct.

• Movement arises out of need for:–More clinical sites–More nurse educators– New clinical practice models to prepare 21st

century graduates in high-tech, complex environments

Pamela R. Jeffries DNS, RN, FAAN

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Reflection from my teaching

• A quantity of handouts for each topic• Video watching• Cases or examples for important concepts• Discussion

I am truly a good and responsible teacher!

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However

http://www.bing.com/images/search?q=in+the+class&FORM=HDRSC2#view=detail&id=344FFE8DAF824B1B087E93E92003ED3B328A9FCD&selectedIndex=86

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My critical care nursing class

• Around 40-60 students in a class

– Problem with student clinical practicum

• Each critical care unit can allow 1 student/ 5 beds

Good transition time

• Look for alternative way to solve the problem with student placement.

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Teaching Strategies

• Traditional lectures• Low fidelity simulation for lectures and quizzes• Videos• Homework• Examines• Self-directed learning

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Becoming a Nurse

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How to promote the student’s motivation and interest in learning?

• Different styles– Visual– Visual / verbal– Physical– Auditory

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Hsun Tzu (ca. 310-237 BC), Confucian philosopher and author of on learning

What I hear I forget

What I see I remember

What I do I understand

https://tw.search.yahoo.com/search?p=%E8%8D%80%E5%AD%90&fr=yfp&ei=utf-8&v=0

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Definition of Simulation-1

• 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 devises such as interactive videos or mannequins.

Jeffries, P. R. (2005). A frame work for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103.

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Definition of Simulation-2

• A simulation may be very detailed and closely simulate reality, or it can be a grouping of components that are combined to provide some semblance of reality.

Jeffries, P. R. (2005). A frame work for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103.

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Simulation Tools / Approaches

• Low-tech simulators• Simulated/standardized patients• Screen-based computer simulators• Complex task trainers• Realistic patient simulators

Ziv, A., Wolpe, P. R., Small, S. D., & Glick, D. (2006). Simulation-based medical education: An ethical imperative. Simulation in Healthcare, 1(4), 252–256.

http://healthcare.kyst.com.tw/products_detail.php?bgid=26&bid=47&gid=973

Five Areas of Simulation

• Objectives• Planning• Fidelity• Complexity• Cues• Debriefing.

Jeffries, P. R. (2005).

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Fidelity of Simulation• Low fidelity– Injection pads, IN cannulation device

• Moderate fidelity– Human simulators without chests or vocal

sounds• High fidelity --> Realism– Human simulator (mannequin or manikin) run

with a computerized program, a chest, and vocal sounds.

Goldsworthy, S., & Graham, L. (2013). Simulation Simplified. A practical handbook for nurse education. USA: Wolters Kluwer.

Realism-1

• Ensuring that equipment and the surrounding environment is similar to the practice environment

• Using ‘props’ to aid a sense of realism to the manikin e.g. patient pajamas, wigs, dressings, moulage for wounds

• Using resources that the student would encounter in the clinical environment, e.g. intravenous lines, dressings, catheter bags, patient identification bracelets

Edgecombe et al., 2013

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OHCA

Triage

10 db, murmur

0 db, can’t talk

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25 y/o,Abdominal pain after drinking

20 y/o, hyperventilation after a big fight

Realism-2

• Ensuring that all paperwork, forms and patient charts are similar to the clinical environment

• Utilizing evidence-based practice to inform realism e.g. date all intravenous lines, use appropriate dressings and dressing techniques.

Edgecombe et al., 2013

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Use Simulators

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Use Standardized Patients

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Use Others

• EKG Games – Dr. Simon Copper in Monash University,

Australia

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Innovation Adoption for Simulation

• Stage 1: Awareness• Stage 2: Interest• Stage 3: Evaluation• Stage 4: Trial• Stage 5: Adoption

Issenberg, S. B. (2006). The scope of simulation-based healthcare education. Simulation in Healthcare, 1(4), 203–208.

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A Bunch of Resources for Simulation

• National League for Nursing– http://sirc.nln.org/

• Monash University– Dr. Simon Cooper– http://www.med.monash.edu.au/nursing/staff/simo

n-cooper.html– http://first2actweb.com/index.php/first2actweb/

• http://www.freebookez.com/sample-nurse-simulation-scenarios/

• http://cms.montgomerycollege.edu/nursingsims/

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Effective use of Simulation

= X XEffective simulation-based healthcare education

Training resources

Trained educators

Curricular institutionalization

Issenberg, S. B. (2006)

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Training Resources• Simulators, task trainers, standardized patients, and

computer software.

• Physical space and equipment (eg, monitors, beds, cameras, microphones, recording and playback equipment).

• Curriculum, outcome measures, learning strategies, and curriculum management system.

Issenberg, S. B. (2006)

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Features of Simulations-1

• Feedback

– The most important feature of simulation-based education to promote effective learning.

• Repetitive practice

– The intent is skill improvement, not idle repetition

• Range of difficulty level

– beginning with basics, advancing to progressively higher difficulty levels based on objective measurements.

Issenberg, S. B. (2006)

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Features of Simulations-2

• Multiple learning strategies

– Including instructor-centered formats, small group tutorials, independent study… etc.

• Clinical variation

– Should represent a wide variety of patient problems

• Controlled environment

– Learners can make, detect, and correct patient care errors without negative consequences.

Issenberg, S. B. (2006)

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Features of Simulations-3

• Individualized learning– Active learners

• Defined outcomes/ benchmarks– Goals should have tangible, objective measures

that document learner progress.• Simulator validity/realism– simulation and the behavior it provokes come

close to, but never exactly duplicate, clinical challenges that happen in genuine patient care contexts. Issenberg, S. B. (2006)

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Why use Simulation-Based Medical Education

• Best standards of care and training• Error management and patient safety• Patient autonomy• Social justice and resource allocation

Ziv et al. (2006).

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Examples of Simulation in Nursing

• Physical assessment• Symptom care• Commutation skill• Discharge planning• Nurse students vs. nurses

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Case Scenario for Chest Pain-1

• Mr. Lee is admitted due to symptoms suggestive of unstable angina including chest pain, dizziness, and cold sweating. He complains that he is still not feeling well and finds his urine output has decreased since last night.

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Case Scenario for Chest Pain-2

• Learning objectives

– Perform a focused assessment based on Mr. Lee’s complaint or change in his status.

– Recognize normal and abnormal assessment findings.

– Prioritize interventions based on findings and assessments.

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Case Scenario for Chest Pain-3

• Debriefing

– Did you predict the development of shortness of breathing?

– Did you provide appropriate care of the symptoms?

– Are you capable of explaining the pathophysiological mechanisms of ileus?

–Were you satisfied with your ability to work through the simulation?

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(Goldsworthy & Graham, 2013)

Sample competency checklists

Expected student action Met Unmet Comments

1. Student immediately assesses level of consciousness, ABC

2. Calls for help and calls a code blue

3. As soon as the defibrillator arrives, defibrillates at 360 joules after calling all clear twice and looking

4. Asks for CPR to be commenced

5. Physician arrives – asks for the “Dopamine to be run wide open” student recognizes that this is not safe.

6. Family member enters room during arrest, very distraught, wants to be at bedside. Student ensures that a team member is present to support family member.

Feedback:

ACLS

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Role of Faculty in Simulation

• Design the curriculum• Set up a topic and objectives• Develop 3 or 4 learning outcomes• Timing• Sequencing of learning• Unfold the case scenario– Case summary– Starting state–Make up (Goldsworthy & Graham, 2013)

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Role of Faculty in Simulation

• Assessing the student’s knowledge, skill, and judgment

• Facilitating the debriefing • Be sensitive to the learner’s emotional well-being• Program the simulator• Care for the equipment– Simulation technologists

(Goldsworthy & Graham, 2013)

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Student Preparation for Simulation• Pre-learning packages / short videos–Well-identified learning objectives– Overview of the simulation– Description of how the simulators work– Clinical scenarios linked with references to review– Evaluation methods– Reinforcing the professional student behaviors

expected in the scenario

Edgecombe, K., Seaton, P., Monahan, K., Meyer, S., LePage, S., & Erlam, G. (2013). Clinical simulation in nursing: A literature review and guidelines for practice, retrieved from http://akoaotearoa.ac.nz/communities/collaboration-clinical-simulation-leading-way

(Goldsworthy & Graham, 2013)

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Learning Outcomes

• Performance related• Contextual• Standard or criterion based• Specific or general (satisfaction, confidence, critical

thinking…)

(Goldsworthy & Graham, 2013)

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Key points

• Make the environment as realistic as possible using screens, curtains, posters, or equipment

• Match learning outcomes with appropriate simulator and equipment

• Select faculty with relevant clinical expertise

(Goldsworthy & Graham, 2013)

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Key points• Clear outcomes and expectations• Is the evaluation for: Student feedback? Facilitator

feedback? Simulation design?• Use the most appropriate measurement tool for the

intended evaluation.• Deliver all evaluations in a caring, constructive, and

positive manner.

(Goldsworthy & Graham, 2013)

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The Future

• Inter-professional education (IPE)• Hybrid• Scenario• National• International

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Discussion

• What do you think about simulation?

• What do you think that students should learn from simulation?