The Future of Simulation:
Innovations and Possibilities
PAMELA R. JEFFRIES DNS, RN, FAAN,ANEF
ASSOCIATE DEAN FOR ACADEMIC AFFAIRS
JOHNS HOPKINS UNIVERSITY
SCHOOL OF NURSING
CLINICAL SIMULATIONS IN HEALTHCARE CONFERENCE –
MAY 19, 2010
TULSA, OKLAHOMA
Objectives of this session:
The participant will be able to:
1.
Discuss changes occurring in nursing education and the use of clinical
simulations
2.
Describe the essential tools and skills nurse educators need to
incorporate simulations into the teaching-learning process
3.
Explore future possibilities nurse educators can embrace using
simulations
Clinical Simulations: a potential solution for
clinical practice and enhancement
There is currently a widespread movement to use simulations
of all types in nursing education as a teaching-strategy
and/or as an evaluation mechanism.
 Why is there a sudden increase in this innovative strategy?
 How do educators know if this mechanism is providing the
learning outcomes needed to prepare the graduate for realtime nursing practice?
Increased Need for Simulations: Why
do educators want to use them?
 Decreasing number of clinical sites for practice
 Nurse educator shortage
 Decision-making/problem-solving skills needed
 Cost-effective clinical education needed
 Gap between academia and practice
 New model of education needed (e.g. technology, realism,
diagnostic reasoning skills)
Why do educators want to use them?
 IOM (2004) challenges health educators to expand
technologies and support innovations
 NLN has challenged educators to be innovative in our
educational practices
 New graduates must be prepared for the demand of
healthcare and increased complexity – need for rapid
decision making
Simulations use continued
 Concept of patient safety increasing – use of simulation as a
safety concepts
 National Council of State Board of Nursing – predicts the
future of clinical education in nursing will include the
increased use of simulations
 Higher education paradigm shift from teaching to learning
paradigms
Current state of
Clinical Nursing Education
 Errors correlated to new graduates inability to make
clinical decisions
(Smith & Crawford, 2002)
 New graduates do not meet their expectation for clinical
judgment as identified by employment in clinical agencies
(De Bueno, 2005)
 Accreditation agencies challenge educators to promote
critical thinking (Long, 2004; NLN, 2003)
Current State -continued
 Teaching practices need to be evidence-based-
educational research needed
(NLN, 2005; IOM, 2001)
 Critical thinking and reflective skills of the
practitioner are correlated with the quality of
patient care
(Conway, 1998; Paget, 2001)
Simulations Have Arrived…
Where are we?
 Simulations in Medicine
 Simulations in Nursing
 Next steps…..
Medical Research
 Integrative review by Issenberg et al., 2005:
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Providing feedback (47%)
Repetitive practice (39%)
Curriculum integration (25%)
Range of task difficulty level (14%)
Multiple learning strategies (10%)
Capture clinical variation (10%)
Controlled environment (9%)
Individualized learning (9%)
Defined outcomes (6%)
Simulator validity for learning (3%)
Medical Research
 N=109 research articles
 Quality is weak.
 Based on research literature, can make statement
that the use of high-fidelity patient simulation does
“facilitate learning under the right conditions”
(Issenberg et al., 2005, p. 10).
Nursing Research - HFPS (n=26)
(Nehring, 2008)
 Since 2001, 26 nursing research studies related to high-
fidelity patient simulation have been conducted.
 These studies have been conducted in the US (n=19), the
UK (n=3), Sweden (n=1), Canada (n=1), China (n=1), and
internationally (n=1).
Nehring, W. (2008) U.S. Boards of Nursing and the Use of High Fidelity Patient Simulators
in Nursing Education, Journal of Professional Nursing, 24(2), 109-117.
Nursing Research
 Methods have included pretest-posttest (n=9), surveys
(n=7), post-test only (n=4), focus group (n=2),
observational and focus group (n=1), theory-driven
description-observation-revision-review method (n=1),
case study (n=1), and correlational (n=1).
 22 studies dealt with nursing education and 4 studies with
team management.
Nursing Research
Emphasis has been placed on:
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Competence (eg., clinical skills, basic knowledge) (n=7)
Confidence
Satisfaction
Use of simulation as educational adjunct (n=9)
Self-directed learning versus instructor-modeled learning
Development of rubric for clinical judgment
Simulation as substitution for clinical (n=2)
Collaboration and teamwork (n=4)
Nursing Research
 In the past 40+ years, nursing educators have
conducted similar studies involving case studies,
computerized patients, standardized patients, and
have achieved similar results.
NLN Study (multi-site 2003-2006)
 In this study, several areas were explored, however the
major contributions to the science of nursing education in
the area of simulations include:
 The theoretically-based Simulation Framework (Jeffries,
Rizzolo, 2004)
 The Development of two instruments: The Simulation
Design Scale and the EPSS
 Identification of 5 key design features to include in the
development of simulations
Simulation Framework
OUTCOMES
• Learning (Knowledge)
• Skill performance
• Learner satisfaction
• Critical-thinking
• Self-confidence
 Program
 Demographics
 Level
 Age
 Active learning
 Feedback
 Student/ faculty
interaction
 Collaboration
 High expectations
 Diverse learning
 Time on task
DESIGN
CHARACTERISTICS
and SIMULATION
(intervention)
 Objectives
 Fidelity
 Problem-solving
 Student Support
 Reflection
Jeffries & Rizzolo, 2004
Changes/Issues in Nursing Education
 Regulatory Boards – watchfully monitoring –
providing research funding
 Faculty skill sets changing
 Partnerships and Collaborations
 Need for better prepared students exiting nursing
programs
Regulatory Boards watchfully monitoring and
calling for multi-site research
 Innovations in Nursing Education and
Clinical
 Numerous questions center on the use of simulation in nursing education.
How it can be used effectively and its role in clinical development of
students is of major importance and of interest to both regulators and
educators alike. In collaboration with Rush University, NCSBN embarked
on a pilot project to evaluate the value and validity of simulation as an
educational strategy. Results indicated further study is needed in this
area and our research agenda includes a large-scale, multi-site study.
National Council of State Board of Nursing (NCSBN), www.ncsbn.org
Faculty Skill Sets Changing and Required
 Changes in teaching –
student-centered
approaches
 High tech- must include
technology into clinical
and classroom teaching
 Must be creative,
innovative – keep
students engaged
 High quality, real skills,
high expectations of our
students
Partnerships and Collaborations
 EcO 15 – 10 county
consortium on improving
healthcare – focus:
developing regional sim
centers and providing
faculty development
 SPRING program – JHI
and the new graduates
 IU SON and Clarian
Health – partners to
improve care
Need to “bridge the gap” between
education and practice
 A gap exists between the academic preparation of nursing
students and the needs of the clinical agency
 There is a growing concern among the frontline hospital
leaders about the new graduates
 Clinical education is not currently working using only the
traditional models we have used for decades
The Nurse Executive center of the Advisory Board (2008)
 Survey taken 2008
 Of 135 nurse executives – 10% who responded to the survey
stated new graduates were fully prepared for practice while
89.9% of the 362 nursing school leaders agreed
 A large preparation-practice gap exists!
The Nursing Executive Center of The Advisory Board Company (2008)
Practice-Readiness defined in 6 general areas
 Clinical knowledge
 Technical skills
 Critical Thinking
 Communication
 Professionalism
 Management of responsibilities
Next Steps
 Most of these competencies are directly related to ways
students gain clinical experiences in the nursing program
 The report identified a “collaborative/partnering” (academe
and practice) would help the gap
 Can the clinical model redesign also include simulations to
help facilitate these practice-ready general areas?
The Evolution of the “new” Educator
Today
 Facilitators of learning
 Innovative, creative
 Technology-savvy or
willing to learn
 Focus: student-centered
learning
 Providing students with
“real-world” experiences
and examples
 Knowledge workers,
creators, and designers
Future Possibilities
 The future is bright for the
use of simulations in
nursing education!
 Simulation centers are
being built all around the
world
 Funding dollars are being
provided to build
simulation centers and to
use technology
 Stimulus monies – some
were earmarked for
simulation!
Stimulus Call for Simulation Center Design
 NIH Announces Availability of Funding for
Simulation in $1bn Stimulus Bill
 Posted: 03-31-2009
 The National Institutes of Health (NIH) has announced that
simulation facilities for training health care providers and
researchers will be eligible for funding from the $1 billion Congress
appropriated in the stimulus bill (The Recovery Act) to NIH for grants
and contracts to construct, repair, or renovate existing research
facilities.
 NIH's inclusion of simulation centers as being eligible for this funding
will provide a tremendous opportunity for the development of new
simulation centers, as well as the enhancement of existing centers.
Future Possibilities
 Uses of Simulation Expanding in Education
 The evolution of “the simulation technology”
 Teaching environments/possibilities
 The learner
Future Uses and Activities where
Simulations are Involved
Research in simulations increasing – e.g. Advanced
Practice Nurses multi-site study
Unfolding cases
Simulations included in large Foundation and partnership
grants
Integrating simulations into patient and caregiver
teaching/health promotion and prevention
Multicenter Study
Effectiveness of Harvey Nurses Curriculum
Mastery Learning - Features
1.
2.
3.
4.
5.
6.
7.
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
Multicenter Study
Effectiveness of Harvey Nurses Curriculum
Training Intervention
Pretest
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• Knowledge - MCQ
• Skills – Checklist
• Confidence - Survey
Pre-Self Study Program
Instructor Guided Sessions
Learner Practice w/Feedback
Self Study Program
Learner Training Logbook
No
Posttest
Advancement
MPS
Achieved
•
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•
Knowledge - MCQ
Skills – Checklist
Confidence – Survey
Instructor Satisfaction
Multicenter Study
Effectiveness of Harvey Nurses Curriculum
Evidence-based Training
 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
Unfolding Cases –
Teaching students differently
Grant funding sources calling for simulations
 Hartford Foundation
partners with the NLN
 Simulations incorporated
into the grant – develop
and implement
simulations focused on
caring for the aged in the
grant
 Special series coming
 AACN Essentials
mandating geriatrics in
curriculum
Hartford Foundation Funding to foster
geriatric nursing using simulations
John A. Hartford Foundation Funds New Three-Year Project
"Fostering Geriatrics in Pre-licensure Nursing Education, Phase II"
Laerdal Medical to Contribute $187K for New Simulation Design for
Geriatric Care
FOR IMMEDIATE RELEASE
New York, NY — April 8, 2009 — Following a successful Hartford Foundation-funded
project to foster geriatrics education among associate degree, pre-licensure nursing
students at the Community College of Philadelphia (CCP), the National League for
Nursing and Laerdal Medical Corporation have joined forces with the college to extend
this preparation to students in all pre-licensure RN programs: associate, baccalaureate,
and diploma. This next phase, supported again by a generous grant of nearly $700,000
from the John A. Hartford Foundation, will build on the work done through "Fostering
Geriatrics in Associate Degree Nursing Education," funded by Hartford in 2007-08.
NLN Web site – http:/www.nln.org
Using simulations to teach patients and & caregivers
 NIH R01 Grants calling for
innovation
 How can
simulations/technology be
incorporated into these
types of research
 Obama’s challenge
equipment grants….many,
many focused on
innovation and health
information technology
Use of Technology
The Simulation Technology and the Future
 Evolution of the
simulators
 Robotics?
 Shift from the majority of
clinical practicum and
teaching to teaching
clinical in a simulated
environment so students
can be learn and practice
problem-solving,
decision-making, and
critical thinking
Virtual Simulation and Patient Care
The student or learner
 What do they look like in
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the future?
High technology skills
Need rapid information
and retrieval
Desire real-life application,
everything else is irrelevant
The Globals –
Generation linked to each other
Borderless environment
Embrace a wider stage
Bring a global perspective to everything!
Desire intercultural dialogues and lessons
Our students
Summary
Simulation has emerged!
The future of simulations
 The future for clinical is
promising!
 Over time, more
evidence will be
disseminated on the use,
implementation, and
best practices of
incorporating clinical
simulation into a nursing
curriculum.
Summary
 Simulation holds the promise to change faculty
assumptions about how students learn and think and
to become an essential teaching/assessment
evaluation strategy in education of nurses.
 One approach for Gateway to change in nursing
education is the incorporation of clinical simulations
in nursing curricula.
 If not on board, get on board to use this amazing
technology!
Goal for using simulations: Optimal Student
Learning for High Quality Patient Care
Questions: pjeffri2@son.jhmi.edu