Clinical Simulation in Nursing (2016) 12, 2-7
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Featured Article
After the National Council of State Boards of Nursing Simulation StudydRecommendations and Next Steps Tonya Rutherford-Hemming, EdD, RN, ANP-BC, CHSEa,*, Lori Lioce, DNP, FNP-BC, CHSE, FAANPb, Suzan ‘‘Suzie’’ Kardong-Edgren, PhD, RN, ANEF, CHSE, FAANc, Pamela R. Jeffries, PhD, RN, FAAN, ANEFd, Barbara Sittner, PhD, RN, APRN-CNS, ANEFe a
Senior Nurse Researcher, Cleveland Clinic, Cleveland, OH 44195, USA Clinical Associate Professor/Executive Director, Learning and Technology Resource Center, The University of Alabama in Huntsville College of Nursing, Huntsville, AL 35805, USA c Professor and RISE Center Director, School of Nursing and Health Sciences, Robert Morris University, Moon Township, PA 15108-1189, USA d Dean and Professor of Nursing, George Washington University, School of Nursing, Washington, DC 20036, USA e Professor, College of Nursing, Bryan College of Health Sciences, Lincoln, NE 68506-1398, USA b
KEYWORDS simulation; faculty development; NCSBN Simulation Study
Abstract Background: The National Council State Boards of Nursing (NCSBN) Simulation Study has generated increased conversation about the use of simulation in nursing education. Method: At the 14th Annual International Nursing Association for Clinical Simulation and Learning (INACSL) conference in Atlanta Georgia, a panel discussed the results and significance of the National Council of State Boards of Nursing (NCSBN) Simulation Study. Results: Panel members discussed movements in nursing education in the eight months since the study’s release, implementation of the recommendations from the study in practice and academic settings, and methods to achieve the necessary faculty development needed in simulation. Conclusion: The use of simulation in nursing education is expanding. Cite this article: Rutherford-Hemming, T., Lioce, L., Kardong-Edgren, S. S., Jeffries, P. R., & Sittner, B. (2016, January). After the National Council of State Boards of Nursing Simulation StudydRecommendations and Next Steps. Clinical Simulation in Nursing, 12(1), 2-7. http://dx.doi.org/10.1016/j.ecns.2015.10.010. Ó 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
* Corresponding author:
[email protected] (T. Rutherford-Hemming).
In fall 2014, findings from the National Council State Boards of Nursing (NCSBN) Simulation Study were released (Hayden, Alexander, Smiley, Kardong-Edgren, & Jeffries,
1876-1399/$ - see front matter Ó 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2015.10.010
After the National Council State Boards of Nursing Simulation Study 2014). The NCSBN study sought to provide evidence to US boards of nursing regarding the use of simulation as a replacement for traditional clinical experiences in prelicensure nursing education. The study aimed to determine (a) whether simulation could be substituted for traditional clinical hours, (b) the educational outcomes of undergraduate nursing Key Points students in the core clinical The NCSBN Simulacourses when simulation tion Study provided was integrated throughout evidence on the use the core nursing curriculum, of simulation. and (c) whether varying Faculty development levels of simulation in the is an area of need in undergraduate curriculum nursing education. impacted the practice of A resource is the Stannew graduate nurses in their dards of Best Practice first clinical positions in Simulation. (Hayden et al., 2014). At the 14th Annual International Nursing Association for Clinical Simulation and Learning (INACSL) conference in Atlanta Georgia, a panel was formed to discuss the results and significance of the NCSBN study (Hayden et al., 2014), movements in nursing education in the 8 months since the study’s release, implementation of the recommendations from the study in practice and academic settings, and methods to achieve the necessary faculty development needed in simulation. The session concluded with open dialogue between panel members and conference attendees discussing relevant simulation topics such as simulation ratios and time, faculty development, debriefing practices, and future endeavors.
Plenary Session During the International Nursing Association for Clinical Simulation and Learning Conference, 2015 The following are excerpts from the panel of experts who presented at the conference.
Suzie Kardong-Edgren, PhD, RN, ANEF, CHSE, Director, RISE Center and Professor, School of Nursing, Robert Morris University The landmark NCSBN Simulation Study provided evidence that up to 50% of traditional hours in the major clinical courses in prelicensure nursing programs could be safely substituted with simulation (Hayden et al., 2014). This opened the door for further discussion about the use of simulation in prelicensure programs; however, the devil is in the details. Many nursing programs may be tempted to gloss over the elements that produced those results. All study faculty shared the same mental model of how simulation would be run for the study. This began
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with the initial orientation, debriefing training, and ongoing evaluation of the dedicated simulation faculty, over the life of the study. The INACSL Standards of Best Practice: SimulationSM (2013) guidelines for orientation, facilitation, debriefing, and evaluation were used to guide and standardize simulation practice across all sites. A high-level Socratic debriefing method was used to develop self-reflection skills. These key elements were all standardized and controlled at all sites and used best-known practices for the use of simulation. Very few United States programs have the trained faculty and standardization to provide the same level of simulation used in the study. These realities must be addressed when schools wish to adopt high levels of simulation within a nursing program.
Pam Jeffries, PhD, RN, FAAN, ANEF, Dean and Professor, George Washington University School of Nursing Implications from the NCSBN study (Hayden et al., 2014) call for faculty to be trained in using simulation pedagogy. Faculty development in designing, implementing, and evaluating clinical simulations still remains a major concern in nursing education. It may be that a shift from ‘‘training all faculty’’ to do simulations to a well-prepared simulation team is needed. A key element in implementing the simulations in the landmark NCSBN study (Hayden et al., 2014) included faculty development and preparation. Resources to facilitate faculty development and to ensure quality simulations are being developed and delivered include the use of the Standards of Best Practice in Simulation (Decker et al., 2015; International Nursing Association of Clinical Simulation and Learning, 2013; Lioce et al., 2015) and becoming a Certified Healthcare Simulation Educator (CHSE) (Society for Simulation in Healthcare [SSH], 2014). Both are available benchmarks for faculty preparation and credentials. The NCSBN study tested an integrated, sustainable simulation model across seven clinical courses (Hayden et al., 2014). Hayden (2010) reported that 87% of Schools of Nursing in the United States included simulations in their nursing programs. Curriculum integration should build on/or be used to ‘‘fill-in the gaps’’ within nursing programs. Simulation directors and simulation teams need to work with clinical coordinators to integrate both if resources and support are available. The NCSBN study (Hayden et al., 2014) provided evidence that ‘‘simulations work.’’ Research is needed in other areas to advance the science in simulation in the United States and internationally. Research in simulation remains embryonic; therefore, many research questions and topics remain available to explore and embrace (Agency for Healthcare Research and Quality, 2015; McGaghie, Issenberg, Petrusa, & Scalese, 2010). Funding sources, pp 2-7 Clinical Simulation in Nursing Volume 12 Issue 1
After the National Council State Boards of Nursing Simulation Study such as the Agency for Healthcare Research and Quality, are available for studies investigating outcome measures, safety, and quality health care environments in simulation (Agency for Healthcare Research and Quality, 2013). The National League for Nursing (NLN) Jeffries Simulation Framework (Jeffries & Rogers, 2012) is moving to a mid-range theory for simulation. The new theory, based on the NLN Jeffries framework (Jeffries & Rogers, 2012), will be unveiled at the NLN Teaching Summit in September 2015 in addition to being featured in the special simulation issue of the NLN journal, Nursing Education Perspectives in the September/October issue. The monograph and new mid-range theory will hopefully help to facilitate more theoretical-based research in the area of clinical simulations and provide a direction for simulation research. The NCSBN Simulation Study is a landmark study that provides needed evidence for this type of pedagogy used in nursing education (Hayden et al., 2014). The results are generalizable across the United States based on the study of 10 different nursing schools that included schools n the urban/rural settings with the study expanding across both associate and baccalaureate degree prelicensure nursing programs. More data/metrics on learning outcomes using simulations are needed, so data-driven decisions can be made to improve learner preparation, practice, and delivery of patient care using a simulation-based curriculum. A next step is to promote the value of simulation by translating the importance of using clinical simulation in education to provide better, quality care, and patient outcomes.
Tonya Rutherford-Hemming, EdD, RN, ANP-BC, CHSE, Senior Nurse Researcher, Cleveland Clinic Nursing education does not cease at the end of graduate studies. Education continues as the clinical nurse practices within the health care setting. Similar to the increased propensity to use simulation in academia, simulation in practice environments has increased in the last decade. A unique aspect of the NCSBN study (Hayden et al., 2014) is that it followed the prelicensure nursing students postgraduationdsomething, few, if any, studies have done. The Cleveland Clinic, like many institutions, uses simulation for many professionals including nurses, physicians, dieticians, pharmacists, and so forth. Simulation is used as part of onboarding and competency testing. It is also used to enhance procedure performance, improve teamwork, and develop communication skills. Cleveland Clinic has dedicated simulation faculty in the multidisciplinary simulation center who are trained in simulation pedagogy. Staff and faculty who want to teach using simulation attend mandatory training courses. The training, based on the Standards of Best Practice: SimulationSM (International Nursing Association of Clinical Simulation
Table 1
4 Items to Measure Outcomes
Measurements 1. Identify and/or hire innovators/early adopters. 2. Consider workload credit for those involved in program development. Complete a facilitator needs assessment. 3. Select a theoretical framework for your simulation education program and review it every 3 years. 4. Collaborate and select policy and procedures to provide transparency and standardize processes. 5. Select a reservation request forms, design template, and evaluation method; and use a simulation objective map. This will decrease the amount of e-mails to coordinate and prepare simulations. 6. Collect usage data to provide evidence for estimating cost per simulation, course, and for the program as well as support consistent staffing. 7. Require faculty/staff training in facilitation/debriefing before participation in simulation and offer additional training at the beginning or end of each semester. 8. Require dry-runs before all new scenario implementation with facilitators. This time allows facilitators to identify content and objective cues and set performance measures and set mutual expectations. 9. Record an orientation to the center, specifics on the simulation process, and specific equipment that will be used for the day to ensure standardization. Play the recording during prebriefing. 10. Offer annual ‘‘open houses’’ for simulation equipment demonstration and coordinate team planning time.
and Learning, 2013), includes sessions on simulation terminology, facilitation, and assessment/evaluation. A half-day interactive session is focused on debriefing.
Lori Lioce, DNP, FNP-BC, NP-C, CHSE, FAANP, Executive Director, Learning and Technology Resource Center, University of Alabama in Huntsville School of Nursing Implications from the NCSBN study support and require changes in daily operations and structure of health care simulation education programs. Table 1 offers ten items for consideration by administrators, directors, coordinators, and facilitators to improve, standardize, and assist in measuring outcomes. It is often said, ‘‘we tend to teach as were taught.’’ This saying offers an explanation for why formal educational systems around the world find change difficult to implement and even harder to measure. The traditions associated with the education of health care professionals are extremely difficult to change. This is especially true when we have new technologies and approaches for teaching that are improving educational effectiveness but also for protecting patients and improving the care we provide. pp 2-7 Clinical Simulation in Nursing Volume 12 Issue 1
After the National Council State Boards of Nursing Simulation Study Table 2
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Simulation Programs
Simulation Programs
Web sites
Boise State University Bryan College of Health Sciences
http://hs.boisestate.edu/nursing/sgcp/ http://www.bryanhealthcollege.edu/bcohs/academic-programs/certificate-programs/simulat ion-certificate/ http://www.drexel.edu/cnhp/academics/continuing-education/Nursing-CE-Programs/Certific ate-in-Simulation/ http://admissions.rmu.edu/online/nursing-and-health-care/simulation-instruction https://www.usfca.edu/nursing/msim/ https://www.usi.edu/health/certificate-programs/clinical-simulation-certificate-program
Drexel University College of Nursing and Health Professions Robert Morris University University of San Francisco University of Southern Indiana
Barbara Sittner, PhD, RN, APRN-CNS, ANEF, Professor, Bryan College of Health Sciences As the science of simulation continues to expand into academic, clinical, and research settings, so does the need for continuing education on this teaching strategy. There are several simulation programs in the United States to address this need and prepare individuals for Society for Simulation in Healthcare certifications (Table 2). It is important that these programs incorporate the standards into their curriculum and remain up to date on revisions and the addition of new Standards. Since the inception of the INACSL Standards in 2011, the Standards were revised in 2013 and presently being reviewed by the INACSL Standards Committee. The 2015 conference was a great example of our Standards as living documents as INACSL unveils two new standardsdStandards of Best Practice: Simulation Standard VIII: Simulation-Enhanced Interprofessional Education (Decker et al., 2015) and Standards of Best Practice: Simulation Standard IX: Simulation Design (Lioce et al., 2015).
Audience Participation When the panel speakers concluded, discussion opened to the audience. In general, four themes emerged from audience questions: (a) simulation ratios and time, (b) faculty development, (c) debriefing practices, and (d) future of simulation. An initial question surfaced related to the ratio of simulation time to traditional clinical time being used. Currently, there is no recommended standardized ratio. The NCSBN study (Hayden et al., 2014) used a 1:1 ratio of time (i.e., one hour of simulation time equaled one hour of traditional clinical time) because no evidence existed to suggest using anything different. A subcommittee of the INACSL Research Committee has completed a national descriptive survey that investigated what ratios are currently being used if the ratios are standardized per course, who makes the decision(s) about the ratio being used, and how the ratio is decided (Breymier et al., 2015). It was suggested that low doses of simulation,
such as a five hours of time in the simulation laboratory per semester, would most likely not yield significant differences in student learning outcomes, no matter what ratio was used. Audience participants discussed costs associated with simulation and strategies to solicit support for simulation from colleagues and leadership within their school of nursing. It was agreed that there is a need to show return on investment with simulation. Simulation can be used to increase patient safety and avoid sentinel events and near misses (Barsteiner & Disch, 2012). Another discussion topic focused on the substitution of traditional clinical experiences with simulation. States are at different stages in the use of simulation as a substitution in this manner. Some states may determine that simulation cannot be substituted for any clinical experiences. Nurse educators may need to secure support for the use of simulation through documentation of competencies that students are unable to acquire in the clinical settings and competencies that students are not able to acquire because clinical sites are so few. California has a state regulation that allows schools of nursing to substitute up to 25% of traditional clinical time per course with simulation. Some schools and the California Simulation Alliance would like to increase the substitution time from 25% to 50%, but the California State Board of Nursing is resisting this request. Participants and the panel discussed strategies to assist state boards of nursing to accept simulation in place of traditional clinical. Bringing a representative from the board to the nursing school to observe simulation is one strategy. Florida increased the percentage of time to 50% that simulation could be substituted for traditional clinical experience as soon as the NCSBN study (Hayden et al., 2014) results were announced. A member of the Florida Simulation Alliance expressed concern that Florida schools of nursing were/are not prepared to institute simulation at this high percentage yet. The participant voiced a fear that the option to use simulation today will become a mandate for simulation in the future. This spawned a discussion related to faculty development for simulation. The question surfaced, ‘‘Are faculty prepared to educate students using 50% simulation time to pp 2-7 Clinical Simulation in Nursing Volume 12 Issue 1
After the National Council State Boards of Nursing Simulation Study replace clinical experiences?’’ Overall, the panel and audience members indicated that they do not think faculty are prepared. There were examples of students receiving poorly run simulations and faculty not using best practices in simulation because faculty are not trained in simulation education or were unfamiliar with the case or setup. There is a need to produce evidence that nursing schools and nurse educators are trained and ready to facilitate simulation before it is actually incorporated in the nursing curriculum. Faculty development can be achieved through formal education such as presentations, workshops, consortiums, and certificate programs. The Standards of Best Practice (International Nursing Association of Clinical Simulation and Learning, 2013) should be an integral component of any education session. The CHSE (Society for Simulation in Healthcare [SSH], 2014) blueprint also provides key elements of simulation which faculty should be familiar. Debriefing is the most important part of the simulation experience. One audience member asked what evidence-based practice debriefing method is best for interprofessional learning. Members of the expert panel recommended Promoting Excellence and Reflective Learning in Simulation (Eppich & Cheng, 2015). This debriefing method incorporates reaction, plus/delta, direct feedback, and advocacy/inquiry methods. It also gives the educator stems of phrases to use to elicit reflective learning in participants. Conversation shifted when a member asked for evidence to support traditional clinical experiences. Members of the panel acknowledged there is little if any evidence to support traditional clinical. However, the Institute of Medicine (2010) report lends support that current practices are not working. There is a need to investigate learning outcomes associated with both traditional clinical and simulation. Additional comments related to the lack of clinical space and what students actually get to do during traditional clinical experiences were made. A panelist voiced concern that students often only complete vital signs and bed baths when they are in the hospital setting. This concern echoes findings that ‘‘teachers’ and students’ focus on task completion which often overshadows the more complex aspects of learning nursing practice’’ (Ironside, McNelis, & Ebright, 2014, p. 185). Another discussion centered on the future of simulation in health care education. One member asked if the future of simulation lies in accredited independent independently run simulation centers. Members of the audience and panel agreed that this could be a next step and would be a fundamental change to health care education as it currently exists. Students would get didactic and high-dose simulation before entering the clinical arena so that when they were at the patient bedside, they could take full advantage of patient experiences.
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The final discussion point concerned the use of simulation in graduate nursing education. A member referenced the position of the National Task Force on Quality Nurse Practitioner Education (2012) against replacing any portion of the 500 mandatory direct patient care clinical hours in NP education with simulation, yet clinical site placements are lacking for graduate practicums in the same manner as undergraduate clinicals. The panel hoped that changes would be made in the future in graduate nursing education. The American Association of Colleges of Nurses has formed an Advanced Practice Registered Nurse task force to investigate the use of simulation in graduate education (American Association of Colleges of Nursing, 2014). There is a need rigorous scientific studies in the future to provide quantitative support simulation to be counted as clinical hours in NP programs.
Addressing Issues and Barriers That Still Exist The NCSBN Simulation Study addressed important gaps in the literature regarding the use of simulation in prelicensure nursing education. Still, many barriers and questions remain. An expert panel and audience brought many of those barriers and questions to the forefront of discussion during the INACSL conference in June. Simulation use continues to grow. Discussion related to the use of simulation in healthcare education will continue.
References Agency for Healthcare Research and Quality. (2015). Healthcare simulation to advance safety: Responding to Ebola and other threats. Retrieved from http://www.ahrq.gov/research/findings/factsheets/errorssafety/simulproj15/index.html. Agency for Healthcare Research and Quality. (2013). Advances in patient safety through simulation research (R18). Retrieved from http://grants. nih.gov/grants/guide/pa-files/PA-14-004.html. American Association of Colleges of Nursing. (2014). Current state of APRN clinical education. Retrieved from http://www.aacn.nche.edu/ APRN-White-Paper.pdf. Barsteiner, J., & Disch, J. (2012). A just culture for nurses and nursing students. Nursing Clinics of North America, 47(3), 407-416, http://dx. doi.org/10.1016/j.cnur.2012.05.005. Breymier, T. L., Rutherford-Hemming, T., Horsley, T. L., Atz, T., Smith, L. G., Badowski, D., & Connor, K. (2015). Substitution of clinical experience with simulation in prelicensure nursing programs: A national survey in the united states. Clinical Simulation in Nursing, 11(11), 472-478, http://dx.doi.org/10.1016/j.ecns.2015.09.004. Decker, S. I., Anderson, M., Boese, T., Epps, C., McCarthy, J., Motola, I., ., & Scolaro, K. (2015). Standards of best practice: Simulation standard VIII: Simulation-enhanced interprofessional education (sim-IPE). Clinical Simulation in Nursing, 11(6), 293-297. http://dx.doi.org/10. 1016/j.ecns.2015.03.010. Eppich, W., & Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS): Development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare, 10(2), 106-115, http://dx.doi.org/10.1097/SIH.0000000000000072.
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After the National Council State Boards of Nursing Simulation Study Hayden, J. (2010). Use of simulation in nursing education: National survey results. Journal of Nursing Regulation, 1(3), 52-57. Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), 1-66. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from www.nap.edu/catalog.php?record_id¼12956. International Nursing Association of Clinical Simulation and Learning. (2013). Standards of best practice: Simulation. Clinical Simulation in Nursing, 9(6S), Si-S32. Ironside, P. M., McNelis, A. M., & Ebright, P. (2014). Clinical education in nursing: Rethinking learning in practice settings. Nursing Outlook, 62(3), 185-191, Retrieved from http://dx.doi.org/10.1016/j.outlook. 2013.12.004.
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Jeffries, P. R., & Rogers, K. J. (2012). Theoretical framework for simulation design. In P. R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation (2nd ed.). New York, NY: National League for Nursing. (pp. 25-41). Lioce, L., Meakim, C. H., Fey, M. K., Chmil, J. V., Mariani, B., & Alinier, G. (2015). Standards of best practice: Simulation standard IX: Simulation design. Clinical Simulation in Nursing, 11(6), 309-315, Retrieved from http://dx.doi.org/10.1016/j.ecns. 2015.03.005. McGaghie, W. C., Issenberg, S. B., Petrusa, E. R., & Scalese, R. J. (2010). A critical review of simulation-based medical education research: 20032009. Medical Education, 44, 50-63. National Task Force on Quality Nurse Practitioner Education. (2012). Criteria for evaluation of nurse practitioner programs. Washington, DC: National Organization of Nurse Practitioner Faculties. Society for Simulation in Healthcare. (2014). Certified healthcare simulation educator. Retrieved from http://www.ssih.org/Certification/CHSE.
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