Facilitating Learning with Simulation

1
Facilitating Learning with Simulation

• Education and Training Services
• Beth Cannata MSN, RN
• Wendy Jo Wilkinson MSN, RN
• Amanda Wilford MA, RN
• Sharon Elliott MSc, RN

2
Objectives

• Demonstrate how to facilitate a simulated
  clinical experience for nursing students
• Identify methods to create suspension of
  disbelief
• Discuss the importance of debriefing and
  demonstrate how to conduct a session

3
Do Not Despair, Simulation is Here!

• Simulated Clinical Experiences (SCEs) provide
  you with the opportunity to meet the needs of
  your learner
• You create a real patient situation in need of
  interventions
• Focus on learners needs, not the patients
• You have the time to facilitate critical
  thinking, diagnostic reasoning and problem
  solving
• Patient safety is not an issue

4
Benefits of Simulation

• Realistic with Active Learning
• Critical Thinking
• Can Pause the Action
• Safe Environment
• Immediate Feedback
• Teamwork, Collaboration, Communication
• Learn from each Other
• Significant Learning Environment

5
Realistic Environment
6
Brings Learning AliveNatural Feedback
7
Critical Thinking and Diagnostic Reasoning
8
Multiple Objectives Multiple Students
9
Communication
10
METI Family

• METI Simulators contain modeled patients to
  represent the physiologic responses for
• Standard Man (woman), healthy person, 33 yrs old
• Unhealthy Middle Aged person (male or female)
• Stannette Normal full term pregnant female
• Standard Elderly male or female
• Soldier, extremely fit, hypermetabolic 20 year
  old
• The child
• The infant

11
METI Simulators

• With these simulators you have a patient that
• Blinks, variable pupil size, chest moves with
  respirations
• Normal/Abnormal Heart, Lung, Bowel Sounds
• All Pulses, Blood pressure measurement
• Waveform monitors can be used or disabled to
  include ECG, SpO2, Temperature, NIBP, Arterial
  Line, CVP, Pulmonary Artery Catheter, EtCO2,
  Thermodilution Cardiac Output
• IVs, IMs, Catheterizations
• Intubation, Tracheotomy, Chest Tube placement and
  maintenance
• Various forms of O2 may be simulated
• Exchangeable Genitalia and Urinary Output
• Moulage with wounds, edema, emesis, stools,
  bleeding, cyanosis, all types of trauma,
  pregnancy and postpartum

12
What We Have Learned

• Positioning and dress have an impact
• Small groups function better
• Challenges are necessary
• Open-ended questions are key
• It is okay for the simulator to die
• Suspension of disbelief is vital
• Debriefing is essential

13
Where is the Instructor?

• Head of the bed?
• Foot of the bed?
• In the other room?

14
What Are They Wearing?
15
Group Size Matters

• Small groups
• Decrease numbers when acuity increases

16
Provide a Challenge!
17
Open-ended Questions

• Why do you think that happened?
• What is going on inside the body to cause that
  sound?
• Tell me about that
• Describe the sound youre hearing
• What is the correlation between the lab results
  and your assessment findings? Why is that test
  important to do?

18
Death is a Normal Part of Life

• Will you allow your simulator to die?
• Amniotic Emboli
• End-of-Life Care
• GI Bleed Secondary to Varices and Liver Failure
• Acquired Immune Deficiency Syndrome Who Develops
  Pneumocystis Carinii Pneumonia and Respiratory
  Distress

19
Suspend Disbelief
20
Suspend Disbelief
21
Moulage

• "Moulage is a mold of an injury to be used to
  help medical personnel see what they are treating
  during a drill. Moulage can be called an art form
  as it takes time and precision to make the injury
  look real." (Mater, 2004)
• Evolved to mean all of the props used to simulate
  actual patient cases
• May include dressings, colostomy bags, pedal
  edema, decubiti, clothing, wigs, etc.
• Also includes environmental moulage such as loud
  music to simulate a bar, furniture, etc.

22
Recipes for Disaster

• www.meti.com
• Education
• Recipes for Disaster
• Be sure to submit
• your own ideas!

23
Teaching Strategies With Simulation

• Decide on the placement of the SCE within the
  curriculum/orientation/evaluation/remediation
• Prepare the Environment
• As realistic as you can make it!
• Suspend disbelief
• Emersion?Transferability
• Supplies
• References/Resources
• Less reliance on memory, more on where to find
  information

24
Teaching Strategies

• Provide time for
• patient assessment and family interactions
• integrating history/assessment data and
  developing plans of care
• entering patient data/orders in computer
• documenting admission process accurately using
  appropriate tools
• coordinating care with other team members
• performing skills
• patient/family education

25
Teaching Strategies

• Schedule time - two hours minimum for students
• Depends on the complexity of SCE and level of
  learners
• Always include time for SCE AND time for
  Debriefing
• Provide time for critical thinking and problem
  solving, for collaboration and teamwork, for
  communication, for practicing skills

26
Practice -gt Confidence -gt Competence
27
Logistics of Debriefing

• Debrief as group, may debrief observers
  separately
• Set ground rules for safe environment and
  confidentiality
• All are expected to be active in discussions of
  the events and their performance
• Focus on critical thinking and specific learning
  objectives
• Faculty is facilitator, not evaluator

Contributed by Dr. Judy Johnson-Russell, TWU and
Mindi Anderson, UTA
28
Goals of Debriefing

• One of the most beneficial parts of simulation
  when it is done correctly
• Enhances student learning through a guided review
  of the Simulated Clinical Experience
• Assist students to evaluate
• Their own performance
• The teams performance
• Their understanding of the patient, his/her
  condition and responses to their interventions

29
Goals of Debriefing

• Reinforce Objectives of Simulated Clinical
  Experience (SCE)
• Students often have a limited picture of what
  happened while involved in simulation while
  involved, they observe only those parts their
  position allows them to (Peters and Vissers,
  2004)
• Assists in learning those things they missed
  while engaged in the SCE

30
Goals of Debriefing

• Enhance Critical Thinking and Problem Solving
• Advantageous to compare different perspectives
  and a joint analysis. This increases student
  understanding (Peters Vissers, 2004).
• Encourages Collaboration and Communication
• Safe place to discuss without constraints of time
  (Mort Donahue, 2004) and pressure of being in
  the simulated clinical experience
• Develop information seekers/processors by having
  them utilize available resources

31
Professional Learning Environment
32
Differences Between Post Conference and Debriefing

• All students have shared the same patient and
  many of the same experiences
• Functioned as a team caring for the patient
• Individual roles contributed to the patients
  care
• Video available
• Logs available

33
Process of Debriefing

• I. Introduction
• II. Personal Reactions
• III. Discussion of Events
• IV. Summary

34
I. Introduction

• Communicate faculty expectations
• Prepare learners to actively analyze and evaluate
  self and simulation activities
• Describe faculty role
• Facilitation vs evaluator or instructor
• Discuss confidentiality
• Signed statement
• Provide a safe environment for learners to
  express feelings and ask questions
• Mistakes are a part of the learning process

35
II. Personal Reactions

• Recognize and release emotions built up during
  simulation (Fritzsche, Leonard, Boscia,
  Anderson, 2004)

36
Personal Reactions

• Learners who have the opportunity to explore and
  deal with the feelings they experienced during
  simulation will be better prepared to deal with
  them in real clinical situations (Henneman,
  Cunningham, 2005)
• Begin with open-ended questions and use
  reflective responses to their statements
• Ensure that all in small groups have the
  opportunity to respond
• Their responses can guide the discussion of
  events

37
III. Discussion of Events

• Begin with, or whenever appropriate, review
  objectives of the SCE
• As learners begin to discuss the events,
  encourage them to continually analyze the events
  in depth and their feelings, thoughts and
  reactions to them
• Remember, students learn and remember more when
  they participate actively and make their own
  analyses (Duvall Wicklund, 1972)

38
Discussion of Events

• Reflective learning (Mort Donahue, 2004)
• Reflection should relate to objectives
• Self-assessment
• Why acted as they did, correct, differently?
• Interested inquiry
• Individually what do they need to work on?
• Encourage feedback from peers
• (Henneman Cunningham, 2005)
• Focus on performance, not performer

39
Discussion of Events

• Ask questions like
• How familiar were you with the patients
  condition, treatments, and complications prior to
  the SCE?
• What happened?
• What did you do as a team or individually when
  that happened?
• What was the outcome?
• What would you do differently next time,
  individually, as a team?
• What additional information, knowledge, skills,
  etc. do you think were/are needed in the
  situation, for the future?

40
Good Questions

• Are relevant to the discussion of the SCE and
  keep the students continually thinking and
  processing information
• Do not imply judgment
• Do not provide information or suggestions
• Try to understand what went on in a positive
  supportive way

41
Discussion of Events

• Clarify Information
• Possible for students to manipulate the data in
  such a way that they distort it and make it fit
  into their previous learning
• Through the debriefing process, faculty can
  insure that new learning is processed correctly
  (Chiodo Flaim, 1993)
• Connect theory to practice

42
Discussion of Events

• Student questions can be answered, student
  thinking can be clarified, teaching points can be
  emphasized (Fritzsche, Leonard, Boscia,
  Anderson, 2004 Jeffries, 2005)
• Published/standardized guidelines can be reviewed
  (Owen Follows, 2006)
• Charting can be reviewed
• Link what has been learned in simulated setting
  to real world (Chiodo Flaim, 1993 Fritzsche,
  Leonard, Boscia, Anderson, 2004 Peter
  Vissers, 2004)

43
Discussion of Events

• View videotape whenever appropriate
• Question errors in judgment as in complacency
  with abnormal vital signs or vigilance errors as
  in the failure to attend to changing status
• Ask about communication with the patient, family
  members, team members
• Discuss errors with protocols/guidelines

44
IV. Summary

• Goal is to assist the students in looking at the
  overall experience. What they did, what they
  learned, what they have said they want to work on
• Could be done by faculty or by asking open-ended
  questions of the students
• Ask what they learned new from the SCE
• Ask what individually and as a group they feel
  they need to work on

45
GROW MODEL

• G GOALS - were the goals/ learning outcomes
  met?R REALITY- was the scenario real related
  to real practice and realisticO OPTIONS - Was
  there other options to what the intervention was
  - alternatives - link to evidence baseW WAY
  Forward - for the learner - what will they do as
  a result of simulation i.e. will they realize
  they know more than they thought, do further
  work on etc....

46
Summary

• End on a positive note
• In summary, these are the things you identified
  as going well.
• These are the things you told me you need to work
  on.
• The take home points include.
• I saw improvement in these areas.
• Thank the students for participating in both the
  SCE and debriefing
• Written Evaluation

47
Evaluations

• Obtain feedback from students after the
  simulation lab
• Do they understand classroom material better?
• Do they feel more confident with assessment
  techniques, medication administration,
  interventions?
• Did the instructors questions help them to think
  critically?
• Obtain feedback from course instructors
• What were the observed outcomes, implications,
  course response?

48
Faculty Debriefing

• Discuss feelings
• Talk about what worked, what did not
• Decide what needs to be changed for the next time
• Discuss what was learned about students in
  general and about the curriculum
• Review student evaluations

49

• "The difficulty lies not so much in developing
  new ideas as in escaping from old ones"
• John Maynard Keynes

50
References/Additional Readings

• Anderson, J. (2005). Debriefing worksheet.
  Unpublished.
• Anderson, J., Cox, S. (n.d.). Strategies for
  successful debriefing Presentation.
• Center for Medical Simulation. (2004, 2005).
  Institute for Medical Simulation comprehensive
  workshop. Author.
• Chiodo, J. L., Flaim, M. L. (1993). The link
  between computer simulations and
• social studies learning Debriefing.
  Social Studies, 84(3), 119-121.
• Dismukes, R. K., Gaba, D. M., Howard, S. K.
  (2006). So many roads Facilitated
• debriefing in healthcare. Simulation in
  Healthcare, 1(1), 23-25.
• Dunn, W. F. (2004). Education theory Does
  simulation really fit? In W. F. Dunn (Ed.).
  Simulators in Critical Care and Beyond. Des
  Plaines, IL Society of Critical Care Medicine.
• Duvall, S., Wicklund, R. A. (1972). A theory of
  objective self awareness. New York,
• NY Academic Press.
• Fritzsche, D. J., Leonard, N. H., Boscia, M. W.,
  Anderson, P. H. (2004). Simulation
• debriefing procedures. Developments in
  Business Simulation and Experiential
• Learning, 31, 337-338.
• Graling, P., Rusynko, B. (2004). Kicking it up
  a notch- successful teaching
• techniques. AORN Journal, 80(3),
  459-475.

51
References/Additional Readings

• Haskvitz, L. M., Koop, E. C. (2004). Students
  struggling in clinical? A new role for
• the patient simulator. Journal of
  Nursing Education, 43(4), 181-184.
• Henneman, E. A., Cunningham, H. (2005). Using
  clinical simulation to teach patient
• safety in an acute/critical care
  nursing course. Nurse Educator, 30(4), 172-177
• Hravnak, M., Tuite, P., Baldisseri, M. (2005).
  Expanding acute care nurse
• practitioner and clinical nurse
  specialist education Invasive procedure training
• and human simulation in critical care.
  AACN Clinical Issues, 16(1), 89-104.
• Jeffries, P. R. (2005). A framework for
  designing, implementing, and evaluating
• simulations used as teaching strategies
  in nursing. Nursing Education
• Perspectives, 26(2), 96-103.
• Knowles, M. (1984). Andragogy in action. San
  Francisco Jossey-Bass.
• Mater, E. (2004). The art of moulage. Retrieved
  January 21, 2006 from http//www.dcmilitary.com
• Mort, T. C., Donahue, S. P. (2004). Debriefing
  The basics. In W. F. Dunn (Ed.),
• Simulators in critical care and beyond
  (pp. 76-83). Des Plaines, IL Society of
• Critical Care Medicine.
• Nehring, W .M., Ellis, W. E., Lashley, R. R.
  (2002). Human patient simulators in nursing
  education An overview. Simulation Gaming,
  32(2), 194-204.

52
References/Additional Readings

• Owen, H., Follows. V. (2006). Really good
  stuff GREAT simulation debriefing.
• Medical Education, 40(5), 488-489.
• Peters, V. A. M., Vissers, A. A. N. (2004). A
  simple classification model for
• debriefing simulation games. Simulation
  Gaming, 35(1), 70-84.
• Rall, M., Manser, T., Howard, S. K. (2000). Key
  elements of debriefing for simulator training.
  European Journal of Anaesthesiology, 17, 515-526.
• Rauen, C. A. (2004). Simulation as a teaching
  strategy for nursing education and orientation
  in cardiac surgery. Critical Care Nurse, 24(3),
  46-51.
• Rhodes, M. L., Curran, C. (2005). Use of the
  human patient simulator to teach
• clinical judgment skills in a
  baccalaureate nursing program. Computers,
• Informatics, Nursing, 23(5), 256-262.
• Rudolph, J. W., Simon, R., Dufresne, R. L.,
  Raemer, D. B. (2006). There's no such thing as
  "nonjudgmental" debriefing A theory and method
  for debriefing with good judgment. Simulation
  in Healthcare, 1(1), 49-55.
• Scherer, Y. K., Bruce, S. A., Graves, B. T.,
  Erdley, W. S. (2003). Acute care nurse
• practitioner education Enhancing
  performance through the use of clinical
• simulation. AACN Clinical Issues, 14(3),
  331-341.