This is the e-learning module for integration of simulation into the curriculum, understanding simulation design, and how to integrate simulation-based educational activities into the curriculum. I am your lecturer, Dr. Loquitrus Lashawn Warren. I am an adjunct assistant professor at the University of Alabama at Birmingham School of Nursing. I am also a clinical simulation instructor at UAB and a member of your AANA Simulation Subcommittee. I want to take this time to thank my fellow co-members of the subcommittee for all their contributions to both the profession of simulation and this committee. The data from this committee is being presented in this module. First, I want to establish that I don't have any disclosures or financial relationships with any commercial interests related to the content of this activity, and I will not discuss any off-label use during my presentation. This e-learning module will, number one, discuss the healthcare simulation standards of best practice. Number two, identify key areas of simulation design. Number three, describe various strategies for the incorporation of simulation-based activities to meet simulation standards. And number four, examine the effectiveness of simulation-based education. The International Nursing Association for Clinical Simulation and Learning is a global leader in transforming practice to improve patient safety through excellence in healthcare simulation. This organization is a community of practice for simulation where members can network with simulation leaders, educators, researchers, and industry partners. This organization has provided a framework or standards of best practice for simulation as an evidence-based framework to guide the simulation design, implementation, debriefing, evaluation, and research. Each box illustrated on the slide shows a component of the standard, and we will discuss each one. So the key areas of simulation design starts with a gap analysis. You want to evaluate the participants, and once you have decided that their learning outcomes is best met through experiential learning or by doing that you receive with simulation, then you come up with your objectives because your objectives guide your design. So you want to do a gap analysis and then create your objectives and then come up with a facilitation plan of how you will facilitate the learning and then followed by a scenario design and then what equipment you're going to need and how you're going to evaluate the participants. Simulation objectives and outcomes should include both short- and long-term learning outcomes. They also must be measurable and specific, be clearly communicated to the participants during pre-briefing and debriefing, and they should guide the simulation activities and outcomes and aid in the simulation grading. Pre-briefing is the activity immediately preceding the start of a simulation activity where the participants receive essential information about the simulation scenario, such as the background information, instructions, or guidelines. Pre-briefing should be purposeful, intentional, and strategic. This process sets the stage for a successful learning experience to support the concept of a safe learning environment. Pre-briefing has essential components that need to be included and they are the following. Number one, purpose of the simulation. You need to include your learning objectives and provide related learning aids, visuals such as videos, lectures, and reading assessments prior to simulation. Number two, you want to include orientation and instructions for the simulation. So everything that the participants need to be successful during simulation need to be provided in this phase. So you want to include where to find things, how things work, you want to discuss the timeline of how long you have for each part of the simulation. You also want to talk about the evaluation process, explain roles and expectations. Number three, you want to set ground rules. You want to discuss that confidentiality is important among the participants and that the information and content from the simulation and what goes on during simulation must be kept confidential. You also talk about the fiction contract, which is essentially a verbal or written contract with the set ground rules. And you want to push integrity. Lastly, you want to set a psychologically safe environment for learning. So you want to talk about the basic assumptions that everyone is here at the simulation to learn and acknowledge that learning needs will vary among participants based on their previous learning experiences. Debriefing is when you discuss the actions and thought processes involved in a particular clinical situation. So you want to ask what happened and is there anything that could be improved? So you as a facilitator will encourage reflection and incorporate improvement into future performances. There are several common methodologies for debriefing. And on this slide, I have listed the most popular ones. Versus plus delta, it is a straightforward approach that asks learners to consider what went well and what would they do differently next time. The next is promoting excellence and reflective learning in simulation, also known as PEARLS. It is a framework and accompanying tools that integrate learner self-assessment, guided discussion, and feedback teaching. Next we have MODEL. It is a framework that includes open-ended questions focused on diffusing, discovering, and deepening, and is designed to facilitate reflection and learning. And lastly, the 7-Step After Action Review that was adopted from the U.S. Army. It is a method focused on identifying lessons learned and applying those lessons to future situations. The facilitator has many roles besides developing the simulation. They also have to create a safe learning environment where they establish trust early in the pre-briefing phase. Facilitator also has to manage personnel and equipment. Studies show again that formal training for consistency is encouraged because with each group of participants, you want them to have the same or similar experience, so everyone with the same type of training, that should occur. There are research studies that show that a designated staff and space for simulation are optimal. And facilitators also have to address issues that arise during simulation, such as equipment failure and unexpected behaviors or events. The facilitator also has to manage evolving participant needs. There are research studies that show that group size plays an important role in participants' learning. It showed that group sizes that are smaller, so three to four learners, were optimal. And then outcomes, the facilitator wants to identify participant performances and feedback and encourage reflective learning. So the initial and ongoing professional development supports the facilitator across their careers. As the practice of simulation-based education grows, the professional development allows the facilitator to stay current with new knowledge, provide high-quality simulation experiences, and meet the educational needs of their learner. So factors have led to our professional development standards, and they were, studies have shown that many of our educators and clinicians had to learn on the job how to perform a simulation. What turns out that this is not the most efficient way of doing things. Also there was this identification of a need to increase focus on a participant-centered learning and evidence-based facilitation, which required more training. So many accredited bodies recognize simulation as a specialized educational strategy that requires special training. So institutions should offer courses to train their facilitators and encourage certification for their staff. There are three criteria to meet the standard for professional development, and they are, the first criteria are that you have to perform an educational needs or gap analysis to first develop a professional development plan. Secondly, you need to participate in professional development activities that address desired learning outcomes and aligned with the individual's role along with the priorities of the institution. And thirdly, and most importantly, you have to reevaluate the professional development plan using a formative and summative methods by both the individual and the organization. This slide has all of the simulation resources and organizations for facilitators to have as a resource because it offers reliable information for facilities to be able to make their simulations effective. Professional integrity, so participants should provide honest and clear feedback in an effective and respectful manner, recognize unprofessional and unethical behavior during the simulation and take steps to abate it, demonstrate mutual respect, and maintain confidentiality. SAM Enhanced Interprofessional Education, or IPE, is defined as members from two or more professions in health or social care learning to train together with the goal of improving collaborative practice to improve the quality of care. There are four criteria for SAM IPE. It's number one, conduct SAM based on theoretical or conceptual framework. Number two, utilize best practices in the design and the development. Number three, recognize and address potential barriers. And number four, devise an appropriate evaluation plan. SAM Enhanced Interprofessional Education, or IPE, is a fairly new concept and there is not a whole lot of research out there and there needs to be more. However, what is out there is that the researchers are saying that the disadvantages can occur if the SIEM IPE is not developed appropriately. So those disadvantages would be to the lack of role clarity, not reaching deep learning, having information overload and being inefficient. There are many other studies that show though that if you meet the criteria for SIEM IPE, that there are many advantages. One is that the SIEM IPE makes simulation more realistic and better reflect real world practice. So it improves teamwork and collaboration and communication. There is one study that showed an improved collaborative attitude because there was a development of an appreciation for each collaborative role. So they improved their attitudes towards one another. One other study showed that it could actually eliminate hierarchy issues within the staff. So SIEM IPE can improve performance and thereby improve patient outcomes. It can reduce costs related to improving efficiencies. There is no information today that would support allowing simulation to substitute for actual administration of an anesthetic case. However, the literature does support the position that simulation is effective in teaching certain procedural skills, team training, crisis management, and improve performance in low frequency, high impact clinical situations that doesn't occur often. These types of high impact clinical situations that doesn't occur often are good examples of what SIEM IPE could help with because it gives you the more realistic version of how things really are in the real world. Some examples of a good simulation IPE that have been utilized in other institutions are OR code blue, OR fire, malignant hyperthermia, and gun intruder. Oftentimes the hospitals will already have training sessions for their staff. And so you could add your participants to that training. But that requires planning to have an adequate pre-briefing and debriefing for your participants to have an optimal learning experience. Also that requires collaboration with the ORs and the hospital educators, providing the training for their staff and so that you can coordinate your schedule. The advantage of this is that you don't have to pay for any additional equipment because the resources are already being utilized. Integration of simulation starts with a gap analysis and planning. The figure shown in this slide provides samples of how other programs evaluate for gap analysis to guide the activities of simulation. The learner receives self-assessments to obtain what areas they feel they need assistance in. Preceptors are also given evaluations and surveys to identify areas that they perceive the participants need more training. Tests such as the C or the self-examination exam with the NBCRNA or the module exams can identify needs. Observing participants utilizing a checklist can identify needs. Changes in our standards of practice or technology guide our need for training also. For example, when COVID occurred, we had to change our intubation techniques and simulation provided a good way for training for those techniques. New standards for skills such as utilizing ultrasound for CVL placement, point of care ultrasound or POCUS, transesophageal echoes or TEE, and reading chest X-rays for assessing the patient to improve care and patient outcomes all became important skills that we need additional training on. Any technology such as video laryngoscopy need additional training to keep our skills strong and additional training to keep our skills sharpened. All of these factors guide our need for simulation training. The operations include planning, logistics such as people, supplies, and timing. Employ strategies to balance risks and outcomes, so real versus simulated equipment, supplies, and tissues. Identify required resources such as personnel, equipment, and supplies. Collaborate in the coordination of the simulation team and prepare material for participants and the simulation team, such as instructions, equipment, and supplies, and a designated simulation lab. Sample integrative operational strategies and other institutions are illustrated on the slide. Where you look at specifically planning, we said is very important when it's time to create a good SIEM program. So planning involves both securing resources and experts, so equipment and personnel. And these are listed are some of the ways that other institutions have obtained some of the resources. So for equipment, they have allocated funds for both equipment and for staff in the budget. Other things they've done is to collaborate with other departments to share expenses like utilizing the SIEM IPE, grants, donations from partnerships and hospitals through utilizing maybe expired supplies. That's where you utilize your relationships with your vendors and your affiliated hospitals. Also, you could borrow expensive equipment from your partnerships. And with your experts, you can utilize your preceptors to assist with simulation. Also, you can get guest experts from other institutions or within the community and even in other disciplines. So the key is to build stronger relationships, including with your alumni, because they can come back and donate their time or even give money. And also you can utilize graduate students with simulation. And there is some research that shows that some programs do a good job with utilizing mentorships of the first year student with the third year student. The facilitator must make sure that the form of evaluations are appropriate for the objectives of the simulation. Measurements for evaluation can be a test, an interview or questionnaire. Evaluations can be either formative or summative. Formative evaluations occur during the learning activity or program with the goal to achieve specific objectives. The purpose of formative evals is to promote self-assessment with constructive feedback with the mission to improve the student's performance. On the other hand, summative evaluations take place at the very end of a learning period. And it can be used for competency determination. Peer evals and self evals are examples of formative evaluations. An example of summative is utilizing a simulation to pass a competency skill, such as demonstrating the correct placement of the CBL line or a final exam. Evaluations can be assessed in a group or individually. So the evaluation of the effectiveness of simulation. Our studies have shown that simulation can actually provide assessment in all three learning domains. In cognitive domain, it can test the factual knowledge and also in clinical decision-making. And in effective domain, you see changes in emotions and beliefs and attitudes in this experiential learning through simulation. And then the psychomotor domain with the reflective analysis of the experience through debriefing, the supervised clinical experiences and the use of models, test trainers and practice by actually doing. There are many other factors that one must consider when designing a simulation. There are many broad educational and learning theories to know. And I suggest that you utilize the reference list at the end of this module to obtain additional resources on learning the varying educational theories. I will review some of my favorites here, but the list is not inclusive of all theories related to simulation. Behaviorism and constructivism are two popular theories utilized in simulation. Behaviorism is the thought that in the environment develops person and positive reinforcement promotes changes in behavior. Constructivism is learning by doing. Learning theories such as experiential learning, scaffolding and social learning are utilized in simulation. Experiential learning is when the student utilizes self-reflection. Scaffolding is the actual process where the facilitator shows the participants how to solve a problem or do a task and then step back and allow the participants to repeat the task. Social learning is a theory where feedback is essential to the learner's performance improvement. There are researchers that suggested that knowledge obtained during simulation usually leads to a deeper understanding of the information than just recall, for example, on a test. Simulation leads to critical thinking skills and metacognition, which includes the knowledge of why steps are taken in a process. Learning styles and participants' previous experiences affect the way they learn and should be factored into the simulation design. Studies have shown that there are differences in how people learn that even from varying generations, people learn differently. Some people are visual learners while others may need auditory aid, reading and writing aids, and do better with kinesthetics, which is hands-on. All of these factors should be considered when designing the simulation. In summary, simulation improves critical thinking, metacognition, crisis training, team performance, collaboration, and procedural training such as placement of CVLs. And because of all of these improvements, every curriculum needs simulation to be integrated. These are the references for this module. This is the end of the module. If you have questions, this is my contact information. Thank you.

simulation design

healthcare simulation

e-learning module

interprofessional education

critical thinking

simulation facilitators