Health care simulation is a teaching modality that now spans nurses’ professional careers. Simulation-based education (SBE) is employed to teach domain-specific skills in undergraduate and graduate nursing education, improve the transition to professional practice, and enhance complex team training in interprofessional teams. In addition to acquiring skills, attitudes, and knowledge, clinicians are participating in SBE to test new hospital services and assess new and existing care environments for latent safety risks.
This teaching approach is grounded in experiential learning, in particular Kolb's experiential learning cycle.1 (To see a video about this cycle, go to http://links.lww.com/AJN/A137.) All health care professionals—including nurses, who make up a substantial proportion of the workforce, and nurse educators—should expect to be involved in SBE; therefore, a familiarity with the foundational concepts of SBE will prepare them to be engaged participants and possible future leaders of SBE activities. Professionals are now transitioning to practice with prior exposure to SBE and an expectation that SBE will be part of ongoing professional development. Moreover, they may also have the expectation that hospital-based SBE faculty will be as qualified and effective as academic nursing faculty. This has implications for nursing educators’ knowledge and skills. Therefore, this article will discuss three foundational concepts of SBE: prebriefing, debriefing, and safety in simulation (including psychological and physical safety of the learner and potential safety threats to real patients), and provide examples of academic, hospital- and health care center–based, and in situ simulation (ISS) programs. (Hospital- and center-based simulation is conducted in a physical space designated for educational purposes only; ISS means that the educational experience takes place in a clinical space used for direct patient care, such as an empty patient room.2)
The simulation facilitator is defined as “an individual who is involved in the implementation and/or delivery of simulation activities”3; other commonly used terms include debriefer and simulationist.3Simulationist is defined more broadly as one who is “involved in the design, implementation and/or delivery of simulation activities.”3 In this article, we focus on prebriefing and debriefing, not scenario design.
In prebriefing, the simulation facilitator orients participants to learning in the simulated environment and establishes a psychologically safe learning environment.4 (Patient safety has become a concern more recently, as SBE has expanded into in situ environments; we will address this concern in more detail below.)
Psychological safety in SBE means that learners know they will not be shamed or humiliated for making mistakes.5 Instead, mistakes made during simulation are treated as valuable data that initiate and support reflective learning during debriefing.4 Importantly, in a psychologically safe learning environment, participants are more likely to admit when they don't know something, ask questions, and be receptive to feedback.5 It is important to note, however, that the prebriefing is also the appropriate time to inform learners about safety issues, such as the use of real, expired, or simulated medications; expired equipment such as central line kits or sterile items; live defibrillators or nonfunctional equipment; and other concerns specific to the setting where the simulated case takes place.6 Reviewing safety principles and engaging learners in a dialogue about the possible risks of simulation in the prebriefing session can reduce the likelihood of unintended consequences related to SBE activities.
Finally, the facilitator should explicitly verbalize respect for the learners by stating a belief in their good intentions, ability to meet the challenges presented in the simulated case, and willingness to try their best.4 While there is no one format for prebriefing, the Debriefing Assessment for Simulation in Healthcare (DASH) tool (https://harvardmedsim.org/resources/dash-raters-handbook-en) identifies essential facilitator behaviors that should be included in all prebriefings (see Key Elements of Prebriefing7). (To see a video of a prebriefing session, go to http://links.lww.com/AJN/A138.) Prebriefing usually occurs in person just prior to the simulation and can be augmented with the use of a video recording or written information or both. The content and amount of time for each prebriefing session will vary based on the objectives of the simulation, the participants’ previous experience with simulation, and the participants’ developmental stage as learners (from prelicensure nursing students to experienced clinicians).8 Those with less experience in the simulation environment usually require more time for thorough orientation.
Researchers have shown that debriefing is the SBE phase in which most of the learning takes place.9, 10 Debriefing is a reflective conversation between a facilitator and one or more learners that encourages metacognitive skills, including the examination of events, thoughts, and emotions, which helps learners understand how they mentally frame a situation when making decisions and gain insights that can improve future patient care.2, 11-14 Debriefing provides a vehicle for “reflection-on-action,” in which learners seek to give meaning to their recent learning experience.1, 15 Reflection of this nature can be very personal; therefore, maintaining the psychologically safe environment created during the prebriefing is essential.4, 16, 17
In a safe learning environment, a reflective debriefing conversation guided by a skilled facilitator includes several key elements, regardless of the specific debriefing model.18 Most models acknowledge several stages of debriefing, including a sharing of the learners’ reactions to the simulated case, understanding through reflective conversation and the facilitator's directed feedback, and summarization of the specific case.
The facilitator first invites participants to express their initial reactions to the simulation, allowing them to vent and dissipate the emotional activation that is part of the normal response to a simulation scenario. This stage of debriefing provides the educator with insight into which issues are uppermost in the participants’ minds. Then the facilitator guides a reflective discussion of the critical events that occurred in the simulation to examine the thought processes that drove participants’ actions and promoted their understanding. This stage of the process allows the educator to provide feedback on practice-related issues, such as clinical problem-solving and communication. Finally, the facilitator asks participants to summarize their “take home” points and describe how they will incorporate new learning into their practice. (To see a video of debriefing—“debriefing with good judgment”19—go to http://links.lww.com/AJN/A139.)
The development of competent SBE facilitators should be a priority in both academic and professional settings. Several professional organizations have acknowledged the importance of having skilled facilitators to lead debriefing sessions to maximize participants’ learning in recently published policy papers, including the “NCSBN Simulation Guidelines for Prelicensure Nursing Programs” issued by the National Council of State Boards of Nursing,20Debriefing Across the Curriculum from the National League for Nursing,21 and the “INACSL Standards of Best Practice: Simulation Debriefing” by the Standards Committee of the International Nursing Association for Clinical Simulation and Learning.17 All explicitly state that debriefing facilitators should undergo a formal educational program. Unfortunately, the majority of debriefing facilitators in undergraduate nursing education do not have formal education in facilitating SBE, and their competence is rarely assessed.13 We know of no published research to date that compares the skills of academic and postgraduate hospital-based SBE educators. It shouldn't be assumed that hospital educators have the requisite teaching skills to maximally leverage the time spent in SBE, and each program, regardless of setting, should devise a supportive educational plan for facilitator development. The INACSL Standards of Best Practice can provide guidance for a sound approach, and a variety of organizations provide SBE facilitator education programs in multiple formats.
The skills required to create and maintain a physically and psychologically safe learning environment, engage learners in critical self-reflection, and demonstrate curiosity and respect for learners’ points of view are transferable to any learning conversation or interaction involving clinical feedback.22 Therefore, time spent in developing these skills can have a greater impact beyond SBE activities.
IMPLEMENTATION OF SBE
The following examples describe the implementation of SBE in academic, hospital-based, and in situ environments.
Academic center. The regional Research and Innovation in Simulation Education (RISE) Center at Robert Morris University in Pittsburgh, Pennsylvania, is accredited by the Society for Simulation in Healthcare (SSH) and currently averages more than 2,000 visits a year from prospective students, faculty, parents, and others interested in simulation. In 2017, RISE Center educators managed 400 individual student participants in 2,600 educational encounters. The center's mission is to serve the students and faculty of the School of Nursing and Health Sciences and to be a regional resource for excellence in SBE. Undergraduate nursing students currently complete about 30% of their clinical hours in a simulation center working with both manikins and standardized patients (SPs). An SP is “an individual trained to portray a patient with a specific condition in a realistic, standardized, and repeatable way and where portrayal/presentation varies based only on learner performance.”3 The NP faculty at the RISE Center use simulation for both foundational instruction and high stakes assessments, such as end-of-course or end-of-program diagnostic assessment encounters and skills check-offs. High stakes assessments, such as an end-of-course summative assessment in physical assessment or, in an NP program, the appropriate assessment, diagnosis, and treatment of a simulated patient, can affect the student's ability to progress academically.
Simulation faculty development. At the RISE Center, full- and part-time SBE facilitators are hired and trained to facilitate and debrief all simulation experiences. They go through a planned onboarding and mentoring process in their first semester that involves extensive reading of classic articles and texts on SBE; discussion with and coaching by colleagues; and simulation, prebriefing, and debriefing observation and practice with an experienced co-debriefer who supports them and attunes them to the RISE culture, which provides a psychologically safe learning environment for both educators and learners.4 All scenarios and debriefings are digitally recorded and archived, allowing for review of all sessions to aid learning and faculty development. Both experienced and new facilitators select a debriefing session once a semester to be viewed by all SBE faculty in a meeting, followed by self- and peer critique. The selected scenario may be one the facilitator thinks went particularly well or one about which she or he desires feedback and suggestions for improvement from peers. The DASH tool is used to guide both the self and peer evaluations.7 After a year, new educators may be funded to participate in an online nine-credit graduate certificate program, Leadership in Simulation Instruction and Management. The courses include scenario writing using the INACSL Standards of Best Practice topics on emerging technologies,23 TeamSTEPPS for use in interprofessional education (see www.ahrq.gov/teamstepps/index.html), and simulation operations. The certificate program further develops the facilitators and prepares them for the SSH's Certified Healthcare Simulation Educator (CHSE) certification examination (see www.ssih.org/Certification/CHSE/Exam-Information). All simulation educators are expected to get their CHSE certification by the third year of employment.
Hospital-based simulation center. Mater Education in Brisbane, Queensland, Australia, is a nationally accredited, hospital-based independent training organization that develops and delivers courses in a world-class clinical simulation facility. The simulation center supports the 6,700 clinical and nonclinical staff members who work in the organization, as well as external fee-paying participants in a number of programs. On average, the center runs 400 education sessions and delivers just under 30,000 learner hours per year. The center provides education to postgraduate health professionals, primarily using an interprofessional approach. Although there are single-discipline, skill-based programs, the philosophy of the center is to train staff in the manner in which they will work, on interprofessional teams, thereby allowing the opportunity to practice eliciting shared team goals and helping to create reflective practitioners.24 Additionally, the nonclinical workforce is considered an essential part of the interprofessional team. Equipping these staff members with communication skills that allow them to speak up, provide feedback, and share their thinking helps to create the positive organizational culture that is the stated goal of the organization's educational mission.
Scenarios are carefully designed to ensure all professions can genuinely engage and contribute, and the debriefing methodology respectfully challenges the skills, attitudes, and behavior of the collective interprofessional team.19 Center-based programs offer the advantage of protected education time, in which participants can be fully present and engaged in the learning activity, away from their everyday duties. This allows for the provision of a longer, more in-depth debriefing than can be offered when running ISS activities.
The majority of Mater Education's simulation-based learning involves formative feedback through structured debriefing, rapid-cycle deliberate practice, and facilitated, just-in-time training.22, 25
Simulation faculty development. Safe, reliable, and effective feedback, whether formative or summative, requires structured simulation faculty development pathways. All simulation faculty have attended a formal training program. A formal development approach engages facilitators in a reflective learning process focused on their own skills to deepen their practice in SBE. Just as the learners are engaging in reflective learning, so too are the facilitators as they lead simulated cases.
Viewing simulation-based interventions as a service to the hospital and health care system is a recent change in perspective, as not only health care providers but now the organization as a whole is included in SBE. Simulation can be thought of as a solution to a variety of organizational challenges, including the testing and development of new service lines and new physical layouts or buildings; detecting latent safety risks; understanding how teams can perform better and improve safety; evaluating new equipment through the lens of human factors; and simulating new protocols prior to implementation with real patients. Staff from all disciplines and competency levels can develop, assess, and shape the system in which they need to function.26 In our experience, the inclusion of both health care providers and nonclinical staff in simulation-based learning has led to stronger systems, fewer work-arounds, and increased staff engagement across the organization. As well as a 24-hour simulated test of a new health care facility,27 simulation has been used to test root-cause analysis recommendations and new patient care protocols and rehearse high-risk procedures, such as Australia's first in utero surgery.28
The 24-hour live simulation activity included diverse cases that were conducted in the new health care facility prior to opening, thereby testing its systems internally and externally. The 24-hour project was resource intensive and required the following:
- 24 separate simulations conducted over all three shifts
- 12 trained community members as patients
- 70 hospital staff
- 14 third-party providers (ambulance, fire services, funeral directors)
- seven simulation educators
The simulations involved both routine care and low-frequency, high-risk events. Routine care processes included patient flow in anticipated, commonly occurring surgical procedures (admission to discharge), medication rounds, physiotherapy sessions in the gym, and routine patient experiences, such as ordering meals and receiving visits from family. The low-frequency, high-risk simulations included cardiac arrests, imminent birth presentations, and management of deteriorating patients across all clinical areas, including the involvement of third-party service providers, such as local ambulance and fire services, a private radiology provider, a private security company, and local funeral homes. Local community members participated as SPs and were engaged in the testing of their future health care facility.
The positive outcomes that result from the use of simulation in this manner across the organization has led to the standard inclusion of simulation-based testing in all new capital projects.
In situ simulation. A key program for Mater Education is the delivery of ISS, typically conducted not in a dedicated educational space but on a unit where health care professionals are conducting authentic patient care. As an educational strategy, ISS has benefits that include higher levels of contextual and environmental fidelity and convenience of access.29 However, ISS also presents additional risks to learners’ psychological safety and patient safety.3 The duration of ISS and debriefing sessions is often shorter than that of center-based sessions because of the demands of patient care. Mater Education delivers a range of ISS activities, including highly immersive team training; just-in-time, procedural, skills-based training and rehearsal; and process and systems testing. The largest ISS activity is the pop-up simulation program that delivers weekly SBE sessions to the workforce with the goals of providing opportunities for teams to train together and to test systems and processes in relation to the recognition and management of medical emergencies. This fully integrated program (in the clinical environment, with real equipment and the activation of real systems and processes) has delivered more than 180 ISS activities over three years across a variety of clinical settings with a participant profile that includes nursing, medical, and allied health professionals and students; unit services; and administrative staff, providing more than 1,200 participant exposures.
Formative assessment, which provides feedback to learners with the goal of improving knowledge, attitudes, and skills, is the most common form of assessment in ISS activities that Mater Education conducts. At the end and sometimes during ISS activities, facilitators conduct debriefing, gather different perspectives, provide direct feedback to learners, and then work to close performance gaps and sustain good performance.22 ISS provides educational opportunities to facilitate improved interprofessional collaboration and teamwork skills and plays an integral role in the identification and rectification of latent safety threats present in health systems and processes.
While the definition of ISS has traditionally been based on the physical location of the simulation activity, recent discussions in the literature suggest that simulationists should look more critically at definitions that emphasize location over other important factors.29, 30 The argument is that while location is important in the definition, timing, notification, participants, and function of the simulation activity, all of these play key roles in truly defining the simulation activity.
When conducting formal in situ systems or process testing simulation activities, Mater Education uses the plan–do–study–act methodology and a self-designed tool, the Simulation-Based Quality Improvement Observation Tool (SQIOT), that focuses on system integrity and quality improvement by capturing data that identifies hazards, latent safety threats, and concerns about the patient experience.27 Mater Education used this methodology and tool to test its new health facility during the 24-hour live simulation activity prior to opening it to the public.27
Data were captured on the SQIOT by trained observers in direct observation of the simulation activities and in discussion during the postsimulation debriefings. Subsequently, the SQIOT data were collated and presented in an evaluation report known as the Healthcare Failure Modes Effects Analysis.27 This allowed hospital leadership and Commissioning Steering Committee team members high-level visibility of the data to support their decisions regarding operational readiness. This example describes the power of simulation to create safer health systems and processes.
The ISS activities mainly support Mater Health, the hospital with which Mater Education is affiliated, and include an interprofessional cohort of participants. This cohort comprises both clinical and nonclinical staff, with the two institutions acknowledging that both staff cohorts are equally integral parts of a workforce that contribute to safe and effective health care delivery.
SAFETY IN SIMULATION
Safety in simulation is often considered primarily in terms of psychological safety for the learner; and while that is a critical foundational principle in creating and maintaining a safe learning environment, physical safety concerns also need to be considered for the learner, educator, and authentic patients, particularly in the case of hospital-based ISS. Simulation accidents can cause physical or emotional damage to patients, participants, and bystanders; therefore, careful planning and implementation of simulation programs, including consideration of safety concerns, potential hazards, and mitigation strategies, is crucial to achieving a safe simulation environment.
Despite good intentions and careful planning, physical simulation mishaps can and do occur. Potential hazards may include accidental activation of resuscitation teams and other emergency responders to a simulation event, which diverts valuable resources and disrupts clinical work. Additionally, disabled or expired equipment used in SBE may be inadvertently used in a clinical setting.
Witnessing a simulated emergency may cause unexpected emotional responses for the learner, as the realistic simulation may trigger past traumatic experiences. For example, Oberleitner and colleagues described a strong grief reaction that occurred during a university simulation laboratory tour, in which a woman who had experienced a perinatal death became distraught at the sight of a simulated baby manikin.31
The Centers for Disease Control and Prevention investigated a serious incident in New York, in which two patients were hospitalized after intravenous administration of simulated saline.32 A national investigation revealed that 43 health care facilities in 23 states inadvertently ordered the simulated fluid. At least 25 patients experienced adverse effects caused by this error.33 While this mistake was not associated with the operation of an SBE facility, simulated supplies entered the real health care supply chain. Hospital-wide policies that address how supplies and equipment used in SBE are differentiated from authentic patient care items are needed to prevent such errors from occurring. Therefore, proactive planning, including interdepartmental policies regarding simulated supplies, decisions about the use of simulated or active equipment, and prebriefing discussions to raise awareness in learners, is necessary. Such discussions may include reminding learners which equipment is real and which is simulated, prohibiting removal of any simulated medications from the simulation laboratory, and developing a checkout procedure to catch items forgotten in pockets.
The Foundation for Healthcare Simulation Safety (see https://healthcaresimulationsafety.org), a nonprofit organization dedicated to promoting education and safe practices in simulation, maintains a registry of safety misses and near misses for the education of the SBE community. The foundation has also compiled a list of safe simulation practices in the form of a “Simulation Safety Pledge” (see https://healthcaresimulationsafety.org/simulation-pledge). To reduce risk to all, including real patients, the goal is to engage all simulation laboratories to consider using this in their educational spaces.
Despite thoughtful planning and appropriate safety measures, accidents still happen. These incidents should be reported and investigated in order for us to learn from them. Sharing these incidents with our colleagues is an important way to ensure safe simulation practices. The long-range goal of all simulation-based endeavors is the same: to improve patients’ health and safety.
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