Charts and forms for all aspects of patient care should be constructed for each SBE. Additional forms that might be appropriate for the SBE, such as emergency department records, blood transfusion and blood bank forms, and incident reports, for example, should also be available. Documentation forms should be as similar as possible to those the students utilize in their clinical areas. Unfortunately, many
students have to learn a different system at each clinical site. While it is helpful to use a system as close to what students see on the traditional clinical unit as possible, simulation EHRs are expensive. Several existing commercial products are available, but many simulation facilitators create their own system. The goal is to help students understand the principles and legalities of documentation.
Multidisciplinary/Interdisciplinary Team Simulations As a result of the prominence of the QSEN competencies and the National Patient Safety Goals (TJC, 2018), nursing faculty are collaborating with other health professions to incorporate SBEs that foster an interdisciplinary team approach with other healthcare students. The IOM has said that “all health professionals should be educated to deliver patient-centered care as a member of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” (IOM, 2003, p. 3). As the population ages and lives with multiple comorbidities and chronic health needs, the care for that population requires the collaboration of multiple healthcare professionals. Therefore, simulation provides the perfect opportunity for students to work together on complex patient care problems. Pharmacy, respiratory therapy, social work, seminary, medical practitioners, medical students, and others have all collaborated with nursing students during SBEs. Students learn the knowledge, roles, responsibilities, and frame of reference that each person brings to the patient situation. They learn to work together as a team, to share the information they have about the patient, and to communicate and resolve differences related to care. An example of planning an interprofessional experience is provided in BOX 18.6.
BOX 18-6 Example: Interprofessional Education
Faculty are concerned that students are not comfortable discussing death and dying or providing care to a terminally ill patient. While at a campus-wide retreat, they learn that this problem is not limited to nursing. Representatives from nursing, medicine, respiratory therapy, pharmacy, and pastoral care begin planning for an interdisciplinary educational event. They agree on overarching outcomes, learning objectives for their students, and a general patient situation for the SBE. They review the INACSL Standard: SIM-IPE to identify the remaining criteria and guidelines that need to be addressed.
Many hospitals and schools of nursing are utilizing the TeamSTEPPS program developed by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ). This program provides materials and a training curriculum for an evidence-based teamwork system to improve communication and teamwork skills. Information about this program can be obtained at http://teamstepps.ahrq.gov/. The goal of TeamSTEPPS
and all interdisciplinary training is to assist in providing higher-quality, safer patient care through more effective communication among health professionals.
After the Simulation-Based Learning Experience Debriefing Debriefing is essential to the simulation experience and should never be omitted (Oriot & Alinier, 2018). It is during this time that students have the opportunity to reflect on the experience, their actions or inactions, and connections to clinical practice. Faculty trained in the art of debriefing function as facilitators by stimulating students to reflect on what they were thinking during the simulation, how they were feeling, what they did, what occurred as a result, and how they can apply what they have learned to their care of real patients. To debrief, the facilitator must have observed the SBE and been attentive to the knowledge, skills, and attitudes of the learners as well as identify areas of opportunity for growth. It is important that the debriefing environment provides privacy to maintain confidentiality, and that the environment created by the debriefer is one where students feel supported through feedback and can engage in reflection (INACSL Standards Committee, 2016).
Debriefing should be based on a structured theoretical framework. Several different models are used by facilitators, who may choose one method or a combination of methods. The plus/delta model is often used for debriefing that must occur in a short period of time. The students and facilitator place actions into two columns: a positive column and a column designated for actions or activities that could be done differently. Debriefing models with varying levels of complexity and overlap have been developed in recent years, including Debriefing for Meaningful Learning (Dreifuerst, 2015), Promoting Excellence and Reflective Learning in Simulation (PEARLS) (Eppich & Cheng, 2015), debriefing with good judgment (Rudolph, Simon, Dufresne, & Raemer, 2006), the 3D (defusing, discovering, and deepening) debriefing model (Zigmont, Kappus, & Sudikoff, 2011), the Gather- Analyze-Summarize (GAS) method (American Heart Association, 2012), and the Outcome-Present State-Test (OPT) model (Kuiper et al., 2008).
Each debriefing model has nuances as to how questions are asked of the learners, and the phases of the model; however, at the heart of debriefing is the need to promote self-reflection so that learners can identify what went well, what didn’t, what happened to the patient or situation as a result, and how learning might extend beyond the simulation lab into the clinical environment. Reflection in-action, on-action, and after-action are key components to the learning that occurs during and after simulation (Schön, 1983). Though each model has its own specific components, the overall goals of debriefing are the same: to understand, analyze, and synthesize thoughts, feelings, and actions; ensure that the experience is interpreted correctly by all participants regardless of their role; ensure that learning
objectives are met; link classroom content to clinical practice; and positively change behaviors or practice. An example of faculty members choosing a debriefing model is provided in BOX 18.7.
BOX 18-7 Example: Debriefing
Faculty teaching in a large nursing program have recently obtained simulators and equipment as a result of grant funding. The faculty are considering the debriefing model that should be used across the organization. Faculty are in disagreement over which model they prefer to use. The fundamentals instructors want to use plus/delta following short simulations that focus on one skill. The mental health faculty want to use the 3D model, while the advanced medical surgical faculty want to use Debriefing with Meaningful Learning. Faculty are encouraged to align debriefing models with the type of simulation experience and desired outcomes, while realizing that learning a variety of debriefing models may create initial confusion and slow the student time to mastery of the models. The faculty decide to focus on the GAS model for the first semester while exploring more information about other models.
The facilitator has many responsibilities for guiding the debriefing, beginning with a review of the expectations for respectful communication without distractions such as cell phones. A trusting environment should be established to promote confidentiality and freedom to become engaged. The facilitator should keep a learner-centered focus based on the learners’ level of engagement by maintaining eye contact and practicing active listening. Using open-ended questions with a Socratic style in conjunction with the advocacy/inquiry technique is a common way to help learners reflect on the experience and what has been learned. Audiovisual records of the experience may be judiciously used for deeper analysis of specific sections of the scenario. It is the facilitator’s responsibility to provide constructive feedback, ensure that the learning objectives are met, and help the learners identify how to take what has been learned and apply it to their clinical practice (Dreifuerst & Decker, 2012).
Debriefing should be conducted immediately following the SBE to capture the initial reactions of the learners; however, debriefing may also occur during the scenario if needed. If a critical error has occurred, an important teaching moment has arisen, or the students have gone down a path that will never meet the learning objectives, then it would be appropriate to pause the SBE for debriefing before resuming the scenario. In general, following the scenario, debriefing should take place away from the bedside in order to separate the actions of patient care from the reflective activity of debriefing. There has also been considerable discussion about how long debriefing should last, but there are no research-based decisions. The length of debriefing is dependent on the objectives, the level of the learners, and the actions or decisions that occurred during the SBE (Dreifuerst & Decker, 2012). As with the scenario itself, educators should err on the side of planning for more time than believed necessary.
After a Simulated Patient Death A special circumstance exists when the SBE involves the death of the simulated patient. There continues to be controversy surrounding simulation of death, especially when it is not tied to the learning objectives of the SBE. Many simulation facilitators are fearful that simulated death experiences will cause the students to believe they killed the simulated patient or are responsible for its death, leading to feelings of guilt. There is also concern that buried feelings may rise to the surface, leading to psychological trauma. The facilitator is charged with recognizing and managing participants’ psychological stress (Leighton, 2009a).
Recommendations for managing simulated death include the need to assess the comfort level of the facilitator when dealing with death, provide adequate prebriefing, save simulator death for more advanced learners, prohibit punitive use of simulator death, balance emotions, provide careful debriefing, and assure psychological safety (Corvetto & Taekman, 2013). The debriefing process is vital to managing the psychological stress, as students are given the opportunity to talk about their feelings and explore the events that occurred during the SBE in a safe, nonjudgmental environment. The facilitator may consider involving a chaplain or mental health practitioner in the scenario or during the debriefing. In some cases, the facilitator may need to refer the student for further psychological assistance (Leighton, 2009a). Anecdotally, many students have reported that experiencing death in the simulation lab helped them to better understand previous real-life experiences.
Evaluation/Assessment The number of valid and reliable tools available for use in SBE has grown dramatically. Adamson, Kardong-Edgren, and Wilhaus (2012) provided a list of these tools, but additional psychometrically sound options have been published since then. For this section, the terms assessment and evaluation are used interchangeably. Four areas of SBE should be assessed: the experience, the participants, the curriculum, and the facilitator. A selection of tools that have undergone reliability and validity testing follow, though numerous others exist and could be considered for use.
Evaluating the Experience Despite an educator’s best efforts, it is possible to create SBEs that do not meet the learning needs of the students; therefore, it is vital to evaluate the effectiveness of the experience. An early tool developed by the National League for Nursing, the Simulation Design Scale, assesses the students’ perception of the objectives, fidelity, problem solving, student support, and debriefing constructs (Franklin, Burns, & Lee, 2014). A tool that evaluates the SBE from prebriefing through the scenario and debriefing is the Simulation Effectiveness Tool-Modified (SET-M). This tool is an update of the SET that was developed in 2005 (Elfrink Cordi, Leighton, Ryan- Wenger, Doyle, & Ravert, 2012) and evaluates items on four subscales: Prebriefing, Confidence, Learning, and Debriefing (Leighton, Ravert, Mudra, & Macintosh, 2015). Students should complete evaluations of the SBE at the end of the experience. These evaluations can provide valuable information about what was most helpful to the students and what might be changed to make the SBE an even better learning experience. It is important to remember that these evaluation tools ask for learner perceptions and do not measure knowledge or skill gain. An example of using an evaluation tool is provided in BOX 18.8.