High fidelity simulation in critical care: A Canadian perspective

Collegian (2012) 19, 139 143 Available online at www.sciencedirect.com jo ur nal homep age: www.elsevier.com/locate/coll High fidelity simulation in critical care: A Canadian perspective Sandra Goldsworthy, RN, MSc, CNCC, CMSN Durham College, University of Ontario Institute of Technology, Collaborative BScN Program, Oshawa, Ontario, Canada Received 23 October 2011; received in revised form 6 June 2012; accepted 6 June 2012 KEYWORDS Critical care; Nursing; High fidelity simulation; Competency evaluation; Simulation networks Summary The use of high fidelity human simulation has exploded into the nursing education context over the last decade. In Ontario, Canada an innovative Critical Care e-learning program was established in 2007 to create accessible critical care education for nurses across Ontario and Canada. The program has a three-pronged approach including online, simulation and practicum components. The purpose of this paper is to present lessons learned during the last five years of development and growth of this program. The paper will focus on the use of simulation to build confidence and prepare registered nurses for critical care nursing practice. In addition, subsequent development of a network of ten simulation partners that deliver critical care simulation will be discussed. High fidelity simulation delivery in the critical care context will be explored and the use of summative or high stakes simulation competency evaluation will be elaborated on. 2012 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. Introduction The use of simulation has gained tremendous momentum in nursing education and has been integrated into many nursing curricula internationally (Rothgeb, 2008). In one Canadian nursing program, a graduate certificate in Critical Care Nursing was developed and launched in 2007. One of the major components of this new program is an intensive critical care simulation course that utilizes high fidelity simulators. A human simulator that has the highest degree of technical capability or realism is considered a high fidelity simulator and is typically run via a computerized program, has a chest that rises and falls with respirations and has vocal E-mail address: Sandra.goldsworthy@dc-uoit.ca sounds. The aim of this paper is to provide an overview of the design of this simulation embedded, innovative program and to present some of the lessons learned during the last five years of implementation and growth of this program. Program design The Critical Care e-learning program utilizes a threepronged approach for student learning which includes eight courses: six online learning courses (introduction to e-learning and five critical care modules), an intensive 39 h high fidelity simulation program and 120 h of preceptored or mentored clinical experience in an adult critical care unit. In the preceptored clinical experience model, nurses new to critical care are directly supervised by an experienced critical care nurse and the dyad share a patient assignment. 1322-7696/$ see front matter 2012 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. http://dx.doi.org/10.1016/j.colegn.2012.06.003

140 S. Goldsworthy The mentoring clinical experience model is used when a critical care nurse taking the program already has a position in ICU and has completed an orientation program with a preceptor. The new staff member then chooses a mentor to work in an indirect capacity in which each have separate patient assignments. The mentor and the novice nurse meet at regular intervals to discuss competency attainment and transition into the ICU. The goal of the Critical Care e-learning program is to increase access to critical care education for nurses across Canada through flexible delivery and self-paced learning. During the online portion (the first six courses), nurses can work at the location and timeframe of their choice, providing maximum flexibility. Evaluations of the Critical Care e-learning program consistently demonstrate that the simulation portion of the program is a critical component for connecting the theory to practice. Simulation network The curriculum for critical care simulation and the clinical experience are offered at nine additional university or college partner sites across Ontario. The network of provincial simulation partners has increased the access to the Critical Care e-learning program for nurses located in rural and remote areas and allows nurses to attend the simulation in or near their own community. The simulation portion of the program is typically held over two weekends or in a one week summer institute format. Class sizes are capped at a maximum of 30 students to allow for small group teaching in the simulation cases with a ratio of no more than five students to one instructor. The simulation program was designed by a team of critical care nurse experts who initially reached a consensus on the essential skills and competencies required by nurses new to critical care. The program was built on a foundation of the Canadian National Standards for Critical Care Nursing Practice (CACCN, 2009) and include four practice pillars related to: mechanical ventilation, vasoactive drips, arrhythmia/12 Lead ECG interpretation and hemodynamics. There were also a number of cross themes to the pillars developed by the program team and integrated into the program, some of which include: patient safety, legal issues, ethics, prioritization, clinical reasoning and advanced communication skills. Once the foundation for the simulation curriculum was developed, the learning objectives and individual simulation cases were developed. Critical care simulation: design and implementation The learning in this simulation program uses a scaffolding approach which allows learners to build on previous successful learning experiences, concepts proffered by Vygotsky, Lave and Wenger and others (Spouse, 1998). The simulation curriculum was created along a three-step process which includes learning skills stations, minor cases and then major cases. In this method, the student begins the course by rotating through a series of four learning stations, progressing on to minor critical care scenarios and ending with major case scenarios. The first step utilizes learning stations based on each of the pillars of the program. The goal of these learning stations is to provide a hands-on application approach to each competency or skill. Students rotate in small groups (one instructor to five students) through four learning stations that include hemodynamics, mechanical ventilation, vasoactive drips and arrhythmia interpretation. In each of the learning stations the instructor first demonstrates the skill and then students are provided with the opportunity to practice on high fidelity human simulators that are attached to cardiac monitors, hemodynamic lines and intravenous infusions and are mechanically ventilated. Application of skills such as wedging a pulmonary artery catheter, performing cardiac outputs, arrhythmia interpretation, vasoactive drip calculation and mechanical ventilation troubleshooting are performed and practiced. In addition to the psychomotor skill application, critical thinking and clinical reasoning are fostered by analysing a case patient s specific hemodynamic profile and providing rationales for titration of vasoactive infusions. Once students completed all four learning stations, they proceed to the second step in the process the minor critical care simulation cases. Students work in small groups of five with one instructor and rotate through a series of five or six cases. Examples of the minor cases include patient s with: myocardial infarction, hemodynamic instability, acute respiratory distress and hypovolemic shock. An important lesson we have learned by running these scenarios over the last five years is the importance of repeating the scenarios. Students often provide feedback on how the opportunity to have skills demonstrated or modeled and an opportunity to repeat the scenario improved their self-efficacy, or confidence they could perform a task, and allowed them to reflect on what they would do differently next time. Selfefficacy is typically developed through mastery experiences and through vicarious learning and modeling, by observing others perform the task (Bandura, 1986). Mastery experiences are largely gained through hands-on experience such as practice in the clinical setting with patients or practice in the simulation laboratory with simulated patients. Bandura (1986) also argued that self-efficacy develops with opportunity to repeat tasks. The minor cases incorporate essential foundational critical care competencies such as managing a patient who is hemodynamically unstable or experiencing a myocardial infarction. The major cases incorporate more complex skills such as care of the patient in septic or cardiogenic shock and build on the minor cases. As scenarios unfold students are coached to focus on patients in specific situations which allows students to rehearse for practice in the actual critical care practice setting. In the second half of the program, students rotate through a series of major cases which include such topics as cardiogenic shock, acute respiratory distress syndrome, abdominal aortic aneurysm and septic shock. In each case, students are assigned a role that may include primary nurse, secondary nurse, medication nurse (2), third nurse or family member. We have tried two approaches for the family member role: we have hired actors to play the family member and have also assigned the role to one of the students. The disadvantage of having a student play an out of role part such as family member is that it can be very distracting to the individual learner and the group and the authenticity of the performance may be limited. To avoid role confusion

High fidelity simulation in critical care 141 we have nurses only adopting a nursing role in the case. The intent of this is to allow the student to focus on their specific nursing role in the scenario and to promote transfer of learning from this specific experience into the practice setting. The instructor assumes the role of nurse practitioner, physician or respiratory therapist in each case as appropriate. There are several elements that are essential when unfolding the scenario. Unfolding the scenario refers to the process in which the scenario is delivered. There is an initial state that the patient presents in, followed by a change or an event that occurs and ending with a conclusion or outcome to the scenario. It is important to have well defined learning objectives and to avoid including too much in a 20 min scenario. This can be challenging with critical care scenarios since the acuity of the patient is very high and there are multiple competing priorities in rapidly changing situations. In order to streamline this process, the coordinator conducts instructor s meetings pre-simulation to discuss the multiple scenario overviews and ensure competencies are covered. The briefing also helps with being clear about student expectations and by guiding the learning experiences, it will help to build confidence and decrease anxiety leading into the scenario. As Schoening, Sittner, and Todd (2006) recommend, instructors who use positive, and encourage coaching during the scenario help the student feel more comfortable in working through simulation cases. Realism In order to create simulation experiences that are as real as possible and to suspend disbelief among participants, there are a number of factors that educators must consider in order to maximize engagement of students. To achieve realism within the simulation the students should be fully oriented to the simulated environment, instructors should stay hands-off as much as possible, the environment and equipment needs to closely match the critical care unit and team members should assume their normal roles (Cheng, Duff, Grant, Kissoon, & Grant, 2007). In order to maximize the realism in the critical care context, there are a number of additional factors we have found to be extremely important. The first is the importance of utilizing high fidelity environment and simulators when conducting critical care simulations. The simulation lab must look like an intensive care unit including patients that are attached to monitor screens displaying realistic waveforms and rhythms. Equipment needs to be current and functional (i.e. mechanical ventilators, IV pumps, defibrillators, 12 lead ECG machines) wherever possible. In addition, props help to make the scene even more realistic. Some of our commonly used props include: simulated urine, blood and blood transfusions, and moulage (makeup) to create bruising or other injuries. When the patient is having a massive hemorrhage it needs to look real so there needs to be a lot of (simulated) blood. In preparing the patient we add case appropriate props such as dressings, drains, pulmonary artery catheters, temporary transvenous pacemakers, arterial lines and central lines. Our students participate in their uniforms and bring resources to the bedside (i.e. cue cards, iphone); this enables them to be in-role for the case scenario. Students download quick reference tools, critical care drug guides, practice guidelines (i.e. ACLS) and other helpful resources to their iphones, tablets or ipods for quick access of information at the bedside through point of care technology. Evaluation All simulation cases in the program run for approximately 20 25 min followed by a 30 min debriefing session. In addition, each case is preceded by a pre-test and followed by a post-test for the group. The pre and post test questions are related to pre-reading or preparation prior to the simulation lab (pre-test) and to capture extension of learning from the actual simulation case (post-test). Generally each station runs for 1 h in total with short breaks integrated after completing two to three cases. Typically students are provided with two or three key questions initially as a pre-test in order for instructors to evaluate knowledge base prior to the scenario start. Once the simulation is complete, another two to three questions are posed to the group to evaluate learning. All students in the Critical Care e-learning program are evaluated through pre and post tests for each learning station, and each instructor evaluates students as they proceed through the case by using a competency checklist specifically tailored to the scenario. The critical care competency checklist was developed by an expert critical care faculty panel and refined over a five year period. The competencies include foundational skills required in critical care nursing (i.e. arrhythmia interpretation, management of hemodynamic lines and titration of vasoactive drips). On the final day of the course, students proceed through two wildcard stations in which they are randomly assigned a station (i.e. cardiogenic shock) to work through in pairs. All competencies must be met to achieve a pass grade in the program. Further, all students must be able to independently and accurately calculate vasoactive drug infusion rates when titrating without relying on pre-programmed IV pump technology (i.e. smart pump technology). We have learned through the implementation of our program that in many instances students math skills had deteriorated, perhaps due to reliance on smart pump technology or charts. There was a need to strengthen the skill of manual calculation and independent double checks of drug dosages and infusion rates to minimize errors in practice. Effective evaluation of simulation involves both summative and formative feedback (Prion, 2008). Formative evaluation allows for learner feedback and motivation, self-monitoring and an opportunity to build academic success whereas summative evaluation provides a mechanism for competency measurement and an ability to compare learning against criteria. There is some controversy in the simulation community on whether simulation should be used for formative or summative evaluation (Goldsworthy & Graham, 2013). Gantt (2011) measured the effect of preparation on anxiety in summative simulation evaluations to quantify if the type of evaluation impacted on performance, and contends that few studies exist that demonstrate best practices for summative evaluation. The results of the Gantt study did not show significant differences in anxiety levels

142 S. Goldsworthy between participants who had preparation prior to the summative assessment and those who did not. Furthermore, valid and reliable tools are essential to support summative assessment in simulation and it has been demonstrated that there are a lack of such tools in the nursing simulation literature (Kardong-Edgren, Adamson, & Fitzgerald, 2010). Are simulation labs considered a safe area for learning prior to moving into practice settings if summative high stakes testing is utilized? Simulation experts generally agree that the purpose of simulation is to build confidence and self-efficacy prior to transitioning into the practice area (Goldsworthy & Graham, 2013; Jeffries, 2007; Sears, Goldsworthy, & Goodman, 2010). Among simulation educators there has been dialog about using summative evaluations, testing in the simulation lab or to whether to reserve simulation for coaching and reflective learning. One of the key points from a roundtable of simulation experts found that the stress level of high stakes simulation testing may negate the learning that occurs during a simulation experience (Kardong-Edgren, Hanberg, Keenan, Ackerman, & Chambers, 2011). Clearly there is more work to be done in the area of summative and formative evaluation within simulation, and scope to develop, test and refine reliable and valid tools. In our critical care program we use simulation for both formative (focused learning stations) and summative assessment (competency assessment) however it is predominately used in final course evaluation of critical care competencies. Students who are not successful in the simulation course are not eligible to proceed to the critical care clinical experience course component. The challenge with this method is that it does create a high stakes type assessment and can potentially create anxiety among participants. The evaluation process has had much discussion within our instructor group and it is clear that further research is needed to develop effective measurement tools to assess competency prior to the student progressing to a critical care practice setting. Reflective debriefing strategies post-simulation The reflective debriefing session for the critical care simulation cases is typically held immediately after the scenario delivery and undertaken at the patient s bedside. We have also conducted reflective debriefing in a separate room away from the bedside. However, feedback from students and instructors has consistently demonstrated that debriefing held immediately after the session at the bedside helped them to remember elements of the case and to even rewind in some cases for a more fulsome discussion of the events that occurred. Another strategy we have found to be helpful is to pause or take a time-out in the scenario and discuss priorities at the moment for patient care. This provides students with the opportunity to discuss and reflect on their perspective at that moment before unfolding the scenario further. We have administered post test questions both after the reflective debriefing or beforehand and found the questions provided additional opportunities for students to demonstrate knowledge reflect and learn. Table 1 Student comments: benefits of the critical care simulation program. I feel confident going into critical care with the knowledge base this program has provided I gained some great hands-on experience in a safe and fun environment... I would definitely recommend this course to other Registered Nurses Lots of learning opportunities What I liked best was the hands-on learning and supportive atmosphere Prepare yourself for intense learning, if you are willing to put the time, energy and effort in, you will see yourself change and become more confident to practice your skills in a clinical (critical care) setting As a novice nurse this program (simulation) did help with my competence and confidence in a critical care environment...the simulation labs definitely added to the foundation of the online (theory) component...simulation course helped integrate theory into practice and build confidence levels The simulation labs were a great way to consolidate learning and focus on important and practical components of critical care nursing practice At times students can be emotionally involved in a scenario particularly if they have had a family member in a similar situation or cared for a patient that was similar to the case. Instructors are encouraged to be vigilant in noting these types of reactions since they can necessitate additional debriefing individually or with the group and to ensure professional support is available should this be needed. Benefits to learners Feedback from students in the Critical Care e-learning program consistently describes the benefits of simulation as being: hands on learning increased their confidence, being fully engaged, active learning and that it helped them as a novice nurse transition into the practice area. Comments from a number of our students are listed below in Table 1. It should be noted that although our program was designed for novice nurses transitioning into critical care, we have had a number of very experienced critical care nurses, managers and educators also enroll in the program. When we asked the experienced nurses if they would want a more condensed simulation course geared to their level of experience, their answer was unanimously no!. The experienced nurses indicated that they would want the full course offering and commented how they enjoyed being in teams with the novice nurses since this is what the practice environment is like. Challenges Although simulation has established itself as a strong teaching and learning tool that engages students and provides maximal hands-on learning, there are challenges to be aware of and to work toward innovative solutions (Gantt,

High fidelity simulation in critical care 143 2011; Nehring & Lashley, 2009). The first challenge is financial investment. In order to have a highly functioning simulation lab, the simulators and supporting equipment is costly. Critical care simulation requires an even higher financial commitment ensuring the equipment needed is available for realistic simulations (i.e. mechanical ventilators, defibrillators, IV infusion pumps, hemodynamic and cardiac monitoring equipment). Since effective simulation delivery relies on low instructor student ratios (i.e. 1:5) for maximal student engagement and practice, investment in professional development for faculty is essential. We have found that instructors rely on three skills sets. First, they must be a content expert (i.e. critical care). Second, the instructor needs to have acquired skills in the delivery and debriefing of simulations and lastly, we recommend that instructors have training in the technology to run the simulators and perform troubleshooting as necessary. Our program mentors faculty from all of our partner sites and delivers train the trainer programs in critical care simulation. The mentoring program has been very successful in building confidence among new simulation instructors and in building capacity and a network of support. Another challenge in simulation is a high level of anxiety among students especially in high stakes testing. In order to help students decrease anxiety levels and feel comfortable in the simulation lab, we strive to provide a supportive, encouraging environment in which students have a clear understanding of the expectations and learning objectives. To achieve this goal we provide a pre-package of information and suggested preparation prior to the simulation course, and prior to each simulation case we review the specific learning outcomes. In addition, we repeat most simulation cases so that students have another opportunity to practice in the scenario after debriefing and reflection has occurred. The fidelity of the simulators can be limiting in critical care scenarios but in recent months, simulation vendors are adding to the basic technology of high fidelity simulators to better suit critical care application and allow realistic lung volumes when mechanically ventilating the patient and performance of 12 lead ECGs from the simulator. Future advances in technology and realism will be beneficial to the delivery of critical care simulation. Opportunities As our experience with simulation continues and technology advances, there will be more opportunities to create innovative learning experiences for critical care students. There are opportunities for partnerships between simulation faculty and labs internationally and through networking and research we will be able to take the science and the art of simulation learning to the next level. Open dialog and sharing experiences will help us to deliver the best possible learning opportunities for students and create effective programs that promote transfer of learning from the simulation lab to the practice setting. Summary This paper has provided an overview of a critical care graduate certificate program that incorporates simulation as one of its key elements for student learning. Some of the important lessons learned from the last five years of the operation of this program have been shared. Some of the key things we have learned are to: make the scenario as realistic as possible, adhere to the learning objectives and timing of the scenario, avoid role confusion and ensure professional development and mentoring of the instructor team. Our experience is that students appreciate a supportive, encouraging learning environment with clear expectations and objectives in addition to preparation whenever possible. The future is bright in simulation teaching and learning with many more opportunities to add to the science and art through research and collaborations locally and internationally while continuing to dialog and share experiences. References Bandura, A. (1986). Social foundations of thought and action: A social-cognitive view. Englewood Cliffs, NJ: Prentice Hall. Canadian Association of Critical Care Nurses (CACCN). (2009). Standards for critical care nursing practice (4th ed.). London, Ontario: CACCN. Cheng, A., Duff, J., Grant, E., Kissoon, N., & Grant, V. (2007). Simulation in paediatrics: An educational revolution. Paediatrics and Child Health, 12(6), 465 468. Gantt, L. (2011). The effect of preparation on anxiety and performance in summative simulations. Clinical Simulation in Nursing, e1 e9. Goldsworthy, S., & Graham, L. (2013). Simulation simplified: A practical handbook for nurse educators. Philadelpia, PA: Lippincott Williams and Wilkins. Jeffries, P. (Ed.). (2007). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League of Nursing. Kardong-Edgren, S., Adamson, K., & Fitzgerald, C. (2010). A review of currently published evaluation instruments for human patient simulation. Clinical Simulation in Nursing, 6(1), e25 e35. Kardong-Edgren, S., Hanberg, S., Keenan, C., Ackerman, A., & Chambers, K. (2011). A discussion of high stakes testing: an extension of a 209 INACSL roundtable. Clinical Simulation in Nursing, 7(1), e19 e24. Nehring, W., & Lashley, F. (2009). Nursing simulation: A review of the last 40 years. Simulation and Gaming, 40(4), 528 549. Prion, S. (2008). A practical framework for evaluating the impact of clinical simulation experiences in prelicensure education. Clinical Simulation in Nursing, 4, e69 e78. Rothgeb, M. (2008). Creating a nursing simulation laboratory: A literature review. Journal of Nursing Education, 47(11), 489 494. Schoening, A., Sittner, B., & Todd, M. (2006). Simulated clinical experience: nursing students perceptions of the educator role. Nurse Educator, 31(6), 253 258. Sears, K., Goldsworthy, S., & Goodman, W. (2010). The relationship between simulation and medication safety. Journal of Nursing Education, 49(1.). Spouse, J. (1998). Scaffolding student learning in clinical practice. Nurse Education Today, 18(4), 259 266.