Evidenced Based Practice in Simulation



Evidenced Based Practice in Simulation

Ann E. Bancroft

Ferris State University

Abstract

Students within the simulation laboratory at Ferris State University School of Nursing experience inconsistent conduction of the simulation education experiences. The purpose of this paper is to propose a Plan Do Act Study method of quality improvement to implement best practices within the simulation laboratory. Discussion of quality and safety initiatives, high reliability organizations, just culture, continuous quality improvement, and ethical standards support the need to implement evidence based practice in the simulation education opportunities.

Evidenced Based Practice in Simulation

The goal of simulation is to create a realistic health care scenario in which the students must act as nurses interacting with a “real” patient, use critical thinking skills, prioritization, organization, and technical skills. Ferris State University’s School of Nursing is relatively new to the simulation education format, with the simulation lab being in use for less than three years. Over the course of time, there have evolved disparate methods of conducting simulation from pre- and post-testing, to preparation for the simulation (from minimal to directed research to complete dissemination of the scenario), and in debriefing. Frequently the simulation is run in a less than realistic fashion, with inattention among the students, sidebar conversations distracting the acting students, or outright unprofessional behavior exhibited by the students. The lack of consistency among faculty in conducting simulation leads the students to approach simulation with varying degrees of seriousness, and the students may arrive ill- or unprepared. This limits the effectiveness of the simulation education experience, and limits the integration of core competencies in nursing education. The time is ripe to re-introduce evidence based practice in simulation education into Ferris State’s simulation lab.

Quality Education

In 2003, the Institute of Medicine (IOM) released five core competencies deemed necessary for health care professionals: delivering patient-centered care, working as part of an interdisciplinary team, practicing evidence-based medicine, focusing on quality improvement, and using informatics technology (Morris and Hancock, 2013). The mandate states that higher education institutions have a responsibility to prepare health care students to develop proficiencies in these competencies that carry over into professional practice. In response to this report, the Quality and Safety in Education for Nurses (QSEN) came to the forefront of nursing education and developed the QSEN competencies and supporting knowledge, skills, and attitudes. Implementing changes in nursing education to direct outcomes to focus on these core competencies can be a challenge. However, incorporating these core competencies into simulation education is only logical. The challenge to successful integration of the competencies lies in developing a consistent approach to simulation education. Faculty may see standardization of educational opportunities within simulation as detracting from established autonomy. Presenting research and developing simulation education policies to create a consistent approach, introducing evidence based simulation education strategies, and supporting the faculty in the incorporation of evidence based simulation education procedures will create an educational environment in which all five core competencies of the IOM are implemented in an effective manner. A systematic approach to incorporating simulation education and integrating QSEN competencies is necessary to achieve the IOM’s mandate. QSEN competencies are designed to assist educators in creating a climate that fosters continuous quality improvement and patient safety (QSEN, 2013).

High Reliability Standards

High reliability organizations establish a culture that promotes safety, encourages continuous learning, and search out and implement evidence based practice (Sherwood and Barnsteiner, 2012). High accountability is a characteristic of high reliability organizations, as is complex communication (Redman, 2008). Ferris State University’s School of Nursing already embraces QSEN’s competencies and implements the knowledge, skills, and attitudes in didactic and clinical settings, which creates a culture of safety and quality. The shared governance approach to management of the School of Nursing allows all faculty members to have input and direction of curriculum and specific learning opportunities, addressing the need for leadership to be dedicated to the quality and safety focus. The program outcomes incorporate many of the IOM’s core competencies and the QSEN competencies including teamwork, evidence based practice, and patient safety (Ferris, 2013). In a study published in 2011, Levett-Jones, Lapkin, Hoffman, Arthur, and Roche explored knowledge acquisition in simulation. It was found that using multiple choice questions did not adequately evaluate students’ acquisition of knowledge following simulation and the researchers suggested that evaluation of student learning should be closely aligned with program objectives. Ideally, a more intentional approach to the simulation laboratory can smoothly dovetail with the didactic and clinical focus on QSEN competencies. Both students and faculty must be invested in the culture of safety, patient-centered care, teamwork, evidenced based practice, and continuous quality improvement. The faculty must adhere to the highest standards of evidenced based education in simulation to inoculate the attitudes inherent in the core competencies within the students.

Just Culture Principles

A just culture, one in which individuals are expected to act responsibly and with accountability, does not blame individuals for the failures of a system (Miranda and Olexa, 2013). This is applicable to simulation laboratory inconsistencies. By establishing a set of policies to ensure consistency and use of evidence based simulation education techniques, the groundwork is laid for strengthening the system. Personal responsibility and dedication to education within the realm of patient safety and quality improvement coupled with an improved system will align the simulation education experience with the core competencies while maintaining and supporting the School of Nursing program outcomes. The faculty should present education opportunities consistent with the best learning practices within the simulation laboratory, and hold the students accountable for the learner-centered learning inherent in the milieu. The students should understand the responsibility they have in arriving to simulation prepared and ready to participate fully. Clear guidelines will aid in creating a just culture that adjusts the systems to be responsive to the needs of the students while promoting the core competencies.

Quality Improvement Models

In the effort to improve the quality of simulation education, a root cause analysis must be done to determine the factors that impact the methodology for simulation education in its current state. Meeting with and soliciting input from the faculty at this two plus year check point will reveal how and why simulation exercises are conducted in an inconsistent manner. Observing simulations from multiple faculty members will reveal the depth or lack of depth of consistency, as well highlight what works well. In implementation of Lean methods of quality improvement, it is important to visit the reality (gemba) and engage the stakeholders (Graban, 2012). Once information is gathered, it will be time to move on to Plan-Do-Act-Study (Sherwood and Barnsteiner, 2012). In the planning stage, it is important to refine the questions to pinpoint the objective. In this case, the objective is the implementation of standardized evidence based education practices within the simulation laboratory. After implementation, it is time to analyze the data or effects of the change in consistency. Finally, acting on the recovered information to fine tune the changes ensures the best practice is being enacted in the simulation laboratory.

Ferris State University School of Nursing is not alone in this dilemma. Murphy (2013) described implementing a Plan Do Study Act quality improvement method to change the usage and standardize the procedures within a simulation laboratory. She reports the very same concerns raised here: lack of realism, lack of professional behavior, lack of consistency, lack of student preparation and engagement, different methods of evaluation, and differences in debriefing methods. Goals were created for faculty, students, and to transform the simulation environment. Addition of a simulation coordinator improved outcomes, usage, and consistency.

Plan for Change

After gaining input from the faculty and analyzing the findings, research will be conducted into simulation best practices. In order to implement evidenced based education practices, a meta-analysis of existing research of simulation needs to be conducted. Narrowing the field of study down to specific outcomes or aspects of simulation will simplify the end results. Therefore, literature review should be conducted in pre- and post-testing, followed by literature review in student preparation for the simulation, followed by debriefing. The meta-analysis of each section will be presented to the faculty in sequential meeting updates as well as in written format with a request for feedback and questions. Policies will be drawn up based upon the research findings and presented to the faculty. The addition of a dedicated laboratory specialist will aid in the formalization of the simulation laboratory policies. Data collected from standardized pre- and post-testing will be analyzed for student cognitive development. Questionnaires will be administered before implementation of policies, and thereafter once a semester to all students in the simulation laboratory seeking information regarding student perception of the simulation experience in regards to cognition gains, anxiety levels, and engagement. This data will be analyzed for patterns supporting or negating the change.

Nursing sensitive quality indicators are used to measure quality improvement efforts in the clinical setting, largely pertaining patient outcomes. QSEN knowledge, skills, and attitudes will be the guiding indicators for changes in the academic setting. Specifically for the purpose of this initiative the pre-licensure QSEN competencies of patient centered care, patient safety, and quality improvement will be the primary focus. The process will be guided by the QSEN Graduate Level Competencies, specifically quality improvement.

Ethical Implications

The ethical implications of standardizing simulation education experiences affect the students, faculty, and the Ferris State University School of Nursing as a whole. The School of Nursing has invested significant resources in the construction, maintenance, and usage of the simulation laboratory. It is ethically imperative that the educational return on investment directly and positively impact the program’s outcomes.

In the American Nurses Association’s (ANA) Code of Conduct with Interpretive Statements (2010), the first provision has a subsection dedicated to ethical interactions with colleagues. This is of paramount importance in implementing a change within the academic environment. The preservation of dignity, respect, communication, and conflict resolution must all be foremost in the minds of those seeking to create a consistent best practice for simulation. In investigating, researching, and proposing change, the valued autonomy of faculty may be impinged upon. It is vital to address concerns openly, honestly, respectfully while seeking consensus and engagement from all stakeholders. In provision three of the ANA’s Code of Conduct (2010), a subsection speaks to the responsibility of the nurse educators to ensure competencies and professional commitment thereby ensuring the best possible outcomes for students. The integration and standardization of QSEN competencies within the simulation laboratory addresses this ethical mandate and forwards the professional development and commitment not only of the students but of the faculty as well. Provision 7.2 addresses the ethical responsibility of the nurse educator to develop and promote best practices in any educational setting. Provision 7.3 speaks directly to seeking out and implementing evidence based practice, as the best practice policy of the simulation laboratory would answer. Simulation, when presented in a systematic and consistent manner, improves learning outcomes, critical thinking, and knowledge acquisition (Lapkin, Levett-Jones, Bellchambers, and Fernandez, 2010; Levett-Jones, Lapkin, Hoffman, Arthur, and Roche, 2011; Sullivan-Mann, Perron, and Fellner, 2009; Nehring, 2008). By improving the clinical reasoning skills of students, introducing and reinforcing QSEN competencies, and using best practices in teaching, educators are indirectly impacting patient outcomes by graduating generations of nurses who are better prepared for the clinical setting and who value evidenced based practice as well as quality and safety initiatives. Nursing educators have an ethical responsibility to present the best evidence based practice in the best, most consistent method possible, and continuously seek to improve the quality of education in this ever-changing health care environment.

Conclusion

The simulation laboratory at Ferris State University School of Nursing is ready for transformation into a best practice learning and teaching environment. The IOM and QSEN quality and safety initiatives are supported by undergraduate nursing education when it is delivered in a consistent, evidence based manner. Integrating the core competencies of patient centered care, patient safety, and continuous quality improvement into the simulation education experience will inoculate students with the mandate to carry these competencies into practice. The Plan Do Act Study method of quality improvement is an excellent method to ensure students are experiencing consistent, high quality education opportunities in simulation.

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