June 29, 2020By Dr. Kim Baily

INACSL Virtual Nursing Simulation Conference Plenary Recaps: Closing the Gap & SP Patient Centered Care

The Nursing Simulation Conference INACSL held its annual event virtually last week. HealthySimulation.com staff writer Dr. Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College, was on hand to cover two of the major plenary sessions including “Simulation As Translational Science: Targeting Educational And Practice Gap” and “That’s Not What Real Patients’ Value: Patient-Centered Learning In Clinical Simulation with Standardized Patients“.

Simulation As Translational Science: Targeting Educational And Practice Gap

Presented by Dr. John O’Donnell from the University of Pittsburgh, this visionary session gave a coherent overview of the healthcare education-practice readiness gap from a number of perspectives. Dr. O’Donnell noted some of the current issues facing nursing simulation:

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  • Since Nursing has multiple entry points, new graduates will have differing skill sets. Should entry into practice be at a higher level?
  • There is no standardization in the set of competencies that all graduates must demonstrate.
  • Required competencies in the clinical setting can change quickly.
  • Both clinical and academic institutions have difficulty keeping pace with changes.

Dr. O’Connell noted that educators tend to focus on meeting program objectives, whereas employers focus on clinical competence. These two endpoints may be close or far apart. Benner’s work on transition from novice to expert follows a series of steps which require rigorous ongoing assessment. O’Connell suggest that simulation offers a tool to link the “knowing” to the “doing” since medical simulation allows educators to present clinical problems authentically. Thus, the student gains knowledge in classroom, shows that they can perform in the simulation lab and then is able to complete the skill safely in the clinical setting.

In 2015, the Accreditation Council for Graduate Medical Education accepted simulation as a core method competency assessment” and a review by Keddington and Moore stated that “Healthcare Simulation is an effective method for competency evaluation for nurses”. The International Nursing Association for Clinical Simulation and Learning has laid out guidelines for using simulation for high-stakes assessment. The process is demanding and requires a committed faculty to ensure that testing is standardized and fair for all students.

In the last ten years, research has focused on the impact of simulation on translation patient outcomes.  There are four levels of translational outcomes:

  • T1 Knowledge, skills, attitudes and professionalism targeted at individuals and teams
    • Setting:Simulation lab
  • T2 Patient Care Practices targeted at individuals and team.
    • Setting: Bedside
  • T3 Patient outcomes – individuals and public health
    • Setting: Clinic and community
  • T4 ROI and cost savings e.g. reduced catheter induced infections.

Dr. O’Donnell goes on to discuss other work related to translation science and simulation concluding that “In almost every well controlled study, simulation is superior to standard education in knowledge change, attitude change (self-confidence) and skill performance. Concluding, Dr. O’Donnell suggests that we should not ask what can you do with simulation, but rather, what should you do with simulation. He suggested various teaching and assessments, for example, managing complex clinical situations, informing patients about bad news, and completing intricate complex skill sets. He questioned the notion that clinical experience cannot be replaced by simulation. He also questioned the value of clinical days noting that the actual clinical experience a student receives, may vary from one location within a hospital to another and from one institution to another.

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As 2016, NCSBN Survey, 85% of responding US SBNs (n=38) allowed replacement of clinical hours with simulation. Evidence is increasing that knowledge, skills and attitudes do transfer to the clinical setting and lead to better clinical outcomes.  There are now many examples of simulation as a vehicle for closing education-practice gaps. Students want and deserve to be well-prepared for the start of their clinical careers. However, there needs to be consensus across SBNs, accrediting agencies, educational institutions and clinical agencies on educational benchmarks/acquired competencies.

This presentation offered a clear and insightful summary of the educational-practice gap and how healthcare simulation may be used to close the gap. During the Covid19 pandemic many nursing schools found themselves struggling to complete clinical assignments. In many states, the SBNs increased the number of simulation hours that could be counted as clinical time. Many schools scrambled to set up simulation to take advantage of the change in state regulation. Sometimes faculty with little or no experience in simulation found themselves valiantly trying to set up simulation experiences to help their students complete their classes.

This author suggests that although some nursing schools have funding and well-educated simulation staff, many do not. If SBNs are going to allow more simulation, the SBNs will have to require nursing programs to show a minimal level of competency in simulation pedagogy and adequate funding. If not, simulation might add to the practice gap rather than reduce it! Read the full research support here: Effect of a Simulation Educational Intervention on Knowledge, Attitude, and Patient Transfer Skills: From the Simulation Laboratory to the Clinical Setting.

Standardized Patients and Patient Centered Care

Dr. Nestel suggests that patient’s voices continue to be filtered by clinician’s prospective. This is reflected in the way that Standardized Patients are trained. In fact, Dr. Nestel believes that standardized patient should be renamed to simulated patient (SP) since each patient is unique and cannot be truly represented by a standardized patient. Simulated patients (SPs) are well individuals trained to portray patients in scenarios that support learning or assessment of participants. SPs may be invited to directly or indirectly contribute to the assessments and to provide feedback to scenario developers. The scope of practice of SPs is also diverse.

There are dynamics that influence relationships between SPs and stakeholders in their practice – those who employ them, who write their scenarios, who train them for role portrayal, who train them for feedback, who work with them in scenarios and of course, participants in scenarios. While it may be assumed that SPs represent patients’ perspectives, there are philosophical positions and systems processes that suggest otherwise. Patients’ ideas, concerns, feelings, reasons for consulting, need for information should be sought, acknowledged and valued and patients should be encouraged to participate in all decisions about their care to the extent they are able and willing.

Dr. Nestel continued that the word “standardize” means to make things the same with the same basic features or to bring in conformity with a standard especially in order to assure consistency and regularity. She challenges the notion that humans (patients) can be standardized and considers that SPs are not proxies for real patients but rather agents for faculty. Dr. Nestel collected comments from SPs about the way they would really act in a given clinical situation rather than the way they were told to act. One SP felt that the examiners were playing a role which was reflected in the way the SP was trained to respond, however the SP would not behave the same way if they were a real patient. Another noted that if it were not a testing situation they would not act the way they were expected to act particularly in terms of emotional responses. The SPs were trained to be a mirror for the teachers’ preconceptions rather than as an authentic reflection of a patient encounter.

Assumptions are made that faculty and actors can really simulate patients and that they know how real patients would respond in a given scenario. Dr. Nestel suggests that even the INACSL Standards of Best Practice which calls for simulation fidelity do not actually include explicit instructions for engagement with real patients when scenarios are being developed. In order to provide patient centered care, scenario development should include input and feedback from real patients.

The following framework for scenario development and SP training for complex procedures was offered:

  • Phase 1: Initial role development including observation of operation, interviews with real patients, data from patient records and surgical expert consultation.
  • Phase 2: SP training including character preparation and simulation development with pilot SP feedback and project team review.
  • Phase 3: Simulations with continuous SP feedback and project team review.

Simulated Patient Development should be an involved process which starts with identification of real patients and the collection of real patient stories which are then written with prompts and cues. After SPs are recruited they should meet with real patients and then they should rehearse their roles. Finally, SP training should be evaluated before the SP interacts with students and real patients should observe the SP and provide feedback before the training materials are finalized.

Dr. Nestel noted that too often patients are known by their diagnosis rather than by their individual characteristics and the term standardized is in tension with notions of patient-centeredness. Simulated patients (SPs) should speak with real patients rather than speak for them and training for SPs role portrayal should include ways to connect SPs and real patients so that students interact with SPs who more accurately portray real patients. The ultimate goal is for healthcare education is to produce practitioners who truly put their the patients at the center of care.

Visit the INACSL Conference Website for More!

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