Keeping it real simulation in education

October 2011

Mannequins can now convulse, blink, pee, sweat and respond to intravenous drugs. FIONA CASSIE finds out more about simulation – both low-tech and high-fidelity.

Gratitude that she was the sponger rather than the spongee is Karen Edgecombe’s first memory of nursing simulation. “I remember thinking ‘oh my goodness, I’m not going to wear my togs’,” recalls Edgecombe of bed-bath simulation back in her nursing school days.

Practising simple procedures on your classmates remains a mainstay of undergraduate nursing education. But simulation has grown far beyond teaching procedural techniques. Edgecombe is one of the growing number of nurse educators specialising in using high-fidelity and problem-solving simulation scenarios to teach the next generation of nurses. The senior lecturer at the Christchurch Polytechnic Institute of Technology (CPIT) nursing school in Christchurch is leader of a research project that recently won funding from AKO Aotearoa (the National Centre for Tertiary Teaching Excellence). The project aims to find out more about where nurse simulation education is at in New Zealand and to create a collaborative community of practice for undergraduate nursing providers.

Nurse educators using simulation in both education and workplace settings are also to gather at next month’s Australasian Nurse Educators Conference (ANEC) to discuss, among other things, how to measure or demonstrate that simulation is a successful learning tool.

Meanwhile, Health Workforce New Zealand (HWNZ) has started work on developing a national skills and simulation-based strategy as part of its push to improve the learning experiences of postgraduate trainees in medicine, nursing and allied health (see sidebar.)

Simulation on the up

Simulation is definitely part of the zeitgeist and becoming increasingly mainstream.

Pressure on clinical placements has played its part in the growth of simulation education in nursing schools. But the increasingly sophisticated high-fidelity mannequins are also providing nurse educators with the tools to create more and more realistic simulation scenarios that test and teach critical thinking and teamwork, along with building technical skills.

Likewise, simulation skill units in hospitals are increasingly using high-fidelity simulation to turn real clinical incidents into learning scenarios and to test and highlight gaps in processes and protocols.

Until recently, many of these simulation pioneers were working in relative isolation.

Edgecombe says it was some off-the-cuff comments from a colleague at EIT’s nursing school that triggered the collaboration simulation project. He shared some useful tips about teaching the reconstitution of IV antibiotics and in return she shared how CPIT sourced products to teach blood transfusion. It was a meeting of minds and highlighted the need for a collaborative community to share knowledge and create dialogue.

The project got under way in August, courtesy of the $30,000 research grant, and a working party of educators from CPIT and four other nursing schools has been set up to see the project’s aims are met (see sidebar).

By the end of the 18-month project, Edgecombe hopes the team will have an inventory of who is doing what, from the low-fidelity, bed-bath practice, to the high-fidelity computer-generated simulation scenarios. Edgecombe emphasises that each has its place in laying down the skills needed to become a nurse. “You do need to know how to take blood pressure on normal people and not just on plastic people.”

Where high-fidelity simulation comes into its own is putting nursing students into the midst of likely clinical scenarios or incidents so they can safely test their assessment and critical thinking skills. Edgecombe points out that the patients students face in a ward today are much sicker than in the past. “They say a patient admitted to a ward today would have been in ICU 15 years ago,” says Edgecombe. “And the patient in ICU today would have been dead. So we have to make sure that our graduates are able to hit the floor running.”

Simulation scenarios are used to teach students from the outset. So year one students who have learnt how to take a pulse and administer medicine are tested with a simple scenario of administering medicine to the high-tech SimMan mannequin. But SimMan is programmed to be bradycardiac, so students have to recognise that his pulse rate is too low for the prescribed medication and decide what to do next.

The clinical scenarios grow in complexity as the nursing student’s knowledge and assessment skills grow, but are always pared back in recognition that the novice nurse cannot be expected to have the quick judgment of an experienced ward nurse, says Edgecombe. Likewise, she says, it is easier to have scenarios built around a conscious high-fidelity mannequin so a student can practise their communication assessment skills and get clues from more than just the vital signs.

Mental health also uses simulations by bringing in well-briefed drama students for roleplays with students. And next year CPIT is looking to create simulation scenarios that bring RN and enrolled nurse students together to demonstrate direction and delegation skills. What all these simulations have in common is allowing students to get a taste of clinical reality without it mattering if they “stuff up”. “It allows students to make a mistake in a safe supported environment rather than out in clinical,” says Edgecombe.

Does simulation count?

In early 2012, the new education standards for registered nurse programmes, adopted by the Nursing Council back in 2010, come into force. These standards, for the first time, clearly state that simulation hours cannot be part of the minimum 1100 clinical experience hours a student has to be provided with.

Debating whether simulation hours should count is far from top of the agenda for an upcoming gathering of nurse educators using simulation, says organiser Willem Fourie. Instead, says Fourie who is head of MIT’s nursing school, the meeting’s main focus is how to use simulation as an effective teaching strategy.

The meeting, held during the Australasian Nurse Educators Conference (ANEC) in Hamilton, looks to bring together nurse educators using simulation in nursing schools and their colleagues in hospitals and other practice settings.

For Fourie, simulation provides a safe environment for students to learn, review and reflect on their clinical skills, be it a simple task-based skill or a complex scenario drawing on critical thinking. “It also creates an opportunity to practise and practise again… it’s the old cliché that practice makes perfect.”

The aim of simulation is to provide students with more confidence and experience when they face a situation for real. But how do you assess or demonstrate that simulation has made a difference to a nurse’s skill or confidence? “What is it that we actually measure?” asks Fourie.

He sees a clear need for simulation standards in New Zealand and rather than re-inventing the wheel and suggests that the sector should look to standards like those created by INASCL (the International Nursing Association for Clinical Simulation and Learning) as a starting point. “There’s a need for more research and working towards some uniformity across the country in the way we use simulation,” says Fourie. “I don’t think anybody is arguing to replace clinical experience in the real world.” Though if national standards can demonstrate good learning outcomes from simulation then a “nice spin-off” would be the Nursing Council allowing some simulation hours to count towards clinical placement hours. “But if that was our major focus I think we would be missing the point,” says Fourie. “It’s about education.” A recent education focus has been on interdisciplinary learning, and Fourie says that aspect of simulation education also needs to be addressed.

The inter-professional approach

Improving the postgraduate learning experiences of medical graduates, nurses and allied health is the aim of a national skills and simulation-based education strategy being developed by HWNZ. It follows a proposal from the interdisciplinary New Zealand Association for Simulation in Healthcare (NZASH).

NZASH chair Jane Torrie is director of The University of Auckland’s Simulation Centre for Patient Safety and a practising specialist anaesthetist. She hopes the strategy will identify what and where the needs are for simulation education and show how those involved can work together to provide a unified approach. The association has about 85 members, but Torrie estimates there are probably at least 500, if not up to 1000 educators and researchers using simulation, including running basic CPR courses for lay people and training paramedics and defense personnel.

Torrie believes simulation education should be inter-professional, but says defining what the terminology means is all-important. For example, some people talk about a skills unit being multidisciplinary simply because a range of health disciplines use the same space, albeit at different times. Or there’s talk of interdisciplinary learning when different professions learn the same skills at the same time. “Then there is true inter-professional learning – it’s not an elephant in the room,” says Torrie. “It’s looking at how we work across all disciplines as a team rather than being an education by-product.”

Torrie’s unit is based in the anaesthesiology department, and its name was chosen carefully to reflect that its focus was not simply anaesthetist training but patient safety and the teamwork that’s required. Next year, the unit will trial bringing together medical interns with third year nursing students for advanced resuscitation learning. Torrie says bringing professions (e.g. theatre nurses, anaesthetists, anaesthetic registrars) together for simulation scenarios brings home the lesson that in health no-one works as an individual. Also that good communication, respect and teamwork is essential for good outcomes for patients. “If people don’t feel able to speak up, then patient safety is at risk.”

All educators are clear that safety is the crux behind simulation’s existence; having the space and time to learn without putting patient or staff safety at risk; the chance to practise skills, discover weaknesses, gain confidence and test competency with the luxury of being able to review and learn from what went right and, most importantly, what went wrong. For these reasons, as well as an answer to finding space and time to teach undergraduate students on busy wards, simulation is likely to be playing an ever-increasing role in education in the future.

Clinical vs simulation hours

Registered nurse requirements

Nursing Council of New Zealand. Nursing schools must provide a minimum of 1100 clinical experience hours for all students and all students are entitled to up to 1500 clinical experience hours to prove competence. Simulation hours cannot be included in clinical experience hours.

UK Nursing and Midwifery Council. Nursing schools can provide up to a maximum of 300 hours of the 2300 hours clinical practice time in a simulated environment.

Australian Nursing and Midwifery Accreditation Council. Nursing schools to provide no less than 800 hours of professional experience placement hours. Professional experience placement hours exclude simulation but simulation can be part of overall professional experience hours used to build students’ competency.

Enrolled nurse requirements

Nursing Council of New Zealand. Students are required to complete 900 clinical experience hours during the programme, which can include up to 200 hours of simulation. The council uses US nursing academic Pamela Jeffries’ definition of simulation, i.e. “Activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making and critical thinking through techniques such as role playing and the use of devices such as interactive videos or mannequins. A simulation may be very detailed and closely simulate reality, or it can be a grouping of components that are combined to provide some semblance of reality.”

Australian Nursing and Midwifery Accreditation Council. The total professional experience placement hours are to be no less than 400 hours. The definition of placement hours is the same as for RNs, i.e. putting theory into practice within the consumer care environment, but unlike for RNs, the definition does not state that simulation is excluded.

Simulation initiatives under way

Nurse education collaborative simulation project

The AKO Aotearoa-funded project is lead by CPIT and aims to:

  • carry out a literature review of undergraduate clinical simulation in New Zealand;
  • hold a two-day workshop for all undergraduate nurse educators involved in simulation in New Zealand;
  • design some teaching and learning guidelines for clinical simulation in undergraduate sector;
  • create a collaborative community of practice in simulation via web community;
  • develop a research plan by the beginning of 2013.

Simulation educators gathering at November conference

A gathering of nurse educators using simulation in nursing schools and practice settings is to be held during the upcoming Australian Nurse Educators Conference in Hamilton to discuss the way forward for nursing simulation.

HWNZ national simulation strategy survey

A Health Workforce New Zealand survey aims to identify existing skills and simulation-based education facilities, equipment, activities and resources; perceived needs and future demands. Using the survey results, HWNZ hopes to:

develop a national register of resources to enable sharing of expertise and possibly equipment;

identify the current use of skills and simulation-based education by vocational and professional groups;

identify the training and education needs of instructors, simulation technicians and clinical staff.

The resulting data will go back to HWNZ’s four regional training hubs to help implement training programmes and regionally consistent training standards.

Quick history of simulation mannequins

One of the first simulation mannequins was Resusci-Anne, first released in1960 for mouth-to-mouth resuscitation training, and later CPR training, by Norwegian toy manufacturer Asmund Laerdal.

An engineer and a physician at the University of Southern California in the mid-‘60s developed the first computer-controlled mannequin used for endotracheal intubation and other training but it was never put into production.

Harvey – a simulation mannequin created to mimic different cardiac functions – followed in 1968.

The latest high-fidelity simulation mannequins are increasingly sophisticated, for example SimMan 3G can “bleed”, has a sweaty forehead, breathes, froths, convulses and pees as well as having a pulse, and recognises and reacts to more than 100 prescription medicines. More overleaf >>

Starship simulation – high fidelity and child actors

A busload of kids draped in bandages hop and stumble into Starship, some crying, some not. And probably some giggling, as the “injured” are not accident victims but students of a local school roleplaying to test Starship emergency department’s contingency plans.

“The children loved it and some of them were great actors,” recalls Trish Wood, nurse educator for Starship’s ED. “We’d been to school and spoken to the teachers and they’d prepared the children with bandages and they all had a (prompt) card that said ‘hop’ or ‘cry’.”

Simulation does not have to involve whizz-bang mannequins, but Wood and nurse educator colleague Dawn Tucker from the Paediatric Intensive Care Unit (PICU), are also advocates for the important role high-fidelity simulation plays.

Tucker says while nursing has used low-fidelity mannequins since “God-invented apples” in 2007, the pair has been using the high-fidelity mannequins, SimBaby (pictured) and SimMan for teaching either in situ or at Auckland District Health Board’s Clinical Skills Unit. “Obviously our kids in intensive care are very sick and so we use a lot of equipment,” says Tucker. “Using the high-fidelity simulation (in situ) allows us to run very realistic scenarios, where we attach SimBaby to our ventilator and plug it into our monitors.”

Simulations on site are convenient for staff and provide a safe environment to challenge and build staff skills, and also to test out protocols and identify system problems without putting patients or staff at risk. Some staff initially find high-fidelity simulation stressful and some push back or resist, says Tucker. “They argue it’s a mannequin and if it was a real patient they’d handle it differently. But the more simulations people do, the more buy-in you get”. And while high-fidelity simulation can be stressful, it is also visual, hands-on and relevant.

Creating a high-fidelity simulation scenario is time-consuming in itself, let alone running the simulation and skillfully managing the de-briefing process to maximise learning. So the educators usually reserve it for testing a nurse’s or team’s response to an unstable patient or a particular patient condition and leave the more straightforward teaching and practising of procedural skills to low-fidelity simulation.

Tucker runs a high-fidelity simulation for PICU nursing staff once a month and another for paediatric registrars. Woods offers fortnightly multidisciplinary teaching using simulation and a more complex simulation every six weeks. High-fidelity simulation is also a regular component of in-house study days at Starship.

The pair says simulation can also be developed opportunistically in response to a skill gap being highlighted, like revisiting securing a breathing tube for a child, or to recreate a critical incident and test staff’s ability to respond.

For instance, if there was an incident such as a medication error by infusion, a scenario could be set up so the mannequin received an incorrect infusion and responded just as the patient did. The nurses in the simulation would then have to identify and solve the problem. “In reality, we wouldn’t let somebody’s inaction run its consequence,” says Wood. She points out that adult learners need the chance to make mistakes and correct themselves, rather than have somebody else correct them. Simulation makes this possible. “In the clinical setting we would never allow that to happen, so it’s a luxury to have this teaching tool.”

The educators can monitor whether somebody has taken the lead in directing care, whether staff are communicating effectively when delegating and carrying out tasks, and whether a team keeps a global perspective of a patient’s condition rather than fixating on a minor aspect of their care.

Tucker and Woods add that an essential part of the learning is the post-simulation debriefing that needs to be skillfully led by the experienced educators to identify problems, whether these are equipment shortages or communication breakdowns, and how to work around or resolve these.