Int. J. Nurs. Educ. Scholarsh. 2015; 12(1): 1–10
Karen Livesay*, Karen Lawrence and Clive Miller
Making the Most of Simulated Learning: Understanding and Managing Perceptions Abstract: Increased emphasis on the use of simulation by nursing education providers is evident world-wide. It is unclear what the implications of this initiative are for academic staff within nursing programs. Programs report a range of responses to simulation pedagogy amongst faculty ranging from enthusiasm to avoidance. This study identified a wide range of concerns encapsulating the staff themselves, their concern for students as well as organisational considerations that impact staff perceptions. Methods: Nineteen in-depth, semi-structured interviews were conducted with faculty in a school of nursing and midwifery. Thematic analysis of data was carried out. Results: This study reinforced other earlier research related to staff feelings about the introduction of a simulation program or uptake of existing equipment and facilities. This study reflects the knowledge and experience staff had of simulation and highlights the importance of ensuring all members have a collective frame of reference in order to create shared language and vision. Conclusion: This study adds to the research on staff attitudes to simulation by identifying the preconceived ideas that contribute to idea formation and relates this to the insight and self-efficacy of the faculty members.
has produced more emphasis on this pedagogy. In the Australian context many nursing programs have introduced simulation with the assistance of government incentives for capital equipment and scenario development as well as a nationwide introductory staff development program. The research question this study investigated was “What are the needs and concerns of academics about the requirements to increase the use of simulation in preregistration curricula?” The aim of this study was to understand staff perceptions when adopting simulation pedagogy into a new nursing curriculum. It was vital to consider the attitudes of incumbent academic staff to the use of simulation. Three researchers were involved in this study. All had minimal experience of learning through simulation prior to conducting this study and were faced with the adoption of simulation as a teaching strategy in the curriculum. In this qualitative study, researchers interviewed 19 staff to examine their perceptions of introducing learning through simulation and identify strategies that could be adopted to assist staff. Interviews occurred prior to implementation of learning through simulation. Interpretive Phenomenological Analysis (IPA) was used to examine data (Smith & Eatough, 2007).
Keywords: simulation barriers, resources for simulation, self-efficacy, shared vision, simulation faculty, technology
Literature review DOI 10.1515/ijnes-2013-0098
Learning through simulation is viewed as a valuable tool in the learning and teaching paradigm of health professional education, with many programs historically incorporating medium to high fidelity simulation (Starkweather & Kardong-Edgren, 2008). Increased availability of technology in combination with competition for clinical places *Corresponding author: Karen Livesay, College of Health and Biomedicine, Victoria University, McKechnie St, St Albans, Melbourne, Victoria 3021, Australia, E-mail: [email protected] Karen Lawrence, Clive Miller, College of Health and Biomedicine, Victoria University, McKechnie St, St Albans, Melbourne, Victoria 3021, Australia, E-mail: [email protected], [email protected]
Use of learning through simulation in nursing education has become widespread over the past decade with many programs reporting use of the pedagogy to some extent (Starkweather & Kardong-Edgren, 2008). The literature describes aspects of staff preparation, either on a program basis or widespread across communities of practice that are geographically or discipline related (Seropian, Driggers, Taylor, Gubrud-Howe, & Brady, 2006; Waxman, Nichols, O‘Leary-Kelley, & Miller, 2011).
Staff perceptions Akhtar-Danesh, Baxter, Valaitis, Stanyon, and Sproul (2009) found that academic staff feared judgement by colleagues during simulation scenarios. This fear was founded on a lack of knowledge and concern regarding
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the currency of clinical skills of facilitators that may be exposed in learning through simulation. They recommended that a culture of safety be established to ameliorate the judgement of colleagues to diminish these concerns. A safety culture can be achieved through practices such as rehearsal and agreements of confidentiality regarding performance within simulation scenarios. Moizer, Lean, Towler, and Abbey (2009) found fear of judgement and exposure of sub-optimal facilitation skills was also associated with problems that may arise during simulation. An example was failure of the simulator or technological malfunctions associated with computerised equipment. Moizer et al. (2009) found that academic staff are challenged by dealing with negative responses from students and others about their facilitation during simulation. In their study, Moizer et al. (2009) indicated they would need support in implementing simulation to offset these risks of simulator malfunction or student negativity. In the context of this study, nurse academics are required to teach clinical skills and facilitate learning through simulation. Mackenzie (2009) identified the divide between nurses in higher education and clinical settings. Due to competing demands upon their time, such as administrative duties, teaching, and research, nurse academics are at risk of losing skills for clinical practice. Mackenzie (2009) suggested that the distance from practice in higher education means that these educators are not well placed to teach clinical skills and by extension learning through simulation, where clinical skills are central. Banning (2005) links effective teaching to competence in the knowledge base as well as self-esteem. In pursuing this argument, Clifford (1996), a pioneer in learning through simulation, suggested that academics using simulation must be clinically up to date. More recently Dowie and Phillips (2011) suggest that credibility can be gained through faculty practice and mentoring in simulation by clinically active staff. Jansen, Johnson, Larson, Berry, and Brenner (2009) report that some faculty in their study felt manikin-based simulation was only suitable for courses covering acute care technical skill development.
Student learning The literature reports learning through simulation as a potential solution to the tensions between student learning needs and protection of patients from error and harm (Ziv, Wolpe, Small, & Glick, 2003). In their systematic review of technology-enhanced simulation, Cook et al. (2011) concluded that simulation provided large effects in outcomes of knowledge, skill, and behaviours, with lesser effects for
patient-related outcomes in comparison with no intervention. Gore, Hunt, Parker, and Raines (2011) showed that simulation decreased anxiety levels in junior nursing students prior to clinical practice. They concluded that despite the barriers, cost, and time for production, there were substantial benefits in using simulation as a teaching strategy. Fidelity, referring to the degree of life-likeness within a simulation, is a complex issue. Norman, Dore, and Grierson (2012) concluded that statistically significant advantages of using high fidelity equipment over low fidelity equipment were not apparent. However, factors such as task complexity, transfer of learning, context, and cognitive load might impact learning outcomes. Lapkin and Levett-Jones (2011) similarly identified that medium fidelity manikins “such as Laerdal’s Megacode Kelly™ with Vital Sim capability” (p. 3545) were capable of evoking similar outcomes for student satisfaction, knowledge, and clinical reasoning as high fidelity models. The proposed program of learning through simulation, about which this study was conducted, intended to use medium fidelity simulation techniques.
Resources Many papers have identified common concerns amongst staff regarding resource requirements for integrating learning through simulation into nursing curricula. Adamson’s (2010) study of facilitators and barriers to introducing Human Patient Simulation (HPS) confirmed that time, technical support, training, and hesitancy to try new methods were prevalent. Billings and Halstead (2005) reported similar findings regarding time requirements, while Touriniemi and Schott-Baer (2008) concurred regarding technical assistance resources. The lack of human resources to support simulation is verified as a disadvantage to using HPS, while lack of facilitator training and experience were also recognised as barriers to use (King, Moseley, Hindenlang, & Kuritz, 2008). Appointment of a champion has been identified as a strategy (Jones & Hegge, 2007) to support faculty members with the introduction of simulation. The champion’s role can include planning and developing simulation materials with staff while they gain experience and knowledge. A champion’s role, while not well defined, is concerned with sponsoring a change while being a source of support, knowledge and skill. Guzic et al. (2012) observed the inverse relationship, where the absence of a simulation specialist can have a negative impact on simulator use. When adopting learning through simulation for the first time a champion would
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K. Livesay et al.: Making the Most of Simulated Learning
act as a change agent and assist others to develop skill, knowledge, and confidence. This review of the literature has highlighted the concerns of academic staff about human resources, time allocation, and fear of judgement as issues, while acknowledging the potential for simulation pedagogy enhancing student learning.
Study design Interpretative Phenomenological Analysis (IPA) was used to inform data collection and analysis (Smith & Osborn, 2008). The primary aim of IPA is to carry out a detailed analysis of the unique subjective experiences of the individual and how individuals make sense of these experiences. In IPA, researchers gather qualitative data from research participants, using individual interview techniques (Smith & Osborn, 2008). Interviews are approached from a position of flexible and open-ended inquiry, gaining accounts of richness and depth. This study used in-depth, recorded interviews. According to Kvale (1996), an in-depth interview is a “conversation that has a structure and a purpose” (p. 6). The analyst reflects upon his or her own preconceptions about the data, and attempts to suspend these in order to focus on grasping the experiential world of the research participant. IPA’s hermeneutic stance is one of inquiry and meaning-making and the analyst tries to make sense of the participants’ explanations of their own experiences (Smith & Eatough, 2007). Thus, one might use IPA if one had a research question that aimed to understand what a given experience was like (phenomenology) and how someone made sense of it (interpretation). This form of interviewing was considered particularly appropriate as it focuses on the participant’s perception of self and simulation as a teaching pedagogy. Thus, it was anticipated that the inquiry would facilitate greater understanding of faculty members’ awareness of their perceptions relating to simulation. Following approval through the Human Research Ethics Committee of the University, a convenience sample of 19 nursing and midwifery academics and clinical educators were recruited to take part in the study. Recruitment took place through the School of Nursing and Midwifery. Flyers were placed on key notice boards and all academic staff received a written invitation to take part in the study. All participants were aged 18 years and older and provided voluntary and written consent to participate. Interviewees were clustered into “New to Academia 3 years” and
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“Clinical Educators”. The design of the study did not intentionally set out to cluster interviewees into three groups. Participation in the study was voluntary and it was only after the interviews had concluded that the researchers noted the balance of participants and the categories they fell into. Two researchers undertook the 19 interviews and all three researchers were involved in data analysis. To enhance validity, researchers carefully followed the order of the in-depth interview schedule (Table 1). Table 1: Examples of interview questions. Can you tell me what you understand the term simulation to mean? Can you tell me how you feel about participating in simulation as a facilitator? Can you tell me the benefits, if any, you will derive from using simulation? Can you tell me the drawbacks, if any, you will derive from using simulation? Can you describe the benefits, if any, you think students will derive from participation in simulation? Can you tell me what drawbacks, if any, you perceive with student participation in simulation? Can you tell me about your experiences with using simulation? What staff development do you think would help you facilitate simulation? Is their other help that you would require to facilitate a simulation session? What barriers, if any, do you envisage in the introduction of simulation into the curricula? How do you think these barriers, if any, could be overcome?
Data collection Individual in-depth qualitative interviews were conducted by the researchers. Interviews varied between 45 min and 72 min and were performed at mutually agreed locations. Interview questions were asked and the interviews were digitally recorded then transcribed verbatim.
Analysis The analysis of the data was undertaken in five phases: Phase One: Phase Two: Phase Three: Phase Four: Phase Five:
Reading and annotation of all transcripts Development of interview concepts Development of emerging themes Comparison of emerging themes and development of cluster themes Reduction of data and development of Superordinate themes (Smith & Osborn, 2008, pp. 64–73)
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Transcripts were coded in considerable detail, with the focus shifting back and forth from the key statements of the participant, to the researcher’s interpretation of the meaning of those claims. The analysis was undertaken in five phases. After transcribing the data, the researchers worked closely and intensively with the text, annotating it (“coding”) for insights into the participants’ experience and perspective on their world. From the annotated comments, five interview concepts were identified: feelings about simulation, understanding, students, wants, and barriers (Figure 1). At this phase, the researchers developed a template to assist with the interpretation of the data using the interview concepts as headings. As the analysis developed, the researchers catalogued their emerging themes. Emerging themes were noted as recurring patterns of meaning (ideas, thoughts, and feelings) throughout the text and identified both something that matters to the participants (i.e. an object of concern, topic of some import) and also something of the meaning of that thing, for the participants. All researchers completed their preliminary analysis of the five interview concepts and came together to review and make sense of their individual emerging themes. Once all the data were saturated, emerging themes were identified, and the researchers commenced looking for patterns with an aim to reduce the themes that had similar meaning. Forty one cluster themes emerged. Cluster themes eventually were grouped under much broader codes called “Superordinate Themes” The final set of superordinate themes capture most strongly the respondent’s concerns on simulation.
Findings A summary of the data analysis process can be seen in Figure 2, which provides a list of findings from all five phases of data analysis.
Discussion There were nineteen participants; five of the staff were working concurrently in clinical nursing roles, while the remainder were working in academic roles with little or no clinical contact. Most staff had used simulation or learned with simulation in basic life support programs. None of the staff had studied the pedagogy of learning through simulation. This research found a wide range of concerns relating to staff, their concern for students, as well as organisational considerations. The superordinate themes follow the pattern of previous studies (Adamson, 2010; Billings & Halstead, 2005), although this study adds to previous research by identification of faculty perceptions not previously described. A total of ten themes were identified; however, only four will be presented as part of this report: vulnerability/apprehension, self efficacy, absent shared vision and resources. These themes relate to staff perceptions when adopting simulation pedagogy into a new nursing curriculum. The remaining six themes (formative assessment, contextual doing, safety, improving student learning and fidelity) relate to student learning, and will be discussed in a separate report.
NEEDS/WANTS
UNDERSTANDING
BARRIERS SIMULATION
STUDENTS
FEELINGS
Figure 1: Interview concepts.
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K. Livesay et al.: Making the Most of Simulated Learning
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INTERVIEW CONCEPTS Feelings
Students
Understanding
Needs/Wants
Barriers
EMERGNG THEMES Over 100 emerging themes identified by the three researchers
CLUSTER THEMES Optimism, Pessimism, Measurement, Staff development, Reflection, Clinical readiness, Fidelity, Psychomotor, Division of labour, Internal reasons, Workload recognition, Self efficacy, Reflective practice, Evidenced based practice, Fear, Vulnerability, Reality, Confronting, Preparation for practice, Role playing, Clinical currency, adequate time, Skilled simulation team, Cost, Preparation, Time, Everybody on board, Without risk (to people), Psychomotor skills, Real world/life, Not real life, Feeling vulnerable, Increase confidence, Support staff, Need staff development, Takes time, Hands on, Faculty practice, Peer review, Student Participation Debriefing SUPERORDINATE THEMES Vulnerability/Apprehension, Self efficacy, Shared vision, Resources (Human, Physical, Internal, External) Formative assessment, Contextual doing, Safety, Improving student learning, Fidelity Figure 2: Data analysis process.
Vulnerability/apprehension In the opinion of participants, findings revealed that simulated environments can be stressful for students and staff. Concern for the stress induced in students by simulation was not compared with stressors in the clinical environment by any participant. In clinical practicums, stress was viewed as inevitable and performance was viewed as private, while students undertake practice with minimal peer observation. Overlooking the stress students feel when unprepared in clinical environments showed staff acceptance of performance stress in other settings. But we have to acknowledge how confrontational and stressful this is for the student. The thing that I think might show us some problems is that the students who are not processing and synthesizing the information as quickly as others will be very obvious
Staff were concerned about students’ inability to tolerate feedback provided verbally and immediately after a simulation as part of a structured debriefing. This staff concern demonstrated naivety of the recommended format and process of simulation debriefing. I think that it’s going to be trial and error you’re not going to know what you don’t know until it happens.
The staff concern for students’ reaction to debriefing in the simulation setting overlooks that students undertaking clinical experience are given feedback. Some clinical staff and facilitators may be inexperienced in the process of providing feedback. Additionally, in the clinical paradigm the feedback may be summative and high stakes for its impact on progression in the program yet structured formative feedback in simulation was regarded as difficult for students to tolerate. So I think that can be one of the problems of simulation particularly when you’re doing it in front of a group of students that when the students themselves are doing it and a student does something wrong you’re obliged to say there and then that it’s wrong and some students can take that well and some students not so well.
While the issue of the simulated experience giving rise to anxiety itself was identified by many participants, the idea that a student may experience the same anxiety in practice was not mentioned. The possibility that practice in simulation may reduce levels of anxiety in clinical settings (Gore et al., 2011) and equally the value students attribute to peer learning was not identified (Sinclair & Ferguson, 2009). While we can see the pedagogical benefits, it can be so stressful for them that they don’t gain anything educationally because they are so stressed
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Most of the literature regarding staff reluctance to work in simulation describes time constraints and resource implications (Adamson, 2010; Starkweather & Kardong-Edgren, 2008), whereas this study produced repeated suggestions of personal apprehension and concern. In some instances staff linked into concern for student vulnerability, by expressing their own vulnerability. This concern for student stress may have been for some staff a projection of their own feelings. Even those participants who would be considered enthusiasts or early adopters of the move to simulation responded with comments related to anxiety.
self-efficacy related to clinical currency indicated a narrow focus dealing with minutiae of task and procedure.
Nervous because I suppose I’ve never been involved in anything like that before
This narrow vision of simulation overlooked areas such as communication, team work, human factors and cultural competence which could be argued to be less dependent upon clinical detail, technological specificity or procedural currency. It also exposed the view that participants considered only simulation in acute inpatient environments, as opposed to the range of settings within which our students would be prepared for practice, reflecting the attitudes of faculty reported by Jansen et al. (2009).
I’d have to admit feeling very nervous about that at the moment, because I have no experience really of working in that kind of setting. But on the other hand I am a fairly experienced educator
This frank disclosure positions participants honestly in a change process. This disclosure demonstrates that, despite their willingness to attempt the adoption of new pedagogy, it gives rise to anxiety. Learning through simulation overlaps the classroom and the clinical setting and feelings of vulnerability were demonstrated from both the academic staff and the clinical teachers. It is possible that the real source of discomfort was the duel requirements of teaching skill and clinical skill where staff identified more strongly with one area over the other. While the convenience sample of participants used may be skewed to those more favourable about simulation, this suggests further research related to the attitudes of those resisting the use of simulation could be enlightening.
Self-efficacy Self-efficacy is described as a belief in one’s ability to engage in particular activities based on the likelihood of success (Sinclair & Ferguson, 2009). Self-efficacy was linked strongly by several participants to clinical currency and credibility. Clinical currency is a phrase that describes clinical competency as well as familiarity with up-to-date protocols and operating procedures (Owen, Ferguson, & Baguley, 2005). Self-efficacy ties closely to the position of Dowie and Phillips (2011) that current clinical expertise is a prerequisite for successful simulation. This insight into participant’s view of themselves and other academic faculty illuminated the divide experienced between the academics and clinical staff (Mackenzie, 2009). The
I think they need to be very up with, and current with their knowledge base, and maybe potentially having actually done some acute work. For nurses, if we’re talking about simulation, we really need to be dealing with people who are fairly skilled up in clinical practice. Not just currency of practice in terms of the hands on clinical stuff but currency of knowledge about current systems of health care delivery, current systems of patient care, hospital wards.
Absence of shared vision Although shared vision was identified amongst participants as a necessary attribute, it was related to understanding of what would or could be done in simulation. Having everybody on board, everybody believing the same thing. So if we all had a similar definition and a similar idea about the outcomes. A similar sort of acceptance, we all have to be enthusiastic for it to work.
When defining their understanding of simulation, all participants provided examples of procedures and tasks related to acute skills and inpatient emergencies. Participants used different language to describe simulation activities and had a wide ranging level of experience and interest in simulation. Written scenarios, written problems that are sort of meant to represent reality. I would say it’s [simulation] the physical act of demonstrating something. I would define simulation as an attempt to create a situation that is as close as possible to an actually clinical situation.
Staff envisioned simulation usage and implementation differently from the possibilities described in the literature
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K. Livesay et al.: Making the Most of Simulated Learning
and held as best practice. Some considered the issues of large groups observing a simulation, while all considered psychomotor skill development, Having people that watch, giving them that choice, those that don’t want to play, to be spectators and learn vicariously. They’ll be able to practise their psychomotor skills, their actual motor skills, and yeah a less threatening environment too because they’re not actually with a real person.
No-one talked of communication skills, teamwork, or situational awareness being developed through simulation. What became apparent was that a disparate group of academic faculty were to be called together to implement learning through simulation without a shared vision The researchers felt this theme helped explain the lack of efficacy that had been identified and the desire for external assistance and potentially even the lack of suggested solutions for issues identified during interviews. This was a significant finding and again the extent of the differing vision was unanticipated given the available literature and immersion in pedagogy that had been undertaken at the time of the study. It did however demonstrate the efficacy of immersion and the need for more significant staff development and practice.
Resources Participants raised concern about staff training, scenario development, equipment and resources such as adequate space and support from experienced staff. Staff were concerned with their capacity to design and implement simulation scenarios. I was talking about the equipment, facilities and personnel and education for me in how to and time, needing time to do this. I suppose just having access to somebody, be it like in person or phone and I would say that the smaller group is the main thing, having a smaller group or two facilitators
A number of factors occurred that addressed these concerns. To overcome staff concerns regarding space adequacy, an internal university grant was sought and gained. This grant enabled the pre-existing nursing skills laboratories to be refitted with technical and simulation equipment creating a purposeful simulated learning environment. Creative issues and those that could be approached flexibly such as “stage dressing” environments for different nursing scenarios were not addressed by the responding participants. The participants thinking reflects
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again the preference to stay with the familiar and may link to the two themes of self-efficacy and shared vision. Staff also viewed time as a potential concern of using simulation. A summary of staff concerns around resources can be seen in Table 2. Table 2: Staff concerns relating to resources. Human
Physical
Internal
External
Lack of preparation
Not having dedicated space.
Not enough time to prepare
Not cost efficient
Not enough time to practice Timetable issues
Not enough equipment
Need for spaces Concern around current resembling different nursing contexts skill level
Moizer et al. (2009) and others suggest support particularly with technological requirements of simulation. Similarly Jones and Hegge (2007) identified that this support should come from an experienced simulation champion. The participants interviewed in this study had concerns for their own ability to develop simulation scenarios. The participants sought the possibility of recruiting others to undertake the development tasks. Participants suggested external expertise was needed to demonstrate and share creativity and innovative use of simulation. Perhaps get some experienced people in to demonstrate the particular things that they have used it for and some creative and innovative ways Writing up simulation scenarios, things like that, we need more practice
Given the depth and breadth of experience of many of the participants, this outcome was unanticipated. Starkweather and Kardong-Edgren (2008) describe the experienced simulation researcher as the spark that ignited interest but note that the champion was an established faculty member. Jeffries (2008) adds that in some programs key staff are groomed as champions to support and empower those who follow.
Recommendations As many of the insights perceived by participants in this study were congruent with those previously documented in the literature, it was anticipated that the recommendations from those studies would be recognised and implemented.
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Where possible these recommendations were incorporated; however, a local study was thought to be helpful to identify specific concerns in this context. Awareness of staff perceptions would enable implementation of strategies to address those specific perceptions gained through this study. It also enabled development of custom-made strategic directions by the research team. Five key recommendations were derived from the research which, although specific to this program, have utility for other programs commencing simulation or in which faculty resistance to simulation is apparent. These are:
Staff preparation to manage perceptions 1.
Design an education orientation program that is accessible to all staff. Competency in this program must be achieved prior to simulation facilitation.
Some orientation to simulation had been undertaken through presentations, staff contribution to planning the physical environment development, and education related to simulation equipment at the time the research was conducted. This preparation was seen to be inadequate for staff to move into a change paradigm. The diversity of ideas could not be seized and used for development purposes while it was contributing to a discord of thought and planning. 2.
Ensure staff participate in practice simulations as learners and facilitators
A structured introductory education program that introduces key concepts and provides examples of use and early practice in technological aspects, such as running a manikin, devising a basic scenario and structured debrief should be the starting point. In Australia the Federal Government through the agency of Health Workforce Australia has recognised the need for this level of education and has developed and funded a program called the National Health Education and Training in Simulation (NHET-Sim) program. This program would be the recommended entry point for Australian teachers, but the authors would add the proviso of local level orientation in respect to policies and differences in program management and support at the institutional level.
Student learning 3.
Implement policies and procedures related to performance in simulation for both staff and students that specifically actions and describes mechanisms to
provide psychological safety or protection and make these overt through publication to staff and students Utilising staff as learners as well as facilitators in the development phase of the simulation program has multiple benefits. Staff members begin to develop experience and have an avenue to build on the NHET-Sim introductory program. Experiencing apprehension in the simulation would enable participants to confront the anxiety and begin to recognise the risks and benefits of activation while learning.
Resources 4.
Appoint a Simulation Coordinator to assist with the design and development of scenarios.
In order to increase emphasis on simulation significant change was required. Staff identified the need to develop new teaching and learning skills and new curricular supports. For example, scenarios needed to be constructed, tested, and validated. During a change process, a simulation coordinator can undertake the development workload and alleviate some concerns for staff time requirements. Additionally the simulation coordinator can act as a change agent and assist others to adopt new behaviours. Further, to avoid the potential negative impacts on simulator use, Guzic et al. (2012) support the appointment of a simulation champion or coordinator. Familiarity with expectations in simulation via policy and procedure development will help to create an overtly safe environment for students to dispel anxiety and vulnerability. The simulation coordinator is well positioned to develop policies and procedures. A safe environment will be established by ensuring confidentiality relating to student performance in simulation, debriefing, and deroleing and follow up of participants as required. Procedures that demonstrate the elements of best practice, identified through bench marking and utilization of research evidence, exhibit adherence with preconceived standards. Development and dissemination of procedures educates the staff and enables confidence with authority. 5.
Develop and disseminate a business plan that addresses funding sources, workload, and sustainability and support services.
Written policies and procedures will have the added advantage of creating a formalised plan for simulation utilisation. This plan enables staff to envision the breadth
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K. Livesay et al.: Making the Most of Simulated Learning
of simulation methodologies within the confines set out for the program and encourage a shared vision. While stand-alone simulation centres often develop business plans to document cost recovery or profit projections, our experience in higher education settings is different. In this University, with little or no external usage of the simulation facilities, the running and management becomes subsumed into the overall program budget. Without a separate budget or business plan, workload or support services are not specifically addressed and become part of teaching requirements. A business plan would have the advantage of making overt the financial and human resources committed to learning through simulation rather than incorporating them into a larger teaching and learning budget. Delineating resource provision in this way segments the resources provided for simulation. Staff overtly identify the provision of resources additional to those subsumed in everyday practice. Management support is additionally demonstrated through sign off on a specific business plan. Recommendations propose to help staff identify how they can utilise a range of simulation techniques for formative learning and teaching, employing agreed principles that support staff and students within a course.
Study limitations/conclusion The findings may have been biased in that staff with a strong interest in simulation participated, while those with less interest did not. The findings may not be generalizable to other education settings. Those who chose not to participate in the research may have held different ideas and concerns. However 67% of the staff was interviewed, providing a substantial representation of staff views at the time. This study reinforced previous research related to barriers to introduction of a simulation program or uptake of existing equipment and facilities, (Adamson, 2010). The attitudes and ideas that staff held at the early stage of the simulation implementation process were illuminated. These ideas and perceptions appeared strongly linked to the level of understanding of simulation methodology and could be a barrier or an enabler to simulation introduction. In particular, absence of a shared vision, coupled with diminished self-efficacy, and concern for student and staff psychological safety, as well as adequate resourcing of the program were identified as barriers to simulation in this study. Five recommendations were produced that could become the subject of further research.
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References Adamson, K. (2010). Integrating human patient simulation into associate degree nursing curricula. Clinical Simulation in Nursing, 6(3), e75–e81. Akhtar-Danesh, N., Baxter, P., Valaitis, R. K., Stanyon, W., & Sproul, S. (2009). Nurse faculty perceptions of simulation use in nursing education. Western Journal of Nursing Research, 31(3), 312–329. Banning, M. (2005). Approaches to teaching: Current opinions and related research. Nurse Education Today, 25(7), 502–508. Billings, D. M., & Halstead, J. A. (2005). Teaching in nursing: A guide for faculty (2nd ed.). St. Louis, MO: Elsevier Saunders. Clifford, C. (1996). Role: A concept explored in nursing education. Journal of Advanced Nursing, 23(6), 1135–1141. Cook, D. A., Hatala, R., Brydges, R., Zendejas, B., Szostek, J. H., Wang, A. T., … Hamstra, S. J. (2011). Technology-enhanced simulation for health professions education: A systematic review and meta-analysis. JAMA, 306(9), 978–988. Dowie, I., & Phillips, C. (2011). Supporting the lecturer to deliver high-fidelity simulation. Nursing Standard (Royal College of Nursing (Great Britain): 1987), 25(49), 35. Gore, T., Hunt, C. W., Parker, F., & Raines, K. H. (2011). The effects of simulated clinical experiences on anxiety: Nursing students’ perspectives. Clinical Simulation in Nursing, 7(5), e175–e180. Guzic, B. L., McIlhenny, C. V., Knee, D. R., LeMoine, J. K., Wendekier, C. M., Demuth, B. R., & Bapat, A. (2012). Distance learning and clinical simulation in senior baccalaureate nursing education. Clinical Simulation in Nursing, 8(1), e459–e467. Jansen, D. A., Johnson, N., Larson, G., Berry, C., & Brenner, G. H. (2009). Nursing faculty perceptions of obstacles to utilizing manikin-based simulations and proposed solutions. Clinical Simulation in Nursing, 5(1), e9–e16. Jeffries, P. (2008). Getting in S.T.E.P. with simulations: Simulations take educator preparation. Nursing Education Perspectives, 29 (2), 70. Jones, A. L., & Hegge, M. (2007). Faculty comfort levels with simulation. Clinical Simulation in Nursing, 3(1), e15–e19. King, C. J., Moseley, S., Hindenlang, B., & Kuritz, P. (2008). Limited use of the human patient simulator by nurse faculty: An intervention program designed to increase use. International Journal of Nursing Education Scholarship, 5(1), 1–17. Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing. Thousand Oaks, CA: Sage. Lapkin, S., & Levett-Jones, T. (2011). A cost-utility analysis of medium vs. high fidelity human patient simulation manikins in nursing education. Journal of Clinical Nursing, 20, 3543–3552. Mackenzie, K. M. (2009). Who should teach clinical skills to nursing students? British Journal of Nursing (Mark Allen Publishing), 18 (7), 395–398. Moizer, J., Lean, J., Towler, M., & Abbey, C. (2009). Simulations and games: Overcoming the barriers to their use in higher education. Active Learning in Higher Education, 10(3), 207–224. Norman, G., Dore, K., & Grierson, L. (2012). The minimal relationship between simulation fidelity and transfer of learning. Medical Education, 46, 636–647.
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Owen, S., Ferguson, K., & Baguley, I. (2005). The clinical activity of mental health lecturers. Journal of Psychiatric and Mental Health Nursing, 12, 310–316. Seropian, M. A., Driggers, B., Taylor, J., Gubrud-Howe, P., & Brady, G. (2006). The Oregon simulation experience: A statewide simulation network and alliance. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 1(1), 56–61. Sinclair, B., & Ferguson, K. (2009). Integrating simulated teaching/ learning strategies in undergraduate nursing education. International Journal of Nursing Education Scholarship, 6(1), 1–11. Smith, J. A., & Eatough, V. (2007). Interpretative phenomenological analysis. In E. Lyons & A. Coyle (Eds.), Analysing qualitative data in Psychology, 51–64. London: Sage. Smith, J. A., & Osborn, M. (2008). Qualitative psychology: A practical guide to research methods. In J. A. Smith (Eds.), Interpretative
phenomenological analysis (2nd ed., pp. 51–80). London: Sage. Starkweather, A. R., & Kardong-Edgren, S. (2008). Diffusion of innovation: Embedding simulation into nursing curricula. International Journal of Nursing Education Scholarship, 5(1), 1–14. Tuoriniemi, P., & Schott-Baer, D. (2008). Implementing a high fidelity simulation program in a community college setting. Nursing Education Perspectives, 29(2), 105–109. Waxman, K. T., Nichols, A. A., O‘Leary-Kelley, C., & Miller, M. (2011). The evolution of a statewide network: The bay area simulation collaborative. Simulation in Healthcare, 6(6), 345–351. Ziv, A., Wolpe, P. R., Small, S. D., & Glick, S.. (2003). Simulationbased medical education: An ethical imperative. Academic Medicine, 78(8), 783–787.
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Karen Livesay*, Karen Lawrence and Clive Miller
Making the Most of Simulated Learning: Understanding and Managing Perceptions Abstract: Increased emphasis on the use of simulation by nursing education providers is evident world-wide. It is unclear what the implications of this initiative are for academic staff within nursing programs. Programs report a range of responses to simulation pedagogy amongst faculty ranging from enthusiasm to avoidance. This study identified a wide range of concerns encapsulating the staff themselves, their concern for students as well as organisational considerations that impact staff perceptions. Methods: Nineteen in-depth, semi-structured interviews were conducted with faculty in a school of nursing and midwifery. Thematic analysis of data was carried out. Results: This study reinforced other earlier research related to staff feelings about the introduction of a simulation program or uptake of existing equipment and facilities. This study reflects the knowledge and experience staff had of simulation and highlights the importance of ensuring all members have a collective frame of reference in order to create shared language and vision. Conclusion: This study adds to the research on staff attitudes to simulation by identifying the preconceived ideas that contribute to idea formation and relates this to the insight and self-efficacy of the faculty members.
has produced more emphasis on this pedagogy. In the Australian context many nursing programs have introduced simulation with the assistance of government incentives for capital equipment and scenario development as well as a nationwide introductory staff development program. The research question this study investigated was “What are the needs and concerns of academics about the requirements to increase the use of simulation in preregistration curricula?” The aim of this study was to understand staff perceptions when adopting simulation pedagogy into a new nursing curriculum. It was vital to consider the attitudes of incumbent academic staff to the use of simulation. Three researchers were involved in this study. All had minimal experience of learning through simulation prior to conducting this study and were faced with the adoption of simulation as a teaching strategy in the curriculum. In this qualitative study, researchers interviewed 19 staff to examine their perceptions of introducing learning through simulation and identify strategies that could be adopted to assist staff. Interviews occurred prior to implementation of learning through simulation. Interpretive Phenomenological Analysis (IPA) was used to examine data (Smith & Eatough, 2007).
Keywords: simulation barriers, resources for simulation, self-efficacy, shared vision, simulation faculty, technology
Literature review DOI 10.1515/ijnes-2013-0098
Learning through simulation is viewed as a valuable tool in the learning and teaching paradigm of health professional education, with many programs historically incorporating medium to high fidelity simulation (Starkweather & Kardong-Edgren, 2008). Increased availability of technology in combination with competition for clinical places *Corresponding author: Karen Livesay, College of Health and Biomedicine, Victoria University, McKechnie St, St Albans, Melbourne, Victoria 3021, Australia, E-mail: [email protected] Karen Lawrence, Clive Miller, College of Health and Biomedicine, Victoria University, McKechnie St, St Albans, Melbourne, Victoria 3021, Australia, E-mail: [email protected], [email protected]
Use of learning through simulation in nursing education has become widespread over the past decade with many programs reporting use of the pedagogy to some extent (Starkweather & Kardong-Edgren, 2008). The literature describes aspects of staff preparation, either on a program basis or widespread across communities of practice that are geographically or discipline related (Seropian, Driggers, Taylor, Gubrud-Howe, & Brady, 2006; Waxman, Nichols, O‘Leary-Kelley, & Miller, 2011).
Staff perceptions Akhtar-Danesh, Baxter, Valaitis, Stanyon, and Sproul (2009) found that academic staff feared judgement by colleagues during simulation scenarios. This fear was founded on a lack of knowledge and concern regarding
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the currency of clinical skills of facilitators that may be exposed in learning through simulation. They recommended that a culture of safety be established to ameliorate the judgement of colleagues to diminish these concerns. A safety culture can be achieved through practices such as rehearsal and agreements of confidentiality regarding performance within simulation scenarios. Moizer, Lean, Towler, and Abbey (2009) found fear of judgement and exposure of sub-optimal facilitation skills was also associated with problems that may arise during simulation. An example was failure of the simulator or technological malfunctions associated with computerised equipment. Moizer et al. (2009) found that academic staff are challenged by dealing with negative responses from students and others about their facilitation during simulation. In their study, Moizer et al. (2009) indicated they would need support in implementing simulation to offset these risks of simulator malfunction or student negativity. In the context of this study, nurse academics are required to teach clinical skills and facilitate learning through simulation. Mackenzie (2009) identified the divide between nurses in higher education and clinical settings. Due to competing demands upon their time, such as administrative duties, teaching, and research, nurse academics are at risk of losing skills for clinical practice. Mackenzie (2009) suggested that the distance from practice in higher education means that these educators are not well placed to teach clinical skills and by extension learning through simulation, where clinical skills are central. Banning (2005) links effective teaching to competence in the knowledge base as well as self-esteem. In pursuing this argument, Clifford (1996), a pioneer in learning through simulation, suggested that academics using simulation must be clinically up to date. More recently Dowie and Phillips (2011) suggest that credibility can be gained through faculty practice and mentoring in simulation by clinically active staff. Jansen, Johnson, Larson, Berry, and Brenner (2009) report that some faculty in their study felt manikin-based simulation was only suitable for courses covering acute care technical skill development.
Student learning The literature reports learning through simulation as a potential solution to the tensions between student learning needs and protection of patients from error and harm (Ziv, Wolpe, Small, & Glick, 2003). In their systematic review of technology-enhanced simulation, Cook et al. (2011) concluded that simulation provided large effects in outcomes of knowledge, skill, and behaviours, with lesser effects for
patient-related outcomes in comparison with no intervention. Gore, Hunt, Parker, and Raines (2011) showed that simulation decreased anxiety levels in junior nursing students prior to clinical practice. They concluded that despite the barriers, cost, and time for production, there were substantial benefits in using simulation as a teaching strategy. Fidelity, referring to the degree of life-likeness within a simulation, is a complex issue. Norman, Dore, and Grierson (2012) concluded that statistically significant advantages of using high fidelity equipment over low fidelity equipment were not apparent. However, factors such as task complexity, transfer of learning, context, and cognitive load might impact learning outcomes. Lapkin and Levett-Jones (2011) similarly identified that medium fidelity manikins “such as Laerdal’s Megacode Kelly™ with Vital Sim capability” (p. 3545) were capable of evoking similar outcomes for student satisfaction, knowledge, and clinical reasoning as high fidelity models. The proposed program of learning through simulation, about which this study was conducted, intended to use medium fidelity simulation techniques.
Resources Many papers have identified common concerns amongst staff regarding resource requirements for integrating learning through simulation into nursing curricula. Adamson’s (2010) study of facilitators and barriers to introducing Human Patient Simulation (HPS) confirmed that time, technical support, training, and hesitancy to try new methods were prevalent. Billings and Halstead (2005) reported similar findings regarding time requirements, while Touriniemi and Schott-Baer (2008) concurred regarding technical assistance resources. The lack of human resources to support simulation is verified as a disadvantage to using HPS, while lack of facilitator training and experience were also recognised as barriers to use (King, Moseley, Hindenlang, & Kuritz, 2008). Appointment of a champion has been identified as a strategy (Jones & Hegge, 2007) to support faculty members with the introduction of simulation. The champion’s role can include planning and developing simulation materials with staff while they gain experience and knowledge. A champion’s role, while not well defined, is concerned with sponsoring a change while being a source of support, knowledge and skill. Guzic et al. (2012) observed the inverse relationship, where the absence of a simulation specialist can have a negative impact on simulator use. When adopting learning through simulation for the first time a champion would
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K. Livesay et al.: Making the Most of Simulated Learning
act as a change agent and assist others to develop skill, knowledge, and confidence. This review of the literature has highlighted the concerns of academic staff about human resources, time allocation, and fear of judgement as issues, while acknowledging the potential for simulation pedagogy enhancing student learning.
Study design Interpretative Phenomenological Analysis (IPA) was used to inform data collection and analysis (Smith & Osborn, 2008). The primary aim of IPA is to carry out a detailed analysis of the unique subjective experiences of the individual and how individuals make sense of these experiences. In IPA, researchers gather qualitative data from research participants, using individual interview techniques (Smith & Osborn, 2008). Interviews are approached from a position of flexible and open-ended inquiry, gaining accounts of richness and depth. This study used in-depth, recorded interviews. According to Kvale (1996), an in-depth interview is a “conversation that has a structure and a purpose” (p. 6). The analyst reflects upon his or her own preconceptions about the data, and attempts to suspend these in order to focus on grasping the experiential world of the research participant. IPA’s hermeneutic stance is one of inquiry and meaning-making and the analyst tries to make sense of the participants’ explanations of their own experiences (Smith & Eatough, 2007). Thus, one might use IPA if one had a research question that aimed to understand what a given experience was like (phenomenology) and how someone made sense of it (interpretation). This form of interviewing was considered particularly appropriate as it focuses on the participant’s perception of self and simulation as a teaching pedagogy. Thus, it was anticipated that the inquiry would facilitate greater understanding of faculty members’ awareness of their perceptions relating to simulation. Following approval through the Human Research Ethics Committee of the University, a convenience sample of 19 nursing and midwifery academics and clinical educators were recruited to take part in the study. Recruitment took place through the School of Nursing and Midwifery. Flyers were placed on key notice boards and all academic staff received a written invitation to take part in the study. All participants were aged 18 years and older and provided voluntary and written consent to participate. Interviewees were clustered into “New to Academia 3 years” and
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“Clinical Educators”. The design of the study did not intentionally set out to cluster interviewees into three groups. Participation in the study was voluntary and it was only after the interviews had concluded that the researchers noted the balance of participants and the categories they fell into. Two researchers undertook the 19 interviews and all three researchers were involved in data analysis. To enhance validity, researchers carefully followed the order of the in-depth interview schedule (Table 1). Table 1: Examples of interview questions. Can you tell me what you understand the term simulation to mean? Can you tell me how you feel about participating in simulation as a facilitator? Can you tell me the benefits, if any, you will derive from using simulation? Can you tell me the drawbacks, if any, you will derive from using simulation? Can you describe the benefits, if any, you think students will derive from participation in simulation? Can you tell me what drawbacks, if any, you perceive with student participation in simulation? Can you tell me about your experiences with using simulation? What staff development do you think would help you facilitate simulation? Is their other help that you would require to facilitate a simulation session? What barriers, if any, do you envisage in the introduction of simulation into the curricula? How do you think these barriers, if any, could be overcome?
Data collection Individual in-depth qualitative interviews were conducted by the researchers. Interviews varied between 45 min and 72 min and were performed at mutually agreed locations. Interview questions were asked and the interviews were digitally recorded then transcribed verbatim.
Analysis The analysis of the data was undertaken in five phases: Phase One: Phase Two: Phase Three: Phase Four: Phase Five:
Reading and annotation of all transcripts Development of interview concepts Development of emerging themes Comparison of emerging themes and development of cluster themes Reduction of data and development of Superordinate themes (Smith & Osborn, 2008, pp. 64–73)
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Transcripts were coded in considerable detail, with the focus shifting back and forth from the key statements of the participant, to the researcher’s interpretation of the meaning of those claims. The analysis was undertaken in five phases. After transcribing the data, the researchers worked closely and intensively with the text, annotating it (“coding”) for insights into the participants’ experience and perspective on their world. From the annotated comments, five interview concepts were identified: feelings about simulation, understanding, students, wants, and barriers (Figure 1). At this phase, the researchers developed a template to assist with the interpretation of the data using the interview concepts as headings. As the analysis developed, the researchers catalogued their emerging themes. Emerging themes were noted as recurring patterns of meaning (ideas, thoughts, and feelings) throughout the text and identified both something that matters to the participants (i.e. an object of concern, topic of some import) and also something of the meaning of that thing, for the participants. All researchers completed their preliminary analysis of the five interview concepts and came together to review and make sense of their individual emerging themes. Once all the data were saturated, emerging themes were identified, and the researchers commenced looking for patterns with an aim to reduce the themes that had similar meaning. Forty one cluster themes emerged. Cluster themes eventually were grouped under much broader codes called “Superordinate Themes” The final set of superordinate themes capture most strongly the respondent’s concerns on simulation.
Findings A summary of the data analysis process can be seen in Figure 2, which provides a list of findings from all five phases of data analysis.
Discussion There were nineteen participants; five of the staff were working concurrently in clinical nursing roles, while the remainder were working in academic roles with little or no clinical contact. Most staff had used simulation or learned with simulation in basic life support programs. None of the staff had studied the pedagogy of learning through simulation. This research found a wide range of concerns relating to staff, their concern for students, as well as organisational considerations. The superordinate themes follow the pattern of previous studies (Adamson, 2010; Billings & Halstead, 2005), although this study adds to previous research by identification of faculty perceptions not previously described. A total of ten themes were identified; however, only four will be presented as part of this report: vulnerability/apprehension, self efficacy, absent shared vision and resources. These themes relate to staff perceptions when adopting simulation pedagogy into a new nursing curriculum. The remaining six themes (formative assessment, contextual doing, safety, improving student learning and fidelity) relate to student learning, and will be discussed in a separate report.
NEEDS/WANTS
UNDERSTANDING
BARRIERS SIMULATION
STUDENTS
FEELINGS
Figure 1: Interview concepts.
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K. Livesay et al.: Making the Most of Simulated Learning
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INTERVIEW CONCEPTS Feelings
Students
Understanding
Needs/Wants
Barriers
EMERGNG THEMES Over 100 emerging themes identified by the three researchers
CLUSTER THEMES Optimism, Pessimism, Measurement, Staff development, Reflection, Clinical readiness, Fidelity, Psychomotor, Division of labour, Internal reasons, Workload recognition, Self efficacy, Reflective practice, Evidenced based practice, Fear, Vulnerability, Reality, Confronting, Preparation for practice, Role playing, Clinical currency, adequate time, Skilled simulation team, Cost, Preparation, Time, Everybody on board, Without risk (to people), Psychomotor skills, Real world/life, Not real life, Feeling vulnerable, Increase confidence, Support staff, Need staff development, Takes time, Hands on, Faculty practice, Peer review, Student Participation Debriefing SUPERORDINATE THEMES Vulnerability/Apprehension, Self efficacy, Shared vision, Resources (Human, Physical, Internal, External) Formative assessment, Contextual doing, Safety, Improving student learning, Fidelity Figure 2: Data analysis process.
Vulnerability/apprehension In the opinion of participants, findings revealed that simulated environments can be stressful for students and staff. Concern for the stress induced in students by simulation was not compared with stressors in the clinical environment by any participant. In clinical practicums, stress was viewed as inevitable and performance was viewed as private, while students undertake practice with minimal peer observation. Overlooking the stress students feel when unprepared in clinical environments showed staff acceptance of performance stress in other settings. But we have to acknowledge how confrontational and stressful this is for the student. The thing that I think might show us some problems is that the students who are not processing and synthesizing the information as quickly as others will be very obvious
Staff were concerned about students’ inability to tolerate feedback provided verbally and immediately after a simulation as part of a structured debriefing. This staff concern demonstrated naivety of the recommended format and process of simulation debriefing. I think that it’s going to be trial and error you’re not going to know what you don’t know until it happens.
The staff concern for students’ reaction to debriefing in the simulation setting overlooks that students undertaking clinical experience are given feedback. Some clinical staff and facilitators may be inexperienced in the process of providing feedback. Additionally, in the clinical paradigm the feedback may be summative and high stakes for its impact on progression in the program yet structured formative feedback in simulation was regarded as difficult for students to tolerate. So I think that can be one of the problems of simulation particularly when you’re doing it in front of a group of students that when the students themselves are doing it and a student does something wrong you’re obliged to say there and then that it’s wrong and some students can take that well and some students not so well.
While the issue of the simulated experience giving rise to anxiety itself was identified by many participants, the idea that a student may experience the same anxiety in practice was not mentioned. The possibility that practice in simulation may reduce levels of anxiety in clinical settings (Gore et al., 2011) and equally the value students attribute to peer learning was not identified (Sinclair & Ferguson, 2009). While we can see the pedagogical benefits, it can be so stressful for them that they don’t gain anything educationally because they are so stressed
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Most of the literature regarding staff reluctance to work in simulation describes time constraints and resource implications (Adamson, 2010; Starkweather & Kardong-Edgren, 2008), whereas this study produced repeated suggestions of personal apprehension and concern. In some instances staff linked into concern for student vulnerability, by expressing their own vulnerability. This concern for student stress may have been for some staff a projection of their own feelings. Even those participants who would be considered enthusiasts or early adopters of the move to simulation responded with comments related to anxiety.
self-efficacy related to clinical currency indicated a narrow focus dealing with minutiae of task and procedure.
Nervous because I suppose I’ve never been involved in anything like that before
This narrow vision of simulation overlooked areas such as communication, team work, human factors and cultural competence which could be argued to be less dependent upon clinical detail, technological specificity or procedural currency. It also exposed the view that participants considered only simulation in acute inpatient environments, as opposed to the range of settings within which our students would be prepared for practice, reflecting the attitudes of faculty reported by Jansen et al. (2009).
I’d have to admit feeling very nervous about that at the moment, because I have no experience really of working in that kind of setting. But on the other hand I am a fairly experienced educator
This frank disclosure positions participants honestly in a change process. This disclosure demonstrates that, despite their willingness to attempt the adoption of new pedagogy, it gives rise to anxiety. Learning through simulation overlaps the classroom and the clinical setting and feelings of vulnerability were demonstrated from both the academic staff and the clinical teachers. It is possible that the real source of discomfort was the duel requirements of teaching skill and clinical skill where staff identified more strongly with one area over the other. While the convenience sample of participants used may be skewed to those more favourable about simulation, this suggests further research related to the attitudes of those resisting the use of simulation could be enlightening.
Self-efficacy Self-efficacy is described as a belief in one’s ability to engage in particular activities based on the likelihood of success (Sinclair & Ferguson, 2009). Self-efficacy was linked strongly by several participants to clinical currency and credibility. Clinical currency is a phrase that describes clinical competency as well as familiarity with up-to-date protocols and operating procedures (Owen, Ferguson, & Baguley, 2005). Self-efficacy ties closely to the position of Dowie and Phillips (2011) that current clinical expertise is a prerequisite for successful simulation. This insight into participant’s view of themselves and other academic faculty illuminated the divide experienced between the academics and clinical staff (Mackenzie, 2009). The
I think they need to be very up with, and current with their knowledge base, and maybe potentially having actually done some acute work. For nurses, if we’re talking about simulation, we really need to be dealing with people who are fairly skilled up in clinical practice. Not just currency of practice in terms of the hands on clinical stuff but currency of knowledge about current systems of health care delivery, current systems of patient care, hospital wards.
Absence of shared vision Although shared vision was identified amongst participants as a necessary attribute, it was related to understanding of what would or could be done in simulation. Having everybody on board, everybody believing the same thing. So if we all had a similar definition and a similar idea about the outcomes. A similar sort of acceptance, we all have to be enthusiastic for it to work.
When defining their understanding of simulation, all participants provided examples of procedures and tasks related to acute skills and inpatient emergencies. Participants used different language to describe simulation activities and had a wide ranging level of experience and interest in simulation. Written scenarios, written problems that are sort of meant to represent reality. I would say it’s [simulation] the physical act of demonstrating something. I would define simulation as an attempt to create a situation that is as close as possible to an actually clinical situation.
Staff envisioned simulation usage and implementation differently from the possibilities described in the literature
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K. Livesay et al.: Making the Most of Simulated Learning
and held as best practice. Some considered the issues of large groups observing a simulation, while all considered psychomotor skill development, Having people that watch, giving them that choice, those that don’t want to play, to be spectators and learn vicariously. They’ll be able to practise their psychomotor skills, their actual motor skills, and yeah a less threatening environment too because they’re not actually with a real person.
No-one talked of communication skills, teamwork, or situational awareness being developed through simulation. What became apparent was that a disparate group of academic faculty were to be called together to implement learning through simulation without a shared vision The researchers felt this theme helped explain the lack of efficacy that had been identified and the desire for external assistance and potentially even the lack of suggested solutions for issues identified during interviews. This was a significant finding and again the extent of the differing vision was unanticipated given the available literature and immersion in pedagogy that had been undertaken at the time of the study. It did however demonstrate the efficacy of immersion and the need for more significant staff development and practice.
Resources Participants raised concern about staff training, scenario development, equipment and resources such as adequate space and support from experienced staff. Staff were concerned with their capacity to design and implement simulation scenarios. I was talking about the equipment, facilities and personnel and education for me in how to and time, needing time to do this. I suppose just having access to somebody, be it like in person or phone and I would say that the smaller group is the main thing, having a smaller group or two facilitators
A number of factors occurred that addressed these concerns. To overcome staff concerns regarding space adequacy, an internal university grant was sought and gained. This grant enabled the pre-existing nursing skills laboratories to be refitted with technical and simulation equipment creating a purposeful simulated learning environment. Creative issues and those that could be approached flexibly such as “stage dressing” environments for different nursing scenarios were not addressed by the responding participants. The participants thinking reflects
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again the preference to stay with the familiar and may link to the two themes of self-efficacy and shared vision. Staff also viewed time as a potential concern of using simulation. A summary of staff concerns around resources can be seen in Table 2. Table 2: Staff concerns relating to resources. Human
Physical
Internal
External
Lack of preparation
Not having dedicated space.
Not enough time to prepare
Not cost efficient
Not enough time to practice Timetable issues
Not enough equipment
Need for spaces Concern around current resembling different nursing contexts skill level
Moizer et al. (2009) and others suggest support particularly with technological requirements of simulation. Similarly Jones and Hegge (2007) identified that this support should come from an experienced simulation champion. The participants interviewed in this study had concerns for their own ability to develop simulation scenarios. The participants sought the possibility of recruiting others to undertake the development tasks. Participants suggested external expertise was needed to demonstrate and share creativity and innovative use of simulation. Perhaps get some experienced people in to demonstrate the particular things that they have used it for and some creative and innovative ways Writing up simulation scenarios, things like that, we need more practice
Given the depth and breadth of experience of many of the participants, this outcome was unanticipated. Starkweather and Kardong-Edgren (2008) describe the experienced simulation researcher as the spark that ignited interest but note that the champion was an established faculty member. Jeffries (2008) adds that in some programs key staff are groomed as champions to support and empower those who follow.
Recommendations As many of the insights perceived by participants in this study were congruent with those previously documented in the literature, it was anticipated that the recommendations from those studies would be recognised and implemented.
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Where possible these recommendations were incorporated; however, a local study was thought to be helpful to identify specific concerns in this context. Awareness of staff perceptions would enable implementation of strategies to address those specific perceptions gained through this study. It also enabled development of custom-made strategic directions by the research team. Five key recommendations were derived from the research which, although specific to this program, have utility for other programs commencing simulation or in which faculty resistance to simulation is apparent. These are:
Staff preparation to manage perceptions 1.
Design an education orientation program that is accessible to all staff. Competency in this program must be achieved prior to simulation facilitation.
Some orientation to simulation had been undertaken through presentations, staff contribution to planning the physical environment development, and education related to simulation equipment at the time the research was conducted. This preparation was seen to be inadequate for staff to move into a change paradigm. The diversity of ideas could not be seized and used for development purposes while it was contributing to a discord of thought and planning. 2.
Ensure staff participate in practice simulations as learners and facilitators
A structured introductory education program that introduces key concepts and provides examples of use and early practice in technological aspects, such as running a manikin, devising a basic scenario and structured debrief should be the starting point. In Australia the Federal Government through the agency of Health Workforce Australia has recognised the need for this level of education and has developed and funded a program called the National Health Education and Training in Simulation (NHET-Sim) program. This program would be the recommended entry point for Australian teachers, but the authors would add the proviso of local level orientation in respect to policies and differences in program management and support at the institutional level.
Student learning 3.
Implement policies and procedures related to performance in simulation for both staff and students that specifically actions and describes mechanisms to
provide psychological safety or protection and make these overt through publication to staff and students Utilising staff as learners as well as facilitators in the development phase of the simulation program has multiple benefits. Staff members begin to develop experience and have an avenue to build on the NHET-Sim introductory program. Experiencing apprehension in the simulation would enable participants to confront the anxiety and begin to recognise the risks and benefits of activation while learning.
Resources 4.
Appoint a Simulation Coordinator to assist with the design and development of scenarios.
In order to increase emphasis on simulation significant change was required. Staff identified the need to develop new teaching and learning skills and new curricular supports. For example, scenarios needed to be constructed, tested, and validated. During a change process, a simulation coordinator can undertake the development workload and alleviate some concerns for staff time requirements. Additionally the simulation coordinator can act as a change agent and assist others to adopt new behaviours. Further, to avoid the potential negative impacts on simulator use, Guzic et al. (2012) support the appointment of a simulation champion or coordinator. Familiarity with expectations in simulation via policy and procedure development will help to create an overtly safe environment for students to dispel anxiety and vulnerability. The simulation coordinator is well positioned to develop policies and procedures. A safe environment will be established by ensuring confidentiality relating to student performance in simulation, debriefing, and deroleing and follow up of participants as required. Procedures that demonstrate the elements of best practice, identified through bench marking and utilization of research evidence, exhibit adherence with preconceived standards. Development and dissemination of procedures educates the staff and enables confidence with authority. 5.
Develop and disseminate a business plan that addresses funding sources, workload, and sustainability and support services.
Written policies and procedures will have the added advantage of creating a formalised plan for simulation utilisation. This plan enables staff to envision the breadth
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K. Livesay et al.: Making the Most of Simulated Learning
of simulation methodologies within the confines set out for the program and encourage a shared vision. While stand-alone simulation centres often develop business plans to document cost recovery or profit projections, our experience in higher education settings is different. In this University, with little or no external usage of the simulation facilities, the running and management becomes subsumed into the overall program budget. Without a separate budget or business plan, workload or support services are not specifically addressed and become part of teaching requirements. A business plan would have the advantage of making overt the financial and human resources committed to learning through simulation rather than incorporating them into a larger teaching and learning budget. Delineating resource provision in this way segments the resources provided for simulation. Staff overtly identify the provision of resources additional to those subsumed in everyday practice. Management support is additionally demonstrated through sign off on a specific business plan. Recommendations propose to help staff identify how they can utilise a range of simulation techniques for formative learning and teaching, employing agreed principles that support staff and students within a course.
Study limitations/conclusion The findings may have been biased in that staff with a strong interest in simulation participated, while those with less interest did not. The findings may not be generalizable to other education settings. Those who chose not to participate in the research may have held different ideas and concerns. However 67% of the staff was interviewed, providing a substantial representation of staff views at the time. This study reinforced previous research related to barriers to introduction of a simulation program or uptake of existing equipment and facilities, (Adamson, 2010). The attitudes and ideas that staff held at the early stage of the simulation implementation process were illuminated. These ideas and perceptions appeared strongly linked to the level of understanding of simulation methodology and could be a barrier or an enabler to simulation introduction. In particular, absence of a shared vision, coupled with diminished self-efficacy, and concern for student and staff psychological safety, as well as adequate resourcing of the program were identified as barriers to simulation in this study. Five recommendations were produced that could become the subject of further research.
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