Perioperative simulation learning and post-registration development.

Perioperative simulation learning and post-registration development Abstract

Competence to practise in the perioperative environment requires specialist knowledge (Gillespie and Hamlin, 2009). Newly qualified staff in this environment can experience difficulty in making the transition into practice (Stratton, 2011) and often feel overwhelmed by the skills required (Callaghan, 2010). Simulation-based learning techniques are increasingly used by practice educators specifically within these environments (Cato and Murray, 2010) to aid with acquisition of skills, emergency care delivery, general post-registration development and also as a standardised indicator of ‘competence’ (Bullock et al, 2008; Cato and Murray, 2010). This article will consider the impact of this educational strategy on the learner’s lifelong development following registration, and its position in relation to the widely accepted learning paradigms of Benner’s ‘Novice to Expert’ and Maslow’s ‘Hierarchy of Needs’. Through discussion of the nature of education in the practice setting, the reader will be prompted to reconsider the actual value of simulation-based learning in the postregistration arena and how this may be used to redefine simulation in the clinical setting. Key words: Simulation-based learning ■ Learning strategies ■ Practice education ■ Perioperative environment ■ Benner ■ Maslow

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t is not always possible to expose learners to common critical situations, yet new nurses are expected to ‘hit the ground running’, prioritising, managing and following protocol as a minimum (Murphy et al, 2011). Simulationbased learning with clinical scenarios is now part of both undergraduate and postgraduate nurse education (Harder, 2010). It aims to provide the individual with the opportunity to experience as close to ‘real-life’ situations as possible, so that established behaviours and procedures can be transferred into the clinical area (Quinn and Hughes, 2007). It includes a vast array of techniques such as high-technology computerised patient feedback systems, case studies, role play and actors (Moule et al, 2008). Learners and educators alike perceive simulation-based learning to be a valuable tool and an effective method for increasing patient safety (Baillie and Curzio, 2009; McCaughey and Traynor, 2010).

Jessica Inch is Practice Development Nurse, Elective Orthopaedic Centre, Epsom, and a postgraduate student at the University of Surrey Accepted for publication: October 2013

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The perioperative environment can be a fast-paced, critical care-based arena leaving no room for delay in the management of the patient requiring emergency care (Jones, 2010). Learning must never be at the cost of patient safety and must always take place in a safe environment (Nursing and Midwifery Council) (NMC), 2008: 27). The assessment of vital life-saving skills therefore lends itself to a simulated environment in the clinical setting (Cato and Murray, 2010). Learning theory should always be used to support the process of simulation (Kaakinen and Arwood, 2009). Referred to as the ‘Simulation Learning Pyramid’ (Figure 1), it is proposed that by combining and following the steps of planning, simulating, and debriefing, transference into the clinical environment will take place (Doerr and Murray, 2008). Planning is indeed fundamental (International Nursing Association for Clinical Simulation (INACSL), 2011) and the educator must evaluate the proposed purpose of the simulation. Kaakinen and Arwood (2009) suggest that if the aim is to change behaviour specifically in the affective domains, design must be aimed at changes in beliefs, attitudes and values. If it is to concentrate on accurate skill reinforcement, the psychomotor domain must be the focus. The overall success of simulation is determined by the debriefing aspect (Doerr and Murray, 2008; Miller et al, 2008; Moule, 2011). This can include many techniques from reflective discussion to video playback. It is here that the learner must have correct behaviours reinforced and those that are undesirable ‘corrected’, so as to inhibit transference into practice (Doerr and Murray, 2008). With simulation, its approach is often considered pedagogical in nature and educator- or patient-centered as opposed to learner-centered (Elfrink et al, 2010; Murphy et al, 2011). According to Dreifuerst (2009), the value of the debriefing within the simulation lies within the learner’s ability to engage in reflection. This approach is considered to lead the individual towards ‘high-order’ critical thinking and, in turn, the synthesis of skills (Liaw et al, 2009). If simulation is to facilitate learning effectively, it must be of a design that encourages the learner in the principles of adult learning (Knowles, 1990, cited in Quinn and Hughes, 2007) and ‘active reflection’ (Gentile, 2012). It is therefore imperative that the educator adopts a ’facilitator’ role when implementing this strategy (Dreifuerst, 2009), as opposed to that of the ‘instructor’, and encourages the qualified nurse in the art of ‘thinking aloud’. However, there is little instruction available to guide educators in debriefing during simulation. Despite offering a clear framework for simulation that emphasises the debriefing aspect as the heart of

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Jessica Inch

British Journal of Nursing, 2013, Vol 22, No 20

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education simulation, the Pyramid of Simulation (Figure 1) is indeed an oversimplification of a strategy for which there exists much empirical evidence suggesting that skills learnt in simulation are not necessarily transferred to the clinical arena (Murray et al, 2008; NMC, 2010a; Norman, 2012). Neither does it necessarily lead to increased patient safety (Galloway, 2009). This casts doubt on simulation’s true purpose as a strategy and its effects on the learner. Irrespective of the empirical evidence, studies still report that simulation bridges the ‘theory-practice’ gap and lends understanding to skill acquisition (Ravert, 2008; Davis et al, 2009). Use of learning theory in relation to simulation is not a new concept (Spring, 2010; INACSL, 2011). The need for robust assessment of learning in the nursing field has led to a vested interest in the Dreyfus model of skill acquisition (Dreyfus and Dreyfus, 1986, cited in Dreyfus, 2004: 177). In her seminal, qualitative work, Benner (2001) proposed the development levels of the nurse involved in this model as ‘novice’ through to ‘expert’ (Figure 2). This is often applied to learning strategies and development programmes in a variety of ways (Gentile, 2012) and proposes interesting questions about how simulation may fit into development. Benner implores that the ‘novice’ be given ‘entry’ to the situation or skill to be learnt, and the opportunity to ‘experience’ it (Benner, 2001; Ricketts, 2011). This is not always appropriate in light of ethical considerations, and simulation gives the educator a vital tool that provides a ‘safe entry point’ for every individual not yet accustomed to the perioperative scenario (NMC, 2008; Callaghan, 2010). Literature suggests that simulation is often approached from a teaching model, as opposed to a learning model, leading to less of a student-centered activity (Berragan, 2011). This pedagogical approach can be of benefit to the content delivery and knowledge transfer (Murphy et al, 2011) needed for the ‘novice’ in a basic simulation scenario. Moving on to Benner’s ‘advanced beginner’, this learner is said to require guidelines or cues from the educator at this stage, which enable the learner to recognise aspects of the situation. These aspects are features that build on the rules learnt by the novice and require experience of the circumstances surrounding the situation to be learnt (Benner, 2001). Even though the educator may provide guidelines (elements not necessarily requiring experience) in simulation, the student still needs to recognise what these aspects sound, look and feel like. For example, a simulation for recognition and treatment of the patient with postoperative laryngospasm may include guidelines of the highly characteristic ‘crowing’ noise emitted by the laryngeal chords in spasm (Hatfield and Tronson, 2009: 263). The student may learn the treatment course, but only true experience of the symptoms in the clinical setting will allow full transference of that skill. This is where our basic simulation scenario starts to wane in its application. There exists a danger that it may be a temptation to consider simulation a suitable substitute for real experience in the qualified practitioner. Full exposure to the clinical setting is integral to the nurse, no matter how newly qualified or inexperienced in the area, and simulation must be in conjunction with all real learning environments and clinical emergencies within them (Newton et al, 2010). This


Transference

Debriefing

Simulation

Simulator plan

Figure 1. The Simulation Learning Pyramid Source: Doerr and Murray, 2008, cited in Kyle and Murray, 2008: 773

is indeed true for the nurses who need to start incorporating these ‘guidelines’ into their knowledge base. These nurses require great levels of support from the educator and wider nursing team, as they cannot necessarily prioritise care and are only just starting to observe the recurring patterns in what they are learning (Carraccio et al, 2008). Once we apply simulation to the ‘competent’ nurse, we are already seeing an individual who, through experience, is starting to adapt the rules learnt, and would benefit from scenarios that incorporate coordination, planning and decision-making in the clinical area (Benner, 2001). Benner asserts that the ‘proficient’ nurse will benefit from case studies that are enhanced when the student can cite experience to share with others. This learner may get frustrated with simple simulations that focus on the objective rules or procedures and will identify instances where the ‘real clinical environment’ experience contraindicates what they have witnessed in simulation (Benner, 2001). This individual is starting to combine processes and subtle differences presented. We can identify this practitioner as the one who is able to highlight the deterioration of the perioperative patient before the simulation makes it explicit, or indeed the risk factors increasing the risk of laryngospasm before the patient presents symptoms. If we are to apply simulation to Benner’s interpretation of Dreyfus model at this level, practice educators should take a constructivist approach to this strategy. Simulation should be planned ‘inductively’, exploring the situation until the practitioner exhausts their resources, and use that stance as a jumping-off point. The educator must be flexible and able to incorporate complex case studies and role play into the scenario (Campbell, 2012). They must be able to judge whether it will be advantageous to include ‘irrelevant’ details along with a degree of ambivalence, in order to provoke transitions between levels and combine knowledge and experience (Benner, 2004). This may be done by the ‘expert’ simulator educator that can combine a multitude of approaches. So it seems that simulation, in relation to Benner’s paradigm, is limited by the need for experience very early on

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Expert: Does not rely on rules, guidelines and breaks them if necessary. Has an intuitive grasp of situation. Is aware of the larger system and is goal-orientated. Views the outcome as a continuing creative process.

Proficient: Combines processes unconsciously. Takes into consideration a large range of experiences and creates own ‘rules’ from these. Outcomes are ‘long-term’-orientated. ‘System’-orientated. Competent: Adapts ‘guidelines’ and is able to respond to unexpected elements. Experience from similar situations with complexities. Is system-orientated. Advanced beginner: Demonstrates ‘acceptable’ performance level. Aware of meaningful situational components. Requires past experience in the actual situation. Novice: No experience of the situation. Taught objective attributes with context-free rules to guide action. ‘Rules’ are measurable attributes of the skill, stripped down to its core maxims.

Figure 2. Benner’s interpretation of the Dreyfus model: From ‘novice’ to ‘expert’ Source: Adapted from Benner, 2004

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‘advanced beginner’ level before experience is needed to prompt synthesis. It must be considered that the learner may not yet have acquired sufficient experience of those procedures or cases to begin synthesis. As a development strategy, experience is vital to the equation and will illuminate the way to further knowledge and evaluation of it.The expert is reported to use intuition, which can only be cultivated alongside experiential exposure (Benner, 2001). The educator must see simulation as a fragment of a larger journey for the student, evolving in part, and providing scaffolding for further learning (Figure 3). It must be remembered that the Novice-to-Expert model is not intended to be static, and one may step on and off at any point. As the learner progresses, or needs change, the aims, objectives and complexities of simulation must change as well, advancing the learner to positions requiring synthesis and evaluation to combine past and present experience (Chmil, 2009). Although synthesis and evaluation are desirable for the registered nurse, we must be individualistic in our approach. Once problem-solving, prioritising and teamwork are integrated into a scenario, the individual is likely to take an increased responsibility for their own learning, be selfgoverning and develop a greater attitude towards lifelong learning in a profession that demands it (Savin-Baden and Wilkie, 2004, cited in Murphy et al, 2011: 142). Once again, these require extensive experience to synthesise correctly and therefore vital requirements for the developing qualified nurse. Complexity is not necessarily an impossibility for the educator in the clinical environment. Technological advances in this area can be significant, with Benner et al (2010) believing that complex high-fidelity simulators can facilitate practitioners to learn from ‘patient’ response and outcomes. Yet, with complexity comes greater cost, as well as greater demands on the clinical educator’s time regarding planning and training for the multifaceted simulation (Moule, 2011). The focus of this article does not allow a full critique of Benner’s interpretation, but we must consider those who maintain that her definitions of the ‘levels’ remain unclear, making them difficult to strive for and difficult to attain ‘expert’ level (Lyneham et al, 2008; Peña, 2010). However, when applied to the use of simulation, the levels seem to fit comfortably into easily measurable factors, aiding the educator in facilitating a progression of learning. One may also consider that when referring to the ‘novice’, Benner discounts ‘experience’ that the newly qualified nurse or nurse new to the perioperative area brings to the table from previous training. This does not allow for the synthesis of previous building blocks and asserts that the novice is starting anew (Gladstone, 2012). Simulation is reportedly vital for non-technical skills such as communication and professional team working (Arundell and Coiffi, 2005; Miller et al, 2008) with self-confidence and perceived competence at last proving statistically significant (Scherer et al, 2007). When considering simulation at its most basic, it is the manufacturing of a safe environment with riskfree opportunities, linked to the reduction of stress on the learner (Rothgeb, 2008; Ricketts, 2011). Although interaction within the simulation itself can be nerve-wracking for the individual (McCaughey and Traynor, 2010), small degrees


in the learner’s journey. Norman (2012) defends simulation as a creation of an environment conducive to experiential learning and it is claimed that the Pyramid of Simulation directly corresponds with Kolb’s theory of experiential learning (Kolb et al, 1974, cited in Dreifuerst, 2009: 110). This is defended by the guaranteed event that ignites the process of learning (Doerr and Murray, 2008). However, by applying Benner’s interpretation of the Dreyfus model, it could be considered a mere crutch for those golden-ticket opportunities that allow progression to levels surrounding the ‘proficient’ learner. Waldner and Olson (2007) suggest that it is these discrepancies within past experiences outside simulation that are responsible for differing development levels within the scenario. If we take a contingency-theory approach, educators must realise that evaluating learning is a multifaceted process involving many contextual factors that must be taken into consideration (Reeves, 2001). Research regarding contingency theory in education is sparse, but Goodnow (1982) suggested that educators refrain from worrying over strategy and accept that any strategy is contingent on the circumstances involved. On this premise, simulation must never be used in isolation in the belief that it replaces experiential learning in any form. It can be argued that simulation in relation to long-term development will only take the learner up to Benner’s



Novice to expert paradigm

Simulation strategy

Proficient

Competent

Advanced beginner

Novice

Experiential value

Expert Scenarios of increasing complexity that include ambivalent details and allow the learner to build on the shared experiences Simulation offers coordination, planning, decision-making and case studies from clinical area

Simulation that offers ‘guidelines’ or ‘cues’

Simulation that provides the context-free ‘rules’

Figure 3. Simulation and the concept of experience within the ‘Novice to Expert’ taxonomy (Adapted from Benner, 2001)

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be suggested that all is not lost in terms of transition of certain behaviours, more so it seems in relation to communication; with role modeling acting as a conduit state of encouragement by inspiring nurses to improve upon their ‘professional’ traits (Campbell, 2012). This way, the learner is further immersed in the complexities of nursing as a whole (Scholes, 2008). From this, we can infer that simulation can guide the nurse to high levels of professional socialisation within the Noviceto-Expert model. It may be implied that the clinical educator has a duty to run simulation scenarios with multi-level nurses, resisting the urge to run preceptorship-only simulations to emphasise the above advantage, while also preparing for differing rates of learning within one simulation (Moule, 2011). Perceptions of confidence and self-efficacy shape one’s overall coping mechanisms, sustainability of effort when faced with hindrances and vulnerability to emotional distress (Bandura, 1997). It is attention to the heightened sense of anxiety in learners which supports success in future learning and retention of staff in the long term (Moscaritolo, 2009). The use of simulation as a strategy could initially be viewed as an ‘empirical evidence versus rationalism’ debate with more research needed regarding whether it is an indicator of safe practice in the clinical setting. Although transference of skills is debated, the learner benefits from a secure environment that builds confidence and promotes reflection in new skills. Although it is referred to as a pedagogical strategy, its benefits lie within its promotion as an adult-learning approach. Therefore, attention should shift away from what simulation can offer for the individual’s skills set to the social experience it gives. If we are to accept and apply the Novice-to-Expert ladder, simulation must be flexible in its approach, incorporating role-play and experiential case studies to meet the advancing needs of the developing registered nurse. However, it may have limited scope for the newly registered nurse with little experience of the perioperative environment to start ‘connecting the dots’. Nonetheless, it provides a robust mechanism for measuring competence in the new environment.

Conclusion It becomes apparent that the educator using simulation is doing so for more than just the measurement or transference of a particular skill or of competence. If planned and debriefed to a high standard, it has the potential to leave its footprint on conceptual knowledge, self-efficacy, confidence and active reflection in situational learning from registration onwards. But is it enough for the modern educator to be satisfied with an increase in confidence, so that nurses may apply knowledge and skill, without distraction in the ‘removed’ environment that does not promise transference? After all, the clinical environment is only set to get busier with increased severity of illness and a dwindling nursing force resulting in an increased workload for both nurse and educator alike. Clinical learning opportunities may dwindle as pressures take hold, leading to an increased need of simulation in the practice setting to aid development. Simulation’s real value lies behind the rapport between


of psychological stress pertaining to clinical situations can motivate and enhance performance (Moscaritolo, 2009), but the educator must be sensitive to the signs of performanceavoidance within the simulation, as these are indications of levels not conducive to optimum learning (Harder, 2010). Although simulation for the developing nurse does not entirely fit comfortably into Benner’s Novice-to-Expert model, the application of Maslow’s pivotal Hierarchy of Needs (Maslow, 1971) is evident. This suggests that in order for the individual to ‘self-actualise’ or reach their potential, certain needs must first be satisfied. In Maslow’s theory, providing that the preceding needs are met, an environment that does not threaten security or confidence in terms of both physical setting and group dynamic is vital for learning to take place (Figure 4). This theory was expanded upon in terms of psychological functioning in Bandura’s (1997) social cognitive theory, with the concept of self-efficacy; confidence in one’s own ability to enact a given behaviour (Campbell, 2012). A key component in enhancing a learner’s self-efficacy is vicarious experience; the idea that experience can be provided in a multitude of ways, more specifically through observation of behaviour (Campbell, 2012). The benefit of simulation in part is the emphasis on rolemodeling and reciprocal learning between the ‘novice’ and ‘expert’; be it either through the practice educator, or indeed the more experienced nurse also taking part in the simulation. This is also referred to as a pedagogical demonstration of the ‘expert’ at work (Lambton, 2008). Could this be a way of gaining a true experiential component of simulation? It may



education ‘novice’ and ‘expert’, in conjunction with constant feedback, positive and negative reinforcement, and constructive probing of high-order thinking in the registered nurse. However, it must be promoted as such, with all educators fully aware of its shortcomings in the absence of experiential impact. Simulation provides a springboard for learning by providing confidence in a situation, not the experience of it. Attention must be paid to its promotion and development of confident, reflective practitioners requiring lifelong learning in a media BJN age so critical of the ‘nurse of today’.


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Key points n

The use of simulation-based learning (SBL) in the clinical environment is essential to post-registration development

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There are limitations to SBL as a strategy for the wider development of the post-registration learner

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Benner’s ‘Novice-to-Expert’ model may be used to highlight SBL’s limitations as a strategy in relation to long-term development

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The application of Maslow’s Hierarchy of Needs highlights the benefits of SBL as a social experience

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Selfactualisation

Esteem

Social

Safety

Physiological

Figure 4. Maslow’s ‘Hierarachy of Needs’ (Adapted from Maslow, 1971)

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Nelson Thornes, London Ravert P (2008) Patient simulator sessions and critical thinking. J Nurs Educ 47(12): 557-62 Reeves S (2001) A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems. J Psychiatr Ment Health Nurs 8(6): 533-42 Ricketts B (2011) The role of simulation for learning within pre-registration nursing education - a literature review. Nurse Educ Today 31(7): 650-4 Rothgeb MK (2008) Creating a nursing simulation laboratory: a literature review. J Nurs Educ 47(11): 489-95 Scherer YK, Bruce SA, Runkawatt V (2007) A comparison of clinical simulation and case study presentation on nurse practitioner students’ knowledge and confidence in managing cardiac event. International Journal of Nursing Education Scholarship 4(1): 1-14 Scholes J (2008) Coping with the professional identity crisis: is building resilience the answer? Int J Nurs Stud 45(7): 975-8 Spring H (2010) Theories of learning: models of good practice for evidencebased information skills teaching. Health Info Libr J 27(4): 327-31 Stratton MD (2011) Helping novice perioperative nurses survive and thrive. AORN J 93(4): 425-6 Waldner MH, Olson JK (2007) Taking the patient to the classroom: applying theoretical frameworks to simulation in nursing education. Int J Nurs Educ Scholarsh 4: Article 18. Epub.

LETTER TO THE EDITOR

Medical simulation with a twist Neel Sharma wrote in to BJN about the importance of medical simulation opportunities for nurses.

Dear Editor,

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ndergraduate and postgraduate training instructors have been quick to recognise that adequate patient exposure is key to gaining experience in the assessment and management of an array of illnesses. The difficulty lies in the ability to gain exposure to such illnesses and finding patients and, of course, senior doctors willing enough to allow students and trainees to dive right in. Mannequin-based simulation has been regarded as a possible solution and evidence in the literature speaks highly of its role in effective replication of clinical scenarios as well as its place in assessment and feedback. During simulation sessions I have attended and delivered, I realised something that’s clearly lacking. For example, a session I

undertook involved me demonstrating my competence in the management of a gastrointestinal bleed after being called by a nursing staff member who noticed new onset peri-rectal bleeding. And a session I helped deliver involved medical students managing a patient with COPD after the nurse had noted a drop in oxygen sats. What we fail to appreciate in such interprofessional learning domains is that surely our nurses should be learning too. After all, they are our guardians of the ward, monitoring patient progress around the clock. And when it may prove difficult to attend to a critically unwell patient straight away, they are left to struggle. I feel we have a duty to educate our nursing colleagues as well and simply not view them as our loyal messengers. After all anyone who is equipped with knowledge of human physiology and illness

can easily undertake an ‘ABC’ assessment and instigate some form of initial treatment with the appropriate training. Many doctors view nurses as their inferiors, but the reality is, they are our ears and eyes in the workplace. We should therefore take it upon ourselves to switch simulation on its head and allow them to also dive right in. After all, health care shouldn’t be about our professional insecurities but rather about the patient lying in front of us.

Neel Sharma Honorary Clinical Lecturer, Centre for Medical Education, Barts and the London School of Medicine and Dentistry

Would you like to share an opinion about a nursing issue or an article published in the BJN? Send it to [email protected] with the subject line ‘Letter to the Editor’ and see your letter in an upcoming issue.

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