THE BENEFITS and CHALLENGES of
HEALTHCARE SIMULATION STANDARDS in PHYSICAL THERAPY EDUCATION
GUIDELINES FOR SIMULATION
JoAnn Moriarty-Baron, PT, DPT
FADavis.com
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CONTENTS
CONTENTS................................................................................................................................................... 1
INTRODUCTION............................................................................................................................................ 2
WHAT IS SIMULATION? ................................................................................................................................. 2
THE BENEFITS .............................................................................................................................................. 2
THE BARRIERS .............................................................................................................................................. 3
THE GUIDELINES............................................................................................................................................ 3
The Professional Development Standard ..........................................................................................................................4
The Prebriefing Standard....................................................................................................................................................4
The Simulation Design........................................................................................................................................................7
Facilitation .......................................................................................................................................................................10
The Debriefing Process .....................................................................................................................................................12
The Operations Standard..................................................................................................................................................13
Learning Outcomes and Objectives .................................................................................................................................15
Professional Integrity.......................................................................................................................................................16
Interprofessional Simulation............................................................................................................................................17
Evaluation of Learning and Performance................................................................................................... 19
APPENDICES ............................................................................................................................................... 20
Table 1. Key Terms and General Concepts in Simulation ......................................................................................20
Table 2. Key Terms Pertaining to Simulation Tools ...............................................................................................24
Table 3. Key terms Pertaining to Fidelity ...............................................................................................................26
REFERENCES .............................................................................................................................................. 28
ABOUT THE AUTHOR................................................................................................................................... 29
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INTRODUCTION A Chinese Confucian philosopher once said, "Tell me and I forget, teach me and I may remember, involve me and I learn." Certainly, this phrase resonates with experiential learning pedagogy which requires that the learner apply previous knowledge and life experience to formulate new learning in novel situations. In contemporary health sciences education, simulations are being used to recreate realistic clinical environments and engage students for more salient learning. Simulation- based learning experiences are effective yet complex teaching tools that should be implemented following the established standards for best practice. WHAT IS SIMULATION? Simulation as defined by the Society for Simulation in Healthcare (SSH) is “A technique that creates a situation or environment to allow persons to experience a representation of a real health care event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions”. This teaching modality, which began in Medical and Nursing education, has been widely adopted by health professions to establish mastery of a wide range of clinical skills and train the characteristics necessary for interprofessional practice. One can think of simulation as “learning by doing” that immerses the learner in a realistic clinic-like environment that contains situational, contextual, and psychomotor elements not available in traditional role-playing or case-studies. Likewise, simulations omit direct teaching customary in traditional lectures or labs reducing passive learning. 1 THE BENEFITS The appeal for using simulation stems from experiential learning that allows students to apply knowledge to clinical scenarios in a low-risk environment for both the learner and the simulated patient. 2 Simulation- based learning experiences/education (SBE) have been found to improve students’ problem- solving, critical thinking, judgment and competence, self-efficacy and perceived readiness for clinical practice. 4 Importantly, students find simulations satisfying! 3,4 Simulations are highly versatile and have been used to orient learners to health care environments or diagnostic-specific groups, train discipline-specific competencies, enhance patient safety and communication, and practice the principles of interprofessional education. They can be designed to consider the needs of the learner along with programmatic or institutional resources and may address curricular content weaknesses or accreditation requirements. The purpose and learning objectives of each SBE should be met through customization of the critical elements including, but not limited to, the type of learning environment (e.g., simulation lab, computer based), the modality and type of simulation tools to be used (e.g., manikin, task trainer, simulated patient), the degree of realism (fidelity), the student’s role (participant or observer), level of preparation and orientation (prebrief), feedback and reflection (debrief) and assessment (summative or formative). The possibilities are endless! Therefore, SBEs should be designed by those with knowledge or training in simulation education and best practice.
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THE BARRIERS SBEs are labor intensive and require extensive planning to coordinate and execute. Increased demand on faculty time for preparation and implementation is one of the most cited barriers to simulation along with cost, and lack of resources and equipment. 4 Scheduling presents another logistical challenge to implementing simulation because finding adequate time to execute the critical elements limits their feasibility. This is particularly true with Interprofessional Simulations which involve more than one professional discipline. According to the 2024 Institutional Profile Survey from the American Council of Academic Physical Therapy (ACAPT) 94% (n=207) of PT programs report using Simulations yet only 37.7 % (n=77) report that faculty have received formal training in this multifaceted teaching modality. 5 Due to high variability, not all SBEs are created equal and profound variations exist in the learning experiences both within and between health care professions, institutions and curricula. In a scoping review of 182 articles describing SBEs in PT education, Stockert et al. found that 94% did not follow the International Nursing Association for Clinical Simulation and Learning (INACSL) Healthcare Simulation Standards of Best Practice, omitting the needs assessment, prebrief, and debrief standards. Furthermore, only 26% used standardized outcome measures to assess students learning. 2 THE GUIDELINES The International Nursing Association for Clinical Simulation and Learning (INACSL) describes simulation as “a specialized educational strategy” and as such requires simulators and facilitators to demonstrate proficiency in the knowledge and skills pertaining to the Healthcare Simulation Standards of Best practice TM . Two readily available resources provide foundational information essential to simulations; the Health Simulation Dictionary Second edition (2.1) published by the Society for Health Care Simulation in conjunction with the Agency for Health Research and Quality (AHRQ) and the Healthcare Simulation Standards of Best Practice established by the International Nursing Association for Clinical Simulation and Learning (INACSL). 6, 7-11 The complete Health Simulation Dictionary can be accessed at https://www.ssih.org/dictionary . Selected terms from this resource are found in the Appendix. The Healthcare Simulation Standards of Best Practice ( HSSOBP TM ) represent a body of work or “living document” which originated in 2011 and has developed over time with the growing evidence in simulation. Access it online at https://www.inacsl.org/healthcare-simulation-standards. The 2.1 version, published in eleven separate articles in Clinical Simulation in Nursing (2021), adds two new standards; Professional Development and Prebriefing to the previous nine. 7 For ease of use, a synopsis and abbreviated versions of the current standards are outlined in Boxes 1-11. The HSSOBP TM acknowledges the following professional organizations involved in the regulation and accreditation of Simulation Education: Healthcare Simulation Standards of Best Practice TM , Certified Healthcare Simulation Educator (CHSE) Standards, Society of Simulation and Healthcare (SSH) Accreditation Standards, Association for Standardized Patient Educators (ASPE) Standards, Association for Simulated Practice in Healthcare (ASPiH Standards), National Organization ofNurse Practitioner Faculties (NOPF), the Canadian Certified Simulation Nurse Educators competencies (CASN). 8
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The Professional Development Standard The Professional Development standard addresses the need for simulationists (administrators, facilitators, educators, researchers, operation and technical specialists) to participate in professional development to ensure that they trained in all levels of simulation design.
Box 1. Healthcare Simulation Standards of Best Practice: Professional Development 8
Criterion
Summary of Elements
▪ Review literature and resources to develop an educational needs assessment of the simulationist’s individual skill set. This should include self-reflection, an assessment of current knowledge, and future goals.
Perform an educational needs assessment for each individual that includes a gap analysis to provide the foundational evidence for a well-designed professional development plan. Participate in professional development activities that address learning outcomes and align with an individual’s role and the priorities of the institution.
▪ Pursue professional development based on learning outcomes. ▪ Obtain professional certification and participate in formal education programs. ▪ Integrate the standards established by professional organizations. ▪ Contribute to the body of knowledge in simulation and attend or contribute to conferences at the local, regional, national, and international level. ▪ Ensure the organization supports an actionable professional development plan.
Reevaluate the professional development plan on a regular basis using formative and summative methods by both the individual and the organization.
The Prebriefing Standard The Prebriefing standard includes both preparation and briefing techniques which should occur before the simulation to orientate everyone involved. The Prebrief session should inform the learner of the objectives of the simulation, convey the ground rules for the experience, and importantly, establish psychological safety. The SBE should not surprise the participants, and they should comprehend content-related materials, assessments, and be competent in use of relevant technology prior to the experience. A comprehensive Prebrief will facilitate a more effective debrief.
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Box. 2 Healthcare Simulation Standards of Best Practice Prebriefing: Preparation and Briefing 9
Criterion
Summary of Elements
▪ Conduct a planned prebriefing session that is tied to the simulation objectives and serves to prepare learners for the SBE and the debriefing. ▪ Follow the HSSOBP TM Professional Development standard. ▪ Plan the prebriefing as a structured part of the simulation experience. ▪ Incorporate requirements for learner preparation and briefing during simulation design. ▪ Preparation and briefing requirements may vary, depending on the overall purpose and objectives of the simulation- based experience. ▪ For summative/high stakes SBEs: ● Provide information to learners regarding the type of scenario and method of evaluation in advance of the SBE. ● Develop preparation materials based on the simulation objectives and the descriptors in the assessment tool/rubric. ● Use a consistent, written, briefing script including orientation to the simulation-based experience, environment and resources to enhance reliability of instructions to learners. ▪ Novices to SBE may require more preparation, briefing and orientation. ▪ The simulation designer and facilitator are responsible for ensuring that preparatory and briefing activities address the knowledge, skills, attitudes, and behaviors that will be expected of the learners during the SBE. ▪ Use adult learning theory principles to prepare prebriefing materials that are designed to decrease cognitive load and equip learners to practice “at the edge of their ability.” ▪ Decrease learner anxiety and increase psychologically safety by providing preparation for scenario content. ▪ Use a variety of activities to ensure learner success in achieving the learning outcomes. ▪ Develop preparation activities and resources to support understanding of the concepts and content related to the SBE, including: ● assign readings or audiovisual materials ● concept mapping or care planning exercises ● review of the simulated patient’s health record/patient report, medications with discussion as needed
The simulationist should be knowledgeable about the scenario and competent in concepts related to prebriefing. Prebriefing should be developed according to the purpose and learning objectives of the simulation-based experience
The experience and knowledge level of the simulation learner should be considered when planning the prebriefing.
Based on needs assessment and purpose of the experience, preparation materials are developed to assure that learners are prepared for the experience and can meet the scenario objectives . Preparation materials should be developed according to the purpose and learning objectives of the simulation-based experience.
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review case studies
●
complete a pretest or quiz
●
● practice skills to be used in the SBE, lecture or other didactic lesson ● virtual simulation activities
▪ Allow learners to complete preparation activities in advance of the SBE to reinforce previous learning and prepare learners for success. ▪ Consider establishing consequences for management of learners attending the simulation experience without having completed the preparation requirements. ▪ Consider additional preparatory activities on the day of the SBE such as a facilitated discussion or student planning session prior to beginning the simulation. ▪ Discuss logistical factors such as: length of scenario, debriefing expectations, times for breaks, location of facilities, agenda for the day. ▪ Use a written or recorded prebriefing plan to standardize the process and content for each scenario/case. ▪ A written or recorded prebriefing plan should be required for SBEs used for high-stakes or summative evaluations. ▪ Identify expectations and roles for the learner and the simulationist including ground rules and a fiction contract. ▪ Provide information related to the use of recording equipment and observations by others (peers, faculty, facilitators, staff, health professionals, administrators). ▪ Review the evaluation methods being used for this experience and notify learners when they can expect to receive the measurement tools. ▪ Orient learners to all technology that will be used during the experience such as manikins, virtual learning environments, screen-based learning, or commercial learning products, and provide guidance if they require technology assistance during the experience. ▪ Establish a psychologically safe environment to ensure the learners feel comfortable expressing thoughts without feeling uncomfortable or fearing negative consequences. ▪ Incorporate activities that help establish an environment of integrity, trust, and respect. ▪ Discuss confidentiality and professionalism. ▪ Prevent defensive behavior and support risk taking which develops learning and professional identity.
Plan the delivery of preparation materials both prior to and on the day of the simulation-based experience.
Prior to the simulation-based experience, the simulationist conveys important information to learners regarding expectations, the agenda, and the logistics for the experience.
Conduct a structured orientation to the SBE environment including the modality.
Establish a psychologically safe learning environment during the prebriefing.
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The Simulation Design The Simulation Design standard acts as a blueprint for effective SBE based on sound pedagogical principles in adult and simulation education and incorporates the mission of the institution along with the clinical standards for best care. Proper simulation planning defines the objectives for the SBE and drives learner-centered outcomes.
Box. 3 Healthcare Simulation Standards of Best Practice: Simulation Design 10
Criterion
Summary of Elements
▪ Experts should be knowledgeable of ethical standards of simulation-based experiences and adhere to the Healthcare Simulationist Code of Ethics. ▪ Follow the HSSOBPTM Professional Integrity. ▪ Follow the HSSOBPTM Professional Development.
Simulation experiences should be designed in consultation with content experts as well as simulationists who are knowledgeable and competent in best practices in simulation education, pedagogy, and practice. Perform a needs assessment to provide the foundational evidence of the need for a well-designed simulation-based experience.
▪ Examine knowledge, skills, attitudes, and/or behaviors of individuals; organizational initiatives; systems analysis; clinical practice guidelines; quality improvement programs; and/or patient safety goals including: ● Causes of concern ● Organizational analysis of strengths, weaknesses, opportunities, and threats (SWOT) ● Outcome data ▪ Use the needs assessment results to guide the development of an overarching goal or broad objective for the simulation which directs the designer in the development of simulation- specific objectives. ▪ Use the results of the needs assessment to create relevant, innovative, and interactive SBEs that: ● Enhance curriculum ● Provide opportunities for standardized clinical experiences. ● Address competencies ● Promote quality of care, patient safety, and readiness for clinical practice. ▪ Follow the HSSOBPTM Objectives and Outcomes. ▪ Use broad objectives to reflect the purpose of the simulation- based experience and are related to organizational goals. ▪ Create specific objectives for learner performance measures. ▪ Determine which objectives will or will not be available to the learner before the experience for instance, specific critical actions may be withheld until the debriefing session to highlight learning. ▪ Follow the HSSOBPTM Objectives and Outcomes.
Construct measurable objectives that build upon the learner’s foundational knowledge.
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▪ Develop the SBE format and conceptual framework based on the needs assessment, resources available, learning objectives, the targeted learners, and the type of assessment or evaluation method. ▪ Select the appropriate modality or platform which includes simulated clinical immersion, in situ simulation, computer- assisted simulation, virtual reality, procedural simulation, and/ or hybrid simulation using standardized patients, manikins, haptic devices, avatars, and partial task trainers as available. ▪ All simulations should include a starting point, structured learner activities, and an endpoint. ● The start point represents the patient’s initial circumstances or situation when the learners begin engaging in the SBE. ● The endpoint represents the stage at which the experience is expected to end; usually, when desired learning outcomes have been demonstrated, time is exhausted or when the scenario can no longer proceed. ▪ Design the scenario/ case/ activity to include a situation or backstory to provide a realistic starting point from which the structured activity begins, and a script to enhance consistency, standardization and to increase scenario repeatability/reliability. This is especially important when the activity will be used with groups of learners. ▪ Clinical progression and cues provide a framework for the advancing of the clinical case or scenario in response to learner actions. ▪ Cues should be linked to performance measures and used to refocus learners when they stray from the intended objectives. ▪ Cues can be delivered in a variety of ways, including verbally, visually or through an embedded participant. ▪ Identify critical actions/performance measures that are required to evaluate achievement of scenario objectives. ▪ Follow the HSSOBPTM Facilitation standard. ▪ Design the simulation through attention to physical, conceptual, and psychological aspects of fidelity that can contribute to attaining objectives. ▪ Represent stimuli and cues that would typically be present to drive decision-making and action from the perspective of the learners. ● Physical (or environmental) fidelity relates to how
Build the simulation-based experience to align the modality with the objectives.
Design a scenario, case, or activity to provide the context for the simulation-based experience that ensures the quality and validity of the content and supports the objectives and expected outcomes.
Use various types of fidelity to create the required perception of realism.
realistically the physical context of the simulation-based activity compares to the actual environment in which the situation would occur in real life. Includes such factors as the patient(s), simulator/manikin, standardized patient, environment, equipment, embedded actors, and related props.
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● Conceptual fidelity ensures that all elements of the scenario or case realistically relate to each other so that the patient makes sense to the learner. ● Psychological fidelity maximizes the simulation environment by mimicking the contextual elements found in clinical environments. Examples include an active voice for the patient(s), noise and lighting typically associated with the simulated setting, distractions, family members, other health care team members, time pressure, and competing priorities. ▪ Fidelity elements work synergistically to promote learner engagement. ▪ Use moulage to replicate features or characteristics of the patient situation and when possible and select manikins that respectfully represent the race and culture of the patients in the scenario. ▪ Determine the planned facilitative approach, including the delivery of cues phase and include preparatory activities, during the simulation in the design. ▪ Facilitator involvement should be appropriate to the learner’s knowledge, competency, and experience. ▪ Facilitators should incorporate evidence-based components of cultural diversity within the simulation design and be aware and mindful of the learners’ diverse cultural differences, values, and responsibilities. ▪ Follow the HSSOBPTM Facilitation. ▪ Follow the HSSOBPTM Professional Integrity. ▪ Prebriefing activities are intended to establish a psychologically safe learning environment. ▪ Prebrief prepares learners for a shared mental model and the educational content and briefs them on the ground rules for the SBE. ▪ Follow the HSSOBPTM Prebriefing: Preparation and Briefing. ▪ Use a planned debriefing, feedback session, or a guided reflection exercise to enrich learning and contribute to the consistency of the SBEs for learners and facilitators. ▪ Debriefing and feedback are different, but both are critical elements that should be structured using best practices. ▪ In skills-based or testing simulation activity, debriefing may be replaced by feedback, so the learners are guided to improve further or confirm their practice. ▪ Guided reflection is an intellectual and affective activity that explores the critical elements to gain understanding and insight. Reflection can be integrated with debriefing or accomplished after the event through journaling or open discussions. ▪ Follow the HSSOBPTM The Debriefing Process.
Plan a learner-centered facilitative approach driven by the objectives, learners’ knowledge and level of experience, and the expected outcomes.
Create a prebriefing plan that includes preparation materials and briefing to guide participant success in the simulation-based experience.
Create a debriefing or feedback session and/or a guided reflection exercise to follow the simulation-based experience.
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▪ Determine the assessment/ evaluation processes in the design phase to ensure quality and effectiveness of the SBE. ▪ Consider an assessment framework to guide the selection and/ or development of a valid and reliable tool to measure expected learner outcomes. ▪ Ensure that participants understand the method of assessment (formative, summative, and/or high stakes) before or at the onset of the simulation. ▪ Plan an evaluation process to determine the quality or effectiveness of the SBE. ● Use evaluation data for continuous quality improvement. ● Include feedback from participants, peer clinicians and educators, stakeholders, and simulation program faculty and staff in the evaluation process. ▪ Follow the HSSOBPTM Evaluation of Learning and Performance. ▪ Pilot-test the entire simulation to ensure that it accomplishes its intended purpose, provides opportunity to achieve objectives, and is effective when used with learners. ▪ Select participants like the target learner group for the optimal pilot test. ▪ Select and review tools, checklists, or other measures to assess validity and to ensure consistency and reliability. ▪ During the pilot-test identify any confusing, missing, or underdeveloped elements of the SBE. Make improvements and revise before the full implementation of the simulation-based experience. ▪ Recognize that it may not always be possible to pilot test SBEs prior to facilitation.
Develop a plan for evaluation of the learner and of the simulation- based experience.
Pilot test simulation-based experiences before full implementation
Facilitation Facilitation guides participants toward attainment of the desired learning outcomes and promotes successful collaboration during the learning experience. According to the Health care simulation Dictionary a Facilitator is “an individual who is involved in the implementation and/or delivery of simulation activities”. 6
Box. 4 Healthcare Simulation Standards of Best Practice: Facilitation 11
Criterion
Summary of Elements
▪ The facilitator demonstrates competency in simulation pedagogy and incorporates the HSSOBP TM . ▪ The facilitator should be familiar with all aspects of SBE including preparatory materials, cueing, scenario scripting and debriefing and evaluation methods. ▪ The facilitator demonstrates the ability to: ● Apply principles of experiential, contextual, constructivist,
Effective facilitation requires a facilitator who has specific skills and knowledge in simulation pedagogy .
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sociocultural, transformative educational theories, systems and organizational change theories. ● Model professional integrity. ● Create a learning environment of mutual respect and manage conflict to promote partnerships in learning. ● Provide accurate, specific, and timely feedback to promote critical and reflective thinking. ▪ Follow the HSSOBP TM The Debriefing Process. ▪ Follow the HSSOBPTM Professional Integrity. ▪ Assess the individual needs of participants and determine the facilitative approach when designing the SBE. ▪ Use facilitation methods that are appropriate to the modality and fidelity of the SBE. ▪ Allow the simulation scenario to progress with or without interruption depending on the level of the participants and learning objectives. ▪ Deliver consistent experiences across cohorts of participants. ▪ Collect assessment and evaluation data through observation and monitoring. ▪ Follow the HSSOBPTM Evaluation of Learning and Performance. ▪ Follow the HSSOBPTM Simulation Design. ▪ Provide participants with information and/or preparatory activities, skills review, and practice time before the SBE and discuss ground rules to create a noncompetitive and safe learning environment. ▪ Recognize that mistakes may happen, and reflection will occur during the debriefing. ▪ Follow the HSSOBPTM Prebriefing: Preparation and Briefing. ▪ Follow the HSSOBPTM Professional Integrity. ▪ Deliver cues / prompts/ triggers to draw attention to significant information related to the context of the scenario or case. They can be predetermined or unplanned. ▪ Predetermined cues are incorporated into the design of the SBE based on common or anticipated actions by participants while unplanned cues aren’t previously anticipated. ▪ Use cues to redirect participants when the simulated reality is unclear or when participants need redirection to obtain expected learning outcomes. ▪ Cues given during the simulation should maintain fidelity of the scenario/ case and may be delivered resourcefully using laboratory results, moulage, phone calls from providers or other health care departments, comments from patient, a family member, or triggered by equipment in the room. An embedded participant or a standardized patient can be used to provide cues to manage unanticipated events.
The facilitative approach is appropriate to the level of learning, experience, and competency of the participants
Facilitation methods prior to the SBE include preparatory activities and prebriefing to prepare participants. This introduction promotes psychological safety for the participant.
Facilitation methods involve the delivery of cues aimed to assist participants in achieving expected outcomes.
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▪ To help standardize the SBE, cues should be delivered in a consistent fashion. ▪ Follow the HSSOBPTM Simulation Design. ▪ Facilitation continues beyond the SBE and debrief as participants form new ways of thinking. Participants may need additional time to reflect, process new knowledge, personally deal with the events that transpired, or clarify clinical experiences that conflict with their simulation experiences. ▪ Facilitation may extend beyond the SBE when addressing issues of professional integrity. ▪ Follow the HSSOBPTM Professional Integrity. ▪ Follow the HSSOBPTM The Debriefing Process.
Facilitation after and beyond the simulation experience aims to support participants in achieving expected outcomes
The Debriefing Process The Debriefing Process , a central tenet to all SBEs, must be thoughtfully planned with the goal of enhancing clinical judgment and critical thinking skills necessary in professional practice. Techniques embedded in the debriefing process such as feedback, guided reflection and personal exploration assist the learner in self-assessment of attitudes, knowledge, and performance to enhance learning.
Box. 5 Healthcare Simulation Standards of Best Practice: The Debriefing Process 12
Criterion
Summary of Elements
▪
The debriefing process is planned and incorporated into the SBE in an appropriate manner to guide the learner(s) in achieving the learning outcomes.
The debriefing process should: ● Follow the SBE and associated prebriefing. ● Be evidenced-based. ● Be timely, learner-centered, structured according to the education and experience of the learners and specific to observable behavior. ● Follow HSSOBPTM Prebriefing: Preparation and Briefing. ● Follow the HSSOBPTM Simulation Design.
▪ Allow adequate time to assist learners in achieving the activity’s desired outcomes, address critical elements, and discuss identified performance or systems gaps. ▪ The duration of the debrief varies. ▪ Debrief group (s) size should promote active participation of learners. ▪ Utilize techniques such as Socratic approach, active listening, and silence to promote self-awareness and critical thinking in a nonjudgemental fashion. ▪ Utilize unbiased critique and positive or negative constructive analysis to correct errors, promote comprehension and reinforce positive behavior.
The debriefing process is constructed, designed and/or facilitated by a person(s) or technology-enhanced system capable and/or competent in providing appropriate feedback, debriefing, and/or guided reflection.
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▪ Identify performance gaps or process issues based on the expected outcomes of the simulation-based experience. ▪ Follow the HSSOBPTM Facilitation. ▪ The Debrief process should be conducted in an environment that provides privacy and discretion, open discussion, and trust, and one that supports learners in the case of unexpected distress or outcome. ▪ The process should include multiple points of view, such as self, peers, external observers, standardized patients, operations/ technology specialists, and/ or automated performance analysis and feedback systems. ▪ Discussion should guide learner(s) toward comprehension and understanding of objectives. ▪ The Debrief process should be structured; incorporate various phases; and conducted depending on the complexity of the scenario, available time, and the learning objectives. ▪ Debrief facilitates analysis or critique of the team, system, or the learner while acknowledging that each learner’s perspective is valid and may not be fully understood without exploration. ▪ Well-designed Debriefing encourages learners to search for evidence-based solutions and fosters transfer of learning to the clinical setting.
The debriefing process is conducted in a manner that promotes self, team, and/or systems analysis. This process should encourage reflection, exploration of knowledge, and resolution of performance/ system gaps while maintaining psychological safety and confidentiality. The debriefing process is planned and structured in a purposeful way based on theoretical frame- works and/or evidenced-based concepts.
The Operations Standard In contrast to the others, the Operations Standard addresses the pragmatic management concerns associated with Simulations including the development and maintenance of a strategic plan, policies and procedures, financial resources, and personnel.
Box. 6 Healthcare Simulation Standards of Best Practice: Operations 13
Criterion
Summary of Elements
▪
Implement a strategic plan that coordinates and aligns resources of the SBE program to achieve its goals.
Perform a needs assessment.
▪ Define a strategic plan (including immediate, short- and long- term goals) that aligns with the governing institution and supports the mission, vision, and values of both the SBE program and organizations associated with the SBE program. ▪ Devise an organizational infrastructure that supports the goals and outcomes of the SBE program, and define roles for leadership, administration, management, operations and/or technology specialists, educators, or other simulationists. ▪ Involve and report progress to key stakeholders. ▪ Implement a systematic evaluation plan of operations with a prescribed review/revision cycle.
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▪ Identify justifiable capital expenditures and articulate the value proposition or return on investment and return on expectation of the program. ▪ Design job descriptions for the SBE program that delineate the scope of practice and educational requirements for each role to ensure that personnel can perform the job skills or be trained to meet expectations. ▪ Incorporate an ongoing professional development plan designed specifically for simulation personnel with associated competency validation and ensure personnel receive necessary training. ▪ Identify roles, tasks, and expectations for the set up and break down of simulation-based experience. ▪ Follow a written plan addressing the educational objective(s), purpose(s) with an accessible list of supplies, equipment, and personnel required to support the activities. ▪ Ensure that all SBE experiences and associated activities are in an environment that complies with institutional, national, international, or other regulatory occupational safety practices. ▪ Perform a periodic review of the above. ▪ Follow the HSSOBPTM Simulation Design. ▪ Plan and sustain a defined annual SBE budget with a quantified, formalized plan to analyze and control costs. ▪ Prepare and execute an operational budget considering the SBE program’s environmental review, current and future goals/objectives, and priorities which includes planned, fixed and variable costs, capital expenditures, and forecasted growth. ▪ Correlate the impact of the SBE program on the organization’s cost/savings. ▪ Develop the program’s mission and/or vision along with written policies and procedures to articulate the role of the SBE program in relation to other stakeholders and the larger organization or region. Communicate to stakeholders how these align with healthcare education and eventually health care delivery. ▪ Actively participate and collaborate in initiatives across organizations, contributing to the improvement of learner, health care, and/or program outcomes. ▪ Ensure ongoing systematic and programmatic improvement processes are in place for the SBE program.
Personnel with appropriate expertise support and sustain the SBE program.
Develop plans to manage space, equipment, and personnel resources.
Secure and manage the financial resources to support stability, sustainability, and growth of the SBE program’s goals and outcomes.
Use a formal process for effective systems integration.
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▪ Consider human resource factors (full-time, adjunct, volunteer, or student) relating to workload, orientation, education, and competency. ▪ Define data collection, storage, access, destruction, and reporting processes that align with institutional and accrediting bodies’ expectations. ▪ Provide safety information for handling, securing, storing, and maintaining any chemical, medication, or other hazardous supplies and how they will be managed by personnel. ▪ Specify guidelines for equipment storage, location, security, safety, and access. ▪ Establish guidelines and procedures for sharing confidentiality expectations for learners, faculty, facilitators, embedded participants, and personnel.
Create policies and procedures to support and sustain the SBE program.
Learning Outcomes and Objectives
Learning outcomes and objectives dictate simulation design and implementation. Although closely related, the Health Simulation Dictionary states that learning outcomes “are a measurable judgement” that “measure the effect on learning: psychomotor, affective and cognitive skills” while a learning objective is the “expected goal of a curriculum, course, lesson or activity in terms of demonstrable skills or knowledge that will be acquired by a student as a result of instruction” 6 Roughly differentiated, outcomes tend to be overarching goals such as those influenced by accreditation and programmatic requirements, while Bloom’s taxonomy is often used to convey learning objectives.
Box. 7 Healthcare Simulation Standards of Best Practice: Outcomes and Objectives 14
Criterion
Summary of Elements
▪
Establish learner outcomes influenced by accreditation, program, curriculum and/or patient care needs that are measurable and appropriately scaffolded to learner knowledge, skills, and attitudes.
Outcomes are: ● Based on programmatic goals and consistent with the mission & vision of the program. ● Based upon needs assessment, evidence-based practice, clinical partners, and stakeholders. ● Representative of equity, inclusivity & diversity. ●
Consistent with an identified framework i.e., New World Kirkpatrick’s Model (reaction, learning, behavior, & results). ● Driven by objectives within educational or clinical setting. ● Communicated purposefully to learners in advance of SBE. ▪ Follow HSSOBPTM Simulation Design
▪
Create objectives for the simulation-based experience to
Outcomes are: ● Goal-driven and scaffolded based upon the revised Bloom’s
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meet defined outcome based on formative or summative Evaluation.
Taxonomy model.
● S.M.A.R.T (Specific, Measurable, Achievable, Realistic, Time phased) ● Mapped to outcomes established for the course, program, institution, and accrediting body.
▪
Identify appropriate fidelity to meet the learning objectives/outcomes. Establish guidelines for facilitation of SBE to meet objectives.
Follow the HSSOBPTM Simulation Design.
▪
Follow the HSSOBPTM Simulation Design.
▪
Follow the HSSOBPTM Facilitation.
▪ Follow the HSSOBPTM Professional Development.
Professional Integrity Every health profession has a Code of Ethics and/or Code of Professional Conduct which must be modeled and practiced by all involved in the SBE. Everyone shares the responsibility for creating a safe learning environment so what happens in Simulations stays in Simulations.
Box. 8 Healthcare Simulation Standards of Best Practice: Professional Integrity 15
Criterion
Summary of Elements
▪
The Healthcare Simulationist Code of Ethics asserts key aspirational values important to the practice of simulation. The Code identifies values important to the welfare of all parties in the healthcare simulation community of practice, and it asserts our identity and
The Simulationist shall: ● Maintain the highest standards of integrity including honesty, truthfulness, fairness, and judgment in all matters affecting their duties. ● Perform all healthcare simulation activities in a manner that Respect the rights, dignity, and worth of all. They shall practice empathy and compassion to support beneficence and non-maleficence towards all involved in simulation activities. ● promotes transparency and clarity in the design, communication, and decision-making processes. ●
commitment to healthcare simulation as a profession.
Conduct themselves in a manner that upholds the professional standards in healthcare simulation and be accountable for their decisions and actions in fulfilling their duties and responsibilities. ▪ Abide by the legal and professional standards of practice and codes of ethics that guide one’s discipline. ▪ Embed professional standards of practice and codes of ethics of learner’s disciplines to develop, remind, and reinforce attributes of professional integrity. ▪ Be aware of other profession’s Code of Ethics to foster respect of Interprofessional teams.
Follow standards of practice, guidelines, principles, and ethics of one’s profession.
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▪ Work with individuals of other professions to maintain a climate of mutual respect and shared values. ▪ Provide clear communication and honest feedback in an effective, respectful manner and maintain professional boundaries. ▪ Recognize disruptive behavior during SBE and take measures to halt it. ▪ Interact and treat simulated patients and other simulation staff with respect as valuable members of the SBE.
Create and maintain a safe learning environment. (Follow the HSSOBP TM Prebriefing: Preparation and Briefing and The Debriefing Process).
▪
Practice inclusion by respecting equity, diversity, and inclusivity among all involved and in all aspects of SBE.
Everyone is expected to be: ● Honest, mindful, and sensitive to all differences and ethical issues related to the SBE. ● Cognizant of issues related to the care of diverse populations. ● Aware of social determinates of health, diverse worldviews and individual differences that characterize patients, populations, and the health team. ● Respectful of the unique perspectives related to cultures, values, roles, responsibilities, and expertise of other health professions and the impact these factors can have on health outcomes
▪ Ethical practice and academic integrity derived from honesty should be the foundation of the learning environment. ▪ Determine Policies and procedures for the appropriate sharing of learner performance with those that need to know and have a legitimate educational interest, including mechanisms for monitoring, reporting, and addressing violations. ▪ Determine Policies and procedures for securing and destroying written documents, audio, and/or video footage.
Require confidentiality of the performances and scenario content based on institution policy and procedures
Interprofessional Simulation An Interprofessional Simulation involves “An educational environment where students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.” (World Health Organization Interprofessional Education and Collaborative Expert Panel, 2011.) 6 Many health care profession’s accrediting bodies now include criteria encompassing Interprofessional Education (IPE). SBEs offer an ideal opportunity for learners from different health disciplines to practice collaboratively to deliver effective care.
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Box. 9 Healthcare Simulation Standardsof Best Practice: Simulation-Enhanced Interprofessional Practice. 16
Criterion
Summary of Elements
▪ Include adult learning theories, frameworks, standards, and competencies to structure the development of Sim-IPE.
Conduct Sim-IPE based on a theoretical or a conceptual framework.
▪ Develop the design in consultation with experts and representatives of the targeted interprofessional learners. ▪ Incorporate authentic, challenging, reality-based activities /scenarios developed and reviewed by the professions involved in the simulation. ▪ Develop mutual goals among the professions involved in the experience. ▪ Determine that the simulation-based experience meaningfully involves all learners. ▪ Determine institutional and leadership commitment to Sim- IPE. ▪ Ensure adequate resources including financial support, simulation space, equipment, supplies, time, support for staff/simulationists, and a budget plan to ensure sustainability. ▪ Incorporate data collection instruments which demonstrate reliability and validity across the professions. ▪ Instruments to consider: Health Professional Collaboration Scale; Interprofessional Collaborative Competency Attainment Survey; InterProfessional Activity Classification Tool; Interprofessional Socialization and Valuing Scale; KidSim Team Performance Scale; Readiness for Interprofessional Learning Scale (RIPLS; Revised); Student Perceptions of Interprofessional Clinical-Education Re- vised Instrument; TeamSTEPPS Teamwork, Attitude Q; Team Readiness Assurance Test/Individual Readiness Assurance Test; Interprofessional Collaborator Assessment. ▪ Measure impact of Sim-IPE on learner’s understanding of team behavior and the Interprofessional education competencies. (IPEC competencies).
Utilize best practices in the design and development of Sim-
IPE. (Follow the HSSOBP TM Design and Prebriefing.)
Recognize and address potential barriers to Sim-IPE. (Follow the HSSOBP TM Prebriefing: Preparation and Briefing, Simulation Design, The Debriefing Process, and Professional Development.) Include an appropriate evaluation plan. (Follow the HSSOBP TM Evaluation of Learning and Performance.)
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Evaluation of Learning and Performance One cannot determine if SBE Outcomes and/or Learning Objectives have been achieved without some form of evaluation process.
Box. 10 Healthcare Simulation Standards of Best Practice: Evaluation of Learning and Performance 17
Criterion
Summary of Elements
Determine the method of learner evaluation before the SBE.
▪ Formative evaluation is conducted to facilitate teaching and learning in knowledge, skills, and attitudes, provide feedback, and monitor progress toward achieving outcomes and clinical competencies. ▪ Consider using the appropriate group ratio to optimize learning and the most appropriate evaluation tool. ▪ Summative evaluation is conducted to evaluate learning, skill acquisition, and academic achievement at the conclusion of a defined period, such as completion of a course and ▪ after learners are informed of the evaluation process. ▪ High-stakes evaluation is conducted based on specific learner objectives to determine competence, gaps in knowledge, skills, behaviors and/or to identify safety issues. ▪ They are conducted after the learner has had multiple exposures to various SBEs including those with summative evaluations and the potential implications have been explained to the learners.
SBEs may be selected for formative evaluation.
SBEs may be selected for summative evaluation.
SBEs may be selected for high- stakes evaluation
Simulation based education provides health care students with realistic and meaningful experiential learning opportunities. However, like producing a play, simulations are challenging to design and deliver. Educators wishing to embed simulations in their curriculum benefit from adhering as closely as possible to the established guidelines published by INACSL for effective learning.
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