Simulation
Combining high-tech and high-touch to build
clinical competence in undergraduate and
practicing nurses
Judy Robinson RN, BA, MHSc
Sandra Goldsworthy RN, BScN, MSc, CNCC
Overview
• MOHLTC Health Human Resource Strategy
• Nursing Secretariat Clinical Simulation Grant
• DC-UOIT Simulation Lab
• Research: Impact of Simulation and Clinical
Competence Among Undergraduate Nurses
• Critical Care Secretariat Grant
• Research: Impact of E-learning and Simulation Among
Practicing Nurses Working in Critical Care
• Next Steps
• Questions and Answers
Ministry of Health and Long Term
Care
Health Human Resource Strategy
• Improve access to care
• Reduce wait times
• Improved patient outcomes by increasing
the recruitment and retention of health
professionals
Nursing Secretariat
Nursing Strategy
Address the instability of the nursing
workforce
• Increase the number of full-time positions
for nurses
• Improve recruitment and retention of
nurses
• Ease the transition for new nurses
entering the workforce
Nursing Secretariat
Nursing Strategy (cont‟d…
• Increase access to clinical learning
opportunities in nursing education
• Make Ontario a leader in nursing
education by offering an innovative
solution to pressures on clinical
placements and opportunities for
interdisciplinary education
MOHLTC
Nursing Critical Care
Secretariat Secretariat
DC - UOIT
Nursing Secretariat
Invests in Nursing Education
Spring, 2005
• $10 million invested in simulation equipment
• DC-UOIT awarded $694,000 (competitive
process)
• 9 adult, 1 pediatric, 2 neonatal simulators
• Video equipment and video streaming
capabilities
• Training faculty and staff
DC – UOIT‟s
Response to the Nursing
Secretariat‟s Simulation Agenda
March, 2005 awarded $694,000
April, 2005 simulators delivered to campus
June, 2005 training faculty and staff
Sept, 2005 integrate use of simulation
into BScN year 2 curriculum
Sept, 2006 integrate use of simulation into
BScN year 1 and 4 (SPA)
Sept, 2006 Research study - BScN
year 2 students in med- surg
and maternal –child courses
Integration of Simulation
Phase 1 – assessment, psychomotor skill
development
Phase 2 – comprehensive approach to
teaching and learning
Phase 3 – advanced integrated critical care
scenarios
Human Simulation: Teaching
Strategy
• Students are required to combine ways of
knowing, assessments, pattern
recognition, reflective practice, clinical
decision-making for optimal patient
outcomes
• Students engage in case based patient
scenarios which increase in complexity of
patient acuity
Human Simulation: Teaching
Strategy
• Engages students in active and interactive
learning and clinical problem solving
without patient risk
• Provide opportunities for thinking-focused
experiences rather than just nursing care
tasks, and allow students to think “on their
feet rather than in their seat” (Rauen,
2001)
Human Simulation Teaching
Strategy
• Students use assessment and critical
thinking skills to determine course of
action, implement care, and receive
immediate feedback through “patient”
outcomes
• Simulation is controlled so that the patient
problems encountered by students are
consistent with actual clinical patient
conditions and desired learning
Human Simulation: Teaching
Strategy
To build student knowledge, skill and
confidence in pattern recognition, and
appropriate and timely response for
optimal patient outcomes without patient
risk
Research: Is Simulation Education
Effective in Undergraduate Nursing
Education?
Why simulation?
• The simulation lab was envisioned to build
confidence and encourage reflective
thinking in a safe environment.
• The simulation experience was thought to
improve patient safety and clinical
judgment while providing many realistic
and complex scenarios.
Purpose
• To examine the benefits of providing a simulation
experience for second year nursing students in both
a medical surgical and a maternal child rotation.
• The aim of this study was to investigate if a
difference exists between self efficacy and the rate
of medication errors/near misses.
Method
• Experimental group: Simulation + Clinical Control
group: Traditional Clinical only
• Random assignment to groups
• Simulation Intervention:
• Med/surg or maternal child case scenarios (high fidelity
simulators + Virtual clinical scenarios)
Measures
• General self efficacy scale (10 items) given as
pre test and post test to all participants.
• Sears(2006) medication administration error tool
used to calculate actual errors and near misses
• Qualitative focus questions to all experimental
group after 2 simulation „clinical‟ days
• Qualitative focus group conducted at the end of
the study.
Intervention
• Scenarios included post op complications and
cardiac arrest, among others
• Teaching/Learning strategies included coaching,
reflection, prioritization, delegation, repeating the
scenario and debriefing
Results: Medication Errors
• There is compelling evidence that
collectively, students in Clinical generate
fewer Medication Errors if the Treatment
(Simulation experience) has been
administered.
Results: Medication Errors
• Additional findings:
• “Lack of Knowledge” a common thread to many
incidents.
– These sub-variables are highly inter-correlated: “Lack of
knowledge of indications for usage”; “Lack of knowledge
of contraindications”; “Lack of knowledge of side
effects”; “Lack of knowledge of normal dose range”;
“Lack of knowledge relating to nursing applications”.
{Cronbach’s Alpha = 0.949}
• Inter-correlation of the responses “Ineffective
Results: Qualitative Focus Groups
• Do you feel the sim cases helped prepare you
for clinical?
• “ I felt it increased my confidence on the floor”
• “It was really helpful”
• “1st day on the floor had a patient that had a similar
scenario to one of the cases in the sim lab-I learned
alot!”
Results: Qualitative Focus Groups
• How did the simulation experience help you?
• “it helped me practice my skills”
• “ it simplified the steps”
• “ I felt safe, supported in the lab, having done it
in the lab I felt more comfortable performing the
skills in real life”
• “ liked the practice in a safe environment”
• “it allowed me to practice things I may not see in
clinical”
Results: Qualitative Focus Groups
• Would you like more/less/same amount of
simulation time?
• All but one participant said they would like at least 1
more sim day, the remaining participant liked the
amount given.
• Most participants liked the sim being placed at the
beginning of clinical.
Results: Qualitative Focus Groups
• What do you see as the limitations to simulation?
• Some participants liked hands on lab more than
virtual cases
• What would you change?
• More time on sim
• Add the sim experience to all of the years
• Use as „up front‟ experience prior to 4th year
Live Feed - simulation
Critical Care Secretariat
• The quality of critical care has the potential
to “make or break” other hospital services
(Critical Care Task Force, 2005)
• The shortage of skilled nurses for CC units
has resulted in crowded ERs for patients
waiting for admission, deferred surgeries
and the transports of patients to other
regional facilities where a CC bed may be
available
Critical Care Secretariat
Recognized
• a need to improve training, recruitment and
retention of critical care nurses to meet the
workplace demand and to reduce “wait times”
• training needs to be consistent with provincially
recognized standards and core competencies
• training needs to be accessible geographically
and accommodate the needs of shift workers
• training needs to meet the needs of the novice
and more experienced nurses working in CC
Critical Care Secretariat: Grant
• October, 2006 – Durham College was the
successful recipient of approval and
support from the MOHLT, CC Secretariat,
for the development and implementation
of an innovative program for critical care
nursing
• $1 million funding grant
DC‟s Response to the Critical Care
Secretariat‟s E-Learning Agenda
June, 2005 responded to RFP
October, 2006 awarded $1 million
Oct – July, 2007 curriculum development
July, 2007 research REB approval
July/Aug, 2007 piloted e-learning courses
Sept, 2007 launched CC program
and research study
Durham College – Critical Care
Nursing Graduate Certificate
• A virtual learning environment with the central
hub at Durham College
• Availability of program to any nurse in Ontario
• Six on-line courses with enhanced faculty
interaction with students
• Clinical simulation course students can access
within their geographical region
• Preceptored critical care practicum students can
access within their geographical region
DC- Critical Care Nursing
Graduate Certificate Program
The overall purpose of the program is to
contribute to the provincial health care
strategy and health human resource
needs to build and sustain skilled critical
care nurses in Ontario through the delivery
of a high quality, competency based and
accessible post secondary educational
program for critical care nursing
DC Critical Care Nursing
Curriculum Team
• Sandra Goldsworthy
• June MacDonald Jenkins
• Debbie Morrison
• Leslie Graham
• Judy Robinson
Specialty Consultants
DC service support (IT, Innovation, Media
Services, Registrar, Library)
Critical Care Nursing – Research
Team
• Judy Robinson
• Sandra Goldsworthy
• June MacDonald Jenkins
• Debbie Morrison
• Leslie Graham
• Dr. Janet Rush, Research Associate
• Samuel Rush, Research Assistant
Research – Practicing Nurses in
Critical Care
Consistent with the start up of the program is the
integration of a research component
The research questions will examine:
• program success (academic and clinical success
of students, attrition/graduate rate)
• Satisfaction with program (curriculum, e-learning,
simulation, integrated practicum)
• Satisfaction with resources/services (library, IT,
registration, availability of faculty support)
Research- Practicing Nurses in
Critical Care (cont‟d…
• Contribution of the number of
available/skilled critical care nurses
graduated from the program at the 2 year
time point
• Differences in ranking of nurses‟ self
perception of critical care nursing
competencies pre and post program
MOHLTC
Nursing Critical Care
Secretariat Secretariat
DC - UOIT
Next steps
Leading the Way and Staying
Ahead of the Curve…
• Application of the learning model (e-
learning, simulation and integrated
practicum) to other areas of nursing and
health education
• Explore the use of E-learning and/or
“Second Life” to interdisciplinary
education in the Bachelor of Allied Health
Sciences degree completion program
Questions and Answers