Elizabeth Blodgett Horsley, Director of Simulation, The Brooklyn Hospital Center
2023 will mark my 30th year as a Registered Nurse. I started in the Operating Room and through a random series of events, I have spent the better part of the past eighteen years working with clinical simulation and education, in both academic and hospital settings. I have seen the trajectory of simulation as a teaching strategy go from somewhat of a novelty that was only in big academic health centers, to now being a commonly accepted teaching strategy across health professions in various configurations of institutions. COVID, as it did with nearly every aspect of healthcare, had its impact on simulation and health professions education with the rapid growth and utilization of virtual simulation activities. Virtual simulation and all that entails is indeed another topic for another thought piece. My thoughts here however are around the best practices and best applications of simulation-based activities, regardless of the medium or platform.
Firstly, for the purposes of this piece, simulation refers to the recreation of realistic situations for teaching or training. Simulation is often associated with high-tech patient mannequin-type units or standardized patients who are actors trained to portray a specific condition or situation. The simulation umbrella however also encompasses the vast array of skill-based training initiatives from arms for practicing blood draws to robotic surgical simulators. A well-thought-out session with focused practice on opening a sterile field and inserting a foley catheter is certainly a simulation-based educational experience. The simulation does not have to have, as they say, all “the bells and whistles.”
“Simulation is often associated with high-tech patient mannequin-type units or standardized patients who are actors trained to portray a specific condition or situation.”
I do quite a bit of work with our newly hired Registered Nurses and our Nurse Residency Program. One of the sessions I help lead is on basic Code Blue skills. Over time I have realized that simply reviewing ACLS algorithms and cardiac medications do not accomplish a whole lot of meaningful learning with a group of novice practitioners. A needs assessment of these groups has shown they need very, very basic and rudimentary information. As such, I developed a relatively simple activity for these learners. (Full disclosure, I adapted this from a paper I had read: Greer JP, Nadim H, Gunter L. Walk the block: Cardiac arrest readiness for basic life support providers. Nursing. 2021 Feb 1;51(2):66-69.). During our session, we literally “walked the block” of the crash cart, exploring what was on each side. Along with this walking tour, I made sure everyone had hands-on experience with connecting oxygen and suction, opening the O2 tanks, using a bag-valve mask, and knowing the codes for the locks on the drug boxes. I even included simple reminders such as unplugging and unlocking the wheels on the cart – tasks that could easily be overlooked by a “newbie” once the adrenaline is pumping in a crisis situation. Each participant was required to connect and place defibrillator pads and then perform two minutes of compressions in which they received feedback from the instructors and the Zoll defibrillator. Again, this may seem very basic, however, one morning, it made a huge impact on one of our new hires. That afternoon, when the oriented were to reconvene, one young woman was missing. She eventually appeared stating that she had been up on her assigned unit. A code blue was called, and without hesitation, she was able to get the crash cart to the patient room, help get the backboard placed, and get things hooked up and ready for the code team’s arrival. When heard this story, I must admit I did some fist bumps in the air and yelled “yes…that’s why I do what I do!”
And this is exactly why those of us who work on the educational side of healthcare do what we do. Our commitment to patient safety and the best patient outcomes possible comes through in how we educate and prepare the next generation of healthcare professionals. A few years back, I contributed a thought piece to this publication on the evolution of simulation as a teaching strategy in hospital settings. From my vantage point, it appears that many hospitals across the country, from academic teaching centers to community-based safety net providers are allotting resources to some form of a simulation program. Bottom line, the general consensus is that simulation “works”. Now, though the onus lies on educators to find the best ways to use simulation. It is all fine and good to have a roomful of the latest and greatest patient simulations that are pretty darn close to life-like or to have access to avatars and virtual worlds however, for any simulation activity to be effective it has to align with solid educational principles. By this I mean that simulation activities are well thought out with specific learning objectives. I mentioned above that I quickly ascertained an ACLS-type course was not at all suitable for new graduate nurses. They needed basic introductions to code blue concepts and a chance to have hands-on practice with tasks like connecting and placing pads. From my experience as a simulation educator, that is probably one of the biggest misconceptions about simulation – that somehow, we are to “throw” learners into harrowing simulations that they have neither the cognitive knowledge nor skills to function. In these types of scenarios very little good learning happens and quite often learners grow to resent/fear/hate simulation. I am a firm believer in cognitive load theories which look at how much new knowledge can be absorbed and the transition from new knowledge to long-term memory. I also subscribe to the concept of scaffolding in which I start with basics and keep building. I will have a group of medical students come to the lab eager to learn how to place a peripheral intravenous line. A quick assessment reveals the number who have no idea how to tie a tourniquet, what “bevel up” means nor that when it comes to gauging, the bigger the number the smaller the needle!
If you come to my workspace and tell me you wish to create and run a simulation activity, the first thing I say is “what do you want your group to know before they walk out the door?” (This phrase was one I picked up from an instructor in my graduate program) It is not enough to have a simulation lab with the latest and greatest technology. You may well have a mannequin that can wet itself and seize, and you may have unbelievable augmented reality complete with headsets that transport you to any environment imaginable but if your simulation activities are not well thought out with the level and needs of the learner in mind, not much quality learning is going to happen. Sure, your learners are interacting with a mannequin or a virtual excursion, but are they truly engaged? Can they reflect on the experience and make sense of it in the context of their practice setting? Can they take the lessons learned forward in their practice?
There are indeed many more topics and nuances to explore when it comes to simulation. I would welcome the opportunity to contribute another thought piece on debriefing and feedback. As I sat to type this, I framed this like I do simulation – what do I want you to know before you leave this article? I want you to begin every simulation activity, big or small with a needs assessment and from there, identify two or three achievable and measurable objectives. Once you have that information, you can begin! In the end, focus on having your learners in appropriate simulated environments so they can truly have a meaningful experience that they can take forward to provide the safest patient care possible.