WEBVTT 00:00:05.316 --> 00:00:07.880 position:50% align:middle - [Katie] Thank you for these previous two presentations. 00:00:07.880 --> 00:00:12.830 position:50% align:middle These have been really great, and kind of a good...obviously, great in their own right. 00:00:12.830 --> 00:00:18.370 position:50% align:middle But in the lead-up to this presentation, and some of the through lines that I wrote down are 00:00:18.370 --> 00:00:22.860 position:50% align:middle this idea of as-good-as simulation. 00:00:22.860 --> 00:00:30.090 position:50% align:middle We've had some evidence to suggest that simulations can be as good as traditional clinical. 00:00:30.090 --> 00:00:39.240 position:50% align:middle And also how this investigation and this close look shining the spotlight on simulation has really started 00:00:39.240 --> 00:00:44.870 position:50% align:middle us asking some questions about how good is traditional clinical, and what's going on there? 00:00:44.870 --> 00:00:49.130 position:50% align:middle And then also just a focus on high-quality simulation. 00:00:49.130 --> 00:00:54.420 position:50% align:middle I'll talk a little bit later about the regulation process that we're going through, 00:00:54.420 --> 00:01:00.130 position:50% align:middle but we know that the 2014 National Simulation Study focused on high-quality simulation. 00:01:00.130 --> 00:01:07.270 position:50% align:middle And somehow that little hyphenated descriptive somehow gets left out of the conversation sometimes. 00:01:07.270 --> 00:01:11.170 position:50% align:middle So I'm going to find my slide advancer somewhere. 00:01:11.170 --> 00:01:12.200 position:50% align:middle Here we go. 00:01:13.880 --> 00:01:15.839 position:50% align:middle And get started. 00:01:17.890 --> 00:01:20.250 position:50% align:middle Okay. So this is me. 00:01:20.794 --> 00:01:28.410 position:50% align:middle And one of the things that I wanted to kind of highlight is just this kind of balancing act of being a 00:01:28.410 --> 00:01:33.600 position:50% align:middle professor in the School of Nursing and Healthcare Leadership, and also a Pro Tem Member of our 00:01:33.600 --> 00:01:34.465 position:50% align:middle board of nursing. 00:01:34.465 --> 00:01:41.830 position:50% align:middle And kind of trying to be this expert witness that lends an expertise to the group, 00:01:41.830 --> 00:01:50.520 position:50% align:middle creating our new simulation regulations, but also an advocate for educators in simulation. 00:01:50.520 --> 00:01:55.260 position:50% align:middle So trying to remain neutral, but also bring the evidence. 00:01:55.260 --> 00:01:59.270 position:50% align:middle So in today's presentation, I am going to spend a little bit of time talking 00:01:59.270 --> 00:02:05.370 position:50% align:middle about some definitions, and history, and kind of how we got to this place. 00:02:05.370 --> 00:02:09.110 position:50% align:middle And then talk about, obviously, the research aims, and methods, and results. 00:02:09.110 --> 00:02:14.690 position:50% align:middle And then some time in discussion and the regulatory implications. 00:02:14.690 --> 00:02:21.720 position:50% align:middle And normally, when we come to conferences, a lot of the research that we're hearing about is 00:02:21.720 --> 00:02:25.320 position:50% align:middle really hot off...it's not even off the press yet. 00:02:25.320 --> 00:02:32.040 position:50% align:middle But the research that I'm going to be talking about actually was published in the January 2023 edition 00:02:32.040 --> 00:02:33.470 position:50% align:middle of the "Journal of Nursing Regulation." 00:02:33.470 --> 00:02:37.950 position:50% align:middle So I'm not going to go into all the data tables, and results, and analysis, and that type of thing, 00:02:37.950 --> 00:02:40.700 position:50% align:middle but really focus on kind of the big, big picture. 00:02:40.700 --> 00:02:42.740 position:50% align:middle So please feel free to ask me questions. 00:02:42.740 --> 00:02:44.570 position:50% align:middle I've got it right here. 00:02:44.570 --> 00:02:48.800 position:50% align:middle If you need to know any of the details, I've got a lot of it in here also. 00:02:48.800 --> 00:02:52.770 position:50% align:middle But that's my plan. 00:02:52.770 --> 00:03:00.585 position:50% align:middle So this is the third presentation in hour and a half, but I am going to go over the definition of simulation. 00:03:00.585 --> 00:03:06.860 position:50% align:middle A technique that creates a situation or environment to allow persons to experience a representation of a real 00:03:06.860 --> 00:03:10.300 position:50% align:middle event for the purpose of practice, learning, evaluation, testing, 00:03:10.300 --> 00:03:13.300 position:50% align:middle or to gain understanding of systems or human actions. 00:03:13.300 --> 00:03:17.480 position:50% align:middle So a really holistic, all-encompassing definition of simulation. 00:03:17.480 --> 00:03:22.690 position:50% align:middle I think a lot of times we think about a computerized manikin in an acute care situation. 00:03:22.690 --> 00:03:28.180 position:50% align:middle But I'd like you to think a little bit more broadly about simulation in public health nursing environment, 00:03:28.180 --> 00:03:32.920 position:50% align:middle or in a non-acute environment, thinking about standardized patients, 00:03:32.920 --> 00:03:39.260 position:50% align:middle thinking about screen-based virtual simulations, thinking about a little bit more holistic definition 00:03:39.260 --> 00:03:42.120 position:50% align:middle of simulation than what we might immediately go to. 00:03:42.120 --> 00:03:47.220 position:50% align:middle Or at least, I'll speak for myself, what I immediately go to when I think of simulation. 00:03:47.220 --> 00:03:54.507 position:50% align:middle And then currently, in our Washington Administrative Code 246-840-534 in 2016, 00:03:54.507 --> 00:04:03.768 position:50% align:middle we adopted reflecting the 2014 NCSBN national simulation study that up to 50% of a specific content 00:04:03.768 --> 00:04:10.500 position:50% align:middle area could...required clinical hours in that area could be replaced with simulation. 00:04:10.500 --> 00:04:17.400 position:50% align:middle And there are some wording in there trying to sort evoke high-quality simulation. 00:04:17.400 --> 00:04:22.632 position:50% align:middle But that administrative code is about the use of simulation for clinical experiences in LPN, RN, 00:04:22.632 --> 00:04:27.100 position:50% align:middle RN to BSN nursing education programs in the state of Washington. 00:04:27.100 --> 00:04:32.340 position:50% align:middle We just have seen an increasing use of simulation for all the reasons that our previous presenters have 00:04:32.340 --> 00:04:38.290 position:50% align:middle talked about, limitations in clinical placement sites, limitations in what students can do when they are 00:04:38.290 --> 00:04:44.760 position:50% align:middle in those clinical placement sites, around medication administration, or very high acuity, 00:04:44.760 --> 00:04:50.150 position:50% align:middle or transmissible diseases, these types of things. 00:04:50.150 --> 00:04:55.270 position:50% align:middle And in addition, oftentimes, when we think about the increasing use of simulation, 00:04:55.270 --> 00:05:05.630 position:50% align:middle we think about all of the gaps that it's filling, or all of the lacking characteristics 00:05:05.630 --> 00:05:06.798 position:50% align:middle of clinical placement sites. 00:05:06.798 --> 00:05:10.590 position:50% align:middle But I also like to think about all of the great developments we've had in simulation. 00:05:10.590 --> 00:05:13.220 position:50% align:middle It's gotten a lot better. It's gotten a lot less expensive. 00:05:13.220 --> 00:05:17.320 position:50% align:middle People have figured out how to do things well. 00:05:17.320 --> 00:05:23.600 position:50% align:middle And so there's been a lot of advances in simulation that have also led to the increased use of simulation, 00:05:23.600 --> 00:05:25.590 position:50% align:middle really since the early 2000s. 00:05:25.590 --> 00:05:29.420 position:50% align:middle And then, obviously, we just saw an explosion in the use of simulation 00:05:29.420 --> 00:05:31.230 position:50% align:middle during the pandemic. 00:05:31.230 --> 00:05:37.810 position:50% align:middle And specifically in the use of screen-based simulations when people were isolated to their homes, 00:05:37.810 --> 00:05:40.290 position:50% align:middle in front of their computers. 00:05:40.290 --> 00:05:46.510 position:50% align:middle And then there's publications really kind of in 2016, and this one that I've quoted here, Sullivan et al., 00:05:46.510 --> 00:05:56.240 position:50% align:middle 2019, is this emerging evidence towards saying that hours spent in simulation are more efficient, 00:05:56.240 --> 00:06:00.440 position:50% align:middle or more effective than time spent in traditional clinical. 00:06:00.440 --> 00:06:07.470 position:50% align:middle And most of the regulations around simulation, when simulation is substituted 00:06:07.470 --> 00:06:15.520 position:50% align:middle for traditional clinical, it's at a one-to-one ratio, where one hour of simulation counts as one hour 00:06:15.520 --> 00:06:17.440 position:50% align:middle of required clinical time. 00:06:17.440 --> 00:06:25.660 position:50% align:middle And so this emerging evidence is suggesting that because the time spent in simulation is more efficient 00:06:25.660 --> 00:06:34.360 position:50% align:middle or more effective than an hour spent in a simulated clinical environment could count as two hours 00:06:34.360 --> 00:06:36.070 position:50% align:middle of required clinical time. 00:06:36.070 --> 00:06:42.007 position:50% align:middle So this emerging evidence towards what we're calling a one-to-two ratio has really gotten 00:06:42.007 --> 00:06:42.930 position:50% align:middle a lot of people thinking. 00:06:42.930 --> 00:06:47.670 position:50% align:middle And in fact, in our state there were temporary regulations during...or temporary rules during the 00:06:47.670 --> 00:06:54.570 position:50% align:middle COVID pandemic that schools who met certain criteria were allowed to count simulation 00:06:54.570 --> 00:06:57.410 position:50% align:middle at this one-to-two ratio. 00:06:57.410 --> 00:07:00.720 position:50% align:middle And schools really want to keep doing that. 00:07:00.720 --> 00:07:08.810 position:50% align:middle And so anyway, there's a lot of conversation about this one-to-two ratio, counting one hour of simulation 00:07:08.810 --> 00:07:11.383 position:50% align:middle towards two hours of required clinical time. 00:07:11.383 --> 00:07:22.730 position:50% align:middle And then in 2023, Washington State passed or directed our board of nursing to create rules to allow nursing 00:07:22.730 --> 00:07:30.070 position:50% align:middle education programs to use one hour of simulation to count as two hours of required clinical time. 00:07:30.070 --> 00:07:37.360 position:50% align:middle So I have been part of the group of people who have been trying to put that down on paper. 00:07:37.360 --> 00:07:41.440 position:50% align:middle There is a question in the back of the room about, "So how do you ensure high-quality simulation?" 00:07:41.440 --> 00:07:43.080 position:50% align:middle And I was like, "Go ahead and tell me. 00:07:43.080 --> 00:07:49.480 position:50% align:middle I'll write it down," because that's what we've been trying to do, is create rules that are both feasible, 00:07:49.480 --> 00:07:58.298 position:50% align:middle that will endure, but also that really encourage high-quality simulation. 00:07:59.680 --> 00:08:01.672 position:50% align:middle So this is where we are. 00:08:02.780 --> 00:08:11.540 position:50% align:middle So the study that I did was really just to kind of get some evidence about this one-to-two simulation ratio. 00:08:11.540 --> 00:08:15.820 position:50% align:middle And so the first aim of the study was to assess the comparative effectiveness of three types 00:08:15.820 --> 00:08:19.590 position:50% align:middle of experiential learning activities, traditional clinical experience, 00:08:19.590 --> 00:08:22.660 position:50% align:middle manikin-based simulation, and screen-based simulation. 00:08:22.660 --> 00:08:28.660 position:50% align:middle And so we were comparing the cognitive learning outcomes, the patient care performance outcomes, 00:08:28.660 --> 00:08:33.480 position:50% align:middle and the students' perceptions of how well each of these met their learning needs. 00:08:33.480 --> 00:08:38.230 position:50% align:middle And the kind of big reveal here is that they spent four... 00:08:38.230 --> 00:08:39.860 position:50% align:middle It was just a one-shot wonder. 00:08:39.860 --> 00:08:43.440 position:50% align:middle This wasn't across a whole course, or even a whole program. 00:08:43.440 --> 00:08:48.820 position:50% align:middle But for this specific intervention, comparing four hours of traditional clinical time 00:08:48.820 --> 00:08:54.440 position:50% align:middle to two hours of manikin-based simulation, or two hours of screen-based virtual simulation. 00:08:54.440 --> 00:08:59.470 position:50% align:middle So this is where we're getting to the as-good-as thing. 00:08:59.470 --> 00:09:03.830 position:50% align:middle The four hours of traditional clinical didn't have to be better than two hours of traditional clinical or two 00:09:03.830 --> 00:09:05.990 position:50% align:middle hours of screen-based virtual simulation. 00:09:05.990 --> 00:09:09.460 position:50% align:middle It just had to be as good as. 00:09:09.460 --> 00:09:14.470 position:50% align:middle And then the second aim was to examine how each type of experiential learning activity informed pre-licensure 00:09:14.470 --> 00:09:17.640 position:50% align:middle registered nursing students' clinical judgments. 00:09:17.640 --> 00:09:22.670 position:50% align:middle And then to conduct a cost-utility analysis because that's a huge part of this conversation. 00:09:22.670 --> 00:09:29.290 position:50% align:middle Simulation is just...at least manikin-based simulation is extremely expensive and resource-intensive. 00:09:29.290 --> 00:09:35.450 position:50% align:middle And screen-based simulation isn't quite as expensive or resource-intensive. 00:09:35.450 --> 00:09:42.070 position:50% align:middle And from the school's perspective, traditional clinical experiences are quite affordable. 00:09:42.070 --> 00:09:50.270 position:50% align:middle But there are some costs that are shared by other entities for that experience to take place. 00:09:50.270 --> 00:09:53.380 position:50% align:middle So we started with program selection. 00:09:53.380 --> 00:10:00.690 position:50% align:middle We asked all of the programs in Washington State who were eligible, who met some certain criteria in terms 00:10:00.690 --> 00:10:09.320 position:50% align:middle of NCLEX pass scores, and being approved by the board to volunteer, 00:10:09.320 --> 00:10:11.140 position:50% align:middle to be part of the study. 00:10:11.140 --> 00:10:16.380 position:50% align:middle Fifteen programs raised their hand, and said that they would be willing to do it. 00:10:16.380 --> 00:10:25.900 position:50% align:middle And we selected five trying to represent urban, rural, associate degree, bachelor's degree, public, private. 00:10:28.049 --> 00:10:32.320 position:50% align:middle Selected five, four of them ended up actually being able to participate. 00:10:32.320 --> 00:10:37.050 position:50% align:middle One had to drop out just due to COVID. 00:10:37.050 --> 00:10:39.690 position:50% align:middle And there are other things that were going on. 00:10:39.690 --> 00:10:41.990 position:50% align:middle So I have this map of Washington State here. 00:10:41.990 --> 00:10:44.860 position:50% align:middle It only shows three counties. 00:10:44.860 --> 00:10:47.010 position:50% align:middle Two of the programs are in the same county. 00:10:47.010 --> 00:10:52.330 position:50% align:middle But one thing that's very important to know is that there's a mountain range that goes right here. 00:10:52.330 --> 00:10:58.930 position:50% align:middle So this does represent urban and rural, even though they're all essentially touching. 00:10:58.930 --> 00:11:05.710 position:50% align:middle And we also wanted to focus on... 00:11:05.710 --> 00:11:09.110 position:50% align:middle And again, since this was kind of a one-shot wonder, we're not doing across the whole course, 00:11:09.110 --> 00:11:10.215 position:50% align:middle let alone a whole program. 00:11:10.215 --> 00:11:14.670 position:50% align:middle We're doing literally one set of learning objectives. 00:11:14.670 --> 00:11:22.298 position:50% align:middle We wanted to focus on students who are in their first acute care clinical site or course. 00:11:22.298 --> 00:11:28.120 position:50% align:middle And we focused on four specific learning objectives that we thought were complex enough that we could see 00:11:28.120 --> 00:11:32.300 position:50% align:middle changes or improvement in them, but also simple enough that you could address them 00:11:32.300 --> 00:11:34.470 position:50% align:middle in somebody's first clinical course. 00:11:34.470 --> 00:11:39.510 position:50% align:middle So our learning objectives were identify actual potential safety hazards in the patient environment, 00:11:39.510 --> 00:11:44.280 position:50% align:middle apply therapeutic communication with patients and families, demonstrate effective interprofessional 00:11:44.280 --> 00:11:48.960 position:50% align:middle communication using Esper, and demonstrate safe medication administration. 00:11:48.960 --> 00:11:56.240 position:50% align:middle And again, similar to one of the other studies that was presented, we had this really well-controlled 00:11:56.240 --> 00:11:58.910 position:50% align:middle simulation environment for two of our arms. 00:11:58.910 --> 00:12:00.884 position:50% align:middle And then we had clinical. 00:12:00.884 --> 00:12:03.820 position:50% align:middle And we had no idea what was going to go on in clinical. 00:12:03.820 --> 00:12:13.050 position:50% align:middle We did, again, try to have learning objectives that can reasonably be addressed in first acute care, clinical. 00:12:13.050 --> 00:12:17.640 position:50% align:middle And also provided training for those clinical instructors to try to get some continuity 00:12:17.640 --> 00:12:25.060 position:50% align:middle around pre-briefing facilitation and debriefing across the screen-based virtual, the manikin-based simulation, 00:12:25.060 --> 00:12:27.320 position:50% align:middle and the traditional clinical experience. 00:12:27.320 --> 00:12:35.674 position:50% align:middle So really trying to compare the times, and the modality that students were exposed to. 00:12:37.630 --> 00:12:40.300 position:50% align:middle So this is what the students did. 00:12:40.300 --> 00:12:43.360 position:50% align:middle We had our group of pre-licensure nursing students. 00:12:43.360 --> 00:12:49.310 position:50% align:middle And before going into their activity, they did a pre-test, 00:12:49.310 --> 00:12:56.100 position:50% align:middle just a cognitive knowledge pre-test of 20 questions for...I'm sorry, five, 00:12:56.100 --> 00:12:58.930 position:50% align:middle addressing each of those four learning objectives. 00:12:58.930 --> 00:13:03.200 position:50% align:middle And then they were randomized to either do four hours of traditional clinical experience, 00:13:03.200 --> 00:13:07.670 position:50% align:middle two hours of screen-based simulation, or two hours of manikin-based simulation. 00:13:07.670 --> 00:13:14.340 position:50% align:middle And again, trying to keep as much control around the variables in terms of pre-briefing facilitation 00:13:14.340 --> 00:13:16.510 position:50% align:middle and debriefing, and really having that modality. 00:13:16.510 --> 00:13:18.040 position:50% align:middle And then, obviously, the time difference. 00:13:18.040 --> 00:13:22.630 position:50% align:middle So the four hours of traditional clinical versus the two hours of each of the simulation. 00:13:22.630 --> 00:13:31.070 position:50% align:middle And then once they were done with those activities, they did a post-test knowledge exam. 00:13:31.070 --> 00:13:34.490 position:50% align:middle Again, different questions, but five addressing each of the 00:13:34.490 --> 00:13:37.000 position:50% align:middle four learning objectives. 00:13:37.000 --> 00:13:39.180 position:50% align:middle And then a patient care performance assessment. 00:13:39.180 --> 00:13:46.240 position:50% align:middle So for this, students individually went in, and there was videotape so that somebody could assess 00:13:46.240 --> 00:13:51.750 position:50% align:middle it later, a standardized patient encounter where they took care of a patient. 00:13:51.750 --> 00:13:54.880 position:50% align:middle And each of these learning objectives were addressed. 00:13:54.880 --> 00:13:56.890 position:50% align:middle So we had a trained actor. 00:13:56.890 --> 00:13:59.640 position:50% align:middle They were videotaped. Students went in individually. 00:13:59.640 --> 00:14:09.550 position:50% align:middle And then we later on, a masked viewer, somebody who didn't know what group the student was in, 00:14:09.550 --> 00:14:15.050 position:50% align:middle rated those patient care performance using the Lasater Clinical Judgment Rubric, 00:14:15.050 --> 00:14:22.130 position:50% align:middle which has the four concepts of noticing, interpreting, responding, and reflecting. 00:14:22.130 --> 00:14:27.420 position:50% align:middle And then the Creighton Competency Evaluation Instrument, which looks at patient safety, assessment, 00:14:27.420 --> 00:14:30.090 position:50% align:middle communication, and clinical judgment. 00:14:30.090 --> 00:14:33.020 position:50% align:middle And then this was all part of their coursework. 00:14:33.020 --> 00:14:37.730 position:50% align:middle So, of course, wanted to give everybody an equal shot at everything. 00:14:37.730 --> 00:14:44.350 position:50% align:middle So then after they had done those assessments, that was our outcome data primarily, 00:14:44.350 --> 00:14:46.840 position:50% align:middle all the students eventually did all of the activities. 00:14:46.840 --> 00:14:48.256 position:50% align:middle Not on the same day. 00:14:48.256 --> 00:14:52.050 position:50% align:middle This happened over a course of several weeks. 00:14:52.050 --> 00:14:55.740 position:50% align:middle But everybody eventually got to do all of the activities. 00:14:55.740 --> 00:14:58.990 position:50% align:middle That makes the IRB really happy, and it's just the right thing to do. 00:14:58.990 --> 00:15:03.650 position:50% align:middle And then once they had done everything, then we did a survey where we asked them. 00:15:03.650 --> 00:15:10.480 position:50% align:middle So there's the Clinical Learning Environment Comparison Scale that we used, and students were able to go in, 00:15:10.480 --> 00:15:15.150 position:50% align:middle and assess how well they thought each environment...now that they'd experienced them all, 00:15:15.150 --> 00:15:19.390 position:50% align:middle how well each environment met their learning needs. 00:15:19.390 --> 00:15:27.270 position:50% align:middle And then a subset of students also came in and did a cognitive task analysis interview, 00:15:27.270 --> 00:15:35.590 position:50% align:middle to get some ideas of how well each learning environment helped them become better clinical judgers... 00:15:35.590 --> 00:15:38.740 position:50% align:middle improve their clinical judgment. 00:15:39.841 --> 00:15:41.870 position:50% align:middle Any questions about this? 00:15:41.870 --> 00:15:45.840 position:50% align:middle I feel like sometimes it makes perfect sense to me, but I've not explained it very well. 00:15:45.840 --> 00:15:47.490 position:50% align:middle [inaudible]. Yeah? 00:15:47.490 --> 00:15:51.465 position:50% align:middle - [Male] What were you using for the performance assessment? 00:15:51.465 --> 00:15:53.826 position:50% align:middle The pre-test and post-test? 00:15:53.826 --> 00:15:57.216 position:50% align:middle - Those were items that Elsevier gave us. 00:15:57.216 --> 00:16:01.302 position:50% align:middle And they were multiple choice items. Yep. Yeah? 00:16:01.302 --> 00:16:02.718 position:50% align:middle - [Female] I have just one question about the manikin. 00:16:02.718 --> 00:16:05.219 position:50% align:middle Is it high fidelity, or just... 00:16:05.219 --> 00:16:08.080 position:50% align:middle - They were high fidelity. Yep. 00:16:08.080 --> 00:16:16.240 position:50% align:middle Across the sites, I'm not sure if there was variability in exactly which model, but they were high fidelity. 00:16:16.241 --> 00:16:18.173 position:50% align:middle Yeah. Great. 00:16:19.691 --> 00:16:20.890 position:50% align:middle Okay, so our results. 00:16:20.891 --> 00:16:28.040 position:50% align:middle A lot more than 152 students did part of this study, but that's how many students did the whole darn thing, 00:16:28.041 --> 00:16:32.177 position:50% align:middle and that we actually were able to use the results for. 00:16:32.177 --> 00:16:41.620 position:50% align:middle 59.21% were the private institution, 88% in urban location, 59.21% were BSN, 00:16:41.621 --> 00:16:45.530 position:50% align:middle so obviously the corollary would be ADN. 00:16:45.531 --> 00:16:48.780 position:50% align:middle Forty-six percent had prior health care experience. 00:16:48.781 --> 00:16:52.500 position:50% align:middle Most had English as a first language. 00:16:52.501 --> 00:16:57.510 position:50% align:middle Eighty-two percent were female, and the age range was kind of what you'd expect. 00:16:57.511 --> 00:17:01.580 position:50% align:middle In fact, I think that might be the exact number that we saw previously. 00:17:01.581 --> 00:17:05.850 position:50% align:middle I think 53 was the highest age that we saw in a previous slide. 00:17:05.851 --> 00:17:13.280 position:50% align:middle So this was our sample, and this is what we found. 00:17:13.281 --> 00:17:17.640 position:50% align:middle So the first aim to assess the comparative effectiveness of the three types of experiential 00:17:17.641 --> 00:17:23.960 position:50% align:middle learning activities, measuring cognitive learning, patient care performance outcomes of students who 00:17:23.961 --> 00:17:28.010 position:50% align:middle participated in either four hours of traditional clinical, two hours of manikin-based simulation, 00:17:28.010 --> 00:17:30.380 position:50% align:middle or two hours of screen-based simulation. 00:17:30.380 --> 00:17:32.770 position:50% align:middle So we've got pre-test, post-test. 00:17:32.770 --> 00:17:36.190 position:50% align:middle There was no difference between the groups. 00:17:36.190 --> 00:17:38.020 position:50% align:middle So again, as good as. 00:17:38.020 --> 00:17:44.450 position:50% align:middle We're not looking for significant improvement. 00:17:44.450 --> 00:17:49.030 position:50% align:middle And then with the patient care performance outcomes. 00:17:49.030 --> 00:17:56.730 position:50% align:middle So this is supposed to represent the little video camera with their standardized patient encounter. 00:17:56.730 --> 00:18:00.490 position:50% align:middle I'm having fun with Microsoft icons. 00:18:00.490 --> 00:18:06.040 position:50% align:middle There were no significant differences between the students who participated in the four hours 00:18:06.040 --> 00:18:08.230 position:50% align:middle of traditional clinical, two hours of manikin-based simulation, 00:18:08.230 --> 00:18:11.550 position:50% align:middle or two hours of screen-based virtual simulation. 00:18:13.700 --> 00:18:15.730 position:50% align:middle I said that wrong. 00:18:15.730 --> 00:18:20.960 position:50% align:middle The students who participated in the virtual or manikin-based simulation did as well or 00:18:20.960 --> 00:18:23.930 position:50% align:middle significantly better, depending on which item we're looking at, 00:18:23.930 --> 00:18:27.190 position:50% align:middle than the students in the four hours of traditional clinical. 00:18:27.190 --> 00:18:32.130 position:50% align:middle The one thing that...and this has been important for the regulatory conversation, 00:18:32.130 --> 00:18:39.960 position:50% align:middle is the students in the screen-based virtual simulation did not perform as well in the area of patient safety. 00:18:39.960 --> 00:18:46.610 position:50% align:middle So that is one thing that has kind of come up again and again, when we tried to say what can be counted using 00:18:46.610 --> 00:18:52.678 position:50% align:middle this one-to-two ratio to replace traditional clinical. 00:18:54.540 --> 00:18:55.465 position:50% align:middle And then the second aim. 00:18:55.465 --> 00:19:01.110 position:50% align:middle Examine how each type of experiential activity informs nursing students' clinical judgments. 00:19:01.110 --> 00:19:08.590 position:50% align:middle So again, this Clinical Learning Environment Comparison Survey is where the students look at after they've done 00:19:08.590 --> 00:19:09.530 position:50% align:middle all the activities. 00:19:09.530 --> 00:19:14.930 position:50% align:middle So again, first outcome data is all from after they've only done one of the activities. 00:19:14.930 --> 00:19:20.050 position:50% align:middle But then after they've done all of the activities, they were able to tell us how well they thought that 00:19:20.050 --> 00:19:24.030 position:50% align:middle each of the learning activities met their learning needs. 00:19:24.030 --> 00:19:28.580 position:50% align:middle And the way I like to describe the results from this piece is that the grass is always greener 00:19:28.580 --> 00:19:30.000 position:50% align:middle on the other side. 00:19:30.000 --> 00:19:36.650 position:50% align:middle So students who did clinical first thought that the manikin-based simulation was significantly better. 00:19:36.650 --> 00:19:41.880 position:50% align:middle Students who did the manikin-based simulation thought that traditional clinical met their 00:19:41.880 --> 00:19:44.320 position:50% align:middle learning needs better. 00:19:44.320 --> 00:19:49.200 position:50% align:middle And nobody really preferred the screen-based virtual simulation. 00:19:49.200 --> 00:19:51.340 position:50% align:middle And then the cognitive task analysis interview. 00:19:51.340 --> 00:19:55.430 position:50% align:middle This just got some themes out. What is it? 00:19:55.430 --> 00:20:00.230 position:50% align:middle What is it about the each of the learning environments that you thought was better or worse? 00:20:00.230 --> 00:20:04.020 position:50% align:middle And I've got a couple of quotes that I wanted to share with you. 00:20:04.020 --> 00:20:08.850 position:50% align:middle The first theme was around the advantages of simulation. 00:20:08.850 --> 00:20:11.950 position:50% align:middle And one of the students said, "Simulations are more..." 00:20:11.950 --> 00:20:15.980 position:50% align:middle Or one of the themes is that simulations are more active than traditional clinical. 00:20:15.980 --> 00:20:20.620 position:50% align:middle So a student said, "When you're in simulation, you're constantly doing something. 00:20:20.620 --> 00:20:25.510 position:50% align:middle We were constantly debriefing on what we could do better." 00:20:25.510 --> 00:20:30.850 position:50% align:middle And then another advantage was that clinical is less focused and has more wait time. 00:20:30.850 --> 00:20:35.390 position:50% align:middle So an example of a quote was, "I feel that I learned most about the nurses and their 00:20:35.390 --> 00:20:40.170 position:50% align:middle daily routine in their shift, but I don't feel like I am learning a lot 00:20:40.170 --> 00:20:44.730 position:50% align:middle about clinical judgment, or how they make their choices for their patients." 00:20:44.730 --> 00:20:51.030 position:50% align:middle And then the second kind of overarching thing was the simulation had some disadvantages. 00:20:51.030 --> 00:20:55.830 position:50% align:middle And so one of the quotes that a student said, "It's always better to have something that's real. 00:20:55.830 --> 00:21:00.090 position:50% align:middle Anything that can give you those initial clues. 00:21:00.090 --> 00:21:04.530 position:50% align:middle With a manikin, you can only do so much, but then you're trusting that the scenario runs some 00:21:04.530 --> 00:21:07.673 position:50% align:middle other way to make up for the nonverbal cues that you miss." 00:21:07.673 --> 00:21:11.320 position:50% align:middle And I thought, "Well, I don't think I could say it better myself." 00:21:11.320 --> 00:21:17.440 position:50% align:middle That's exactly the advantages and disadvantages of the simulations, at least that they did as part 00:21:17.440 --> 00:21:18.632 position:50% align:middle of this study. 00:21:20.800 --> 00:21:26.090 position:50% align:middle And I should say that the screen-based virtual simulations were open source ones that are 00:21:26.090 --> 00:21:32.630 position:50% align:middle available online, where there's live action, and then you pick kind of a branching scenario of 00:21:32.630 --> 00:21:34.052 position:50% align:middle what will happen next. 00:21:36.490 --> 00:21:40.860 position:50% align:middle And then the third aim was to conduct the cost utility analysis, comparing the three types 00:21:40.860 --> 00:21:42.720 position:50% align:middle of experiential activities. 00:21:42.720 --> 00:21:46.450 position:50% align:middle And this kind of inverted triangle here is just... 00:21:46.450 --> 00:21:49.990 position:50% align:middle Manikin-based simulation is super expensive. 00:21:49.990 --> 00:21:56.210 position:50% align:middle And even though it was shown to be as effective, or by some measures, 00:21:56.210 --> 00:22:04.810 position:50% align:middle more effective than the traditional clinical, the costs completely obliterated that in terms 00:22:04.810 --> 00:22:06.400 position:50% align:middle of the cost utility. 00:22:06.400 --> 00:22:14.490 position:50% align:middle And then the screen-based simulation is less expensive, but also a little bit less effective 00:22:14.490 --> 00:22:15.820 position:50% align:middle than the manikin-based simulation. 00:22:15.820 --> 00:22:23.620 position:50% align:middle And then clinical is quite affordable from the perspective of the nursing education program. 00:22:23.620 --> 00:22:30.850 position:50% align:middle So when you look at things in terms of the cost per unit of utility, it switches things up a little bit. 00:22:30.850 --> 00:22:37.520 position:50% align:middle And certainly, when you're thinking about a program director or dean, who's trying...if you count an hour 00:22:37.520 --> 00:22:43.060 position:50% align:middle spent in simulation as two hours of required clinical time, you're kind of getting double bang for your buck. 00:22:43.060 --> 00:22:45.840 position:50% align:middle But it's even more expensive than double. Yeah? 00:22:46.400 --> 00:22:50.382 position:50% align:middle - [Female] What was your clinical faculty-to-student ratio? 00:22:50.382 --> 00:23:00.000 position:50% align:middle - Super, super good question. For the clinical, it was 8-to-10-ish. 00:23:00.000 --> 00:23:02.310 position:50% align:middle We have another publication that's coming out. 00:23:02.310 --> 00:23:05.730 position:50% align:middle I'm pretty sure that it's around that, 8-to-10. 00:23:05.730 --> 00:23:09.270 position:50% align:middle Whereas for the manikin-based simulation, and even the screen-based simulation, 00:23:09.270 --> 00:23:10.590 position:50% align:middle it was four-to-five. 00:23:10.590 --> 00:23:14.120 position:50% align:middle So that makes a huge, huge difference in this cost-utility analysis. 00:23:14.120 --> 00:23:19.750 position:50% align:middle We think about the equipment and the facilities, albeit expensive, but people are really expensive too, 00:23:19.750 --> 00:23:25.130 position:50% align:middle high-trained people, to be clinical instructors, or to be simulation facilitators. 00:23:25.130 --> 00:23:30.080 position:50% align:middle So yeah, this has been a huge part of the conversation in the rule-making process. 00:23:30.080 --> 00:23:32.890 position:50% align:middle And I guess I'll just tell you. 00:23:32.890 --> 00:23:37.880 position:50% align:middle One of the things that we've kind of boiled down to, there's some evidence, 00:23:37.880 --> 00:23:45.750 position:50% align:middle one recommendation from Kurl et al., 2016, was to have a faculty-to-student ratio of, I think, 00:23:45.750 --> 00:23:48.070 position:50% align:middle it was one-to-five. In the Sullivan et al. 00:23:48.070 --> 00:23:51.740 position:50% align:middle article, the students that were followed, it was actually a very small number of students who 00:23:51.740 --> 00:23:56.830 position:50% align:middle were...that data were collected on who were participating in the simulation study. 00:23:56.830 --> 00:24:01.410 position:50% align:middle And finally, what we're thinking at this time, we're still in the middle of the rule-making process, 00:24:01.410 --> 00:24:06.790 position:50% align:middle is that it needs to be driven by the learning needs of the student, and we need to document that the student's 00:24:06.790 --> 00:24:08.760 position:50% align:middle learning needs are being met. 00:24:08.760 --> 00:24:13.840 position:50% align:middle So if you have a really good observation tool, or something like that, 00:24:13.840 --> 00:24:18.700 position:50% align:middle that active observers are using, maybe that can increase your faculty-to-student ratio. 00:24:18.700 --> 00:24:22.160 position:50% align:middle But that's a big part of the conversation. 00:24:22.160 --> 00:24:24.380 position:50% align:middle Thank you for asking that. 00:24:24.380 --> 00:24:28.370 position:50% align:middle So the big takeaway for students who are in their first clinical course, again, 00:24:28.370 --> 00:24:32.420 position:50% align:middle kind of narrowing down the generalizability of this a little bit, focusing on the 00:24:32.420 --> 00:24:34.360 position:50% align:middle four study-related objectives. 00:24:34.360 --> 00:24:39.700 position:50% align:middle Those who participated in two hours of high-quality manikin-based simulation performed as well or 00:24:39.700 --> 00:24:44.140 position:50% align:middle significantly better on measures of cognitive learning and patient care performance than those who 00:24:44.140 --> 00:24:50.140 position:50% align:middle participated in two hours of high-quality screen-based simulation, or four hours of high-quality 00:24:50.140 --> 00:24:52.169 position:50% align:middle traditional clinical activities. 00:24:53.430 --> 00:25:00.500 position:50% align:middle And this is supposed to be a pie, but I couldn't find the appropriate icon. 00:25:00.500 --> 00:25:08.330 position:50% align:middle But the point that I'm trying to make here is that this is one very tiny slice of an entire pie of conversation 00:25:08.330 --> 00:25:12.820 position:50% align:middle around regulating simulation, regulating that you're applying the 00:25:12.820 --> 00:25:16.160 position:50% align:middle one-to-two simulation, talking about faculty-to-student ratio. 00:25:16.160 --> 00:25:22.730 position:50% align:middle And this is the publication, the top one that's in the "Journal of Nursing Regulation." 00:25:22.730 --> 00:25:27.610 position:50% align:middle The second one will be coming out in "Journal of Nursing Education" someday. 00:25:27.610 --> 00:25:34.820 position:50% align:middle And then we are in the rule-making process for SB 5582 in Washington State. 00:25:34.820 --> 00:25:36.190 position:50% align:middle So stay tuned. 00:25:36.190 --> 00:25:39.420 position:50% align:middle And that's my email address. And I thank you all very much. 00:25:39.420 --> 00:25:43.870 position:50% align:middle Oh, and thank you to all of these people, the Washington Board of Nursing, Northwest University, 00:25:43.870 --> 00:25:46.500 position:50% align:middle Seattle University, Tacoma Community College, and Yakima Valley College, 00:25:46.500 --> 00:25:50.590 position:50% align:middle and to NCSBN Center for Regulatory Excellence. 00:25:50.590 --> 00:25:52.100 position:50% align:middle So I'm happy to take questions. 00:25:52.100 --> 00:25:55.134 position:50% align:middle I see we're dialing down here on the clock. Yeah? 00:25:55.134 --> 00:25:59.296 position:50% align:middle - [Female] [inaudible] I'll come to the mic. 00:26:00.464 --> 00:26:08.430 position:50% align:middle I'm wondering, from board of nursing perspective, as a past educator, I guess, working in academia, 00:26:08.430 --> 00:26:15.780 position:50% align:middle and now with board of nursing, what was the compelling evidence, 00:26:15.780 --> 00:26:22.570 position:50% align:middle or body of compelling evidence that was the impetus for, "Hey, board of nursing, 00:26:22.570 --> 00:26:28.922 position:50% align:middle you need to make rules surrounding one-to-two ratio versus one-to-one." 00:26:28.922 --> 00:26:31.300 position:50% align:middle - I would love to know. 00:26:31.300 --> 00:26:36.050 position:50% align:middle But I guess the conversation that I have tried to tell all of our stakeholders, 00:26:36.050 --> 00:26:41.670 position:50% align:middle and interested parties as they come and giving us input, is we have this much evidence to support 00:26:41.670 --> 00:26:42.580 position:50% align:middle the one-to-two ratio. 00:26:42.580 --> 00:26:49.040 position:50% align:middle So we are in the weeds, and trying to extrapolate from that to help guide the 00:26:49.040 --> 00:26:52.110 position:50% align:middle rules from the board of nursing, if that makes sense. 00:26:52.110 --> 00:26:53.290 position:50% align:middle - Yeah, absolutely. 00:26:53.290 --> 00:26:58.215 position:50% align:middle I mean, this is exactly where I am living, because I'm living in this world, 00:26:58.215 --> 00:27:05.089 position:50% align:middle sort of watching and waiting [inaudible] sort of, and using what we have [inaudible] 00:27:05.089 --> 00:27:11.465 position:50% align:middle national council, as sort of our guardrails, if you will, while we're sort 00:27:11.465 --> 00:27:12.500 position:50% align:middle of [inaudible] it out. 00:27:12.500 --> 00:27:16.290 position:50% align:middle - Yeah. And we do have the healthcare simulation standards of best practice. 00:27:16.290 --> 00:27:22.210 position:50% align:middle We do have the ability to ask people to evaluate how this is going. 00:27:22.210 --> 00:27:25.320 position:50% align:middle Because yeah, it's a pretty small body of evidence. 00:27:25.320 --> 00:27:27.560 position:50% align:middle - Thank you for your work. - Yeah. Yeah. 00:27:27.560 --> 00:27:29.320 position:50% align:middle - Thank you for digging in and doing the hard work. 00:27:29.320 --> 00:27:30.200 position:50% align:middle - For sure. 00:27:30.785 --> 00:27:35.760 position:50% align:middle - [Barbara] Hi, Barbara Blozen, [SP] New Jersey and Area 4 director. 00:27:35.760 --> 00:27:39.400 position:50% align:middle So first, thank you for this simulation work. 00:27:39.400 --> 00:27:42.970 position:50% align:middle I'm reading everything simulation right now. 00:27:42.970 --> 00:27:45.050 position:50% align:middle I'm doing my homework. 00:27:45.050 --> 00:27:55.000 position:50% align:middle Because we are looking at making a statement about how much simulation we allow in New Jersey. 00:27:55.000 --> 00:28:05.710 position:50% align:middle So one of the questions I have for you is, in the article, in the original watershed study done 00:28:05.710 --> 00:28:20.230 position:50% align:middle by NCSBN, that was for programs...the 50% was for programs that had 600 hours or over of clinical time. 00:28:20.230 --> 00:28:26.800 position:50% align:middle So do any of these programs have clinical time that's less than 600? 00:28:26.800 --> 00:28:29.260 position:50% align:middle - Yes. - Okay. 00:28:29.260 --> 00:28:33.220 position:50% align:middle And you're still applying the same standard? 00:28:33.872 --> 00:28:39.070 position:50% align:middle - I wish I'd brought my stakeholder slides, because I have got this whole pie chart of how 00:28:39.070 --> 00:28:44.600 position:50% align:middle for LPN programs, who require significantly less than 600 hours, this is what it's going to do 00:28:44.600 --> 00:28:47.420 position:50% align:middle to the contact time. 00:28:47.420 --> 00:28:55.574 position:50% align:middle I don't want to say it wrong, but I think BSN is 600, ADN is 500, and LPN, I think, is 300. 00:28:55.574 --> 00:28:56.560 position:50% align:middle Don't quote me on that. 00:28:56.560 --> 00:28:59.260 position:50% align:middle But yeah, when you take 50% of that, it gets really small. 00:29:00.000 --> 00:29:02.006 position:50% align:middle - Okay. Thank you. - Yeah. 00:29:06.200 --> 00:29:08.870 position:50% align:middle - [Rebecca] Hi. I'm Rebecca from Mississippi. 00:29:08.870 --> 00:29:12.870 position:50% align:middle Out of education now, I'm with a private stakeholder. 00:29:12.870 --> 00:29:21.820 position:50% align:middle So my question is, we're talking about the time in simulation versus time in clinical. 00:29:21.820 --> 00:29:26.090 position:50% align:middle And we're very rigid, and we want to regulate what we do in SIM. 00:29:26.090 --> 00:29:30.740 position:50% align:middle And I'm sure you've probably clearly defined it in your study. 00:29:30.740 --> 00:29:33.930 position:50% align:middle Did anyone dare to clearly define what you did in clinical? 00:29:33.930 --> 00:29:36.030 position:50% align:middle - In the study, yes. 00:29:39.174 --> 00:29:44.720 position:50% align:middle The clinical instructors came to a facilitation training where we went over basically what we go 00:29:44.720 --> 00:29:50.450 position:50% align:middle over in pre-briefing facilitation, debriefing, very short but just to provide some standardization 00:29:50.450 --> 00:29:53.360 position:50% align:middle across those experiences. 00:29:53.360 --> 00:29:57.990 position:50% align:middle And there is a whack around requirements for clinical instructors and those types of things. 00:29:57.990 --> 00:30:01.340 position:50% align:middle But I think you ask a great question, is that we're getting down to the nitty-gritty 00:30:01.340 --> 00:30:03.964 position:50% align:middle around simulation, but what's going on in the clinical environment. 00:30:03.964 --> 00:30:05.570 position:50% align:middle That's great. 00:30:05.570 --> 00:30:07.620 position:50% align:middle And we're out of time, so if people need to go on to the next thing, 00:30:07.620 --> 00:30:10.900 position:50% align:middle I'm happy to stick around and answer questions, but I also don't want to...