# data[].attributes.body
Introduction to the Future of information management and nursing informatics

# data[].attributes.attachment_link.authors[].name
HealthySimulation - Medical Simulation Resources

# data[].attributes.attachment_link.title
Pocket Nurse Distributes New VR Training Tool for Nurses | IMSH 2017 Interview

# data[].attributes.body
Enhances delivery of care :

# data[].attributes.attachment_link.readable_text
by June Kaminski, RN MSN PhD(c) Editor in Chief

CJNI was initiated by June Kaminski in 2006 when she was President-Elect of CNIA. She is currently Curriculum Coordinator of a BSN Advanced Entry nursing program at Kwantlen Polytechnic University; Past President of the Canadian Nurses for Health and the Environment and Editor in Chief of the Online Journal of Nursing Informatics In 2012, June was honored to receive the CASN and Canada Health Infoway's inaugural Nursing Faculty E-Health Award 2012 in Ottawa Canada. She also won the Distinguished Teaching Award from Kwantlen Polytechnic University in 2016. She offers the Nursing Informatics Learning Centre for nurses.

EDITORIAL

Technology and informatics-related processes and activities continue to evolve with each passing year. As we finish 2019 and move into 2020, a few trends in this evolution come to mind - ones that could serve healthcare and nursing well. Here are my predicted top trends for 2020.

Speech Recognition Software

Several experts including Dr. Eric Topol have advocated for speech-recognition software to address the burn-out and time consuming need to document through typing into electronic health systems. Although voice-recognition software has been available for decades, the precision that is needed to be useful to healthcare has rarely been realized until recently. Even now, available software requires more sophistication to be seamless and adaptable to health provider needs. Dr. Topol expanded on why voice recognition software could be a real boon for healthcare communication and documentation through "...keyboard liberation or using natural language processing of speech to synthesize notes and eliminate the ultimate source of distraction and dislike in medical encounters" (O'Connor, 2019, p.1). This is a trend to watch for in 2020, one that could make nurses' work life much easier and less time-consuming.

View the Video: The Benefits of Speech Recognition - G2 Speech (1:26 minutes)

G2 Speech. (2019, June 6). The Benefits of Speech Recognition - G2 Speech. Video File. Retrieved from https://youtu.be/GdA6g1gHOcc

As well, speech-recognition software can act as an assistant to people in general. For example, Amazon Alexa and Leela can interface with clients to help them to set appointments, receive results, and record readings. This virtual assistant approach can also be used within healthcare facilities to enhance access to information and support. This is another trend to look out for this year. View this brief video to see examples of these systems in action within people's homes:

Voice technology for the healthcare industry (0.32 minutes)

Personalized Healthcare

Machine learning, artificial intelligence, wearable and portable biosensors will contribute to the rise of true personalized medicine and healthcare. This trend includes personalized or precision medicine, defined as "...the tailoring of medical treatment to the individual characteristics of each patient. The approach relies on scientific breakthroughs in our understanding of how a person's unique molecular and genetic profile makes them susceptible to certain diseases. This same research is increasing our ability to predict which medical treatments will be safe and effective for each patient, and which ones will not be" (Personalized Medicine Coalition, n.d., p. 1).

Personalized healthcare also has a more expansive meaning, that incorporates client preferences, choices, and input to truly tailor their own healthcare. "An array of new technology advancements, including 3-D printing, robotics, nanotechnology, genetic coding, and therapeutic options can permit more personalized and accessible patient care. Many devices and equipment are getting smaller and more portable, and treatments will likely become more targeted-all of which can make future health care more mobile and precise. This, in turn, should increase staff and process efficacy and improve patient outcomes, as clinicians will be able to quickly find the best treatment option rather than try multiple interventions. Personalization of medications, for instance, will be based on a patient's genetic profile and the use of precision medicine, whereas designs for 3-D-printed prostheses will be based largely on a patient's specific anatomy" (Deloitte Development, 2017, p. 6).

Many people use health apps that they can download from the Apple or Android Stores to monitor their own health particulars, track health behaviors or data progressions such as weight loss, or fertility related data. People also often use wearable devices such as fitness trackers to monitor and track their physical activity which may include GPS related data such as location, and routes used for running and walking. Other apps may be used to monitor more physiological data such as pacemaker activity, heart rate, blood pressure, and so on. All in all, apps must meet standards to be recommended to clients. Health professionals can suggest which apps are the best choices for keeping their data secure, affording the best experience for the client through expert design, and API connected so that data can be shared with their health providers if they so choose.

Mobile apps used within practice need stringent measures built in to ensure personal health information (PHI) protection using APIs, encryption, and data capture solutions. Using mobile and wearable apps can significantly boost communication and understanding between health professionals and patients. When apps are designed according to national standards, they can be very efficient modes for sharing data on a regular basis that can support goals, tracking to gauge progress, and keep an eye on conditions that require monitoring which all contribute to personalized healthcare.

View this brief video to see examples of these systems in action:

Dr Eric Topol: Preparing the healthcare workforce to deliver the digital future (3:57 minutes)

Predictive, Prescriptive and Cognitive Analytics

As technology continues to evolve, exciting new abilities are emerging which show great potential in supporting personalized, value-based care. Technologies such as artificial intelligence (AI), predictive analytics and cognitive computing all show great promise in helping health professionals make valuable predictions of trends, diagnoses and outcomes. "AI is the field of study that attempts to replicate human abilities, but without human limitations of time, energy and power. By using advanced algorithms, data processing capabilities and IT systems can produce data driven predictions within seconds - with little to no human intervention. Predictive analytics backed by real time and historic data processing can identify risky medical conditions ahead of time.

Predictive analytics uses technology and statistical methods to search through massive amounts of information, analyzing it to predict outcomes for individual patients. In medicine, predictions can range from responses to medications, to hospital readmission rates. Examples include predicting infections from methods of suturing, determining the likelihood of disease, helping a physician with a diagnosis, and even calculating future wellness" (Patil, 2019, p.1).

Innovators in healthcare technology are working on ways to seamlessly incorporate predictive analytics and AI into electronic health records (EHR) using deep and machine learning coupled with natural language processing techniques to move more towards personalized healthcare. Predicting outcomes from historical data is nothing new in healthcare - health professionals have used it for years. For instance if people engage in certain behaviors such as smoking, eating a high-fat, high-sugar diet, living sedentary lives, and so on, health care professionals can predict likely outcomes. However with predictive analytics, health professionals can tie together all sorts of protected health information (PHI) or big data to personalize predictions beyond common generalizations such as smoking leads to lung cancer or chronic lung conditions in many people. But it does not stop there: predictive analytics is just the beginning of imminent powerful analytics in healthcare. Analytic types currently include descriptive, diagnostic, predictive, prescriptive, and cognitive analytics (Figure 1).

Figure 1: Descriptive, diagnostic, predictive, prescriptive, and cognitive analytics.

Predictive analytics is only one type of analysis that can be used in healthcare. An essential dichotomy of analysis methods are now within reach - each level provides a unique perspective of health data and degree of sophistication. Descriptive and diagnostic analysis have been used in healthcare for decades, but predictive is just emerging, and prescriptive and cognitive analysis are still very rare.

Prescriptive analytics uses optimized algorithms, modeling, rules and decision techniques to build on predictive results and propose actions to be taken. "Prescriptive analytics attempt to quantify the effect of future decisions in order to advise on possible outcomes before the decisions are actually made, it tries to provide how to do the actions and what are the consequences of these actions to derive a better decision. Prescriptive Analytics can be used anytime you need to advise users on what action to take" (Sami, 2017, p. 1).

"Cognitive analytics combines a number of intelligent technologies like artificial intelligence, machine-learning algorithms, deep learning etc. to apply human brain-like intelligence to perform certain tasks. Basically, this type of analytics is inspired by how the human brain processes information, draws conclusions and codifies instincts and experience into learning such as understanding not only the words in a text but the full context of what is being written or spoken. All these intelligent technologies make a cognitive application smarter and more effective over time by learning from its interactions with data and with humans" (WeirdGeek, 2018, p. 1).

Together, predictive, prescriptive, and cognitive analytics can transform healthcare in astounding ways.

Although predictive analytics offers amazing insights that can support patient outcomes, personalizing healthcare also requires prescriptive and cognitive analytic capabilities coupled with stringent security features. Systems like IBM Watson can help health professionals support their clients in personalized ways that customize their treatments, client education, and healthcare decisions.

Watch the following video, for greater understanding of how predictive, prescriptive and cognitive analysis and AI can be applied to personalize healthcare for individual clients.

How It Works: IBM Watson Health (4:03 minutes)

3D Printing

3D printing is one of the most amazing and practical technologies that is rising in healthcare. "3D printing has come a long way since its debut, especially in its uses in the healthcare industry. The technology offers faster prototypes, creating everything from personalized prosthetics to "poly-pills" at a fraction of the cost. The customizable aspect of 3D printing is revolutionizing organ transplants and tissue repair, and it's even able to produce realistic skin for burn victims" (Ghosh, 2019, p. 1).

This astonishing breakthrough presents mega-opportunities to health care since these printers can be tailored to use anything from plastics to stem cells as their medium. Artificial bones can be constructed that are accepted by the body and work well after surgical reconstruction. Prosthetics can be customized more accurately for amputees, and poly-pills can be created that combine several drugs at once for people with multiple illnesses.

View the following videos to get an idea of how 3D Printing can revolutionize healthcare.

The Ultimate List of What We Can 3D Print in Healthcare - The Medical Futurist (2:58 minutes)

3D printing for biomedical applications (2:54 minutes)

Although there are many other technological breakthroughs coming down the pipeline of innovation, these trends of Speech Recognition Software, Personalized Healthcare, Predictive, Prescriptive and Cognitive Analytics, and 3D Printing are far-reaching and utilize many of these other innovations in their processes. Keep your eyes open to see how these predictions play out over the next year, and how they affect or could enhance your professional practice.

References

Conduent. (2019, February 6). Voice technology for the healthcare industry. Video File. Retrieved from https://youtu.be/HiGZHuiUO5c

Deloitte Development. (2017). The hospital of the future: How digital technologies can change hospitals globally.Retrieved from https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/us-lshc-hospital-of-the-future.pdf

G2 Speech. (2019, June 6). The Benefits of Speech Recognition - G2 Speech. Video File. Retrieved from https://youtu.be/GdA6g1gHOcc

Ghosh, I. (2019). 5 Ways Technology is Transforming the Healthcare Industry. Visual Capitalist, February 27.Retrieved from https://www.visualcapitalist.com/5-ways-technology-healthcare-industry/

Health Education England. (2018, June 26). Dr Eric Topol: Preparing the healthcare workforce to deliver the digital future.Video File. Retrieved from https://youtu.be/f2UTxtgSFzU

IBM Think Academy. (2015, May 20). How It Works: IBM Watson Health. [Video File]. Retrieved from https://youtu.be/ZPXCF5e1_HI

Intel AI. (2018). Predictive analytics in health care. White Paper. Santa Clara, CA: Intel Corporation. Retrieved from https://www.intel.ai/nervana/wp-content/uploads/sites/53/2018/05/Predictive-Analytics-in-Healthcare.pdf

O'Connor, A. (2019, March 11). How Artificial Intelligence Could Transform Medicine. The New York Times. Retrieved from https://www.nytimes.com/2019/03/11/well/live/how-artificial-intelligence-could-transform-medicine.html

Patil, A. (2019, Jan. 15). AI and predictive analytics lead to improved delivery of healthcare services. Healthcare Business & Technology. Retrieved from https://www.healthcarebusinesstech.com/ai-and-predictive-analytics-lead-to-improved-delivery-of-healthcare-services/

Personalized Medicine Coalition. (n.d.). The Age of Personalized Medicine. Retrieved from http://www.personalizedmedicinecoalition.org/Userfiles/PMC-Corporate/file/pmc_age_of_pmc_factsheet.pdf

Research Square. (2019, August 21). 3D printing for biomedical applications. Video File. Retrieved from https://youtu.be/vk6ALcQiZ2w

Sami, M. (2017). The Evolution of Analytics | The 5 Types of Analytics. Retrieved from https://melsatar.blog/2017/07/30/the-evolution-of-analytics/

The Medical Futurist. (2018, May 14). The Ultimate List of What We Can 3D Print in Healthcare - The Medical Futurist.Video File. Retrieved from https://youtu.be/9XYLRaVqzNY

WeirdGeek. (2018). 5 Types of analytics: Prescriptive, Predictive, Diagnostic, Descriptive and Cognitive Analytics.Retrieved from https://www.weirdgeek.com/2018/11/types-of-analytics/

# data[].attributes.attachment_link.description
by June Kaminski, RN MSN PhD(c) Editor in Chief CJNI was initiated by June Kaminski in 2006 when she was President-Elect of CNIA.

# data[].attributes.attachment_link.readable_text
We're often asked to explain what nursing informatics is. While it's difficult to quickly summarize this complex field, at its core, it takes the clinical and the technical languages of health and translates them into one. It also promotes meaningful, user-friendly and patient-centric innovation while driving improved outcomes for patients and enhanced clinical workflows for healthcare staff.

What is Nursing Informatics Definition?

The definition provided by the American Nurses Association (ANA) and recommended by HIMSS has become widely referenced in response to the question, "What is nursing informatics?"

Nursing informatics "is the specialty that integrates nursing science with multiple information and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice."

As a global advisor and thought leader in healthcare information and technology, HIMSS has focused on this professional field for decades. Understanding the integral role this specialty plays today in the healthcare workforce, we've worked to amplify awareness by convening the experts and conducting extensive research on the topic.

What Are Nursing Informatics Roles and Requirements?

If you're looking to venture into this field of informatics, there are a variety of different skills and qualifications that can help ensure your success:

A bachelor's degree in nursing (BSN), at minimum

A master's degree and certifications, particularly for executive roles (chief nursing informatics officer)

Experience and/or strong understanding of working in a clinical setting

Strong technical skills; ability to quickly adapt to emerging technologies and innovation

Strong project management skills

An affinity for obtaining, analyzing and strategizing about data

Understanding of medical economics

Strong interpersonal skills

Leadership experience

Here are a few of the many job titles in use today:

Nurse informaticist

Nursing informatics specialist

Nursing informatics clinician

Clinical nurse informatics specialist

Chief nursing informatics officer

Perioperative informatics nurse

The field of nursing informatics has helped drive healthcare's application of technologies such as EMRs and computerized provider order entry. Nursing informatics professionals work with a diverse group of stakeholders across the care continuum, ultimately helping to bridge the gap between clinical and technical perspectives. Their number one priority is maintaining focus on patient safety.

This role was included in the top 15 highest paying nursing professions in the U.S. The HIMSS Nursing Informatics Workforce Survey, led by the HIMSS Nursing Informatics Committee, unveiled a multitude of findings about the profession:

Over two-thirds (68%) of the 1,359 survey respondents work for a hospital or multifacility health system

Ambulatory nurse informaticists are on the rise, with 6% of respondents reporting the ambulatory environment as their primary work place

The percentage of respondents (66%) who have a master's degree in nursing (24%), nursing informatics (27%), or some other field (11%) has gone up

The role of chief nursing informatics officer/senior nursing informatics officer continues to be on the rise with 41% of respondents reporting that their organization had the formal role

Overall, the results of the survey indicated that most professionals are burning bright with potential. After all, these findings confirm that many make higher wages than the average nursing professional, they enjoy the work they do, and many of them plan to keep doing it in the future.

What is Nursing Informatics Value?

" Nursing informatics specialists are the translators that have evolved into health tech innovators who establish businesses, manage medical economics, create technology and amplify the voice of end-user clinicians," said Danielle Siarri, MSN, RN, a HIMSS member and social media ambassador, global nursing expert and the lead publisher at InnoNurse. "Healthcare and technology were separate entities that have now fused into one language which evolves daily."

Nursing informatics professionals are unique, hybrid heroes of healthcare. As advocates for impactful innovation, their work keeps patients safe and at the center. Through their contributions and guidance, workflows are improved for healthcare staff and best practices followed in the effective management of information structures, processes and technology.

Through consistent leadership and hard work, the dynamic language and energy of health information and technology continues to grow and evolve along with the nursing informatics profession.

Empowering Nursing Informatics Professionals
National Nurses Week
HIMSS joins the American Nurses Association and the Alliance for Nursing Informatics and numerous other partners in celebrating National Nurses Week each May. The purpose of this week-long celebration is to raise awareness of the value of nursing and help educate the public about the role nurses play in meeting the healthcare needs of Americans. Join us in celebrating the nurses of our nation, who are at the forefront of improving patient care and transforming healthcare.
Online Journal of Nursing Informatics (OJNI)
Powered by the HIMSS Foundation and the HIMSS Nursing Informatics Community, the OJNI is a free, international, peer-reviewed publication that is published three times a year and supports all functional areas of the field. The journal was launched in 1996, with readership spanning over 49 countries.
Alliance for Nursing Informatics (ANI)
ANI represents thousands of nurses and brings together nursing informatics groups that function separately at local, regional, national and international levels. ANI is a collaboration of organizations that represent a unified voice for nursing informatics and provides the synergy and structure needed to advance the efforts of nursing informatics professionals in improving the delivery of patient care.
Identifying for a Unique Nurse Identifier
While nurses are making a difference in patients' health outcomes, without a nurse identifier, which is a unique numeric identifier automatically generated for each RN at the time of their state board exam, health systems have no way of demonstrating the full value of nursing.

It is a free, unique identifier, publicly available, that is automatically generated for each RN and LPN at the time of their NCLEX exam. No additional action is needed. The workgroup recommends that the NCSBN ID should be used by key stakeholders as the unique nurse identifier to enable identification and demonstration of the value of nurses through documentation in the EHR and other health IT systems.
Change Management Infographic
Formed within the HIMSS CNO-CNIO Vendor Roundtable, the infographic was created with a purpose to realize the value of the health IT investment, achieve benefits and sustainable transformation required for an organizational change management approach, as well as ongoing organization/vendor relationships for continued innovation for leaders across the healthcare spectrum.
CNIO Job Description
As the Chief Nursing Informatics Officer (CNIO) role varies within healthcare organizations, it is essential to have a standardized job description that can be referenced for needed competencies regardless of specific job title. This document provides recommendations for a C-Suite level CNIO job description including qualifications and Experience, Key Responsibilities, and Reporting Structure.
The TIGER Initiative
TIGER (Technology Informatics Guiding Education Reform) is a grassroots initiative focused on education reform, fostering interprofessional community development and global workforce development. The spirit of TIGER is to maximize the integration of technology and informatics into seamless practice, education and research resource development.
Register now Originally published May 14, 2019, updated February 27, 2023

# data[].attributes.attachment_link.description
You asked, "What is nursing informatics?" And we answered. Explore the profession and how it is a driving force behind improved outcomes for patients and enhanced workflows for healthcare staff.

# data[].attributes.attachment_link.title
The Future Model of Medicine: Quantum Medicine

# data[].attributes.attachment_link.title
Better Healthcare with Quantum Computing

# data[].attributes.attachment_link.readable_text
Michelle Aebersold, PhD, RN, CHSE, FAAN

Simulation, once the domain of those faculty who enjoyed the technical aspects of using computerized mannequins, has now moved to center stage in nursing education. Nursing programs realize that they can no longer afford to consider simulation as merely an 'add-on.' Simulation today includes role play, standardized patients, virtual simulation, and computerized mannequins. It is now imperative to integrate simulation throughout the entire curriculum. Today, simulation allows students to learn skills; develop clinical reasoning abilities; and to become competent in caring for patients/families in a safe environment. The variety of simulation-based learning options can offer a way to replace traditional, and often hard to find, clinical experiences. In this article, the author describes the background, theoretical basis, and current uses of simulation; reports on simulation effectiveness in nursing; shares educational strategies to enhance effectiveness; and considers simulation methods and feedback and debriefing strategies. The conclusion addresses simulation evaluation, and the future of simulation in nursing education.

Citation: Aebersold, M., (April 3, 2018) "Simulation-Based Learning: No Longer a Novelty in Undergraduate Education" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 2.

DOI: 10.3912/OJIN.Vol23No02PPT39

Key Words: undergraduate education, simulation, virtual reality, simulation standards, mannequins, patient safety, NCLEX, NCSBN, research, fidelity

...simulation-based learning has matured as an educational strategy and research about this area has increased. Simulation in undergraduate (UG) education has become one of the new policy areas to which leaders in both nursing education and practice will want to pay careful attention. As the nursing shortage increases, the number of faculty available to educate new nurses decreases. The number and availability of clinical sites is diminishing ( American Colleges of Nursing, 2017), and we will need to rely increasingly on simulation to fill the gaps. The good news is that simulation-based learning has matured as an educational strategy and research about this area has increased. However, there remains much work to be done.

In this article, I will briefly discuss the background of simulation; address the theoretical basis, and the current uses of simulation; report on simulation effectiveness in nursing; and share educational strategies to enhance simulation effectiveness. I will discuss simulation methods, including feedback and debriefing strategies; consider simulation evaluation; and share my insights on the future of simulation opportunities for undergraduate nursing education.

[Simulation] is not defined by a technology but rather an educational approach grounded in learning theories. Simulation-based education is an educational or training method that is used to "replace or amplify real experience with guided experiences" ( Gaba, 2004b, p.i2). It is not defined by a technology but rather an educational approach grounded in learning theories. Simulation is meant to replicate aspects of the real world in an interactive manner that allows learners to be immersed in the learning environment ( Gaba, 2004b; Jeffries, 2012). Aviation and the military have used simulation to train pilots and personnel in both skills and safety-related behaviors (e.g., communication and teamwork), for many years ( Aebersold, 2016). Historically, simulation in nursing has been used primarily in undergraduate (UG) education to teach nursing skills.

The first mannequin was a life-size doll named Mrs. Chase. She was built in 1911 by a doll maker, Martha Jenkins Chase, to train nurses to dress, turn, and transfer patients ( Weir, 2012). Some early 'sim labs' were called demonstration rooms, the skills laboratory, or the nursing laboratory ( Nickerson & Pollard, 2010). Nursing students would practice on mannequins, such as Mrs. Chase, or on each other by using various training devices to learn to administer injections, insert a nasogastric tube, and other basic nursing skills.

In the 1990s there was a significant change in the world of educational simulation, a change that impacted the nursing skills laboratories. Companies, such as Laerdal™ and Medical Education Technologies, Inc. (METI), developed affordable, high fidelity simulators based on the earlier pioneering work of David Gaba and others ( Gaba, 2004a). METI was bought out by CAE™ which is now a major producer of high fidelity simulators, along with Gaumard Medical™, and Laerdal™. Subsequently, nursing education has moved from a traditional skills laboratory into the world of high fidelity simulation (HFS).

...although a sophisticated, computerized mannequin can produce a high fidelity simulation, so also can an actor who is playing a role. Many think of high fidelity simulation as highly sophisticated, computerized mannequins that can mimic the body's physiology. However, it is important to recognize today that, although a sophisticated, computerized mannequin can produce a high fidelity simulation, so also can an actor who is playing a role. Fidelity refers to realism or the ability to replicate the real 'thing' that the simulator or actor is representing. Therefore, high fidelity simulation can be done with a high fidelity simulator (i.e., a computerized mannequin) or a live person. There are a variety of simulators available, as well as several different simulation methods. The most common methods utilize computerized mannequins, role-play, standardized or simulated patients, and virtual simulations. There is now a Healthcare Simulation Dictionary, which includes all commonly used terms in simulation (Loprieato et al., 2016).

Since the 1990s there has been a tremendous amount of knowledge and research in the area of simulation-based learning. Some very important, landmark studies have been completed. Simulation has become a cornerstone of UG nursing education. It is important to understand benefits and policy implications of this shift.

Simulation-based experiences (SBEs) most often occur in a simulation laboratory setting in which the UG students come for a defined period of time and engage in activities specifically designed around a set of learning objectives. These activities are developed into simulation scenarios. The scenario contains the learning objective, the patient information (e.g., background, current condition, medications, and other relevant information), actor scripts as needed, information for the high fidelity simulator, a timeline for the unfolding of the scenario, cues needed by the facilitator to help the action flow along, and other essential information to ensure that the simulation-based learning education experience is successful.

Simulation-based education is a learner-centered approach, grounded in learning theories based on constructivism. Several educational learning theories and conceptual models guide development of SBEs. Some of the more popular ones are described below. Simulation-based education is a learner-centered approach, grounded in learning theories based on constructivism. As such, learners create their own reality and truth. To support this type of learning, activities include discussion, self-reflection, and questioning so that learners can engage actively in the learning process ( Kriz, 2010).

One popular learning theory often used to guide and develop SBEs is Kolb's Experiential Learning Theory (ELT) ( Kolb, 1984). This theory has four steps (concrete experience, reflective observation, abstract conceptualization, and active experimentation). These steps form a continuous cycle. As applied in SBEs, concrete experimentation occurs initially when learners or students engage in a simulation scenario, such as caring for a simulated patient (i.e., a high fidelity mannequin) who is experiencing a stroke. After the scenario ends, students engage in reflective observation as they debrief and reflect on their performance during the simulation and identify any gaps. The next step is abstract conceptualization. During this step, or phase, the facilitator of the SBE helps learners create or adapt their mental model to incorporate what they have learned. This is where learning occurs and where knowledge can transfer into practice when the next opportunity arises. The process in which learners put newly gained mental models into practice is referred to as the active experimentation step ( Zigmont, Kappus, & Sudikoff, 2011).

An additional theory is the NLN/Jefferies Simulation Theory ( Jeffries, Rodgers, & Adamson, 2015). This theory evolved from the NLN/Jeffries Framework ( Jeffries, 2012). It includes context, background, and simulation design characteristics. These elements lead into the simulation experience itself, which includes a dynamic interaction between the facilitator and the learner through the use of appropriate educational strategies. Outcomes occur in three areas: the system, the patient, and the participant. Adamson ( 2015) conducted a systematic literature review that included 153 articles; findings from this review supported the major components of the NLN/Jeffries ( 2015) framework.

...faculty have integrated simulation into many different undergraduate courses. A review of current literature demonstrates that faculty have integrated simulation into a many different undergraduate courses. This section will describe how simulation has already been integrated into a number of nursing programs via undergraduate course content that includes mental health, end-of-life care, mass causality situations, anatomy, and intradisciplinary and interdisciplinary communication (virtual simulation).

Mental Health
In the mental health undergraduate curriculum, use of standardized or simulated patients (SPs) (trained actors) has been found to reduce student anxiety and develop interview and therapeutic communication skills, thus increasing student confidence prior to the clinical experience ( Doolen et al., 2014). Another use of simulation in mental health nursing is to involve students in 'voice-hearing' simulations, to give them an opportunity to appreciate what it is like to live as a patient with auditory hallucinations, and to help them understand the behavioral risks associated with these conditions ( Orr, Kellehear, Armari, Pearson, & Holmes, 2013).

End-of-Life Care
Simulation at the UG level also helps students learn to provide appropriate end-of-life (EOL) care for patients and families. Students receive didactic information in class ( Allchin, 2006), yet seldom have an opportunity to care for dying patients during clinical rotations. Through simulation, however, students are exposed to EOL in several ways.

Students agreed that this type of multi-patient simulation experience improved their ability to prioritize patient needs, resolve conflicts, and track multiple responsibilities. One UG EOL simulation experience centered on an elderly patient with lung cancer that had metastasized to the liver and bone. This patient was admitted for palliative care ( Fabro et al., 2014). After students participated in this scenario, caring for the patient and family with the goal of managing the patient's pain and the family's grief, they completed a qualitative questionnaire about their experience. Students described their experiences as awkward and uncomfortable, and with feelings of sadness and helplessness. However, they also learned about what a 'good death' can look like, and how difficult it can be to administer medications and assess vital signs while the family is crying. Students went on to say that they gained new knowledge and hoped they would remember this experience when they cared for similar patients in the future.

Another multisite study about EOL care considered knowledge, self-confidence, and communication skills among baccalaureate, associate degree, and accelerated baccalaureate degree pre-licensure students. The setting for this simulation was a hospice setting. The 336 students who participated in the simulation demonstrated a significant increase in knowledge, self-confidence, and perceived communication skills ( Fluharty et al., 2012).

Mass Causality and Multi-Patient Situations
Simulation has also been used in disaster training for UG nursing students. Collaborating with a local health center to participate in a mass causality event can provide an opportunity for nursing students to experience the role of triage and also for teamwork with other care providers. Austin et al. ( 2014) found that senior nursing students, under the guidance of pediatric nursing faculty, were able to successfully participate in a community-wide, mass-causality event that increased their understanding of the disaster response process, role clarity, and teamwork. Additionally, Horsley et al. (2014) have developed a multi-patient simulation to prepare students to care for multiple patients at a time on an inpatient unit. Students agreed that this type of multi-patient simulation experience improved their ability to prioritize patient needs, resolve conflicts, and track multiple responsibilities.

Anatomical simulation is another area of virtual reality that continues to grow. Anatomical simulation is another area of virtual reality that continues to grow. Some schools are investing in virtual anatomy tables that allow students to visualize patient anatomy by 'virtually dissecting' patients ( Choi, 2013). Future technology in this area will include immersive virtual reality and augmented reality. Immersive virtual reality is currently represented by two major companies, Oculus, which makes the Oculus Rift, and HTC, which makes the Vive. Websites for the Oculucs Rift, HTC, Vive, and other Virtual Resources (VRs) are presented in Table 1.

These resources use head-mounted displays to immerse the wearer into a three-dimensional, virtual world that completely visually isolates them from the physical world. The devices can be used for skills training (e.g., practice to insert a small bore feeding tube or perform a sterile procedure). Augmented reality enables a virtual object or image to be projected into the room or onto an object, such as a simulator. Microsoft® has developed the HoloLens, which is the current product in this market. This is very new technology and currently is at the 'proof of concept' testing stage.
Table 1. Virtual Resources
Intra and Interdisciplinary Communication (Virtual Simulation)
Many educational institutions have developed islands into spaces where faculty can engage in virtual simulations. Virtual simulations are a small but growing part of UG simulation experiences. Some virtual products currently in use include: Second Life® (Linden Labs); vSim® for Nursing (Laerdal); and Shadow Health™. Second Life®is a three-dimensional virtual world built by Linden Labs that enables people to visit as avatars. This is done by downloading a free computer program, creating a free account, selecting an avatar, and traveling to various 'open' spaces called islands. Many educational institutions have developed islands into spaces where faculty can engage in virtual simulations ( Aebersold, Tschannen, Stephens, Anderson, & Lei, 2012).

A systematic review of studies published on the experience of using Second Life® in UG education found that although positive learning can occur, Second Life® is an emerging technology; further research is needed to enable this platform to become a common teaching strategy ( Irwin & Coutts, 2015). Virtual simulations using Second Life® have been an acceptable method for teaching students from different professional backgrounds to work together as a team to deliver difficult news to patients. Caylor, Aebersold, Lapham, and Carlson ( 2015) studied 21 students from nursing, pharmacy, and medicine who participated in a multi-professional simulation in which they had to disclose to a 'virtual patient avatar' that a medication error had occurred. Students rated the experience as realistic, effective, and a convenient platform for learning.

Early research has shown that students view these experiences positively... For comparison vSim® and Shadow Health™ are both commercial products that contain pre-built cases and activities. vSim® is a computer simulation that allows students to care for patients with a variety of healthcare needs. This product includes scenarios for students taking courses in medical-surgical concepts, maternal-child health, gerontology, fundamentals, health assessment, and pharmacology. Because this technology is very new, there are few published studies evaluating its use. However, some UG programs are counting simulation technologies, such as vSim, as part of clinical replacement hours (personal communication, B. Cambridge, September, 2016). Early research has shown that students view these experiences positively and recommend their use ( Foronda et al., 2016). Another study found that the addition of vSim in a fundamentals nursing course increased student knowledge significantly when compared with that of other students who received only the usual course content ( Gu et al., 2017).

Another commercial, virtual-simulation experience is CliniSpace™, an online, virtual, clinical environment developed with Unity, an open-source game design platform. CliniSpace™ has developed a game-like environment where nurse and physician avatars can interact and deliver care in patient care units. Foronda et al. ( 2014) used this virtual world to pilot a simulation with UG students to determine whether simulations focused on handoffs would improve their skills. After a series of two simulations, significant improvement was noted in student scores on the Identify, Situation, Background, Assessment and Recommendation (ISBAR) rating sheet, thus supporting the ISBAR process as a safe process for transferring patient information in clinical handoffs.

Nehring and Lashley ( 2009) published their 40-year review of simulation, finding that simulation was used in nursing education in many forms, including standardized patients, computerized instruction, and mid- and high-fidelity simulators (HFSs). They predicted that the use of simulation would grow in nursing education; yet they cautioned that standards needed to be developed to ensure that quality education would be associated with its use.

Simulation-based education today has matured to the point where we have good evidence to demonstrate effectiveness. Simulation-based education today has matured to the point where we have good evidence to demonstrate effectiveness. A recently published 'review of reviews' found seven review articles on HFS in the last ten years that focused on UG nursing education and HFS ( Doolen et al., 2016). Of the five integrative reviews, three validated simulation as an effective teaching-learning strategy in pre-licensure nursing education. Behaviors addressed in these reviews included medication safety, handwashing, communication related to safety, knowledge acquisition, and knowledge transfer. Also noted in these reviews, however, were a lack of randomized studies, few valid and reliable measurement tools, and overuse of 'confidence' as an evaluation measure. To date, both the topic of pre-briefing and that of debriefing have not been studied sufficiently in nursing.

Another review by Cant and Cooper ( 2017) found that simulation has become a well-accepted method of learning by students, a method which enables them to reconcile theory with practice. Study outcomes demonstrated the positive impact of simulation on knowledge acquisition, psychomotor skills, self-efficacy, satisfaction, confidence, and critical thinking skills.

For students who had either 25% or 50% of their hours replaced with simulation, there was no difference in NCLEX pass rates or end of program educational outcomes... The most significant research to date to influence nursing education at the pre-licensure level was a two-part study conducted by the National Council of State Boards of Nursing (NCSBN). The first part was a randomized, controlled trial looking at the effectiveness of simulation in UG nursing; the second part was a survey study of the new graduates and their managers during their first six months of employment ( Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). This study measured the effect of simulation as a replacement of clinical hours for either 25% or 50% of each school's total clinical hours. The control group could have no more than 10% of student clinical hours replaced by simulation. For students who had either 25% or 50% of their hours replaced with simulation, there was no difference in NCLEX pass rates or end of program educational outcomes when compared with students who had more clinical time. Students also perceived that simulation enabled their learning needs to be met; that they could perform well on tests; that they could synthesize content they had learned; and that they did well in all subject areas (pediatrics, maternal child, mental health, medical-surgical, and community health).

...results demonstrated that clinical hours can be effectively replacement by simulation. Phase two of the study ( Hayden et al., 2014) followed students into their first jobs. In this phase, managers were asked to rate the new graduates readiness for practice and overall global competency. That there were no differences between the three groups was important, because these results demonstrated that clinical hours can be effectively replacement by simulation. It also identified best practice methods for conducting those simulations.

After completion of the study, the NCSBN convened a panel of experts in simulation who put forth a set of guidelines ( Hayden, et al., 2014). These guidelines were based on the study ( Hayden et al., 2014); International Nursing Association for Clinical Simulation and Learning (INACSL); Standards of Best Practice: SimulationSM; and current knowledge of best practice from the study ( Hayden et al., 2014). As a result of the study, some state boards of nursing have started to incorporate these recommendations into nursing school guidelines.

As these state boards begin making decisions about how many clinical hours can be replaced, some boards that offered no guidelines in the past have started moving to implement a 25% or 50% replacement with the adoption of NCSBN guidelines. The National League of Nursing (NLN) has also been a significant contributor to the educational and research efforts with simulation. The NLN has published a visionary statement endorsing the study and making some very strong recommendations to deans, directors, and chairs of nursing programs, and to faculty on how best to support and incorporate simulation into UG programs ( NLN, 2015).

...simulation done poorly, or poorly integrated into the curriculum, will not be any better than the traditional clinical approach. Simulation has become a significant part of the UG curriculum. It is a theory-based, effective teaching method with a growing body of research evidence support. With nursing schools facing a growing shortage of clinical placements ( American Colleges of Nursing, 2017), as well as restrictions on the activities in which nursing students can engage, simulation provides an effective alternative to clinical training. One might argue that simulation can be more effective than the 'see one, do one, teach one' model that has often been the mainstay of the clinical teaching model. However, simulation done poorly, or poorly integrated into the curriculum, will not be any better than the traditional clinical approach. Teaching via simulation must be done as carefully as any other new teaching method. It requires a careful, thoughtful approach to ensure success for both students and faculty. The paragraphs below describe a few strategies for such careful and thoughtful approaches.

Curricular Mapping and Integration
To begin, it helps to think about using a curriculum development strategy. Examples of these include the Six-Step Curriculum Development Process for healthcare education ( Thomas, Kern, Hughes, & Chen, 2016) which starts with a needs assessment and ends with evaluation and feedback. You can also find other excellent resources at the National League of Nursing-Simulation Innovation Resource Center (NLN-SIRC), including a faculty toolkit that contains curriculum integration information and links to helpful resources ( NLN, n.d.). These resources promote simulation not just as something to add to a course, but as a strategy to integrate throughout the entire curriculum.

...it is important to create a curricular map of the concepts and high-level learning... To gain the most value from simulations, it is important to create a curricular map of the concepts and high-level learning occurring in each simulation for each course. This ensures that you are not focusing on the same topics in each simulation (e.g., simulations in pediatrics, maternal health, and community health that all focus around the death of a newborn). Unless each one will teach something novel, or the goal is to ensure scaffolding of learning in a particular area, you are likely repeating something without purpose due to a lack of awareness about what others are doing. A better way to approach this is to meet with key faculty from different courses to explore what is done, or might be done, in simulation, and then determine how student needs can be best met overall. However, there may still be skills or concepts (e.g., patient handoffs or medication safety) which merit repeating in many simulations because they are key skills.

Simulation Outcomes
...it is critical to establish ground rules during the pre-brief period so that students understand expectations. Simulation allows students to practice caring for 'patients' in ways that they cannot in the hospital or other settings. Faculty are encouraged to leverage this freedom to give students experiences that they may not get in ordinary clinical settings. For example, faculty can have students play the role of the nurse (not student nurse). Students need to practice the role of the bedside nurse, to include making decisions, calling other healthcare providers, documenting without a co-signer, and administering medications independently. This experience offers students the opportunity to evaluate how well they can perform, while remaining within a safety net. To do this, it is critical to establish ground rules during the pre-brief period so that students understand expectations. They need to know it is okay to make mistakes, and that those mistakes will be discussed during debriefing, giving them the opportunity to learn from the mistakes and consider ways to improve.

Simulation can be incorporated into the curriculum as a way to support student achievement of knowledge, skills, and attitudes (KSA) and competencies needed to attain the overall program goals set forth by the school curricular plan. These goals also link curriculum planning to program accreditation; the National Council Licensure Examination (NCLEX) test outcomes; the Quality and Safety in Nursing Education (QSEN) competencies; The Joint Commission Safety Goals; and other areas. Simulation can be included in either formative or summative assessment methods, as long as faculty are clear with students regarding the goals of a given simulation experience. Developing curricular maps with the simulation scenario, major content, and concept threads is the best way to track what you are doing in simulation. Table 2 offers some specific ideas for incorporation of simulation into the curriculum.
Table 2. Simulation Ideas for Undergraduate Nursing Education

Pediatrics

Create a simulation for students to practice infant assessment in a clinic setting.

Create a challenge when parents state they do not want their child to receive vaccinations.

Add a cultural dilemma or language barrier.

Pediatrics

Asthma

Patient handoff/Transitions of care

Nurse Role(s)

Create an unfolding set of simulations where a school age child has an acute exacerbation of asthma at school. The school nurse follows her asthma action plan, calls EMS and the child goes to the ED. There is a handoff to the inpatient unit or an observation unit where the child receives care.

Maternal Health

Students need to understand the care of the laboring mom, so it would be important to learn to care for a mom in labor. For simulation centers that do have access to a birthing simulator there are options such as:

Mama Natalie® by Laerdal (less than $1000)

Parto Pants™ (Pronto) another low cost solution; worn by a student or SP.

Both allow for normal or complicated deliveries.

Newborn assessment can be done using a newborn simulator or even a doll that is appropriately sized.

Maternal Health

Managing obstetrical emergencies

Post-partum hemorrhage

Teamwork

Communication

Situational awareness

Conducting a simulation on post-partum hemorrhage is essential in the maternal health curriculum. This simulation can be found in most vendor-offered packaged curriculums or other free resources. This teaches students to recognize and manage an area with a high rate of mortality as well as many other important skills.

Medical-Surgical

Cardiac

Respiratory

Sepsis

Stroke

Acute MI

Patient handoff

Medication Management

Multiple patient management

Communication

Critical Thinking

The importance of simulation at the medical-surgical level is focus on:

developing student clinical judgment and skills

determining how to prioritize assessments

gathering data

making decisions

implementing interventions correctly

reflecting about what they are doing

The content is less important. This is not the time to load content that does not seem to fit elsewhere. This is an opportunity to think about key patients for whom it would be great if every student had an opportunity to provide care.

Medical-Surgical or Advanced Medical-Surgical

Focus on a case to assist students to recognize signs of a stroke in a patient who is in the hospital for another problem, such as an elderly man who had a hip replacement and has a history of atrial fibrillation and sleep apnea.

This will teach students to recognize a stroke and learn how to react in a crisis. This type of simulation generally requires a high-fidelity mannequin.

Leadership

Impaired nurse

Nurse-to-nurse bullying

Root Cause Analysis for a Sentinel Event or medication error

In leadership courses, simulation can be used to address topics nurses face on the unit. There are articles and resources available to assist in developing simulation on these topics. Students find it beneficial to learn how to deal with nurse-to-nurse bullying and they need opportunities to role-play these types of strategies.

There are many simulation methods from which to choose... The key is selecting the technology or method that provides for active engagement with the learner. There are many simulation methods from which to choose, as evidenced by the review of types of simulation used in various areas. The challenge for faculty and simulation educators is choosing the most appropriate methods. In the Simulation Model for Improving Learner and Health Outcomes (SMILHO), Aebersold and Titler ( 2014) address this challenge. The key is selecting the technology or method that provides for active engagement with the learner. This links back to the theoretical models upon which simulation is based. If the goal of the simulation is to practice therapeutic communication skills, then using a standardized simulation patient (SP) will be the 'best' option. Another option would be to use a mannequin and provide the voice for the mannequin through a microphone placed near the mannequin's head with the faculty providing the voice. You do not need a sophisticated computerized (i.e., high-fidelity) mannequin. Rather you can use any mannequin; by adding clothes, a wig, and glasses, one can simulate a person.

Standardized or simulated patients can also be effective to play family members in simulations that include role play (e.g., a mom of an infant coming for a well-baby checkup). Students could then interview mom to provide a history for baby. A simulation patient can create tension around immunizations for baby when parents are unwilling to have their child vaccinated. Although students could play this role, younger students often lack the life experiences for effective role play unless they have some background in the specific area or perhaps have been students in the performing arts.

If students are practicing a specific skill, such an intravenous or Foley catheter insertion, you only need a task trainer or a 'body part' (e.g., an arm or torso). These allow students to practice the skill and do not tie up mannequins or increase 'wear and tear' on expensive equipment. It is best to use mid-fidelity or mid-level mannequins for mid-level students practicing basic scenarios. Although these mannequins often lack more sophisticated features (e.g., chest movement, pupillary response), they can produce vital signs such as lung and heart sounds. They can be used successfully to run many simulations, such as identifying changes in lung sounds during early congestive heart failure or performing a priority assessment. They are also great for multiple patient simulations that may be run in a skills laboratory along with SPs.

... a newer style of debriefing and feedback is emerging that is showing promising results. It is important to note that in simulation experiences, goals and objectives will likely be different from goals in the clinical area. Simulation is intense and there may only be 2 to 4 learning objectives for a short focused simulation. Learning in simulation occurs primarily during debriefing ( Cheng et al., 2014; Shinnick, Woo, Horwich, & Steadman, 2011) thus it is important that all debriefing facilitators are trained and use a debriefing framework ( Cheng et al., 2014). Most faculty are familiar with common debriefing frameworks; however, a newer style of debriefing and feedback is emerging that is showing promising results. This newer method is based on the deliberate practice work of Anders Ericsson ( 2004). Deliberate practice and feedback, using a pause and discuss approach, provides instant feedback to learners about a skill they are learning and then they 'rewind' and practice that skill again ( Eppich et al., 2015). This can be very effective for certain types of simulations, such as cardiopulmonary resuscitation training, where repetition with feedback is important ( Hunt et al., 2015).

The concept of debriefing is one of the most studied areas in the field of simulation. Faculty must keep informed about current literature and research. They should receive training about debriefing and practice their skills. It is important for faculty to receive feedback from other facilitators, and also students or learners, when possible. There are excellent tools available to help in this regard, such as the Debriefing Assessment for Simulation in Healthcare ( Center for Medical Simulation, n.d.) which offers both faculty and student debriefing versions to provide feedback to the debriefer. Other tools, such as the Simulation Effectiveness Tool (SET), can evaluate student perceptions of the effectiveness of simulation. This tool has been recently modified (SET-M) and has demonstrated good psychometric properties (Leighton et al., 2015).

... measurement of learning outcomes and transfer of knowledge and behaviors is expected, although still not consistent. Research about the effectiveness of simulation has grown from earlier stages, in which learner self-confidence was the only measure, to the present day where measurement of learning outcomes and transfer of knowledge and behaviors is expected, although still not consistent. The most commonly used evaluation framework in simulation is the Kirkpatrick model of training effectiveness ( Kirkpatrick, 1994). This evaluation framework includes four evaluation levels: reaction (satisfaction with the training); learning (increase in knowledge and skills); behavior (the participant performs differently); and results (change is noted). Applying this framework to simulation training provides an effective way to measure how well simulation-based education has improved learner knowledge, skills, and ability to transfer knowledge and behavior to the practice site.

As with all research, it is important to use tools with established validity and reliability and ensure good rater training. Fey, Gloe, and Mariani ( 2015) published a helpful rubric for assessing simulation-research articles. In addition, the 2016 International Nursing Association for Clinical Simulation and Learning (INACSL) Standards for Best Practice: SimulationSM provides evidence-based standards for developing, facilitating, and measuring the effectiveness of simulation-based education ( INACSL Board of Directors, n.d.). Information about the standards can be found on the INACSL website.

Simulation can provide students with opportunities they would not get in the clinical area. Simulation is a safe way for students to learn: they can practice until they achieve skill competency; and they learn how to reflect upon what went wrong; how to self-correct; and how to accept feedback. Clinical sites are often scarce and students may only 'shadow' another person; these clinical learning experiences can be less than optimal. Simulation can provide students with opportunities they would not get in the clinical area.

However, simulation is a different way to facilitate learning. It is not clinical teaching and it is not classroom teaching. To do it well, faculty need to learn to effectively design, facilitate, and debrief simulation-based experiences to meet objectives for learning experiences. Use of virtual simulations needs to become part of the overall simulation program. Although virtual and augmented reality are still in early stages, this option will grow quickly now that the technology is becoming available and affordable. Quality of devices will provide opportunities to train students in skills that required physical trainers in the past, thus opening new opportunities for schools to re-allocate space resources.

Simulation has become a large part of the undergraduate curriculum. It has grown from something that happens in the simulation laboratory by a few faculty who enjoy 'playing around' with technology to an evidence-based, effective learning technology. Use of simulation offers a safe space where students can learn skills they need to be comfortable and competent before entering the clinical site. Although simulation requires a significant financial investment to purchase simulators and provide dedicated space and personnel, there are many advantages to incorporating more simulation into the UG curriculum.

Michelle Aebersold, PhD, RN, CHSE, FAAN
Email: mabersol@umich.edu

Michelle Aebersold, a Certified Healthcare Simulation Educator, is a Clinical Associate Professor and Director for Simulation and Educational Innovation at the University of Michigan School of Nursing (Ann Arbor, MI). Previously she served as Nurse Manager for the Neuro Intensive Care Unit, Neuro Acute Care Area, and the Stroke Unit at Michigan Medicine. Her scholarship is focused on advancing the science of learning as applied in simulation, with the goal of aligning clinician and student nursing practice behaviors with research evidence to improve health outcomes of populations. Her interest in healthcare simulation arose both from her love of video games and from her knowledge about how simulations in other educational areas can help people learn. She publishes extensively, most prominently in the area of virtual simulation. She is also actively involved in the development of simulation standards and in guiding future research efforts related to simulation-based learning.

Adamson, K. (2015). A systematic review of the literature related to the NLN/Jeffries simulation framework. Nursing Education Perspectives, 36(5), 281-291.

Aebersold, M. (2016). The history of simulation and its impact on the future. AACN Advanced Critical Care, 27(1), 56-61. doi:10.4037/aacnacc2016436

Aebersold, M., & Titler, M. G. (2014). A Simulation Model for Improving Learner and Health Outcomes. Nursing Clinics of North America, 49(3), 431-439. doi:10.1016/j.cnur.2014.05.011

Aebersold, M., Tschannen, D., Stephens, M., Anderson, P., & Lei, X. (2012). Second Life®: A new strategy in educating nursing students. Clinical Simulation in Nursing, 8(9), e469-e475. doi:10.1016/j.ecns.2011.05.00

Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice & Palliative Nursing, 8(2), 112-117.

American Association of Colleges of Nursing. (2017). Fact sheet: Nursing shortage. Retrieved from http://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet-2017.pdf?ver=2017-10-18-144118-163

Austin, E. N., Bastepe-Gray, S. E., Nelson, H. W., Breitenbach, J., Ogle, K. T., Durry, A., . . . Haluska, M. (2014). Pediatric mass-casualty education: Experiential learning through university-sponsored disaster simulation. Journal of emergency nursing, 40(5), 428-433. doi: 10.1016/j.jen.2014.05.015

Cant, R. P., & Cooper, S. J. (2016). Use of simulation-based learning in undergraduate nurse education: An umbrella systematic review. Nurse Education Today, 49, 63-71. doi: 10.1016/j.nedt.2016.11.015

Caylor, S., Aebersold, M., Lapham, J., & Carlson, E. (2015). The Use of Virtual Simulation and a Modified TeamSTEPPS™ Training for Multiprofessional Education. Clinical Simulation in Nursing, 11(3), 163-171.

Center for Medical Simulation. (n.d.) Debriefing Assessment for Simulation in Healthcare © (DASH). Retrieved from ( https://harvardmedsim.org/debriefing-assessment-for-simulation-in-healthcare-dash/

Cheng, A., Eppich, W., Grant, V., Sherbino, J., Zendejas, B., & Cook, D. A. (2014). Debriefing for technology enhanced simulation: A systematic review and meta analysis. Medical Education, 48(7), 657-666. doi:10.1111/medu.12432

Cheng, A., Grant, V., Dieckmann, P., Arora, S., Robinson, T., & Eppich, W. (2015). Faculty development for simulation programs: Five issues for the future of debriefing training. Simulation in Healthcare, 10(4), 217-222. doi:10.1097/SIH.0000000000000090

Choi, J. (2013, February), Jack Choi: On the virtual dissection table [Video file]. Retrieved from https://www.ted.com/talks/jack_choi_on_the_virtual_dissection_table

Doolen, J., Mariani, B., Atz, T., Horsley, T. L., O'Rourke, J., McAfee, K., & Cross, C. L. (2016). High-fidelity simulation in undergraduate nursing education: A review of simulation reviews. Clinical Simulation in Nursing, 12(7), 290-302. Doi:10.1016/j.ecns.2016.01.009

Eppich, W. J., Hunt, E. A., Duval-Arnould, J. M., Siddall, V. J., & Cheng, A. (2015). Structuring feedback and debriefing to achieve mastery learning goals. Academic Medicine, 90(11), 1501-1508. doi:10.1097/ACM.0000000000000934

Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine, 79(10), S70-S81.

Fabro, K., Schaffer, M., & Scharton, J. (2014). The development, implementation, and evaluation of an end of life simulation experience for baccalaureate nursing students. Nursing Education Perspectives, 35(1), 19-25. doi:10.5480/11-593.1

Fey, M. K., Gloe, D., & Mariani, B. (2015). Assessing the quality of simulation-based research articles: A rating rubric. Clinical Simulation in Nursing, 11(12), 496-504. Doi:10.1016/j.ecns.2015.10.005

Fluharty, L., Hayes, A. S., Milgrom, L., Malarney, K., Smith, D., Reklau, M. A., . . . McNelis, A. M. (2012). A multisite, multi-academic track evaluation of end-of-life simulation for nursing education. Clinical Simulation in Nursing, 8(4), e135-e143. doi:10.1016/j.ecns.2010.08.003

Foronda, C., Gattamorta, K., Snowden, K., & Bauman, E. B. (2014). Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study. Nurse Education Today, 34(6), e53-e57. doi:10.1016/j.nedt.2013.10.007

Foronda, C. L., Swoboda, S. M., Hudson, K. W., Jones, E., Sullivan, N., Ockimey, J., & Jeffries, P. R. (2016). Evaluation of vSIM for Nursing™: A Trial of Innovation. Clinical Simulation in Nursing, 12(4), 128-131. doi:10.1016/j.ecns.2017.01.005

Gaba, D. M. (2004a). A brief history of mannequin-based simulation and application. In W. F. Dunn (ed.) Simulators in Critical Care and Beyond (7-14). Mount Prospect, IL:Society of Critical Care Medicine.

Gaba, D. M. (2004b). The future vision of simulation in health care. Quality and Safety in Health Care, 13(suppl 1), i2-i10.

Gu, Y., Zou, Z., & Chen, X. (2017). The Effects of vSIM for Nursing™ as a teaching strategy on fundamentals of nursing education in undergraduates. Clinical Simulation in Nursing, 13(4), 194-197. doi:10.1016/j.ecns.2017.01.005

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). Supplement: The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), C1-S64.

Hunt, E. A., Duval-Arnould, J. M., Nelson-McMillan, K. L., Bradshaw, J. H., Diener-West, M., Perretta, J. S., & Shilkofski, N. A. (2014). Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training. Resuscitation, 85(7), 945-951. doi:10.1016/j.resuscitation.2014.02.025

International Nursing Association of Clinical Simulation and Learning (INACSL) Board of Directors. (2016) Standards for best practice: SimulationSM, Clinical Simulation in Nursing, 12, S48-S50. doi:10.1016/j.ecns.2016.10.001

Irwin, P., & Coutts, R. (2015). A systematic review of the experience of using Second Life in the education of undergraduate nurses. Journal of Nursing Education, 54(10), 572-577.

Jeffries, P. R. (2012). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nursing.

Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing Education Perspectives, 36(5), 292-293.

Kirkpatrick, D. L. (1996). Techniques for evaluating training programs. In D.P. Ely & T. Plomp (eds.). Classic writings on instructional technology (119-142). Englewood, CO: Libraries Unlimited, Inc.

Kolb, D. A. (1984). Experiental learning. Englewood Cliffs, NJ: Prentice Hall.

Kriz, W. C. (2010). A systemic-constructivist approach to the facilitation and debriefing of simulations and games. Simulation & Gaming, 41(5), 663-680. doi:10.1177/1046878108319867

Lopreiato, J. O. (Ed.), Downing, D., Gammon, W., Lioce, L., Sittner, B., Slot, V., Spain, A. E. (Associate Eds.), and the Terminology & Concepts Working Group. (2016). Healthcare Simulation Dictionary. Retrieved from http://www.ssih.org/dictionary.

National League of Nursing (n.d.) Simulation innovation resource center. Retrieved from http://sirc.nln.org/

NLN. (2015) A vision for teaching with simulation. Retrieved from http://www.nln.org/docs/default-source/about/nln-vision-series-(position-statements)/vision-statement-a-vision-for-teaching-with-simulation.pdf?sfvrsn=2

Nehring, W. M., & Lashley, F. R. (2009). Nursing simulation: A review of the past 40 years. Simulation & Gaming, 40(4), 528-552.

Nickerson, M., & Pollard, M. (2010). Mrs. Chase and her descendants: A historical view of simulation. Creative Nursing, 16(3), 101-105.

Orr, F., Kellehear, K., Armari, E., Pearson, A., & Holmes, D. (2013). The distress of voice-hearing: The use of simulation for awareness, understanding and communication skill development in undergraduate nursing education. Nurse Education in Practice, 13(6), 529-535.

Shinnick, M. A., Woo, M., Horwich, T. B., & Steadman, R. (2011). Debriefing: The most important component in simulation? Clinical Simulation in Nursing, 7(3), e105-e111.

Thomas, P. A., Kern, D. E., Hughes, M. T., & Chen, B. Y. (Eds) (2015). Curriculum development for medical education: A six-step approach (3rd ed). Baltimore: John Hopkins University Press.

Weir, W. (2012, March 29, 2015). At 101, 'Mrs. Chase' is a Medical Marvel. The Hartford Courant. Retrieved from http://articles.courant.com/2012-03-29/health/hc-mrs-chase-hartford-hospital-0328-20120327_1_doll-nursing-student-mannequins

Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47-51. doi:10.1053/j.semperi.2011.01.002

© 2018 OJIN: The Online Journal of Issues in Nursing

Article published April 4, 2018

# data[].attributes.attachment_link.title
Simulation-Based Learning: No Longer a Novelty in Undergraduate Education

# data[].attributes.attachment_link.description
Michelle Aebersold, PhD, RN, CHSE, FAAN Simulation, once the domain of those faculty who enjoyed the technical aspects of using computerized mannequins, has now moved to center stage in nursing education. Nursing programs realize that they can no longer afford to consider simulation as merely an 'add-on.'

# data[].attributes.attachment_link.readable_text
Quantum computing is no longer a thing of science fiction. The technology is here, now. Healthcare is one industry that holds a lot of potential to integrate quantum.

If you watch the news at all, you'll see quantum computing is everywhere, as Google researchers are claiming quantum supremacy for the first time. While we are still a while away from commercially available quantum computers, it does open up the discussion about "the possible."

How will industries, like healthcare, be disrupted by this future technology?

A Bit of Background

Quantum computers differ from classical computers in that they go beyond the traditional "zero or one" bit model. Quantum bits, called qubits, can be both zero, one, or zero and one at the same time. This ability to be in the same state at the same time is called superposition.
Superposition, along with entanglement, allows quantum computers to perform numerous calculations in parallel. In doing so, it creates substantially more computational processing power to solving complex problems.
Thanks to technological advances such as cloud computing, we now have more computational power at our fingertips than ever before. These advantages resulted in breakthroughs in natural language processing, image recognition, and machine learning, among other areas.

However, quantum computers will eventually far exceed anything we see today. This advancement will lead to new opportunities and challenges in several industries, including healthcare.

Healthcare Applications Accelerate with Advanced Quantum Compute Power

Quantum's ability to compute at scale will allow clinicians to incorporate a vast number of cross-functional data sets into their patient risk factor models. For instance, we'll be able to analyze environmental databases to evaluate the effect of pollution on a patient's health history.

Another way quantum's compute power creates an advantage is in its ability to process imagery at scale. Analyzing images, such as CT scans, require much more processing power than traditional data sets. With increased compute available, clinicians could easily review CT scans over time and quickly identify changes and anomalies.

Similarly, we'll be able to accelerate precision medicine. Also, quantum computing will allow us to select clinical trial participants using more reference points, ensuring a better fit between protocol and patient. We can identify targeted chemotherapy protocols quicker, and with more customization, with quantum's enhanced data processing abilities. And post-treatment, being able to understand where and why a protocol succeeded or failed more accurately, will give clinicians and researchers valuable insight.

But There Will Be Challenges, Too

Healthcare tends to lag behind other industries in technology adoption. The industry is only beginning to harness Artificial Intelligence, trailing advancements already made in this space by the private sector. Thus, they may also be slow to embrace quantum, causing healthcare innovation to fall behind advancements in other industries.

Other concerns include privacy and ethics. Quantum computing has the potential to give individuals much clearer insights into their future healthcare risks. Patients tend to be receptive to this information when they understand those risks might migrate via preventative medicine. However, when the future prognosis indicates health conditions with grim outlooks, ethical situations arise.

Will the predicted future prognosis impact the patient's current mental health? What if health insurers or employers use the information to make negative coverage or employment decisions? These are questions circulating for current healthcare technologies, of course. Quantum amplifies the need for a thoughtful approach to predictive medicine.

We Can't Forget About Security

Because of its advanced processing power, quantum computing can destroy our current encryption practices, making your personal healthcare history vulnerable.

Thankfully, many institutions, including the US Government, are researching "quantum-proof" encryption, with promising initial results.

Assuming that healthcare providers can implement quantum-resistant encryption promptly, patients and providers may have greater peace of mind in a quantum world. Not only will personal data be better protected with next-generation security practices, but healthcare organizations will be able to prevent malicious activity and limit data breaches better than before. Quantum's increased processing power will allow cybersecurity departments to process and analyze large amounts of access activity and recognize potential threats in advance.

Finally

Quantum computing may provide life-saving medical applications we have never seen the likes of before. Implementing these applications, however, will take a measured and mindful approach. Thankfully, we have a few years before this technology becomes mainstream, allowing the healthcare industry to fully grasp quantum's true capabilities and challenges in the meantime.

# data[].attributes.attachment_link.title
How Quantum Computing Will Impact Healthcare

# data[].attributes.attachment_link.description
If you watch the news at all, you'll see quantum computing is everywhere, as Google researchers are claiming quantum supremacy for the first time. While we are still a while away from commercially available quantum computers, it does open up the discussion about "the possible."

# data[].attributes.body
Example: John Hopkins Bayview Medical Center

# data[].attributes.attachment_link.title
Next Generation of Health Care Technology at Johns Hopkins Bayview Medical Center

# data[].attributes.attachment_link.readable_text
It's fascinating to think about the power in our pocket-today's smartphones have the computing power of a military computer from 50 years ago that was the size of an entire room. However, even with the phenomenal strides we made in technology and classical computers since the onset of the computer revolution, there remain problems that classical computers just can't solve. Many believe quantum computers are the answer.
The Limits of Classical Computers
Now that we have made the switching and memory units of computers, known as transistors, almost as small as an atom, we need to find an entirely new way of thinking about and building computers. Even though a classical computer helps us do many amazing things, "under the hood" it's really just a calculator that uses a sequence of bits-values of 0 and 1 to represent two states (think on and off switch) to makes sense of and decisions about the data we input following a prearranged set of instructions. Quantum computers are not intended to replace classical computers, they are expected to be a different tool we will use to solve complex problems that are beyond the capabilities of a classical computer.

Basically, as we are entering a big data world in which the information we need to store grows, there is a need for more ones and zeros and transistors to process it. For the most part classical computers are limited to doing one thing at a time, so the more complex the problem, the longer it takes. A problem that requires more power and time than today's computers can accommodate is called an intractable problem. These are the problems that quantum computers are predicted to solve.
The Power of Quantum Computers
When you enter the world of atomic and subatomic particles, things begin to behave in unexpected ways. In fact, these particles can exist in more than one state at a time. It's this ability that quantum computers take advantage of.

Instead of bits, which conventional computers use, a quantum computer uses quantum bits-known as qubits. To illustrate the difference, imagine a sphere. A bit can be at either of the two poles of the sphere, but a qubit can exist at any point on the sphere. So, this means that a computer using qubits can store an enormous amount of information and uses less energy doing so than a classical computer. By entering into this quantum area of computing where the traditional laws of physics no longer apply, we will be able to create processors that are significantly faster (a million or more times) than the ones we use today. Sounds fantastic, but the challenge is that quantum computing is also incredibly complex.

The pressure is on the computer industry to find ways to make computing more efficient, since we reached the limits of energy efficiency using classical methods. By 2040, according to a report by the Semiconductor Industry Association, we will no longer have the capability to power all of the machines around the world. That's precisely why the computer industry is racing to make quantum computers work on a commercial scale. No small feat, but one that will pay extraordinary dividends.
How our world will change with quantum computing
It's difficult to predict how quantum computing will change our world simply because there will be applications in all industries. We're venturing into an entirely new realm of physics and there will be solutions and uses we have never even thought of yet. But when you consider how much classical computers revolutionized our world with a relatively simple use of bits and two options of 0 or 1, you can imagine the extraordinary possibilities when you have the processing power of qubits that can perform millions of calculations at the same moment.

What we do know is that it will be game-changing for every industry and will have a huge impact in the way we do business, invent new medicine and materials, safeguard our data, explore space, and predict weather events and climate change. It's no coincidence that some of the world's most influential companies such as IBM and Google and the world's governments are investing in quantum computing technology. They are expecting quantum computing to change our world because it will allow us to solve problems and experience efficiencies that aren't possible today. In another post, I dig deeper into how quantum computing will change our world.

# data[].attributes.attachment_link.title
What Is Quantum Computing? A Super-Easy Explanation For Anyone

# data[].attributes.attachment_link.description
In the tech and business world there is a lot of hype about quantum computing. Here we provide a very simple explanation of what quantum computing is, the key promises of quantum computers and how qubits might change our world.

# data[].attributes.attachment_link.description
Learning Nurse Game - This game tests your knowledge of the terms and cooncepts used used in nursing informatics.

# data[].attributes.headline
Virtual Training VS. Clinical Experience 

# data[].attributes.subject
Virtual Training VS. Clinical Experience 

# data[].attributes.attachment_link.provider_name
Technology Solutions That Drive Healthcare

# data[].attributes.attachment_link.readable_text
Nursing instructors are leading the charge when it comes to adopting new educational technologies, outpacing efforts in medical and general education. The COVID-19 pandemic underscores the value of tools that supplement a hands-on experience.

Sixty-five percent of nursing education programs already were using virtual simulation and other adaptive digital learning methods to enhance onsite learning and to ensure students are practice-ready, according to information services company Wolters Kluwer.

These applications, the firm notes in a blog post, can address a shortage of nurse educators and eliminate patient confidentiality concerns at hospital training sites.

And now, as educational programs of all types pivot to remote learning, nursing students have the advantage of leveraging digital simulation platforms designed for use outside of a traditional classroom.

These systems - which present hundreds of real-life scenarios and teach electronic health record use - offer a lifeline, often via a laptop or tablet. Virtual sessions could cover proper use of protective gear, for instance, or how to calm an aggressive patient.

"It's so important that we keep students engaged in patient care activities while learning from a distance," Hollie Moots, a nurse education specialist for Elsevier, noted in a recent webinar. "In order to build solid clinical judgement, our students need opportunities to apply content in the care of a patient."

The approach, though necessary, isn't new: The National Council of State Boards of Nursing has long affirmed that targeted simulations could support up to half of clinical educational experiences - a viewpoint affirmed by the National League for Nursing.
READ MORE: VR addresses healthcare training needs to improve outcomes.
VR Simulations for Nurses Promote Learning from Anywhere

One tool poised for growth in this space is virtual reality, which Patricia Sengstack, an associate professor of nursing at the Vanderbilt University School of Nursing, calls a "game changer."

"We often have to train nurses on a new skill on the front lines; we could use VR to put a group of them through a simulation," she told HealthTech last year.

Not only is the tech effective, it's also enjoyable: A VR game developed at Robert Morris University that allows nursing students to practice urinary catheter insertion produced the same pass rate as students who practiced on manikins, research published in Clinical Simulation in Nursing has found.

Students who trained with VR spent more time practicing, could complete more procedures in a 60-minute period and gave higher marks to the immersive experience.

The uses are many. At the University of Nevada, Reno, nursing students have used HTC Vive headsets to take notes while watching actors portraying a doctor and nurse tend to a patient with pregnancy complications - with the team asking the student for feedback.

Although some tools may require a higher investment, other mobile headsets can be used with or without smartphones. Finding VR solutions for e-learning outside of a classroom can bridge the gap to support current safety measures without sacrificing lesson plans.

A new training lab at the University of New England equipped with Oculus Rift headsets is temporarily closed due to COVID-19, but nursing students may continue the virtual activities at home with a mobile device.

"It's still a key way to teach skills," Dawne-Marie Dunbar, who directs the college's Interprofessional Simulation and Innovation Center, told CNN last month.

Benefits of Simulated Training Programs for Nurses

Whether or not they're deployed during a time of crisis, immersion technologies can influence point-of-care decision-making when a nurse enters the workforce. The National League for Nursing credits immersive tech with:

Engaging diverse learners to bridge clinical and classroom experiences

Standardizing lesson plans to reduce unpredictable or unequal opportunities

Providing high-quality scenarios in lieu of a growing lack of clinical placements

These are key reasons why the efforts should continue. "Nurse educators must be nimble enough to embrace new technology and explore fresh approaches to teaching," a 2019 vision statement from the American Association of Colleges of Nursing notes.

Not only does the association support simulated learning to provide "adequate exposure to essential high-risk, low-volume clinical experiences," it affirms that opening satellite centers stocked with the immersive tools - accessible by students and clinicians - could save programs money and ensure caretakers can leverage these lifelike lessons.

This article is part of HealthTech 's MonITor blog series. Please join the discussion on Twitter by using #WellnessIT.

# data[].attributes.attachment_link.title
How Virtual Training Is Set to Change Nursing Education

# data[].attributes.attachment_link.description
Nursing instructors are leading the charge when it comes to adopting new educational technologies, outpacing efforts in medical and general education. The COVID-19 pandemic underscores the value of tools that supplement a hands-on experience.

# data[].attributes.attachment_link.readable_text
From the treatments patients receive and the technologies used, to the services provided and even the ways medical records are kept, healthcare - and the nursing profession - have grown increasingly complex.

Not surprisingly, to keep up with these advances, the ways in which nurses are trained have also changed, and that's a good thing. Today's nursing students graduate better prepared to make decisions and face high-pressure clinical situations, thanks in part to considerable advances in simulation technology and how it's used in nursing school.

So what is simulation in nursing school?

Clinical Simulations Prepare You for Real-World Nursing Practice

Imagine you are evaluating a patient. Reviewing his chart, you see he has a history of heart failure and is on a daily fluid restriction, though he says he hasn't been keeping track of his fluid intake today. He feels a bit clammy to the touch, but his vital signs appear stable, so you don't think much of it. However, as you're about to leave the room, you hear him cough and notice he is having a difficult time breathing while talking. Suddenly, you realize you forgot a key piece of the assessment. Upon listening to his lungs, you recognize the sound of crackles and immediately halt continuous fluids, as well as call the physician. Your patient is experiencing the early signs of fluid overload.

A scenario such as this one could have easily turned fatal had his cough and breathing not caught your attention. Ultimately, you made the right decision; however, you initially missed some tell-tale signs that something was wrong.

As real as this situation sounds, it was a clinical simulation in a nursing lab - the 'patient' was a high-tech patient simulator. And it illustrates just how quickly a patient's condition can change, as well as why it's essential that you enter the hospital setting prepared to think critically and exercise sound clinical judgment. It also illustrates just how important a role simulation labs play in preparing students for the kinds of emergency situations nurses experience on a daily basis.

The Role of Clinical Simulation in Nursing School

Of course, as valuable as they are, clinical simulations are just one part of your nursing education. To understand how clinical simulation fits into nursing school as a whole, let's take a brief look at the three main components of Marquette University's Direct Entry MSN program in Pleasant Prairie. This accredited, second-degree program makes it possible for eligible students to earn a Master of Science in Nursing (MSN) degree in 19-21 months through a combination of:

Online coursework designed to teach you the fundamental theories behind nursing practice while allowing you to study wherever you prefer - whether at home, your favorite coffee shop or local library.

Skills and simulation labs that provide you the opportunity to apply what you're learning to hands-on practice at our state-of-the-art Pleasant Prairie learning site.

Clinical rotations that let you experience firsthand what it's like to work in real-life healthcare settings while under the close supervision of an experienced clinical instructor.

What's the Difference Between Skills and Simulation Labs?

Though both labs are designed to give you the skills and confidence you need to succeed in the nursing profession, each plays a unique (but complementary) role in your education.

Skills lab is exactly what it sounds like - where you learn and practice essential nursing skills, such as checking vital signs, inserting catheters and IVs, conducting nursing evaluations, and more. Or as May 2019 program graduate Kassielle puts it, "Skills lab is where you take everything you're learning in theory and put it into practice."

Simulation lab takes the concept further, bridging the gap between skills labs and theory coursework, and clinical rotations. Set in a life-like healthcare environment, sim lab is where you apply your newly acquired skills and knowledge to mock nursing scenarios featuring high-tech, anatomically correct patient simulator manikins."These manikins, they're almost like real people," says Shelby, another May 2019 graduate of Marquette's Direct Entry MSN program. "They can cry. They can talk back. They blink. Their pupils dilate. This is just another stepping stone to get to that real-person interaction."

Three Benefits of Clinical Simulation in Nursing School
Simulation labs are a critical component of your nursing education, allowing you to:

1. Become confident dealing with high-pressure situations.

2. Learn from your mistakes in a safe, supportive environment.

3. Gain experience with conditions you may not encounter during clinicals.

Nursing Simulation Labs: Before, During and After

As we touched on earlier, simulation labs play a crucial role in your nursing education. However, there's more to them than simply participating in the simulation scenario itself. What you do before and after simulation lab is equally important, which is why it's best to think of sim labs as consisting of three distinct steps: preparation, simulation and debrief.

Preparation

To get the most out of your clinical simulations in nursing school, it is essential that you show up prepared. Prior to attending a simulation lab, you'll be given a list of patients that you may see. For example, one might have chronic obstructive pulmonary disease (COPD), another asthma and so on.

You could be given a patient with one symptom or one issue, or you could be given a patient with multiple issues.

- Lisa, a May 2019 graduate of the Direct Entry MSN program in Pleasant Prairie

It's on you to complete any assigned readings, review your week's coursework and research the patients' conditions before showing up for simulation lab. Keep in mind that if you show up unprepared, not only will you not make the most of this valuable learning experience, it will be obvious to your instructor and the other members of your cohort.

Simulation

As illustrated in our opening example, one thing you'll quickly learn about simulation lab is that you don't know what is going to happen, and that's the point. Working in a hospital, a patient could be in stable condition one minute and coding the next. As a nurse, you have to be ready to act on a moment's notice, because things can change quickly. Simulation lab is the same way.

When you show up for simulation lab, you'll be assigned to care for a 'patient' exhibiting one or several of the conditions you were assigned. This could be with another student or solo. Meanwhile, your instructor will observe you through a two-way mirror, where he or she can control the simulator and even talk to you (as the patient). This allows him or her to test your ability to critically assess the situation and respond to what is happening in real time.

Did you know?
At first, it might appear to students that the patient simulators they interact with display behaviors and symptoms at random; however, simulations are anything but. These simulated experiences are designed and managed by a well-educated team of technologists, based on best practices and grounded in science and research, and can be varied by your instructor as he or she sees fit.

"In simulation [lab], you'll walk into the room and you'll have a manikin lying in the bed, and then behind a screen that you can't see, you'll have someone that's operating the manikin," says Lisa, who recently graduated from Marquette's Direct Entry MSN program. "The scenario might perhaps be a patient that's having respiratory distress. The manikin will start coughing or the lips will turn blue, and then you have to step into action and take those skills that you have learned in skills lab to help that patient."

However, the lesson doesn't end when the simulation does...

Debrief

Just as important as participating in simulations are the debrief sessions that follow. Each simulation is filmed so that you and your cohort can review what went right, what went wrong and what could be improved upon - similar to how a sports team 'reviews the tapes' after a game. And there's a lot of value in this.

Based on the Debriefing for Meaningful Learning (DML) model developed by Marquette faculty member Kristina Thomas Dreifuerst, PhD, RN, CNE, ANEF, FAAN - and used the world over - these sessions are where a significant portion of the learning occurs. That's because when you experience a scenario, you are in the moment - as a nurse is. However, reviewing it afterward (and seeing your actions) allows you to think more clearly about what you did and why, absent the stress you may have experienced during the simulation itself.

"Our professors set up a lot of scenarios that we could run into in the real world, so it's really nice to get that experience and see how I would really react before I get into the real world and the profession," says Alyssa, a May 2019 Direct Entry MSN program graduate. "I also learn a lot from watching my peers in the simulations because you watch somebody and think, 'I wouldn't have thought to do that.' That's a really good thing."

Additionally, these sessions provide you the opportunity to ask your instructor follow-up questions, and allow him or her to identify areas where you and your classmates may be struggling to grasp concepts. The end result is that you enter clinicals better prepared and more confident in your abilities.

Do You Have What It Takes to Be a Marquette Nurse?

A career in nursing could be closer than you think with Marquette University's Direct Entry MSN program in Pleasant Prairie. Contact an admissions adviser today to learn more about how you can earn your MSN in 19-21 months.

# data[].attributes.attachment_link.title
What Is Simulation in Nursing and Why Is It So Important?

# data[].attributes.attachment_link.description
From the treatments patients receive and the technologies used, to the services provided and even the ways medical records are kept, healthcare - and the nursing profession - have grown increasingly complex. Not surprisingly, to keep up with these advances, the ways in which nurses are trained have also changed, and that's a good thing.

# data[].attributes.attachment_link.title
Virtual reality is finding a place in health care

# data[].attributes.attachment_link.title
Indiana University: Improving nursing education through virtual reality

# data[].attributes.attachment_link.readable_text
Voice recognition technology has become a normal part of many people's lives. Programs such as Apple's Siri help users find restaurants, get directions and call contacts without having to use their phone's keypad. Hospitals may find themselves using similar tech in the not-so-distant future.

One hospital has already started experimenting with the idea of a voice-activated personal assistant helping clinicians with various tasks related to patient care.

According to an article in Stat News, Boston Children's Hospital has piloted its own voice software initiatives.

Boston Children's created several voice-activated apps based on Amazon's Alexa technology. Similar to Siri (or Microsoft's Cortana), Alexa is the voice-activated virtual assistant software that powers Amazon's devices - and it uses open source technology, meaning IT pros can use it to develop their own customized programs.

The first app Boston Children's created was Kids MD, an app where parents with access to Amazon devices could verbally ask questions about common ailments in children. The app would offer users information about the best treatments and medicines for these conditions.

Expanded application to treatment areas

Expanding on that app's success, the facility decided to try and apply the same technology to areas directly related to patients' treatment while they're in the hospital.

Per the article, staff created several programs that could be used in the operating room, the intensive care unit and a young patient's room.

Doctors used voice-recognition technology in the operating room to automatically take and label pictures of various parts of a patient's intestinal tract during a colonoscopy. Voice-activated apps helped nurses draw and properly categorize blood samples in the ICU.

In a patient's room, the Kids MD app could help better communicate discharge instructions to young patients' families, everything from how much acetaminophen is needed for a fever to how to flush a catheter if a patient still has one post-discharge.

Staff also brainstormed other possible uses for voice-activated virtual-assistant technology powered by Alexa, including allowing patients to dim the lights or change the temperature in their rooms.

This tech could also be used to record patients' stories about how they became ill - reducing the times they have to repeat themselves to multiple doctors and nurses. The software could even act as an electronic DJ to choose music as background noise during surgery.

Future for voice tech

Because technology like Alexa is open source and available to anyone who wants to use it, and it has many applications for a hospital setting, voice-activated software could become more common. This is especially true since the feds are pushing hospitals to implement more user-friendly (and patient-friendly) technology.

With that in mind, you may want to check if your hospital's network has the infrastructure in place to support such a change, including strong and secure wireless Internet access throughout the facility, as well as the capability to protect the data recorded and stored in a voice app.

Now's the time to plan and budget for any required updates so your network's able to adapt to these and other similar technological developments.

# data[].attributes.attachment_link.title
Voice-recognition tech could soon be norm in hospitals

# data[].attributes.attachment_link.description
Voice recognition technology has become a normal part of many people's lives. Programs such as Apple's Siri help users find restaurants, get directions and call contacts without having to use their phone's keypad. Hospitals may find themselves using similar tech in the not-so-distant future.

# data[].attributes.headline
How mobile devices can be used by healthcare providers and patients

# data[].attributes.subject
How mobile devices can be used by healthcare providers and patients

# data[].attributes.attachment_link.readable_text
Figure

ALARMS WERE DEVELOPED to improve patient safety, but may actually put patients at higher risk for harm. The literature identifies alarm fatigue as a lack of response to an alarm due to an excessive number of alarms, resulting in sensory overload and desensitization. 1 Redundant alarms can interfere with patient care and delay nurse response times. 2 The ECRI Institute identified alarm fatigue as a top health hazard from 2012 to 2015. 3-6 Cardiac monitoring alarms are among the top contributors to alarm fatigue in most hospitals.

This article follows the journey of one acute care institution's search for a better alarm management solution using new technology to replace its beeper-based system for telemetry alarm events.

Cardiac monitoring and alarm fatigue

Cardiac monitoring provides caregivers with continuous electrocardiography with heart rate tracking, rhythm interpretation, and audible alarms for identified conditions. Telemetry monitoring is a form of cardiac monitoring where each patient wears a wireless transmitter that sends continuous electrocardiography to the central station. This primary monitor is where all real-time tracings of the heart's electrical activity are analyzed and recorded, and where alarms are generated.

In 2017, the American Heart Association (AHA) published the updated practice standards for the use of cardiac monitoring in the hospital setting. The classification of recommendations and level of evidence in the practice standards define Class I (monitoring always required), Class IIa and IIb (monitoring may be required), Class III (no benefit), or Class III (harmful). 7 Cardiac monitoring in non-ICU settings has increased, and patients are often monitored for reasons not supported by AHA practice standards. 8-11

Recognizing the dangers inherent in clinical alarms and the potential for serious patient harm, The Joint Commission put forth a national patient safety goal. By 2014, hospitals were required to establish alarm system safety as a priority and identify strategies to improve the safety of clinical alarm systems. By 2016, they were required to establish policies and procedures for managing alarms and educate staff about the purpose and proper operation of alarm systems for which they are responsible. 12

Problem identification

An analysis of the telemetry monitoring needs at one 473-bed acute care institution revealed the need to replace the notification device for telemetry alarm events. At this institution, five inpatient units have telemetry monitoring capabilities, and the total number of telemetry beds at the time of this project was 74. Each patient on telemetry monitoring wears a wireless telemetry box that sends the activity of the heart to the central station. In select clinical areas, the patient is also monitored with a bedside monitor. To allow for timely alarm response, support patient safety, and optimize nursing

workflow, nurses use an alarm notification device on the five units with telemetry monitoring capabilities. The institution used a beeper-based system prior to the start of this project that notified assigned nurses of all crisis and warning level alarms. Unanswered alerts were forwarded to all nurses (telemetry technicians are not used).

Problems with the existing beeper-based system included the inability to obtain replacement parts and system maintenance from the vendor. The system did not provide alarm filtering, so the primary monitor sent every crisis and warning level alarm to the beeper device. All unit alarms were sent in one queue, meaning only one alarm was transmitted at a time, resulting in delays during times of high alarm volume. Staff reported alarm fatigue and a lack of confidence in the system. An opportunity existed to use new technology to meet the requirements of The Joint Commission's safety goal, support best practices in alarm management, and reduce alarm redundancy.

Project planning

In response to The Joint Commission's safety goal, this institution created an Alarm Management Committee composed of physicians, nurses, administrators, and technical staff. A primary assignment was identifying and selecting a replacement alarm notification device. The new device needs to support the requirements of the safety goal, provide for alarm filtering, reduce staff alarm fatigue, and reflect current best clinical practices for managing alarms.

The committee interviewed multiple vendors; deliverables included sending the alarm to an endpoint device with patient name, room number, and an event waveform. No one vendor could provide all required elements and most offered less functionality than the current device. The committee discovered a smartphone alarm management application (app), waveform app, and middleware software system used together at another institution that could meet all the goals. Middleware software connects client-based network requests to the data needed. 13 In this example, the software bridges the telemetry system with the smartphone app. The committee selected this system as the solution to replace the beeper system.

From this larger organizational committee, a core multidisciplinary project team was created with representatives from information technology, nursing informatics, and clinical nursing departments. Using Plan-Do-Study-Act performance improvement methodology, the team worked collaboratively with vendors to implement the new smartphone solution. The project team provided periodic updates to the alarm management committee.

Prepilot

A collaborative working relationship with the four vendors was key to the project's success. Vendors participated in weekly meetings to review project deliverables, status, and issues. Technical deliverables included infrastructure readiness, multisystem integrations, and information security reviews. To engage the clinical nurses and solicit feedback on current alarm management, each vendor did walking rounds on each monitoring unit. Most nurses mentioned alarm fatigue and the tachycardia alarm volume as most bothersome. A prepilot survey was conducted and analyzed to further explore nurses' perception of alarms and alarm fatigue. Participation in the survey was voluntary.

A nursing superuser group, with representation from each unit, met weekly with the clinical nurse specialists, nursing professional development specialists, and nursing informatics staff. The superuser group supported the core project team's efforts by agreeing on key components of the nursing policy and developing safe workflows with the new device. For example, the new system automatically sends a sample alert to the smartphone every 4 hours. This alert confirms nurse assignments for each telemetry patient and reminds nurses to return to the primary system and/or central station to review alarm history every 4 hours. Charge nurse responsibilities, including verifying the accuracy and equity of the telemetry assignment and creating the assignment in the middleware software system, were delineated. Superuser responsibilities were standardized across the institution; superusers shared project status updates and meeting minutes with their colleagues to facilitate nursing engagement.

System changes

The four components include the telemetry monitoring system, middleware software, smartphone alarm app, and waveform app. As the primary monitoring system, the telemetry system analyzes patient cardiac rhythms and generates alarms. The middleware software receives alarm information from the primary system and forwards select filtered alarms to the smartphone. It also records and reports a time stamp for alarm receipt and acknowledgment. The alarm management smartphone app provides ringtone alerts and banner notifications with patient alarm information including patient name, alarm type, time, and room number. Nurses acknowledge the alarm condition and launch the waveform app with a single swipe on the screen. The mobile waveform app allows nurses to view both the corresponding static alarm waveform or event strip and livestream waveforms of the patient's current rhythm at the point of care. Nurses receive alarms for their assigned patients. Select alarms escalate to all unit staff if not responded to within a designated amount of time. The team selected a smartphone device that could house these two apps, meet future clinical needs for bar code scanning and secure text messaging, and was durable in the clinical environment.

Figure:

Count trigger tachycardia alerts

The new system allowed the project team to access and analyze alarm data, which helped identify and confirm alarm priorities, as well as frequency and length of alarm types. Tachycardia was identified as an outlier alarm occurring frequently on all telemetry units. This supported anecdotal reports from nurses of a fatiguing amount of tachycardia alarms. Baseline alarm data from the pilot unit during a 5-day period showed 1,972 dysrhythmia alarms, of which 1,771 were tachycardia. The team analyzed the average length of tachycardia alarms and noted most alarms were less than 10 seconds and attributable to a small number of outlier patients.

At this institution, the tachycardia parameter is set at 140 beats/minute as the high heart rate parameter. When a patient alarms for tachycardia, nurses collaborate with the medical team to treat the underlying condition, escalate care to the rapid response team if needed, and customize the alarm parameters to reduce redundant alarms. Despite these interventions, tachycardia continued to alarm frequently.

Based on data, patient population, and trial-and-error testing, all tachycardia events that were sustained for at least 10 seconds were sent to the smartphone. This 10-second delay reduced the number of short duration tachycardia events sent to the smartphone. Such events reflected clinically insignificant brief heart rate elevations and artifact alarms. A tachycardia count trigger alarm was created to manage tachycardia events that were shorter in duration and occurred frequently. This alarm counts and captures six tachycardia events that are less than 10 seconds in length and occur within 2 minutes. The six tachycardia alarms are bundled into one alert for the nurses on their smartphones, potentially reducing alarm fatigue. (See Count trigger tachycardia alerts.)

Filters were created for other alarm conditions. For example, ventricular couplets labeled as VT>2 (ventricular tachycardia greater than two) alarms are bundled and sent as one count trigger alarm when they occur frequently. Delays were placed on system alarms. On units with pulse oximetry monitoring, filters were created to reduce alarm redundancy.

Multiple design features were added to improve design, functionality, and patient safety. The ringtones on the alarm app were set to match the same audible alarms from the primary central station so staff did not have to relearn and manage new sounds. The slide button to acknowledge an alarm was customized to automatically launch the waveform app, display the event strip, and capture clinical strip acknowledgment. Multiple rounds of testing and troubleshooting by the project team and vendors improved workflow, alarm configuration safety, and secondary alarm management by clinical staff.

To prepare for implementation, training sessions for nurses were collaboratively created and presented by the clinical nurse specialist and the vendor technical trainers. Training provided an overview of the secondary alarm management system and included hands-on training of new smartphones and alarm simulations. Workflow expectations for securing and inventorying the smartphones, cleaning the smartphones between use, and troubleshooting both the middleware assignment and smartphone app were reviewed. Over 300 nursing and nonnursing employees attended the training sessions. Additional simulation-based staff development programs during implementation contributed to nursing skill and confidence.

Results

The pilot was conducted on one telemetry unit over a 6-week period before expansion to the remaining units. The pilot allowed the team to fine-tune the alarm filters to support safe patient care and better reflect nursing workflows. Daily issue calls allowed for an organized team-oriented approach to solving problems. For example, the team increased the time the nurse is allotted to acknowledge an alarm before it escalates. Based on nursing feedback, the smartphone ringtones were lengthened to ensure they were easily heard. The project team and vendors provided onsite support for the first week of the pilot. The project was then implemented on the five remaining units over 3 months.

Using the middleware vendor application to analyze data, the project team examined alarm data from the pilot unit. During a 1-week time frame, patients alarmed a total of 6,884 times for telemetry alarms inclusive of all crisis, warning, advisory, and message alarms recorded at the primary alarm with tachycardia, representing 59% of the alarms, or 4,048 alarms. Of the total 4,048 tachycardia alarms, 440 alarms were longer than 10 seconds and sent immediately to the smartphone. Of the total 4,048 tachycardia alarms, 2,610 alarms were less than 10 seconds in length, but occurred frequently in a short period of time (six times in 2 minutes), meeting the system's requirement to notify nursing. These alarms were bundled into 435 alarms labeled as "tachycardia count trigger" alarms for the smartphone. Of the total 4,048 tachycardia alarms, 998 were less than 10 seconds, did not occur frequently, did not meet the filtering criteria, and only alarmed at the primary monitor or central station. The nurses viewed these alarms at the primary monitor every 4 hours and as needed during alarm reconciliation.

Seventy-five percent, or 3,050, of the original 4,048 tachycardia alarms were filtered and bundled into a total of 875 tachycardia and tachycardia count trigger alarms and delivered to nurses' smartphones, reducing the total number of alarms by 78% when considering the institution's former beeper-based system would have delivered all 4,048 alarms.

To better understand nurses' perceptions of alarm fatigue and incorporate nursing feedback into the design of the secondary alarm device, a pre- and postsurvey of nurses was conducted on each unit using an adapted version of the 2011 National Health Technology Foundations Clinical Alarms Survey. 14 The survey was distributed via e-mail to RNs working on each of the monitoring units, and participation was voluntary.

The sample size reflects the number of nurses who completed the survey. See Survey results (pre- and postsurveys). Postsurvey data showed a 16.2% reduction to "agree/strongly agree" responses that nuisance alarms occur frequently, and a 16.4% increase to "agree/strongly agree" responses that alarms are adequate to alert staff of potential or actual changes in patient conditions.

Discussion

Using middleware technology to filter and bundle the most clinically significant alarms to the nurse provides real-time alerts and escalations for urgent alarms while also greatly reducing the number of redundant alarms. The success of alarm filtering and bundling is reflected in the 78% fewer tachycardia alarms received by nurses on the pilot unit. Nurses continue to reconcile all alarms at the Central Station every 4 hours and as needed throughout the shift. No adverse patient events have been noted. The app allows for clear and concise alarm recognition and reconciliation. Acknowledged versus unacknowledged alarms are different colors and fonts so it is more difficult for nurses to miss an alarm. During times of high alarm volume, alarms are efficiently sent to the smartphone without delays related to alarm traffic. This is a significant improvement compared with the beeper-based system. Having both the static and livestreaming waveforms on the smartphone allows the nurse to access vital clinical information at the point of care, respond to changes in patient condition quickly, and maximize nursing workflow efficiency.

Upon admission to a telemetry bed, patients, caregivers, and visitors are educated about the use of smartphones for alarm management. Anecdotal patient and caregiver feedback has been positive.

Engaging nurses throughout the process was integral to fostering engagement and enthusiasm during the rollouts. Incorporating nurses' feedback into the design of the smartphone increased user satisfaction. Adjusting alarm filtering and escalation times based on nursing feedback during the pilot allowed for safe and efficient expectations in alarm response. Nurses' perceptions of enhanced confidence in alarms are reflected in the pre- to postsurvey results.

The project team and vendor partnership was successful because of clearly delineating responsibilities, timelines for completion of tasks, and appropriate allocation of human resources to complete required tasks.

This organization is working toward leveraging available alarm data into meaningful reports. The organizational alarm management committee is currently exploring reporting options that illustrate alarm response timeliness and examine individual nurse alarm burden.

Table:

Survey results (pre- and postsurveys)

The smartphone device is being piloted for additional alarm management purposes, such as nurse call and sepsis alerts. Future expansions for more communication functionality, such as Voice over Internet Protocol calling and Health Insurance Portability and Accountability Act-compliant secured text messaging, are being explored. The smartphone is equipped with a bar code scanner, and other project teams are working to test, plan, and support knowledge-based bar code scanning for medication administration.

Customizing smartphone and middleware technology revolutionized management of clinical alarms in real time and at the point of care. This model can serve other organizations in their efforts to standardize alarm configuration and escalation pathways, manage a highly complex technical project, and successfully implement a new system across multiple monitoring units through onsite education and staff engagement.

# data[].attributes.attachment_link.title
Solving alarm fatigue with smartphone technology : Nursing2020

# data[].attributes.attachment_link.description
ALARMS WERE DEVELOPED to improve patient safety, but may actually put patients at higher risk for harm. The literature identifies alarm fatigue as a lack of response to an alarm due to an excessive number of alarms, resulting in sensory overload and desensitization. 1 Redundant alarms can interfere with patient care and delay nurse response times.

# data[].attributes.attachment_link.readable_text
Truman Medical Centers needed to optimize nursing workflow while increasing staff satisfaction and improving patient safety.
THE PROBLEM
The devices nurses were using, such as pagers, old CareMobile devices and health system-issued phones, were nearing the end of their productive life. The time was right to implement new mobile technology, with a priority on allowing nurses to protect Protected Health Information while texting providers.
PROPOSAL
Truman Medical Centers and health IT giant Cerner have been working together since 1992, and that agreement took a big step in 2015 with the creation of the KC One Health Innovation Alliance. This alliance included a "living lab" goal that has allowed for focusing on solving top issues Truman Medical Centers was experiencing by using the latest solutions from Cerner.

The Cerner CareAware Connect project is an example of what it means to be that living lab for both caregivers and patients by adding more robust features and capabilities to streamline the nursing workflow, ultimately giving nurses time back to spend at the patient bedside, said Amy Peters, RN, chief nursing officer at Truman Medical Centers.

CareAware Connect replaced several devices with one, eliminating the need for phones for calling physicians, pagers to reach nurses, CareMobile for scanning medications, cameras for clinical photo collection and a computers for data entry.

"Nurses feel more empowered by using a more convenient device," Peters said. "CareAware allows for increased data on one device, information at their fingertips, and reduces frustration in searching for equipment."
MARKETPLACE
There are a variety of technology vendors on the market today selling all-purpose mobile computers for healthcare. These vendors include Honeywell, ICP America, Janam, Motorola, RMS Omega and Sparton.
MEETING THE CHALLENGE
The Zebra Technologies TC51-HC mobile computer and Cerner CareAware Connect system enable nurses to instantly connect with physicians, family members, other healthcare staff such as social workers, and the patients themselves, regardless of location. Most important, all communication is secure and Protected Health Information is secured, Peters said.

"Our nurses can take high-quality pictures of wounds or other medical issues and securely text those images to a member of the care team using the TC51-HC and Cerner's Camera Capture application," she explained. "What is great about this is that it saves nurses time and creates a perpetual, real-life record automatically saved in a patient's chart."

"When comparing a nurse's steps over two 12-hour shifts, one nurse using CareAware Connect benefitted by reducing her steps from more than 15,000 steps to 7,800."
Amy Peters, RN, Truman Medical Centers

Uploading the photograph into the patient's chart is streamlined when using the TC51-HC; the device also has a flash LED that improves image quality, she added.

"Nurses also can use the mobile device to instantaneously retrieve data from patients' electronic health records and other critical information," she said. "The built-in barcode scanning capabilities in the TC51-HC support many patient safety-related applications. For example, when nurses launch Cerner CareAware Connect on the device they can scan patient identification bracelets, allowing them to double-check medication and track specimens; for example, breast milk."
RESULTS
With nurses now carrying just one mobile device instead of using five, Truman estimates the mobile computers and CareAware Connect platform have improved communication workflows.

"When comparing a nurse's steps over two 12-hour shifts, one nurse using CareAware Connect benefitted by reducing her steps from more than 15,000 steps to 7,800," she reported.

The TC51-HC mobile computer also provides three times more battery life than the previous mobile devices Truman Medical Centers nurses carried, allowing seamless usage throughout the entire shift without requiring recharging.

Further, since Truman Medical Centers nurses started using the TC51-HC and CareAware Connect, patient wristband scanning has improved 12 percent from October 2017 for lab specimen collection. And the provider organization has sustained a 93 percent scan rate for medication scanning.
ADVICE FOR OTHERS
"To ensure for the greatest support, I'd recommend having buy-in from your medical center's CNO and physicians," Peters advised. "It is also valuable to have clear goals and expectations for your devices. Those goals are best met when the CNO communicates clearly about how the devices work, and why the medical center is making the conversion."
Twitter: @SiwickiHealthIT
Email the writer:bill.siwicki@himssmedia.com

# data[].attributes.attachment_link.title
All-in-one mobile devices increase nurse satisfaction at Truman Medical

# data[].attributes.attachment_link.description
Truman Medical Centers needed to optimize nursing workflow while increasing staff satisfaction and improving patient safety. THE PROBLEM The devices nurses were using, such as pagers, old CareMobile devices and health system-issued phones, were nearing the end of their productive life.

# data[].attributes.attachment_link.title
Essential Nursing Informatics: Impact on Healthcare and Quality Initiatives

# data[].attributes.attachment_link.readable_text
Rachel Moscicki is on the leading edge of a movement for nurses to use speech recognition and natural-language-processing technology to record their clinical documentation, saving time and optimizing use of scarce staff.

Software that converts the human voice to digital text and extracts meaning from those words previously was reserved for doctors. Now some health systems are deploying the technology for nurses and ancillary providers.

Moscicki, a cardiology nurse practitioner at the Hudson Valley Heart Center in Poughkeepsie, N.Y., and some of her colleagues switched in May to using speech recognition for real-time documentation in the hospital's electronic health-record system. The heart center is part of the three-hospital Health Quest system, based in LaGrangeville, N.Y., which initially rolled out speech recognition for its physicians to replace their transcribed dictation as part of a documentation-improvement initiative.

The system is now making that same technology available to nurses and other hospital staff, using software from Nuance Communications, a Burlington, Mass.-based developer of speech recognition and natural-language-processing technology.

Moscicki and her colleagues use the new system for all their progress notes, admissions, patient histories, physical exam results and discharge summaries. Progress notes were previously recorded on paper. Moscicki said the software can translate her speech to text faster and more accurately than she can type-and she can type fast. But, she said, "When you're using a dictation system, you don't have typos." And when she's done, the hospital's EHR system, from Cerner Corp., is immediately updated.

Improving nurse efficiency will be a necessity given growing healthcare demands from baby boomers combined with a predicted nursing shortage. The U.S. Bureau of Labor Statistics projects a demand for 1.1 million new nurses over the next seven years. Half that number will be needed to replace nurses who will retire by 2020; the other half will be required to fill an expected 575,000 new positions. The squeeze is made more acute by a scarcity of qualified nursing-school faculty.

The introduction of speech-recognition technology for nurses is significant because of the amount of time they typically spend on documentation. A 2008 study published in the Permanente Journal found nurses spent more time during their workdays on documentation than on direct patient care. The study assessed more than 700 medical-surgical nurses at 36 hospitals.

Nursing experts say EHRs have not helped much with that time crunch, at least partly because they weren't designed with nurses in mind. A study published in the journal CIN: Computers Informatics Nursing in 2012 found that nurses at 55 hospitals spent 19% of their time on documentation, whether they used paper records or an EHR.

"It's probably worse now," said Carol Bickford, a senior policy fellow at the American Nurses Association. "The reporting requirements are terrible." But, she added, "Nurses make it work. We find the workarounds."

A paradigm shift in nursing documentation is needed to improve care delivery, said Joyce Sensmeier, vice president of informatics for the Healthcare Information and Management Systems Society. Speech recognition could help with that. "We need the structured data so we can use computers to aggregate, perform data analytics and look for treatment patterns to improve patient care," Sensmeier said. "But we also need some of that contextual information that's in free text." Designing systems to do both "would advance us much more rapidly," she said.

Joe Petro, senior vice president of healthcare research and development at Nuance Communications, said using speech-recognition technology to reduce the time nurses spend on documentation frees up more time for patient care. "Even if we could improve that with a modest goal of 10 minutes a day, that's an additional 40 hours over the course of a year we could move toward patient care," he said.

# data[].attributes.attachment_link.title
Nurses turn to speech-recognition software to speed documentation

# data[].attributes.attachment_link.description
Rachel Moscicki is on the leading edge of a movement for nurses to use speech recognition and natural-language-processing technology to record their clinical documentation, saving time and optimizing use of scarce staff. Software that converts the human voice to digital text and extracts meaning from those words previously was reserved for doctors.

# data[].attributes.attachment_link.title
Electronic Health Record - Speech Recognition

# data[].attributes.attachment_link.title
Simulation technology helping nursing students make

# data[].attributes.attachment_link.readable_text
[NOTE: Pulsara recently spent at day at the FirstNet Innovation Lab in Boulder Colorado where Pulsara is now installed. The Lab is a centralized location to showcase the capabilities of FirstNet. Pulsara is collaborating with FirstNet to showcase the importance of real-time team communications that crosses healthcare entities. Thank you @FirstNet for your hospitality. - Shawn Olson & Brandon Means]
-

It's unlikely you've heard of FirstNet, unless you work in Public Safety.

But for those of us in EMS, Fire and Law Enforcement, FirstNet was a good idea that has been on our radar since 2012. And for many years it was just that - a good idea. While the vision was solid, the early years were full of arm wrestling politics and big thinkers with a lot of patience.

Things are changing. AND, they're changing fast.
A BIT OF HISTORY
The problem started long ago. We still use archaic communication technologies when seconds count. Technology like handheld radios and pagers permeate communications. Yet, our kids have access to highly efficient technology right in their pockets - their smartphones.

After September 11, 2001, there was a call to action to the federal government. This call highlighted the inability of current networks to handle true crisis situations.

In 2012, more than a decade later, Congress created FirstNet as an independent government authority. The mission was to build and deploy a broadband network dedicated to first responders.

In March 2017, AT&T was selected by FirstNet to build and manage the first nationwide public safety network dedicated to first responders.

Of course, I'm skipping a lot of history like the high-tech inner workings behind the scene. Those innovations include Priority, Quality of Service, and Preemptive technologies ... but that's another topic for another day.
THE POTENTIAL IMPACT
As it currently stands, studies have shown that first responders in the U.S. use ~ 10,000 different and incompatible land mobile radio networks. This hodgepodge of broken systems effectively blocks the ability of first responders to efficiently communicate with each other during an emergency.

But FirstNet addresses these problems head on. For me, as a flight paramedic, here are a few real benefits of the Network:

1. In areas that are crowded (sports stadium, concert, school), first responders can now communicate without concern that citizens are congesting bandwidth that's already limited. By having a dedicated broadband channel, it's now possible for first responders to coordinate the care needed during any event without the worry of a congested network.

2. In rural areas, the expanded network access allows coverage that wasn't readily available prior.

3. With dedicated bandwidth, first responders have the option to transmit real data. Imagine high speed telemedicine via video. What about secure streaming of video during an active shooter incident to the incident commander? Imagine sending live photos of the MCI so that the hospital is better prepared.

The list goes on. In fact, FirstNet built this great i nfographic to explain 10 ways the network helps public safety save lives and secure communities.
WHAT'S NEXT?
First, you should familiarize yourself with FirstNet. In fact, when you have four minutes, take the time to watch this video .

We are in the early adoption phase of FirstNet. So don't feel like you're left out. In fact, it was only a few months ago when all 50 states, two U.S. Territories and Washington D.C. all officially opted into the FirstNet network.

From the FirstNet website, Key FirstNet milestones and activities planned for 2018 include:

Expanding the Network and Building Out Band 14: The First Responder Network Authority will issue work orders to deploy the Radio Access Networks in all 50 states, Washington, D.C., and two opt-in territories in early 2018. This will give AT&T the green light to expand FirstNet's footprint and deploy Band 14 capacity and coverage throughout the nation, providing first responders with the bandwidth and mission critical connections they need to communicate, share information, and use innovative technologies every day and in every emergency.

Driving Public Safety Innovation: FirstNet will also unlock a new technology marketplace for public safety, enabling first responders to benefit from advancements in innovation. The FirstNet App store will be filling up with FirstNet-approved mobile apps that are optimized for public safety use over the first responder network.

Securing Emergency Communications: FirstNet's first-of-its-kind core infrastructure will give first responders the dedicated, highly secure, non-commercial network they deserve. On schedule to be operational in March, the FirstNet public safety core will provide full encryption of public safety data over FirstNet and provide end-to-end cyber security. FirstNet subscribers will also have access to a dedicated Security Operations Center, offering 24/7/365 support.

Engaging with Public Safety: Public safety outreach and advocacy will not stop as the network is further built out. The First Responder Network Authority will continue to engage with public safety in the states, territories, federal agencies, and tribal nations to ensure the network meets their needs and incorporate their feedback in the design of future FirstNet products and services.

Remember, medical errors are the 3rd largest killer of our population. 80% of those are from miscommunication. FirstNet is another step in the right direction to address this crisis.

# data[].attributes.attachment_link.title
FirstNet 101 - What is it? And, How Does it Affect Healthcare?

# data[].attributes.attachment_link.description
The FirstNet Network is taking public safety by storm, helping to transform the way we communicate by ensuring first responders have a reliable network, wherever they may be. Recently, Pulsara toured their lab. Here are some things we learned and an overview of the benefit the network brings to EMS.

# data[].attributes.body
Old vs New