# data[].attributes.attachment_link.title
Effective Utilization of Computerized Curricular Assistive Tools in Improving NCLEX-RN Pass Rates for a Baccalaureate Nursing Program

# data[].attributes.attachment_link.title
Walking the Red Carpet_ A Multicultural Association of Nursing Students Promotes Diversity in an Urban University’s Prelicensure Programs

# data[].attributes.attachment_link.readable_text
Contributors

National Academy of Medicine; National Academies of Sciences, Engineering, and Medicine; Committee on the Future of Nursing 2020-2030; Mary Wakefield, David R. Williams, Suzanne Le Menestrel, and Jennifer L. Flaubert, Editors

Description

The decade ahead will test the nation's nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions.

A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

Topics

Suggested Citation

National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/25982.

Import this citation to:

Publication Info

502 pages | 6 x 9
ISBNs:

Prepublication: 978-0-309-49151-8

Paperback (forthcoming): 978-0-309-68506-1

DOI: https://doi.org/10.17226/25982

Copyright Clearance Center
22 Rosewood Drive
Danvers, MA 01923
Tel (toll free): 855/239-3415 (select option 1)
E-mail: info@copyright.com
Web: https://www.copyright.com

Loading stats for The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity...

# data[].attributes.attachment_link.authors[].name
Committee on the Future of Nursing 2020-2030

# data[].attributes.attachment_link.title
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity

# data[].attributes.attachment_link.description
National Academy of Medicine; National Academies of Sciences, Engineering, and Medicine; Committee on the Future of Nursing 2020-2030; Mary Wakefield, David R. Williams, Suzanne Le Menestrel, and Jennifer L. Flaubert, Editors The decade ahead will test the nation's nearly 4 million nurses in new and complex ways.

# data[].attributes.body
The NCSBN protects the public’s health and welfare by assuring that safe and competent nursing care is provided by licensed nurses (NCSBN, 2021). NCSBN (2021) develops and governs the psychometrically sound and legally defensible nurse license and certification examination known as the National Council of Licensure Exam (NCLEX). The exam is consistent with curriculum practice (NCSBN, 2021). Approximately 20% of the standardized testing questions on the NCLEX questions are based on individual competency in safe and effective care environments (NCSBN, 2016). A major component that falls under this domain is the management of care, which includes information technology (NCSBN, 2016). These scores are pertinent to students obtaining licensure and reflect the institution’s accreditation status. ATI is a curricular assistive tool that combines technology and evidence-based techniques to improve student testing outcomes.

# data[].attributes.headline
The CCNE, in accordance with the American Association of Colleges of Nursing (AACN), requires that the nursing program identify professional nursing standards (CCNE, 2018). Essential IV of AACN’s Baccalaureate Education for Professional Nursing highlights information management and the application of patient care technology as a core competency of healthcare professionals (AACN, 2008). Students who have access to ATI and simulation gain knowledge and skills in information management and patient care technology that prepares them for professional practice.

# data[].attributes.subject
The CCNE, in accordance with the American Association of Colleges of Nursing (AACN), requires that the nursing program identify professional nursing standards (CCNE, 2018). Essential IV of AACN’s Baccalaureate Education for Professional Nursing highlights information management and the application of patient care technology as a core competency of healthcare professionals (AACN, 2008). Students who have access to ATI and simulation gain knowledge and skills in information management and patient care technology that prepares them for professional practice.

# data[].attributes.body
-Identify future Guided Studies pertinent to dissertation project
-Begin orientation to new position as Assistant Professor of Nursing for Lincoln University
-Attend orientation for ATI Engage in Fundamentals Course
-Develop a methodology tool for research
- Obtain IRB institutional approval
-Implement curricular changes with ATI integration

# data[].attributes.body
- ACPA/NASPA Competencies gained during this course:
Student Learning & Development (Design and Application, Assessment & Integration, & Technical Tools and Software)
Ex: Developing the Curriculum, Syllabus, Padlet
Technology (Data Use & Compliance, Digital Identity & Leadership, Online Learning Environments)
Ex: Zoom, Canvas, Email, Padlet
Leadership (Change Movement & Innovation)
Ex: ATI Engage Fundamentals Integration
Personal & Ethical Foundations ( Wellness & Healthy Living)
Ex: Self-care measures like exercise, Communication of needs or requests for assistance, Vacation, Time with family, Reading for pleasure)

# data[].attributes.body
CCNE
AACN
NCSBN
Middle States Commission on Higher Education

# data[].attributes.body
Adult Learning Theory

# data[].attributes.attachment_link.readable_text
*

This article integrates essentials from the framework of NLN Jeffries Simulation Theory (2016) into simulation-based education that includes simulated participants.

*

Simulation programs desiring to integrate a simulated participant program must ensure the psychological and physical safety of their participants, staff, and SPs when designing policies and procedures.

*

This framework can be referenced to establish, evaluate, and/or modify simulated participant education programs.

Inclusion of human role players (simulated participants) in simulation learning is growing rapidly (
Szauter, 2014
Adding the human dimension to simulation scenarios.

). This article proposes modifications to the NLN Jeffries Simulation Theory to support the design, implementation, and evaluation of simulation-based education (SBE) with SPs portraying various roles. The NLN Jeffries Theory serves to identify essential practices and foundational principles for SBE. However, without modification, the theory does not include best practices related to SP methodology. The intention of this article is to set a foundation for a theoretical framework, a Simulation Framework for SP Methodology, that includes SP methodology.

NLN Jeffries Theory

Much has changed in healthcare simulation education since the dissemination of the Jeffries Simulation Model in 2005. Jeffries' initial work, supported by the National League for Nurses and the Laerdal Corporation, was seminal work that provided structure and essential support for a fledgling educational modality. The Simulation Model was renamed the NLN Jeffries Simulation Framework and underwent three additional iterations between 2005 and 2012 (

). In 2016, the new NLN Jeffries Simulation Theory was published following a deep review of the literature (

). Although some simulationists are still struggling with many of the same issues first outlined in

publication, much has happened to propel simulation education forward.

The six core elements in NLN Jeffries Simulation Theory-context, background, design, educational practices, simulation experience, and outcomes-are briefly introduced here for reference. Context is defined as the purpose, physical location, and evaluation criteria of the learning experience, providing the needed framework for each developed simulation. The background, embedded within the context, identifies learner expectations and overarching goals for the simulation, needed resources for the simulation, and how this SBE supports the curriculum. Simulation design includes specific learning objectives, desired fidelity, learner role assignments, simulation flow, and strategies for pre-briefing/debriefing. Commencing from an environment of trust on the parts of both the facilitator and learners, the simulation experience is defined as interactive, learner centric, experiential, and collaborative. Wrapped within the simulation experience is the dynamic interaction between facilitator and participants via pre-briefing, simulation progression, cues, and debriefing. provide significant facilitator and participant attributes that contribute to positive learning outcomes during the simulation experience. The NLN Jeffries Theory separates the final core element outcomes into three areas: participant, patient, and system outcomes. Predominantly, the outcomes of the participant have been widely researched and reported. However, there is a small body of literature indicating that simulation learning translates to better patient outcomes, reduced cost, and improved processes within systems. The core elements outlined in the NLN Jeffries Theory described above remain intact; the proposed modifications originate from the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP), findings from a body of literature related to SP methodology, and accreditation standards established by the Society for Simulation in Healthcare (SSH) (see Table). Similar to how Jeffries' work has evolved, it is anticipated that as the simulation community builds a more robust body of literature relating to SP methodology, requiring further improvements to this framework.

Simulated Participants (SPs) and Other Terminology

Currently, terms, such as standardized and simulated participants, are often used interchangeably with inconsistent definitions within the global simulation community (). For that reason, ASPEs SOBP identifies a universal term, simulated participant, to describe all human role players within simulation-based education (SBE) who have been correctly trained for the consistent portrayal of a role (). This article will align with the ASPE recommendation to utilize the term simulated participant to describe both standardized patients and simulated patients, as well as many other roles that could fit within the context of formative, summative, and high-stakes simulation. Additional examples can include family members, visitors, and other members of the healthcare team.

Additionally, the term participant for this article is defined as anyone involved in the simulation experience as a healthcare provider seeking the opportunity to gain knowledge in their professional role, and/or the role of other healthcare professionals comprising an interdisciplinary team. According to the ASPE SOBPs, the accepted professional title for any individual whose primary role is to educate SPs, ensure SPs are prepared for SBE, and/or function as the subject matter expert (SME) for SP methodology is SP Educator ().

As the context for the simulation is being developed, the inclusion of an SP should also be considered. Simulated participants provide significant value if the purpose of the SBE includes the development of nontechnical skills, such as empathy, patient/family education, assessment of clinical skills, shared decision making, communication during a procedure, and/or patient-centered care principles (

). There is significant documentation in the literature about the need to ensure psychological safety for the participants (

). When an SBE includes SPs, their physical and psychological safety must also be considered throughout development (). Some examples related to physical safety are needle safety, live defibrillators, and air quality. Regarding psychological safety, it is important that each SP is given a detailed description of the simulation and role they will portray in order for them to identify potential emotional conflicts and allow them to "opt-out" if necessary (). There are some simulations that warrant an SP but, if there is any concern that their safety could be compromised, an alternative simulation modality, such as hybrid or manikin simulation, should be utilized.

The setting of the SBE should also be considered when planning the integration of SPs. Best practice standards indicate that learners should not see or interact with the SP outside of the simulated setting. The purpose of this standard is to improve cognitive fidelity, that is, the ability to ensure that all elements of the simulation are presented realistically to the participants (

). As an example, if the participants were to watch a patient with a spinal cord injury walk into the simulation room without difficulty and get into the hospital bed, this would serve as a breech in cognitive fidelity. Programs should evaluate options for modifying the flow of the simulation spaces to avoid unplanned interaction between participants and SPs as they transition into the simulation room. Many simulation programs that were built to integrate SP learning were done so with concealed entrances and hallways established in the floor plan, so learners and SPs do not "meet" outside the simulated setting (

). However, for simulation programs looking to add an SP program after construction has been completed, minor adjustments can be made to reduce the intermingling of SPs and learners outside the simulated setting (

). As an example, SPs can be sequestered in the control room during pre-briefings that occur in simulation spaces. Once the pre-brief is concluded, participants can step out of sight of the simulation room so SPs can enter the room and get situated before the participants enter for the simulation.

Background

The background of NLN Jeffries Simulation Theory includes identifying goals, considering expected benchmarks, targeting the SBE within the curriculum map, and identifying the availability of resources such as time and equipment. Following INACSL Standards of Best Practice Simulation (2016), "Simulation-based experiences are purposefully designed to meet identified objectives and optimize achievement of expected outcomes." The simulation should not be implemented as an educational experience of last resort without significant planning. This best practice holds true more so for a simulation involving SPs. Success requires pre-planning, SP preparation, and clear guidelines for participants, facilitators, SP educators, and SPs. Simulation-based education with SP methodology requires that each of the key stakeholders (see Simulation Experience) understands the role and is invested in the success of each SBE.

For many simulation centers, the barrier to including SPs into SBE is the needed financial resources to pay SPs for their work. However, several simulation programs are identifying unique ways to initiate and maintain a thriving SP program with no or little budgetary allowances. Some examples of unique ways to integrate SP methodology on a small budget include development of a three-credit elective course, partnering with local senior centers or assisted living facilities to identify volunteers, and including SP "workers" as an opportunity for service learning or work-study credit within the institution (, , ).

The Triple Constraint-quality, time, and money (

)-comprises the three leading factors to be considered when initiating a new program. Organizations desiring to start an SP program on a small budget need to ensure they are allocating the necessary time and energy to create a successful, well-developed SP program. One suggestion for success is to start small with one pilot simulation to evaluate the SBE and then to buy it from both participants and administration. Allowing the SP program to start with small, targeted SBE reduces the strain on time and scales costs slowly to meet the demand for SP simulation. Regardless of an institution's financial resources, best practice standards require that time is allocated for SP education, standardization, and feedback training (). The education for simulated participants needs to include professionalism, essentials of standardization, improvisation, feedback, and preparation for role portrayal (, ).

It is imperative that simulation programs that include SP methodology as an educational modality have established policies and procedures for the design, planning, and evaluation of simulation education concordant with both ASPE's and INACSL SOBP (). SP Educators should be included as a part of the team when developing SBEs that include SPs. SP Educators collaborate on character development, the capability of the SP pool, and serve as advocates for SPs to ensure that their physical and psychological safety is being considered during the SBE design.

Jeffries includes the following elements for simulation design: specific learning objectives, desired fidelity, learner role assignments, simulation flow, and strategies for pre-briefing/debriefing. All of Jeffries' elements are still significant with regard to simulation design, including SPs. However, within the constructs of SP methodology, immersion and standardization are additional considerations for SBE with SPs.

With the integration of SPs in SBE, the simulation authenticity and the ability of the SP to portray the assigned role affects the emotional buy-in from participants (, ). If participants perceive a breach in the fidelity or a nonverbal cue from the SP that signals that the SP is "just acting," the ability of participants to remain fully immersed in the learning process is compromised (). Additionally, if the SPs' physical characteristics (age, gender, physical attributes) do not match closely with the character they are representing in the simulation, suspension of disbelief is challenged, negatively impacting learning objectives (

). All types of simulation learning, regardless of the chosen modality, requires resources. Investing in activities that engage participants and promote full immersion maximizes learning outcomes.

Standardization

There are two types of standardization to consider when incorporating humans into the learning experience: individual and team (, ). Individual standardization is the ability of the SP to remain true to the character and present a consistent performance for each simulation experience. Team standardization is similar to inter-rater reliability; it is the ability of all SPs playing a role to create a consistent level of difficulty and fidelity to the character (). With the integration of SPs in simulation learning, team controlling and individual standardization is essential for formative, summative, and high-stakes simulation learning.

Educational Principles

If standards of best practice are being followed, each simulation experience will be collaborative, experiential, and learner centered. The interaction throughout the SBE will also be wrapped in an environment of trust among the SP, participants, and facilitator. With the inclusion of SPs in the SBE, interprofessional education (ISBE) can also be included as a core element of the simulation experience.

Simulation Experience

A truly successful simulation experience occurs when the objectives and design stretch participants to the edges of their ability and create an environment of full psychological and contextual fidelity. The simulation experience in NLN Jeffries Theory includes educational strategies, participants, and facilitators (). With the inclusion of SPs as a part of the educational strategy, there are two additional key stakeholders to consider within the context of the simulation experience: simulated participant educator and simulated participant.

Facilitator

The NLN Jeffries Theory added many additional factors for the facilitator of the SBE. In addition to the demographics identified in the NLN Jeffries Framework, personality, competence, interpersonal relationships, technological skill, attitude, attributes, roles, responsibilities, values, self-awareness, and teaching ability were also identified from the extensive literature review completed by . When including SPs in SBE, there are several additional facilitator factors that influence outcomes.

The structure and educational strategies for SBE differ from a didactic or clinical learning environment (); this truth is amplified when SP methodology is included. Facilitators who integrate SPs into SBEs should have a thorough understanding of SP methodology and ASPEs SOBP (). As key stakeholders, facilitators should actively participate and collaborate during all phases of simulation development, providing context for the SBE, feedback on the performance of the SP, and clearly identify expectations for SP feedback during the debriefing (). Simulation outcomes are enhanced if each facilitator is completely acquainted with the SBE and possesses the needed social and emotional intelligence to provide leadership and direction as they facilitate each SBE ().

Similar to disruptions in clinical practice, outside distractions/responsibilities of a facilitator during any phase of the SBE will affect outcomes (). This is especially true with SP SBE. Facilitators need to be aware of potential threats to SPs safety and intervene if necessary (). Similarly, the International Nurses Association for Clinical Simulation and Learning Standards of Best Practice sm: Simulation highlights the need for facilitators to be familiar with the debriefing process and to adhere to an established debriefing model for consistency. This principle is heightened when SPs are integrated into the debriefing.

The challenges associated with including SP feedback in debriefing can be addressed by including the facilitator(s) and SPs in a cooperative workshop designed to practice this skill. This workshop would be especially helpful for new programs or programs that have not included the SP in the debriefing process previously. An additional recommendation in the literature is to have expert SP facilitators model the debriefing several times for a novice facilitator before the novice facilitates independently (). Facilitators typically invite SP feedback after the participants have had time to defuse/de-role. However, the facilitator should encourage the participants to engage the SP throughout the debriefing process to answer questions from the unique perspective of the SP. There is true benefit in including patient and/or family member-centered insights during the debriefing process. This is especially true if the SBE objectives include development of nontechnical skills, patient/family education, assessment of clinical skills, shared decision making, communication during a procedure, and/or patient-centered care principles (, , ).

Simulated Participant Educator

Both INACSL and ASPE SOBP highlight the importance of "dry runs," or pilots, for every new or revised SBE. The dry run is conducted in advance of the planned SBE to identify gaps in the development process (, , ). During dry runs, the SP educator will typically play the role of the SP from their understanding of the role portrayal while facilitators, SMEs, or advanced "participants" take on the participant role. The purpose of the dry run for the SP educator is to identify gaps in the character description, get feedback from subject matter experts (SMEs) concerning appropriate emotional portrayal, and ensure a thorough understanding of the simulation objectives before the first dress rehearsal.

The SP educator can lead the dress rehearsal that includes all SPs cast for the role, facilitators, and SMEs, when appropriate. SPs seasoned to the role should still participate in dress rehearsals of the SBE; this ensures that all SPs playing the role have gotten the same information, that the details regarding the subsequent performances are consistent, and that the SP educator can update the entire SP pool for the role on any last-minute notes (, ). Furthermore, experienced SPs often have additional information that adds a richness and depth to the role of a novice SP during dress rehearsal.

Once the simulations have begun, SP educators should observe the initial simulations, obtain notes from the facilitator(s) on performance, and provide coaching to the SP between simulations to ensure quality performance (

, , ). For SPs new to a role, SP educators can enhance an SP's confidence, standardization, and feedback quality by scheduling the novice to observe an experienced SP portraying the role (). Ideally, observations would be done in the control room in real time so the SP can ask questions of the SP educator or a seasoned SP as the simulation is unfolding. However, an alternative is to have the novice watch archived videos from previous SP experiences.

Simulated Participant

Cognitive fidelity can be maximized if SPs are fully immersed in the character before the participants enter the room and maintain accurate character portrayal until the SBE concludes (, ). This ensures that the SBE flows naturally and promotes the full engagement of the participants. Simulations that are repeated year after year or semester after semester will gather a cadre of SPs that take ownership of the character and mentor novice SPs as they become familiar with the nuances of that specific SBE. This experience and ownership facilitate consistency in character, the richness of feedback, and a quality learning experience for participants.

There is a multitude of considerations when integrating an SP program into SBE. Most importantly, SPs are human beings with emotions, perceptions, and individual senses of purpose. The suggested modifications to the NLN Jeffries Simulation Theory serve as a framework for simulation centers that currently integrate SP methodology, as well as new simulation programs desiring to include SPs in their simulation experiences. For programs new to SP methodology, it is vital to understand that while SP programs provide extensive benefits, workflow in such programs is different from what many simulationists may be used to. There needs to be time set aside in the simulation calendar for SP education and simulation training. Once the SPs have been properly prepared for the simulation experience, the facilitator is free to focus on the evaluation tool, participant performance, and highlights for the debriefing. The intended simulation outcomes outlined in this framework are affected by the program's commitment to best practice. The Simulation Framework for Simulated Participant Methodology can be referenced to establish, evaluate, and/or modify simulated participant education programs.

Acknowledgment

The author would like to acknowledge Pamela Jeffries, Suzanne Kardong Edgren, Megan Weldon & Gina Ostmann for their feedback, proofreading and organizational assistance in writing this article.

# data[].attributes.attachment_link.title
NLN/Jeffries Simulation Framework for Simulated Participant Methodology

# data[].attributes.attachment_link.description
The integration of human role players into simulation education is at an all-time high. In 2017, the Association of Standardized Patient Educators released the Standards of Best Practice with the intention of complementing the International Nurses Association for Clinical Simulation and Learning Standards of Best Practicesm: Simulation.

# data[].attributes.body
Concept-Based Curricula
A concept-based curriculum is designed to improve students’ ability to apply content knowledge to practice (Johnston, 2017). The concept-based approach connects content, skills, and actions through active learning strategies and when didactic material aligns with clinical experience and application (Johnston, 2017). According to Johnston (2017), conceptual learning allows students to build upon current knowledge and experiences, relate that information to new material, and integrate new learning into practice.

# data[].attributes.attachment_link.title
HEL 8501 GS1 Trill Curriculum Mission Statement

# data[].attributes.body
The integration of Assessment Technologies Institute (ATI) program and the effects on student performance and testing outcomes in an undergraduate, pre-licensure nursing fundamentals course.