October 6, 2020

Episode 32: How COVID-19 has made simulation more relevant than ever

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Description

As the COVID-19 pandemic has spread across the country and forced many nursing schools to pivot to online learning, the use of simulation in nursing curriculum has skyrocketed. And no one is more passionate about and more of an expert on simulation than our guest for this episode, KT Waxman

KT is an Associate Professor and the Director of the Executive Leadership DNP Program at the University of San Francisco and the immediate past president of the Society for Simulation in Healthcare. She’s been working in the field of simulation for 15 years and has seen her work take on more relevance than ever over the last several months. 

Dan and KT and I discuss the shift to VR and screen-based learning in both schools and hospitals, how she’s focused on helping nurses achieve the outcomes of their coursework while relying heavily on simulation and how simulation can be used in some lesser known scenarios, like leadership development. 

Links to recommended reading: 

Podcast

Transcript

Dan:
KT, welcome to the show.

KT:
Thank you very much, Dan.

Dan:
KT, you have a lot of balls in the air as you described it. A lot of things you're up to, everything from teaching to the Editor-in-Chief of Nursing Administration Quarterly to Simulation. What's the most interesting thing you're doing right now?

KT:
Balancing everything is the most interesting. Well, it all dovetails together. I think that my role as the Director of the Executive Leadership DNP program at University of San Francisco is the hub. I do a lot through that, including simulation. I think the most exciting thing right now is the simulation world and screen-based learning. I've been spending a lot of time on that, helping create whitepapers and working with our board and our state capitol to move this agenda forward and enable our students to get the experiences that they need during the COVID pandemic.

Dan:
Simulation is near and dear to my heart. I did my dissertation on simulation, the adoption of simulation in nursing schools. I started with SIM man in the closet and was just interested in like some sort of technology in nursing school that was better than lecture and PowerPoint. Kind of jumped in on simulation. How did you get your start into the simulation world?

KT:
Excellent question. Well, in 2004, 2005, I've been in this since then. I had the good fortune of working with the California Institute for Nursing and Healthcare, which is now Health Impact. I helped write a grant that was funded through the Gordon and Betty Moore Foundation for about a million dollars to create the Bay Area Simulation Collaborative. That was just at the boom of mannequin-based simulation, just starting. I had the ability to convene 65 hospitals in 35 schools of nursing to come together to create a critical mass, if you will, of simulation educators, as all the schools had purchased a mannequin and nobody knew how to do simulation. I learned a lot about technology and I would say that over the five years past that grant, I learned that it's not about the mannequin. It's not about the technology, it's about the methodology and the whole pedagogy. I've been in it for a while and haven't stopped and I'm still doing it.

Dan:
You're the immediate past president for the Society of Simulation in Healthcare. You have this global landscape of where simulations add. I remember, I mean, it started with mannequins in closets and everyone did like code scenarios, code blue scenarios, and now it's ubiquitous across almost every aspect of learning you could do in health professions. What are the major kind of breakthroughs or themes that are happening in the simulation world now?

KT:
Well, the hottest topic is a virtual reality, screen-based learning and really being able to conduct a simulation on a web-based platform and debrief it and have the learners meet the outcomes of the course in both nursing, medicine, allied health, all of the above. What I believe is that we have learned how to do this. We have evidence to support it, and now we're able to apply it in a virtual manner. Unfortunately, some of our regulatory bodies don't believe in it or support it. We're building cases every day to get that to be accepted. California in particular is a big state that's pushing back. We have some states that when COVID hit, they said, "Do whatever you need to do to get these students to graduate and get their clinical hours. You can go up to a hundred percent sim for the time being. We are in a crisis, it's an emergency, right? We need pipeline." California unfortunately hasn't been that aggressive.

Dan:
Well, they weren't aggressive on some of the licensure stuff related to COVID either. It seems like we're a little bit behind the times in the California state related to some of the professional workforce stuff, but you mentioned a lot of evidence is out there. I remember the initial studies were Likert scales of do students and faculty like simulation. I know we've evolved into now outcomes and patient-related things. Why is there such pushback with such a good body of evidence now seeing simulation actually enhances learning and even data that's saying clinical experiences are not as consistent as we had hoped in the past and, and may not actually add as much as we had hoped. Why is there so much pushback against that evidence?

KT:
I think there's some pushback from individuals that are either in our nursing union or CNA or at the BRN board level that feel very strongly that our students should touch real patients. Although I do support that our students need to touch patients, there's not a lot of evidence out there that concludes that the clinical experience actually makes a difference because as you know, our students go into the hospital setting, looking for an experience and it may not happen. They might not see a birth.

KT:
They may not be able to see a certain diagnosis. Where in simulation, we can guarantee that experience. I think that the concern is, well, it's a mannequin. It's not the same. Well, there's a whole movement toward standardized patients was the term that was used as sort of evolving into simulated participants or embedded participants, because a human being who is an actor is not always a patient. It could be a family member. When we're talking about delivering bad news or dealing with a disgruntled family member or doing an assessment, you can use real people. I don't understand why that wouldn't be similar, if not better, than a clinical experience in a hospital setting.

Dan:
Yeah. Why, and our medicine colleagues. One of the roles I had recently is helping build the Kaiser School of Medicine and medicine has been using standardized patients or embedded participants for a very long time as the foundation of their early learning. It seems weird that nursing is so far behind when there's other professions that have jumped whole-hog and are producing wonderful graduates.

KT:
I agree. I know that our FNP colleagues are really embracing SPs, especially with Oskies and that summative assessment just like in medical school. That's really evolving.

Dan:
Tell me a little bit more about the screen-based simulation efforts. I mean, I think people associate mannequin sim and standardized patients as a form of sim, but I think the emerging virtual reality and some of the deeper screen-based, or computer-based simulations have not kind of evolved. Can you kind of give an overview of that?

KT:
Oh, and it's a big space. When you say virtual reality, what comes to mind is really a headset looking at something and doing something and moving around and feeling for things and that where screen-based learning could be a software program that's created by a vendor with an algorithm or an avatar approach to learning. Students would have to us do an assessment, answer some questions, and then they're evaluated at the end. We have to be careful with our terminology and the society for simulation in healthcare actually has a policy statement that is in conjunction with INACSL, which is our International Nursing Association for Clinical Simulation and Learning jointly, put out a paper on screen-based or virtual learning and how valuable it is, especially during the pandemic.

Dan:
What's the uptick now? Has COVID pushed nursing schools into adopting simulation more, or is it the same or what's your perspective there?

KT:
Oh, they're doing more than they ever have. My concern is that a lot of the faculty haven't been trained in simulation. There's a whole methodology around it. There's a pre-briefing. There's the simulation itself, whether it's screen-based or maybe a trigger video that you got off of YouTube, and then there's the debriefing component. They also run the California Simulation Alliance. We have been very, very busy training faculty in our state so that they have the debriefing skills and understand the pedagogy of simulation because they are being forced overnight to do sim online.

Dan:
Yeah. I'm hearing similar struggles. Back in 2012, 2011, the impetus for simulation really was the reduction of clinical site availability. At least at the school I was studying. That's why they went whole hog into, into simulation. It seems like COVID is creating those conditions again. It's kind of forcing people's hand to have to adopt something that may have been on the fringe, or maybe in a little scary. And now there's no other choice, but you're right. I mean, the pedagogy has to go with it. Otherwise, you're just throwing people into a scary situation and potentially even doing damage.

KT:
Exactly. Once COVID hit hospitals to shut down and said, "No students." All over the state of California, we were ... Schools were receiving letters from hospitals saying, "Effective immediately will not take students." The students were just hanging out there waiting. They maybe only had 30 hours left before they could graduate. Hence this movement towards getting it authorized in regulation and that the board being able to approve these different methodologies, it's been very stressful for the students as well as the faculty.

Dan:
What's a state that is doing well with simulation? I can't remember, maybe it was Texas that has up to 75% of the hours, or maybe a hundred percent now, what are the states that have adopted simulation and allowed it through the regulation side. Then what is the rationale for doing that?

KT:
Yeah. Well, some of the States are much more progressive. Yeah, Texas and I think Ohio and a couple of others have said, "Do whatever you need to do during the emergency." Others have gone up to 50%. There are, I think 26 states that prior to COVID allowed up to 50% simulation. They also were able to get waivers if they had couldn't find peds or OB, that's a big one. It's very limited even before COVID. How do we get them their hours? They have allowed them to do a hundred percent and peds and OB. I wonder what's going to happen going forward with the nursing school curriculum and end click. We go through peds, we go through OB, do we never work in peds or OB. How critical is it for them to be in a hospital setting?

KT:
It isn't the board, doesn't say they have to be in a hospital. They just need to get this experience, whether it's a clinic or whatever, but those are limited. Some of the states are very progressive and I think it helps to have nursing leadership at the top at the board level, speaking on behalf of our schools and our students. I know that there's a nurse at the helm in North Carolina and because of her leadership, they've been able to move the simulation agenda much further than we have. Several states and INACSL, when you go onto INACSL.org, you can click on one of the tabs and it'll show an active current map of what every state is doing relative to simulation percentages.

Dan:
Wow. Yeah. I'll have to check that out. That's INACSL.org and we'll put that in the show notes. Switching gears a little bit still in the simulation vein, we've talked a lot about nursing schools and training new nurses in simulation. How are hospital systems using simulation for existing nurse training? Have you seen a system really be, I hate to use the word innovative in this approach, but not just doing those annual evals, where you go to watch poster boards and check the restraint box that you can put on restraints again, but actually use immersive simulation in some fashion to do those types of competency exams?

KT:
There are several, and I think that schools really were the early adopters of sim and now it's moved into the hospital space. Most hospitals are doing some form of simulation. I know Banner Health in Arizona had a hospital within their system that was closed down. They built a new hospital. They turned that entire hospital into a simulated hospital. Every new employee has to go through as if they're taking care of patients. Whether they're a housekeeper, a pharmacist, whatever, in a simulated fashion, before they can actually go into the real hospital setting.

KT:
There is regulation in Israel, which is a phenomenal model where any healthcare professional has to go through their regional simulation center for training before they can ever go into a hospital setting. Kaiser is doing a lot of work in sim. They have a new leader in that space in the Northern California area that I know that has been really doing a lot of training and development relative to residency programs, nurse residency programs, incorporating simulation there, as well as doing these mock codes and IPE training and a professional education, and really doing it as looking at low volume, high risk events.

KT:
The California Hospital Association and American Hospital Association both support simulation as it relates to patient safety and quality. I think that there is a big movement toward increasing sim in the hospital space right now, especially now. We had to do simulation and COVID training before you went into a room, you have to know how to don and doff and all that. It reminded me of that the whole Ebola era, there's a place for it. I think that the other piece is that hospitals and schools need to partner together to identify what equipment they have, what space they have and work with each other in a collaborative way. So that the pipeline is there for the students to be trained in simulation before they come to work for them. Those models are out there as well.

Dan:
That's a good point. I think sim's evolved in the hospitals beyond kind of early team training in high risk events like codes or whatnot, and moved into more team dynamic training as well, like team steps. Where the clinical situation doesn't matter all that much. It's more about how leadership occurs and people interact with teams. Is that a fair assessment?

KT:
Absolutely. I would add to that systems integration. I know that one hospital actually created a cath lab. They simulated the patient being checked in from admission or from the ED all the way through to find out what their gaps were. We've seen OR simulations in malignant hypothermia to identify where the ice machine is. Is it over the red line? Is it behind the red line? Those kinds of things. Doing root cause analysis, delivering bad news to a family member. Then my favorite leadership development, we are able to take aspiring emerging leaders. Instead of throwing them in into the role as a manager director, taking them into a safe environment and having them practice counseling and employee. Creating a budget, doing a budget presentation, creating an elevator pitch for something that they need with their boss. We've learned how to do sim and now we can apply it to these things I just spoke about without ever using a mannequin.

Dan:
I love that. I was going to segue us over into the leadership simulation because one of the things that I talked about on this show and write about is this lack of leadership training in nursing specifically. We tend to promote really good clinicians into leadership roles. We don't necessarily always assess leadership capacity or leadership competency as we promote people up through the ranks. One of my passions is let's get a better training system for leaders as they emerge so that they have the skill sets. You mentioned a couple of examples, but I wonder if there's one that you could go deep on where you've seen a really big difference in leadership ability because they went through a simulation.

KT:
Oh yeah. Well, right now we have what? Four or five generations in healthcare. Depends on whether you're 80 years old and still working in the OR. I keep seeing that on Facebook, but, and then you could be 21, you just graduated. How would you like to be a 28 year old manager having to have a conversation with a 75 year old that reports to you? That's been in the hospital for 40 years and it's difficult. It's challenging. Those kinds of things they can practice. What about walking by two staff nurses violating HIPAA, talking about a patient? How do you say, "Let's talk about this. We have a policy around this." How do you have those conversations? Those are the things that you don't learn as a staff nurse in leadership. Also promoting these aspiring leaders into the C-suite, providing them with some executive coaching kinds of skills through simulation and getting feedback.

KT:
How often do we get feedback from our peers, we're thrown into a role. Then a year later, we have our performance review, right? Then we hear what we're doing wrong. What about creating an environment where I can say, "Dan, I want to give you some feedback right now. I saw you do this. I noticed you did this. And here's what I was suggesting in the future. Tell me why you did it like that." Honing those debriefing and feedback skills and creating that culture can only help cultivate this next generation of leaders.

Dan:
Yeah. I think it provides the ability to have the debriefing and reflection around the leader actions and how they impact people that you may not get from your live environment. Like if you do something out of the normal, as a leader and you go ask your team, like, "How did that feel?" You're kind of got a 50, 50 chance of if they're going to give you honest feedback on like, did you suck or not in that situation, but in sim, you can have your peers. Your friends, your classmates, whatever, give you that honest view. Like, "The way you presented that really kind of would hurt people's feelings." I think it's a really awesome opportunity to have leaders reflect on the impact their nonverbal and verbal communication has on team mates.

KT:
Exactly. On the flip side, even positive feedback. It's always, "Come into my office. I want to talk to," "Oh, I'm in trouble." "Well, how about this? You know, I've noticed that you have a very high retention rate. Tell me how you're doing that. What is your secret?" It could be positive feedback. I just want to reinforce that to everyone out there that's listening that it's not all about providing negative feedback.

Dan:
It's not.

KT:
As a leader.

Dan:
Isn't that leadership though, KT? Isn't that the definition of transactional leadership? Oh, that's it. It's so exciting to see this stuff emerge and we get more leaders involved. I think at Ohio State, we had something called the Corporate Athlete that we did. One of the tenants in that is that professional athletes spend about 90% of their time training and about 10% of their time working. They only work for like four hours a week or whatever in game time. Then in the corporate world, you work in 20 hours a day, but you only train like 5% or 10% of the time. You're kind of always on. And so I think flipping that and saying like, you actually need to have focused development efforts around leadership because you actually have almost a more stressful job than professional athletes do. I think that paradigm shift is important and now we have tools to be able to send leaders through these interesting training environments.

KT:
Absolutely. It all goes back to budget. When we're building our budgets, we need to have a line item that provides for professional development. Because what I hear time and time again is, "Oh, that's a great program, but we can't afford it." Nurses need to be able, nurse leaders need to be able to build a business case and say, "Yeah, if you send us for this training or professional development, the return on investment or ROI could be that our retention rate goes up, that our satisfaction rate goes up and that translate to better patient care and better patient outcomes."

Dan:
Yeah. I think that's the link that is missing. Sometimes it's like, "Oh, you want to go take that crucial conversations class." Now that's easy to cut in a bad budget year, but the long-term impact of that could be retention. It could be H caps. It could be burnout. It could be all these different things that I sometimes hear as soft things. I know you teach finance, you teach it to the American Organization of Nurse Leaders, Executive Fellowship, you teach it to the USF students. What are some of those outcomes that you can tie to dollars that nurse leaders should think about as they're building business cases for personal development?

KT:
Well, that's why I wrote that book because there was not a book. What do you do? How do you do this? I've been talking about this since the like mid-'90s and it's the same stuff. I mean, finance is pretty black and white. Now more than ever, nurses need to be able to quantify quality. If they have made a difference in decreasing infections, decreasing falls, decreasing sitters over time, whatever that is, it equates to dollars. Our CFOs of the world who don't understand really quality, we have to quantify and say, "Okay, if you give us another half FTE or send us to this class, or let us go to this program, and we decrease our whatever rate. Sepsis rate, fall rate by X, Y, or Z, we will save you this amount of money."

KT:
Being able to say that, that resonates with a financial person rather than, "Oh, you just don't understand. Patients are falling, we need more sitters." Well, build the business case and put dollars around it. It's the same old thing. And I think part of the thing is we don't get that as an undergrad and in your graduate school, unless you get an MBA, you maybe have one class in finance for nursing. Then in the doctoral program, you'll have another class. It's just a critical skill. I don't think it's just for students, I'm encouraging CNOs all over the country to hold budget and finance and business skills classes at their institutions to get these guys able to talk the talk.

Dan:
What are some of the best resources that you know of? Obviously your book is one of them. I mean, it's used all over the country and probably the world to teach, but what are some of those great resources that a nurse leader could go look at tomorrow and start building their financial and business acumen?

KT:
That's a good question. I would become a member of the state association for nurse leaders in California. It's ACNL. Nationally, it's AONL. American Organization for Nursing Leadership. They have programs, they have a finance class in conjunction with the HFMA, which is the healthcare finance management association. If you do hfma.com, I think. I'm not sure org or com. They have tools that you can download. They have partnered with the AONL because the CFOs of the world now really are embracing nurses and coming forward as a partnership? I would say those are some organizations. Then there's lots of articles. In Nurse Leader, NAQ. There's at least one article on finance. I would read as much as I could on that and do a search on these types of articles.

Dan:
Yeah. Those are great resources, there's even certifications in some of those as well that you can get just to qualify a little bit more your skill set and competency in the business side of things. What advice do you have for nurse leaders? Let's say they go and they take some of the trainings. They get up to speed, but they're having trouble finding their voice with their CEO, their CFO. What's some advice that you would give an emerging nurse leader to kind of feel confident in those conversations as they're advocating for resources?

KT:
I think that I would, first of all, make it known to your manager or your leader that you're interested in moving up and having these conversations. I would say at a staff meeting, volunteer to bounce something off of the staff and say, "Hey, I want to talk about decreasing sepsis rates. And here's what I'm thinking I'm going to say when I have that meeting." Get some feedback from them. I think that they need to listen and read what's out there that comes across the desk and that our memos that are sent out or journals that are out there to see what the latest topics are and become articulate and building that acumen if you will. I would also collaborate with a non-nurse. Find some leader that is in a different area and partner with them as maybe a mentor or a partnership to bounce these things off of. The way I always did it was I ... In the morning, I would just look in the mirror and say, "Okay, it's show time. This is what I'm going to say today." I would practice in front of my mirror.

Dan:
There's science behind that. I was watching a video about a speed skater, and he was having some trouble in the Olympics. He had to put sticky notes on his mirror in his bathroom that said, "You can do this. You're not going to fall today." Whatever it was, and that makes your mind believe itself and can actually add to the confidence. I love that tactic.

KT:
That's great.

Dan:
KT, where's the best place to find you? Where can our listeners find out more information about what you're up to, both on the NICU front, simulation front, USF, where do you live online?

KT:
I would say I live mostly on LinkedIn. I would encourage people to connect with me on LinkedIn. I post a lot of things on simulation and leadership there. I tweet a lot @KTWaxman on Twitter, and then you can always find me on the USF website, but I'm out there on social media a lot. I use #stimulation #nursingleadership, #womeninleadership, because that's the other thing we didn't talk about, but maybe another time.

Dan:
Yeah. We'll definitely have to have you back on the show because there's a week ago, you have so much cool stuff that you're doing that we could go all day I think.

KT:
I would love that, Dan.

Dan:
One of the things we like to do here is hand off pertinent information to the listeners, that one nugget that you think they should take away and start tomorrow. What would you like to hand off to our listeners?

KT:
I would like to hand off the fact that I believe this is nursing's time to shine. We lead people, we lead communities, we lead patients and we need to be able to articulate our value. I think this is a big time for us to show our value in healthcare and through COVID, we have definitely done that, but we need to capture it. We need to document it, and we need to continue to lead in this healthcare environment.

Dan:
I love it. That's such a great message. There's one other thing that I was thinking, as you were saying that too, I'm sure there's a bunch of listeners out here who are interested in advocating for the simulation path as well. One thing I wanted to ask is where can they connect to become an advocate to push the regulatory bodies a little bit on the adoption of simulation?

KT:
They can join one of our committees, CaliforniaSimulationAlliance.org. They can find me there. We've got a group of individuals on a steering committee through Health Impact that have been working very closely on AB 2288, which has now passed the Senate floor and it's in appropriations at this point.

Dan:
Awesome. Check that out too, especially if you believe in simulation in the future of education, that's the place to be. KT, thank you so much for being on the show. I really appreciate it. We're going to have to have you back to dive into some of these other topics as well, but just really appreciate the time.

KT:
Happy to do it, Dan. Thanks so much for inviting me.

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