As the area of simulation-based education has grown in the health professions, so has interest in using simulation to develop a variety of clinical skills. Although initially used to develop psychomotor skills, simulation has now been linked to improved clinical decision-making (Sharpnack, Goliat, Baker, Rogers, & Shockey, 2013) and improved communication (Hetzel-Campbell, Pagano, O'Shea, Connery, & Caron, 2013). Simulation can take many forms, and depending on the objectives and anticipated outcomes of the simulation-based experience (SBE), the modality can vary. Purchasing simulation equipment can be expensive, and not all SBEs require high-fidelity equipment. SBEs can be created without the use of manikins and still apply concepts of the simulation pedagogy.
Creating non-manikin SBEs requires the same amount of planning and development as creating simulations that use manikins. The International Nursing Association for Clinical Simulation and Learning (INACSL) has developed Standards of Best Practice: SimulationSM Simulation Design, which can assist in guiding the development of SBEs. This article discusses the development of non-manikin simulation experiences that adopt a ShadowBox technique and follow the INACSL (2016) standard of simulation design.
BACKGROUND
The ShadowBox technique is a video decision-making approach that was originally developed to train New York State and New York City Fire Department officers. Based on cognitive transformation theory (Klein & Baxter, 2009), this technique allows trainees or students to see the world through the eyes of the expert without having the expert present (Hintze, 2008). In the ShadowBox technique, videos of challenging situations are presented to small groups of students with decision points and pauses. Students discuss their course of action and priorities, along with their rationales. Following this, the video resumes with the experts' actions and priorities, presented along with rationales. The debriefing includes reflection and comparison of similarities or differences in decision-making. Evaluation of this technique indicates that it can lead to the development of higher level cognitive skills (Hintze, 2008).
Using the ShadowBox technique addresses both theoretical and practical concerns, mainly that, in addition to developing cognitive skills, it is an effective use of the experts' time and availability. The technique has been effectively used with practicing nurses to prioritize and with military members to develop social skills for positive encounters with civilians (Klein, Klein, Lande, Borders, & Whitacre, 2015).
A significant strength of the ShadowBox technique is the ability to develop cognitive skills that depend on tacit knowledge (Klein & Borders, 2016), which may not be easily transmitted. The ShadowBox allows students to see the world through the eyes of the expert and exposes them to the mental models of the expert. Participants have improved decision-making skills after using this technique (Hintze, 2008; Klein & Border, 2016; Sharpnack et al., 2013).
The INACSL (2016) simulation design standard allows for the development of SBEs grounded in research and the current literature that optimize learning in simulation and provides a framework for developing effective SBEs (INACSL Standards Committee, 2016). Criteria included in this standard act as a guide to develop individual SBEs and include creating objectives, prebriefing, and evaluation. Although some of the criteria, such as debriefing, are thoroughly addressed in separate standards, the simulation design standard provides an excellent overall framework to develop both manikin and non-manikin-based simulation experiences. This framework was used to develop our ShadowBox experiences.
DESIGNING THE SIMULATION EXPERIENCE
In order to develop non-manikin simulation experiences for our students that promote clinical decision-making, we used the INACSL Standards of Best Practice: SimulationSM Simulation Design as a framework and applied the ShadowBox technique as the modality. We conducted a needs assessment with our faculty and identified areas that were challenging to teach, and our faculty subject matter experts assisted in developing the case. One such area was communicating with patients who recently received bad news.
The student learning objectives were linked to communication, which included being able to interpret verbal and nonverbal communication and identifying the patient's priority concern. As the ShadowBox technique uses video, this was predetermined as our modality. The video cases were developed under the direction of our subject matter experts to be as realistic as possible to ensure higher fidelity. Preparatory materials were provided to students in the form of readings, and a prebriefing was conducted as a verbal report that students would hear in the clinical setting. Our simulation program has adopted a reflective learning framework for debriefing, and all simulation facilitators have participated in workshops to develop their debriefing skills.
To provide a concrete example of how we applied the ShadowBox technique in a palliative care, non-manikin simulation, the activity unfolded as follows. Our palliative care faculty indicated that discussing end-of-life situations with patients is a challenge for students and new graduates. Faculty and clinical instructors indicated that it is common for students to feel ill prepared to walk into the room of a palliative patient who is emotionally distressed. This was the basis of our scenario. The objectives focused on communication and were as follows: a) employ communication techniques that support the patient's psychological well-being; b) interpret the patient's verbal and nonverbal communication and respond accordingly; and c) identify the patient's priority concern. Our focus was on maintaining psychological fidelity in the SBE. The simulation was conducted during the first term of the third year of a four-year baccalaureate nursing program. The students were in groups of 10 with one simulation facilitator; over the course of a week, a total of 120 students worked though this simulation experience.
After the initial report was given, the students viewed a brief, one-minute video that depicted a young woman crying in a hospital bed. In the video, the nurse enters the room and indicates that she can see something is wrong and sits at the bedside. The patient then says that she doesn't know what to tell her children about her terminal illness. From there, the video is paused, and students break into pairs to discuss and role-play how they would respond to the patient; they are provided with guiding questions to help focus their discussions. The students are then brought together to discuss their strategies, discuss what they would say, and discuss their overall approach to the situation. Following this, another video is viewed that depicts the expert nurse interacting with the patient. The facilitator then guides a discussion that compares the students' strategies to those of the experts. A final debriefing based on a reflective model is conducted.
An important aspect of the video development is that, although the opening situation has a semistructured script, the responses by the experts are not scripted. This is to allow the expert to respond as she or he normally would and to provide insight into the mental modeling of the expert. This cannot and should not be scripted; rather, it should flow from the experience of the expert. Students have indicated in the past that when it is scripted, the wrong responses can appear to be "too wrong" and the appropriate responses can appear to be "too right."
CONCLUSION
Using the ShadowBox technique and the Standards of Best Practice: SimulationSM Simulation Design as a framework, we were able to create a non-manikin simulation experience for nursing students that can assist in developing clinical decision-making and communication skills. We are currently in the process of evaluating this technique as a means to develop comfort in nursing students to communicate with palliative patients who are emotionally distressed.
REFERENCES