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Welcome to today's episode of the NLN Nursing EDge Unscripted. I am Raquel Bertiz, your host from the National League for Nursing Center for Innovation in Education Excellence. In today's episode, we're diving into an essential topic in nursing education simulation design and its role in fostering clinical judgment. With us today is Dr. Beth Rogers, an expert nurse educator who is deeply immersed in simulation education practice
and research. Dr. Rogers is currently a professor at the Texas Christian University and also the associate editor of Clinical Simulation in Nursing. Dr. Rogers, welcome! Thanks so much Raquel. Thank you for having me and thanks to the listeners for joining in today. Okay, I'm ready to dive into this conversation. It's amazing that today we have so many options in implementing simulations, but how do we ensure that we're doing them effectively? So let's start with your research
findings. What did you uncover about simulation and clinical judgment? Well, yeah, thanks for the
opportunity to let me share my research. You know, some of my research has revealed that the complexity of simulation scenarios has a direct impact on clinical judgment outcomes and I think it's really kind of important that we let that sink in because learners really struggle with clinical judgment when complexity is increased in the slightest, especially if they haven't had time in simpler routine situations to
develop like foundational skills. So one of the key findings from my research is that learners would have really likely benefited from spending more time in those routine, less complex simulations. A more gradual progression would allow them time to master basics and build clinical judgment in a more manageable way. As I reflect more and more about the research that I did, I think another key takeaway from my research relates to competency and that it develops at an
individual pace. We really have to keep that in mind because if we push learners into high stakes and complex sims too soon we can actually hinder their clinical judgment development and this is something that I think we observe in simulation
like on a day-to-day basis. I just had this conversation recently about how we can spend an entire semester helping students build confidence in med administration and they can make progress but maybe in the beginning they still like run out of time to give meds or give some slightly incorrectly and they don't really master those medication skills and then we put them in an urgent and high pressure stimulation and they skills just completely fall
apart. So if we don't let students accurately and consistently apply what they've learned to those routine situations, how can we expect them to handle really highly complex situations? I do think I should tell you that the research that I have done is in junior students, which is like their second semester of nursing school.
And we need to know more about the other levels too, but there's lots of literature showing that what I found is what other people find too - that complexity matters and whenever we put students in really complex situations they can't always manage them. We need to know what we can reasonably expect students to do to better handle those difficult situations. Those are great points and they really highlight how foundational skills need time to develop before we throw
our learners into more complex scenarios. And that really brings us to a bigger conversation in nursing education - how we think about time in in simulation? We often put a premium or we measure success of our simulation programs by the amount of time spent in simulations or clinical rotations.
I know that's very similar to my experiences as well that we would like to have this many hours in simulations and this many hours in our traditional clinical rotations, but your research suggests that there's really more to it than just hours logged in. So how do you think about this connection to the broader conversation about time spent in learning experiences in simulation? Yeah I think that's a great question. I think my research confirms that time alone doesn't
guarantee learning progression. You know, at the NLN conference there was a a big call to shift away from thinking about education as time served, you know essentially like, yeah, exactly and instead of focusing on ensuring, we need to ensure that there's mastery of essential skills, right, so you know this really resonated with me because I think a lot of simulation programs approach them as a series of essential experiences and that if
you go through the, go through these experiences you're going to gain what we want you to gain. But the idea really is that, well, I guess the idea that we use is that the more scenarios students are exposed to the better prepared they'll be for practice. But I don't know that that's necessarily true to me. I was talking to a colleague the other
day and he shared a great analogy. He was like, you know, it's like we're trying to teach students how to cook by handing them a bunch of different recipes without first teaching them the foundational skills of cooking. Chefs, to graduate from chef school, don't have to master every single recipe. They master knife techniques and seasoning and balancing flavors and then they apply that to their own recipe and make it their own, their
own like touch, right. But in nursing education, I think we should kind of do the same thing. We should prioritize building a strong foundation and routine, less complex scenarios.
So we should like focus on basic assessment, communication, decision making skills before putting them into complex high pressure scenarios because if we push learners into complex situations too soon, it's like asking somebody to prepare this extremely intricate dish before they even know how to boil water.
Well, that's such a great analogy kind of like I kind of get that right so learning the basics first so it it really illustrates how crucial it is to give learners the time and space like, well, like a kitchen in all its amenities right and in our similar circumstances it's the simulation lab, the clinical labs to master foundational skills first before diving into more complex scenarios. And really this ties into a larger issue when we often see nursing education how
we think about time in simulation. So it's not just really the number of hours, right? It's about how effectively that time is used to build up skills, step by step, and this is where cognitive load becomes really important. You've researched how simulation design impact learners' learning ability to manage the demand placed on them. So how do you think a cognitive load factors into these decisions and how does it influence how we as educators should be
designing simulations? Oh yeah, I think cognitive load is really crucial to clinical judgment development. We know from cognitive load that the way we design sims can either help or overwhelm learners. You know, I've found that factors like sim fidelity, time pressure, multitasking, and we've been talking about task complexity, those all increase cognitive load. And when learners are placed in like a really complex scenario too soon they end
up overloaded. They have more stress, uncertainty they have multiple competing priorities to think about ,and it makes it difficult for them to think and make good decisions and learn. But on the flip side, when we start like with simpler situations that focus on the basics, learners can put their energy, their mental energy, into mastering those core skills. And so it helps them build confidence and confidence, making it easier to like handle
more complex situations down the line. As we, or as students gain mastery, they can tap into like long-term memory and not have to remember as much because they can use what they've already learned to tackle the new challenges. And you know in sim, we're finding things like pre-briefing, repeated practice, modeling, really help reduce cognitive
load. But these strategies are ,they all are kind of related to the scaffolding conversation because they all intend to give learners support to reduce their cognitive load as they move forward. It's really about finding the sweet spot between giving learners the right amount of challenge so they're not overwhelmed but pushing them and growing to improve and that's, that's I think our role as nursing educators and nursing simulationists. Yeah. Yeah, I agree with that that's
such an important point. And those strategies can actually apply not just in simulations but to all other learning activities as well. But let's get back to what strategies can educators use to scaffold complexity and promote growth in learners? That's a good question. I think we all want to know that answer. I think that scaffolding complexity really starts with meeting learners where they are and building
from there. Right now, we assume that we know where students stand because of previous coursework. So, for example, we assume that because students have taken pharmacology that they know their medications. But how many times have you thought or heard someone say, man, I know they were I knew students were taught this and that class. Why can't they remember that in this sim? But that's kind of where we run into trouble.
Just because students were taught something or took a class in a previous course or introduced something in a previous course doesn't mean that they've mastered it, right. So students might know the information but not know how to apply it or
think through a situation. So our first step is really understanding the foundation that students bring to us, what skills do they already have, how comfortable are they with like basic skills, and when we know where they stand, then we can design sims that meet them where they are and like gradually increase their skills instead of assuming where they're at and jumping ahead too
quickly. So after we know where they are, I think the next step is ensuring students have enough time to master simpler, routine, more like skills before we move them on into more complex situations, because that'll give them a stronger foundation and confidence to tackle that same situation later on in a more complex situation. I mean it's kind of like building a house - you don't build the second floor until you have a solid foundation otherwise it's
going to crumble. And we can look to other professions for for guidance here on this scaffolding topic. Like take engineering for example. Engineers don't start by having students design a skyscraper. That is not their expectation of students whenever they graduate. They first focus on the fundamentals of understanding physics and the materials they're working with and how structures fit together and the kind of key concepts of what is needed to make
a building work. It's not about rushing to the final product of designing the most complicated task. It's about grasping the why and understanding the thinking and how behind a design so that whenever they get to a complex project they can use what they know and apply it to that complex situation. And that's really what we should do in nursing. We need students to master core skills before they face those more intricate
sims. So to me, I think a great way to scaffold effectively is to first break down like sims into smaller manageable pieces and focus on the skills like one at a time. For example, maybe early on you can focus on basic clinical judgment skills like assessment or prioritization and like a low stakes routine scenario. But then once they master that you can add in complexity with maybe time pressure or taking care of two
patients instead of one. But it doesn't take a lot of complexity to overwhelm students and I know you were at the conference at the NLN Summit in the fall and you got to hear Dr. Jared Kutzin give us a really good example of scaffolding and I really think that was a really great example. In case you weren't there, he told us that in his sim program he starts with a knowledge assessment to check can see where students are.
Do they understand the material? And then they have to actually pass it to move on, unlike nursing school. A 'C' on an exam gets you to move forward, but they have to pass that knowledge test. So after that he'll introduce a skill related to the knowledge and then maybe build complexity with applying it to the real world situation or a virtual sim, but he
scaffolds within a skill, within a concept. And the key concept is it's a step-by-step approach that really helps learners build skills at a manageable pace and master a part of the skill, add more
complexity. And you know, there's a lot of ways to achieve that example of scaffolding, but at the end of the day, scaffolding is about understanding the building blocks of learning and really giving learners the experience at the right time so that they can grow and be ready for more challenging
situations. And that illustrates starting with a solid foundation right and then building from there rather than jumping straight into to complex situations in simulations, which, by the way, we love to do as nurse educators sometimes. Also I think highlights the need for intentional planning and designing of simulations to kind of like really illustrate that scaffolding concept and also the time element to have our students master all those necessary building blocks or
or competencies as we said. And of course, another important element there is really constant checks of where they are, meaning assessments, right? And therefore there's really a lot of discussions in nursing education right now about transitioning to competency based education. Given your research on the importance of foundational skills and gradual progression, how do you think your findings align with or contribute to this ongoing conversation of concept based education
in nursing? Yeah, I think that's a really important question because with the push towards competency based education, you know there's a lot of focus on designing the assessment and the evaluation to in to make sure that learners are meeting our program outcomes. And as nurses I think our main focus is on what can we do, how can we do it well, how can we get this
problem attacked, right? But sometimes in our rush to get those evaluations in place, we might lose sight a little bit of something that's kind of critical - the learners themselves. We need to think deeply about what they find challenging, what foundational skills do they need to master, and how can we guide them in learning how to think,
not just do. And in nursing education there's a, there's a push to prepare students for managing highly complex patients before they graduate because patients are getting sicker in hospitals. And I can definitely understand that point, but I don't know that it's realistic to expect students to handle every
possible scenario. What's more important is that we provide them those foundational skills that they have hopefully mastered that can still develop as they're practicing and a lot of those skills, both physical skills and cognitive skills, but if we focus on the core skills that then we can help students build confidence and competence to, okay, I may not understand everything about this complex patient but I know how to do an assessment, I know how to ask questions, I know
how to think through is medication appropriate or not, rather than just kind of pushing them into the deep end without having the essential thought processes and skills to care for that complex patient. So if we think about it in a care type situation, if we think about like a newly graduated nurse, would we expect them to take over care for a post-op patient with we'll like
design the most complicated patient ever. We'll say they have a balloon pump and multiple drips and instability they are going up and down in their stability and maybe sound, yeah, we'll throw in they're pregnant and preeclamptic too. That is not a realistic patient. What we should really focus on is whether they've mastered foundational skills to build toward
that level of care. So can they take take a thorough report, can they identify the most important cues and plan their assessment accordingly, or do they understand why they're performing specific interventions and what priorities they want to make. To me, mastering those foundational skills is key to learning how to deal with a complex patient. Once we ensure that learners are secure those basics, then they can apply skills and in a more logical
type way to complex situations. So I just think we might need to shift our concept of what we are working towards learners achieving. It's not really about preparing them for the end evaluation. It's about teaching them the thought processes and clinical reasoning that will get them there. So it's just rethinking how we define complexity because I think we think of complexity in terms of like a scenario topic, but like even if we just take
medication for example. There are levels of complexity within medication. So complexity in medication could just be given a routine medicine versus a non-routine medicine, different routes, whether it's appropriate for the patient's condition or not. We can scaffold complexity within those basic foundational skills with all of it, really, like no matter whether it's an assessment or order management, any of those things. We can view complexity within the foundational skill.
We don't have to make complexity mean they're taking care of super complex patients in an inappropriate situation. So I really think we can just restructure our thinking related to simulation experiences. It's not about passing assessments or exposure to as many scenarios as possible. It's about creating opportunities to practice, develop thinking, ensure mastery of foundational skills, and understanding the why.
And that's how we set students up for for success, not just in sims, but in the real world too. Right, right. And hopefully as a profession or as a nursing education community we can eventually kind of get united as to the end in point of what we want our students to achieve
eventually. And I think we're getting there. and I know that we can talk about this dear topic or topic dear to our our heart on and on and on, but for now I would like you to I guess both of us, I would like us to really kind of like take a pause, reflect some more, and really just push forward with things that we need to kind of like implement in our daily practice as nurse educators. And thank
you so much for sharing your insights. This has been a thought-provoking conversation about the importance of intentional simulation design and building foundational skills before tackling a complex sim. Yeah, thank you so much for inviting me and thank you to the listeners for tuning in
to today's conversation. You know, I know shifting our thinking is never easy but I'm always proud to be a part of a dedicated group of nurse educators who are just as committed to continuous growth and success as we all want to be. So always remember, you know, it doesn't take too much complexity to overwhelm learners. I appreciate this
opportunity to be on this podcast. Yes, so I hope that as nurse educators we continue to reflect on how we are designing our simulation experiences and all other learning experiences in our curriculum and how we frame them in educational theories, standards of practice and evidence. So bye for now and until our next episode. [Music]