Digital Repository Doctoral Projects Spring 2023 Implementation of Virtual Simulation Into Clinical Learning Experiences for Family Nurse Practitioner Students Anne Kendrick Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Kendrick, A. (2023). Implementation of Virtual Simulation Into Clinical Learning Experiences for Family Nurse Practitioner Students. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. IMPLEMENTATION OF VIRTUAL SIMULATION 1 Implementation of Virtual Simulation Into Clinical Learning Experiences for Family Nurse Practitioner Students by Anne Kendrick A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 28, 2023 Anne Kendrick April 28, 2023 ____________________________ Date Kristy A. Baron April 28, 2023 _____________________________ Date _______________________________ Anne Kendrick, DNP Executive Leadership, RN, CNE _______________________________ Kristy A. Baron, PhD, RN _______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director April 28, 2023 _____________________________ Date Note: The program director must submit this form and paper. IMPLEMENTATION OF VIRTUAL SIMULATION 2 Abstract Purpose: The project aimed to integrate virtual simulation (VS) into didactic courses in a DNPFNP program to supplement clinical experiences that were not consistently available in pediatric, women's health, and mental health settings. In preparation for VS implementation, DNP-FNP faculty received training on simulation basics, such as facilitating, debriefing, and promoting learning in simulation and VS. Methods: The faculty simulation training was presented on the basics of simulation, VS, and the application of VS into the curriculum, including a post-VS discussion assignment template. The faculty also participated in a mid-fidelity simulation and scenario debriefing. In addition, two pre- and post-survey assessments were administered to assess faculty attitudes and the adoption of simulation. Results: The post-survey results indicated that faculty had an increased perception of simulation's positive effects on students' learning. Faculty also improved their knowledge and adoption of simulation. In addition, faculty had an increased belief that learning about simulation prepared them to implement VS, positively affecting students' clinical judgment skills. Implications for Practice: The faculty's comfort level with facilitating and debriefing simulation, including VS, improved after the training, so faculty were more prepared to implement VS into the DNP-FNP curriculum. Faculty used the post-VS discussion assignment template in the curriculum to facilitate student debriefing through reflection questions and an online discussion. VS scenarios implemented into the curriculum focused on pediatrics, women's health, and mental health to improve the clinical preparedness of DNP-FNP students. Keywords: simulation, faculty simulation training, virtual simulation, student clinical learning IMPLEMENTATION OF VIRTUAL SIMULATION 3 Table of Contents Implementation of Virtual Simulation Into Clinical Learning Experiences for ............................. 5 Family Nurse Practitioner Students ................................................................................................ 5 Background and Problem Statement ........................................................................................... 5 Diversity of Population and Project Site ..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership ............................................. 6 Literature Review............................................................................................................................ 7 Search Methods ........................................................................................................................... 8 Health Professions Clinical Learning ......................................................................................... 8 Nursing .................................................................................................................................... 8 Factors ..................................................................................................................................... 9 Barriers .................................................................................................................................. 10 Consequences ........................................................................................................................ 11 Simulation ................................................................................................................................. 11 Use of Simulation ................................................................................................................. 13 Virtual Simulation................................................................................................................. 15 Discussion ................................................................................................................................. 15 Implications for Practice ........................................................................................................... 16 Framework and Project Application ............................................................................................. 16 Framework Description ............................................................................................................ 16 Framework Application to Project ............................................................................................ 17 Project Plan ................................................................................................................................... 17 Project Design ........................................................................................................................... 17 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 18 Cost Analysis and Sustainability of the Project ........................................................................ 18 Project Outcomes ...................................................................................................................... 19 Consent Procedures and Ethical Considerations....................................................................... 20 Instruments to Measure Intervention Effectiveness .................................................................. 20 Project Implementation ................................................................................................................. 21 Project Intervention ................................................................................................................... 21 Project Timeline ........................................................................................................................ 22 Project Evaluation ......................................................................................................................... 23 Data Maintenance/Security ....................................................................................................... 23 IMPLEMENTATION OF VIRTUAL SIMULATION 4 Data Collection and Analysis.................................................................................................... 23 Findings..................................................................................................................................... 25 Strengths ............................................................................................................................... 26 Weaknesses ........................................................................................................................... 26 Quality Improvement Discussion ................................................................................................. 26 Translation of Evidence into Practice ....................................................................................... 26 Implications for Practice and Future Scholarship ..................................................................... 27 Sustainability......................................................................................................................... 28 Dissemination ....................................................................................................................... 28 Conclusion ................................................................................................................................ 28 References ..................................................................................................................................... 30 Appendix A ................................................................................................................................... 35 Appendix B ................................................................................................................................... 36 Appendix C ................................................................................................................................... 40 Appendix D ................................................................................................................................... 44 Appendix E ................................................................................................................................... 45 Appendix F.................................................................................................................................... 47 Appendix G ................................................................................................................................... 64 IMPLEMENTATION OF VIRTUAL SIMULATION Implementation of Virtual Simulation Into Clinical Learning Experiences for Family Nurse Practitioner Students Health care is an evolving dynamic field requiring the incorporation of innovation, technology, and evidence-based practice (Papathanasiou et al., 2014). Therefore, nursing students must have the training and skills to administer the safest patient care possible. Simulation is an effective method for educating health professionals, including nurses. This method allows nursing students to practice skills in an environment that does not have the potential to cause patient harm. The benefits of using simulation include student satisfaction, reflecting improved confidence, critical thinking, clinical reasoning, and communication skills (Nye et al., 2019). The primary purpose of this project is to provide Doctor of Nursing Practice Family Nurse Practitioner (DNP-FNP) students with consistent clinical learning opportunities through virtual simulation (VS), improving skills and enhancing didactic learning. The knowledge and skills prepare them for health care delivery to their patients. Background and Problem Statement Clinical sites in the community are limited, and students are not always exposed to consistent clinical experiences preparing them for clinical practice. Unfortunately, with the shortage of clinical placement sites, DNP-FNP students may not fully obtain the comprehensive clinical experience necessary to prepare them for safe practice (McQueen et al., 2018). These limitations involve women’s health, pediatric, and mental health clinical experiences (M. NeVille Norton, personal communication, January 27, 2022). As a result, the Annie Taylor Dee School of Nursing is expanding the use of VS experiences in the DNP-FNP program at Weber State University (WSU). 5 IMPLEMENTATION OF VIRTUAL SIMULATION 6 The National Task Force on Quality Nurse Practitioner Education (2021) has recommended increasing direct patient care clinical practice hours. Although simulation is a recognized learning modality for developing clinical skills, confidence, and critical thinking in nursing students, these skills do not count toward clinical practice hours (Gatewood, 2019). Simulation connects academic and clinical knowledge in preparing DNP-FNP students for comprehensive clinical practice. Simulation tailors specific learning experiences in a low-stakes learning environment where mistakes can be made without the risk of harming a patient (Society for Simulation in Healthcare, n.d.). Diversity of Population and Project Site The populations benefitting from this project are students and faculty in the DNP-FNP program. In addition, consistent clinical learning experiences for the DNP-FNP students can indirectly benefit the patients in the community. Through varied learning opportunities, including clinical, simulation, and didactic, DNP-FNP students are better prepared to care for the healthcare needs of diverse patient populations within the community (Warren et al., 2016). The project benefits for the DNP-FNP faculty include being trained on VS and implementing it into the curriculum, giving them a better understanding of VS. Significance for Practice Reflective of Role-Specific Leadership The desired outcome of this project is to use VS to provide consistent clinical learning opportunities for DNP-FNP students in women’s health, pediatric, and mental health clinical experiences. In addition, the project outcome supports the leadership role of the DNP-postmaster’s prepared nurse by using leadership attributes to advocate for, influence, and successfully implement VS into the DNP-FNP curriculum. Domain 10 of the American IMPLEMENTATION OF VIRTUAL SIMULATION 7 Association of Colleges of Nursing (2021) outlines the role of the DNP-post-master’s nurse in applying nursing knowledge and expertise to promote leadership development. This project allows the DNP leader to identify a gap, create a plan, guide and implement the change, and evaluate the effectiveness. Implementing VS into the curriculum affects the students using it and the faculty teaching the courses. Therefore, understanding and advocating for the needs of the students and faculty with the planned change is vital. Furthermore, identifying the need for consistent clinical experiences and training DNP-FNP faculty on simulation and implementing VS into the curriculum can improve the clinical preparedness of DNP-FNP students. Therefore, having robust academic learning and clinical experiences produces competent and confident DNP-FNPs who can deliver safe and comprehensive health care (Dover et al., 2019). Literature Review The literature review shows clinical learning in nursing programs, specifically graduate ones. Multiple factors affect clinical learning, including the limited availability of preceptors and clinical sites and inconsistent clinical learning opportunities (Gatewood, 2019). DNP-FNP students need to be clinically competent to meet the demands of their roles. Clinical competence improves confidence and patient safety (Dover et al., 2019). Due to decreased clinical sites and preceptors, alternate options for clinical learning have become apparent. Simulation is a form of clinical learning that can be customized to meet objectives and outcomes (INACSL Standards Committee, 2016). An interactive web-based simulation option is VS, where students can direct patient care decisions in a scenario that offers immediate feedback (Foronda et al., 2017). IMPLEMENTATION OF VIRTUAL SIMULATION 8 Search Methods Search terms for this project were simulation, nursing simulation, NP simulation, virtual simulation, nursing clinical hours, nursing clinical learning, and clinical learning. The search engine used was Google Scholar, linked to WSU Library for full-text articles, and OneSearch, the library’s search tool. Exclusion criteria were articles over ten years old and articles that did not include full text. Health Professions Clinical Learning The healthcare profession’s rigorous education integrates classroom knowledge and hands-on skills to be applied in the clinical setting. As healthcare providers, such as doctors and nurses, learn skills, there is a need for a corresponding clinical learning environment to acquire competencies (Nasca et al., 2014). Traditional classroom learning is necessary but does not verify skill competency. A clinical learning environment is where healthcare students attend clinical placements as part of their educational program (Pitkanen et al., 2018). Clinical placements provide an environment for hands-on learning in a healthcare facility under the supervision of a professional who provides support and feedback to the student. Having a clinical environment to apply knowledge, develop patient care skills, and provide professional development builds clinical thinking and reasoning through experience. Clinical learning prepares healthcare students to care for patients in the clinical setting by building clinical competence (Pitkanen et al., 2018). In addition, clinical learning provides professional development opportunities in a student-centered learning environment. Nursing Nurses’ clinical learning is integrated throughout nursing education to provide students with hands-on experience caring for patients in the healthcare environment (Papathanasiou et al., IMPLEMENTATION OF VIRTUAL SIMULATION 9 2014). As nursing students participate in these clinical learning experiences, they are better prepared to participate fully in the care of patients through practical experience. Clinical experiences include more than direct patient care; they include using a practice lab, simulations, and preceptorship (Nye et al., 2019). As students practice skills in the lab, they can use equipment such as task trainers to learn and practice skills. Simulation allows students to implement skills in a safe, controlled environment (Au et al., 2016). During preceptorship, nursing students work alongside a nurse to guide them through participation in the clinical experience (Papathanasiou et al., 2014). As the student nurse gains more theoretical and practical knowledge, they take on more patient care responsibilities, improving confidence and providing holistic patient care. As nurses assume advanced roles, such as the NP role, they participate in clinical learning at their particular level of practice. NP students must complete clinical training hours to fulfill program requirements (Gatewood, 2019). These clinical practice hours provide experiences and develop competencies in caring for populations using their advanced role. Advanced practice nurses also engage in preceptorship experiences, which help them apply their knowledge in overseeing direct patient care (McQueen et al., 2018). Factors Many factors impact clinical learning, such as having limited clinical sites, increasing student enrollment, needing clinical preceptors, and lacking consistent learning opportunities (Cobbett & Snelgrove-Clarke, 2016; Gatewood, 2019). For example, the availability of clinical sites has decreased due to the shortage of preceptors in clinical placements as NP enrollment increases. In addition, the preceptor shortage has also been compounded due to an increased need IMPLEMENTATION OF VIRTUAL SIMULATION 10 for primary care providers, requiring clinical preceptors full-time (Gatewood, 2019; McQueen et al., 2018). Real-life clinical learning experiences rely on patient diagnoses and corresponding care, varying within clinical sites and patient demographics (McQueen et al., 2018). In addition, nursing students’ learning experiences depend on what patients present with, and they cannot pre-select specific experiences. Therefore, it can be challenging to ensure NP students are exposed to all essential clinical experiences to prepare them for practice. In addition, providing NP students with a well-rounded clinical experience due to patient conditions availability is a concern and may require additional options. NP programs rely on community clinicians and preceptors to provide clinical experiences for their clinical hours. The National Task Force on Quality Nurse Practitioner Education (2021) has recommended increasing the required direct patient care clinical practice hours for NPs. However, the recommendation of increasing direct clinical practice hours makes fulfilling NP program requirements difficult due to decreased clinical site availability (Gatewood, 2019). Therefore, alternative ways to fulfill direct clinical practice hours may be necessary. Barriers Barriers to clinical learning could negatively impact the learning experience. McQueen et al. (2018) conducted a cross-sectional descriptive survey (n = 77) of NP students from multiple universities, looking at students’ preceptorship experience, including the perceived positive attributes and barriers to clinical learning. The positive attributes included having a good mentor with communication skills, providing clear expectations, and enhancing learning opportunities. The barriers identified were lack of time, unclear expectations, poor communication, and high stress. Additionally, a quantitative descriptive, correlational design study (n = 463) was IMPLEMENTATION OF VIRTUAL SIMULATION 11 performed by Papastavrou et al. (2016), indicating that nursing students’ relationship with their clinical preceptors positively influenced the clinical learning environment. In contrast, O’Mara et al. (2014) indicated through a qualitative study design, using an interpretive descriptive method (n = 54), that negative clinical learning experiences can adversely affect clinical learning. Therefore, preceptorships for NP students are an essential component of NP programs. Identifying and addressing the barriers can enhance the clinical learning experience for the student. Consequences Consequences exist for NP students being unprepared clinically to meet the role’s demands. These consequences include decreasing patient safety, difficulty passing the board certification examination, and reducing confidence and expertise (Dover et al., 2019; Li et al., 2021). For example, NPs who do not exhibit the necessary clinical skills to care for patients safely can cause harm to patients by inappropriately managing and treating them. In addition, a lack of NP clinical learning widens the gap from novice to expert, decreasing clinical experience and expertise. Improving NP clinical learning experiences can improve patient safety, competence, and confidence (Dover et al., 2019). NPs have multiple methods they can use to engage in clinical learning. In addition to real-life clinical experiences, simulation is beneficial for clinical learning. Simulation creates an effective environment conducive to clinical learning (Warren et al., 2016). Simulation According to the Society for Simulation in Healthcare (n.d.), simulation represents or imitates a situation or process and can vary from simple to complex. Simulation was initially created within the aviation, space, nuclear, shipping, and military arenas to prepare for high- IMPLEMENTATION OF VIRTUAL SIMULATION 12 stakes situations without compromising safety. The use of simulation includes high and mediumfidelity (technology) mannequins, task trainers, virtual reality, VS, role-playing, and standardized patients (Cobbett & Snelgrove-Clarke, 2016). High-fidelity simulation (HFS) is when a full-size computer-controlled mannequin portrays realistic signs and symptoms of a clinical scenario and can communicate and interact with the participants (Au et al., 2016). Simulation helps students connect academic learning and clinical practice (Society for Simulation in Healthcare, n.d.). Learning can be customized through simulation to create specific learning situations that may be difficult to encounter in real life. A standardized approach creates experiences to meet objectives and achieve outcomes (INACSL Standards Committee, 2016). Standardization gives a framework to deliver a consistent simulation experience to maximize the learning potential. Thus, simulation is purposeful but also creates a flexible environment. Society for Simulation in Healthcare (n.d.) states that simulation is an excellent place for students to make mistakes without the risk of causing harm to a patient (Society for Simulation in Healthcare, n.d.). Feedback on the simulation experience is given through debriefing and evaluating how to improve performance. Performance can be evaluated through observing, videotaping, and gathering data from the mannequins or task simulators to indicate the effectiveness of the care given. Evidence has shown that simulation effectively improves clinical judgment, decisionmaking, critical thinking, confidence, and student satisfaction (Cobbett & Snelgrove-Clarke, 2016). Bland and Tobbell (2016) indicated that learning through simulation in small groups improved confidence, support, and social collaboration. Simulation has offered the students an environment where they are part of the healthcare team communicating with each other, asking questions, and making decisions, thus improving clinical judgment and critical thinking (Walton IMPLEMENTATION OF VIRTUAL SIMULATION 13 et al., 2011). The study revealed that students prefer the hands-on learning and active participation that simulation provides. A safe, non-threatening learning environment enhanced knowledge and practice skills and decreased the stress of caring for a patient in real-life clinical situations (Cobbett & Snelgrove-Clarke, 2016). Cobbett and Snelgrove-Clarke (2016) conducted a randomized experimental study (n = 56) of undergraduate nursing students, looking at virtual and face-to-face simulation effectiveness with student knowledge, self-confidence, and anxiety. The study showed no significant difference in knowledge and self-confidence among face-to-face simulation versus VS. However, anxiety scores increased in students who participated in virtual simulations with reported technology issues. The increased anxiety may be relieved through improved orientation and training in the VS program. In contrast, a grounded theory qualitative study (n = 26) performed by Walton et al. (2011) identified that students had less anxiety in simulation when faculty demonstrated enthusiasm, a willingness to learn, patience, good communication, and clinical experience. Faculty has played a role in decreasing anxiety by supporting students in the simulation learning experience. Use of Simulation Simulation is extensively used in undergraduate nursing programs (Bland & Tobbell, 2016) and is part of the curriculum in many graduate programs (Nye et al., 2019). Nye et al. (2019) conducted a descriptive survey examining simulation usage in 408 advanced practice nurse programs. The survey found that 98% of respondents used simulation as a formative evaluation. Additionally, a grounded theory study (n = 46) by Bland and Tobbell (2016) on undergraduate nursing students indicated that simulation promotes curiosity and learning through collaboration. Likewise, a systematic review by Warren et al. (2016) looked at the effects of HFS IMPLEMENTATION OF VIRTUAL SIMULATION 14 within NP education programs. Ten studies in the final review showed that simulation promotes learner satisfaction, knowledge, confidence, competence, and critical thinking in NP education. Though the available literature addressing simulation in NP programs has been limited, it does indicate benefits to NP education. The National Council of State Boards of Nursing has indicated that quality simulation can be substituted for some clinical hours in undergraduate nursing education (Alexander et al., 2015). However, according to the National Task Force on Quality Nurse Practitioner Education (2021), simulation is not considered direct patient care. Therefore, it cannot replace direct patient hours for graduate nursing students, but it does aid in developing necessary competencies before beginning clinical experiences. Studies have indicated the benefits of undergraduate simulation. For example, a quasiexperimental study by Curl et al. (2016) examined the effectiveness of using HFS in three undergraduate nursing programs to replace half of the traditional clinical nursing experiences. Results suggested that the participants in the intervention group exposed to HFS and clinical experiences scored higher on a pre-graduation exit exam and higher on the NCLEX-RN than the control group that only participated in traditional clinical experiences. Additionally, a nonexperimental descriptive survey conducted by Nye et al. (2019) on simulation in 408 advanced practice nursing programs indicated that HFS increased nursing knowledge more than traditional clinical experiences. Moreover, the respondents supported using simulation to meet required clinical hours. A few disadvantages were noted with all the stated benefits of simulation, such as the cost and maintenance of equipment, lab personnel training, and necessary lab space (Cobbett & Snelgrove-Clarke, 2016). Considering these items has been essential when deciding on needs and IMPLEMENTATION OF VIRTUAL SIMULATION 15 resources for nursing programs. A solution to assist with in-person simulation concerns may be resolved using VS, which uses less lab personnel and space. Virtual Simulation VS uses interactive web-based learning that takes the participant through a scenario or virtual world (Cobbett & Snelgrove-Clarke, 2016). VS is accessible and easy to use once oriented to the program. The learner makes patient care decisions that direct the scenario and the outcomes, preparing NP students for clinical practice (Foronda et al., 2020). VS in NP programs has been shown to promote skill development and clinical reasoning and effectively supplement direct patient care clinical learning (Moore & Montejo, 2022). The research on the use of virtual simulation is still emerging, but many nursing students appreciate the use of technology with virtual simulation. In addition, VS offers application-based learning that is engaging and meaningful, where students receive immediate feedback (Foronda et al., 2017). Foronda and Bauman (2014) stated that VS enhanced web-based instruction, hybrid simulation (combining online and face-to-face), lectures and assignments, testing, high-risk situations, clinical practicum, documentation, training, and collaboration. Discussion The literature review showed that simulation effectively bridges the gap between academic learning and clinical practice (Society for Simulation in Healthcare, n.d.). Simulation provides skill practice and improves confidence, clinical judgment, and critical thinking (Nye et al., 2019). VS, a form of simulation, is application-based learning where the student’s decisions guide a virtual patient scenario, and immediate feedback is given (Foronda et al., 2020). The limitations noted in the literature review were small sample sizes and limited available evidence. Multiple studies had small sample sizes, including using one program or one IMPLEMENTATION OF VIRTUAL SIMULATION 16 specific year of nursing, limiting the applicability to other nursing programs. The strengths of some studies included multiple nursing programs, randomization, and an extensive systematic review. Future exploration and research are needed to examine the effectiveness of simulation and VS in NP programs. Implications for Practice Implementing simulation and VS into graduate nursing programs augments direct patient clinical learning. Students may not be exposed to specific experiences in clinical learning where VS can be customized to meet learning objectives and outcomes (INACSL Standards Committee, 2016). This learning method lets students practice skills without the risk of causing patient harm. Simulation improves patient safety by increasing confidence, clinical judgment, and critical thinking. Graduate students can be better prepared through simulation to face the clinical challenges of patient care with enhanced clinical learning experiences (Nye et al., 2019). Framework and Project Application The framework used for this project is Knowles’s adult learning theory. Using this framework helps guide, direct, and structure the project. Adult learning theory also helps organize the project and identifies strategies to make it more successful. Framework Description The adult learning theory addresses how to facilitate learning with adult learners best. Knowles identified six assumptions of adult learners in his model, which include (a) the need to know the why behind learning, (b) self-concept and self-direction, (c) experiences are valuable, (d) readiness to learn, (e) application to real-life situations, and (f) internal motivation (Halpern & Tucker, 2015). Keeping these assumptions in mind creates a more satisfying and engaging IMPLEMENTATION OF VIRTUAL SIMULATION 17 experience for adult learners. In addition, adult learners want a safe learning environment where they can participate actively and collaboratively (Clapper, 2010). Framework Application to Project The adult learning theory is a valuable framework for this project, with students and faculty being adult learners. Students and faculty want a valuable learning experience that is applicable and relevant. Engaging faculty and students in learning the VS platform and implementing VS into the curriculum requires using adult learning assumptions. Training faculty in simulation pedagogy to be more comfortable with VS use in their courses also integrates the learning theory. The project’s educational content and experience can be tailored to engage adult learners using adult learning theory strategies. Project Plan This project integrated VS into didactic courses in the DNP-FNP program at a university in the western United States. The purpose was to supplement clinical experiences not consistently available in women’s health, pediatrics, and mental health. In preparation for VS implementation, DNP-FNP faculty received training on simulation basics, such as facilitating, debriefing, and promoting learning in simulation and VS. The project details, such as the design, needs assessment, cost analysis, outcomes, ethical considerations, and instruments used, are further discussed in this section. Project Design This quality improvement project aimed to improve the clinical learning experiences for DNP-FNP students through more consistent clinical learning opportunities using VS. VS was implemented into the DNP-FNP curriculum to supplement clinical learning experiences that were not consistently available. As a result, VS offered consistent clinical learning and enhanced IMPLEMENTATION OF VIRTUAL SIMULATION 18 didactic learning to prepare the DNP-FNP students to deliver safe, high-quality patient care (Moore & Montejo, 2022). Needs Assessment/Gap Analysis of Project Site and Population The direct population involved with this project included the DNP-FNP faculty and students at the Annie Taylor Dee School of Nursing at WSU. The DNP-FNP faculty participated in the simulation training and implemented the VS into their didactic courses. The DNP-FNP students participated by utilizing the VS program to enhance academic and clinical learning. The indirect population who benefited from this project were the patients within the community being cared for by the DNP-FNP graduates. The key stakeholders included the Graduate Programs Director, Department Chair, and the administrative nursing team. A needs assessment of the DNP-FNP student's clinical learning experiences was conducted, and a gap was identified due to inconsistent clinical learning experiences. Due to limited clinical placement sites, DNP-FNP students felt less prepared and confident to clinically care for patients in women’s health, pediatrics, and mental health. Addressing the gap, DNP-FNP faculty provided students with consistent clinical learning experiences using VS to prepare them to deliver safe health care to diverse populations, including women’s health, pediatrics, and mental health. Cost Analysis and Sustainability of the Project The cost analysis of the project budget (see Appendix A) included the implementation and ongoing expenses. The Annie Taylor Dee School of Nursing covered the implementation expenses, including the ongoing new faculty training and simulation equipment fee. The DNPFNP students were responsible for the VS program fee, which was included in student fees. Different VS programs were investigated, and the cost was a determining factor in deciding IMPLEMENTATION OF VIRTUAL SIMULATION 19 which program to use. The VS program was integrated throughout the DNP-FNP program, so the students benefited from the cost of the VS program. Project Outcomes The following were the short-term and long-term outcomes of this project: 1. Decide on a virtual simulation program to be implemented into the DNP-FNP program at WSU in the Annie Taylor Dee School of Nursing by March 2022. The short-term outcome includes narrowing the VS product options after demonstrations and researching programs. 2. Develop a curriculum to integrate the VS program (i-Human) into the DNP-FNP program at WSU in the Annie Taylor Dee School of Nursing in NRSG 7902 at the end of Fall 2022 to support clinical learning in adults, older adults, pediatrics, mental health, and women’s health. The short-term outcome includes compiling ideas from the stakeholders to create an assignment template for the VS assignments. 3. Develop a simulation PowerPoint training for DNP-FNP faculty at WSU in the Annie Taylor Dee School of Nursing on the basics of leading and debriefing simulation and using VS by September 2022. The short-term outcome includes meeting with stakeholders on the content to ensure it meets the training needs. 4. Develop an evaluation survey tool by the Summer of 2022 for pre- and post-simulation and VS training for faculty at WSU in the Annie Taylor Dee School of Nursing to complete before and after the simulation training. The short-term outcome includes having the stakeholders preview and give feedback on the surveys. 5. Complete faculty training on facilitating and debriefing simulation in preparation for VS into the curriculum for the faculty in the DNP-FNP program at WSU in the Annie Taylor IMPLEMENTATION OF VIRTUAL SIMULATION 20 Dee School of Nursing during the Fall Semester of 2022. The short-term outcome includes giving faculty a basic understanding of facilitating and debriefing simulation to assist with VS integration into the curriculum. 6. Implement VS, i-Human, into the curriculum for NRSG 7902 for the DNP-FNP students at WSU in the Annie Taylor Dee School of Nursing in the Spring of 2023. The shortterm outcome includes adjusting the curriculum according to faculty feedback. 7. Evaluate results from the pre- and post-surveys for the simulation and VS training for the faculty at WSU in the Annie Taylor Dee School of Nursing in the Fall of 2022 and follow up with any training needs. The short-term outcome includes identifying the strengths and weaknesses of faculty perceptions of simulation facilitation and debriefing basics and adjusting the curriculum as needed. Consent Procedures and Ethical Considerations The Institute Review Board (IRB) at WSU confirmed that this project met the quality improvement standard, did not need full IRB approval, and could proceed as planned. The participants gave informed consent through their participation in the survey. The survey results were reported using aggregated data with anonymous and confidential responses. The data collected was used for quality improvement purposes to improve outcomes. Instruments to Measure Intervention Effectiveness The project used two formative assessments, pre-survey (see Appendix B) and postsurvey (see Appendix C), to assess DNP-FNP faculty attitudes and adoption of virtual simulation. Before completing the in-person simulation training, the pre-survey was given to faculty using Qualtrics. After completing the in-person simulation training, the post-survey was given to faculty using Qualtrics. Faculty accessed the surveys using QR codes. The Faculty IMPLEMENTATION OF VIRTUAL SIMULATION 21 Attitudes and Adoption of Simulation instrument (see Appendix D) was used with permission from one of the authors (Min & O’Rourke, 2017). Project Implementation The DNP-FNP faculty were previously trained on i-Human over multiple meetings, and VS cases were selected to meet the needs of the students, faculty, and program. The next step was completing the project intervention, which was presenting the training to the DNP-FNP faculty on the basics of leading and debriefing simulation and VS. The training was completed in preparation for implementing VS into their courses. A template (see Appendix E) was also created for the students’ post-VS discussion assignment. Project Intervention The two-hour in-person DNP-FNP training was presented on October 4, 2022, in the Annie Taylor Dee School of Nursing simulation lab. At the beginning of the training, the participants were asked to complete the pre-survey in Qualtrics with their cell phones by scanning the QR code provided in the PowerPoint presentation or using a printed QR code available at the training. The first hour was the PowerPoint presentation (see Appendix F) that specifically outlined the basics of simulation, VS, psychological safety, and debriefing and how these topics applied to implementing VS into the curriculum. In addition, during the training, a discussion was conducted on what should be included in the post-VS discussion assignment template to meet student and faculty needs. After the discussion and PowerPoint presentation were completed, the faculty participated in a mid-fidelity simulation scenario of a pediatric patient. The DNP-FNP faculty managed the simulation scenario in two separate simulation rooms and played the roles of the IMPLEMENTATION OF VIRTUAL SIMULATION 22 provider or the mother of the pediatric patient. The simulation scenario ran for 10 minutes, with the participants focusing on assessment, differential diagnosis, labs, and referrals. Once the simulation was completed, the faculty participated in a scenario debriefing. The faculty could explore their initial thoughts and reactions to the scenario. The scenario was then analyzed with a discussion of what went well and what the faculty would change if they were to do it again. The debriefing session ended with the faculty stating their “takeaway” from something they learned in the simulation scenario. The purpose of the simulation was to give the faculty a hands-on experience in a scenario. This experience helped them understand simulation and ways to implement VS into their courses effectively. After the completion of the simulation debriefing, any remaining questions were addressed. Faculty were then asked to complete the post-survey, which they accessed on their cell phones by scanning the QR code. Finally, the faculty was given a certificate of completion for attending the simulation training. The certificates and training PowerPoint were emailed to the DNP-FNP faculty three days after the training. Over the three weeks following the training, the post-VS discussion assignment template was created. The template was then presented to the DNP-FNP faculty for feedback. Finally, the finalized template was emailed to the faculty for course integration into NRSG 7902, starting in the Spring of 2023. The template was a discussion assignment DNP-FNP students used after completing the VS cases. Project Timeline The project timeline (see Appendix G) was a guidance tool to track the initial proposal through evaluation. The project proposal and literature review included an analysis of simulation and clinical hours within nurse practitioner programs across the state and surrounding states. IMPLEMENTATION OF VIRTUAL SIMULATION 23 Additionally, the project proposal included VS program demonstrations and selection. The project followed the projected timeline and informed the team of the status. Project Evaluation After completing the project implementation, which included completing the DNP-FNP faculty simulation training, the next step of the project was to evaluate whether the outcomes were achieved. Outcome evaluation included analyzing the data and looking for any trends. Finally, assessing the project’s intended impact on the DNP-FNP faculty was another critical step in determining the project's success. Data Maintenance/Security The results from the pre- and post-surveys were kept confidential using the Qualtrics program to store the anonymous data. Therefore, there was no identifying information gathered from the participants. Only the DNP student over the project and the DNP project lead had access to the survey results, which were accessible through password-encrypted logins to Qualtrics. Data Collection and Analysis After completing the DNP-FNP faculty simulation training, the pre- and post-survey quantitative data were collected and analyzed using Qualtrics. The descriptive data analysis was conducted using percentages comparing the data from the pre- and post-surveys (see Tables 1 and 2). Table 1 shows faculty responses to using simulation as a learning tool and in preparation for using VS. Using VS to build clinical judgment skills was also presented. Table 2 shows faculty responses to their knowledge and adoption of simulation. IMPLEMENTATION OF VIRTUAL SIMULATION 24 In Table 1, the post-survey results for question two indicated that faculty had an increased perception of simulation's positive effects on students' learning (80% Strongly Agree). In addition, the post-survey results increased for question nine, suggesting that faculty felt more prepared to implement VS after learning about simulation (80% Strongly Agree). Similarly, for question 10, the faculty believed VS could positively affect students' clinical judgment skills (80% Strongly Agree). Table 1 Pre (Post) Measures of Faculty Attitudes and Adoption of Simulation Survey Survey Question Q2. I believe that using simulation in teaching could have a positive effect on student learning Q9. I believe that learning about simulation can prepare me to use virtual simulation for student learning Q10. I believe that using virtual simulation in teaching could have a positive effect on clinical judgment skills Strongly Disagree 17 (0) Percentage of Participants Disagree Neutral Agree 0 (0) 0 (0) 33 (20) Strongly Agree 50 (80) 0 (0) 0 (0) 0 (0) 67 (20) 33 (80) 0 (0) 0 (0) 0 (0) 50 (20) 50 (80) Note. N = 6 (N = 5). This table demonstrates participant responses in the Faculty Attitudes and Adoption of Simulation survey before (and after) the educational intervention. In Table 2, faculty increased their knowledge and adoption of simulation. In the presurvey, most faculty chose Advanced Beginner as their simulation knowledge. In the post- IMPLEMENTATION OF VIRTUAL SIMULATION 25 survey, 40% of the faculty chose Competent, and 40% chose Proficient, indicating an improved comfort level after the simulation training. In addition, the post-survey showed that faculty had an increased level of adoption of simulation, with 20% selecting Leading the Process and 40% choosing Understanding and Applying the Process. Table 2 Pre (Post) Measures of Faculty Attitudes and Adoption of Simulation Survey Survey Question Novice Q7. My knowledge of simulation can best be described as: 0 (0) Awareness Q8. My level of adoption of simulation can best be described as: 16 (0) Percentage of Participants Advanced Competent Proficient Beginner 66 (20) 17 (40) 17 (40) Learning the Process 67 (40) Expert 0 (0) Understanding Facilitating Leading and Applying the Process the Process the Process 0 (40) 17 (0) 0 (20) Note. N = 6 (N = 5). This table demonstrates participant responses in the Faculty Attitudes and Adoption of Simulation survey before (and after) the educational intervention. The demographic data of the study participants included female faculty between the ages of 45 and 65 years. The participants taught in the DNP-FNP program and held an MSN degree or higher. In addition, participants had been with the school of nursing for three or more years. Findings Overall, the project outcomes were met by improving faculty comfort and knowledge of simulation and VS, thereby effectively implementing VS into the DNP-FNP curriculum and enhancing student learning. Before the training, faculty were not as comfortable with simulation IMPLEMENTATION OF VIRTUAL SIMULATION 26 and VS. However, their comfort level increased following the training. They could apply the concepts of simulation and lead the process. VS was a new process for many faculty, and the training gave them the confidence to successfully implement i-Human within their curriculum. Integrating VS into the curriculum could promote clinical judgment skill development by enhancing DNP-FNP student clinical learning (Moore & Montejo, 2022). Strengths The project's strengths included using a valid and reliable instrument. The instrument used was The Faculty Attitudes and Adoption of Simulation (see Appendix D) (Min & O’Rourke, 2017). In addition, the project was versatile and could be implemented in other DNPFNP programs to enhance student learning. Weaknesses The weakness noted in the project was the low number of participants (N = 6 pre-survey, N = 5 post-survey). In addition, not all participants who took the pre-survey completed the postsurvey. Therefore, having a more significant number of participants could change the survey results. Quality Improvement Discussion The last step of the quality improvement project is incorporating project findings into future practice. Looking at the evidence used to complete the project successfully and identifying new knowledge gained aids in the process for future practice. In addition, the project gives a foundation for future projects, including sustainability and dissemination. Translation of Evidence into Practice Simulation connects academic and clinical practice and improves learning and patient safety (Society for Simulation in Healthcare, n.d.). Because students are not always exposed to IMPLEMENTATION OF VIRTUAL SIMULATION 27 consistent clinical learning experiences, it can leave them unprepared for clinical practice. Therefore, integrating VS into graduate nursing programs can improve student clinical judgment, thinking, and decision-making (Cobbett & Snelgrove-Clarke, 2016). Project findings show that simulation and VS training improved faculty’s confidence and knowledge of simulation. Moreover, these findings show faculty were more comfortable after the training to use VS as a learning tool to enhance clinical learning. Training faculty on simulation and VS can facilitate implementing VS into the curriculum. The same training technique can be used on other quality improvement projects involving simulation to improve confidence and knowledge for a successful implementation. Implications for Practice and Future Scholarship The use of VS in nurse practitioner programs can positively impact clinical learning. Selecting specific VS cases in which DNP-FNP students encounter inconsistent clinical experience can improve their clinical skills and confidence. Preparing faculty to use VS within the curriculum enhances the implementation process by increasing their comfort level and knowledge of VS. Training faculty on simulation and VS gives them the improved confidence and tools to successfully use VS. Undergraduate and graduate nursing programs that are interested in incorporating VS into their curriculum can use this project as guidance. Faculty that are more confident and knowledgeable about simulation can give students a more robust learning experience. The post-VS assignment template is a debriefing tool that facilitates students’ selfreflection on their completed VS scenarios. Moreover, the assignment serves as an opportunity for students to engage in discussion posts. The assignment helps students use the computergenerated VS performance report to identify areas they do well in and areas for improvement, IMPLEMENTATION OF VIRTUAL SIMULATION 28 reflecting on their clinical decisions. Students can also ask questions and engage in a discussion dialogue with other students. Sustainability VS in the DNP-FNP program continues to be utilized for future students. The cost associated with using the VS program is included in student fees. In addition, the VS program is cost-effective and utilized throughout the DNP-FNP program, giving students ample opportunity for use. A contract is established between i-Human and the school of nursing, including ongoing product and technology support for faculty and students. The training resources created on simulation and VS can be utilized by new faculty using VS in the DNP-FNP program. A need for future scholarship exists to identify the student’s response to using VS and how it prepares them for clinical practice. Dissemination This quality improvement project is available digitally through the Stewart Library Repository at WSU and is open to the public. Additionally, the results were presented at the Western Institute of Nursing conference as a poster presentation in April of 2023. Finally, the project continues to be shared within the professional community as opportunities arise. Conclusion Inconsistent and limited clinical learning experiences may leave DNP-FNP students unprepared to deliver safe practice. Utilizing VS in the DNP-FNP program curriculum can improve clinical judgment and critical thinking, improving clinical learning. The project’s intervention shows that faculty in the DNP-FNP program attended training on the fundamentals of simulation and VS. Results indicate the training increased faculty simulation knowledge in IMPLEMENTATION OF VIRTUAL SIMULATION 29 preparation for implementing VS into the nursing curriculum. Additionally, faculty show an increased level of adoption of simulation, increasing their confidence. Preparing DNP-FNP students to be clinically competent in all aspects of care can be challenging as clinical sites are limited with inconsistent clinical experiences. VS offers a solution to meet the clinical gap and more fully prepare students to deliver safe clinical care. In addition, training on simulation and VS improves faculty confidence and knowledge for the successful implementation of VS into the nursing curriculum. IMPLEMENTATION OF VIRTUAL SIMULATION 30 References Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-Edgren, S., Kesten, K. S., Spector, N., Tagliareni, E., Radtke, B., & Tillman, C. (2015). NCSBN simulation guidelines for prelicensure nursing programs. Journal of Nursing Regulation, 6(3), 39-42. https://doi.org/10.1016/S2155-8256(15)30783-3 American Association of Colleges of Nursing. (2021, April 6). The essentials: Core competencies for professional nursing education. http://aacnnursing.org/AACNEssentials Au, M. L., Lo, M. S., Cheong, W., Wang, S. C., & Van, I. K. (2016). Nursing students’ perceptions of high-fidelity simulation activity instead of clinical placement: A qualitative study. Nurse Education Today, 39, 16-21. http://dx.doi.org/10.1016/j.nedt.2016.01.015 Bland, A. J., & Tobbell, J. (2016). Towards an understanding of the attributes of simulation that enable learning in undergraduate nurse education: A grounded theory study. Nurse Educator Today, 44, 8-13. http://dx.doi.org/10.1016/j.nedt.2016.05.011 Clapper, T. C. (2010). Beyond Knowles: What those conducting simulation need to know about adult learning theory. Clinical Simulation in Nursing 6(1), 7-14. http://dx.doi.org/10.1016/j.ecns.2009.07.003 Cobbett, S., & Snelgrove-Clarke, E. (2016). Virtual versus face-to-face clinical simulation in relation to student knowledge, anxiety, and self-confidence in maternal-newborn nursing: A randomized controlled trial. Nurse Educator Today, 45, 179-184. http://dx.doi.org/10.1016/j.nedt.2016.08.004 IMPLEMENTATION OF VIRTUAL SIMULATION 31 Curl, E. D., Smith, S., Chisholm, L., McGee, L. A., & Das, K. (2016). Effectiveness of integrated simulation and clinical experiences compared to traditional clinical experiences for nursing students. Nursing Education Perspectives, 37(2), 72-77. http://dx.doi.org/10.5480/15-1647 Dover, N., Lee, G. A., Raleigh, M., Baker, E. J., Starodub, R., Bench, S., & Garry, B. (2019). A rapid review of educational preparedness of advanced clinical practitioners. Journal of Advanced Nursing, 75(12), 3210-3218. http://dx.doi.org/10.111.jan.14105 Foronda, C. L., Alfes, C. M., Dev, P., Kleinheksel, A. J., Nelson, D. A., O’Donnell, J. M., & Samosky, J. T. (2017). Virtually nursing: Emerging technologies in nursing education. Nurse Educator, 42(1), 14-17. http://dx.doi.org/10.1097/NNE.0000000000000295 Foronda, C., & Bauman, E. B. (2014). Strategies to incorporate virtual simulation in nurse education. Clinical Simulation in Nursing, 10(8), 412-418. http://dx.doi.org/10.1016/j.ecns.2014.03.005 Foronda, C. L., Fernandez-Burgos, M., Nadeau, C., Kelley, C. N., & Henry, M. N. (2020). Virtual simulation in nursing education: A systematic review spanning 1996 to 2018. Journal of the Society for Simulation in Healthcare, 15(1), 46-54. http://dx.doi.org/10.1097/SIH.0000000000000411 Gatewood, E. (2019). Use of simulation to increase self-directed learning for nurse practitioner students. Journal of Nursing Education, 58(2), 102-105. http://dx.doi.org/10.3928/01484834-20190122-07 Halpern, R., & Tucker, C. (2015). Leveraging adult learning theory with online tutorials. Reference Services Review 43(1), 112-124. http://dx.doi.org/10.1108/RSR-10-2014-0042 IMPLEMENTATION OF VIRTUAL SIMULATION 32 INACSL Standards Committee. (2016). INACSL standards of best practice: Simulation design. Clinical Simulations in Nursing, 12, S5-S12. https://dx.doi.org/10.1016/j.ecns.2016.09.005 Li, A. A., De Gagne, J. C., Howard, V., Thornlow, D., Smallheer, B. S., Richard-Eadlin, A., & Krieder, K. E. (2021). Student success factors in a nurse practitioner program. The Journal for Nurse Practitioners, 17(9), 1124-1127. https://doi.org/10.1016/j.nurpra.2021.05.025 McQueen, K. A., Poole, K., Raynak, A., & McQueen, A. (2018). Preceptorship in a nurse practitioner program: The student perspective. Nurse Educator, 43(6), 302-306. http://dx.doi.org/10.1097/NNE.0000000000000498 Min, H., & O’Rourke, J. (2017). Faculty Attitudes and Adoption of Simulation: Pilot testing of a new instrument. Journal of Nursing Education, 56(6), 356-359. http://doi.org/10.3928/01484834-20170518-07 Moore, J. & Montejo, L. (2022). Case-based learning: Facilitating nurse practitioner clinical learning with virtual patient cases. Journal of the American Association of Nurse Practitioners, 34(1), 129-134. http://doi.org/10.1097/JXX.0000000000000560 Nasca, T. J., Weiss, K. B., & Bagian, J. P. (2014). Improving clinical learning environments for tomorrow’s physicians. The New England Journal of Medicine, 370(11), 991-993. http://dx.doi.org/10.1056/NEJMp1314628 National Task Force on Quality Nurse Practitioner Education. (2021). A report of the National Task Force on quality nurse practitioner education: Standards for quality nurse practitioner education, 6th edition. National Task Force. IMPLEMENTATION OF VIRTUAL SIMULATION 33 https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Draft-NTF-Standards-forQuality-Nurse-Practitioner-Education-10-20-21.pdf Nye, C., Campbell, S. H., Hebert, S. H., Short, C., & Thomas, M. (2019). Simulation in advanced practice nursing programs: A North-American survey. Clinical Simulation in Nursing, 26, 3-10. https://doi.org/10.1016/j.ecns.2018.09.005 O’Mara, L., McDonald, J., Gillespie, M., Brown, H., & Miles, L. (2014). Challenging clinical learning environments: Experiences of undergraduate nursing students. Nurse Education in Practice, 14(2), 208-213. https://doi.org/10.1016/j.nepr.2013.08.012 Papastavrou, E., Dimitriadou, M. Tsangari, H., & Andreou, C. (2016). Nursing students’ satisfaction of the clinical learning environment: A research study. BCM Nursing, 15(44), 2-10. https://doi.org/10.1186/s12912-016-0164-4 Papathanasiou, I. V., Konstantinos, T., & Sarafis, P. (2014). Views and perceptions of nursing students on their clinical learning environment: Teaching and learning. Nurse Education Today, 34(1), 57-60. http://dx.doi.org/10.1016/j.nedt.2013.02.007 Pitkanen, S., Kaariainen, M., Oikarainen, A., Tuomikoski, A., Elo, S., Ruotsalainen, H., Saarikoski, M., Karsamanoji, T., & Mikkonen, K. (2018). Healthcare student’s evaluation of the clinical learning environment and supervision – a cross-sectional study. Nurse Education Today, 62, 143-149. https://doi.org/10.1016/j.nedt.2018.01.005 Society for Simulation in Healthcare. (n.d.). About simulation. Retrieved November 11, 2021, from https://www.ssih.org/About-SSH/About-Simulation Walton, J., Chute, E., & Ball, L. (2011). Negotiating the role of the professional nurse: The pedagogy of simulation: A grounded theory study. Journal of Professional Nursing, 27(5), 299-310. https://dx.doi.org/10.1016/j.profnurs.2011.04.005 IMPLEMENTATION OF VIRTUAL SIMULATION 34 Warren, J. N., Luctkar-Flude, M., Godfrey, C., & Lukewich, J. (2016). A systematic review of the effectiveness of simulation-based education on satisfaction and learning outcomes in nurse practitioner programs. Nurse Education Today, 46, 99-108. http://dx.doi.org/10.1016/j.nedt.2016.08.023 IMPLEMENTATION OF VIRTUAL SIMULATION 35 Appendix A Project Budget Project Budget Implementation Expenses Items Cost per Unit Number Total Cost Staff training (7 faculty/2 hours) $32.00 14.00 $448.00 Training materials (handouts) $0.50 7.00 $3.50 Presenter time $32.00 2.00 $64.00 Simulation equipment $75.00 2.00 $150.00 25.00 $665.50 Total $ 139.50 Ongoing Expenses Items Possible new faculty training Cost per Unit Number Total Cost $ 32.00 2.00 $64.00 Student fee per academic term $ 165.00 1.00 $165.00 Simulation equipment $ 75.00 2.00 $150.00 Total $ 272.00 5.00 $379.00 IMPLEMENTATION OF VIRTUAL SIMULATION 36 Appendix B Faculty Attitudes and Adoption of Simulation Pre-Survey Q1. The following online pre-survey takes approximately five (5) minutes to complete. The survey questions will be about Faculty Attitudes and Adoption of Simulation (FAAS). Questions 2-8 will use the FAAS instrument. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact annekendrick@weber.edu. I agree to participate I do not agree to participate Q2. I believe that using simulation in teaching could have a positive effect on student learning Strongly Disagree Disagree Neutral Agree Strongly Agree Q3. I believe that using simulation in teaching could have a positive effect on students' depth of understanding of course content Strongly Disagree Disagree Neutral Agree Strongly Agree IMPLEMENTATION OF VIRTUAL SIMULATION 37 Q4. I believe that using simulation in teaching could have a positive effect on students' use of problem-solving strategies Strongly Disagree Disagree Neutral Agree Strongly Agree Q5. I believe that using simulation in teaching could have a positive effect on students' ability to analyze data Strongly Disagree Disagree Neutral Agree Strongly Agree Q6. I believe that using simulation in teaching could have a positive effect on student participation and feedback Strongly Disagree Disagree Neutral Agree Strongly Agree IMPLEMENTATION OF VIRTUAL SIMULATION 38 Q7. My knowledge of simulation can best be described as: Novice - I have little to no knowledge of simulation Advanced Beginner - I have a basic knowledge of simulation Competent - I have an average understanding of simulation principles Proficient - I have a solid understanding of simulation principles Expert - I have a deep understanding of simulation principles Q8. My level of adoption of simulation can best be described as: Awareness - I rarely use simulation to teach students Learning the Process - I am learning how to use basic simulation experiences with my students Understanding and Applying the Process - I use all levels of simulation (low to highfidelity) in my instructional delivery, and evaluation of students Facilitating the Process - I am comfortable experimenting with various uses of simulation for teaching and have used simulation to teach a variety of nursing concepts and to get students to analyze and synthesize information Leading the Process - I am eager to share my knowledge of simulation with my colleagues and I encourage student/faculty interactions in discovering and utilizing different ways to use simulation that are beneficial to learning Q9. I believe that learning about simulation can prepare me to use virtual simulation for student learning Strongly Disagree Disagree Neutral Agree Strongly Agree IMPLEMENTATION OF VIRTUAL SIMULATION Q10. I believe that using virtual simulation in teaching could have a positive effect on clinical judgment skills Strongly Disagree Disagree Neutral Agree Strongly Agree Powered by Qualtrics 39 IMPLEMENTATION OF VIRTUAL SIMULATION 40 Appendix C Faculty Attitudes and Adoption of Simulation Post-Survey Q1. The following online post-survey takes approximately five (5) minutes to complete. The survey questions will be about Faculty Attitudes and Adoption of Simulation (FAAS). Questions 2-8 will use the FAAS instrument. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact annekendrick@weber.edu. I agree to participate I do not agree to participate Q2. I believe that using simulation in teaching could have a positive effect on student learning Strongly Disagree Disagree Neutral Agree Strongly Agree Q3. I believe that using simulation in teaching could have a positive effect on students' depth of understanding of course content Strongly Disagree Disagree Neutral Agree Strongly Agree IMPLEMENTATION OF VIRTUAL SIMULATION 41 Q4. I believe that using simulation in teaching could have a positive effect on students' use of problem-solving strategies Strongly Disagree Disagree Neutral Agree Strongly Agree Q5. I believe that using simulation in teaching could have a positive effect on students' ability to analyze data Strongly Disagree Disagree Neutral Agree Strongly Agree Q6. I believe that using simulation in teaching could have a positive effect on student participation and feedback Strongly Disagree Disagree Neutral Agree Strongly Agree IMPLEMENTATION OF VIRTUAL SIMULATION 42 Q7. My knowledge of simulation can best be described as: Novice - I have little to no knowledge of simulation Advanced Beginner - I have a basic knowledge of simulation Competent - I have an average understanding of simulation principles Proficient - I have a solid understanding of simulation principles Expert I have a deep understanding of simulation principles Q8. My level of adoption of simulation can best be described as: Awareness - I rarely use simulation to teach students Learning the Process - I am learning how to use basic simulation experiences with my students Understanding and Applying the Process - I use all levels of simulation (low to highfidelity) in my instructional delivery, and evaluation of students Facilitating the Process - I am comfortable experimenting with various uses of simulation for teaching and have used simulation to teach a variety of nursing concepts and to get students to analyze and synthesize information Leading the Process - I am eager to share my knowledge of simulation with my colleagues and I encourage student/faculty interactions in discovering and utilizing different ways to use simulation that are beneficial to learning Q9. I believe that learning about simulation can prepare me to use virtual simulation for student learning Strongly Disagree Disagree Neutral Agree Strongly Agree IMPLEMENTATION OF VIRTUAL SIMULATION Q10. I believe that using virtual simulation in teaching could have a positive effect on clinical judgment skills Strongly Disagree Disagree Neutral Agree Strongly Agree Powered by Qualtrics 43 IMPLEMENTATION OF VIRTUAL SIMULATION 44 Appendix D Faculty Attitudes and Adoption of Simulation (FAAS) Please indicate your level of agreement with each of the following statements using the following scale: 1= Strongly Disagree, 2= Disagree, 3= Neutral, 4= Agree, 5= Strongly Agree Perceptions of Simulation 1 2 3 4 5 I believe that using simulation in teaching could have a positive effect on student learning I believe that using simulation in teaching could have a positive effect on students’ depth of understanding of course content I believe that using simulation in teaching could have a positive effect on students’ use of problem-solving strategies I believe that using simulation in teaching could have a positive effect on students’ ability to analyze data I believe that using simulation in teaching could have a positive effect on student participation and feedback Please circle the term that best describes your knowledge of simulation and your adoption of simulation: Novice My knowledge of simulation can best be described as: My level of adoption of simulation can best be described as: Advanced Beginner I have a basic knowledge of simulation Competent Proficient Expert I have an average understanding of simulation principles I have a solid understanding of simulation principles I have a deep understanding of simulation principles Awareness Learning the Process Facilitating the Process Leading the Process I rarely use simulation to teach students I am learning how to use basic simulation experiences with my students Understanding and Applying the Process I use all levels of simulation (low to high-fidelity) in my instructional delivery, and evaluation of students I am comfortable experimenting with various uses of simulation for teaching and have used simulation to teach a variety of nursing concepts and to get students to analyze and synthesize information I am eager to share my knowledge of simulation with my colleagues and I encourage student/faculty interactions in discovering and utilizing different ways to use simulation that are beneficial to learning I have little to no knowledge of simulation From “Faculty Attitudes and Adoption of Simulation: Pilot Testing of a New Instrument,” by H. Min, and J. O’Rourke, 2017, Journal of Nursing Education, 56(6), 356-359. http://doi.org/10.3928/014843420170518-07. Copyright 2017 O’Rourke. Reprinted with permission. IMPLEMENTATION OF VIRTUAL SIMULATION 45 Appendix E Assignment Template NRSG Course # Unit ? Virtual Simulation Debrief Online Reflection/Discussion Unit Outcome(s): 1. The nurse practitioner student will perform and document both a focused and complete physical examination on a patient while attending the clinic. 2. The nurse practitioner student will analyze diagnostic tests performed in the clinical setting and interpret their meanings. 3. The nurse practitioner student will create a plan of care for patients (from across the lifespan) who are evaluated in the clinic. 4. The nurse practitioner student will collaborate and communicate with the clinical preceptor and clinical faculty advisor. Assignment Description: Virtual simulation offers an interactive web-based learning environment where students are taken through scenarios specific to women's health, pediatrics, and mental health. The scenarios create customized learning experiences where learner-decision making directs the scenario and outcomes. The learner receives immediate feedback on the actions taken in the scenario. Virtual simulation supplements clinical learning through skill development and clinical reasoning. Assignment Directions: 1. Complete the assigned i-Human virtual simulation case 2. Have the i-Human student performance report available 3. Answer the online reflection/discussion questions using the discussion instructions below. Discussion Instructions: 1. For this discussion assignment, students must answer the top three (3) questions (1-3). In addition, students will also select one (1) of the questions underneath (4-10). Each student must select a different question. 2. A minimum of two peer replies must be made to a peer's original post, which can be recorded or written in the discussion area. Additional replies that support dialogue and discussion are encouraged. IMPLEMENTATION OF VIRTUAL SIMULATION 46 Video Discussion Instructions: 1. For this video discussion assignment, students must answer the top three (3) questions (13). In addition, students will also select one (1) of the questions underneath (4-10). Each student must select a different question. 2. Record your video in Canvas within the discussion post. 3. To access the video: • Click the 'Reply' button in the discussion • Click on the 'Record/Upload Media' button • A box will pop up. Click on the 'Record' tab. Allow your camera and mic to record. • Click on 'Start Recording'. When you are done, click on 'Finish' and then 'Save'. • Once the video is loaded, click on the 'Post Reply' button. It may take several minutes for your video to load. 4. A minimum of two peer replies must be made to a peer's original video post, which can be recorded or written in the discussion area. Additional replies that support dialogue and discussion are encouraged. Online Reflection/Discussion Questions: Answer all three (3) of the following questions: 1. Using your i-Human performance report, how many items on the physical exam were performed correctly (look at the green circles)? How many physical exam items were missed? Why do you think you missed them? 2. If you were to repeat the case, would you do anything differently? 3. What can you apply from the case to your NP clinical practice? Using your i-Human performance report, answer one (1) of the following questions. Each student must select a different question. 4. Do you have any unanswered questions about the virtual simulation case? 5. Under the case section, what did you score highest in? What do you think contributed to that? 6. Under the case section, what did you score lowest in? What do you think contributed to that? 7. How many history questions did you ask? Are there any you would have asked if you were to do the case again? 8. How many key findings did you identify? How many were listed for the case? If you missed any key findings, why do you think that is? 9. How many differentials did you identify? How many were listed for the case? If you missed any differentials, why do you think that is? 10. Did you identify the correct diagnosis? If so, how did you come to that conclusion? What do you think contributed to not identifying it correctly if you did not? IMPLEMENTATION OF VIRTUAL SIMULATION Appendix F PowerPoint Presentation 47 IMPLEMENTATION OF VIRTUAL SIMULATION 48 IMPLEMENTATION OF VIRTUAL SIMULATION 49 IMPLEMENTATION OF VIRTUAL SIMULATION 50 IMPLEMENTATION OF VIRTUAL SIMULATION 51 IMPLEMENTATION OF VIRTUAL SIMULATION 52 IMPLEMENTATION OF VIRTUAL SIMULATION 53 IMPLEMENTATION OF VIRTUAL SIMULATION 54 IMPLEMENTATION OF VIRTUAL SIMULATION 55 IMPLEMENTATION OF VIRTUAL SIMULATION 56 IMPLEMENTATION OF VIRTUAL SIMULATION 57 IMPLEMENTATION OF VIRTUAL SIMULATION 58 IMPLEMENTATION OF VIRTUAL SIMULATION 59 IMPLEMENTATION OF VIRTUAL SIMULATION 60 IMPLEMENTATION OF VIRTUAL SIMULATION 61 IMPLEMENTATION OF VIRTUAL SIMULATION 62 IMPLEMENTATION OF VIRTUAL SIMULATION 63 IMPLEMENTATION OF VIRTUAL SIMULATION 64 Appendix G Project Timeline Enter WSU ATD SON Anne Kendrick Enter Th e Di Ce Th lls is TASK ro Ce ll Project Proposal and Literature Review B8 Ce ll Analysis of simulation and clinical hours B9 R o Literature Review w Th e ce Sam Sam Project Start: Display Week: Mon, 10/11/2021 66 Jan 9, 2023 PROGRESS START END 100% 10/11/21 11/9/21 100% 10/19/21 12/5/21 Complete Project Proposal 100% 1/15/22 2/28/22 Virtual simulation demo and program selection 100% 1/16/22 3/17/22 Present Project Proposal 100% 6/21/22 6/21/22 Create pre/post faculty surveys 100% 6/16/22 6/23/22 Obtain IRB approval 100% 6/20/22 7/18/22 Create faculty sim training PPT 100% 7/7/22 9/26/22 Orient to iHuman and develop curriculum plans 100% 7/11/22 8/13/22 i-Human Orientation 100% 8/22/22 8/31/22 Develop virtual simulation curriculum plans 100% 8/29/22 10/4/22 Implement FNP faculty simulation training 100% 10/4/22 10/4/22 Administer pre and post faculty sim training surveys 100% 10/4/22 10/4/22 Create virtual simulation activity and assessment 100% 10/15/22 11/1/22 Implement virtual simulation into 7902 curriculum 100% 1/9/23 1/9/23 Evaluate results from pre and post surveys 100% 10/4/22 1/30/23 Complete evaluation of project 100% 1/15/23 1/30/23 Final paper/project submitted 100% 3/13/23 3/13/23 Project Plan Project Implementation Project Evaluation Jan 16, 2023 Jan 23, 2023 Jan 30, 2023 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 M T F S S M T W T F S S M T W T F S S M T W T F S S M T W