Symposium 7 Developing professional judgement skills in nurses using simulation training: Applying the expert performance approach

Symposium lead:
Deborah Mazhindu, Head of Research Development & Pedagogy, School of Nursing & Primary Care Practice, Faculty of Health & Applied Social Sciences, Liverpool John Moores University,UK, Faculty of Health & Applied Social Sciences, Liverpool John Moores University, Liverpool, United Kingdom d.m.mazhindu@ljmu.ac.uk

Symposium chair:
Williams, A.M., Professor of Motor Behaviour, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, UK

Symposia focus:

Aims:

  • To explore how empirical researches in simulation have conceptualised definitions of expert performance and professional judgement in nursing
  • To examine how simulation training can be used to improve professional judgement skills in nurses working in a range of critical/acute care settings
  • To present a systematic framework for evaluating the benefits of simulation training. Simulation is used extensively to train professional judgement skills in nurses and other medical practitioners in many countries, notably in the United Kingdom (UK), the United States of America (USA) Australia and parts of Europe

Simulation training is linked to patient safety by improving the ability of health care staff to rapidly implement key interventions (Kyrkjebø et al 2006). The significant growth in simulation training is precipitated by the shrinking pool of suitable learning placements in actual health care settings (Nunn 2004). The use of simulators in health care is well established and the benefits described as “clear” and “beneficial” (Hegarty & Bloch 2002), but there is scant empirical evidence to support the effectiveness of this form of training.

We present 5 papers, 2 of which are empirical research papers on the expert performance approach as a conceptual and systematic framework for evaluating and improving professional judgement skills in health care settings using simulated task environments.

Paper 1- explores the conceptual definitions of expert performance and professional judgement.

Paper 2 - demonstrates the effect of simulation based training in improving judgement skills by describing the results of empirical research using the expert performance approach. To demonstrate the expert performance approach in action to symposia participants,

Paper 3 - presents further empirical research analysing performance differences between highly experienced and novice critical care nurses in a simulated task environment.

Paper 4- highlights some key methodological issues when applying the expert performance approach.

Paper 5- discusses implications for future research and training using simulated task environments.

References:

  • Hagarty, M.K. and Bloch, M.B. (2002) The use of simulators in intensive care training. Current Anaesthesia & Critical Care. Vol:13, Issue 4, August:194-200
  • Kyrkjebø, J.M., Brattebø, G, and Smith-Strøm, H. (2006) Improving patient safety by using inter-professional simulation training in health professional education. Journal Of Interprofessional Care, October, 20(5): 507-516
  • Nunn, A. (2004) “Almost the real Thing” Nursing Management, 11 (7):14-18

Abstract 1: Expert performance and professional judgement: What is it and how do we know it?

 Mazhindu, D.M. Head of Research Development & Pedagogy, School of Nursing & Primary Care Practice, Faculty of Health & Applied Social Sciences, Liverpool John Moores University,UK, Williams, A.M., Professor of Motor Behaviour, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, UK.

Aims:

  • To introduce symposium delegates to recent theoretical developments
  • To discuss a conceptual analysis of expert performance, professional judgement, critical thinking, knowledge development and clinical judgment in nursing
  • To describe how expertise and professional judgement has been modelled, measured and taught

Background:

Defining expertise and the need for highly skilled nursing is essential to patient safety, a vital component of professional performance and crucial in preventing iatrogenic injury to patients. The need to reduce errors related to the administration of health care in hospitals is paramount (Kohn et al., 1999). Preventable hospital mistakes have been estimated to kill 44,000 to 98,000 Americans every year, and cause temporary or permanent injury to many more, while similar error rates have been discovered in the UK and in Australia (Warburton 2003). Hospitalised patients suffering adverse events, (injury or morbidity induced by medical management, operative, drug related procedure, diagnostic/therapeutic mishap), are a leading cause of impairment, death and disability in the USA and UK (Naylor 2002). Drug related adverse events (iatrogenesis) are the single most common adverse effect of which 50% are preventable (Naylor 2002). Educators of health care professionals, workers, patients, politicians and society need to be informed by research into clinical decision making and the development of professional judgement as a way of reducing errors related to the administration of healthcare (Naylor 2002) and to justify the costs involved with simulation training (Alinier et al 2006).

Outcomes:

  • Demonstrate why research using the expert performance approach is useful in offering a richer conceptual definition of expert performance and professional judgment
  • How the expert performance approach has been adopted to identify individual differences in nursing practice in critical care settings
  • Improve expert practitioner performance and professional judgement through a simulation-based training.

References:

  • Kohn, L.T., Corrigan, J.M., & Donaldson, M. (1999). To err is humanBuilding a safer health system. Washington, DC: Institute of Medicine
  • Naylor, R, (2002) Medication error: lessons for education and health care. Radcliffe Publishing, Oxford.
  • Alinier, G., Hunt, B., Gordon, R., & Harwood, C. (2006) Effectiveness of intermediate-fidelity simulation training technology in undergradyate nursing education. Issues aand innovations in Nursing Education. Journal of Advanced Nursing 54 (3) pp:359-369

Abstract 2: What is the effect of simulation based training on the development of expert performance and professional judgement in practitioners of health care?

Mazhindu, D.M.,Head of Research Development & Pedagogy, School of Nursing & Primary Care Practice, Faculty of Health & Applied Social Sciences, Liverpool John Moores University,UK, Williams, A.M., Professor of Motor Behaviour, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, UK, Raw, D.,Consultant in Anaesthesia, University Hospitals Aintree NHS Foundation Trust, Medical Faculty, Cheshire and Merseyside Simulation Centre,UK, Jones, N., Manager of The Cheshire & Merseyside Simulation Centre, University Hospitals Aintree NHS Foundation Trust, UK & President of The National Association of Medical Simulators, North, J. Post-graduate Research Assistant, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, UK & McRobert, A. Post-graduate Research Assistant, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, UK (2007) AIMS: Liverpool John Moores University, (LJMU) and the Cheshire & Merseyside Simulation Centre (C&MSC) UK,

Two-phase programme of research which aims to develop a systematic framework for performance evaluation and enhancement of professional judgment skills for nursing by evaluating the effect of simulation based training provided to NHS staff. Phase One, the Pilot project is presented, describing the methodology: The expert performance approach (Ericsson & Smith, 1991, Williams & Ericsson, 2005); a 3 step systematic framework for examining issues related to patient safety, based on analysis of reproducibly superior performances, tracing the acquired mechanisms responsible for the development of high-level skill. Phase One, the expert performance approach was applied to a voluntary, purposively sampled cohort of critical care nurses (N=10) to identify the mechanisms responsible for effective decision-making and the implementation of successful interventions in time-critical, emergency care situations.

Sample:

Two groups of 10 nurses, one experienced one novice, participated in a range of simulated emergency situations within a systematic framework for performance evaluation and enhancement of professional judgment.

Methods:

A combination of laboratory-based clinical simulations for performance assessment, together with questionnaire and interview data relating to the nurses’ engagement in professional development activities were used and simulation-based training designed to improve the ability to make accurate and effective decisions in the practice setting. A METI high fidelity Human Patient Simulator was used to help simulate care scenarios in Theatre, Intensive Care and A&E settings.

Data analysis:

The antecedents of, and cognitive mechanisms responsible for, superior performance were analyzed via the use of experimental manipulations and process tracing measures, such as verbal reports and eye movement recording, during task performance under representative or simulated conditions (Ericsson & Simon, 1993; Williams & Ericsson, 2005).

Outcomes:

Cognitive mechanisms related to expert performance and professional judgement were acquired, the activities deliberately designed to improve performance are identified and discussed.

Reference:

  • Ericsson, K.A., & Smith, J. (1991). Prospects and limits of the empirical study of expertise: An introduction. In K.A. Ericsson and J. Smith (Eds.), Toward a general theory of expertise: Prospects and limits (pp.1-38). New York: Cambridge University Press
  • Ericsson, K. A., & Simon, H. A (1993). Protocol analysis: Verbal reports as data (Rev. Ed.). Cambridge, MA: MIT Press
  • Williams, A. M. & Ericsson, K. A. (2005). Some considerations when applying the expert performance approach in sport. Human Movement Science, 24, 283-307

Abstract 3: Analyzing performance differences in highly experienced and novice critical care nurses in a simulated task environment.

Whyte J, ND, ARNP, Assistant Professor, The Florida State University, College of Nursing,United States of America (USA) Ward, P, PhD, Assistant Professor, The Florida State University, Learning Systems Institute and Department of Psychology, Tallahassee Florida, USA.

Aims:

To determine performance differences between differentially experienced practicing critical care nurses performing within a simulated task environment.

Methodology:

The guidelines of the Expert Performance Approach (EPA) (Ericsson & Smith, 1991) were used as a theoretical framework and to guide the experimental research approach. The hypothesis was consistent with key aspects of the EPA that dictate that experience alone would not differentiate performance in the novice and expert groups. Instead, we predicted that a multi-factorial definition of performance would be required to characterize levels of deliberate practice.

Methods:

The experiment first observed individual differences in performance in the real world. Then, after recreating the performance context under simulated and controlled conditions, measuring superior performance during challenging and representative tasks, and concurrently recording the behaviors and thoughts that were responsible for performance superiority. The experiment was based upon 10 clinical scenarios, that although diverse in their presentation of events, were based primarily on cardiovascular, respiratory and mixed cardiovascular-respiratory events, three minutes in length, during which the nurse would either ‘rescue’ or ‘fail to rescue’ the patient. Patient outcome in physiologic terms, including Oxygen Saturations (SaO2) and Mean Arterial Blood Pressure (MABP), and the participants’ actions that brought about these outcomes were used as the dependent variables SAMPLE: (N=12) experienced and (N=10) novice nurses.

Data Analysis:

Initial analysis was performed to differentiate performance based solely upon initial group’s classification as either experienced or novice and yielded no statistically significant differences. Additional analysis were then performed by classifying participants into high and low performing groups based upon their ability to achieve control of scenarios in which reliable differences were identified.

Conclusion:

A new definition for performance in the context of nursing which disputes current systems that rely primarily on level of experience and peer nomination as a means of identifying ‘experts’. The implications for future nursing practice, education and research are discussed.

Reference:

  • Choudhrey, N. K., Fletcher, R. H., & Soumerai, S. B. (2005). Systematic review: the relationship between clinical experience and quality of health care. Annals of Internal Medicine, 142, 260-73
  • Ericsson, K. A., & Smith, J. (1991). Prospects and limits in the empirical study of expertise: An introduction. In K. A. Ericsson and J. Smith (Eds.), Toward a general theory of expertise: Prospects and limits (pp. 1-38). Cambridge: Cambridge University Press
  • Ericsson, K.A., Whyte, J., & Ward, P. (2007). Expert performance in nursing: Reviewing research on expertise in nursing within the framework of the expert-performance, Advances in Nursing Science, 30(1), 58-71

Abstract 4: The methodological issues raised in researching the art and science of expert performance and professional judgement

Mazhindu, D.M.,Head of Research Development & Pedagogy, School of Nursing & Primary Care Practice, Faculty of Health & Applied Social Sciences, Liverpool John Moores University, UK, Williams, A.M., Professor of Motor Behaviour, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, UK, Raw, D.,Consultant in Anaesthesia, University Hospitals Aintree NHS Foundation Trust, Medical Faculty, Cheshire and Merseyside Simulation Centre, UK, Jones, N., Manager of The Cheshire and Merseyside Simulation Centre, University Hospitals Aintree NHS Foundation Trust, UK & President of The National Association of Medical Simulators,& McRobert, A. Post-graduate Research Assistant, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, UK (2007)

Background:

This paper details how the expert performance approach as a methodology is unique. Expert performance and professional judgement lends itself to being examined typically using more subjective and qualitative methods (Ericsson et al., 2006). Expert professional judgement in clinical practice does not exist in a vacuum, but is both contextual and unique requiring a combination of approaches to capture and represent comprehensively.

Aims:

First, to describe how the expert performance approach focuses on individual differences in performance as measured in a series of high-fidelity simulation scenarios, using traditional quantitative methods that can be analysed statistically. Clinical simulation offers the opportunity to modify behaviour in a completely safe environment. Although mistakes occur in simulated environments impacting on performance as they would in a ‘real-world’ environment, the individual research participant is presented with an opportunity to modify and improve on behaviours without the risk inherent in the hospital setting. Second, the observed performance in the simulated scenarios relates to the participants’ experiences, skill, knowledge, practice backgrounds, and records of past engagement in related practice activities, thereby providing an opportunity to identify qualitatively important precursors of skilled behaviour and other qualitative issues, requiring critical and analytical approaches to capture. Authors such as Goffman (1959), and Glaser and Strauss (1966) were influential in redefining how participants could be defined as actors, playing a part in the drama of life and constructing their worlds according to what they perceived as the story line and main actors in the drama.

Outcomes:

Symposium participants are invited to extend debate regarding methodological issues raised from using a unique combined methodological approach and a critical and analytical approach to data analysis. How the participants (the actors) use their own stories and descriptions of how they constructed (and we interpret) their working worlds to compliment the data derived and analysed through traditional scientific observational approaches is explored.

References:

  • Ericsson, K.A., Whyte, J., & Ward, P. (2007). Expert performance in nursing: Reviewing research on expertise in nursing within the framework of the expert-performance, Advances in Nursing Science, 30(1), 58-71
  • Glaser, B.G. and Strauss, A.L (1967) The discovery of Grounded theory: Strategies for qualitative research. Aldine De Gruyter, New York Goffman, I. (1959) The Presentation of Self in Everyday Life. Penguin Books, England

Abstract 5: “It’s life Jim, but not as we know it!” enterprise and future directions for simulation based training

Mazhindu, D.M.,Head of Research Development & Pedagogy, School of Nursing & Primary Care Practice, Faculty of Health & Applied Social Sciences, Liverpool John Moores University,UK, Williams, A.M., Professor of Motor Behaviour, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, UK, Raw, D.,Consultant in Anaesthesia, University Hospitals Aintree NHS Foundation Trust, Medical Faculty, Cheshire and Merseyside Simulation Centre UK, Jones, N., Manager of The Cheshire and Merseyside Simulation Centre, University Hospitals Aintree NHS Foundation Trust & President of The National Association of Medical Simulators,& McRobert, A. Post-graduate Research Assistant, Research Institute for Sport & Exercise Sciences, Liverpool John Moores University UK

Aims:

  • To invite participants to discuss future simulation research
  • To establish if using simulation enchances the ability of nurses to make effective decisions in ‘life-or-death’ situations
  • To discuss research evidence that simulation training is effective and needed to support educational policy

Background:

The expert performance approach proposes that learning, and improvement of performance, is not a passive accumulation of professional experience, but is mediated by engagement in goal-directed and self-regulated learning (termed ‘deliberate practice’) in a way that is quantitatively and qualitatively different from the mere accumulation of experience (Ericsson 2004, Ericsson & Lehmann 1996).

Research using simulation aims to evaluate objectively the performance of expert nurses in simulated critical-case scenarios without endangering the lives or safety of actual patients and is being considered as a viable alternative to “live” patient learning placements for student nurses by the NMC (UK). The expert performance approach was originally conceived in light of growing evidence that some experienced and knowledgeable individuals do not outperform more naïve individuals within their domain of expertise. For instance, in a review of the expertise literature by Ericsson and Lehmann (1996) revealed that highly experienced financial, medical and psychology professionals failed to make superior forecasts or implement interventions that led to enhanced treatment outcomes than less-qualified and less-experienced professionals. A number of authors in medicine and other domains have demonstrated that the length of professional experience is often unrelated, and sometimes negatively related, to quality of performance and objective treatment outcomes (Choudhrey et al., 2005; Ericsson, 2004).

Outcomes:

  • Why a paradigm change is needed to research expertness and professional judgements
  • Identify and capture reliable and objective, measurable performances in simulation to ensure patient saftey and inform student learning
  • Identify the role of using simulation for mandatory clinical updating

References:

  • Choudhrey N. K., Fletcher, R. H., & Soumerai, S. B. (2005). Systematic review: the relationship between clinical experience and quality of health care. Annals of Internal Medicine, 142, 260-73
  • Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine, 10, S1-S12
  • Ericsson, K. A., & Lehmann, A. C. (1996). Expert and exceptional performance: Evidence of maximal adaptations to task constraints. Annual Review of Psychology, 47. 273-305