Laerdal’s Head of Competency-Based Education, Amy Kline, recently sat down with Dr. Laura Klenke-Borgmann, Director of Simulation Education and Clinical Associate Professor at the University of Kansas School of Nursing.  

In this interview, explore how Dr. Klenke-Borgmann is scaffolding multi-modal simulation activities, including vrClinicals for Nursing, using the scaffolded SimZones framework for building competence. 

Watch the video or view the transcript below. 

Amy: “Can you introduce yourself and share a brief overview about your program?”  

Dr. Klenke-Borgmann: “I’m Dr. Laura Klenke-Borgmann. I am the Director of Simulation Education and Clinical Associate Professor at the University of Kansas School of Nursing. In my Director role, I oversee our simulation program and our simulation curriculum that includes both undergrad, pre-licensure students and also graduate DNP students. So I see students on both sides of graduation.”  

Shifting the “Evaluation as a Grade” Mindset 

Amy: “We’re going to talk about your experience with competency-based education and some specific solutions that you’ve used to help develop your students – specifically in the simulation labs of course, but also across the program. What specific challenges or programs did you identify when you started this shift to CBE (or competency-based education) within your curriculum at Kansas?” 

Dr. Klenke-Borgmann: “I’ll start by saying that the thing that I really loved about it – and the reason that I really wanted to change and pivot our focus a little bit – was in the true spirit of competency-based education.  

I love this idea of, competency-based education is more about the output that our students can show us and what they can actually do and how the focus and the importance is so much more on that than the input: what we tell them, what we teach them, what we say our objectives are.”  

“That being said, in the true spirit of competency-based education, one of the challenges or problems was getting over – not just for myself but for the students and faculty – getting over this traditional way of thinking about learning and about evaluations as being for a grade: good, bad, pass, fail. ‘I got a 97%,’ ‘I got a 73%.’

With competency-based education, it’s more about what you can do and what you can show us. How many times it may take you to be able to show us, or do, may be an iterative process. It may be a different pace than the student to your right or the student to your left. That can be really, really difficult for students to understand. It’s also hard for faculty to wrap their head around.”

Amy: “It’s a big shift – not just in how we teach, but also in how our students learn and receive their feedback and assessments. It’s a big change for everyone. How do you get them all on board?” 

Dr. Klenke-Borgmann: “A grade has been the currency for students’ motivation, for them to study, or practice, or how they’re going to perform. 

Unfortunately, for better or for worse, sometimes their motivation is getting that grade. Without the grade, it’s hard for them to wrap their head around, ‘What’s my motivation and what am I supposed to accomplish?’ We have to really show them what that means.”

Scaffolding Simulation Activities with the SimZones Framework 

Amy: “You’ve been doing a lot of work with the SimZones approach to transitioning your sim program. Can you explain a little bit how you implemented that and then how you scaffolded some different learning modalities to enhance the learning outcomes?” 

Dr. Klenke-Borgmann: “For those who may not be familiar with SimZones, it’s an organizational, scaffolded framework initially by Roussin and Weinstock. It is a framework for how to plan and scaffold a longitudinal simulation program to get to some type of competency-based output at the end of the framework. It consists of five zones.  

Zone 0 is basically saying that before learners can show us, or do anything, they have to have that baseline foundational requisite knowledge. So that’s what the framework of Zone 0 basically is: that we know students have to come to an experiential learning experience with some type of baseline, requisite knowledge – from class or automated feedback that they’ve gotten from a virtual sim or something like that. 

Then, once the students have achieved that level, the framework says that you move the learner to Zone 1, which is deliberate practice of psychomotor skills. Not really context-based – just practice, practice, practice giving an IV push medication or hanging some IV fluids. 

Zone 2 takes the level or the learner up to another level, where now they’re practicing those psychomotor skills that they did in Zone 1 but now in a context-based format. Maybe it’s not just coming into the lab and practicing deliberate practice of psychomotor skills, but now they’re doing those skills in the context of a case. So more like a simulation. But now it’s because it’s contextual and it’s still coaching. They can stop and start the sim, they can ask questions, they can get feedback from the faculty or from their peers. It’s like a sim, but it’s more contextual. 

Then once we’ve accomplished Zone 2, we can take them up to Zone 3. That is what people would think of as more of a traditional simulation where they get pre-briefed, they do a sim, they don’t get stopped no matter what happens. Then we debrief them afterward. 

Zone 4 really isn’t simulation at all. It’s them actually taking all of that knowledge and all those leveled experiences into practice and actually doing in the clinical setting.  

That’s just a really brief explanation of SimZones.” 

Amy: “I think sometimes that’s where we see that cognitive overload. Students are thrown into a sim where they maybe don’t have some of that practice. In Zone 1 or 2, where they’ve really gotten the exposure, they feel comfortable to then put it all together. Giving that feedback and coaching and laying a nice foundation with opportunities to practice, as we know AACN has really advocated for, is going to be so important.”

Building Readiness for Multi-Patient Simulation with vrClinicals 

Amy: “You had a specific senior-level course where you recognized that students weren’t quite ready for that traditional sim. Can you talk through that experience of uncovering that challenge and then how you use this approach and some simulation activities to rectify that for your students?” 

Dr. Klenke-Borgmann: “Here at the University of Kansas School of Nursing, at the very end of program for our senior level nursing students, in their very last semester for quite some time, there has been a multi-patient simulation as part of the curriculum. Truly at the end of the program, as they’re transitioning out to graduation. 

When I took over as the Director, I noticed that the sim is great. It is very well designed, it’s very thought-out, the faculty do an amazing job at it. But goodness, the students were struggling. They were really struggling with putting all the pieces together: delegation, prioritization, remembering all their psychomotor skills from the entire program, putting it all together, managing interruptions. It was hard. They were really struggling with it.  

I thought, if we can work backward and start at the beginning of the semester with intentionally preparing them and moving through those SimZones to get them ready for that very intense, overwhelming kind of multi-patient simulation, I think we can use that SimZones approach as our organizational approach. So that’s exactly what we did.

We ensured that we started with Zone 0. We knew what the end product was going to be. We knew in Zone 3 we wanted them to be able to perform this simulation in this mult-person multi-patient sim. We worked backwards. We ensured that in Zone 0, as students started their last semester, that they had the requisite knowledge to do so: ensuring with faculty and the courses that they were taking that semester that that requisite knowledge would be there as their foundation.  

Then, for the psychomotor aspect of the skills that they were going to be asked to do and required to do in the multi-patient simulation, we scheduled and designed into the curriculum a multi-patient sim lab day where we focused on deliberate practice of the psychomotor skills.  

We intentionally created a lab session for them to practice skills that they will be required to do in multi-patient sim: central line dressing changes, nasogastric tube placement, IV push medications, wound dry dressing changes. These are all things that we knew they were going to have to do and that they were struggling with in multi-patient sim because it has been a while since they’ve done some of it, if they didn’t get opportunities to do it in clinical. So that was our Zone 1, was this multi-patient sim skills day lab. 

Once they got that deliberate practice of the psychomotor skills, we moved them up into Zone 2, which is more of the contextual learning but still being able to stop start and ask questions. That is where vrClinicals came in.  

We knew they had the psychomotor practice of the skills in Zone 1, but we still wanted them to get some great contextual prep with the cognitive skills that would be required in the multi-patient sim.  

We felt that putting vrClinicals in that Zone 2 was a great bridge between Zone 1 psychomotor skills and then actually getting them ready for putting it all together in an in-person multi-patient sim. The multi-patient vrClinicals was great to bridge the psychomotor skills, the cognitive skills and put it all together for that Zone 3 in-person multi-patient sim.”

Amy: “I think vrClinicals for Nursing is such a unique solution because it does give that contextual experience like you said. Because it’s hard to understand, when interruptions come up and you’re with one patient, do you even go to another patient? Or when there’s another patient that has a change in status, how does that affect the care of the other three patients that you’re taking care of? Students don’t get a lot of exposure to that.  

To give them just the one experience at the end of the semester, which is I think is pretty common across a lot of nursing programs without the ability to practice and have that exposure and context, is a challenge. I think that’s what you said you saw and I’m really excited to hear that that’s a solution that you’ve scaffolded, mixing in that psychomotor skills lab as well.  

How have your faculty and your students responded to using vrClinicals in this way and maybe just to the format as a whole?” 

Dr. Klenke-Borgmann: “It was definitely a transition for us. It was a big change. It was the first time we really in earnest have incorporated intentionally VR into our curriculum here. Certainly there was a learning curve for myself and the faculty who were going to be leading those. And, it was a learning curve for the students as well.  

It was interesting: we made the assumption … that the students would be so much more evolved than us in terms of the technology. And certainly there were students who were, but there were also a lot of students who truly needed the hands-on practice time, the orientation, the tutorials – even more so than maybe I expected.  

They weren’t just all gamers that just jumped in and knew exactly what to do. So the tutorials and the orientation that vrClinicals provided was definitely helpful and needed for us and also the students. 

Because you want the experience to be about the learning and about making their decisions and all of those cognitive skills that I mentioned – the delegations, the prioritizations – not troubleshooting the tech. We wanted the objective to actually be able to get accomplished, not spend the whole time troubleshooting the tech or explaining how to work the hand controls and things like that.  

The tutorials and the orientation that come with vrClinicals was a huge asset in that respect and onboarding and getting everybody up to the same level and the same speed to actually then be able to jump into the learning.  

They really did enjoy it and for a lot of students, it was a new experience for them. They liked that novel aspect of ways to practice things that they’re not necessarily always getting an opportunity to do in practice or in clinical or even in simulation all the time, to be able to be in that immersive environment.  

I’ve had so many students say during debriefing, ‘It’s just so hard to know where to start.’ I can’t tell you how many times students said, ‘I just got into it and got on the unit and thought, what do I do? Where do I go? Who do I see first? How do I even get started?’ I think that is a huge value to this particular product, is that realism.”  

Evaluating Progress with Simulation Data 

Amy: “How have your faculty and students responded to the complete scaffold of the approach? Are you seeing some better outcomes?” 

Dr. Klenke-Borgmann: “We don’t have all the finalized data, but we are collecting some data from the multi-patient sim. Specifically, we have a competency checklist that we’re using to evaluate the students on that includes the competencies that we’re looking for. So obviously the basic things, like doing a good assessment of hand hygiene and safety, doing the six rights when they give a med, communication with the patient, clinical judgment. But then, also looking more at some of those skills that are higher level because it is the end of the program: prioritization skills, management of interruptions, things like that.  

We also collect data on the students when they’re done in the in the multi-patient sim experience on their cognitive load. We use the NASA Task Load Index. It basically is a valid and reliable measure of the participants’ experience and perspective of cognitive load. It asks specific questions regarding temporal load – like how rushed in terms of time they felt, physical load, how actually tasking or physical their load felt, cognitive load, and then some other things that it measures on a Likert scale. 

We actually had the students fill that out in last year’s cohort and now we’re having the students fill it out in this cohort to see if there’s a difference in their cognitive load now that this cohort has gone through this scaffolded approach of preparing them better for that multi-patient sim. We’ll be really interested to see the final data of that to see whether or not their cognitive load is diminished based on this intentional prep that we’ve done for them.  

I think students have appreciated that  – now because we’ve included VR – it is truly a multi-modal scaffolded approach. In Zone 1, we’re talking about deliberate practice and Zone 2, we are doing VR. 

They have two different VR sessions that they do a week apart in Zone 2. One of them is the three-patient one and then we level them up the next week when they come back to the four-person. So we even scaffolded the vrClinicals into that approach. Then, in the actual multi-patient sim, they have standardized patients playing patients and we have high-fidelity manikins. It’s a mix of different types of patients in the multi-patient sim. Truly from beginning of the process to the end, we basically have hit all the modes.” 

Amy: “I think what you’ve done was to really capitalize on the learning outcomes. There are things that manikins can do and things that standardized patients can do. There are things that VR can afford you and there are things that task trainers can still afford you as well. So when you’re looking at, what is the outcome we’re trying to meet, it’s so important to match that modality to outcome. Finding solutions, mixing solutions like you’ve done, I think it’s just a really beautiful picture that you don’t have just one thing.”