TN Sim Alliance  00:14
Good afternoon, everybody. How are you? Hi, Angel. Hey, guys. I see some familiar faces. Hey. I'm Shana McBrayer. Welcome to Fourth Thursday Simulation Connections. We have Angel Bowling with us today, and she is going to present with a colleague of hers. And I'll let her introduce Lily, but I'll introduce Angel. Angel is serving as our secretary and treasurer right now for Tennessee Simulation Alliance, and she's the chair at Baptist Health Sciences. So welcome, and just to remind everybody, we're going to record, and then it'll be available on our website later this afternoon. So, welcome, Angel. It's all yours.

Angel Boling  01:05
Can everybody hear me? Okay. I'm going to turn my video off because I do think sometimes that's distracting, just when you're doing a presentation. But as Shannon introduced me, I'm Angel Boling. I serve as the BSN program chair at Baptist Health Science University. I'm also the secretary and treasurer for the Tennessee Simulation Alliance. I have Dr. Lily Browning who is joining me as well, and she serves as one of the professors over at the Osteopathic Medical College here at Baptist Health Science University as well. I'm sure when you first saw the title of this and Shannon posted it, you were like, "What does this have to do with simulation? I think this is probably one of the most unique IPE simulations that I've been in. I give a lot of kudos to Lily. We worked really hard on this one, and we would love to really share what we've done. So, of course, the title is "Making Food as Medicine Actionable Through motivational interviewing, and what we did was propose a interprofessional education event that integrated both senior nursing students and osteopathic medical students within simulation using standardized patients, which we add that little lift to it too, which makes it another complicated piece, making sure you're getting those trained. So we're going to go ahead and get started. You'll see some other authors on here outside of Lily and I. Dr. Kathy Stepter, she serves as the dean of nursing who worked along with us. Dr. Jason Salmon and Dr. Tyler Roach, who both work over in what we call the BuCom Baptist University College of Medicine for there. Let me get us started. So, why this event? I will say, Lily came to me with this great idea, and we just kind of started brainstorming. You know, how do we get our students together, especially when you think about medical students and nursing students in an interprofessional event, and really help them improve and understand different aspects that go along with healthcare professionals. We know one of the leading causes of medical errors and mistakes in healthcare goes back to communication and collaboration. So we felt like, from an educational standpoint, that we wanted to really help our students start to understand what it is to practice together in a team, whether it's a team of two, three, or four, depending on the numbers, and what it looked like to work and plan for a patient and help work through patient counseling. And so we use first-year osteopathic medical students who have never been to clinical, so that was I think eye opening for them, with our senior nursing students who were fixing to graduate, who had been in practice at least clinical for a year and a half, maybe even two years. So that was a challenging piece, but I think we actually had some phenomenal results. So the primary goal for this event was to look at the trans-theoretical model change and really focus on motivational interviewing techniques during the simulated patient encounters, and so that was a big piece that Lily was really kind of helping our students with, especially from the BuCom perspective, and then brought in the secondary goal for her special topics class, and I'm gonna let her talk about that a little bit of how do we really help reinforce nutrition counseling? And so we focused on two populations of healthcare patients, and that were those that had pre-diabetes that had not been officially diagnosed, but had been told you're leaning towards it, as well as those with borderline hypertension. Anything you like to add, Dr. Browning?

Lily Browning  04:43
No, I think this has been a great introduction.

Angel Boling  04:46
Okay, I'll keep us going then.

Lily Browning  04:49
Yep.

Angel Boling  04:51
If it'll let me, there we go. All right. So student prep we thought was very important. These students, even though they pass each other in the cafe at the university, don't spend a lot of time with one another, and so making sure that they knew the different pieces from both sides, from both nursing as well as medicine, as well as the importance of interprofessional communication, and so one of the things we had in terms of, and the both students got these. So even though the nursing students were not privy to motivational interviewing, and even though the College of Medicine students were not, you know, privy to the SBAR handoff report that nurses uses, they all had the same prep work. So they had readings and video modules that they could watch, interprofessional communication, the definition, what it was, what was SBAR? We did learn the first time we did it. We needed to provide a little bit more SBAR in terms of resources, but the second time we felt a lot better with how we had actually did that. We brought in evidence-based dietary recognitions, and the other thing that we had that we brought in was registered dietitians. So we had another factor that came in to work with both faculty members from the College of Nursing and the College of Osteopathic Medicine. So registered dietitians actually helped us. They prepared videos where they could talk about those aspects with nutrition, and both students were required to watch those. The other aspect that was very important is the registered dieticians participated in the debriefing of this simulation, and so we really included that to bring in another discipline. We made sure that that preparation that was provided for the students helped them understand the skills that they would need to actually walk in and do the encounter. So here is our simulation design and flow. So we had our standardized patients that were trained appropriately with our two cases that we'll talk about shortly. The nursing student was given just a very brief history and vitals outside the room. The focus for the nursing student was not to walk in and do a complete head to toe. This was a patient that was coming back for their three month, six month follow up with their primary care provider of where they were with their care regarding health, wellness, exercise, diet, and what we were focused on with them, so it's really just kind of getting an idea what they were doing to help promote health and wellness. The nurses' big impact was to take that information out to the College of Medicine students and give that SBAR report. So that's why we felt it was important for the College of Medicine students to understand what that was, what it represented, how they could ask questions if they wanted to, and so that was observed. A lot of us as faculty would walk around and listen to that S bar to really hear what was being said. Then the two made a plan. That plan first required, of course, the College of Medicine student going back in with nursing and doing their motivational interviewing process to really understand where the patient was. Could we predict change? Could we plan change? And could we actually do a plan for our patients? From that, both the College of Nursing students and College of Medicine students worked very closely together to develop joint counseling for the patient that focused on diet and health. From that, they brought that back into the debriefing room. Once they finished, they went through their plans, and then we had a very structured debrief. And so you can see some of the reflection questions here. We also had some questions from the dietitian, as well as some questions that came from motivational interviewing. A big focus on working with different healthcare disciplines. How do you feel like the teamwork influenced the care and the outcomes of patients? Of course, with the College of Medicine students, they really had to reflect on that motivational interviewing. You know, was the framework useful? Did it help them to really ask the questions they needed to ask? Do they feel like their interviewing approach went well?

Angel Boling  09:13
And we know that's important, not just for nurses, but for most healthcare disciplines to be able to ask questions, do a good job with interviewing, but also how do we motivate to make change, and how that they were going to go about improving their skills. From that, the team had to come up with dietary recommendations for the two different cases that they may have had. Anything you want to add there, Lily? Before I move forward,

Lily Browning  09:40
yeah, I think one of the strengths was the this was the medical students, their first year medical students. This is their really their first true interprofessional event, and they were paired with senior nursing students. So there was a degree of seniority and experience there that the senior nursing student had and brought to help guide the medical student that was really beneficial for our students and got them excited to work interprofessionally, which of course will be a huge part of their career.

Angel Boling  10:11
Yeah, some interesting things came from debrief. We always heard the College of Medicine students saying, "How did how did that become so natural for you to do that and walk in and feel comfortable asking questions, and so a lot of it was some reflection that we didn't even think about that we got just secondhand from the students discussing how they learned from each other. So to me, that was you know that takes you far and above what your goals and outcomes were for the simulation for the students to recognize those things. Okay, we had two standardized patients. We had a case A, which is a pre-diabetes follow-up, and then case B, which was borderline hypertension. Now, because of the the ratio of college of medicine students to college of nursing students, each nursing student went through this twice with different college of medicine students. So they got to see both the pre-diabetes case as well as the borderline hypertension case, whereas the College of Medicine student only went through one case. So we were able to make sure that all students were able to participate, which is kind of sometimes challenging when you have those ratios of numbers, and we're fixing to be challenged again when we do this coming in next. I think it's March, but we always figure it out. We always do. So the patient that was pre-diabetes, you can see both of these patients were in the early ages of 50. We made it very simple for us because of our standardized patients. We didn't know whether we had male or female that would volunteer. So, if you notice, both could easily be flipped from a male or female based on name. We didn't make it very focused on sex until we determined who our standardized patients were. So, chief complaint. You see, both of these is just a follow up. Whether it's a three month follow up versus a six month follow up, looking at the previous diagnosis and really focusing on what they've been doing. You know, have they made changes in their diet? Why are they making the changes? Why can't they make changes? Of course, we threw in, you know, always the outside piece with the standardized patients. They were taking care of a loved one. You know, their family member didn't want to change their diet. You know, or how that impacted. So, of course, we put those little variables in, which makes them really have to work towards that motivational interviewing and figuring out we're not just thinking about the patient, but we're thinking about how it impacts the entire family that they may live with. Of course, we had a lot of built-in barriers, like you said. You see the limited time financial constraints, and we talked about the caregiving duties. We wanted to make this very much like the communities that we live in, because that's where they're going to be focusing their care to see that there are a lot of different things that impact that, especially when we start looking at social determinants of healthcare. So this is our counseling framework, and Lily, I'm going to let you step in here, if you don't mind.

Lily Browning  13:21
Sure. Yeah. So we at the College of Medicine we do a decent amount of education on how to counsel patients and how to make and how to have patient-centered counseling. A lot of that's coming through the trans-theoretical model and motivational interviewing. So both the nursing students and the medical students were given a video that was made by our physician specialist in this area, and they reviewed that in advance. We also had handouts that we had for the the students to have, you know, kind of during the encounter to remind them of these these frameworks that we use in motivational interviewing. So one is the stages of change model, where you assess their willingness to change and also explore explore barriers for being able to change, and then yeah, I think this was a really important that both the nursing student and the medical student were aware of stages of change and how to go back about counseling patients on making meaningful change that meets the patient really where they are, and this can be applied to any part of of a person's life. It could be with medication compliance. It could be with showing up for appointments. But we wanted to focus on nutrition because it is so foundational to chronic disease prevention and it affects everybody. Everybody has to eat, and especially in our culture, we are constantly kind of tempted with diets heavy and processed foods, saturated fats. So this kind of counseling can affect everybody, so this was where we focused, and it it went very well. Yeah,

Angel Boling  15:28
and I will just elaborate. We all had different assignments. Of course, Lily was really keeping things moving and going, and I spent a lot of time doing debriefing, and I think this was one of the the unique pieces of this of really talking about you know how do you understand if a person is ready for change or if they're you know thinking about the things that impact it like we were talking about you know stopping smoking you you just walk in and tell them to stop smoking and not realize that that's an addictive behavior and do they have the motivation to want to stop do they have the motivation to change their dot, you know, and making them think about those other pieces, but realistic pieces, and not just handing them here's your cheat for how to understand the dash dot. You know, do you understand it? So I think it made some really good conversation with our students interprofessionally, both when they were making a plan and as they were doing debriefing, that was very very unique to this simulation. So of course, you know, you always got to do surveys. You always got to evaluate now what did the students think, and so these were just some of the walkaways. Of course, you know we evaluated interprofessional teamwork, collaboration, those basic things, but we really felt like some of the qualitative really taught us a lot. You know, for our senior nursing students, you can see the difference, of course, in the level of student. The senior nursing student, I think, added a little bit more, where the OMS students were just really thinking about how how working with other people because it was their first introduction, as Lily said, of being with a different healthcare discipline. But one thing that I think was very very important, and this one OMS student said it, and we've heard it several times, is the different perspectives. You know how you bring in different perspectives from you know your own cultures, your own background, your own education, and how you talk it out at the table and come to a well-rounded plan. Understanding, and this one to me, how powerful teamwork is, you know, and what impact it makes on the patient and their overall outcomes, and just some the value. I think pulling out that value of what interprofessional collaboration and communication is and working together was important, and I think that was one of the biggest things we kept hearing in the debriefing aspect, and even after. I mean, you know, I don't know all the college of medicine students, but some of them came by later on. They saw me. They're like, Dr. Boling, that was so awesome. You know, I think Lily was hearing the same thing, and it was just the the aha's that they walked away from this that we didn't even dream about. So we felt like it really gave us a lot of value to doing this again. So we've done it twice. We're fixing to do it a third time. So we're hoping to have those same outcomes. So results and feedback overall, they reported high satisfaction. They felt like the scenarios were much more realistic, and I think having the standardized patients really help. You know, a lot of times we use faculty, we may use other students, you know, and that makes it kind of confusing to the student of who they're talking to, so I think the standardized patients required us to do a little bit more work, making sure our cases were available. They had to have their training that Dr. Roach did, you know, all those pieces. But I think it made it as realistic as possible for these students that they took something back, and it was very meaningful for their practice and their ongoing education skills practice. They very they value that interviewing and how they did the counseling together and doing it collaboratively. And we just heard that over and over. And then of course, just that increased confidence in working in a team and understanding that dynamics of teams. One of the big things that they did reflect on you know what worked really well with communication. You know, was it because of the fact they felt very comfortable walking in the room? Some of the students had already established relationships before.

Angel Boling  19:32
They knew they were working together. We saw them meetings sometimes over the cafe. You know, just kind of doing some prep work to get to know each other. So some of those dynamics, I think, made big differences in you know what they were learning and the value that brought from this actual simulation. Anything you want to add, Lily? Because I think that's the end. I think we've got one more slide.

Lily Browning  19:56
Yeah, in our in our curriculum, we are trying to. establish a precedence of patient-centeredness, right? You're not preaching at your patients. You're you're you're creating plans that are sustainable, are realistic, are doable, meet the patient where they are in their life, and so that's where the motivational interviewing was very important to practice, and then the nutrition counseling. We're also developing a curriculum where nutrition is interwoven into all four years, so that when they get out to practice, they're very comfortable with talking about nutrition, even if it's a 20-second kind of conversation. Every virtually every encounter, there's a chance to talk about nutrition or food insecurity, or you know, are you eating a healthy, balanced diet? Do you understand what that is? So the more practice that we get with this, I think, the better. And this was really a way to we're kind of you know, we hear about two birds in one stone. There were like really three birds in one stone for this event, where we covered interprofessional work, communication, practicing with talking to patients, and motivational interviewing, and then that nutritional counseling for pre-diabetes and for pre-hypertension, really conditions that are very prevalent and very lifestyle-based. So, yeah, if you have any questions, please let us know.

Angel Boling  21:37
And before we end, I'll say the first time we did this, me and Lily encountered a big challenge, which prepared us better for the second time. The first time, you know, we were planning on having about 20 standardized patients, and it was right before Thanksgiving, Christmas time, and that just fell in our lap. And we had, I think, nine or 10, or maybe it was eight, but we had to end up, you know, grabbing a few faculty and get them trained, and so we went from having 20 to half, and we're like, "What are we going to do with this? And so I was like, "You know, one of the things that I think is very important is students learn also from observing. So the first time we had to flip our script, it wasn't a med student and a nursing student. It was a med student, nursing student doing the simulation, but then we had a med student, a nursing student observing the simulation and observing the interactions, and so we had to get very, very creative because we were not going to throw this in the trash because we had done so much work. Whereas this last time we were better prepared, you know, we really tried to make sure that we had enough to do it where that nobody was having to be in that observation. They were actually able to be in the role of the nurse or the med student. So challenges happen. I think the thing is thinking about how flexible you can be. But I would say this is probably one of the best simulations I've seen, and we've done a lot of them. But it just seemed so natural. Now I will say the other challenge. It takes about 15 to 16 faculty or volunteers with faculty to run this, because you've got standardized patients' rooms going. You have the prep work where they're coming in and being taught doing the pre-briefing. Then you have the folks in debriefing. Then you have the people that are you know being the volunteers to make sure they need to get where they need to get, so I'd say 16 to 20 volunteers, and that includes me and Lily as well, to manage this simulation in a day. But the results are phenomenal. So I will say that much. The results have been phenomenal. So

Lily Browning  23:37
it's a heavy lift, but you know I come from a primary care background, a family medicine physician, and how many times I know from my experience, my working with a patient that I'm not getting anywhere with. I don't seem to really be, you know, helping them make a change. Then I realize my nurse or my MA actually have a really deep relationship with that patient, or they connect on a different level, and so by working with you know other healthcare providers in the clinic, coming together, you know how what's the best way for me to approach this patient? Can you help me talk to this patient about compliance or or diet? That can make much greater strides. So this really mirrored that.

Angel Boling  24:23
Yeah. So these are kind of our conclusions. You know that we know it strengthened interprofessional teamwork through pairing them together. They voiced that. They voiced the learning that occurred between just the two of them in a team. You know how they learn from a senior student and just how do you get more comfortable and how do you build confidence? I mean, that's walkaways we didn't ask for. You know, they're getting, as she said, that meaningful practice and motivational interviewing. Nurses are learning more of what that means and that kind of aspect, and they're really doing that plan of care together, recognizing the role of diet managing early stage chronic disease. So we have our next one coming up, I believe it's March. Future plans is we'll have an additional 40 medical students. Nursing numbers have not changed, so we'll be as creative as we can get. One of the things that we did with the second one, we added in kind of some more social determinants of care, where they had to like map out. You know, what do you think impacted different pieces of these things, and so we really think the debriefing period needs to be a little bit more extended because one, the discussions were so deep in that room that I felt like we cut them off to move the next group. So how can we be more intentional with our debriefing time to not lose, you know those really what I call enrichment discussions from us. So that's where we are, and it has been, I think, an exciting event and a very challenging event. But I think it, like I said, it has really shown us what we can do with just even students that are not at the same level. So exactly. Any questions? I'll turn my camera back on. Of

TN Sim Alliance  26:20
course, IPE is the buzzword, right? So, anytime get two groups of people together for a common goal and learn something from each other-that's amazing. So, it sounds like it was quite an undertaking.

Angel Boling  26:35
Yeah, and

TN Sim Alliance  26:36
excited or nervous to do it again?

Angel Boling  26:39
I'm probably excited. We've gotten really good. Usually, Lily and I, like the last time we went through it again, and we, you know, just like anybody, when you're evaluating something or tweaking it for a class, we're like, well, that was a little bit too much. That worked really well. Oh, that that was that was a struggle. So I feel like Lily and I do a really good job of that, and so we tried to do that and get it ready again for the bigger team. So, but having the registered dietitian and debriefing, I thought was also really good because you know we had enough people that they were walking the tables and really trying to you know add some of that on. And so some of the questions that were asked with them, I think, were very important. I think a lot of people don't understand that role, so we learned about a different role as well outside of just nursing and medicine. So I think that was an added extra to the debriefing piece for students.

TN Sim Alliance  27:33
Yeah, like use your resources. They're out in the facilities too, not just right here. So that's amazing. Yeah, that's right. We we don't have like an RD

Lily Browning  27:41
program at Baptist. It would be amazing if we didn't. So I

Angel Boling  27:46
I

Lily Browning  27:47
kind of put a call out to registered dietitians at some of our local hospitals or clinics, and that's where I got the dietitians that we

Angel Boling  27:54
we worked with. It'd be great if we did have

Lily Browning  27:57
students, but you know, barring that we don't have that, it's really important that we have the registered dietitian piece. The preparation is a chance for them to say, "Hey, what is a registered dietitian? What do they do? What are their qualifications? And then let me talk to you about this, these basic dietary patterns like the DASH diet and the Mediterranean diet for the conditions that you're going to see. Then you know we can take and apply that counseling that the registered dietitians give us to the patients at their level of readiness, and then we have a debrief with the registered dietitian and say, you know, that gives you a chance of you know at what point in time would this patient need to be referred, for instance, or what could a registered dietitian add that we weren't able to add. So it was really great to have our registered dietitians at the debrief.

Angel Boling  28:45
Yeah, I think one of the things they really elaborated on is the same thing that we teach our students. You know, yes, we would love to walk in and say, "Don't eat more fried food, but you know, when you say no, no doesn't work, and it's always always about can you reduce or start limiting. You know, so they were using a lot of keywords to help them how to counsel, how to teach, you know, saying, okay, let's do small changes, you know, small changes that may, you know, impact the patient, but you've got a whole family, you know, you've got a family at home, and how does that impact them? So I think it made them think outside of the patient, and think more about who all is involved in that, because you know, I mean, it's just common. If we're moms and we're cooking dinner for our kids, and it's something we shouldn't be eating, and we're cooking them, we tend to you know take a bite or two, or we try it out, or we instinctively eat that because it's already cooked. When how can we make healthier for our whole family, but still make it where everybody enjoys it? You know, so they did a lot of those conversations. We also talked about social determinants of health and really focusing on, you know, we we tell these folks we'll go to the grocery store and you know buy A, B, and C, and you don't even know their only store is a quick stop. Yeah, you know, and so I think it challenged the students to really think outside of who they were, and that's hard to do. So,


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