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Transition to Nursing Practice: A Capstone Simulation for the Application of Leadership Skills in Nursing Practice
Teaching and Learning in Nursing 14 (2019) 283–287
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Transition to nursing practice: A capstone simulation for the application of leadership skills in nursing practice Teresa D. Welch, Ed.D, RN, NEA-BC ⁎, Haley P. Strickland, Ed.D, RN, Andrea F. Sartain, Ed.D, RN The Capstone College of Nursing, The University of Alabama, Tuscaloosa, AL, 35487, USA
a r t i c l e Article history: Accepted 6 June 2019 Keywords: Capstone simulation Nursing students Transition to practice Leadership Simulation
i n f o
a b s t r a c t A large-scale capstone simulation was implemented to fully immerse nursing students into the authentic role of the professional nurse by giving them the autonomy to independently manage the care of multiple complex patients with competing priorities in a realistic hospital environment. This innovative learning experience gave students an opportunity to transfer theory into practice. Overwhelmingly positive feedback from students supports the implementation of a capstone simulation to promote a smoother transition into the nursing workforce. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction The transition from the role of nursing student to that of the professional nurse is a challenging and multifaceted process. New graduate nurses are expected to effectively manage multiple patients, each with their own set of challenges and complexities, to be successful in the role of the professional nurse. Transition to nursing practice challenges have been discussed over the past few decades; however, limited academic clinical experiences have been available to prepare student nurses for the leadership role of the professional nurse (Houston et al., 2018; Kaihlanen, Haavisto, Strandell-Laine, & Salminen, 2017; Murphy & Janisse, 2017; Thomas & Mraz, 2017). Safety concerns and intricacies within the clinical environment of health care systems have placed restrictions on essential opportunities for nursing student experiences. These limitations have significantly impacted the nursing student's ability to engage in situations that support the development and advancement of skills needed to be successful in the art of delegation, prioritization, and management of patient care, independent decision-making, and interprofessional collaboration (Thomas & Mraz, 2017). New graduates arrive to the nursing workforce with expectations to function autonomously in an ever-changing technological
The authors declare no conflict of interest. Funding: This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. Tel.: +1 205 792 1636; fax: +1 205 348 5559. E-mail address: [email protected]. (T.D. Welch).
environment and manage competing priorities with patients as well as family members (Missen, McKenna, & Beauchamp, 2016; Strickland & Welch, 2018). Today's busy and highly specialized clinical environment has become more complex as length of stay has become progressively shorter creating an environment of fast-paced turnover for patients. In addition, patient acuity levels are noticeably higher as patient populations are more complex and demanding of nursing resources. These vigorous conditions place significant demands on new graduate nurses who are also attempting to master delegation, prioritization, and patient care management while trying to adapt to their new role as a professional nurse (Clark & Springer, 2012; Kavanagh & Szweda, 2017; Missen et al., 2016). In addition to adjusting to the realities of everyday practice, new graduates are expected to demonstrate immediate competence and proficiency in the provision of evidence-based care and make critical decisions regarding patient care (Missen et al., 2016). Preparing the next generation of graduating nurses to be successful in a complex health care environment where change is continuous and patients are sicker than ever before requires innovative and transformative educational experiences (Africa, 2017; Kavanagh & Szweda, 2017). Nursing faculty must be willing to explore and implement creative learning opportunities to provide nursing students with the requisite tools and resources to successfully overcome the transitional challenges that lie ahead. Immersive simulated clinical experiences place nursing students in a controlled environment with complex patients and competing priorities. Placing nursing students in a position of leadership to independently assess, make decisions, and manage all aspects of patient care cultivates strong
https://doi.org/10.1016/j.teln.2019.06.002 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
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assessment skills and the clinical judgment skills necessary to be successful. Simulated experiences provide a unique opportunity for development of delegation, prioritization, and time management skills by allowing students to function independently (Kavanagh & Szweda, 2017). Providing an authentic practice environment where the nursing student is expected to function autonomously in a dynamic clinical situation managing multiple patients supports the development of decision-making and leadership abilities required in nursing practice (Africa, 2017; Thomas & Mraz, 2017). A capstone simulation event was designed to provide nursing students with a culminating learning experience that utilized the knowledge and skills learned throughout the program of study. Nursing student engagement in capstone simulations is limited with the use of low fidelity mannequins or human patient simulators alone (Adamson, 2015; Ayers et al., 2015). This capstone simulation was intentionally designed to elevate the authenticity of the patient care experience. The strategic use of multiple complex patients with live actors portraying family members provided a dynamic clinical experience that supports a smooth transition into practice (Pritchard, Blackstock, Nestel, & Keating, 2016).
Simulation and Nursing Education Nurse educators have incorporated high-fidelity simulation (HFS) into nursing education to provide students with a safe environment to practice high-risk, high-acuity situations. To the greatest extent possible, HFS utilizes manikins to mimic real-life situations. This life-like simulation allows students greater opportunity for autonomy in decision-making, unlike in the clinical setting where students must collaborate with faculty before performing patient care (Thomas & Mraz, 2017). When standardized actors are incorporated into HFS, it adds to the authenticity of the scenario. These actors add an additional layer to the scenario encouraging students to improve communication skills and learn to balance the physical care of the patient with the demands of the family. Standardized actors allow faculty to incorporate legal and ethical aspects to the scenario, which may not be possible with the use of manikins alone (Strickland & Welch, 2018). New graduate nurses frequently struggle with the demands of the complex health care environment. Assuming the role of primary care for a team of patients can be overwhelming at times for the new nurse (Strickland & Welch, 2018). HFS has been shown to improve student confidence in the performance of psychomotor skills, interprofessional collaboration, as well as communication between student/patient and student/health care provider. Competence in all of these attributes results in improved patient outcomes in the clinical setting by decreasing actual errors (Livesay, Lawrence, & Miller, 2015; Shin, Park, & Kim, 2015; Tuzer, Dinc, & Elcin, 2016). An additional benefit of simulation is the ability of students to link theory to practice. The use of debriefing allows students to think through the scenario presented and critically think about the situation, areas in which they performed well, and areas the students can improve in the future (Thomas & Mraz, 2017).
The Mock Hospital The purpose of this capstone simulation was to fully immerse senior-level nursing students into the authentic role of the professional nurse by giving them the autonomy to independently manage the care of multiple complex patients with competing priorities in a realistic hospital environment. This capstone simulation was developed to represent both general medical/surgical and intensive care unit (ICU) clinical environments. This article focuses on the development and implementation of the ICU experience.
Design/Environment The “Mock Hospital” capstone simulation was designed for senior nursing students as a part of the Leadership in Professional Nursing Practice course in an undergraduate nursing program. The simulation was presented as a required, but non-graded assignment within the course to reinforce theoretical and didactic knowledge but was not intended nor did it replace actual clinical time required within the course. Within the large-scale “Mock Hospital” simulation, four simulation rooms, housed within a simulation center, were designated as the ICU. These rooms were intricately set up to replicate the environment of a general ICU, utilizing i-Stan high-fidelity simulators as critical patients. Based upon the elements within the chosen scenario, the ICU room was replete with ventilators, monitors, ventriculostomy, multiple intravenous lines, and so forth to support the authentic context of the ICU. In addition, to add dimension to the ICU simulation, faculty and staff served as actors to represent family members within the ICU setting. The capstone simulation occurred over a 2-day period and was divided into eight 1-hour simulations. Each 1-hour simulation accommodated 14 senior-level nursing students with 12 students randomly assigned to the general medical/surgical area and two students assigned to the ICU. Out of the 112 senior-level nursing students participating in the large-scale capstone simulation, 32 were selected for the ICU experience and functioned as the professional nurse and were assigned and expected to manage a team of two ICU patients. Patient team assignments were randomized for each simulation to maintain integrity of the clinical experience. Students received a brief bedside report on each patient prior to the beginning the simulation. Following report, students were expected to make accurate assessments, prioritize care, and delegate appropriately while working through the decisionmaking process meeting the complex needs of their patients and families in a safe and competent manner. Utilization of students' leadership skills was critical to successfully manage their team of patients. Junior-level nursing students provided support and were assigned the role of patient care assistants throughout each simulation and could be delegated to as needed. In addition, one of the 14 senior nursing students was randomly selected to function as charge nurse during the hour-long simulation providing an additional venue for delegation and/or assistance. Students from the school of social work participated in each simulation and were available for consultation and support as needed. Simulation Patient/Family Scenarios Four detailed and comprehensive scenarios were developed to provide the student with an authentic ICU patient/family presentation reflective of the ICU experience. Table 1 summarizes the ICU scenarios used to make student assignments. Senior nursing students were randomly assigned two of the four patient scenarios as their ICU patient team. In addition, to promote an authentic clinical experience, staff and faculty were utilized as actors in supporting roles to represent family members and visitors in the simulated hospital environment. While these roles were orchestrated and scripted to enhance the clinical presentation of the patient/clinical scenario, staff and faculty were given the autonomy to improvise as the situation unfolded. Students were given the autonomy to interact within the clinical scenario not only to address the patients' clinical needs but also to address social, emotional, and legal aspects of care. Supplies Planning for the capstone simulation began the previous academic year and was accounted for in the school's fiscal operating budget. Patient scenarios were analyzed to identify essential equipment and supplies needed to provide an authentic environment for the
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Table 1 Abbreviated ICU patient/family scenarios Patient
Diagnosis
Current situation
Scenario
Patient 1
Intracranial bleed/hemorrhagic stroke
Physical examination and EEG indicate cerebral death. At request of common law wife, cerebral arteriogram was completed last evening with definitive diagnosis of cerebral death.
Chief complaint: 58-year-old Black male patient arrived per EMS active seizures and intubated.
Supportive common law wife of 25 years present at bedside for the last 7 days. Expects full recovery. Wants all medical measures necessary to help him get better. Ethics committee meeting has been scheduled for later in this shift.
PMH: noncompliant HTN, renal insufficiency, PUD, GERD, arthritis Home medications: see medical record
Introduce estranged wife of 30 years to the situation: She was contacted by family members. She is a case manager from out of state. Demanding to see LIP. All heroic measures must be stopped immediately.
Patient 2
Patient 3
MVA/bilateral proximal femur and pelvic fractures
DKA
Situation has potential to escalate quickly. Direct admit to the ICU 30 minutes prior to shift report from operating room. Receiving nurse obtained initial vital signs, got the patient settled in bed, and wrote an admit note. Oncoming nurse will need to do assessment.
Angioedema/intubated requiring ventilation
PMH: Noncontributory
Doting, concerned parents at bedside.
Home medications: Ortho-Novum I tab by mouth daily
Situation has potential to deteriorate to respiratory distress/ arrest secondary to pulmonary embolism depending. Admitted to the ICU on the previous shift NPO with insulin drip, maintenance fluids, and hourly blood glucose with electrolytes
Chief Complaint: 22-year-old patient found unresponsive. Blood glucose is 800 mg/dl, ph 7.1.
Situation has potential to escalate. Boyfriend is disruptive to care; giving patient regular soda, smoking in bathroom. Patient 4
Chief complaint: 21-year-old female trauma alert; bilateral pelvic femoral fractures
Concerned, overly anxious family at bedside. Patient single mother with small children. Agitated, coughing, asynchronous with ventilation. Ventilator alarming. Elevated heart rate and blood pressure, oxygen saturation dropping (89%) and alarming on bedside monitor. Situation has potential to deteriorate quickly.
PMH: Type I diabetic, noncompliant Current medications: see medical record Chief complaint: 32-year-old Black female patient arrived per EMS intubated with upper airway swelling. PMH: HTN, Type II diabetes, arthritis, PUD, GERD Home medications: Lisinopril (Zestril) 40-mg tab by mouth daily Furosemide (Lasix) 40-mg tab by mouth daily Nicardipine (Cardene) 60-mg tab by mouth every 12 hours KCL (KDur) 10-mEq capsule daily Omeprazole (Prilosec) 20-mg tab by mouth daily Ibuprophen 400-mg tid as needed Calcium carbonate (Tums) 1500 mg by mouth daily
Note. PMH - Past medical history, HTN - hypertension, PUD - Peptic ulcer disease, GERD - Gastroesophageal reflux disease, EMS - Emergency medical services, EEG - Electroencephalogram, LIP - Licensed independent practitioner, ICU - Intensive care unit, NPO - Nothing by mouth.
implementation of the capstone simulation. The simulation specialist was included in the planning phase to ensure that supply needs were included in the annual simulation budget. Due to the complexity of each scenario, the direct care cost of consumable supplies varied. An essential component of the simulated hospital experience included detailed health records created to mimic patient charts, normally found within the clinical setting. Every patient chart included an individualized comprehensive health record with a thorough health history, health care provider orders, previous and current laboratory/diagnostic tests, and nurse's notes. Nursing students were given the opportunity to document patient findings, and when indicated, students were also expected to implement standing/protocol orders. Role of the Nurse Learning modules were assigned to the students 1 week prior to the simulation and were validated by faculty prior to participation in the simulation experience. Modules included didactic content, interactive videos, and practice questions related to delegation, critical thinking and clinical judgment, decisionmaking, and prioritization skills. A week prior to the simulation, faculty discussed expectations for the simulated clinical
experience. Students were informed to come in uniform, bring their assessment kit, and arrive 10–15 minutes prior to their assigned session. Before beginning the ICU “shift” students were given a brief orientation to the simulated hospital environment. The orientation included a brief description of the supply areas, the process for contacting health care providers and/or ancillary support, the location and accessibility of the patients' medical record, the and mechanism for “time out” if they became overwhelmed. The ICU patient scenarios were presented as a verbal bedside shift report with family introductions as appropriate. Based upon the report and clinical presentation, the students were expected to make clinical decisions and prioritize care when patients and/or families competed for the nurses' time and attention. The students had to prioritize which patient to see first, which interventions to address first, and which tasks could be delegated to a patient care assistant, social worker, or RN charge nurse. They were challenged to perform accurate assessments and psychomotor skills while relying heavily on therapeutic communication. Students were also required to assess the situation, make accurate clinical judgments, prioritize care, and delegate tasks based upon the report and clinical presentation of the patient. The fluid environment of the simulation changed based upon the students' decisions and actions.
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Faculty Role The success of the simulation relied heavily on the support of the faculty who served in many roles. These roles included voice and operation of i-Stan simulator, family member, evaluator, and health care provider. The logistics of the simulation were managed by leadership faculty, which ensured the consistency and integrity of the simulation experience. While the ICU scenarios were scripted, the use of faculty and staff members as actors to portray family members in the scenarios created an additional dimension of authenticity. Debriefing Debriefing is an essential component within any simulated clinical experience (Adamson, 2015; Jefferies, Rodgers, & Adamson, 2015; Sabei & Lasater, 2016). According to Sabei and Lasater (2016), giving the student an opportunity to debrief through self-reflection and assessment of performance is emerging as the most important phase of simulation. Students were given multiple opportunities to receive formative and summative feedback throughout the simulation. Debriefing and self-reflection occurred on an individual and group basis: (a) individually, during the simulation; b) immediately following each of the simulation sessions; and b) during scheduled leadership course time the following day. Identified learning needs and concerns were addressed on an individual basis during the simulation. Post-ICU simulation debriefing was held immediately after the completion of the simulation experience and again in conjunction with the students who were assigned to the medical/surgical experience. All 112 students were provided an opportunity to participate in a guided debriefing discussion during scheduled class time the following day. The large group discussion allowed the students to share their experiences across sessions and across role assignments enhancing learning opportunities for all students (Strickland & Welch, 2018). Discussion and Recommendations Nursing students rarely, if ever, have an opportunity to personally experience the responsibility and accountability of making critical decision in the clinical setting. They are not given the primary responsibility of managing multiple complex patients or practicing essential problem management, delegation, and prioritization skills required of new nurses. A capstone simulation in the leadership course provided the student with an opportunity to apply these skills in an authentic, safe environment. This practical experience improves self-confidence and enhances the students' critical thinking, prioritization, decision-making, and delegation skills, which allow the opportunity to practice and refine these skills for successful transition into professional practice (Houston et al., 2018; Strickland & Welch, 2018; Thomas & Mraz, 2017). Student feedback from this learning experience was overwhelmingly positive. Several themes emerged through individual and group debriefing and included the following: (a) Students appreciated the opportunity to be autonomous in managing multiple complex patients, a task they had not had previously;, and (b) students enjoyed the authenticity of the simulation and their interaction with “actors.” The integration of social, legal, and ethical dilemmas into the scenarios added a layer of complexity that gave students an opportunity to balance multiple issues simultaneously; (c) students valued the ability to apply problem-solving, decision-making, and critical thinking skills under pressure. The positive nature of the feedback received from students supports the implementation of a large-scale capstone simulation to develop these skills. Successful implementation of a capstone simulation of this scale requires a significant amount of time, resources, and dedicated
faculty. Planning began a year in advance to coordinate the details of such a large-scale simulation event involving an interdisciplinary team. While faculty made every attempt to project the anticipated course of the patient scenarios, it was not feasible to anticipate all clinical or social situations, as each scenario evolved and unfolded based on the actions or inactions of the student and the improvisation of the actor. The environment was fluid and dynamic, allowing faculty, student, HFS, and actor to authentically respond within the evolving scenario as it progressed. This type of interaction and engagement made each scenario unique for the students. Throughout each simulation, faculty were readily available to provide formative feedback to the students and manage the operation of the simulators. Faculty presence and support were critical to the success of the simulation. If a student lost focus, or got off target, they received the support and guidance that they needed at that time to get back on task. This formative feedback was beneficial to the learning experience. The success of this capstone simulation was because of the collective support of a dedicated team of nurse educators who strive to give senior nursing students the tools that they need for a successful transition into nursing practice. Conclusion New graduate nurses are expected to transition seamlessly into the nursing workforce and function autonomously in an increasingly chaotic, technologically advanced clinical environment (Missen et al., 2016; Strickland & Welch, 2018). The purpose of this capstone simulation experience was to give students an opportunity to assume an interactive leadership role in the provision of patient care. For the first time, they were the primary nurse prioritizing and making the decisions rather than observing others as they went through the processes of problem-solving, decision-making, prioritization, and delegation. Post simulation debriefing and reflection with students reinforced the faculties' belief that the practical application of learned concepts would reinforce the students understanding and transferability of knowledge. This simulation provided an innovative learning experience for students that allowed an opportunity to transform theory into practice ultimately promoting a smooth transition into the nursing workforce. References Adamson, K. (2015). A systematic review of the literature related to the NLN/Jeffries simulation framework. Nursing Education Perspectives, 36(5), 281–291. https:// doi.org/10.5480/15-1655. Africa, L. (2017). Transition to practice programs: Effective solutions to achieving strategic staffing in today's healthcare systems. Nursing Economics, 35(4), 178–183. Ayers, C., Binder, B., Lyon, K., Montgomery, D., Koci, A., & Foster, W. (2015). The simulated hospital environment: A qualitative study applying space industry techniques. Journal of Professional Nursing, 18–25. Clark, C., & Springer, P. (2012). Nurse residents' first-hand accounts on transition to practice. Nursing Outlook, 60, E2–E8. Houston, C., Phillips, B., Jefferies, P., Todero, C., Rich, J., Knecht, P., & Lewis, M. (2018). The academic–practice gap: Strategies for an enduring problem. Nurse Forum, 53, 27–34. Jefferies, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing Education Perspectives, 36(5), 292–293. Kaihlanen, A., Haavisto, E., Strandell-Laine, C., & Salminen, L. (2017). Facilitating the transition from a nursing student to a Registered Nurse in the fnal clinical practicum: A scoping literature review. Scandinavian Journal of Caring Science, 32(2), 466–477. https://doi.org/10.1111/scs.12494. Kavanagh, J., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nursing Education Perspectives, 38(2), 57–62. Livesay, K., Lawrence, K., & Miller, C. (2015). Making the most of simulated learning: Understanding and managing perceptions. International Journal of Nursing Education Scholarship, 12(1), 17–26. Missen, K., McKenna, L., & Beauchamp, A. (2016). Registered nurses' perceptions of new nursing graduates' clinical competence: A systematic integrative review. Nursing Health Science(2), 143–153.
T.D. Welch et al. / Teaching and Learning in Nursing 14 (2019) 283–287 Murphy, L., & Janisse, L. (2017). Optimizing transition to practice through orientation: A quality improvement initiative. Clinical Simulation Nursing, 13(11), 583–590. Pritchard, S., Blackstock, F., Nestel, D., & Keating, J. (2016). Simulated patients in physical therapy education: Systematic review and meta-analysis. Physical Therapy, 96(9), 1342–1353. Sabei, S. D., & Lasater, K. (2016). Simulation debriefing for clinical judgement development: A concept analysis. Nurse Education Today, 45, 42–47. https://doi.org/10. 1016/j.nedt.2016.06.008. Shin, S., Park, J. H., & Kim, J. H. (2015). Effectiveness of patient simulation in nursing education: Meta-analysis. Nurse Education Today, 35(1), 176–182. https://doi. org/10.1016/j.nedt.2014.09.009.
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Strickland, H. P., & Welch, T. D. (2018). A capstone simulation for leadership development: Bridging theory to practice. Nurse Educator. https://doi.org/10.1097/NNE. 0000000000000553. Thomas, C. M., & Mraz, M. A. (2017). Exploration into how simulation can effect new graduate transition. Clinical Simulation Nursing, 13(10), 465–470. https://doi.org/ 10.1016/j.ecns.2017.05.013. Tuzer, H., Dinc, L., & Elcin, M. (2016). The effects of using high-fidelity simulators and standardized patients on the thorax, lung, and cardiac examination skills of undergraduate nursing students. Nurse Education Today, 45, 120–125. https://doi.org/10. 1016/j.nedt.2016.07.002.
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Transition to nursing practice: A capstone simulation for the application of leadership skills in nursing practice Teresa D. Welch, Ed.D, RN, NEA-BC ⁎, Haley P. Strickland, Ed.D, RN, Andrea F. Sartain, Ed.D, RN The Capstone College of Nursing, The University of Alabama, Tuscaloosa, AL, 35487, USA
a r t i c l e Article history: Accepted 6 June 2019 Keywords: Capstone simulation Nursing students Transition to practice Leadership Simulation
i n f o
a b s t r a c t A large-scale capstone simulation was implemented to fully immerse nursing students into the authentic role of the professional nurse by giving them the autonomy to independently manage the care of multiple complex patients with competing priorities in a realistic hospital environment. This innovative learning experience gave students an opportunity to transfer theory into practice. Overwhelmingly positive feedback from students supports the implementation of a capstone simulation to promote a smoother transition into the nursing workforce. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction The transition from the role of nursing student to that of the professional nurse is a challenging and multifaceted process. New graduate nurses are expected to effectively manage multiple patients, each with their own set of challenges and complexities, to be successful in the role of the professional nurse. Transition to nursing practice challenges have been discussed over the past few decades; however, limited academic clinical experiences have been available to prepare student nurses for the leadership role of the professional nurse (Houston et al., 2018; Kaihlanen, Haavisto, Strandell-Laine, & Salminen, 2017; Murphy & Janisse, 2017; Thomas & Mraz, 2017). Safety concerns and intricacies within the clinical environment of health care systems have placed restrictions on essential opportunities for nursing student experiences. These limitations have significantly impacted the nursing student's ability to engage in situations that support the development and advancement of skills needed to be successful in the art of delegation, prioritization, and management of patient care, independent decision-making, and interprofessional collaboration (Thomas & Mraz, 2017). New graduates arrive to the nursing workforce with expectations to function autonomously in an ever-changing technological
The authors declare no conflict of interest. Funding: This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. Tel.: +1 205 792 1636; fax: +1 205 348 5559. E-mail address: [email protected]. (T.D. Welch).
environment and manage competing priorities with patients as well as family members (Missen, McKenna, & Beauchamp, 2016; Strickland & Welch, 2018). Today's busy and highly specialized clinical environment has become more complex as length of stay has become progressively shorter creating an environment of fast-paced turnover for patients. In addition, patient acuity levels are noticeably higher as patient populations are more complex and demanding of nursing resources. These vigorous conditions place significant demands on new graduate nurses who are also attempting to master delegation, prioritization, and patient care management while trying to adapt to their new role as a professional nurse (Clark & Springer, 2012; Kavanagh & Szweda, 2017; Missen et al., 2016). In addition to adjusting to the realities of everyday practice, new graduates are expected to demonstrate immediate competence and proficiency in the provision of evidence-based care and make critical decisions regarding patient care (Missen et al., 2016). Preparing the next generation of graduating nurses to be successful in a complex health care environment where change is continuous and patients are sicker than ever before requires innovative and transformative educational experiences (Africa, 2017; Kavanagh & Szweda, 2017). Nursing faculty must be willing to explore and implement creative learning opportunities to provide nursing students with the requisite tools and resources to successfully overcome the transitional challenges that lie ahead. Immersive simulated clinical experiences place nursing students in a controlled environment with complex patients and competing priorities. Placing nursing students in a position of leadership to independently assess, make decisions, and manage all aspects of patient care cultivates strong
https://doi.org/10.1016/j.teln.2019.06.002 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
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T.D. Welch et al. / Teaching and Learning in Nursing 14 (2019) 283–287
assessment skills and the clinical judgment skills necessary to be successful. Simulated experiences provide a unique opportunity for development of delegation, prioritization, and time management skills by allowing students to function independently (Kavanagh & Szweda, 2017). Providing an authentic practice environment where the nursing student is expected to function autonomously in a dynamic clinical situation managing multiple patients supports the development of decision-making and leadership abilities required in nursing practice (Africa, 2017; Thomas & Mraz, 2017). A capstone simulation event was designed to provide nursing students with a culminating learning experience that utilized the knowledge and skills learned throughout the program of study. Nursing student engagement in capstone simulations is limited with the use of low fidelity mannequins or human patient simulators alone (Adamson, 2015; Ayers et al., 2015). This capstone simulation was intentionally designed to elevate the authenticity of the patient care experience. The strategic use of multiple complex patients with live actors portraying family members provided a dynamic clinical experience that supports a smooth transition into practice (Pritchard, Blackstock, Nestel, & Keating, 2016).
Simulation and Nursing Education Nurse educators have incorporated high-fidelity simulation (HFS) into nursing education to provide students with a safe environment to practice high-risk, high-acuity situations. To the greatest extent possible, HFS utilizes manikins to mimic real-life situations. This life-like simulation allows students greater opportunity for autonomy in decision-making, unlike in the clinical setting where students must collaborate with faculty before performing patient care (Thomas & Mraz, 2017). When standardized actors are incorporated into HFS, it adds to the authenticity of the scenario. These actors add an additional layer to the scenario encouraging students to improve communication skills and learn to balance the physical care of the patient with the demands of the family. Standardized actors allow faculty to incorporate legal and ethical aspects to the scenario, which may not be possible with the use of manikins alone (Strickland & Welch, 2018). New graduate nurses frequently struggle with the demands of the complex health care environment. Assuming the role of primary care for a team of patients can be overwhelming at times for the new nurse (Strickland & Welch, 2018). HFS has been shown to improve student confidence in the performance of psychomotor skills, interprofessional collaboration, as well as communication between student/patient and student/health care provider. Competence in all of these attributes results in improved patient outcomes in the clinical setting by decreasing actual errors (Livesay, Lawrence, & Miller, 2015; Shin, Park, & Kim, 2015; Tuzer, Dinc, & Elcin, 2016). An additional benefit of simulation is the ability of students to link theory to practice. The use of debriefing allows students to think through the scenario presented and critically think about the situation, areas in which they performed well, and areas the students can improve in the future (Thomas & Mraz, 2017).
The Mock Hospital The purpose of this capstone simulation was to fully immerse senior-level nursing students into the authentic role of the professional nurse by giving them the autonomy to independently manage the care of multiple complex patients with competing priorities in a realistic hospital environment. This capstone simulation was developed to represent both general medical/surgical and intensive care unit (ICU) clinical environments. This article focuses on the development and implementation of the ICU experience.
Design/Environment The “Mock Hospital” capstone simulation was designed for senior nursing students as a part of the Leadership in Professional Nursing Practice course in an undergraduate nursing program. The simulation was presented as a required, but non-graded assignment within the course to reinforce theoretical and didactic knowledge but was not intended nor did it replace actual clinical time required within the course. Within the large-scale “Mock Hospital” simulation, four simulation rooms, housed within a simulation center, were designated as the ICU. These rooms were intricately set up to replicate the environment of a general ICU, utilizing i-Stan high-fidelity simulators as critical patients. Based upon the elements within the chosen scenario, the ICU room was replete with ventilators, monitors, ventriculostomy, multiple intravenous lines, and so forth to support the authentic context of the ICU. In addition, to add dimension to the ICU simulation, faculty and staff served as actors to represent family members within the ICU setting. The capstone simulation occurred over a 2-day period and was divided into eight 1-hour simulations. Each 1-hour simulation accommodated 14 senior-level nursing students with 12 students randomly assigned to the general medical/surgical area and two students assigned to the ICU. Out of the 112 senior-level nursing students participating in the large-scale capstone simulation, 32 were selected for the ICU experience and functioned as the professional nurse and were assigned and expected to manage a team of two ICU patients. Patient team assignments were randomized for each simulation to maintain integrity of the clinical experience. Students received a brief bedside report on each patient prior to the beginning the simulation. Following report, students were expected to make accurate assessments, prioritize care, and delegate appropriately while working through the decisionmaking process meeting the complex needs of their patients and families in a safe and competent manner. Utilization of students' leadership skills was critical to successfully manage their team of patients. Junior-level nursing students provided support and were assigned the role of patient care assistants throughout each simulation and could be delegated to as needed. In addition, one of the 14 senior nursing students was randomly selected to function as charge nurse during the hour-long simulation providing an additional venue for delegation and/or assistance. Students from the school of social work participated in each simulation and were available for consultation and support as needed. Simulation Patient/Family Scenarios Four detailed and comprehensive scenarios were developed to provide the student with an authentic ICU patient/family presentation reflective of the ICU experience. Table 1 summarizes the ICU scenarios used to make student assignments. Senior nursing students were randomly assigned two of the four patient scenarios as their ICU patient team. In addition, to promote an authentic clinical experience, staff and faculty were utilized as actors in supporting roles to represent family members and visitors in the simulated hospital environment. While these roles were orchestrated and scripted to enhance the clinical presentation of the patient/clinical scenario, staff and faculty were given the autonomy to improvise as the situation unfolded. Students were given the autonomy to interact within the clinical scenario not only to address the patients' clinical needs but also to address social, emotional, and legal aspects of care. Supplies Planning for the capstone simulation began the previous academic year and was accounted for in the school's fiscal operating budget. Patient scenarios were analyzed to identify essential equipment and supplies needed to provide an authentic environment for the
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285
Table 1 Abbreviated ICU patient/family scenarios Patient
Diagnosis
Current situation
Scenario
Patient 1
Intracranial bleed/hemorrhagic stroke
Physical examination and EEG indicate cerebral death. At request of common law wife, cerebral arteriogram was completed last evening with definitive diagnosis of cerebral death.
Chief complaint: 58-year-old Black male patient arrived per EMS active seizures and intubated.
Supportive common law wife of 25 years present at bedside for the last 7 days. Expects full recovery. Wants all medical measures necessary to help him get better. Ethics committee meeting has been scheduled for later in this shift.
PMH: noncompliant HTN, renal insufficiency, PUD, GERD, arthritis Home medications: see medical record
Introduce estranged wife of 30 years to the situation: She was contacted by family members. She is a case manager from out of state. Demanding to see LIP. All heroic measures must be stopped immediately.
Patient 2
Patient 3
MVA/bilateral proximal femur and pelvic fractures
DKA
Situation has potential to escalate quickly. Direct admit to the ICU 30 minutes prior to shift report from operating room. Receiving nurse obtained initial vital signs, got the patient settled in bed, and wrote an admit note. Oncoming nurse will need to do assessment.
Angioedema/intubated requiring ventilation
PMH: Noncontributory
Doting, concerned parents at bedside.
Home medications: Ortho-Novum I tab by mouth daily
Situation has potential to deteriorate to respiratory distress/ arrest secondary to pulmonary embolism depending. Admitted to the ICU on the previous shift NPO with insulin drip, maintenance fluids, and hourly blood glucose with electrolytes
Chief Complaint: 22-year-old patient found unresponsive. Blood glucose is 800 mg/dl, ph 7.1.
Situation has potential to escalate. Boyfriend is disruptive to care; giving patient regular soda, smoking in bathroom. Patient 4
Chief complaint: 21-year-old female trauma alert; bilateral pelvic femoral fractures
Concerned, overly anxious family at bedside. Patient single mother with small children. Agitated, coughing, asynchronous with ventilation. Ventilator alarming. Elevated heart rate and blood pressure, oxygen saturation dropping (89%) and alarming on bedside monitor. Situation has potential to deteriorate quickly.
PMH: Type I diabetic, noncompliant Current medications: see medical record Chief complaint: 32-year-old Black female patient arrived per EMS intubated with upper airway swelling. PMH: HTN, Type II diabetes, arthritis, PUD, GERD Home medications: Lisinopril (Zestril) 40-mg tab by mouth daily Furosemide (Lasix) 40-mg tab by mouth daily Nicardipine (Cardene) 60-mg tab by mouth every 12 hours KCL (KDur) 10-mEq capsule daily Omeprazole (Prilosec) 20-mg tab by mouth daily Ibuprophen 400-mg tid as needed Calcium carbonate (Tums) 1500 mg by mouth daily
Note. PMH - Past medical history, HTN - hypertension, PUD - Peptic ulcer disease, GERD - Gastroesophageal reflux disease, EMS - Emergency medical services, EEG - Electroencephalogram, LIP - Licensed independent practitioner, ICU - Intensive care unit, NPO - Nothing by mouth.
implementation of the capstone simulation. The simulation specialist was included in the planning phase to ensure that supply needs were included in the annual simulation budget. Due to the complexity of each scenario, the direct care cost of consumable supplies varied. An essential component of the simulated hospital experience included detailed health records created to mimic patient charts, normally found within the clinical setting. Every patient chart included an individualized comprehensive health record with a thorough health history, health care provider orders, previous and current laboratory/diagnostic tests, and nurse's notes. Nursing students were given the opportunity to document patient findings, and when indicated, students were also expected to implement standing/protocol orders. Role of the Nurse Learning modules were assigned to the students 1 week prior to the simulation and were validated by faculty prior to participation in the simulation experience. Modules included didactic content, interactive videos, and practice questions related to delegation, critical thinking and clinical judgment, decisionmaking, and prioritization skills. A week prior to the simulation, faculty discussed expectations for the simulated clinical
experience. Students were informed to come in uniform, bring their assessment kit, and arrive 10–15 minutes prior to their assigned session. Before beginning the ICU “shift” students were given a brief orientation to the simulated hospital environment. The orientation included a brief description of the supply areas, the process for contacting health care providers and/or ancillary support, the location and accessibility of the patients' medical record, the and mechanism for “time out” if they became overwhelmed. The ICU patient scenarios were presented as a verbal bedside shift report with family introductions as appropriate. Based upon the report and clinical presentation, the students were expected to make clinical decisions and prioritize care when patients and/or families competed for the nurses' time and attention. The students had to prioritize which patient to see first, which interventions to address first, and which tasks could be delegated to a patient care assistant, social worker, or RN charge nurse. They were challenged to perform accurate assessments and psychomotor skills while relying heavily on therapeutic communication. Students were also required to assess the situation, make accurate clinical judgments, prioritize care, and delegate tasks based upon the report and clinical presentation of the patient. The fluid environment of the simulation changed based upon the students' decisions and actions.
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Faculty Role The success of the simulation relied heavily on the support of the faculty who served in many roles. These roles included voice and operation of i-Stan simulator, family member, evaluator, and health care provider. The logistics of the simulation were managed by leadership faculty, which ensured the consistency and integrity of the simulation experience. While the ICU scenarios were scripted, the use of faculty and staff members as actors to portray family members in the scenarios created an additional dimension of authenticity. Debriefing Debriefing is an essential component within any simulated clinical experience (Adamson, 2015; Jefferies, Rodgers, & Adamson, 2015; Sabei & Lasater, 2016). According to Sabei and Lasater (2016), giving the student an opportunity to debrief through self-reflection and assessment of performance is emerging as the most important phase of simulation. Students were given multiple opportunities to receive formative and summative feedback throughout the simulation. Debriefing and self-reflection occurred on an individual and group basis: (a) individually, during the simulation; b) immediately following each of the simulation sessions; and b) during scheduled leadership course time the following day. Identified learning needs and concerns were addressed on an individual basis during the simulation. Post-ICU simulation debriefing was held immediately after the completion of the simulation experience and again in conjunction with the students who were assigned to the medical/surgical experience. All 112 students were provided an opportunity to participate in a guided debriefing discussion during scheduled class time the following day. The large group discussion allowed the students to share their experiences across sessions and across role assignments enhancing learning opportunities for all students (Strickland & Welch, 2018). Discussion and Recommendations Nursing students rarely, if ever, have an opportunity to personally experience the responsibility and accountability of making critical decision in the clinical setting. They are not given the primary responsibility of managing multiple complex patients or practicing essential problem management, delegation, and prioritization skills required of new nurses. A capstone simulation in the leadership course provided the student with an opportunity to apply these skills in an authentic, safe environment. This practical experience improves self-confidence and enhances the students' critical thinking, prioritization, decision-making, and delegation skills, which allow the opportunity to practice and refine these skills for successful transition into professional practice (Houston et al., 2018; Strickland & Welch, 2018; Thomas & Mraz, 2017). Student feedback from this learning experience was overwhelmingly positive. Several themes emerged through individual and group debriefing and included the following: (a) Students appreciated the opportunity to be autonomous in managing multiple complex patients, a task they had not had previously;, and (b) students enjoyed the authenticity of the simulation and their interaction with “actors.” The integration of social, legal, and ethical dilemmas into the scenarios added a layer of complexity that gave students an opportunity to balance multiple issues simultaneously; (c) students valued the ability to apply problem-solving, decision-making, and critical thinking skills under pressure. The positive nature of the feedback received from students supports the implementation of a large-scale capstone simulation to develop these skills. Successful implementation of a capstone simulation of this scale requires a significant amount of time, resources, and dedicated
faculty. Planning began a year in advance to coordinate the details of such a large-scale simulation event involving an interdisciplinary team. While faculty made every attempt to project the anticipated course of the patient scenarios, it was not feasible to anticipate all clinical or social situations, as each scenario evolved and unfolded based on the actions or inactions of the student and the improvisation of the actor. The environment was fluid and dynamic, allowing faculty, student, HFS, and actor to authentically respond within the evolving scenario as it progressed. This type of interaction and engagement made each scenario unique for the students. Throughout each simulation, faculty were readily available to provide formative feedback to the students and manage the operation of the simulators. Faculty presence and support were critical to the success of the simulation. If a student lost focus, or got off target, they received the support and guidance that they needed at that time to get back on task. This formative feedback was beneficial to the learning experience. The success of this capstone simulation was because of the collective support of a dedicated team of nurse educators who strive to give senior nursing students the tools that they need for a successful transition into nursing practice. Conclusion New graduate nurses are expected to transition seamlessly into the nursing workforce and function autonomously in an increasingly chaotic, technologically advanced clinical environment (Missen et al., 2016; Strickland & Welch, 2018). The purpose of this capstone simulation experience was to give students an opportunity to assume an interactive leadership role in the provision of patient care. For the first time, they were the primary nurse prioritizing and making the decisions rather than observing others as they went through the processes of problem-solving, decision-making, prioritization, and delegation. Post simulation debriefing and reflection with students reinforced the faculties' belief that the practical application of learned concepts would reinforce the students understanding and transferability of knowledge. This simulation provided an innovative learning experience for students that allowed an opportunity to transform theory into practice ultimately promoting a smooth transition into the nursing workforce. References Adamson, K. (2015). A systematic review of the literature related to the NLN/Jeffries simulation framework. Nursing Education Perspectives, 36(5), 281–291. https:// doi.org/10.5480/15-1655. Africa, L. (2017). Transition to practice programs: Effective solutions to achieving strategic staffing in today's healthcare systems. Nursing Economics, 35(4), 178–183. Ayers, C., Binder, B., Lyon, K., Montgomery, D., Koci, A., & Foster, W. (2015). The simulated hospital environment: A qualitative study applying space industry techniques. Journal of Professional Nursing, 18–25. Clark, C., & Springer, P. (2012). Nurse residents' first-hand accounts on transition to practice. Nursing Outlook, 60, E2–E8. Houston, C., Phillips, B., Jefferies, P., Todero, C., Rich, J., Knecht, P., & Lewis, M. (2018). The academic–practice gap: Strategies for an enduring problem. Nurse Forum, 53, 27–34. Jefferies, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing Education Perspectives, 36(5), 292–293. Kaihlanen, A., Haavisto, E., Strandell-Laine, C., & Salminen, L. (2017). Facilitating the transition from a nursing student to a Registered Nurse in the fnal clinical practicum: A scoping literature review. Scandinavian Journal of Caring Science, 32(2), 466–477. https://doi.org/10.1111/scs.12494. Kavanagh, J., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nursing Education Perspectives, 38(2), 57–62. Livesay, K., Lawrence, K., & Miller, C. (2015). Making the most of simulated learning: Understanding and managing perceptions. International Journal of Nursing Education Scholarship, 12(1), 17–26. Missen, K., McKenna, L., & Beauchamp, A. (2016). Registered nurses' perceptions of new nursing graduates' clinical competence: A systematic integrative review. Nursing Health Science(2), 143–153.
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