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Exploration Into How Simulation Can Effect New Graduate Transition
Clinical Simulation in Nursing (2017) 13, 465-470
www.elsevier.com/locate/ecsn
Featured Article
Exploration Into How Simulation Can Effect New Graduate Transition Christine M. Thomas, PhD, RN, CHSE*, Megan A. Mraz, PhD, RN Department of Nursing, West Chester University, Exton, PA 19341, USA KEYWORDS transition into practice; simulation; reflection; critiquing; debriefing; independent practice
Abstract Background: Transition into the professional role can be difficult for new graduate nurses. The level of responsibility changes immediately on licensure. Simulation experiences may assist with this transition. Method: A descriptive phenomenological methodology was used to explore how simulation affected practice of new graduate nurses. Result: Six themes emerged: confidence, communication, critiquing, theory to practice integration, seeing the big picture of patient care, and responsibility for independent practice. Conclusion: Although transition into the profession is influenced by many factors, simulation experiences that support student confidence, communication skills, reflection, and decision making can help new graduate transition into the professional role and its responsibilities. Cite this article: Thomas, C. M., & Mraz, M. A. (2017, October). Exploration into how simulation can effect new graduate transition. Clinical Simulation in Nursing, 13(10), 465-470. http://dx.doi.org/10.1016/ j.ecns.2017.05.013. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
When taking on the professional role of nurse, new graduate nurses experience transition shock (Duchscher, 2009). Preparing nursing students for the transition from learner to professional has been a difficult endeavor for schools of nursing. Constraints placed on student experiences by safety concerns, faculty-to-student ratio, and clinical placements limit the type and level of experiences, responsibility, and accountability students are given. The complexity of nursing skill and decision making continues to escalate and requires both autonomy and
interprofessional talents to deliver holistic, safe care. New graduate nurses are challenged by delegation, prioritization, management of patient care, independent decision making, collaboration with other disciplines, and giving and receiving feedback for improved practice (Benner, Tanner, & Chesla, 2009b; Kramer, 1974). Simulationbased education (SBE) during academic courses may be one way to bridge undergraduate education challenges and growing expectations for new graduate nurses.
Literature Review This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author: [email protected] (C. M. Thomas).
Transition shock is the negative experience of suddenly shifting from the known student role to the less familiar role
1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.05.013
New Graduate Transition
466
of professional nurse. The shock of this role transition for the new graduate is the difference between the relationships, roles, responsibilities, knowledge, and performance expectations of the previous academic environment to those now required in the professional practice setting (Duchscher, 2009). This transition can be abrupt, overwhelming, and Key Points filled with mixed emotions Transition into pracfor new graduate nurses. tice is difficult for Duchscher (2009) found that new graduate RNs, transition shock affected and simulation expenew graduates physically, riences may help. emotionally, sociodevelop New graduates used mentally, and intellectually. simulation experiences The National Council of to assist with transition State Boards of Nursing into the professional study helped to highlight role and continued to the value of SBE for students implement debriefing as they transition into the for continued growth. professional practice role. Further research is The study compared three needed on how simucohorts from a national pool lation can fill the of students during school and gaps left from school six months after graduation clinical experiences (Hayden, Smiley, Alexander, to help prepare stuKardong-Edgren, & Jeffries, dents for professional 2014). The three comparison practice. cohorts had 10% or less, 25%, and 50% of clinical experiences replaced with SBE. No significant differences were noted between groups in overall clinical competency and readiness for practice. However, statistically significant differences in submeasures of clinical knowledge and critical thinking based on preceptor/manager ratings and self-reported feelings of readiness for practice of new graduates were identified. Six-week postgraduation ratings of clinical knowledge for groups who had 25% and 50% simulation were rated significantly higher (p ¼ .017) in the area of clinical knowledge than the control group (10% or less simulation). Critical thinking ratings for the 25% group at six weeks were also significantly higher (p ¼ .037). All new graduates in the three comparison groups did not feel prepared for practice and rated their clinical knowledge low after graduation. However, findings related to the Global Assessment of Readiness for Practice for the 50% simulation group reported higher levels of feeling prepared for practice compared with their study peers (p ¼ .033) six months after graduation (Hayden et al., 2014). Kumaran and Carney (2014) identified that new graduates experience feelings of stress, fear, and lack of organization. Participants felt ignored and invisible as students then surprised at the sudden change in attitude toward them from other health care providers (HCPs) (physicians, respiratory therapist, social workers, etc.). McCallaGraham and De Gagne (2015) found that new graduates
believed school provided basic knowledge of care but did not prepare them to function effectively in the acute care environment. Participants suggested that including worstcase scenarios as part of their clinical experience in school would have helped them acquire the needed knowledge and skills to function effectively and safely in the practice setting. High-fidelity SBE could fill gaps in skills related to interprofessional collaboration, responsibility, and support that may be limited during school clinical experiences. SBE can supplement clinical experiences to provide encounters that new graduates can draw on as they transition into the professional role of RN. In a review of simulation literature, Weaver (2011) noted that high-fidelity SBE benefits nursing students in terms of knowledge, value, and realism. However, the author identified a need for studies that investigate the transfer of knowledge from SBE during school as students transition into the role of professional nurse.
Purpose The purpose of this study was to discover what aspects of high-fidelity SBE supported undergraduate alumni as they transitioned into the practice role of nursing. The research questions included (a) how did the simulation course/ method affect practice as a new graduate and (b) how did simulation affect growth as a new nurse?
Method A descriptive phenomenological approach was used for this study to explore what aspects of SBE affected practice as a new graduate nurse. University institutional review board approval was obtained. Informed consent that included the study purpose, procedure, risks, and benefits was acquired from each participant. A descriptive phenomenology method, as outlined by Colaizzi (1978), was used to investigate the structures of consciousness in the lived experience of new graduates who used SBE as a learning method during nursing school. By describing the everyday lived experience, one can capture its meaning by identifying essential themes. The phenomenological framework is founded on the assumption that individuals assign meaning to their world through conscious reflection on situations and events (Creswell, 2012). A seven-step phenomenological approach, as outlined by Colaizzi (1978), was used to analyze the study data by the one researcher. The steps included the following: (a) reading each participant’s accounts several times to achieve an understanding of their descriptions and lived experiences; (b) each individual transcript was then reread and phrases that directly relate to how SBE could affect transition into the role of RN were identified; (c) the researcher carefully considered participant statements and identified
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meanings relevant to new graduate transition into practice and bracketed presuppositions to remain close to the phenomenon as experienced by participants; (d) these steps were repeated for each transcript, and clusters of themes that were common across all accounts were aggregated; (e) an exhaustive description was developed incorporating all the themes that emerged; (f) six themes were identified that condensed the exhaustive description to short, dense statements that captured aspects essential to the structure of the experience; (g) transcripts and themes were audited by a researcher experienced in qualitative methods; and (h) participants were contacted by e-mail for member check of themes for validity and authenticity.
Sample and Setting A purposeful sample was drawn from alumni of a BSN program. For inclusion, participants had to be baccalaureate alumni nurses, currently practicing as an RN, and have completed at least one of the program’s two SBE electives during school. The SBE electives use high-fidelity simulation and debriefing as the primary learning methods once a week for three hours. Debriefing with good judgment was the primary debriefing method used (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007). Students in the course are rotated through simulation cases weekly in small groups. Rotations had students performing the role of RN in simulation cases at least three times during the semester and participating in debriefing at least ten weeks of a 15-week semester, during their third or fourth year of the program. Sixteen alumni agreed to meet for an interview. Two alumni were not yet working as RNs and were excluded. Therefore, the final sample was 14. Eight-six percent were female, and ages ranged from 21 to 35 with mean of 24 years old. Of the 14 participants, 3 completed the second degree accelerated BSN program and 11 completed the traditional four-year BSN program. Five participants completed both elective courses, whereas nine completed one. Participants reported working as RNs from 6 months to 3 years, with 57% working for 6 months. The majority (57%, n ¼ 8) worked in medicalesurgical units, three in intensive care unit/step-down units, one in a maternity unit, and one in a long-term care facility.
Data Collection During participant interviews, the researcher guided discussions with the following statements: ‘‘Describe how simulation affected your practice as a new graduate nurse’’; ‘‘Tell me about how simulation affected your thinking as a new graduate nurse’’; ‘‘Describe how simulation affected your growth as a new nurse’’; ‘‘Describe what simulation scenarios were of most value as you began your practice career’’; and ‘‘Tell me how debriefing as a learning method affected your thinking/problems solving as a new graduate
nurse.’’ Participants were interviewed over a six-month period. Each interview was digitally recorded and lasted about 35 to 55 minutes. Digital recordings were transcribed verbatim for analysis of themes.
Data Analysis Interview transcripts were stripped of participant identifiers and loaded into Dedoose qualitative analysis software. The researcher interpreted themes from the narratives that provided answers to the research questions related to the lived experience of participants. During immersion, the data findings were compared and contrasted, lending credence and adding depth to themes developed from the data analysis process (Miles, Huberman, & Saldana, 2014). Dedoose software helped to display and organize patterns and connections between participant narratives. After data analysis, participants were contacted by e-mail for member check of themes for authenticity. Three participants responded and confirmed the results described their ideas and experiences.
Findings Six themes emerged: confidence, communication with patient and coworkers, critiquing, theory to practice integration/clinical problem solving, seeing the big picture of patient care, and responsibility for independent practice. Four subcategories emerged in the critiquing theme: comfort in, value in, confidence in, and need for critiquing.
Confidence Participants identified that SBE supported confidence in psychomotor skill acquisition, demystified procedures, and provided knowledge in how to care for patients during periods of crisis or patient deterioration. SBE diminished fear during critical patient encounters as new RNs and increased confidence in their ability to function effectively and independently during periods of patient crisis. As was stated by Interviewee 12, ‘‘Even those little things, even though it’s a mannequin, for me it was very real. I knew it was on camera and I felt like that carried over very easily to when I was on my own as a nurse. I was not as nervous with the family sitting there or the crazy family like the situations we did here, and then when the worst happeneddthe codedI felt calm even though I’m inside panicking a little. But I do not know, I felt like without this class, not that I could not have been a nurse, but I think a lot of situations would have been a lot more difficult for me.’’ This quotation demonstrates that SBE provided clinical experiences that supported confidence to take action and intervene. The combination of scenario performance and
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debriefing helped to demystify the implementation of psychomotor procedures and decision making during care. SBE diminished fear of actively intervening during patient care as they transitioned into the professional role.
Communication with Patient and Coworkers Participants discussed how communication with patients and health teaching were supported through SBE. SBE provided students with opportunities and the responsibility to identify patient needs and call HCPs for further orders. This is not a permitted practice for nursing students in clinical settings. Communication with HCPs during SBE helped students in organizing reports and providing recommendations to others during patient crisis situations. As stated by Interviewee 12: ‘‘Going back to calling the doctor with all your vitals and any pertinent information you have, and just the skill of calling the doctor is an art in itself coming out of school. Having the ability to acknowledge, okay, we both have the chart, can you pull that up while I pull this up ..’’ Compared with clinical courses, simulation faculty have more control over what students are exposed to during SBE. Students have similar responsibilities to professional RNs during clinical experiences but lack the authority to fulfill all RN responsibilities as a student. This can include patient crisis situations or communicating with other HCPs.
Critiquing Four subcategories emerged in the critiquing theme: comfort in, need for, value in, and confidence in. Participants identified that they found value in critiquing, giving and receiving feedback, use of debriefing in practice, and investigation of mistakes. They identified that they continued to critique formally with others or informally themselves for the purpose of improving their care and patient outcomes. Participants valued other perspectives during debriefing and used it for improved problem solving and practice. They gained comfort in the process of group reflection and continued to seek out peer perspectives after a patient crisis. Participants noted a desire to overcome fear of self-critique through reflection and growing confidence in critiquing their performance for improvement and better patient outcomes. As stated by Interviewee 10, ‘‘After shift, if I have an experience or something to report I always ask for feedback. I always say like if there’s anything you’ve seen that I’ve missed prior, just let me know, anything that I can improve on, just because that was important. If you go into sim you think like oh, I did a great job. She’s gonna have nothing to say about me. It’s not what nursing is. . I feel like it helped, just with thinking of other questions that my classmates were asking, like sometimes people would say something and I have to say like oh, that’s a pretty good question and then I’d be intrigued with what the answer
was.’’ Interviewee five added, ‘‘It helped me to learn to take criticism better I would say. Obviously it was all constructive criticism, but at the same time I think as a person in general it’s hard to hear that sometimes .. So yeah definitely, it helped me like I said hear and accept more constructive criticism from my peers.’’ Interviewee six affirmed, ‘‘I really liked doing that (debrief). I precept people now with the newer people. We always debrief every little scenario. I’ve applied that as well. What could you have done differently? I think that reflection is how you improve practice.’’
Theory to Practice Application Participants identified that simulation scenarios and debriefing conferences assisted their ability to relate theory to practice, problem solve, and critically think through issues. Participants felt that these activities enhanced their transition into professional practice and growth. Participants actively sought out evidence to support decision making and actions. As stated by Interviewee 12, ‘‘So that was something we all pointed out (during debriefing), like you need to secure (the NGT) before you can walk away from the bed because it’s going to come right back out. Then you want to listen to the lungs, you want to make sure you do not hear anything funny there before you get the X-ray, but that’s the only way to confirm it. .. But that was something here that we had stressed, that you always get the X-ray first. Evidence best practice is the X-ray and not listening because it could not be in the right spot.’’ Interviewee 10 added, ‘‘I think psychologically it helps to talk through . how they felt, what they felt, what they learned, or what they felt they could improve upon. You know make them think through, kind of connect the dots I think, psychologically figure out what you should do next time.’’ Participants valued previous and current debriefing methods that supported reflective practice toward improved patient care. Other professional perspectives were sought out and valued in this problem solving process for them. As they transitioned into the professional role, participants sought out clinical experts and/or scientific evidence to inform and support patient care.
Big Picture of Patient Care Simulation cases and debriefing conferences assisted students to see the big picture of patient care and how multiple components (lab values, diagnostic testing, medications, family issues, and knowledge deficits) impacted care. Participants identified that SBE assisted them to investigate multiple aspects of patient conditions to make informed decisions and judgments. Interviewee one asserted, ‘‘You learn to not just walk in, go right to the patient and start talking. You know you look around the room, make sure
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nothing is out of place or where it should be, and just kind of help you get a bigger picture of what’s going on exactly, what’s not right, what should be happening that’s not happening, you know, always checking the oxygen level and making sure that’s where it should be . it got students out of that one-track mind you know of just being very task oriented. It’s kind of your job is to look at the bigger picture, look at everything, and that kind of helped with that.’’ Simulation scenarios and debriefing assisted with reflection-in-action and reflection-on-action for deeper understanding of patient conditions, needs, and situations. This deeper understanding assists new graduates to pull together multiple aspects into a comprehensive ‘‘big picture’’ to problem solve for informed decisions and actions.
Responsibility for Independent Practice In clinical courses, students were required to report and discuss care with faculty before providing care. This process assisted to confirm assumptions and safe guard patients. However during SBE, students were responsible to provide care without this supervision thus requiring that they independently prioritize and intervene without input from faculty during the patient encounter. Participants believed this process assisted in their transition into practice as they intervened with less hesitation and took responsibility for making decisions. This difference between clinical and SBE was highly valued by participants and they identified how this had a positive impact on their transition. As stated by Interviewee 8, ‘‘I think it definitely helped just putting most of the things together. I think you see more of the whole picture in the simulation than in clinical, because you are the one that’s actually looking at meds and calling the doctor, and then doing an intervention. Then looking at the symptoms and seeing if the intervention works. I think that’s more so, you can do it in a simulation than in clinical.’’ Interviewee two also stated, ‘‘You’re like all right, this is the real world. Somebody is not going to be like oh yeah I’m having trouble breathing and can you check my pulse ox. Like they do not necessarily clue you into that in the real world, so it was nice in a sense that we got to do it, like I said, in a low-risk environment.’’ Participants described how they felt more responsibility for patient care during SBE versus traditional clinical experiences. In clinical experiences, care was first discussed and/or cleared by clinical instructors and nurses. Where as in SBE, students were expected to make decisions and take action without input from instructors, which is more similar to current practice as an RN. They were able to practice reflection-in-action during SBE that could be used later during patient care (Schon, 1987). Participants described scenario performances as clinical experiences that they used to inform current and future patient care.
SBE as clinical experience may enhance a student’s transition from novice to advanced beginner to competent levels of professional practice (Benner et al., 2009a, 2009b).
Discussion This study explored how SBE impacted transition into the professional nursing role. The major implications of this study are that SBE in nursing school can positively impact student transition into practice. Although new graduate transition into the professional role is multifaceted, SBE that supports student confidence, communication skills, reflection, and decision making can help with this transition. This study supports findings of other studies that identified that SBE supports confidence in ability to provide patient care and critical thinking in management of patient priorities and organization (Thomas & Mackey, 2012; Weaver, 2011). Although traditional clinical experiences provide valuable learning for students, previous studies found clinical experiences many times do not provide students with opportunities in caring for patients in crisis, responsibility in decision making, and experience in interdisciplinary communication (Clark & Holmes, 2007; Li & Kenward, 2006; McCalla-Graham & De Gagne, 2015). The use of SBE can fill this gap. Faculty review of curricular outcomes and examination of learning experiences provided during traditional clinical courses in their program will assist in outlining what experiences are needed at individual nursing programs. Simulation scenarios that include learning objectives that address identified gaps in student clinical experiences can be designed and provided. This will enhance ability to control and standardize student experiences. This study found that new graduates actively used and sought out debriefing to critique their performance and performance of other professionals for continued growth. This finding has not been outlined in the literature regarding new graduates. Although hospitals and other health care agencies are increasing their use of simulation for staff education, little is known about experienced nurses’ attitudes about debriefing in nonacademic settings. Debriefing can be impacted by lack of experience on the part of participants and facilitators, which can lead to dysfunctional interplay, embarrassment, and anxiety (Dieckmann, Friis, Lippert, & Ostergaard, 2012). Peer feedback is not well received in an atmosphere of blame or punishment. As more new graduates and experienced nurses become experienced with debriefing and comfortable with self/peer critique in a supportive environment, it has the potential to improve patient care. More study in this area is needed. The responsibility for making decisions and implementing interventions independently is often not encouraged or
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safe for nursing students to do. During clinical experiences, students are expected to discuss their assessments and plans with instructors or preceptors before implementation. For new graduates, this safety net is no longer easily accessible. However, during SBE, students are expected to perform as the nurse during the scenario, not the nursing student. This practice in the role of nurse during SBE where they use reflection-in-action as a patient encounter unfolds can assist new graduates as they make the transition into the professional role (Schon, 1987).
Limitations This study used a convenience sample and was conducted in one academic institution. Although results of this qualitative study may not be generalized to the population of new graduate nurses, findings outline how SBE can positively impact new graduate nurse transition. Although the participants were alumni of the nursing program, the interviewer was the instructor for the SBE elective course, which may have influenced participants’ responses.
Conclusion Study results contribute to increasing the knowledge about how SBE impacts students as they grow into independent practitioners. Benner, Sutphen, Leanard, Day, and Shulman (2009a) noted that nurses are undereducated for current practice demands and called for radical transformation of nursing education. They recommended health care agencies provide one-year residency programs to provide further clinical experience for new graduates. However, these programs are expensive, and, to date, there are a limited number of residency programs for this purpose. SBE may be one way to fill this gap of knowledge and experience. Further research is needed to investigate the impact of SBE on student transition into the real world of nursing. As academic simulation programs continue to grow, new graduates will be familiar and comfortable with the method. This could enhance how new graduates assess, react in crisis situations, think through problems, communicate with professional peers, implement interventions, and
critique their own performance, as well as, those of other HCPs.
References Benner, P., Sutphen, M., Leonard, V., Day, L., & Shulman, L. S. (2009a). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Benner, P., Tanner, C., & Chesla, C. (2009b). Expertise in nursing practice: Caring, clinical judgment, and ethics (2nd ed.). New York, NY: Springer. Clark, T., & Holmes, S. (2007). Fit for practice? An exploration of the development of newly qualified nurses using focus groups. International Journal of Nursing Studies, 44(7), 1210-1220. Colaizzi, P. F. (1978). Psychological research as the phenomenologist views. In Valle, R., & King, M. (Eds.), Existential-phenomenological alternatives for psychology. New York, NY: Oxford University Press. (pp. 48-71). Creswell, J. W. (2012). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Washington, DC: Sage. Dieckmann, P., Friis, S. M., Lippert, A., & Ostergaard, D. (2012). Goals, success factors, and barriers for simulation-based learning: A qualitative interview study in health care. Simulation & Gaming, 43(5), 627-647. Duchscher, J. E. (2009). Transition shock: The initial stage of role adaptation for newly graduated Registered Nurses. Journal of Advanced Nursing, 65(5), 1103-1113. http://dx.doi.org/10.1111/j.1365-2648.2008.04898.n. Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN national simulation study: A longitudinal, randomized controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S1-S64. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: Mosby. Kumaran, S., & Carney, M. (2014). Role transition from student nurse to staff nurse: Facilitating the transition period. Nurse Education in Practice, 14(6), 605-611. Li, S., & Kenward, K. (2006). A national survey of nursing education and practice of newly licensed nurses. JONA’s Healthcare Law, Ethics, and Regulation, 8(4), 110-115. McCalla-Graham, J. A., & De Gagne, J. C. (2015). The lived experience of new graduate nurses working in an acute care setting. Journal of Continuing Education in Nursing, 46(3), 122-128. http: //dx.doi.org/10.3928/00220124-20150220-17. Miles, M. B., Huberman, A. M., & Saldana, J. (2014). Qualitative data analysis: A methods sourcebook (3rd ed.). Los Angeles, CA: Sage. Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: Combining rigorous feedback with genuine inquiry. Anesthesiology Clinics, 25(2), 361-376. Schon, D. A. (1987). Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco, CA: Jossey-Bass. Thomas, C., & Mackey, E. (2012). Impact of a clinical simulation elective on BSN student clinical confidence. Journal of Nursing Education, 51(4), 236-239. Weaver, A. (2011). High-fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives, 32(1), 37-40.
pp 465-470 Clinical Simulation in Nursing Volume 13 Issue 10
www.elsevier.com/locate/ecsn
Featured Article
Exploration Into How Simulation Can Effect New Graduate Transition Christine M. Thomas, PhD, RN, CHSE*, Megan A. Mraz, PhD, RN Department of Nursing, West Chester University, Exton, PA 19341, USA KEYWORDS transition into practice; simulation; reflection; critiquing; debriefing; independent practice
Abstract Background: Transition into the professional role can be difficult for new graduate nurses. The level of responsibility changes immediately on licensure. Simulation experiences may assist with this transition. Method: A descriptive phenomenological methodology was used to explore how simulation affected practice of new graduate nurses. Result: Six themes emerged: confidence, communication, critiquing, theory to practice integration, seeing the big picture of patient care, and responsibility for independent practice. Conclusion: Although transition into the profession is influenced by many factors, simulation experiences that support student confidence, communication skills, reflection, and decision making can help new graduate transition into the professional role and its responsibilities. Cite this article: Thomas, C. M., & Mraz, M. A. (2017, October). Exploration into how simulation can effect new graduate transition. Clinical Simulation in Nursing, 13(10), 465-470. http://dx.doi.org/10.1016/ j.ecns.2017.05.013. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
When taking on the professional role of nurse, new graduate nurses experience transition shock (Duchscher, 2009). Preparing nursing students for the transition from learner to professional has been a difficult endeavor for schools of nursing. Constraints placed on student experiences by safety concerns, faculty-to-student ratio, and clinical placements limit the type and level of experiences, responsibility, and accountability students are given. The complexity of nursing skill and decision making continues to escalate and requires both autonomy and
interprofessional talents to deliver holistic, safe care. New graduate nurses are challenged by delegation, prioritization, management of patient care, independent decision making, collaboration with other disciplines, and giving and receiving feedback for improved practice (Benner, Tanner, & Chesla, 2009b; Kramer, 1974). Simulationbased education (SBE) during academic courses may be one way to bridge undergraduate education challenges and growing expectations for new graduate nurses.
Literature Review This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author: [email protected] (C. M. Thomas).
Transition shock is the negative experience of suddenly shifting from the known student role to the less familiar role
1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.05.013
New Graduate Transition
466
of professional nurse. The shock of this role transition for the new graduate is the difference between the relationships, roles, responsibilities, knowledge, and performance expectations of the previous academic environment to those now required in the professional practice setting (Duchscher, 2009). This transition can be abrupt, overwhelming, and Key Points filled with mixed emotions Transition into pracfor new graduate nurses. tice is difficult for Duchscher (2009) found that new graduate RNs, transition shock affected and simulation expenew graduates physically, riences may help. emotionally, sociodevelop New graduates used mentally, and intellectually. simulation experiences The National Council of to assist with transition State Boards of Nursing into the professional study helped to highlight role and continued to the value of SBE for students implement debriefing as they transition into the for continued growth. professional practice role. Further research is The study compared three needed on how simucohorts from a national pool lation can fill the of students during school and gaps left from school six months after graduation clinical experiences (Hayden, Smiley, Alexander, to help prepare stuKardong-Edgren, & Jeffries, dents for professional 2014). The three comparison practice. cohorts had 10% or less, 25%, and 50% of clinical experiences replaced with SBE. No significant differences were noted between groups in overall clinical competency and readiness for practice. However, statistically significant differences in submeasures of clinical knowledge and critical thinking based on preceptor/manager ratings and self-reported feelings of readiness for practice of new graduates were identified. Six-week postgraduation ratings of clinical knowledge for groups who had 25% and 50% simulation were rated significantly higher (p ¼ .017) in the area of clinical knowledge than the control group (10% or less simulation). Critical thinking ratings for the 25% group at six weeks were also significantly higher (p ¼ .037). All new graduates in the three comparison groups did not feel prepared for practice and rated their clinical knowledge low after graduation. However, findings related to the Global Assessment of Readiness for Practice for the 50% simulation group reported higher levels of feeling prepared for practice compared with their study peers (p ¼ .033) six months after graduation (Hayden et al., 2014). Kumaran and Carney (2014) identified that new graduates experience feelings of stress, fear, and lack of organization. Participants felt ignored and invisible as students then surprised at the sudden change in attitude toward them from other health care providers (HCPs) (physicians, respiratory therapist, social workers, etc.). McCallaGraham and De Gagne (2015) found that new graduates
believed school provided basic knowledge of care but did not prepare them to function effectively in the acute care environment. Participants suggested that including worstcase scenarios as part of their clinical experience in school would have helped them acquire the needed knowledge and skills to function effectively and safely in the practice setting. High-fidelity SBE could fill gaps in skills related to interprofessional collaboration, responsibility, and support that may be limited during school clinical experiences. SBE can supplement clinical experiences to provide encounters that new graduates can draw on as they transition into the professional role of RN. In a review of simulation literature, Weaver (2011) noted that high-fidelity SBE benefits nursing students in terms of knowledge, value, and realism. However, the author identified a need for studies that investigate the transfer of knowledge from SBE during school as students transition into the role of professional nurse.
Purpose The purpose of this study was to discover what aspects of high-fidelity SBE supported undergraduate alumni as they transitioned into the practice role of nursing. The research questions included (a) how did the simulation course/ method affect practice as a new graduate and (b) how did simulation affect growth as a new nurse?
Method A descriptive phenomenological approach was used for this study to explore what aspects of SBE affected practice as a new graduate nurse. University institutional review board approval was obtained. Informed consent that included the study purpose, procedure, risks, and benefits was acquired from each participant. A descriptive phenomenology method, as outlined by Colaizzi (1978), was used to investigate the structures of consciousness in the lived experience of new graduates who used SBE as a learning method during nursing school. By describing the everyday lived experience, one can capture its meaning by identifying essential themes. The phenomenological framework is founded on the assumption that individuals assign meaning to their world through conscious reflection on situations and events (Creswell, 2012). A seven-step phenomenological approach, as outlined by Colaizzi (1978), was used to analyze the study data by the one researcher. The steps included the following: (a) reading each participant’s accounts several times to achieve an understanding of their descriptions and lived experiences; (b) each individual transcript was then reread and phrases that directly relate to how SBE could affect transition into the role of RN were identified; (c) the researcher carefully considered participant statements and identified
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meanings relevant to new graduate transition into practice and bracketed presuppositions to remain close to the phenomenon as experienced by participants; (d) these steps were repeated for each transcript, and clusters of themes that were common across all accounts were aggregated; (e) an exhaustive description was developed incorporating all the themes that emerged; (f) six themes were identified that condensed the exhaustive description to short, dense statements that captured aspects essential to the structure of the experience; (g) transcripts and themes were audited by a researcher experienced in qualitative methods; and (h) participants were contacted by e-mail for member check of themes for validity and authenticity.
Sample and Setting A purposeful sample was drawn from alumni of a BSN program. For inclusion, participants had to be baccalaureate alumni nurses, currently practicing as an RN, and have completed at least one of the program’s two SBE electives during school. The SBE electives use high-fidelity simulation and debriefing as the primary learning methods once a week for three hours. Debriefing with good judgment was the primary debriefing method used (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007). Students in the course are rotated through simulation cases weekly in small groups. Rotations had students performing the role of RN in simulation cases at least three times during the semester and participating in debriefing at least ten weeks of a 15-week semester, during their third or fourth year of the program. Sixteen alumni agreed to meet for an interview. Two alumni were not yet working as RNs and were excluded. Therefore, the final sample was 14. Eight-six percent were female, and ages ranged from 21 to 35 with mean of 24 years old. Of the 14 participants, 3 completed the second degree accelerated BSN program and 11 completed the traditional four-year BSN program. Five participants completed both elective courses, whereas nine completed one. Participants reported working as RNs from 6 months to 3 years, with 57% working for 6 months. The majority (57%, n ¼ 8) worked in medicalesurgical units, three in intensive care unit/step-down units, one in a maternity unit, and one in a long-term care facility.
Data Collection During participant interviews, the researcher guided discussions with the following statements: ‘‘Describe how simulation affected your practice as a new graduate nurse’’; ‘‘Tell me about how simulation affected your thinking as a new graduate nurse’’; ‘‘Describe how simulation affected your growth as a new nurse’’; ‘‘Describe what simulation scenarios were of most value as you began your practice career’’; and ‘‘Tell me how debriefing as a learning method affected your thinking/problems solving as a new graduate
nurse.’’ Participants were interviewed over a six-month period. Each interview was digitally recorded and lasted about 35 to 55 minutes. Digital recordings were transcribed verbatim for analysis of themes.
Data Analysis Interview transcripts were stripped of participant identifiers and loaded into Dedoose qualitative analysis software. The researcher interpreted themes from the narratives that provided answers to the research questions related to the lived experience of participants. During immersion, the data findings were compared and contrasted, lending credence and adding depth to themes developed from the data analysis process (Miles, Huberman, & Saldana, 2014). Dedoose software helped to display and organize patterns and connections between participant narratives. After data analysis, participants were contacted by e-mail for member check of themes for authenticity. Three participants responded and confirmed the results described their ideas and experiences.
Findings Six themes emerged: confidence, communication with patient and coworkers, critiquing, theory to practice integration/clinical problem solving, seeing the big picture of patient care, and responsibility for independent practice. Four subcategories emerged in the critiquing theme: comfort in, value in, confidence in, and need for critiquing.
Confidence Participants identified that SBE supported confidence in psychomotor skill acquisition, demystified procedures, and provided knowledge in how to care for patients during periods of crisis or patient deterioration. SBE diminished fear during critical patient encounters as new RNs and increased confidence in their ability to function effectively and independently during periods of patient crisis. As was stated by Interviewee 12, ‘‘Even those little things, even though it’s a mannequin, for me it was very real. I knew it was on camera and I felt like that carried over very easily to when I was on my own as a nurse. I was not as nervous with the family sitting there or the crazy family like the situations we did here, and then when the worst happeneddthe codedI felt calm even though I’m inside panicking a little. But I do not know, I felt like without this class, not that I could not have been a nurse, but I think a lot of situations would have been a lot more difficult for me.’’ This quotation demonstrates that SBE provided clinical experiences that supported confidence to take action and intervene. The combination of scenario performance and
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debriefing helped to demystify the implementation of psychomotor procedures and decision making during care. SBE diminished fear of actively intervening during patient care as they transitioned into the professional role.
Communication with Patient and Coworkers Participants discussed how communication with patients and health teaching were supported through SBE. SBE provided students with opportunities and the responsibility to identify patient needs and call HCPs for further orders. This is not a permitted practice for nursing students in clinical settings. Communication with HCPs during SBE helped students in organizing reports and providing recommendations to others during patient crisis situations. As stated by Interviewee 12: ‘‘Going back to calling the doctor with all your vitals and any pertinent information you have, and just the skill of calling the doctor is an art in itself coming out of school. Having the ability to acknowledge, okay, we both have the chart, can you pull that up while I pull this up ..’’ Compared with clinical courses, simulation faculty have more control over what students are exposed to during SBE. Students have similar responsibilities to professional RNs during clinical experiences but lack the authority to fulfill all RN responsibilities as a student. This can include patient crisis situations or communicating with other HCPs.
Critiquing Four subcategories emerged in the critiquing theme: comfort in, need for, value in, and confidence in. Participants identified that they found value in critiquing, giving and receiving feedback, use of debriefing in practice, and investigation of mistakes. They identified that they continued to critique formally with others or informally themselves for the purpose of improving their care and patient outcomes. Participants valued other perspectives during debriefing and used it for improved problem solving and practice. They gained comfort in the process of group reflection and continued to seek out peer perspectives after a patient crisis. Participants noted a desire to overcome fear of self-critique through reflection and growing confidence in critiquing their performance for improvement and better patient outcomes. As stated by Interviewee 10, ‘‘After shift, if I have an experience or something to report I always ask for feedback. I always say like if there’s anything you’ve seen that I’ve missed prior, just let me know, anything that I can improve on, just because that was important. If you go into sim you think like oh, I did a great job. She’s gonna have nothing to say about me. It’s not what nursing is. . I feel like it helped, just with thinking of other questions that my classmates were asking, like sometimes people would say something and I have to say like oh, that’s a pretty good question and then I’d be intrigued with what the answer
was.’’ Interviewee five added, ‘‘It helped me to learn to take criticism better I would say. Obviously it was all constructive criticism, but at the same time I think as a person in general it’s hard to hear that sometimes .. So yeah definitely, it helped me like I said hear and accept more constructive criticism from my peers.’’ Interviewee six affirmed, ‘‘I really liked doing that (debrief). I precept people now with the newer people. We always debrief every little scenario. I’ve applied that as well. What could you have done differently? I think that reflection is how you improve practice.’’
Theory to Practice Application Participants identified that simulation scenarios and debriefing conferences assisted their ability to relate theory to practice, problem solve, and critically think through issues. Participants felt that these activities enhanced their transition into professional practice and growth. Participants actively sought out evidence to support decision making and actions. As stated by Interviewee 12, ‘‘So that was something we all pointed out (during debriefing), like you need to secure (the NGT) before you can walk away from the bed because it’s going to come right back out. Then you want to listen to the lungs, you want to make sure you do not hear anything funny there before you get the X-ray, but that’s the only way to confirm it. .. But that was something here that we had stressed, that you always get the X-ray first. Evidence best practice is the X-ray and not listening because it could not be in the right spot.’’ Interviewee 10 added, ‘‘I think psychologically it helps to talk through . how they felt, what they felt, what they learned, or what they felt they could improve upon. You know make them think through, kind of connect the dots I think, psychologically figure out what you should do next time.’’ Participants valued previous and current debriefing methods that supported reflective practice toward improved patient care. Other professional perspectives were sought out and valued in this problem solving process for them. As they transitioned into the professional role, participants sought out clinical experts and/or scientific evidence to inform and support patient care.
Big Picture of Patient Care Simulation cases and debriefing conferences assisted students to see the big picture of patient care and how multiple components (lab values, diagnostic testing, medications, family issues, and knowledge deficits) impacted care. Participants identified that SBE assisted them to investigate multiple aspects of patient conditions to make informed decisions and judgments. Interviewee one asserted, ‘‘You learn to not just walk in, go right to the patient and start talking. You know you look around the room, make sure
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nothing is out of place or where it should be, and just kind of help you get a bigger picture of what’s going on exactly, what’s not right, what should be happening that’s not happening, you know, always checking the oxygen level and making sure that’s where it should be . it got students out of that one-track mind you know of just being very task oriented. It’s kind of your job is to look at the bigger picture, look at everything, and that kind of helped with that.’’ Simulation scenarios and debriefing assisted with reflection-in-action and reflection-on-action for deeper understanding of patient conditions, needs, and situations. This deeper understanding assists new graduates to pull together multiple aspects into a comprehensive ‘‘big picture’’ to problem solve for informed decisions and actions.
Responsibility for Independent Practice In clinical courses, students were required to report and discuss care with faculty before providing care. This process assisted to confirm assumptions and safe guard patients. However during SBE, students were responsible to provide care without this supervision thus requiring that they independently prioritize and intervene without input from faculty during the patient encounter. Participants believed this process assisted in their transition into practice as they intervened with less hesitation and took responsibility for making decisions. This difference between clinical and SBE was highly valued by participants and they identified how this had a positive impact on their transition. As stated by Interviewee 8, ‘‘I think it definitely helped just putting most of the things together. I think you see more of the whole picture in the simulation than in clinical, because you are the one that’s actually looking at meds and calling the doctor, and then doing an intervention. Then looking at the symptoms and seeing if the intervention works. I think that’s more so, you can do it in a simulation than in clinical.’’ Interviewee two also stated, ‘‘You’re like all right, this is the real world. Somebody is not going to be like oh yeah I’m having trouble breathing and can you check my pulse ox. Like they do not necessarily clue you into that in the real world, so it was nice in a sense that we got to do it, like I said, in a low-risk environment.’’ Participants described how they felt more responsibility for patient care during SBE versus traditional clinical experiences. In clinical experiences, care was first discussed and/or cleared by clinical instructors and nurses. Where as in SBE, students were expected to make decisions and take action without input from instructors, which is more similar to current practice as an RN. They were able to practice reflection-in-action during SBE that could be used later during patient care (Schon, 1987). Participants described scenario performances as clinical experiences that they used to inform current and future patient care.
SBE as clinical experience may enhance a student’s transition from novice to advanced beginner to competent levels of professional practice (Benner et al., 2009a, 2009b).
Discussion This study explored how SBE impacted transition into the professional nursing role. The major implications of this study are that SBE in nursing school can positively impact student transition into practice. Although new graduate transition into the professional role is multifaceted, SBE that supports student confidence, communication skills, reflection, and decision making can help with this transition. This study supports findings of other studies that identified that SBE supports confidence in ability to provide patient care and critical thinking in management of patient priorities and organization (Thomas & Mackey, 2012; Weaver, 2011). Although traditional clinical experiences provide valuable learning for students, previous studies found clinical experiences many times do not provide students with opportunities in caring for patients in crisis, responsibility in decision making, and experience in interdisciplinary communication (Clark & Holmes, 2007; Li & Kenward, 2006; McCalla-Graham & De Gagne, 2015). The use of SBE can fill this gap. Faculty review of curricular outcomes and examination of learning experiences provided during traditional clinical courses in their program will assist in outlining what experiences are needed at individual nursing programs. Simulation scenarios that include learning objectives that address identified gaps in student clinical experiences can be designed and provided. This will enhance ability to control and standardize student experiences. This study found that new graduates actively used and sought out debriefing to critique their performance and performance of other professionals for continued growth. This finding has not been outlined in the literature regarding new graduates. Although hospitals and other health care agencies are increasing their use of simulation for staff education, little is known about experienced nurses’ attitudes about debriefing in nonacademic settings. Debriefing can be impacted by lack of experience on the part of participants and facilitators, which can lead to dysfunctional interplay, embarrassment, and anxiety (Dieckmann, Friis, Lippert, & Ostergaard, 2012). Peer feedback is not well received in an atmosphere of blame or punishment. As more new graduates and experienced nurses become experienced with debriefing and comfortable with self/peer critique in a supportive environment, it has the potential to improve patient care. More study in this area is needed. The responsibility for making decisions and implementing interventions independently is often not encouraged or
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safe for nursing students to do. During clinical experiences, students are expected to discuss their assessments and plans with instructors or preceptors before implementation. For new graduates, this safety net is no longer easily accessible. However, during SBE, students are expected to perform as the nurse during the scenario, not the nursing student. This practice in the role of nurse during SBE where they use reflection-in-action as a patient encounter unfolds can assist new graduates as they make the transition into the professional role (Schon, 1987).
Limitations This study used a convenience sample and was conducted in one academic institution. Although results of this qualitative study may not be generalized to the population of new graduate nurses, findings outline how SBE can positively impact new graduate nurse transition. Although the participants were alumni of the nursing program, the interviewer was the instructor for the SBE elective course, which may have influenced participants’ responses.
Conclusion Study results contribute to increasing the knowledge about how SBE impacts students as they grow into independent practitioners. Benner, Sutphen, Leanard, Day, and Shulman (2009a) noted that nurses are undereducated for current practice demands and called for radical transformation of nursing education. They recommended health care agencies provide one-year residency programs to provide further clinical experience for new graduates. However, these programs are expensive, and, to date, there are a limited number of residency programs for this purpose. SBE may be one way to fill this gap of knowledge and experience. Further research is needed to investigate the impact of SBE on student transition into the real world of nursing. As academic simulation programs continue to grow, new graduates will be familiar and comfortable with the method. This could enhance how new graduates assess, react in crisis situations, think through problems, communicate with professional peers, implement interventions, and
critique their own performance, as well as, those of other HCPs.
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