A collaborative approach to simulation development

Abstract

Background

Meeting employer expectations is a challenge for new nurse graduates and their nurse educators. Designing studies to collect specific data on hospital expectations and new nursing graduate deficiencies is needed.

Sample

Hospital-based educators and preceptors (n=13) participated in one of two focus groups, to identify problem areas. Senior nursing students (n=64) participated in simulations developed from data obtained in the sessions.

Methods

Audio-recorded focus groups were conducted with the goal to identify deficiencies in new graduate nurses. Recordings were transcribed and analysed using thematic analysis.

Results

Hospital employer expectation themes identified include attending to basic patient needs, organisational skills, anticipation of risks and consequences, higher order technical skills, communication and ownership/accountability. Two simulations for senior nursing students were developed to address identified deficiencies.

Conclusion

Developing meaningful simulations which address deficiencies prior to graduation, in collaboration with potential employers, has the potential to lower the cost of graduate nurse orientation, improve patient outcomes, provide a greater sense of readiness to the graduate nurse and ultimately meet the needs of both the student and employer.

Introduction

Faculty are challenged to prepare nursing graduates who meet the expectations of employers. Although many different teaching strategies are available, the best way to educate nursing students to meet these expectations remains unclear. Using simulation to address expectations of hospital-based employers is one way that allows faculty to observe student practice and provide guided learning in targeted debriefing sessions.

This research used a collaborative approach to develop simulations designed to assist students to better meet employer expectations. The focus groups comprising hospital system-level educators, unit-based educators and unit-based preceptors were used to explore and identify deficiencies observed in new graduate nurses. These roles will be collectively identified in this manuscript as professional nurse developers (PNDs). Those who participated in the focus groups were in a unique position to know what new nursing graduates lack on graduation as they play a significant role in on-boarding and orienting new graduates. Deficiencies identified in the focus groups were developed into themes and integrated into simulations as concepts and tasks for the simulation participant. The simulations were delivered during the final semester, as a way to better prepare the student for the professional role. Delivering simulation at this time is supported by recent research that found delivering simulation during the final year of nursing school can improve the experience of the student transitioning to nursing practice.¹

Background

Hospital employers and academics have shown a difference of opinion with regards to graduate nurse preparedness. While almost 80% of academic leaders believe their graduates are prepared for the professional world, only 10% of hospital nurse executives believe new graduate nurses are prepared to provide safe and effective care.² This research provides a historical perspective on this topic. Similarly, newly graduated nurses report a lack of preparedness for their job.³ Qualitative interviews with 16 nurses to explore factors that impact transition from student to nurse found inadequate preparation for transition as the main theme.⁴ Researchers studied 33 recent baccalaureate graduates and found only half reported learning advanced technical skills in their clinical rotations, while 91% reported that this is either important or very important for entry into practice.⁵ Only 56% of the sample reported developing organisational skills either some of the time or all of the time, but 82% believed that this is important for their transition into practice. Simulation is one option for facilitating application of skills in the clinical setting.⁵

In most nursing programmes, simulation topics result from perceived need, end of semester testing results and scores on state licensing exams. A group of researchers consulted alumni of their nursing programme who were current practising nurses to assist in simulation development for final semester students.¹ They recognised the importance of the academic–practice partnership to improve the experience of the new graduate nurse to transition from academia to practice. Similarly, this project engaged current PNDs from two acute care agencies to participate in focus groups to identify what they perceive as deficiencies in new graduate nurses.

Methods

A qualitative approach was used to understand what new graduate nurses lack on entry into the nursing workforce. It was determined that using focus groups to glean needed data was a fitting approach for this research. Focus groups typically involve 8–12 people, discuss a specific topic, with the use of a moderator who encourages interaction and keeps participants on topic, and lasts 1.5–2.5 hours.⁶ In this research, the moderator role was minimal, allowing the participants of the focus group to drive the conversation, with interjection from the moderator only when the conversation drifted off topic or when clarification was needed. Additionally, members of the focus groups prompted each other by commenting on thoughts and comments made during the conversation.⁷

After institutional review board approval, PNDs (n=13; 100% female) from two large metropolitan hospital systems, who have direct contact with new graduates, participated in one of two focus groups. Verbal consent was obtained and freely given from focus group participants as well as students who participated in the simulation that was developed. Ethical challenges related to this research were considered and addressed, including the relationship between the researchers and the students and the researchers and the focus group participants. While the researchers were also educators at the university, data collected were never about any one student specifically, but about graduates from the nursing programme in general. No student names were ever mentioned. The researchers maintained a professional relationship with the focus group participants throughout the research, never asking more of one participant than was asked of all. Data and participation remained confidential, and all participants in this research were free to withdraw from the study at any time, although no one did. The discussion within the focus group was directed at identifying deficiencies in nurse graduates, and though this conversation could have been uncomfortable due to its negative nature, because it was the expectation that discussions would be around this topic there did not seem to be any issue related to this.

Researchers used a semistructured interview guide to gather information on new nurse graduate deficits. The focus groups intentionally included representatives from both hospitals to foster a welcoming environment that promoted robust conversation. The goal of the focus group is to promote dialogue that is specific rather than vague and general and to foster an environment that is non-threatening.⁸ The environment was designed to be non-threatening by arranging the seats where everyone could see each other, there was a comfortable distance between participants, and the session was held at the college as opposed to a specific hospital. Audio recordings were transcribed and data were analysed using thematic analysis. Thematic analysis is a useful method to identify, analyse and organise themes.⁹ Saturation was met when no new information was gained and there was redundancy in the stories and comments made by participants.¹⁰ The transcripts of the focus groups and the identified themes were shared with focus group participants for further validation. Based on the themes, the researchers developed simulations for senior nursing students.

Using the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation^SM as the underpinning framework, the researchers constructed two simulations after a needs assessment which provided the foundation for the simulations.¹¹ Measurable objectives were developed and high-fidelity mannequins were used. Attempts to maintain physical fidelity included realistic clinical suite with actual clinical documents from clinical partners (glycaemic protocol). Careful attention to conceptual fidelity included matching vital signs with patient presentation, and expected lab values. Psychological fidelity was maintained by using the researchers as the patient’s voice throughout the simulations. In addition, the scenario included a disruption where the learner was asked to step out of the patient’s room to receive report on a new patient admission. The simulations were reviewed by a panel of senior nursing students (n=7) to garner consensus that the identified themes were addressed in the simulations. None of these students participated in the simulation. Feedback from these students was reviewed and slight modifications to the simulations were made. Expert review was provided by the PNDs who participated in the original focus groups to ensure that the concepts identified were addressed in the simulations. The researchers provided subject matter expertise. The researchers evaluated three simulations concurrently and compared results with ensure inter-rater reliability.

Results from focus groups

Key themes

Qualitative analyses of the focus group transcripts resulted in the identification of six key themes. All of the participants of the focus groups concurred with the analyses.

Attending to basic patient needs

Participants described new graduate nurses as typically seeking out others to help their patient with basic needs, such as bathing, toileting, dressing and personal hygiene. One participant explained, ‘The day-to-day skills are lost on them, prefer nursing assistants and techs to do basic care’.

General organisational skills

The lack of organisational skills was repeatedly discussed in a variety of ways. Organisation of the entire shift in general and the organisation of the care provided were brought up multiple times. One participant shared, “Make a list!”, and another mentioned “New nurses need organization skills—they have papers all over the place”. In general, participants believed new graduate nurses seem a bit disorganised.

Anticipation of risk and consequence

New graduates may not be able to anticipate consequences and risks of action or inaction. One participant said, “They lack the ‘now what?’ factor”, and another specifically stated the new graduate nurse has “…no anticipation of risk”.

Higher order technical skills

Participants of the focus groups reported that students had the ability to perform some skills, but they were not able to perform higher order technical skills. Of the nurse PNDs interviewed for this research, all believed new graduates were not capable of caring for very sick patients, such as those with advanced heart failure requiring multiple cardiac drips, patients with ventricular assist devices or multisystem illness. One participant said, “They are learning some of the skills, but not learning how to incorporate those skills with everything else that is needed, such as every one hour checks and keeping the environment clean”.

General communication skills

Communication is a major component of patient care and essential to positive patient outcomes. Research shows that nurse-enhanced communication fostered the dyad with the patient, and ensured healthy outcomes.¹² This research further emphasised the need to incorporate communication skills in simulation.

Recently, a group of researchers completed an integrative literature review on interprofessional communication in healthcare and found that simulation training incorporating communication techniques was effective to promote communication among nurses and physicians.¹³ These researchers further report, based on their review, that simulation should be considered the gold standard for training nurses and physicians in communication skills. From this research, it is clear that education and practice with communication is necessary, as one focus group participant said “they don’t seem capable of talking to the physician” while another said “…if they could only text the patient”.

Ownership/accountability

For many new graduate nurses, ownership and accountability as they relate to patients are difficult concepts and require time to fully understand and operationalise. One participant said, “Most professional nurses are fiercely protective of their patients and invested in their care and outcomes”. Another participant said, “….they have no buy in, they are not invested in patient care”.

The last part of the focus group sessions was about simulations that participants believed would increase a student’s level of competence. The main themes from this portion of the conversation were the need to increase the rigour, realism and complexity of simulations. One participant stated, “They have to prioritize. Communication would be ideal with provider”. Another participant offered, “No prompting – let them feel the emotion of making a mistake”. Allowing students to make mistakes in a safe environment is important in simulation.¹⁴ According to the INACSL Standards of Best Practice: Simulation: Standard IV: Facilitation, one of the tenets of facilitation is to allow students to explore their actions whether positive or negative and allow for reflection in a safe environment.¹⁵

Description of simulations

Based on the study themes and suggestions from PNDs, two simulations were developed using the Standards of Best Practice: Simulation Standard IX: Simulation Design.¹⁶ The first simulation involved the care of a 63-year-old patient with hypertension and Type 2 diabetes (needing insulin). The simulation included the use of a glycaemic protocol, prioritisation, organisation, physical assessment, medication administration and communication. The second simulation involved a 64-year-old patient with angina, heart failure and type 2 diabetes (diet controlled). The simulation included interpretation of laboratory values, administration of medication, prioritisation, physical assessment, communication and noticing physiological changes. These concepts may seem relatively common in simulation, but combining all of these elements in one simulation was not traditionally done. Until this project, students had not been exposed to the use of glycaemic protocols in simulation and exposure in the hospital setting was random, based on patient assignment. Because of this research, it was discovered that students lack a full understanding of how to operationalise a glycaemic protocol; so providing them this experience in simulation was very appropriate to meet an expectation of the new graduate nurse.

Sixty-four students in their final semester participated in one of the newly developed simulations with a 1:1 student to faculty ratio. Although 1:1 simulation is time-intensive and costly, all 64 students in this study received the experience of the 1:1 simulation because the researchers believe that it is important in order to thoroughly evaluate the student’s understanding of the concepts and skills involved in the simulation, and through debrief, ensure comprehension of those concepts not fully understood by the student. Each student was given objectives and relevant reading material in advance of the simulation. Immediately preceding the simulation, students were oriented to the simulation suite and equipment in the room. At the research site, simulation is integrated throughout the curriculum; therefore, all students participating in this research had multiple exposures to the simulation environment.

Students had the opportunity to provide basic patient care and show organisation through a complex patient scenario. Students had the chance to communicate with others on the healthcare team (embedded simulation participants) and demonstrate understanding of the risks associated with both action and inaction. On completion of the simulation each student was debriefed using the principles of debriefing for good judgement.¹⁷ In addition, the researchers used a dichotomous checklist and referred to it during debrief to ensure the learning loop was closed. Specific data related to student performance are not being reported as that is not the focus of this research, but rather the collaborative process of developing meaningful simulations to assist the student transition to professional practice.

Discussion

The goal of this study was to develop a collaborative and targeted approach to simulation development that addressed the perceived deficiencies in new graduates as identified by PNDs. Findings from this study are consistent with earlier findings from other researchers.^{2 18} Data from the focus groups indicate that new graduate nurses are expected to care for high acuity patients. Academic educators must examine the content of nursing curricula to ensure that high acuity skills are included, as the focus in academia continues to be generalist preparation. Likewise, we need students with effective communication skills, and for that opportunities need to be provided for students to engage in meaningful activities that require challenging communication.¹⁹ Addressing these needs prior to graduation will lead to a greater sense of readiness for practice in the graduate nurse.

Limitations

There are several limitations identified in this study. The focus groups included invited members of the professional nursing development community. These participants represent a small segment of staff development nurses working with our graduate students. We worked with hospitals in the surrounding geographic area where our students go for clinical experiences. The focus group participants were familiar with our graduates and happen to hold the nursing programme in high regard. This could introduce bias. This was a curricular enhancement with no control group. To date, we have been unsuccessful measuring the longitudinal impact of the simulation on graduating seniors entering the professional role. Further research is planned to follow new graduates into their professional nursing practice to determine the effect simulation has on practice preparation.

Conclusion

It was evident that our hospital partners are committed to seeing new graduates succeed. This research provided an opportunity for academicians and hospital-based educators to collaborate and share information with the free flow of ideas from our hospital partners. The focus group participants were fully engaged in the process throughout the research project. The process was viewed as positive and was actually enjoyed by all. At times the comments were not positive, which could have been uncomfortable, but the information was received with an attitude of openness and concern. The researchers wanted to hear factual information, positive or negative, so that specific efforts could be made to decrease the deficiencies in the nurse graduates.

PNDs should share expected competencies, clinical expectations, and new hire on-boarding content with academic institutions. This would allow academic partners to better prepare potential new hires. Aligning industry expectations and education outcomes also allows hospitals to hire well-prepared graduates, potentially lowering the cost of graduate nurse orientation and improving patient outcomes. By collaborating with local hospitals and their nursing professional development team, meaningful simulations were created collaboratively that targeted employer-identified deficiencies, meeting the needs of both the student and employer.