A Simulation Nurse Residency: An Exemplar to Improve Outcomes    

Introduction

Research Question

Does the implementation of a pediatric simulation nursing residency program affect the confidence and competence of nurses caring for pediatric patients in a community hospital setting?

Hypothesis   Not applicable to this study

Literature Review       

Community hospitals across the nation provide quality, cost-effective care. Skilled providers manage a considerable variety of illnesses across the lifespan continuum, from benign sore throats to catastrophic injuries. The pediatric population presents a particular quandary for community hospitals as infrequent exposure to seriously ill or injured children creates a substantial barrier to the maintenance of essential skills and clinical competency (IOM, 2007a).  According to the Institute of Medicine (IOM) report, Emergency Care for Children: Growing Pains (IOM, 2007a), pediatric care across the country is practiced in silos; thus, care is compartmentalized. The vast majority of pediatric patients receive emergency care in general-population emergency departments (ED); however, only 6 % of hospital emergency rooms have the necessary equipment to care for pediatric patients, who comprise 27% of all ED admissions. Pediatric inpatient admission rates are 4%, while only 1 % of ED visits result in transfer to a higher level of care.  Additionally, more than half of hospitals without inpatient pediatric units do not have written transfer agreements. The report is a disquieting account of the current state of practice provided to one of our most vulnerable populations; and this situation is in desperate need of transformation.

The burgeoning demand faced by tertiary hospitals emphasizes the need for community hospitals to treat common pediatric ailments at the local level to ease the burden on tertiary centers (Freedman & Thakkar, 2007).  A large cross-sectional study revealed that 25% of pediatric patients transferred from community hospitals to a higher level of care were directly discharged from the tertiary ED or within 24 hours of admission (Li, 2012). The cost of transferring patients influences reimbursement to the transferring and receiving hospitals.  Another study comparing community hospitals and academic medical centers found that nursing costs per patient day were significantly higher in medical centers than in community hospitals. These larger medical centers had lower nurse-to-patient ratios and a higher skill mix (Welton, Unruh, & Halloran, 2006). Conversely, when comparing length of stay (LOS) and readmission rates of children treated in rural hospitals, researchers found no difference in LOS or readmission rates (Lorch, Zhang, Rosenbaum, Evan-Shoshan, & Silber, 2004).

Costs are not the only consideration, as patient satisfaction is also impacted. The transfer process of both the transferring and receiving hospitals is often associated with mixed satisfaction (Freedman & Thakkar, 2007).  Patient satisfaction with nursing care, as a quality indicator, ties directly to patient satisfaction with hospital care, which may indirectly affect cost (Larabee & Bolden, 2001). Community hospital nurses describe patient satisfaction as the priority quality indicator.  Moreover, they convey a deep connectedness to the community they serve that is unique to the culture of community hospitals in rural areas (Baerbholdt, Jennings, Merwin, & Thornlow, 2010). Nursing leaders are in an ideal position to challenge the status quo by instituting measures to lower costs, improve care, outcomes, and overall safety for the pediatric population in community hospitals.

The IOM (2007a) cites a decline in pediatric skill competency with reduced exposure, and many facilities have little to no educational competencies for skill preservation.  Simulation is a practical methodology to address this need. The literature suggests that no one singularly preferred method of simulation would meet the needs of all learners and stresses that additional teaching modalities need to be employed (Fox & Draycott, 2011). The last 40 years has seen the expansion of high-tech, simulation-based training using enhanced technology in medical education with positive outcomes (McGaghie, Issenberg, Petrusa, & Scalese, 2009). Furthermore, simulation as a pedagogical approach in nursing emulates similar success in medical education and reinforces the theoretical construct of what it means to be a nurse in a safe learning environment Berragan, 2011).

The IOM (2007b) supports the use of simulation for all providers as a means to attain and maintain skill competency.  Simulation offers an opportunity to practice emergencies before they become a reality. Participants evaluate both their own skills and those of their team members, as well as their decision-making ability (Riley, Davis, Miller, Hansen, Sainfort, & Sweet, 2011).  Simulation is an educational and assessment tool essential to improved pediatric outcomes (Weinberg, Auerback, & Shah, 2009). Simulation exposes care providers to rare clinical situations where the quality and safety competences of patient-centered care, teamwork, collaboration, evidence-based practice, quality improvement, safety, and informatics can be implemented specifically for the pediatric population Decker, Utterback, Thomas, Mitchell, & Sportsman, 2011). Simulation has been effective for resuscitation, trauma and airway management, procedural skills, crisis management, team training, and disaster training. 

Although the literature does not support clear, theory-driven outcomes, there are theoretical underpinnings to support simulation in nursing practice. Dr. Patricia Benner heralds experiential learning as paramount to progression (Benner, 2001). Benner’s conceptual practice model Novice to Expert, (2001) creates a template for clinical practice progression as a means of extrapolating knowledge embedded in clinical practice.  Benner’s work is pivotal to understanding the learning needs of nurses, their role at the bedside, and what it means to be a competent nurse.  Her theory recognizes that change occurs through the phenomenological prism as clinical expertise progresses through the five stages of proficiency: novice, advanced beginner, competent practitioner, proficient practitioner, and expert. (16)  Nurses today are caring for individuals with complex health problems within health systems where evidence-based care is expected using advanced informatics technology (Goode, Lynn, Kresk, & Bednash, 2009).) This multifaceted environment has raised the bar for practicing nurses to maintain competent nursing practice. Nurse residency programs are an effective strategy to increase skill acquisition, competence, and improved quality of care through a structure of support, knowledge, and mentorship (IOM, 2011).  

Team Formation  

The Chief Nursing Officer fully supported the 8-week project. The Clinical Educator facilitated the logistics of equipment, location, videotaping, and debriefing of all simulations. The project recruited interested nurses from the ED and medical-surgical floor, pairing volunteer participants into four complementary teams. In addition to their full-time work schedules, nurses volunteered their time to participate without compensation.  A patient actor (nurse), portraying an anxious mother, used the hospital-owned VitalSim® Infant Simulator to create a low-fidelity simulation setting.   

 

Principal investigator - Susan McCarthy, MS, RN, Clinical Nurse Birthing Center, Department of Nursing  

Interprofessional Team:

• Hazel Robertshaw, PhD, RN, CENP Vice President of Patient Care Services/CNO, Hospital Administration 
• Adrian Hordon, MSN, RN, Clinical Nurse Educator and Magnet Project Director, Nursing Administration, Patient Care Services
• Dr. Donna Schue, Family Practice Physician
• Dr. Michel Foote, Family Practice Physician
• Dr. Susan Landgraf, Family Practice Physician
• Dr. Margaret Hollister, Pediatrician
• Dr. David Ragonesi, Pediatrician
• Sarah Russell, BSN, RN, CBC (Patient actor), Clinical Nurse, Birthing Center, Department of Nursing

 

Project Participants –

• Emergency Department:
  • Jonathan Fulmer, RN, Clinical Nurse, Research participant
  • Megan Didas, BSN, RN, Clinical Nurse, Research participant
  • MJ O’Neill, RN, Clinical Nurse,Research participant
  • Brianne Jennison, BSN, RN, Clinical Nurse, Research participant
• 3East:
  • Whitney Barrett, BSN, RN, Clinical Nurse, Research participant
  • Alisa Mayer, RN, Clinical Nurse, Research participant
  • Megan Blums, RN,Clinical Nurse, Research participant

Methods

Study design

• Mixed methods design    

Study timeline

• October 09, 2012 to January 18, 2013  

IRB approval date

• An expedited IRB was submitted on June 12, 2012 and approved on July 15, 2012 through the St. John Fisher IRB.    

Research sample

• N=7   Three (3) RNs from 3East and four (4) RNs form the Emergency Department

Data Collection Methods

• Data collection was accomplished through a mixed methods design.  

• Digitally videotaped simulations pre- and post-residency were used to evaluate knowledge of general pediatric assessment. All simulations were videotaped and scored for efficiency of assessment, prioritization of intervention, accuracy of medication administration, and interaction with the patient, family, and physician.  
• The videotaped debriefing session and the audiotaped focus group were transcribed verbatim and analyzed for content. Themes were elicited through coded and categorized data.  
• Participants completed the 13-item METI® Simulation Effectiveness Tool and the NLN Simulation Design Scale (SDS) and Educational Practices in Simulation Scale (EPSS).

Simulation Residency

The residency began with each team completing a simulation scenario to assess the baseline skill level. Following the first simulation, each participant had the opportunity to work a 12-hour shift on each other’s home unit to gain an appreciation for work flow. Physician-provider experiences allowed for increased knowledge of pediatric assessment as well as improved interprofessional communication.  The opportunity to work with anesthesia in the operating room encouraged skill development in airway management and intravenous (IV) access.  An online learning module for medication calculation and administration focused on fluid management, dosage calculation, and developmentally appropriate administration of medication. Following these residency components, participants completed the American Heart Association’s PEARS certification at the affiliated tertiary-care facility.  A didactic session provided focused content on identified areas of needed skill development.  The residency concluded with a second simulation experience using the same scenario.

Results and Analysis

• Nurses and providers expressed concerns related to caring for the pediatric population in an unpredictable environment. Interviews with providers, nurses, administrators, supervisors, and EMS workers revealed a climate of care that echoes similar themes highlighted in the aforementioned IOM report.
• Nurses conveyed apprehension related to staffing, skill mix, physician accessibility, and safe medication administration as the rationale for their discomfort when caring for children. Physicians expressed limited confidence in the skill mix of the nurses in both the ED and the medical-surgical floor. The initial simulation identified gaps in the ability to prioritize nursing actions, threats to effective communication, and inaccurate dosage calculation.   
• The second simulation demonstrated a marked improvement in the participant’s ability to manage the infant’s airway, prioritize actions to improve respiratory function, and calculate and administer medications accurately.     A discernible difference was noted in the communication skills utilized with the provider and patient actor (mother).   
• Participants articulated increased confidence when comparing the first and second simulation experiences.
• The METI® Simulation Effectiveness Tool demonstrated unanimous agreement for all 13 items measuring confidence and learning in cognitive, affective, and psychomotor domains.  Additionally, participants affirmed the value of all components of the residency to their learning. 

• The majority of participants believed the PEARS certification was the most beneficial component, while the medication calculation module was thought to be the most challenging. 
• Physicians expressed satisfaction with the shadow experiences, as they had an opportunity to interact outside the clinical setting.

 

Implications

A practical strategy to implement change begins by first identifying “where you are” and then moving forward from that point to build safe, quality practice. Rurality cannot encumber the building of a stronger nursing workforce that is critical to improved patient outcomes.  The interprofessional team must rise to the occasion and embrace opportunities for growth.  Creative, cost-effective educational development enhances clinical expertise for all populations.     

References

Baernholdt, M., Jennings,  B. M., Merwin, E., & Thornlow, D. (2010). What does quality care mean to nurses in rural hospitals? Journal of Advanced Nursing, 66(6), 1346-1355.
Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.
Berragan, L. (2011). Simulation: An effective pedagogical approach for nursing? Nurse Education Today, 31, 660-663.
Decker, S., Utterback, V.A., Thomas, M.B., Mitchell.  M., & Sportsman, S. (2011). Assessing continued competency through simulation: A call for stringent action. Nursing Education Perspectives, 32(2),120-125.
Fox, R., & Draycott, T. (2011). Medical simulation for professional development - science and practice. BJOG: An International Journal of Obstetrics and Gynaecology, 118(Suppl 3), 1-4.
Freedman, S.B.  & Thakkar, V. A. (2007). Easing the strain on a pediatric tertiary care center: Use of a redistribution system. Archives of Pediatric and Adolescent Medicine, 161(9), 870-876.
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Institute of Medicine of the National Academies (2007a). Emergency care for children: Growing pains. Retrieved from http://nap.edu.
Institute of Medicine of the National Academies (2007b). Improving the efficiency of hospital-based emergency care. In Future of emergency care: Hospital-based emergency care at the breaking point. (pp. 129-64). Washington, DC: National Academies Press.
Institute of Medicine of the National Academies (2011). The future of nursing: Focus on education. Washington, DC: National Academies Press. Jefferies, P. (2007). Simulation in nursing education: From conceptualization to evaluation. NY: National League for Nursing.
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Li, J. (2012). Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics, 130(1), 83-92.
Lorch, S.A., Zhang, X., Rosenbaum, P.R., Evan-Shoshan, O., & Silber, J.H. (2004). Equivalent lengths of stay of pediatrics patients hospitalized in rural and nonrural hospitals. Pediatrics, 114, 400-408.
McGaghie, W.C., Issenberg, S.B., Petrusa, E.R., Scalese, R.J. (2009). A critical review of simulation-based medical education research: 2003-2009. Medical Education, 44, 50-63.
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