Caring for multiple patients simultaneously can be challenging for even the most experienced RNs. Such challenges are greater for new graduate nurses, who often do not feel adequately prepared when they enter clinical settings and are required to administer care to multiple patients. In such situations, patient safety becomes an area for particular consideration. Although simulation-based learning is standard in many schools of nursing, most simulation experiences involve single-patient scenarios. Improved patient safety could be better accomplished by providing nursing students with ample opportunities to deliver safe, high quality care prior to entering clinical practice.
The purposes of this project were a) to implement a multiple-patient simulation experience in a BSN program and b) to determine students' perceptions of the multiple-patient simulation. Benner's novice-to-expert theory provided the appropriate framework for nursing students who had "no experience with the situations in which they are expected to perform tasks" (Benner, 1982, p. 403), in this case caring for multiple patients concurrently before beginning their careers as clinical nurses. Participating in a multiple-patient simulation experience may support the transition to promote safe, quality health care for patients once nurses enter the professional arena.
LITERATURE REVIEW
Some nursing programs have begun experimenting with multiple-patient simulation. In their 2009 multisite study, Ironside, Jeffries, and Martin (2009) looked specifically at the relationship between patient safety competencies and participation in simulation exercises, where students were required to care for four patients in similarly complex health conditions. Ironside et al. found "significant differences in the implementation of the patient safety competencies from week 3 to week 10, p < 0.0002" (p. 336). Their findings indicated that students who experience simulations involving multiple patients are more likely to have better patient safety competencies.
Kaplan and Ura (2010) developed a learning experience using three simulators for a multiple-patient simulation scenario; participants were 97 seniors in their final semester of a university-affiliated nursing program. The multiple-patient experience was found to be "successful because self-reported confidence in both prioritizing and working in teams was increased, as well as understanding about how to prioritize and delegate care" (p. 375).
The inclusion of multiple-patient simulation in nursing curricula addresses Institute of Medicine (IOM) concerns regarding health care quality and safety. The IOM (2003) and the National League for Nursing (NLN, 2003) have indicated that all disciplines involved in health care need to examine, question, and challenge current practices in order to achieve patient safety and improve quality of care. Although findings concerning multiple-patient simulation for nursing students are limited, existing evidence establishes this practice to be beneficial, with positive effects for safety and quality of care and the confidence and skills of new nurses.
METHOD
This multiple-patient simulation experience was created and piloted for BSN students. Three medical-surgical scenarios were developed, and related patient charts were created. The scenarios involved patients with diabetic ketoacidosis, chronic obstructive pulmonary disease, and postoperative partial gastrectomy. Prior to participation in the simulation experience, students were required to complete an assignment on each disease and condition. To help students prepare, they received an overview of the scenarios days prior to participation.
Upon institutional review board approval, the multiple-patient simulation pilot program was administered during the fall semester 2014 to third-year nursing students. The pilot was conducted during the fifth and final laboratory experience of the medical-surgical rotation. All 52 students in this rotation were required to participate in the simulation, but participation in the survey was voluntary.
Anonymous questionnaires (prebriefing and debriefing) were developed with input from two content experts. The questionnaires had 12 questions, three affective statements and nine self-efficacy statements focused on the cognitive objectives of the scenarios (three for each scenario). The debriefing questionnaire included an open-ended request for suggestions about improving the experience.
Students provided consent and completed the questionnaire at the beginning of the prebriefing session. Students were divided into seven groups and then divided again over three days, with eight students per group (two groups had six students). Within each group, two students acted as assessment nurses, two students acted as medication nurses, one student acted as the recorder, and three students observed via video/audio in a separate room. The observers completed forms on prioritization, delegation, teamwork, and communication.
Halfway through the simulation, the assessment nurses, medication nurses, and recording nurse gave a five-minute handoff report to the three observers and switched roles. Each experience took two hours to complete, including the prebriefing, bedside report, simulation, and debriefing.
RESULTS
Results from the prebriefing and debriefing questionnaires showed acceptable reliability (pre, Cronbach's alpha = .754; post, Cronbach's alpha = .871). The questionnaire results indicated that, following participation, students experienced increased motivation, feelings of positivity, and self-efficacy. Using a 5-point Likert scale, differences between the means for the prebriefing and debriefing responses were calculated for each statement, and scores for each category were found to improve.
The affective statements focused on attitudes and motivation about multiple-patient simulation ("I am interested in the content[horizontal ellipsis]"; "I think the material[horizontal ellipsis]is useful for me to learn"; "I will be able to use what I learn[horizontal ellipsis]in clinical practice"). Mean differences from pre to post ranged from +0.06 to +0.31 (prebriefing mean scores, 4.15 to 4.53; debriefing mean scores, 4.46 to 4.62). Examples of the nine self-efficacy statements are as follows: "I am able to recognize symptoms of[horizontal ellipsis]"; "I am able to design a plan of care for the nursing management of[horizontal ellipsis]"; "I am able to modify nursing care as appropriate." Mean differences from pre to post ranged from +0.06 to +0.69 (prebriefing mean scores, 3.52 to 4.18; debriefing mean scores, 3.98 to 4.42).
The open-ended question was answered by 47 students. Qualitative responses were placed into four categories according to frequency. Overwhelmingly, the most frequent response was that students wanted to have the opportunity to do more multiple-patient simulations. Comments were positive and included: "More realistic to hospital setting"; "Helps me critically think and practice prioritizing"; and "Great learning experience." The second most frequent comments concerned preference about working in smaller groups or individually to allow individuals more responsibility, experience, and accountability. Third, students desired more time to go through the multiple-patient simulation. A few students stated that, during the prebriefing, clearer explanations of expectations were needed.
DISCUSSION
Similar to previous findings about greater confidence in prioritizing, teamwork, and delegation with multiple-patient simulation (Ironside et al., 2009; Kaplan and Ura, 2010), results from this pilot study confirmed multiple-patient simulation to be an effective learning experience. Higher group means for all affective and self-efficacy statements focused on the cognitive objectives of the scenarios. Improved scores were underlined by a reported increase in positive attitudes and motivation. In addition, feedback during the debriefing exercises and student responses to the open-ended question were overwhelmingly positive. Students expressed that they found the multiple-patient simulation experience beneficial to their learning and a more realistic representation of the clinical setting, helping them to think critically. (Although students indicated they would prefer smaller groups, this was not logistically possible.)
This simulation project advances the science of nursing education by providing a more realistic clinical setting for students about to enter the nursing workforce. This project describes a mechanism to ensure accountability for improving care delivery, promote patient safety, and achieve excellence in practice. Indeed, the IOM (2003) and the NLN (2003) have indicated that all disciplines involved in health care need to take an active role in improving care delivery and guaranteeing patient safety. With the availability of clinical sites for educating health care workers a growing concern, the benefits of simulation, specifically multiple-patient simulation exercises, make any increased demands to the education system warranted and worthwhile.
The college of nursing requirement that all 52 students participate in the simulation experience did not allow for a comparison group. Also, this was the first time the questionnaires were used with students. For future research, it would be beneficial to engage an experienced researcher to review the research design, include a comparison group, and have a larger sample size to further evaluate reliability and validity of the questionnaire.
Overall, the students perceived the multiple-patient simulation experience to be a benefit to their education. By providing teaching methods that are more realistic to the clinical setting, this type of educational experience may help meet IOM and NLN concerns about patient safety. The BSN program found this pilot endeavor a valuable learning experience for students and has since incorporated it into the curriculum.
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