Each first-semester nursing course offered during the junior year of our baccalaureate program has been taught in a silo. Content for pathophysiology and pharmacology is presented using a lecture/discussion format. Health assessment and fundamentals are taught with lecture and discussion as well as low-fidelity, task trainer models and peer practice sessions. This isolated approach has limited students' ability to integrate the information necessary for safe, competent nursing care.
Faculty at the school of nursing noted that academic success in the classroom does not reliably predict students' ability to transfer knowledge to the patient care environment. This article reports on a collaborative simulation experience (CSE) designed by first-semester faculty as an intradepartmental innovation to promote the transition to clinical practice and the achievement of student learning outcomes by preparing students for their first clinical encounter.
STRATEGY
Students frequently spoke of lacking confidence when entering a patient's room, introducing themselves, establishing a therapeutic relationship, and performing basic patient care. Clinical faculty confirmed that student behaviors were consistent with their reports of anxiety and uncertainty. On the basis of the findings of Bambini, Washburn, and Perkins (2009) and National League for Nursing (2015) recommendations for simulation, first-semester faculty met to formulate overall as well as individual course goals for the CSE.
Faculty agreed it was of primary importance that students verbalize decreased anxiety and increased confidence and demonstrate the transfer of knowledge to the clinical setting. Overall goals for student learning encompassed the goals of the four first-semester courses:
* Analyze each disease process to include the potential impact on the nursing care of the case-study patient (pathophysiology).
* Demonstrate therapeutic communication skills; an initial, hospitalized patient shift assessment; and accurate documentation of physical assessment findings (health assessment).
* Demonstrate appropriate body mechanics during patient transfer, appropriate use of equipment, and awareness of patient activity tolerance and concerns (fundamentals).
* Demonstrate safe medication administration with accurate documentation and appropriate patient/family teaching (pharmacology).
Faculty worked together to determine a day and time for the CSE and developed a case study that closely resembled a typical patient on the nursing unit most commonly used for fundamental clinical experiences (see Figure 1.) All department faculty and graduate assistants were invited to participate in the collaboration. As an incentive, lunch was provided for faculty and graduate assistant participants.
The CSE consisted of two stations per topic area (physical assessment, mobility, medication administration) and required a total of 10 faculty/graduate assistants for implementation. The physical assessment stations required two evaluators (they served as both patient and the evaluator); the medication administration and mobility stations required two evaluators and two simulated patients each. Students were scheduled for one hour of simulation (20 minutes at each station), allowing for six students to complete the CSE per hour. Student schedules and graduate assistant/faculty station assignments were posted along with the case study and faculty-developed evaluation rubrics on the school of nursing learning platform, Moodle, two weeks prior to the event.
The pathophysiology component consisted of guided questions addressing the comorbidities of the CSE patient. This written activity was required to be submitted the day of the CSE. Prebriefing, one week prior to the CSE, consisted of a review of the case study and the evaluation rubrics and a demonstration of expected performance. Students were permitted to video record the demonstrations to allow for improved performance. The CSE was implemented the week immediately preceding the first clinical experience. To promote realism, students were required to wear the approved uniform and bring with them the necessary equipment for patient care (i.e., pen light, stethoscope, drug note cards).
IMPLEMENTATION
Graduate assistants and faculty met one hour prior to the scheduled student arrival to encourage standardization of the simulated patient performance and interrater reliability for evaluators. In addition, the necessary equipment (hospital gowns, oxygen delivery systems, intravenous therapy devices, dressings, wheelchairs, gait belts, medications) was assembled to ensure station consistency.
Faculty/graduate assistants assumed the role of the patient. Students provided the designated patient care at each station and faculty used the rubrics to score their performance. Debriefing took place at each station immediately after the student performance. Individual faculty members reviewed the evaluative rubric and offered feedback regarding positive performance and areas for improvement. Students were required to submit documentation of the nursing care provided at each simulation station one week following the CSE.
EVALUATION
After three clinical experiences, students completed an evaluation of the CSE. The evaluation tool, created by first-semester faculty, contained10 Likert scale items as well as room for comments. Students reported the following: a) They understood the purpose and objectives of the simulation (100 percent). b) Instruction before the simulation prepared them for the CSE (86 percent). c) The stations were designed to resemble actual patient care experiences (100 percent). d) The simulation experience increased their level of self-confidence (97 percent). e) They received constructive feedback about their performance at each station (93 percent). f) They felt better prepared to perform physical assessment skills (96 percent), administer medications (93 percent), and assist with mobility (98 percent).
Written comments regularly noted the CSE was very helpful in reducing anxiety prior to the first clinical experience. One student stated, "If I can assess my faculty member, I can assess any patient."
Following the CSE, faculty reported a significant increase in student confidence as evidenced by students entering the patient's room independently, introducing themselves to patients and families, and initiating patient care. Remarks relative to the transfer of knowledge included: "This experience allowed us to apply everything we learned"; "Being in an actual situation, I feel better about doing the skills as opposed to going through them step-by-step"; "I learned that real patients require us to respond and react to comments"; "I was required to be able to adapt, because all situations are different"; and "This taught me to put everything together."
LESSONS LEARNED
A number of lessons learned from the first CSE resulted in changes going forward. The greatest challenge encountered was adhering to the designated schedule. The fundamentals station exceeded the 20-minute time allocation, delaying timely progression for the entire experience. This created frustration for everyone, particularly students who were also experiencing performance anxiety.
During the faculty evaluation, it was identified that the fundamentals station had a dual focus - on therapeutic communication and mobility activities. It was decided to primarily emphasize patient positioning and transfer techniques at the mobility station and incorporate therapeutic communication as an integrated concept within all stations. Having a timer or timekeeper to promote more efficient transfer from station to station was recommended.
Interrater reliability was a concern at the pharmacology station. A substitute faculty evaluator was used for 75 minutes so the original evaluator could teach a class. Although the team was grateful that a faculty member participated at the last minute, this contributed to inconsistencies in scoring. (Students also noted this as a concern in their evaluations.) Now, greater attention is given to faculty time schedules, and all possible evaluators are oriented to the expectations for each station.
Prior to the CSE, course faculty communicated information regarding goals, expectations, and grading at their discretion. Students stated that this led to a sense of disconnect, and they asked that information about grading be communicated within the same week. Faculty agreed to post CSE materials on course websites at a designated time and review expectations two weeks prior to the CSE.
In summary, the CSE has allowed learners to develop, refine, and apply knowledge and skills in a relatively realistic clinical situation without the fear of harming an actual patient. This experience, in a safe learning environment, affords faculty the opportunity to supervise performance, provide feedback, and enhance student learning. Student comments included "The immediate feedback allowed me to learn from my mistakes before having a real patient."
Implementation of the CSE has been beneficial for both students and faculty. Students reported reduced anxiety and increased confidence following participation, and faculty noted a greater transfer of theoretical knowledge to the clinical environment. An unexpected benefit for faculty is having greater insight into the strengths and weaknesses of individual students. The CSE will continue to be implemented for all first-semester nursing students, with ongoing formative and summative evaluation. The experience can be modified to benefit nursing students at any level of education.
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