Newly graduated nurses face many challenges as they transition into the workplace. Because of the nursing shortage and increasing retirements, there is a shortage of experienced nurses to help mentor new nurses, even while patient care is increasingly complex (Hofler & Thomas, 2016). New nurses also face generational diversity and bullying, which add to already heightened levels of performance anxiety (Hofler & Thomas, 2016). The Health Care Advisory Board has projected that 42 percent of the nurses hired into the acute care setting will be new graduates (Theisen & Sandau, 2013). For nurse educators, the challenge is to develop effective teaching strategies to ensure readiness for practice by new graduates.

The Nursing Executive Center conducted a nationwide survey with frontline nurse leaders on new-graduate proficiency across 36 competencies deemed essential for safe and effective care (Berkow, Virksitis, Stewart, & Conway, 2009). Although all 36 competencies were found to need improvement, the greatest needs centered on skills such as recognition of changes in patient status, taking initiative, tracking multiple responsibilities, anticipating risk, prioritizing and delegation (Berkow et al., 2009). Beroz (2016) had similar results when evaluating students in a multiple-patient simulation (MPS) experience in which patients had many needs. The data identify that, in order to help in the transition to the workplace, there is a need to provide learning experiences that challenge the nursing student to think beyond caring for a single patient. What is needed are learning experiences that challenge students to provide care for multiple patients as required in the clinical setting.

For nurse faculty seeking to provide patient assignments that mirror the experiences of the new registered nurse, it is important to provide MPS experiences that place the emphasis on the competencies ranked last in the nurse executive survey (Berkow et al., 2009). Ironside, Jeffries, and Martin (2009) explored the use of multiple-client simulation in fostering patient safety. Their findings suggest that immersing nursing students in an MPS increased the ability of students to meet patient safety competencies.

Ironside and Jeffries (2010) used MPS to foster clinical judgment. Chunta and Edwards (2013) developed an MPS for students transitioning into practice; student evaluations on the use of these simulations supported their benefit in developing prioritization and delegation skills. The development, implementation, and evaluation of MPS have been shown to improve student outcomes for safe and effective care as the new graduate transitions into practice. Horsley, Bensfield, Sojka, and Schmitt (2014) provided guidelines on creating and implementing an MPS that focuses on types and numbers of students, outcomes, time frame for the scenario, costs, and resources.

THE PURPOSE

The purpose of our project was the construction of an adaptable and flexible template for the development and documentation of an MPS for use in a variety of clinical settings to create realistic and effective simulations to enhance student-learning outcomes. Jeffries' (2012) template for the development of a single patient scenario is a highly effective tool. On multiple pages, it provides information on objectives, background, students' prework, details on simulation setup, patient report, and, most importantly, the flow of the scenario. Also included, depending on the scenario, are physician order sheets, laboratory values, and medication administration forms.

Without simply duplicating the single-patient scenario, our aim was to develop a template that provides all necessary information and allows the visualization of all patients at a glance without wading through multiple pages. The template would concisely detail the objectives, setup, and flow of the scenario and serve as a guide to describe its use.

THE PROCESS

Using the NLN Jeffries theory as a framework (Jeffries, Rodgers, & Adamson, 2015), the project began with a search of the evidence for information on MPS and data regarding nursing graduates from the National Nurse Executive Center. Based on that data, the target audience - transitioning students - was determined. An important next step was developing objectives for MPS. The objectives developed were as follows:

1. Utilize principles of prioritization and delegation in caring for multiple patients within a complex environment.

2. Demonstrate therapeutic communication to express respect, patience, and sensitivity to patients, inclusive of plan of care.

3. Collaborate with interprofessional health care team to provide safe and effective patient-centered care.

4. Utilize relevant assessment data to develop evidence-informed (evidence-based) plans of care for the patients(s).

5. Use clinical reasoning processes in modifying patient care decisions.

6. Provide and receive constructive feedback to/from health care team members to improve performance (patient outcomes).

Next, practice environments were surveyed to determine an average number of patients to include in the template; the average was three. With that information, a draft template for a three-patient scenario was developed based on the Jeffries model. The core components of the template include the following as they appear on the pages of the template:

* Page 1: The roles, objectives, skills, simulation-time, and debriefing time.

* Page 2: The patient setup for all three patients side by side. Some standard information was included for all (e.g., IDs, orders, automatic blood pressure cuff, thermometer, oximeter, headwalls with outlets for air, and oxygen). Examples of other information included in the setup are preparation of the manikin, medications, intravenous fluids, bedside equipment and enhancements, chart forms, and prebrief information.

* Page 3: The scenario progression with all three patients visible side by side.

* Page 4: Student version with student prework.

* Page 5: Report on all three patients.

* Last pages: Forms as necessary per scenario to include orders, labs, patient information sheets, plan of care, and medication administration records for each patient. These remaining forms are for use when an electronic medical record is not in use.

The key feature of the template is that it is a tool that concisely details the objectives, setup, and flow of a three-patient scenario. Through utilization, it was recognized that additional components were needed to effectively operationalize the template. Ultimately a multiple-patient scenario toolkit was developed, including a template, operational guide, and bibliography. A populated template was created as an example.

INITIAL PILOT TESTING RESULTS

The template has been pilot-tested in seven settings, including both associate and baccalaureate programs. In most cases, the schools used scenarios of their own choosing, not the example. Varying student roles were included in each simulation (e.g., charge nurse, bedside nurse, night nurse, and resource nurse), and varying numbers of students have been included (from two to six).

Overall, the feedback has been positive. Comments included feedback such as, the template streamlined documentation and was easy to read and operationalize. One user stated, "I have been waiting for a multiple-patient template. The lack of tools was why we had not developed the simulation previously." Importantly, the feedback stated that the template provided enough information to adequately set up and run the scenarios, ultimately the most important component of a tool to design simulations.

Faculty review of nursing curricula is recommended in order to identify essential content and competencies best learned using MPS methodology. The authors suggest incorporating an MPS in a capstone or senior-level clinical course. The toolkit will facilitate the implementation of the experience, enhancing new-graduate transition into practice.

Moving forward, the plan is to continue pilot testing and evaluation. A debriefing tool and facilitator checklist to aid in the evaluation of expected student outcomes are in development. The toolkit is available on the National League for Nursing Simulation Innovation Resource Center website at http://sirc.nln.org/mod/page/view.php?id=843#toolstips.

REFERENCES