Today's nursing students are entering a practice world that will require them to work collaboratively with other professionals and communicate effectively to ensure safe patient care. Nursing practice is currently faced with the need to adopt a culture of safety in practice. The Quality and Safety Education for Nurses (2017) project notes that the competencies of teamwork and collaboration need to be integrated in nursing education to improve health care quality and safety.
Quality simulation enables students to gain clinical experiences in a safe environment while also improving collaboration and communication skills. Richardson, Goldsamt, Simmons, Gilmartin, and Jeffries (2014) described a new clinical teaching model using simulation that had students alternate weekly between the simulation lab and the clinical location. In this model, faculty members at the NYU Rory Meyers School of Nursing were assigned a total of 12 students at clinical locations, with only six students per week on the clinical unit.
To be able to admit more students while improving student retention, a state university in Pennsylvania used the tenets of the Richardson et al. (2014) model to develop a new clinical model that would allow for increasing the size of clinical groups. This model not only has students learning in the simulation lab and clinical but also focuses on communication and teamwork by having students in related courses collaborate in simulations.
THE NEW CLINICAL TEACHING MODEL
Adapted from the NYU College of Nursing clinical model, our new model has two to three students from each section of Adult Health I, Adult Health II, and management and leadership clinical courses participate in simulations collaboratively. Unlike the NYU model, our simulation model brings together junior students from Adult Health I and senior students from Adult Health II and the management and leadership courses. The goal in bringing students of different levels together in the simulation experience is to enhance collaboration and teamwork and the development of effective communication skills, delegation, and prioritization of care. It is recognized that, as students enter practice, they will be working with practitioners of various levels of expertise and that, although learning happens while collaborating with experts, it can also happen while working with a novice practitioner.
Prior to using this model, our program used a traditional clinical teaching model, with a majority of hours spent at the clinical site and a few hours spent in simulation. Faculty at clinical sites were assigned 9 to 10 students per clinical group. Some students were assigned to a hospital unit with their clinical instructor, whereas others rotated through various departments such as IV team, the cardiac catheterization lab, and the operating department. This design allowed the faculty-to-student ratio to be reduced to 1:6 or 1:7 on the clinical unit, which aligned with the expectations of the clinical institutions.
In the original model, simulations were conducted by the simulation expert with the assistance of individual clinical instructors within each clinical group. These simulations were not standardized and typically took place at the end of a clinical day. Topics were chosen by the clinical faculty and related to course content. Faculty chose scenarios on an individual basis and did not coordinate with the other faculty teaching the same clinical course. For example, when one Adult Health I faculty member chose angina and chronic obstructive pulmonary disease, another chose a situation involving a preoperative and postoperative patient.
With increased enrollment in the program, the new clinical structure allows for groups of 11 to 12 students, with simulation as an additional out rotation to help reduce the student-to-faculty ratio to 1:6 or 1:7. Two to three students attend simulations per clinical day, and, as in the original model, two students take part in clinical rotations in various settings. The remaining students attend clinical on the assigned hospital unit with the clinical instructor. A benefit to this model is that faculty are able to spend more time with each student and may be able to assign multiple patients to each student.
DEVELOPING THE MODEL
The new model required dedicated faculty with expertise in simulation. Simulation faculty with knowledge in the principles of medical-surgical nursing, leadership-management, and critical care were trained in simulation development, operations of the simulation lab, and effective debriefing.
Faculty support was important for the planning and implementation of the new model. Syllabi for each course were reviewed in order to incorporate appropriate content and key elements in modified standardized scenarios and faculty-developed scenarios.
An example of a faculty-developed simulation that incorporates all levels of students is a scenario involving a patient who sustains multiple fractures following an all-terrain vehicle accident. In the beginning of the scenario, junior-level students assume the roles of primary and secondary nurses. Later, the patient experiences a change in condition due to the development of a fat embolism, and the junior students must call a code blue. At that point, senior-level students assume the roles of code team members. Additional roles for seniors include charge nurse and physician.
The students must work together to provide quality care for the patient. There was concern that junior-level students might lack some of the content needed for participation, and efforts were made to include roles for both the junior and senior students that encompassed skills and content that were appropriate for their level in the program. The model is built on the basic principles of nursing care, and key safety, leadership, and collaboration concepts are incorporated into simulations to enhance this aspect of practice.
To help students prepare for simulation experiences, they are provided with the subject topics for each simulation in the rotation and the overall simulation objectives. Simulation faculty thoroughly explain the new clinical teaching model and expectations during the first rotation.
IMPLEMENTATION
With the new model, two to three students per clinical group rotate to the simulation lab for their clinical day. Students take part in a full day of simulation four times during the semester (three simulation rotations and a simulation "code" day). The schedule is designed so that students are exposed to different simulations each time they take part.
Simulation experiences focus on medical-surgical, critical care, and management scenarios and include topics such as completing an admission assessment, discharge planning, leaving against medical advice, cultural issues with a blood transfusion, a multiple-patient assignment, and HIPAA violations. Some scenarios involve typical medical-surgical issues, and then complications or problems develop that require leadership and critical care issues to be addressed. During the code day, students participate in various stations related to cardiac arrest and emergency scenarios. The Quality and Safety Education for Nurses competencies of safety, communication, and teamwork are integrated into all simulations.
Simulation faculty randomly select participants for each scenario and try to ensure that all students are chosen to participate in the different roles throughout the semester. Students who are not chosen to participate in a simulation watch the scenario live in the debriefing room and complete a faculty-developed debriefing sheet. During debriefing, all students are encouraged to participate. Students are held accountable during debriefing by random selection; they are expected to discuss the topics on the debriefing sheets in order to facilitate learning and self-reflection.
LESSONS LEARNED
The key lesson we learned through development and implementation of the new simulation model is that preparation and coordination are crucial to success. For the model to be successful and for each simulation rotation to be a successful experience, the model requires coordination by simulation and other faculty about space, schedules, and courses. The importance of preparing students for the simulations cannot be underestimated.
With the implementation of the new model, students from the junior and senior levels were uncomfortable about the prospect of working together. Some juniors felt intimidated by the seniors, and some seniors did not feel confident about mentoring juniors. That changed as students became more accustomed to the experience. In addition, even though students were provided with topics prior to taking part in simulations and were given briefing reports for each, they requested more information for preparation. Students are now provided with learning objectives for each simulation and patient report prior to the start of the semester. These are reviewed on the day of the simulation along with additional patient histories, and students are reporting they feel better prepared for the experience.
Overall, the new clinical simulation teaching model has been effective in helping the program have larger clinical group sizes to assist with admitting more students. However, the model's greatest attribute is that it has improved student education. Simulations are now standardized, with expert faculty conducting the debriefing. Students are practicing the intraprofessional collaboration skills they will need in their future practice and report that the simulation experiences help them with teamwork, collaboration, and communication. The model enhances student learning and provides a way to have a larger clinical groups while focusing on each individual student.
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