Effective care prioritization for multiple patients is an important skill for nursing students to learn. However, the fast-paced, unpredictable nature of clinical environments can impose high risks for students, instructors, and patients, resulting in barriers to prioritization skill acquisition. Further, instructor-to-student ratios can be as high as 1:10, creating challenges in promoting delegation, prioritization, and collaboration opportunities and potentially restricting student assignments to 1 or 2 patients per shift.1 Therefore, although prioritization competency is essential for safety and quality,2 these skills can be difficult to teach and for students to master in traditional clinical settings.3 One way to meet this challenge is through the use of multipatient simulation (MPS),4 where a deliberate focus is placed on prioritization skills in controlled, low-risk environments.3
Although much of the original prioritization research focused on disaster response and emergency departments, the literature was lacking in studies using MPS to teach prioritization during routine care.5,6 However, the area gained recognition as the need for new nurses to be better prepared in caring for multiple patients emerged.3,4 The current growing body of simulation literature supports the use of MPS as an effective tool to assist students in developing prioritization, delegation,3,4,7,8 and teamwork9 skills when caring for multiple patients simultaneously.
Historically, creating successful MPSs has been challenging.10,11 Limited space, faculty time, and staffing contribute to difficulties in exposing numerous students to simulations in a relatively short academic semester. To fill a curricular gap, we developed a series of MPSs requiring student pairs to prioritize care for 3 patients, with slight differences in patient presentations between pairs. Our unique approach encouraged student collaboration, required rationale for prioritization decisions, and used student teaching assistants (TAs) to facilitate MPSs. The project aims were to (1) promote student collaboration, teamwork, and prioritization skill acquisition through MPS participation; (2) assess student ability to collaboratively prioritize care for 3 patients; and (3) assess student confidence in ability to prioritize care post-MPS participation.
Simulation Details
Three MPS scenarios with slightly varied scripts and props were developed and labeled A, B, and C. A panel of content experts reviewed scenarios and validated the objectives, care priority order, and debrief questions. Care priority was predetermined based on patient needs: urgent (airway, breathing, circulation), less than urgent but if unmet could result in harm (bladder distention, delirium, vomiting), or nonurgent. To promote consistency, patient names, histories, and diagnoses (ruptured appendix, urosepsis, bowel obstruction) remained constant. However, seemingly small yet key variations were incorporated into scenarios, resulting in different orders of priority and thus helping maintain the simulation's integrity. For example, reports A and C included "Mr Amarado is comfortable and sleeping," whereas B included "Mr Amarado is moaning and requesting pain medication." After the TAs randomly selected and read rounds to student pairs, students were instructed to collaborate and determine order of priorities.
A unique component of the project required students to sit down after rounds and formulate rationale for priority order as a team. Both from experience and from the literature,1,3,4,9,10 we anticipated challenges in promoting student teamwork, communication, and collaboration skills. Although we typically encourage students to problem solve independently, we highlighted the importance of collaboration during this MPS. After collaborating, students worked in teams to provide care.
Simulation Logistics
Following institutional review board approval, the project was implemented with first-semester junior-year baccalaureate students (N = 86). Students chose a partner, and the pairs were asked to sign up in 1-hour blocks and to review pain management, physical assessment, vital signs, and wound, nasogastric, and urinary care. Grading was pass/fail, and passing requirements included arriving on time, in uniform, and fully prepared to participate throughout the MPS.
Limited faculty time can be a barrier to running numerous scenarios quickly. To alleviate this barrier, we piloted using 2 graduate family nurse practitioner students as TAs to facilitate simulations, gather data, and debrief. Both TAs were previously educated in simulation pedagogy and had assisted in prior simulations. Course faculty instructed them in multiple areas: project goals, student learning objectives, and expectations; use of evaluation instruments; scripts; and equipment, props, and manikins. We conducted pilot tests to resolve potential issues and answer TA questions. Other than weekly check-ins, this "up-front" preparation allowed for simulation orchestration to be fully delegated to TAs, saving significant faculty time during the semester.
We anticipated barriers in requiring major prop or manikin changes between simulations. In further efforts to incorporate time- and cost-effective strategies, we incorporated minor and easily executed variations that allowed for rapid changes and differing priorities. Prop revisions included substituting bloody saturated dressings for dry ones, inserted nasogastric tubes for packaged ones, and full urinary drainage bags for empty ones.
During the simulation, TAs documented student performance using the Creighton Competency Evaluation Instrument (CCEI),12 a 23-item checklist designed to measure student competence in Assessment, Communication, Judgment, and Safety. CCEI content validity ranges from 3.78 to 3.89 with Cronbach's [alpha] > .90.13 Using answer keys to validate correct order, TAs documented under CCEI's comments if the pair ordered all care correctly or if there were errors in what was completed first, second, or third.
By the end of the semester, all students were emailed anonymous surveys to gather self-reported data related to their MPS participation. This survey included questions from the Simulation Effectiveness Tool-Modified.14 In addition, several faculty-developed questions were added, asking students if their confidence in prioritizing and caring for multiple patients improved as a direct result of participating.
Findings
The simulation ran successfully 43 times over 60 days, allowing for 86 students to practice collaboration, teamwork, and prioritization skills for multiple patients and meeting the first project goal. CCEI12 results indicated that after collaborating 33 pairs (77%) demonstrated competence in the ability to prioritize care appropriately, 9 pairs (21%) made 1 or more prioritization errors, and 1 pair had missing data. Of pairs with errors, 2 selected urgent (first) priorities correctly but ordered the 2 less urgent interventions incorrectly, whereas the other 7 pairs had all 3 interventions incorrectly ordered, suggesting the need for further education. However, despite prioritization errors among pairs, of the 76 completed surveys, students reported increased confidence in ability to prioritize (n = 65 [86%]) and care for multiple patients (n = 56 [74%]) after participating in this MPS. Students found value in participating, with 96% reporting debriefing aided most in their learning.
Piloting the sole use of TAs for simulation facilitation was successful. The TAs were valuable and cost-effective team members, saving nearly 60 hours of faculty and simulation staff time. An unanticipated benefit was TA off-hour availability, allowing simulations to run during evenings and weekends, and using simulation space more effectively in a concentrated time period.
Conclusion
Results of this project validate the successful use of MPS to promote student teamwork, collaboration, and prioritization practice. In this setting, students, faculty, and TAs found the project beneficial. The focus on multipatient care prioritization outside emergency settings, student collaboration, and incorporation of minor script and prop changes to alter outcomes made this MPS unique. In addition, using TAs to run the MPS saved faculty time, enhanced use of simulation rooms during off-hours, and provided TAs with experience in facilitating this important teaching pedagogy. Based on positive student feedback and findings related to prioritization errors, adding MPSs earlier in the curriculum will be initiated.
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