The number of students enrolled in entry-level baccalaureate nursing programs has increased by more than 20 percent since 2010 (American Association of Colleges of Nursing, 2018). With the continued growth in student enrollment and a decrease in traditional clinical site availability (Richardson, Goldsamt, Simmons, Gilmartin, & Jeffries, 2014), nurse educators have been challenged to provide quality clinical learning experiences. As the National Council for State Boards of Nursing National Simulation Study (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014) has indicated that up to 50 percent of students' traditional clinical time can be replaced with simulation without impacting student outcomes, schools of nursing have sought to incorporate meaningful simulation learning experiences as part of clinical practicum courses. However, many schools of nursing struggle with organizing and implementing a clinical education delivery model that can accommodate the large number of students enrolled in these courses.
Like many schools of nursing, the entry-level baccalaureate nursing program at Carroll University, a small, private, liberal arts university in Wisconsin, has experienced significant growth over the past decade. Since 2013, enrollment in the nursing program has increased by more than 25 percent. The increase of students enrolled in the program has been felt most acutely in clinicals precepted by nursing faculty in hospitals or long-term care facilities. Faculty may only supervise a maximum of 8 to 10 students while providing direct patient care in a hospital or other clinical setting (Chappy & Stewart, 2004).
During the 2013 to 2014 academic year, the five-credit-hour medical-surgical nursing practicum course offered eight clinical and simulation laboratory sections to accommodate the 64 students enrolled each semester. In 2018, the number of clinical and laboratory sections offered during the spring and fall expanded to 12 to accommodate the 93 students enrolled each semester. The significant program growth led to the need for creative strategies in structuring the simulation laboratory portion of the course while continuing to ensure students were able to meet the practicum course objectives.
PROCESS/IMPLEMENTATION
To accommodate the growing number of students in the program, a simulation laboratory model was developed that allows multiple clinical groups to take part simultaneously. Throughout the semester, students take part in a traditional clinical day in a hospital setting with their clinical instructor for nine hours one day each week; on the following day, students work in the nursing simulation laboratory for six hours each week. The model utilized for simulation laboratory days was designed to include five different student activities each week, with each activity lasting approximately one hour (see Supplemental Digital Content, available at http://links.lww.com/NEP/A165, for Table 1). The five activities each week include student simulation preparation time, two high-fidelity simulation learning experiences, one skills station, and one station where students are able to collaborate with clinical faculty members on written assignments. Simulation preparation time is similar to preparing for hospital clinicals; students review electronic health records and patients' medication administration records, and they create patient care plans with interventions. Each high-fidelity simulation learning experience is developed by course faculty and incorporates elements of the NLN Jeffries' Simulation Theory (Jeffries, Rodger, & Adamson, 2015).
A maximum of six student participants, assigned roles as participants and observers, take part in all simulation learning experiences. Each simulation also incorporates faculty-led prebriefing and debriefing, as well as student peer evaluation. The skills stations are designed to introduce students to a new nursing skill, such as tracheostomy care or blood administration, and allows students time to review, demonstrate, and practice these skills with laboratory assistants.
After a skill is introduced during a simulation laboratory day, it is expanded upon the following week and integrated into one of the high-fidelity simulation learning experiences. Two sessions of the simulation laboratory schedule are held each week; each session accommodates 48 students from six different clinical groups simultaneously.
The medical-surgical nursing theory coordinator and medical-surgical practicum coordinator collaborate to align simulation laboratory activities with didactic content to enhance student learning. The objective is to assist students in connecting concepts learned in lecture to hands-on application experiences. Simulation-based activities are faculty written to ensure scenarios include relevant skills and build upon didactic content.
Facilities
To facilitate simulation laboratory days, adequate space, facilities, and equipment are often a concern for nursing faculty (Jeffries, 2012). Prior to 2018, Carroll University housed a 4,500 square foot laboratory space with one high-fidelity simulation room on campus and four additional high-fidelity simulation rooms at a remote location. In January of 2018, the university opened a new, 13,500 square foot simulation laboratory space with five high-fidelity simulation rooms to accommodate the growing number of students enrolled in the nursing program.
Staffing
Adequate staffing is necessary to ensure all components of the simulation laboratory day are properly facilitated. To ensure adequate staffing, instructors for each clinical group attend each weekly simulation laboratory day with their student groups. In addition, one baccalaureate-prepared RN functions in the role of lab assistant for each clinical group. BSN lab assistants serve as simulation manikin operators and skills practice station facilitators. They are an asset in the development of high-fidelity simulations as they are able to advise on current practices and provide content suggestions. The nursing program also employs a full-time simulation laboratory manager, an RN prepared at the BSN level, who is responsible for ensuring supplies are stocked, simulations are set up according to current standards, moulage, and organizing the scheduled simulation laboratory activities.
EVALUATION
Student feedback is evaluated weekly using the Simulation Effectiveness Tool (Leighton, Ravert, Mudra, & Macintosh, 2015). Qualitative feedback from students has indicated that they enjoy the setup of the simulation laboratory day and that they appreciate having preparation time scheduled into their simulation laboratory day rather than having to complete preparatory work at home.
Failure to maintain consistency in simulation operations, debriefing practices, and skill demonstration has been noted to be an area of frustration for students. Between the simulation laboratory manager and the numerous clinical faculty and BSN lab assistants, it is difficult to ensure everyone performs exactly the same. Measures continue to be implemented to ensure consistency, such as faculty development on the proper use of evaluation tools; group faculty preparation time prior to each simulation laboratory day; and the use of standardized simulation templates, debriefing guides, and skills checklists. Evaluation of the simulation laboratory model is an ongoing process, and revisions to the model are made prior to each semester based on student and faculty feedback.
CONCLUSION
As the numbers of students within nursing programs continue to increase and clinical site availability decreases, nurse educators will seek models that can incorporate meaningful simulation learning experiences to supplement hospital-based learning experiences. Innovative models for clinical education delivery continue to be needed and shared among nurse educators.
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