High Fidelity Patient Simulation: Process and Outcomes to Improve Competency Education and Validatio

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High Fidelity Patient SimulationProcess and
Outcomes to Improve Competency Education and
Validation

• Susan Sportsman, RN, Ph.D., Dean
• Midwestern State University
• College of Health Sciences and Human Services
• Wichita Falls, Texas, USA

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Texas Higher Education Coordinating Board (THECB)
Grant

• Purpose of 2004 funding
• To provide funding to eligible institutions to
  address the shortage of RNs by developing
  innovative educational projects for initial
  RN-licensure nursing students and faculty
• Primary Outcome Increase enrollment

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North Central Texas Health Care Consortium

• Midwestern State University (MSU)-BSN
• Vernon College (VC)-ADN
• United Regional Health Care System (URHCS)
• (350 bed regional hospital)

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Purposes of 1.27 Million Grant

• Pilot the implementation of a collaborative
  regional simulation center
• Increase the number of students admitted to
  clinical courses at MSU and VC by 56.
• Evaluate the effectiveness of such a center upon
  graduates perceived clinical competence.
• Determine the cost-effectiveness of such a
  center.

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Structure of Regional Simulation Center (RSC)

• 3,410 square feet renovated nursing unit at URHCS
• 7 high fidelity patient simulators (4 adults and
  3 infants/child manikins)
• 4 clinically strong BSN lab mentors, supervised
  by a MSN director
• Responsible for providing competency education
  and validation to BSN, ADN, and hospital
  clinicians.

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Strategies for Development and Evaluation of
Scenario Based Simulations

• Marcy S. Beck, RN, MSN
• Co-director Regional Simulation Center
• Midwestern State University

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Literature Supports Using Simulation as a
Teaching Strategy

• Active engagement
• Development of psychomotor skills and critical
  thinking skills
• Interactive
• Create a real and risk free environment
• Explore feelings and outcomes
• Communication and teamwork skills
• Provides for knowledge application
• Increase in learner satisfaction and confidence

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Getting Started

• Large investment of faculty time
• Write simulation programs
• Limited number of students at one time
• Faculty inexperience with high fidelity
  simulators
• What do faculty need?
• Support from Simulation Center staff
• Educational programs
• Writing scenarios
• Operating the simulator

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What Do We Do?

• Learning objectives
• Patient initially admitted in diabetic
  ketoacidosis. She is better and has been
  transferred from the ICU to the medical-surgical
  unit.
• Patient becomes hypoglycemic and requires
  recognition and treatment by the learner
• Later, the patient becomes hyperglycemic and
  requires recognition and treatment by the learner
• Debriefing points

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Nursing Education Simulation Framework (Jeffries,
2007)

• Outcomes
• Learning (Knowledge)
• Skill Performance
• Learner Satisfaction
• Critical Thinking
• Self-Confidence

Student
Teacher

• Simulation Design Characteristics
• Objectives
• Fidelity
• Problem Solving
• Student Support
• Debriefing

Educational Practices
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Scenario Format
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Evaluation

• Students
• Formative
• Summative
• Scenarios
• Feedback from students
• Staff review of scenarios
• Immediately
• Annually

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Keys to Successful Simulations

• Keep the groups small
• Few objectives
• Use Evidence Based Practice
• Support from your staff in your simulation lab
• Practice, Practice, Practice!

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Simulation is Fun!
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Using High Fidelity Simulation for Annual
Competency Validation of Hospital Staff

• Melody Chandler, RN BSN
• Co-Director Regional Simulation Center
• Midwestern State University

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History of Hospital Competency Validation

• Hospital staff dissatisfied with the process of
  repetitive competency validation through annual
  table top offering
• Hospital educators approached Regional Simulation
  Center (RSC) in an effort to enhance the
  educational offerings to the hospital staff using
  simulation

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Initial Planning

• Joint Commission
• Accrediting body that ensures patient safety and
  quality of care
• Department Specific Competencies
• Scenarios development based on department
  specific events and medical conditions
• Desired Outcomes
• Hospital staff competency validation
• Increased participant satisfaction

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Unique Perspectives

• Regional Simulation Staff
• Curriculum and theory
• Professor driven objectives
• Hospital Educators
• Institutional policy and procedure

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Developing Department Specific Objectives

• Recommendations from the Joint Commission
• 2007 Joint Commission National Patient Safety
  Goals
• Evidence Based Practice
• Surviving Sepsis Campaign
• 5 Million Lives Saved Campaign How to Guide on
  Preventing Ventilator Associated Pneumonia
• Institutional Reporting (Incident Reports)
• High risk low volume
• Low risk high volume

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Simulation Clinical Learning and Evaluation

• Knowles
• Adult Learners bring lived experiences to the
  classroom
• Prefer self-directed learning opportunities
• Bandura
• Social Learning
• Learners optimize learning through observation,
  imitation and modeling

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Processes

• Scheduling
• Participants self-scheduled into work blocks of
  4 to 5 participants per group per scenario
• Specialty staff were divided into designated
  scenario timeslots prior to the skills fair
• Check In
• Staff checked-in and received checklist
  specific to their specialty care area
• Checklists
• Color coded for each specialty care area (ie
  critical careyellow, traumagreen)

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Skills Fair

• Station 1 Scenarios (Individual Specialty Care
  Competencies)
• Department-specific scenarios were conducted in
  30 minute intervals in department-specific
  scenario rooms
• Station 2 Skills (Institutional Staff
  Competencies)
• Completed in a central location
• Average time for participant completion 1 ½
  hours
• Skills fair run time 2weeks M-F, ½ Saturday
• Mandatory completion for 900 participants

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Skills Fair Survey Results
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Simulation Survey Results
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Outcomes of Grant

• 20,074 duplicated learner visits
• 13,444 - MSU
• 4,042 - VC
• 2,688 - URHCS
• 44,963 duplicated learner hours
• 34,116 - MSU
• 7742 - VC
• 3,105 - URHCS
• 900 members of URHCS Clinical Staff participated
  in annual competency validation through the RSC
• ,

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Development of a Competency Transcript for Nurse
Graduates

• Kathleen Roberts, RN, DNP
• Assistant Professor
• Midwestern State University
• Wichita Falls, Texas, USA

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Overview

• Project developed in response to Nursing Redesign
  Taskforce of the Texas Nurses Association call
  for innovation and a redesign of nursing
  education.
• Plan
• Develop implement competency-based orientation
  process
• Documentation of psychomotor decision making
  skills given to employer
• Accepted as graduates credentials
• Used to determine orientation needs of graduate

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Background

• 57 nurse administrators BSN grads do not meet
  competency expectations
• Only 35 nurse graduates meet entry level
  expectations of clinical judgment
• Orientation 7 weeks
• Costs 15,000 - 50,000
• 55-61 turnover of grad nurses
• CNOs believe orientation can be shortened 10-50

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Problem

• No user-friendly methodology to describe the
  nursing competencies of new grads to their
  employers
• Apprentice-like mindset discounts professional
  preparation RNs required to re-enter training to
  practice their craft

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Goal

• Develop implement a competency based
  orientation process
• Create documentation process using competency
  transcript (CT)
• Psychomotor skills
• Clinical judgment ability
• Accepted as graduates credentials for practice
• Employers train to the gap

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Theoretical Framework

• Patricia Benners (1984) Novice to Expert
• Used two of her developmental levels created a
  third Unsafe

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Scenario-Based Decision Making

• 12 patient care situations
• Same scenarios practiced in regional simulation
  center (RCS)

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Reliability and Validity

• Established content and construct validity
• Content 83 items quite relevant 17 very
  relevant
• Construct RNs scored significantly higher than
  students in 11 of 12 scenarios
• Established intra-rater reliability
• 92 agreement of scores 3 months apart

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Construct Validity
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Construct Validity
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Outcome Measures

• Orientation time decreased 25
• Fewer items trained for RNs with CT
• Cost of orientation decreased 10
• RNs with CT are retained longer
• Employers trust CT

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Results

• Orientation time with CT longer than non-CT
• No difference in orientation costs
• No data available to evaluate other measures

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Other Findings

• Graduates score as Novice - different than
  Benners findings
• Differences in complexity of care
• Benner recommended using Beginner
• Results from critical thinking tool
• Applicable to educators and service
• Educators dont know how to use clinical judgment
  information
• Clinical judgment rubric difficult to use

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Recommendations

• Implement transcript at pilot test site
• Larger sample
• Automate clinical judgment rubric
• Provide guidance in use of clinical judgment
  information
• Preceptor training
• Implementation tools

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High Fidelity Patient SimulationCost
Effectiveness

• Susan Sportsman, RN, Ph.D., Dean
• Midwestern State University
• College of Health Sciences and Human Services

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Cost Effectiveness

• Cost-Benefit Analysis (CBA)
• Traditional framework in which the value of
  net social benefits is compared to value of the
  project.

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Cost Effectiveness

• Cost Effectiveness Discounted cash-flow analysis
  (DCF)
• Organization-centered, focusing on the extent to
  which the project can be funded through cash flow
  and cash savings

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Reasons for choosing DCF framework

• Although project was initiated through a grant,
  should ultimately be self sufficient
• Provides a framework to assess financial
  viability of such an assessment for other
  organizations

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Objective of DCF

• To determine if the investment costs for setting
  up the patient simulation center are offset by
  the net savings and additional cash in-flows that
  may derive from using the simulation center
  rather than school or hospital-specific lab
  approach

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Costs of the Project

• Investment cost-simulation equipment
• Staff time to set-up lab and develop scenarios
• Faculty costs savings
• RSC staff costs

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Results

• There are substantial savings in instructional
  costs that should occur as a result of the use of
  patient simulators.
• The savings are not sufficient to offset the
  investment costs based on the study assumptions.
• Harlow, K. Sportsman, S. An economic analysis
  of patient simulators for clinical training in
  nursing education. Nursing Economics. 25(1)
  January, 2007.

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Qualitative Evaluation Focus Groups
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Quantitative Data/Results

• Three Year Data Collection Process
• January 2005, 2006, 2007 Juniors
• April 2005,2006 2007 Seniors
• 2005 Seniors - Little or no simulation experience
• 2005 Juniors/2006 Seniors - 3 semesters of
  simulation experience
• 2006 Juniors/2007 Seniors - 5 semesters of
  simulation experience

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Data Collection Instruments

• Clinical Competence Appraisal Scale (PSP,
  Leadership, Teaching/Collaboration, Interpersonal
  Relations/Communication, Planning/Evaluation)
• LASSI (Motivation, Attitude, Concentration,
  Anxiety)
• Clinical Learning Environment
• Demographic Data Sheet
• GPA
• Scores on HESI

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Conclusions

• 2005 juniors (no simulation) rated their PSP
  performance significantly higher (p.0001) than
  juniors in 2006 and 2007.
• Participating in simulation early in their
  clinical experience may provide a dose of
  realism for students in their clinical courses.
• ________________
• Substituting clinical experience in the RSC for a
  portion of the time required in clinical agencies
  does not make a difference in students
  perception of their clinical competence.
• Argues for the substitution of simulation
  experience for some clinical experiences as a
  strategy for increasing student admissions when
  there are limited clinical experiences available
  to schools

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Conclusions

• 2005 seniors had a significantly higher mean
  anxiety score (p.015) (less anxiety) than the
  seniors in 2006 and 2007
• Increased participation in simulation experiences
  may have contributed to the increase in the 2006
  and 2007 senior students anxiety.
• 
  -------------------------------
• The mean scores on the CLE Scale for the 2005
  seniors were significantly lower than the mean
  scores for seniors in 2006 and 2007.
• Simulation may positively influence students
  perceptions of the clinical environment where
  they are assigned during the last semester of
  their course of study.

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Conclusions

• No significant difference in graduating GPA or
  HESI E2 Exit Exam for seniors in 2005, 2006 and
  2007
• Participation in scenario-based simulation does
  not negatively impact performance on the HESI
  exam. (Results highly correlated with success
  on the NCLEX-RN licensing exam (Morrison, et. al,
  2004).

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After the Grant

• Funding Based on Usage

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MOU for Consortium

• The North Central Texas Health Care Consortium
  (NCTHCC) Board is responsible for
• Selection and evaluation of the Director of the
  RSC
• Determination of overall policies regarding the
  RSC
• Financial management of RSC funds, including
  budget development
• Determination of future research or program
  development
• Consortium Members
• Dean of the College of HSHS, MSU
• Chair, MSU Nursing
• Director, VC Program
• Senior VC faculty member from VC
• Vice President , Patient Care Services, URHCS
• Manager of Education, URHCS
• Director (s) of RSC.

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The Consortium

• The Chair - senior representative of the
  organization who serves as the financial manager.
• All decisions of the NCTHCC are made through a
  simple majority.
• Member organizations responsible for operational
  costs of the RSC based upon the percentage of
  time learners partner spent in RSC the previous
  academic year.
• The NCTHCC Board will meet at least four times a
  year.

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• QUESTIONS?