Jennifer  Hayden,  MSN,  RN

2

•   Small  sample  size
•   No  control  group
•   No  randomiza*on
•   Variability  in  study  design
•   No  longitudinal  studies
3

1.
Does  subs*tu*ng  clinical  hours  with  25%  and  50%   simula*on  impact  educa*onal  outcomes
(knowledge,  clinical  competency,  cri*cal  thinking   and  readiness  for  prac*ce)  assessed  at  the  end  of   the  undergraduate  nursing  program?
4

2.
Are  there  course  by  course  differences  in  nursing   knowledge,  clinical  competency,  and  percep*on  of   learning  needs  being  met  among  undergraduate   students  when  tradi*onal  clinical  hours  are   subs*tuted  with  25%  and  50%  simula*on?
5

3.
Are  there  differences  in  first-­‐*me  NCLEX  pass  rates   between  students  that  were  randomized  into  a   control  group,  25%  and  50%  of  tradi*onal  clinical   subs*tuted  with  simula*on?
6

1.
Are  there  differences  in  clinical  competency,  cri*cal   thinking  and  readiness  for  prac*ce  among  the  new   graduate  nurses  from  the  three  study  groups?
2.
Are  there  differences  among  new  graduates  from   the  three  study  groups  in  acclima*on  to  the  role  of   the  professional  nurse?
7

•   Randomized
•   Controlled
•   Large-­‐scale
•   Mul*-­‐site
•   Longitudinal
•   Follow-­‐up  component
8

•   Tradi*onal  clinical  experiences  as  usual
(up  to  10%  simula*on)
•   25%  of  clinical  *me  spent  in  simula*on
•   75%  spent  in  tradi*onal  clinical
•   50%  of  clinical  *me  spent  in  simula*on
•   50%  of  *me  in  tradi*onal  clinical
9

10

•   Fundamentals  of  Nursing
•   Medical-­‐Surgical  Nursing
•   Advanced
Medical-­‐Surgical  Nursing
•   Maternal-­‐newborn  Nursing
•   Pediatrics
•   Mental  Health  Nursing
•   Community  Health  Nursing
11

12

•   Nursing  knowledge
ATI  Content  Mastery  Series®
•   Clinical  competency
Creighton  Competency  Evalua*on  Instrument  (CCEI)
New  Graduate  Nurse  Performance  Survey
Na*onal  Council  Licensure  Exam®  (NCLEX)
•   Global  assessment  of  clinical  competency  &  readiness  for   prac*ce
13

•   Learning  needs  met
Clinical  Learning  Environment  Comparison  Survey
(CLECS)
•   Cri*cal  thinking
Cri*cal  Thinking  Diagnos*c
•   Acclima*on  to  the  role  of  the  RN
Lee  first  nursing  posi*on,  pa*ent  loads,  charge  nurse   responsibili*es,  workplace  stress
14

15

Interven*on:  Simula*on  as  used  in  the  study
For  the  purpose  of  this  study,  simula*on  includes
•   scenario  based  simula*on  using  high  and  medium   fidelity  manikins
•   standardized  pa*ents
•   role  playing
•   computer  based  cri*cal  thinking  simula*ons
•   Skills  sta*ons
16

•   En*re  clinical  group  reported  to  the  sim  lab  with   clinical  instructor
•   Students  were  assigned  to  two  nursing  roles
•   Clinical  instructor  completed  CCEI  ra*ngs

•   Needed  a  standardized   simula*on  curriculum   so  that  all  10  schools   were  doing  the  same   thing  for  the  study

•   Select  group  of  experts
•   Itera*ve  process
•   Consensus  of  opinion
3  round  Delphi  study   used
•   Round  1:  Survey
•   Round  2:  Refine  the  list
•   Round  3:  Topics  ranked

•   Link  to  electronic  survey   distributed  to  2  nursing   simula*on  communi*es
•   Link  ac*ve  for  4  weeks
October-­‐November
2010

•   Lists  distributed  back  to  the  10  par*cipa*ng  schools
•   Course  faculty  were  asked  to  rate  each  of  the  items   as:
–   most  important
–   important
–   good  content  to  cover  if  there’s  *me

23

24

25

•   Consented:  847
Started  study          Completed  study
Control      268        218
25%  group    293        236
50%  group    286        212
•   Female:  86%
•   White:  84%
•   Age:  26.3  years  (SD  8.0,  range  18-­‐60)
•   Experience  as  nursing  assistant:  16%
26

Number  of  students  randomized
Number  of  students  comple*ng  the  study
Rate  of  Comple,on
Number  of  students  who  failed  a  course  during  the  study
Rate  of  Failure
Number  of  students  who  withdrew  or  were  withdrawn  from  the   study  for  any  reason
Rate  of  Withdrawal
Overall
847
666
78.6%
66
7.8%
115
13.6%
Control  group   25%    group   50%    group
268
218
81.3%
25
293
236
80.5%
22
286
212
74.1%
19
9.3%
25
9.3%
7.5%
35
11.9%
6.6%
55
19.2%**
27

28

Does  subs*tu*ng  clinical  hours  with  25%  and  50%   simula*on  impact  educa*onal  outcomes  (knowledge,   clinical  competency,  cri*cal  thinking  and  readiness  for   prac*ce)  assessed  at  the  end  of  the  undergraduate   nursing  program?
29

Knowledge-­‐End  of  Program
ATI  Comprehensive  Predictor
100%
80%
60%
40%
20%
0%
69.1%   69.5%
Control  group   25%  group
70.1%
50%  group
30   p=0.478

Clinical  Competency-­‐End  of  Program  Preceptor
Ra*ngs
New  Graduate  Nurse  Performance  Survey  (1-­‐6  scale)
Control  group
(n=155)
25%  group
(n=171)
50%  group
(n=136)
Effect   size
P  value
Mean
Clinical  Knowledge
5.12
Technical  Skills
Cri*cal  Thinking
5.06
5.11
Communica*on
Professionalism
Management  of
Responsibili*es
1=lowest  ra*ng,  6=highest  ra*ng
5.30
5.38
5.22
SD
0.73
0.76
0.72
0.65
0.69
0.71
Mean   SD   Mean   SD
5.18   0.60   5.09   0.72   0.14   0.481
5.09   0.64   5.01   0.86   0.11   0.659
5.06   0.71   5.03   0.88   0.10   0.668
5.34   0.65   5.24   0.87   0.13   0.478
5.47   0.61   5.39   0.85   0.14   0.432
5.20   0.70   5.17   0.85   0.06   0.849
31

Cri*cal  Thinking-­‐End  of  Program
Preceptor  Ra*ngs
CriTcal  Thinking  DiagnosTc  (1-­‐6  scale)
Control  group
(n=155)
25%  group
(n=171)
50%  group
(n=136)
Mean
Problem  Recogni*on
Clinical  Decision  Making
4.97
5.09
Priori*za*on
Clinical  Implementa*on
5.14
5.10
Reflec*on
5.13
1=lowest  ra*ng,  6=highest  ra*ng
SD
0.70
0.60
0.66
0.61
0.64
Mean
5.07
5.18
5.08
5.19
5.23
SD
0.65
0.61
0.63
0.60
0.59
Mean
5.02
5.12
5.03
5.10
5.15
SD
0.75
0.81
0.77
0.76
0.78
32
Effect   size
P  value
0.15
0.15
0.15
0.15
0.16
0.494
0.469
0.418
0.361
0.318

Overall  Clinical  Competency-­‐EOP
Preceptor  Ra*ngs
Global  assessment  of  clinical  competency  &  readiness  for  pracTce  (1-­‐10  scale)
Control  group
(n=156)
Mean   SD
Overall  ra*ng   8.20
1=lowest  ra*ng,  10=highest  ra*ng
1.34
25%  group
(n=168)
Mean   SD
8.29   1.48
50%  group
(n=135)
Mean   SD
8.34
Effect   size
1.44   0.10
P  value
0.688
33

Are  there  course  by  course  differences  in  nursing   knowledge,  clinical  competency,  and  percep*on  of   learning  needs  being  met  among  undergraduate   students  when  tradi*onal  clinical  hours  are  subs*tuted   with  25%  and  50%  simula*on?
34

Fundamentals  of  Nursing
Knowledge
100%
ATI  Assessment  Total  Score  (n=800)
80%
60%
40%
20%
0%
68.1%   67.3%   68.6%
Control  group   25%  group   50%  group
35   p=0.155

Fundamentals  of  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Se\ng
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5   6   7   8
#  of  Weeks
9   10   11   12   13   14
36
Control  group
25%  group
50%  group

Medical-­‐Surgical  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Environment
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5   6   7   8
#  of  Weeks
9   10   11   12   13   14   15
37
Control  Group
25%  Group
50%  Group

40%
20%
0%
Advanced  Medical-­‐Surgical  Nursing
Knowledge
100%
ATI  Assessment  Total  Score  (n=683)
80%
62.7%
64.1%
60%
65.5%
Control  group   25%  group   50%  group
38   p=0.005

Advanced  Medical-­‐Surgical  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Se\ng
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5   6   7   8
#  of  Weeks
9   10   11   12   13   14
39
Control  Group
25%  Group
50%  Group

Maternal-­‐Newborn  Nursing
Knowledge
100%
ATI  Assessment  Total  Score  (n=680)
80%
60%
40%
20%
0%
68.4%   69.2%
Control  group   25%  group
71.1%
50%  group
40   p=0.011

Maternal-­‐Newborn  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Se\ng
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5   6   7
#  of  Weeks
8   9   10   11   12   13
41
Control  Group
25%  Group
50%  Group

Pediatric  Nursing
Knowledge
100%
ATI  Assessment  Total  Score  (n=620)
80%
60%
40%
20%
0%
63.7%   65.0%
Control  group   25%  group
67.1%
50%  group
42   p=0.002

Pediatric  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Se\ng
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5   6
#  of  Weeks
7   8   9   10   11
43
Control  Group
25%  Group
50%  Group

Mental  Health  Nursing
Knowledge
100%
ATI  Assessment  Total  Score  (n=633)
80%
63.4%   65.2%
60%
40%
20%
0%
Control  group   25%  group
66.3%
44
50%  group   p=0.011

Mental  Health  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Se\ng
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5   6   7   8
#  of  Weeks
9   10   11   12   13   14   15
45
Control  Group
25%  Group
50%  Group

40%
20%
0%
Community  Health  Nursing
Knowledge
100%
ATI  Assessment    Total  Score  (n=252)
80%
65.5%   65.5%
60%
67.1%
Control  group   25%  group   50%  group
46   p=0.387

Community  Health  Nursing
Clinical  Competency
CCEI  Scores:  Clinical  Se\ng
100.0
80.0
60.0
40.0
20.0
0.0
1   2   3   4   5
#  of  Weeks
6   7   8   9
47
Control  Group
25%  Group
50%  Group

Learning  Needs  Met-­‐End  of  Program
Clinical  Environment  Comparison  Survey  (CLECS)
Tradi*onal
Simula*on   n
Control  group
Mean   SD
197   3.50   0.42
174   2.82   0.67
Effect
Size
1.23
Scale  1-­‐4
1=Learning  needs  not  met
4=Learning  needs  well  met   n
202
202
25%  group
Mean   SD
3.41   0.41
3.28   0.51
Effect
Size
0.28   n
187
187
50%  group
Mean   SD
3.26   0.53
3.54   0.45
Effect
Size
0.57
48

Are  there  differences  in  first-­‐*me  NCLEX  pass  rates   between  students  that  were  randomized  into  a  control   group,  25%  and  50%  of  tradi*onal  clinical  subs*tuted   with  simula*on?
49

NCLEX
100%
80%
60%
40%
20%
0%
88.4%
Control  group
85.5%   87.1%   p=0.737
25%  group   50%  group
50

51

•   Completed  aeer  start   date:
6  weeks
3  months
6  months
52

Follow-­‐up  Study
Response  Rate
•   575  students  agreed  to  be  contacted  for  follow-­‐up   surveys  (86.3%  of  study  completers)
•   379  new  graduates  provided  their  start  date   informa*on  (65.9%  of  those  who  agreed  to  follow-­‐up   study)
•   355  completed  at  least  one  follow-­‐up  survey
53

Study  Part  II
Research  Ques*on  1
Are  there  differences  in  clinical  competency,  cri*cal   thinking  and  readiness  for  prac*ce  among  the  new   graduate  nurses  from  the  three  study  groups?
54

Clinical  Competency
6  Month  Manager  Ra*ngs
New  Graduate  Nurse  Performance  Survey  (1-­‐6  scale)
Control  group
(n=72)
25%  group
(n=86)
Mean
Clinical  Knowledge   5.21
Technical  Skills
Cri*cal  Thinking
5.28
5.11
Communica*on   5.40
Professionalism
Management  of
Responsibili*es
5.54
5.26
1=lowest  ra*ng,  6=highest  ra*ng
SD
0.63
0.65
0.78
0.66
0.58
0.73
50%  group
(n=84)
Effect   size
P  value
Mean   SD   Mean   SD
5.07   0.92   5.21   0.66   0.17   0.376
5.09   0.95   5.19   0.65   0.23   0.325
5.06   0.92   5.15   0.72   0.11   0.741
5.22   0.95   5.42   0.70   0.24   0.203
5.30   0.95   5.50   0.65   0.30   0.096
5.13   0.94   5.32   0.73   0.23   0.284
55

Cri*cal  Thinking
6  Month  Manager  Ra*ngs
CriTcal  Thinking  DiagnosTc  (1-­‐6  scale)
Control  group
(n=72)
Mean   SD
Problem  Recogni*on
Clinical  Decision  Making
Priori*za*on
Clinical  Implementa*on
Reflec*on
5.36
5.40
5.36
5.40
5.42
0.60
0.53
0.68
0.49
0.53
25%  group  (n=85)   50%  group  (n=84)   Effect   size
Mean   SD   Mean   SD
5.17
5.28
5.25
5.21
5.26
0.88
0.88
0.90
0.92
0.92
5.28
5.36
5.35
5.38
5.39
0.57
0.53
0.57
0.55
0.58
0.25
0.16
0.14
0.25
0.21
P  value
0.251
0.491
0.559
0.116
0.325
1=lowest  ra*ng,  6=highest  ra*ng
56

Overall  Clinical  Competency
6  Month  Manager  Ra*ngs
Global  assessment  of  clinical  competency  &  readiness  for  pracTce  (1-­‐10  scale)
Overall  ra*ng
Control  group
(n=72)
Mean   SD
8.60   1.37
25%  group
(n=86)
Mean   SD
8.36   1.46
50%  group
(n=84)
Mean   SD
8.55   1.16
Effect   size
0.16
P  value
0.527
1=lowest  ra*ng,  10=highest  ra*ng
57

Study  Part  II
Research  Ques*on  2
Are  there  differences  among  new  graduates  from  the   three  study  groups  in  acclima*on  to  the  role  of  the   professional  nurse?
58

6  Week  Survey
Very  well  prepared
Quite  a  bit  prepared
Somewhat  prepared
Not  at  all  prepared
6  Month  Survey
Control  group
(n=68)   freq
15
%
22%
25
26
2
37%
38%
3%
25%  group  (n=99)   freq
20
42
37
0
%
20%
42%
37%
0
Very  well  prepared
Quite  a  bit  prepared
Somewhat  prepared
Not  at  all  prepared
Control  group
(n=98)
14
44
38
2
14%
45%
39%
2%
25%  group  (n=108)
21
40
46
1
19%
37%
43%
1%
50%  group
(n=99)   freq
36
%
36%
36
27
0
36%
27%
0
Effect   size
0.16
50%  group
(n=109)
29
46
33
1
27%
42%
30%
1%
59
0.11
P  value
0.030**
0.261

Lee  First  Nursing  Posi*on
6  Month  Survey
Lee  first  posi*on
Control  group   freq   %
5   7.2%
25%  group   freq   %
9   7.3%
50%  group   freq   %
11   9.1%
Effect   size
0.07
P  value
0.462
60

Pa*ent  Care  Assignments
6  Month  Survey
Control  group
(n=88)
25%  group
(n=106)
Not  challenging  enough
Just  right
Too  challenging   freq
4
73
11
%
5%
83%
13%   freq
5
89
12
%
5%
84%
11%   freq
5
87
13
50%  group
(n=105)
%
5%
83%
12%
Effect   size
P  value
0.01   0.999
61

70%
60%
50%
40%
30%
20%
10%
0%
I  am  experiencing  stress  at  work
3  month
100%
6  week
13.0%   11.9%   12.0%
15.1%   13.5%
90%
16.2%   17.5%
25.0%
80%
50.9%
32.3%
52.9%
26.5%
3.7%   4.4%
Total   Contol
Group
47.5%
36.6%
4.0%
25%
Group
53.0%
32.0%
3.0%
50%
Group
54.7%
44.6%
25.2%   30.4%
2.6%
Total   Contol
Group
54.7%
26.4%
3.8%
25%
Group
63.1%
19.8%
3.6%
50%
Group
Strongly  disagree   Disagree   Agree   Strongly  agree
13.7%
6  month
18.2%
13.2%
10.5%
63.5%
67.1%
57.6%
66.7%
19.7%
3.0%
11.4%
3.4%
Total   Contol
Group
25.5%
3.8%
25%
Group
21.0%
1.9%
50%
Group
62

50%
40%
30%
20%
10%
0%
In  the  last  week,  I  felt  expectaTons  of  me  were  unrealisTc
6  week   3  month   6  month
100%
4.0%
6.9%
9.0%
3.6%
9.1%
5.4%
1.9%
11.3%
3.0%
8.4%
4.6%   2.8%
8.0%   11.3%
90%
12.0%
20.6%
80%   19.7%   16.8%   22.0%   24.3%
24.3%   23.6%
70%   25.0%
32.4%
30.2%
39.8%
60%
71.0%   72.1%   72.3%
69.0%
63.1%
57.6%
63.2%
67.6%
56.2%
47.7%
55.7%
Total   Contol
Group
25%
Group
50%
Group
Total   Contol
Group
25%
Group
50%
Group
Total   Contol
Group
25%
Group
Almost  never   Some*mes   Oeen   Almost  always
28.6%
63.8%
50%
Group
63

•   Par*cipa*ng  schools  were  not  randomly  selected
•   Only  used  one  method  of  conduc*ng  simula*ons
•   Quality  of  the  clinical  experiences  was  not  assessed
64

•   End  of  program  preceptors  and  nurse  managers  not   blinded  as  to  study  group
•   Distribu*on  of  end  of  program  and  nurse  manager   surveys  relied  on  the  study  par*cipants
65

1.
Up  to  50%  simula*on  can  be  effec*vely  subs*tuted   for  tradi*onal  clinical  experience  in  all  core  courses   across  the  prelicensure  nursing  curriculum.
2.
50%  simula*on  can  be  effec*vely  used  in  various   program  types,  in  different  geographic  areas  in   urban  and  rural  seqngs  with  good  educa*onal   outcomes.
66

3.
NCLEX  pass  rates  were  unaffected  by  the   subs*tu*on  of  simula*on  throughout  the   curriculum.
4.
All  three  groups  were  equally  prepared  for  entry   into  prac*ce  as  a  new  graduate  RN.
5.
Policy  decisions  regarding  the  use  and  amount  of   simula*on  in  nursing  needs  to  be  dependent  upon   the  u*liza*on  of  best  prac*ces  in  simula*on.
67

These  results  were  achieved  using:
•   INACSL  Standards  of  Best  Prac*ce
•   High  quality  simula*ons
•   Debriefing  method  grounded  in  educa*onal  theory
•   Trained  and  dedicated  simula*on  faculty
68

•   Formally  trained  faculty  in  simula*on  pedagogy
•   Use  of  theory-­‐based  debriefing  methods  using   subject  majer  experts
•   Adequate  numbers  of  simula*on  faculty  to  support   the  learners
•   Equipment  and  supplies  to  create  a  realis*c   environment
69

70