High-Fidelity Patient Simulation As a Orientation and ...



High-Fidelity Patient Simulation as an Orientation and Retention Strategy of Graduate Nurses: An Integrative Review of the Evidence.Jessica OwenSUNY Polytechnic InstituteAbstractHigh-fidelity patient simulation makes for an ideal learning environment for healthcare professionals: it utilizes computerized manikins that respond to interventions and mimic patient’s responses in a controlled setting which mirrors the clinical environment, without the risk of harming patients. An integrative review was undertaken using guidelines set forth by Ganong to analyze the use of high-fidelity patient simulation (HFPS) in graduate nurse orientation (Ganong, 1987). The articles meeting the inclusion criteria were analyzed, and findings form the literature were linked to three themes: learning in a safe and supportive environment, fostering of collegiality and communication, and knowledge transfer and confidence. Recommendations for future research are suggested.High-Fidelity Patient Simulation as an Orientation and Retention Strategy of Graduate Nurses: An Integrative Review of the Evidence.Each day, thousands of medical errors harm the patients and families served by the American healthcare system. According to the report, To Err is Human: Building a Safer Health System, preventable adverse events are a leading cause of death in the United States (Institute of Medicine, 2000). In fact, health experts estimate that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year from medical errors (Berwick, 1999). As the single constant professional presence with hospitalized patients, nurses uniquely gather, filter, and interpret data from bedside care into the meaningful information required to diagnose, treat and deliver care to a patient. Evidence suggests that physicians, pharmacists, administrators and nurses assign primary responsibility for patient safety to nurses. In the United States, it is estimated that the shortage of Registered Nurses will be 340,000 by the year 2020 (Auerbach, Buerhaus, & Staiger, 2007). Furthermore, the greater life expectancy of individuals with acute and chronic conditions requires more complex nursing care (Heller & Nichols, 2001). Sicker patients, combined with the worsening nursing shortage, make it essential to instrument ways to ease the transition from student nurse (SN) to graduate nurse (GN). Research has shown how complex the transition from student nurse to graduate nurse can be, and how new nurses often experience difficulties transitioning from training to work. GN orientation typically involves classroom instruction and assignment to a nurse mentor. Florence Nightingale, structured her educational model with students working with nurses ‘who were trained to train (Udlis 2008, p.20). The preceptor concept is ingrained but the benefits to the GN are unclear. Research suggest that the preceptor experience has little effect on a GN critical thinking abilities, and that many GN’s have difficulty transitioning to their new role even with preceptor experiences (Udilis, 2008 & Myrick, 1988). What is clear is that the increased stress placed on staff nurse preceptors is a factor in nurse retention and burnout (Kemper, 2007). High-fidelity patient simulation makes for an ideal learning environment: it utilizes computerized manikins that respond to interventions and mimic patient’s responses in a controlled setting which mirrors the clinical environment, without the risk of harming patients. Research investigating the efficacy of simulation shows that critical thinking, clinical judgment, and competencies among health care providers is improved (Lasater, 2007; Alinier et al., 2003; Jeffries, 2005). The purpose of this article is to provide a summary of current evidence related to the use of simulation in GN orientation. Findings from the literature are categorized into three themes and recommendations for future research are suggested.MethodsAn integrative review of the literature was conducted according to the guidelines set forth by Ganong (Appendix A). Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PubMed, and the Cochran Library were searched with the following terms: GN, high-fidelity simulations, orientation, retention, and nursing education. The search was limited to nursing, although extensive literature exist about the use of simulation during orientation for other disciplines. Additional articles were obtained through citation chasing. Body of EvidenceOnly a small portion of the published research explores the effects of simulation on GN orientation, none discuss retention rates. A large subset of literature supports the use of simulation as an educational strategy in nursing. Authors of many articles describe how useful simulation can be to review, update, or teach healthcare personnel new techniques or procedures.Inclusion and Exclusion Criteria Inclusion criteria for the sample: HFPS in GN orientation, written in English, published after 1998. The year 1998 was chosen because information prior to that date focused on low and medium-fidelity simulation. Non-research articles and articles that addressed simulation for education in nursing schools were excluded. Two studies were included in the final sample (Appendix B). Common Themes IdentifiedIn this integrative review, three themes emerged: learning in a safe and supportive environment, knowledge transfer and confidence, and fostering of collegiality and communication. These themes are also supported by other articles involving high-fidelity training of other medical professionals. Learning in a Safe and Supportive EnvironmentEducation in a controlled environment allows mentors and GNs to focus on teachable moments without distractions and take full advantage of learning opportunities. GNs may make, detect, and correct patient care errors without adverse consequences, while mentors can focus on the GNs learning experience and not patients. The safe and supportive environment that simulation provides, allows for self-evaluation, in addition to feedback from peers and experienced nurses, which aids in the learning process (Ackermann et al., 2007; Beyea et al. 2007). Furthermore, simulation allows GNs the opportunity to participate in clinical events or situations on-demand, so that they may develop their clinical reasoning and decision-making skills, these clinical events may not always be available at specific times during their orientation process. Knowledge Transfer and ConfidenceGNs often suffer overwhelming feelings that they lack knowledge to make sound clinical judgments and respond appropriately. Deliberate practice is the key to the development of clinical competence. Deliberate practice involves repetitive performance of skills coupled with arduous assessment that provides GNs with feedback so they may learn from the event. When deliberate practice occurs in the setting of simulation training, GNs can evaluate their competence, synthesis of knowledge, and abilities to manage critical events. Research supports that GNs, after being involved in simulation exercises, felt more confident in emergency situations (Ackermann et al., 2008). The IOM report To ERR is Human: Building a Safer Health System called on health care organizations to develop and use simulation to train novice practitioners as part of an effort to reduce medical errors (Institute of Medicine, 2000). GNs often miss significant patient symptoms or incorrectly perform procedures that ultimately results in unfavorable patient outcomes. Researchers found that performance concerns could be identified during simulated scenarios. These concerns then could be addressed through deliberate practice and structured clinical education experiences. The inclusion of simulation in orientation programs may decrease the time required to become clinically proficient. This could result in GNs who are more confident and skilled practitioners. Fostering of Collegiality and CommunicationAccording to data from the Joint Commission on Accreditation of Healthcare Organizations, breakdown in team communication is a top contributor to sentinel events. Optimal care of patients mandates that the focused knowledge and skills of nurses, physicians, and multiple other professionals be integrated. This integration will be accomplished only through frequent, respectful interaction and skilled communication. Simulation enables GNs to practice communication techniques. The interdisciplinary team can be involved in pre-programmed scenarios which provides opportunities for teamwork and communication (Beyea et al., 2007). Intimidating behavior and deficient interpersonal relationships lead to mistrust, chronic stress and dissatisfaction among nurses. This unhealthy situation contributes to nurses leaving their positions and often their profession altogether. Fostering collegiality facilitates the transition from novice to competent nurse in addition to creating a culture within nursing that expects civility and respects. ConclusionsGN orientation programs should be able to offer ongoing supportive clinical environments that foster safe practice. The literature indicated that high-fidelity simulation provides the supportive and safe environment that GNs desire during transition to their professional role. Simulation also functions as a highly effective approach for developing confidence and seems to be effective to develop competency. Augmenting mentor and/or residency programs with simulation may assist GNs to move more quickly form novice to advanced beginner. Lastly, simulation enables GNs to practice clear and effective communication and provides experience with teamwork with other members of the healthcare team. Having open and effective communication with supportive staff is essential to guide new nurses and promote retention. Several limitations of this integrative review should be noted. The evidence available for GN orientation using high-fidelity simulation is limited; therefore, only a small number of articles were reviewed. The quality of research evidence is weak because there are a limited number of experimental studies. Evidence is also limited by a dependence on self-report measures rather than presentation of quantifiable objective outcomes. Recommendations for Future ResearchContinued research efforts are needed to determine whether simulation causes new nurses to respond more effectively in actual patient situations. In addition, further research could explore GN’s knowledge acquisition through HFPS, as compared with traditional clinical experience. No studies of residency programs using simulation have been conducted to determine whether GN’s development of clinical judgment is affected. Studies that examine the effectiveness of HFPS on GN’s clinical judgment are warranted. Another study should be designed to examine whether nurses who are oriented using simulation have greater retention rates and job satisfaction than nurses who are oriented in the traditional mentor model.The facility I work at, like many rural facilities struggles with a shortage of skilled nurses. The solution has been the recruitment of GNs. The current model of the preceptor experience program in conjunction with a nurse residency program has been implemented to help new graduate nurses assume their professional role. The problem with the current model is that the preceptor role is a demanding one, and the responsibilities and stressors associated with teaching GNs can be a factor in skilled nurses leaving employment secondary to stress and role overload. My proposal is that adjustments should be made in the current orientation/residency program to reduce the amount of stress for nurse preceptors and increase satisfaction of new graduate nurses, thus increasing retention of new gradate and skilled staff. I believe this can be accomplished through incorporating structured high-fidelity scenario training into the orientation and nurse residency program. Learning in a safe and supportive environment, competence and confidence is self-ability, and fostering of collegiality are aspects that have been identifies as being important when transitioning GNs to the role of the professional nurse. Simulation may be one way to facilitate this transition. Furthermore, this allocation of scheduled teaching time would offload mentor overload and allows mentors and GNs to focus on teachable moments without having to worry about patients. My mentor for my project, acknowledges the potential benefits of simulation training, the problem that exist is that no one knows how to utilize the high-fidelity technology that the facility has to its fullest potential. The plan will be to seek out training opportunities so that educators can develop a strong and comprehensive understanding of how to most effectively use simulation within their education programs. ReferencesAckermann, A. D., Kenny, G., & Walker, C. (2007). Simulator programs for new nurses' orientation: A retention strategy. Journal for Nurses in Staff Development, 23, 136-139. Alinier, G., Hunt, W. B., & Gordon, R. (2004). Determining the value of simulation in nurse education: study design and initial results. Nurse Education in Practice, 4, 200-207. Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O. (2007). Better late than never: Workforce supply implications of later entry into nursing. Health Affairs, 26(1), 178-185. Berwick, D. (1999). Reducing errors in medicine: It's time to take this more seriously. BMJ, 319, 136-137. Beyea, S. C., & Slattery, M. J. (2007). A Nurse Residency Program for Competency Development Using Human Patient Simulation. Journal for Nurses in Staff Development, 23, 77-82. Ganong, L. H. (1987). Integrative reviews of nursing research. Research in Nursing & Health, 10, 1-11.Heller, B., & Nichols, M. (2001). Workforce development in nursing: Priming the pipeline. Nursing and Health Care Perspectives, 22, 70-74. Jefferies, P. (2005). Designing, implementing, and evaluation: Simulations used as teaching strategies in nursing. Nurse Education Perspectives, 26, 96-103. Kemper, N. J. (2007). Win-win strategies help relieve preceptor burden. Nursing Management (springhouse), 38(2), 10-12. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: students' experiences. Journal of Nursing Education, 46, 269-276. Myrick, F. (1988). Preceptorship: a viable alternative clinical teaching strategy? Journal of Advanced Nursing, 27(3), 136-138. Udlis, K. A. (2008). Preceptorship in undergraduate nursing education: An integrative review. Journal of Nursing Education, 47(1), 20-29.Appendix AAppendix B ................
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