Active Learning for Nurse Residents

The University of Utah Hospital is developing a transition-to-practice program for their new graduate nurses (NGNs) entering practice. This program comes after the COVID-19 pandemic, which has challenged hospitals nationwide with the retention of experienced employees. These NGNs are entering the workforce with significantly less patient care experience than those pre-pandemic. The program seeks to bridge the knowledge gap for these new-to-practice nurses. This project consisted of two phases: the first entailed a Needs Assessment with the Intensive Care Units managers and educators to evaluate the current situation and identify areas of improvement. The second phase involved the development of a high-fidelity simulation involving a decompensating patient for the nurse residents to learn in a safe, controlled environment. Approximately 33% of the survey respondents completed the survey. Several takeaways were identified upon analysis: less clinical time in school has resulted in less proficient nurses upon entry to the workforce, most educators perceive the new graduates can process work-related emotional stress appropriately, and inconsistent onboarding processes on the inpatient units. The second phase was not implemented during the timeframe of this project but has been turned over to the Nursing Education Department for future use in the nurse residency program. It has been reviewed by outside nurse educators to add validity for its use in NGN learning. Adapting to educating nurses in a post-pandemic environment comes with new challenges that must be overcome. Adopting technology in educational environments to create realistic scenarios that relate to experiences that nurses will see at the bedside will be most helpful. Lastly, open lines of communication between the inpatient units and the nursing education department to review and adjust educational content based on feedback from the units and the nurses are most beneficial for maintaining the optimal educational environment.

1 Active Learning for Nurse Residents William L. Patzke College of Nursing: The University of Utah NURS 6881: Master’s Practicum and Project Capstone II May 3, 2023 2 Abstract Background: The University of Utah Hospital is developing a transition-to-practice program for their new graduate nurses (NGNs) entering practice. This program comes after the COVID-19 pandemic, which has challenged hospitals nationwide with the retention of experienced employees. These NGNs are entering the workforce with significantly less patient care experience than those pre-pandemic. The program seeks to bridge the knowledge gap for these new-to-practice nurses. Methods: This project consisted of two phases: the first entailed a Needs Assessment with the Intensive Care Units managers and educators to evaluate the current situation and identify areas of improvement. The second phase involved the development of a high-fidelity simulation involving a decompensating patient for the nurse residents to learn in a safe, controlled environment. Results: Approximately 33% of the survey respondents completed the survey. Several takeaways were identified upon analysis: less clinical time in school has resulted in less proficient nurses upon entry to the workforce, most educators perceive the new graduates can process work-related emotional stress appropriately, and inconsistent onboarding processes on the inpatient units. The second phase was not implemented during the timeframe of this project but has been turned over to the Nursing Education Department for future use in the nurse residency program. It has been reviewed by outside nurse educators to add validity for its use in NGN learning. Conclusions: Adapting to educating nurses in a post-pandemic environment comes with new challenges that must be overcome. Adopting technology in educational environments to create realistic scenarios that relate to experiences that nurses will see at the bedside will be most helpful. Lastly, open lines of communication between the inpatient units and the nursing education department to review and adjust educational content based on feedback from the units and the nurses are most beneficial for maintaining the optimal educational environment. Keywords: New graduate nurses, residency, nurse, simulation-based learning 3 Active Learning for Nurse Residents Problem Description Nurses completing their education and entering the professional healthcare environment face significant challenges. Not only are they adjusting from their role of student to licensed practitioners, but current new graduate nurses (NGNs) are now facing the additional challenge of entering the workforce in a post-COVID-19 era. Students have had a decrease in educational experience with canceled clinicals due to pandemic protocols implemented to reduce viral spread. Colleges and Universities accommodated the new environment by rapidly adjusted to virtual training platforms, allowing for more independent work. While they are beginning to integrate back into the classroom and clinical setting, trends in education are moving towards having more asynchronous, virtual education for aspiring healthcare workers. This has led to pre-licensure instructors being less confident than ever about their students' abilities going into practice and having success in their careers, particularly in their technical skills (Powers et al., 2021). The University of Utah Hospital (UofU Hospital) has yet to offer a Transition-to-Practice program to their NGNs outside the Critical Care Internship program for select nurses. Coming off the Great Resignation (U.S. Bureau of Labor Statistics, n.d.), the organization has experienced higher levels of staffing turnover than usual. The hospital’s administration has decided that implementing a complete residency program throughout the entire organization, not just the Intensive Care Units (ICUs), will help NGNs with the transition into the workforce. The addition of the Residency Program will also aim to help improve retention rates and satisfaction amongst the staff who participant in it. Available Knowledge Hospitals have been utilizing transitional programs to help their nurses adjust from theoretical classrooms to the clinical environment for some time. Spector et al. (2015) surveyed over one hundred institutions in their retrospective study and demonstrated that transitional programs 4 notably increase NGNs' competency, patient safety, and job satisfaction; while reducing stress and voluntary turnover. In addition, there are then the long-term cost savings that come from reducing staffing turnover; the cost savings for the hospitals in the areas of recruitment and staff orientation are substantial (Perron et al., 2019; Knighten, M.L., 2022; Agosto et al., 2017; Reebals et al., 2022). A second growing issue that hospitals have been challenged with is that turnover rates have been continually rising over the past years. Under current trends, a hospital will have an entirely new nursing staff after only six years (Knighten, M.L., 2022). The state of Utah has not been exempt from this; in the second quarter of 2020, the nursing turnover rate was up 39% from the same quarter in 2019 (Ruttinger et al., 2020). These increasing turnover rates pose several issues for hospitals, such as fewer experienced nurses to help orient new nurses, and to effectively deliver high-quality care. During the pandemic, many experienced nurses left their positions to take advantage of the higher paying contract nursing positions, further exacerbating an already present issue in the state. NGNs are being introduced into an environment that does not have the optimal support structures to aid in their transition into competent clinicians. New graduate nurses often need help adjusting from the idyllic academic environment to the practicing clinical setting as licensed nurses. NGNs want to “perform safe practice; however, they felt unprepared to meet the demands of the practice setting. Following analysis of the main theme, two sub-themes emerged: skill dexterity and real-world knowledge” (Toothaker et al., 2022, pg 12). The missing skill dexterity Toothaker et al. (2022) described refers to the amount of equipment that a nurse will use during a given shift. Infrequently used items can cause anxiety if there has been little previous exposure for the NGNs as they lack understanding of the device’s operation. The realworld knowledge deficit was often described in the study sample by the discrepancy between learning about disease processes and theoretical knowledge in school, but then having to change and begin learning how to advocate and care for patients. This shift was the leading cause of anxiety during the first few months of NGNs’ practice. 5 Another significant cause of NGNs' anxiety during their transition to practice was their fears of making an error, manifesting in comments like: “’ practicing safely,’ ‘don’t want to hurt anybody,’ and ‘being nervous.’ The participants desired to render safe patient care but felt hindered by internalized fear about making a mistake” (Toothaker et al., 2022, pg 14). Toothaker et al. (2022) report that NGNs diminished clinical experiences during school have made these anxieties and fears worse than previous NGNs. The UofU Hospital has concluded that helping the NGNs be as best prepared in the everevolving healthcare environment will require the usage of a Transition-to-Practice program for all of their NGNs starting in the institution. The UofU Hospital will provide a program for each of their service lines, helping the NGNs throughout the entire organization. Rationale The educational learning theory of Constructivism appears to be best suited for this project, given how the nursing residency program fits in with their unit-based orientation. Bada and Olusegun (2015) describe Constructivism as a “piecing together” of new materials with what students already know. The other is to understand that learning is an active process, not a passive one. Since the residency focuses on nurses who are currently learning and practicing care on their units, the information may not be, at least in part, unfamiliar to some of them. Their learning on the units will actively engage the students, and what they are exposed to during the residency should work to fill in gaps in their knowledge or supplement what they may have seen on their units. Students can also take parts of their own bedside experiences and apply them to the simulation, building and being provided with the opportunity to ask questions for improvement or hypothetical “what-ifs” they were unable to during the previous experience. Sharing student experiences will help others learn and incorporate them into their knowledge. These social learning experiences are another characteristic of Constructivism, noted by Narayan et al. (2013). 6 With Constructivism, instructors must move away from providing information, give up some control, and allow students to be equal with the instructors. The instructors will still need to provide a framework for the students to build their knowledge on, referred to in Constructivism as a scaffolding (Trif, L. 2015). This idea adds to the benefits of Constructivism for framing of the residency, with the newly practicing nurses needing to view their educators as peers and no longer superiors. Specific Aims This project aimed to develop content for the UofU Hospital’s Transition-to-Practice Program for the critical care area to meet the educational needs of the NGNs, as well as the skill sets required by nurses working on those units. The set objectives for the project were to assess areas of opportunity for improvement for NGNs entering the ICUs from current nursing staff and unit-based management. Secondly, to develop a high-fidelity interactive simulation using a mannikin with critical care emphasis for the nurse residents to help residents develop critical thinking and assessment skills based on the feedback from the educators and observed needs from the education department. Methods Context The Nursing Education Department at the UofU Hospital is uniquely positioned because it can design its Transition-to-Practice program to meet the current needs of its ICUs in the postpandemic environment. The UofU Hospital anticipates beginning the residency program for nonCritical Care Internship ICU nurses in the summer of 2023. There is a wide breadth of knowledge among the staff in the clinical education department, along with access to a new simulation space entailing high-fidelity mannequins for simulation use. This experience and resources allow the department to design a residency program more suited to the needs of the NGNs at the UofU Hospital. The department evaluated the potential use of an existing curriculum, such as the 7 Vizient/AACN Nurse Residency Program through the American Association of Colleges of Nursing (AACN). Still, it determined it would not meet the department’s need for a tailored, cost-effective solution. The residency program will have fixed start dates, approximately every quarter of the year, for the NGNs hired on a rolling basis in the ICUs. Based on past years' hiring trends, the clinical education department estimates that each cohort of residents will be fifty to sixty nurses. Interventions The department has begun developing goals and interventions for the new program design. Taking advantage of the new location and simulation laboratory, the desire of the UofU Hospital Nurse Educators is to incorporate those high-fidelity simulations in the lab to work through skills and help NGNs with their critical thinking skills. For this project, the interventions were broken up into two distinct, based on their specific topic, phases to keep to the necessary timeline of the class and organization’s project. Phase I: To gain some perspective from the nursing units, a Needs Assessment survey was developed (Appendix A) and sent out to the managers and nurse educators of the ICUs. Their input will benefit the overall aim of this project in two ways: determining where they are seeing gaps in skills and knowledge and aiding the relationship between the clinical education department and the ICUs. Their feedback on the current status of NGNs transitioning into practice can help influence this project by illustrating their needs. The Nursing Education Department can utilize the information collected beyond the project for future course content. Phase II: Interactive activities are the growing theme in modern education, working beyond a lecture format to reach the engagement of younger generations (Harper, M.G., 2021; Malone, M., 2021). The education department at the UofU Hospital seeks to reflect this and desires the residency to be as interactive as possible to complement the experience that the nurses have at the bedside. To support this educational format, the department has planned to purchase interactive high-fidelity 8 mannikin able to talk, have cardiac and respiratory sounds, and have a palpable pulse, for their new space in downtown Salt Lake City. This simulation aims to emulate the type of patient that could be seen in any of the intensive care units. This will allow the opportunity to see the progression of care and provide a safe environment to explore mistakes or errors. The development of the simulation (Appendix B) proved to be a convoluted endeavor as there were multiple drafts and rewrites required. This resulted from being too specific in certain patient populations and not maintaining a broad scope. The decision was made to move away from how nurses should respond during a decompensating patient to why we have specific systems to help prevent or limit issues in the intensive care areas. Incorporating systems that meet resistance with the implementation, such as Bedside Shift Report, into the simulation. Additionally included, those softer communication skills and techniques like SBAR, which often takes longer for residents to develop. The need is more pressing to have NGNs understand these basic skills as there is more pressure to practice at a higher level earlier. Determining that this direction for the simulation was more appropriate meant more focus had to be placed on the debriefing process. More time than initially planned was dedicated to the debriefing process to ensure the ability to cover the cognitive, physical, and emotional domains. Care was given to the types of questions to prompt students, and information was placed to aid the facilitators with the debrief. Study of the Interventions There are two studies of the intervention for this project. Since the project's implementation phase will occur after the conclusion of the course, the interventions will be assessed solely by the Nurse Educators. The developed survey (Appendix C) hopes to provide insight into what the nurse residents appreciated from their simulation experience and where the areas of improvement exist. The Nurse Educators, should they choose, will be able to adjust aspects of the simulation to fit the 9 needs of the nurse residents. Given the timeline change during the project, the decision was made to have an outside clinician review the content to establish its validity and credibility and verify that the objectives are being met through the simulation. Measures The measures chosen to study the intervention outcomes for this project entailed developing a Needs Assessment to gain insight from the ICU nurse managers and their Educators, along with ascertaining the needs already determined by the Nursing Education Department. The Needs Assessment was selected to provide insight into what is occurring on the units, to ascertain potential skills that NGNs need further exposure to, and their ability to process work-related stress and anxiety. And, in addition to assess if the demographics of nurses appears to be different than historically. Any of the developed materials from this project will be able to be adapted and reviewed by the Nursing Education Department. Since the materials were developed remotely, they may need to accurately reflect the simulation lab's design or the nurse residents' needs. Through use, the Nurse Educators can modify the deliverables to improve flow based on feedback from the nurse residents and adjustments to the units' needs, either reported in the created simulation survey or observed during the simulation experiences with NGNs. In an effort to obtain the highest quality and largest quantity of data from the Needs Assessment, the survey that was sent was delivered through the Microsoft Forms application in the University’s Microsoft Office interface, allowing the recipients to receive the survey directly in their work email inbox. There was a total of fourteen questions included in the Needs Assessment. Respondents were provided with ample time, approximately fourteen business days, was given to the respondents before the survey closed. The survey also included free-text submission space with nine 10 questions, even if the question was not open-ended, to elicit the most data from the managers and unit educators. Analysis Analysis of the data in the needs assessment came through interpretation of the results and compiling to discern any commonalities or significant differences between the answers. The survey results were analyzed using descriptive statistics and content analysis to identify the most common gaps between knowledge and skills. Ethical Considerations The Department of Health and Human Services (HHS) guides to help determine whether a project is considered research and subject to institutional review board (IRB) oversight (Office for Human Research Protections, n.d.). This quality improvement project at the University of Utah Health was evaluated under the HHS criteria. It was determined that the project did not meet the definition of research and was, therefore, not subject to IRB oversight. Regardless, the quality improvement activities were conducted in accordance with generally accepted ethical standards in research and healthcare. Results The first phase of the interventions was focused on gathering information about the needs of current NGNs in the ICU setting. To accomplish this, working with the clinical education department to learn the already established needs of the NGNs. The information collected was obtained through informal conversations about the project and the Residency Project status with the capstone preceptor in the Education Department. The second component involved sending out a Needs Assessment as a Microsoft Forms survey to the ICU nurse managers and clinical educators in the inpatient units. The participants were given approximately two weeks to complete the survey. Out of the fifteen surveys sent out, there was a 33% response rate. The Needs Assessment responses 11 were evaluated and outlined into tangible ideas for usage in the project simulation development and for the Nursing Education Department to carry forward with future developments. Three overarching themes were found in the needs assessment related to stress management, foundational skills, and specialty skills. Four of the five responses noted that the nurses could adequately process the emotional stress of being a NGN in the ICU. However, one respondent noted that nurses need to leave the bedside earlier in their careers than before. Approximately three of the five responses noted that there are strategies to lessen stress, primarily through a mentor-nurse and having that experienced nurse on the unit with whom they can form a relationship. Three of the five responses also included using the support systems available throughout the hospital, reinforcing their usage to their staff. One response described utilizing mindfulness and meditation during staff meetings to improve the nurses’ resilience throughout the unit, not just the NGNs. Regarding the skill sets of the nurses entering practice, there does not appear to be a major difference in the amount of previous experience the nurses have. Only one response remarked that there was less hospital work experience than before the pandemic. Three of the five remarked that the NGNs are having more trouble with the basics of nursing care. One response mentioned that the trouble was a byproduct of fewer clinicals in school, while another pointed out an observation that there is less interest in the NGNs and that they do not appear to take as much pride in their work. One respondent mentioned that the nurses who are exposed to more patient care hours in school, say through a capstone or nurse apprentice experience, are better with those foundational skills. The Needs Assessment sought insight into how these inpatient critical care units were trained throughout the organization. One response described a core skills session, followed by a new hire day. The respondent mentioned that this is not exclusive to NGNs but includes all new nurses in their particular unit. The second response mentioned that in addition to the fourteen-week patient care orientation, NGNs receive the Basic ICU course given by the Nursing Education Department, a quality initiatives class on Nurse Sensitive Indicators, and a class on mock codes. One Needs 12 Assessment result is described as a combination of a Canvas-based course in conjunction with inperson lectures, labs, and simulations. When asked about other strategies utilized on the units, one response made mention of the anticipated inclusion of the mega code scenario into the critical care onboarding group as strategies used. The third response that mentioned an additional strategy was having a tenured staff member serve as a “skill expert” for the rarely used, high-risk skills to teach the NGNs or anyone needing a refresher on that particular skill. The Needs Assessment inquired if there were any specific skills that the ICU Educators believed NGNs needed more exposure to. Their results included one selecting Medication Administration, one unanswered, two responses for ACLS/Code Blue (Advanced Cardiac Life Support), and one selection of Other with a description noting that the need is more interaction with patients directly at the bedside. Other comments to this question were for additional education on peripheral intravenous catheter insertion skills, management of titratable vasoactive medications, and further reinforcement of a lack of comfort with ACLS. The last question of the Needs Assessment inquired to the unit leadership how the Nursing Education Department can help with the education of the NGNs. Two survey responses mentioned having materials for anxiety and resiliency management. One response remarked that fostering a relationship between the Nursing Education Department and the units to meet the needs of the NGNs collectively would be helpful. The last response on how the Education Department can assist involved fostering a culture surrounding working at the bedside before moving on to a graduate nursing program after one or two years of experience. The second phase of this project results comprises feedback from the content expert. The simulation was sent to the Nurse Residency Coordinator & Nursing Professional Development Specialist at Thomas Jefferson University Hospital (TJUH) in Philadelphia, Pennsylvania, along with a Clinical Practice Leader, a Master’s prepared nurse working as an inpatient unit educator at TJUH. 13 Since they oversee the nurse residency program, and unit-level orientation, for a large academic medical center, comparable in size and service volume to the UofU Hospital, they were able to provide informative guidance to this project. Both the educators at TJUH had generally high praise for the simulation and its design. Each educator mentioned how it was easy to read and felt that there was broad applicability for a simulation environment. The Clinical Practice Leader did share suggestions on areas for improvement. The first was related to the stated patient’s history, and that NGNs likely will not be familiar with New York Heart Association (NYHA) Classification for staging heart failure, especially those not working in a cardiac unit. They advised including a facilitator note for information on the NYHA scale to educate the residents given how prevalent heart failure is. The second constructive feedback was including a facilitator note regarding the UofU Hospital’s peripheral intravenous vasopressor policy. In the simulation, the patient has norepinephrine running through a peripheral intravenous line, and there was no mention of a central venous line being placed. After receiving the feedback from these clinical experts, the simulation was updated to account for their comments. The Nursing Education Department will be able to collect feedback from the included survey within the scenario and analyze the data independently as it is being used in their Residency Program. Since the implementation of the residency will occur after the conclusion of the project, there will not be results available at this time. Discussion Summary Examining the skill sets of NGNs entering the nursing profession, there is a slight difference in the nurses entering the workforce post-pandemic, as discovered in the Needs Assessment. Many receive a different quality of clinical experience during school and have more difficulties adjusting to practice upon graduation. The simulation developed as Phase II of this project is an attempt to fill 14 the educational gaps for these nurses as a part of the UofU Hospital’s Nurse Residency program that is undergoing development. Interpretation Using simulation in nursing education has become the new operational standard to provide safe, realistic learning environments for students. Harper, Bodine, and Monachino analyzed numerous available studies and found that “simulation use in TTP [transition-to-practice] programs positively influences NLRN [newly licensed registered nurse] self-perception of skills, competence, readiness for practice, and confidence” (2021, pg. 339). In a post-COVID-19 era, simulation can be used to help the NGNs gain a better understanding of the lost sense of human connection, both socially and clinically, that was taken away from them during the peak of lockdowns (Malone, M. et al. 2020). The Phase I interventions identified areas where NGNs needed assistance acclimating to practice, and the developed simulation in Phase II seeks to fulfill those needs upon implementation later this year. While there are often high costs with developing, supplying, and implementing a large-scale program for an institution the size of the UofU Hosptial, there is a clear precedent for long-term financial benefits. The usage of an “evidence-based TTP [transition-to-practice] program, designed by the National Council of State Boards of Nursing (NCSBN) and more than 35 other nursing organizations and key collaborators. On the whole, 81.2% of the new graduate RNs remained employed at the hospitals at the end of the first 12 months” (Knighten, M. L., 2022, pg. 187). The initial funding expenditures to develop and supply the residency program with equipment will be a return on investment with the turnover cost savings. Retaining and effectively training NGNs has the potential to vastly improve the quality of patient care that the UofU Hospital provides. The project aspires to be frequently reused and altered to help the education department achieve those overarching goals. 15 Limitations The project did have external factors limiting its impact. The initial timeline set by the UofU Hospital changed during the planning phase. Initially, the critical care portion of the residency program was planned to roll out during the Spring quarter of 2023 but was deferred to the next fiscal year. This harbored the simulation from being implemented on the nurse residents during the involvement of this project in the department’s overall program build. To adjust, the developed simulation was sent to be reviewed by external nursing educators to verify its validity before future implementation in the residency program. Conclusions The past several years of adapting to the COVID-19 pandemic have proved challenging for nurse educators. NGNs are becoming less adequately prepared during their education for a more complex and challenging work environment than ever before. Hospitals are facing an additional lack of experienced staff nurses continuing to stay at the bedside, with many moving on to pursue advanced education or to take a contract positions. Nurse Educators must address these gaps by providing the highest quality educational experiences. This project was designed to help identify the needs of current NGNs and help to provide future content for the Nurse Residency program at the UofU Hospital. After receiving positive feedback from content experts, the designed simulation developed in this project will aid the UofU Hospital provide those high-quality educational experiences to their New Graduate Nurses. 16 Acknowledgments - Bonnie Leman & Sarah Muir - Capstone preceptors - - University of Utah Nursing Education Department Dr. Rebecca Wilson - MS Nursing Education Specialty track advisor - University of Utah College of Nursing 17 References Agosto, P., Cieplinkski, J. A., Monforto, K., Griffin, M., Roberts, K., Tracy, E., & Hickerson, K. (2017). The Central Staffing Office Intensive Care Nurse Residency Program: A Pilot Program. Nursing Economics, 35(3), 147–149. Bada, & Olusegun, S. (2015). Constructivism Learning Theory: A Paradigm for Teaching and Learning. IOSR Journal of Research & Method in Education, 5(6), 66–70. https://doi.org/DOI: 10.9790/7388-05616670. Harper, M. G., Bodine, J., & Monachino, A. M. (2021). 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Procedia - Social and Behavioral Sciences, 180, 978–983. https://doi.org/10.1016/j.sbspro.2015.02.184. U.S. Bureau of Labor Statistics. (n.d.). The "great resignation" In perspective: Monthly labor review. U.S. Bureau of Labor Statistics. Retrieved from https://www.bls.gov/opub/mlr/2022/article/the-great-resignation-in-perspective.htm. 19 Appendix A Needs Assessment Survey – Inputted into Microsoft Forms for dissemination 1) Do you find that NGN are able to process their work-related stress and anxieties appropriately, or are presenting with higher emotional exhaustion during their transition into practice a. Yes b. No 2) Does your unit have any strategies to lessen work-related stress and anxiety for its employees? a. Open ended 3) Do you find NGNs are having a more difficult time with the basic foundations of nursing care? a. Yes b. No 4) Are you seeing NGNs enter your units with less hospital experience than before? Whether working or clinical experiences a. Yes b. No 5) How do your units provide unit-based education to your newly hired nurses? a. Open ended 6) What are some strategies you have tried with unit-based orientation to meet their needs? a. Open Ended 7) To you view these issues discussed regarding NGNs to be temporary as a by-product of the pandemic? a. Yes b. No 8) Are there any particular skills that NGNs are in need of more practice of? a. Sterile dressing changes b. Peripheral IV insertion/phlebotomy 20 c. Medication administration d. ACLS/Code Blue e. Other 9) How could the Nursing Education Departments Transition to Practice Program help your units? a. Open Ended 21 Appendix B DECOMPENSATING PATIENT SIMULATION UNIVERSITY OF UTAH NURSE RESIDENCY PROGRAM 1. Scenario Overview: The scenario focuses on a critically-ill patient being admitted from an outside hospital into the Intensive Care Unit. The patient will decompensate as the simulation progresses, allowing the nurse residents to recognize and understand how to intervene. The outline of the storyboards provides room for the scenes to diverge based on how the residents react. Though, it will require creativity and improvisation from the facilitators. 2. Storyboard TIME 10 min STORYBOARD/SET UP ACTIVITY: PREBRIEF OVERVIEW: The simulation will follow a patient through their admission into the ICU after being brought in from an outside hospital by AirMed. Residents should receive a report paper to take the following report below. ACTIVITY: ROOM ORIENTATION Orient all residents to equipment and supplies. Re-orient them to the Omnicell if needed and the nursing care areas. The nurse residents will have selected roles to get started with the scenario. There will be active roles and observers for each scene - every resident should have a chance for an active role. If need be, the primary nurse can have a student/orientee with them to allow for more roles. Much of the patient dialogue is not included and will have to be done ad-lib by a facilitator, allowing flexibility throughout the simulation. OSH Report: “Tim Daniels is a 67y.o. male with a past medical history of smoking, ETOH use, NYHA II, HTN, CABGx2 in 2019, stent x2 in 2015, OSA, and COPD. He came in because he felt very dizzy and weak at home. We didn’t have much time to work him up, but his COVID swab was negative. He said he’s supposed to wear oxygen at home but often doesn’t. We put him on 4L NC before he got picked up, and his sat was around 93% afterward. We put an 18 in his LAC and drew labs, but the lab is pretty backed up, so we haven’t gotten anything back yet. Otherwise, 22 Vitals were HR 102, BP 88/51, 93%, RR 16, and temp 37.3. We gave a 2L LR bolus for the BP and started a maintenance drip at 100mL/hr.” TIME 10 min STORYBOARD – Scene 1 Room/Mannequin/Set-up Supplies Background: The patient has just been dropped off by AirMed. The charge nurse and CNA got the patient settled in their bed for you and hooked up to the monitor. The only updates from AirMed are that the patient is still on 4L but has been more anxious and tachycardic since the start of the flight. The family will come down tomorrow since it is a long drive into SLC. Cart/Room Type: Inpatient ICU room has a supply cart stocked with basic supplies. Two IV pumps needed for infusing medications. Tasks for RN to Complete: ● Physical Head-to-Toe Assessment. ● IV Pump Check. ● Verbalize the need to place another PIV. ● Acknowledge that Norepinephrine is being administered, and adjust the dose based on the patient’s vitals. ● Realize the need for further workup, requiring communication with physicians for orders. Patient Prompts: “I came in because I was at home, getting ready for bed like usual, and I just started feeling significantly worse. My wife made me come to the ER … I didn’t think it was a big deal.” “I live outside of Casper, WY. Never been to Utah before.” “I’ve been feeling under the weather for a few days, groggy, and not the same pep in my step as usual.” Moulage/Patient Appearance: ● Patient appears anxious, restless, and tachycardic. Facilitator Notes: ● Patient has a wound on R Anterior thigh with notable cellulitis. The wound was not covered with dressing upon admission. ● The patient was started on IV norepinephrine during the flight, was not communicated. RN should assess the patient in realizing the medication is being administered and may ask for clarification. ● Norepinephrine was programmed for 0.2mcg/kg/min, and IVF was set to 100mL/hr. ● If the mannikin can have PIV placed, RN should place one or use a different arm capable of being stuck. ● Since the provider has not assessed the patient yet, they will not have placed any orders. 23 “I got bit by my neighbor’s dog a few weeks ago. The wound just isn’t healing up ... still hurts quite a bit too.” 20 min ACTIVITY: DEBRIEF Facilitator should discuss how RN got the patient settled and the performance of their initial assessment. Use this opportunity to elicit the group’s critical thinking skills to see their thoughts based on the patient's condition … possible causes, expected treatments, and concerns. The facilitator can provide a refresher lecture on SBAR (See attached example below) to help residents gain confidence speaking with providers. Having a list of what to recommend will help the efficiency of the conversation. See the debriefing guide below for additional prompts. ● Provider should end SBAR conversation by stating they will be down to assess the patient shortly, ending the scene. ● Debrief activity should include having students practice giving SBAR communications to the physician to build confidence in skills. ● Residents should develop a list of things to ask the provider for o To come to assess the patient. o IV Fluids. o Labs. o Norepinephrine Order. o Admission Orders. o Sepsis workup. TIME STORYBOARD – Scene 2 10 min Background: It has been a couple of hours since your patient arrived, and their initial assessment was performed. The patient has been trying to get some sleep through the night. The provider came in and Moulage/Patient Appearance: placed orders for a sepsis workup along with ● Patient appears more lethargic and standard admission orders. The phlebotomist hasn’t fatigued than earlier. stopped by overnight to obtain any labs so far. Tasks for RN to Complete: ● Draw (attempt to draw) labs. ● Effectively communicate/de-escalate with the irate physician. Physician Prompts: “I don’t understand why everyone on this unit is so incompetent and can’t get anything done.” Room/Mannequin/Set-up Supplies Facilitator Notes: ● During the break between scenes, residents will switch roles. A facilitator performs the physician's role. ● The patient’s physical exam will be relatively similar to before; the only difference is increased crackles in BL lung fields. 24 “I didn’t realize you had to work here for X amount of time to do the most basic things.” 20 min ACTIVITY: DEBRIEF Discussion with residents should focus on deescalation tactics that were used with the physician and can be applied to all patients. Facilitators can focus on how the residents handled the issue and their verbal/non-verbal communication during the simulation. This debriefing session can help nurse residents gain insight into the physician’s perspective regarding how delays in care can be frustrating. Examining system flaws, like staffing or delays in care, can impact the patient and how nurses can be proactive in prevention, such as taking the initiative to obtain labs instead of waiting for phlebotomy to draw. See the debriefing guide below for additional prompts. 10 min BREAK TIME STORYBOARD – Scene 3 10 min Background: Cultures have been obtained, and sepsis antibiotics have been started. The shift change has occurred, and the next nurse will assume care. Report was given outside of the bedroom to allow some time for the patient to attempt to get more sleep leading into the daytime. Tasks for RN to Complete: ● Shortly into the scenario, the physician should call the RN and aggressively inquire about the delay in blood cultures, admission labs, and the ABG being obtained. Recommended strategies by Joint Commission: Utilize verbal communication techniques that are clear and calm. Staff attitudes must contain non-confrontational verbiage. Avoid using abbreviations or healthcare terms. • Use non-threatening body language when approaching the patient. • Approach the patient respectfully, supporting their issues and problems. • Use risk assessment tools for early detection and intervention. • Staff attitudes, knowledge, and skill in de-escalation techniques must be practiced and discussed in an educational format. • Respond to the patient’s expressed problems or conditions. This will help create a sense of trust with the healthcare professional. • Set clear limits for patients to follow. • Implement environmental controls, such as minimizing lighting, noise, and loud conversations. Room/Mannequin/Set-up Supplies Set-up Supplies: Intubation equipment required for this scene. Moulage/Patient Appearance: ● Patient is noticeably more somnolent than during the night. They appear very fatigued in trying to breathe. 25 ● Acknowledge the decline in patient condition. ● Verify alarm parameters and adjust to appropriate settings. ● Determine appropriate intervention for respiratory status. ● Gather or list all necessary supplies for intubation. ● Work with the physician to intubate the patient. 20 min ACTIVITY: DEBRIEF Topics for the debrief should include verification of alarm settings at the beginning of the shift and how alarms should/should not be set in the ICUs. Discussion about the importance of BSR in the ICU setting and how it impacts patient care. Based on resident performance during simulation, facilitators can determine whether reviewing how to go through the process of intubating a patient is required or not. See the debriefing guide below for additional prompts. 10 min Final Wrap-Up Facilitator Notes: ● This section allows nurse residents to recognize and work to intubate the patient safely. ● Residents may need prompting to go directly toward intubating the patient. Other less invasive interventions should be deterred. If the residents choose to draw labs, results will not be available until after the scene. ● The SpO2 alarm should be turned off at the beginning of the scene. The residents must acknowledge that it was turned off and not alarming to provide a quiet environment for the patient. • If it has not come up previously, the norepinephrine remains running through peripheral line. Reviewing the peripheral pressor policy with residents so they understand when to ascertain CVC placement from physician. • While partaking in BSR may not have prevented this outcome, it could have been identified earlier. There is substantial evidence for the participation in BSR from nursing as it improves: - Patient safety and quality. - Patient experience of care. - Nursing staff satisfaction. - Time management and accountability between nurses. Finish any remaining debriefing topics or answer any remaining student questions. SIMULATION DAY END 26 3. Programming Initial Monitor Display/Mannequin Program Monitor Display: HR: 118 BP: 168/94 RR: 28 T: 36.1 SpO2: 91% AIRWAY: Lungs: Left: Diminished Heart: Sounds: S1S2 ECG rhythm: NSR Bowel sounds: WDL Right: Diminished Sinus Tachycardia, occasional PVC Pupils: PERRL NOTES: If participant administers: 1. Leaves Norepinephrine dose – BP 188/102 2. Stops Norepinephrine – BP 81/47 3. Titrates Norepinephrine to ~0.1mcg/kg/min – BP 105/68 Advancement of Monitor Display/Mannequin Program: Scene 2 Monitor Display: BP: 115/68 HR: 130 RR: 30 T: 37.2 SpO2 88% NOTES: Patient remains on If RN increases NC to 6L -> SpO2 increases to 92% 0.1mcg/kg/min of If the RN requests for a more advanced airway, they should be prompted to call Norepinephrine the physician. Advancement of Monitor Display/Mannequin Program: Scene 3 Monitor Display: BP: 98/57 HR: 133 RR: 18 T: 36.4 SpO2: 84% Lungs: Left: Diminished, wet crackles Right: Diminished, wet crackles throughout. throughout. Heart: Sounds: S1, S2 ECG Rhythm: NSR, ST NOTES: Norepinephrine remains at 0.1mcg/kg/min. RN may titrate to improve BP during the scene. With intubation, the SpO2 -> 98% 27 4. Medication Set-up Current Medications: Drug (special Instructions) Dose Route Frequency Maintenance IVF Lactated Ringers Colace Heparin Norepinephrine Tylenol (temp >38.5/mild pain) 100mL/hr IV cont. 100mg 5,000 units 0.01-1mcg/kg/min 650mg PO Subcut IV PO BID q8hrs cont. q6hrs 5. PROVIDER ORDERS: PROVIDER ORDERS: Admit Patient Name: Tim Daniels DOB: 8/15/1956 Age: 67 Allergies & Sensitivities: NKA Date Time 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 3/17/23 Signature 0200 0200 0200 0200 0200 0200 0200 0200 0200 0200 0200 MRN: 000258502 Diagnosis: Sepsis r/o PROVIDER ORDER AND SIGNATURE Condition: ICU Code Status: Full Vital Signs: Parameters: Call HO if SBP <90 or >160; DBP <60 or change of 10 pts; or MAP <60, HR <60 or >100; T>38.5; RR <8 or >30; UOP <30 ml/hr; mental status changes Activity: As tolerated Diet: NPO Patient Care: Routine IV: per unit policy Laboratory: ABG STAT, CBC, BMP, Tox Screen Diagnostic Tests: CXR in AM Respiratory Care: per unit policy Consults: None Tom Delonge 6. Debriefing Guide: General 1. How did the simulation experience feel? 2. Can someone give me a quick summary? 3. What did you observe during the simulation? 28 4. Is there anything else you would like to discuss that hasn’t been mentioned? Cognitive 1. What are some of the possible disease processes this patient is presenting? 2. What barriers do nurses have to participate in BSR? 3. What did you learn from this simulation? Psychomotor 1. What was done well, and what could have been handled differently? 2. Were the skills performed correctly during the simulation? 3. How can we work to maintain skills on tasks we don’t often do? 4. What are some safety checks we should be performing in all of our rooms? Affective 1. Why do you think the physician had the emotional response he/she displayed? 2. Did you recognize any heightened feelings when the physician acted that way? 3. How did their reaction make you feel? 4. What strategies can we use to not take this stress and negative feelings home with us? 7. Reviewers: Reviewed By Will Patzke BSN, RN, CCRN - MS Nursing Education Student Date April 2023 29 8. References Agency for Healthcare and Research Quality. (n.d.). Nurse Bedside Shift Report Implementation Handbook. Nurse Bedside Shift Report. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital /engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf Quick Safety: Deescalation in health care. (2019). The Joint Commission, Division of Healthcare Improvement, (47), 1–5. https://doi.org/https://www.jointcommission.org//media/tjc/documents/resources/workplaceviolence/qs_deescalation_1_28_18_final.pdf Sharma, P. (2019, May 14). Nursing notes and SBAR technique. EklavyaParv. March 27, 2023. https://eklavyaparv.com/content/communication-skills/400-nursing-notesand-sbar-technique 30 Appendix C Simulation Survey – Inputted into Microsoft Forms for dissemination. 1) This simulation was relevant to my nursing practice: Strongly Disagree Disagree Neutral 1 2 3 Agree 4 Strongly Agree 5 2) The content of this simulation felt realistic: Strongly Disagree Disagree Neutral 1 2 3 Agree 4 Strongly Agree 5 3) I felt comfortable asking questions during the experience: Strongly Disagree Disagree Neutral 1 2 3 Agree 4 Strongly Agree 5 4) I found benefit from participating in the included debriefing sessions: Strongly Disagree Disagree Neutral 1 2 3 Agree 4 Strongly Agree 5 5) The instructor was engaged with the simulation: Strongly Disagree Disagree Neutral 1 2 3 Agree 4 Strongly Agree 5 6) This simulation experience has improved my nursing practice: Strongly Disagree Disagree Neutral 1 2 3 Agree 4 7) Any additional feedback for the Nursing Education Department: a. Open Ended. Strongly Agree 5