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  1. 1. Simulation Combining high-tech and high-touch to build clinical competence in undergraduate and practicing nurses Judy Robinson RN, BA, MHSc Sandra Goldsworthy RN, BScN, MSc, CNCC
  2. 2. Overview • MOHLTC Health Human Resource Strategy • Nursing Secretariat Clinical Simulation Grant • DC-UOIT Simulation Lab • Research: Impact of Simulation and Clinical Competence Among Undergraduate Nurses • Critical Care Secretariat Grant • Research: Impact of E-learning and Simulation Among Practicing Nurses Working in Critical Care • Next Steps • Questions and Answers
  3. 3. Ministry of Health and Long Term Care Health Human Resource Strategy • Improve access to care • Reduce wait times • Improved patient outcomes by increasing the recruitment and retention of health professionals
  4. 4. Nursing Secretariat Nursing Strategy Address the instability of the nursing workforce • Increase the number of full-time positions for nurses • Improve recruitment and retention of nurses • Ease the transition for new nurses entering the workforce
  5. 5. Nursing Secretariat Nursing Strategy (cont’d… • Increase access to clinical learning opportunities in nursing education • Make Ontario a leader in nursing education by offering an innovative solution to pressures on clinical placements and opportunities for interdisciplinary education
  6. 6. MOHLTC Critical Care Secretariat Nursing Secretariat DC - UOIT
  7. 7. Nursing Secretariat Invests in Nursing Education Spring, 2005 • $10 million invested in simulation equipment • DC-UOIT awarded $694,000 (competitive process) • 9 adult, 1 pediatric, 2 neonatal simulators • Video equipment and video streaming capabilities • Training faculty and staff
  8. 8. DC – UOIT’s Response to the Nursing Secretariat’s Simulation Agenda March, 2005 awarded $694,000 April, 2005 simulators delivered to campus June, 2005 training faculty and staff Sept, 2005 integrate use of simulation into BScN year 2 curriculum Sept, 2006 integrate use of simulation into BScN year 1 and 4 (SPA) Sept, 2006 Research study - BScN year 2 students in med- surg and maternal –child courses
  9. 9. Integration of Simulation Phase 1 – assessment, psychomotor skill development Phase 2 – comprehensive approach to teaching and learning Phase 3 – advanced integrated critical care scenarios
  10. 10. Human Simulation: Teaching Strategy • Students are required to combine ways of knowing, assessments, pattern recognition, reflective practice, clinical decision-making for optimal patient outcomes • Students engage in case based patient scenarios which increase in complexity of patient acuity
  11. 11. Human Simulation: Teaching Strategy • Engages students in active and interactive learning and clinical problem solving without patient risk • Provide opportunities for thinking-focused experiences rather than just nursing care tasks, and allow students to think “on their feet rather than in their seat” (Rauen, 2001)
  12. 12. Human Simulation Teaching Strategy • Students use assessment and critical thinking skills to determine course of action, implement care, and receive immediate feedback through “patient” outcomes • Simulation is controlled so that the patient problems encountered by students are consistent with actual clinical patient conditions and desired learning
  13. 13. Human Simulation: Teaching Strategy To build student knowledge, skill and confidence in pattern recognition, and appropriate and timely response for optimal patient outcomes without patient risk
  14. 14. Research: Is Simulation Education Effective in Undergraduate Nursing Education? Why simulation? • The simulation lab was envisioned to build confidence and encourage reflective thinking in a safe environment. • The simulation experience was thought to improve patient safety and clinical judgment while providing many realistic and complex scenarios.
  15. 15. Purpose • To examine the benefits of providing a simulation experience for second year nursing students in both a medical surgical and a maternal child rotation. • The aim of this study was to investigate if a difference exists between self efficacy and the rate of medication errors/near misses.
  16. 16. Method • Experimental group: Simulation + Clinical Control group: Traditional Clinical only • Random assignment to groups • Simulation Intervention: • Med/surg or maternal child case scenarios (high fidelity simulators + Virtual clinical scenarios)
  17. 17. Measures • General self efficacy scale (10 items) given as pre test and post test to all participants. • Sears(2006) medication administration error tool used to calculate actual errors and near misses • Qualitative focus questions to all experimental group after 2 simulation ‘clinical’ days • Qualitative focus group conducted at the end of the study.
  18. 18. Intervention • Scenarios included post op complications and cardiac arrest, among others • Teaching/Learning strategies included coaching, reflection, prioritization, delegation, repeating the scenario and debriefing
  19. 19. Results: Medication Errors • There is compelling evidence that collectively, students in Clinical generate fewer Medication Errors if the Treatment (Simulation experience) has been administered.
  20. 20. Results: Medication Errors • Additional findings: • “Lack of Knowledge” a common thread to many incidents. – These sub-variables are highly inter-correlated: “Lack of knowledge of indications for usage”; “Lack of knowledge of contraindications”; “Lack of knowledge of side effects”; “Lack of knowledge of normal dose range”; “Lack of knowledge relating to nursing applications”. {Cronbach’s Alpha = 0.949} • Inter-correlation of the responses “Ineffective
  21. 21. Results: Qualitative Focus Groups • Do you feel the sim cases helped prepare you for clinical? • “ I felt it increased my confidence on the floor” • “It was really helpful” • “1st day on the floor had a patient that had a similar scenario to one of the cases in the sim lab-I learned alot!”
  22. 22. Results: Qualitative Focus Groups • How did the simulation experience help you? • “it helped me practice my skills” • “ it simplified the steps” • “ I felt safe, supported in the lab, having done it in the lab I felt more comfortable performing the skills in real life” • “ liked the practice in a safe environment” • “it allowed me to practice things I may not see in clinical”
  23. 23. Results: Qualitative Focus Groups • Would you like more/less/same amount of simulation time? • All but one participant said they would like at least 1 more sim day, the remaining participant liked the amount given. • Most participants liked the sim being placed at the beginning of clinical.
  24. 24. Results: Qualitative Focus Groups • What do you see as the limitations to simulation? • Some participants liked hands on lab more than virtual cases • What would you change? • More time on sim • Add the sim experience to all of the years • Use as ‘up front’ experience prior to 4th year
  25. 25. Live Feed - simulation
  26. 26. Critical Care Secretariat • The quality of critical care has the potential to “make or break” other hospital services (Critical Care Task Force, 2005) • The shortage of skilled nurses for CC units has resulted in crowded ERs for patients waiting for admission, deferred surgeries and the transports of patients to other regional facilities where a CC bed may be available
  27. 27. Critical Care Secretariat Recognized • a need to improve training, recruitment and retention of critical care nurses to meet the workplace demand and to reduce “wait times” • training needs to be consistent with provincially recognized standards and core competencies • training needs to be accessible geographically and accommodate the needs of shift workers • training needs to meet the needs of the novice and more experienced nurses working in CC
  28. 28. Critical Care Secretariat: Grant • October, 2006 – Durham College was the successful recipient of approval and support from the MOHLT, CC Secretariat, for the development and implementation of an innovative program for critical care nursing • $1 million funding grant
  29. 29. DC’s Response to the Critical Care Secretariat’s E-Learning Agenda June, 2005 responded to RFP October, 2006 awarded $1 million Oct – July, 2007 curriculum development July, 2007 research REB approval July/Aug, 2007 piloted e-learning courses Sept, 2007 launched CC program and research study
  30. 30. Durham College – Critical Care Nursing Graduate Certificate • A virtual learning environment with the central hub at Durham College • Availability of program to any nurse in Ontario • Six on-line courses with enhanced faculty interaction with students • Clinical simulation course students can access within their geographical region • Preceptored critical care practicum students can access within their geographical region
  31. 31. DC- Critical Care Nursing Graduate Certificate Program The overall purpose of the program is to contribute to the provincial health care strategy and health human resource needs to build and sustain skilled critical care nurses in Ontario through the delivery of a high quality, competency based and accessible post secondary educational program for critical care nursing
  32. 32. DC Critical Care Nursing Curriculum Team • Sandra Goldsworthy • June MacDonald Jenkins • Debbie Morrison • Leslie Graham • Judy Robinson Specialty Consultants DC service support (IT, Innovation, Media Services, Registrar, Library)
  33. 33. Critical Care Nursing – Research Team • Judy Robinson • Sandra Goldsworthy • June MacDonald Jenkins • Debbie Morrison • Leslie Graham • Dr. Janet Rush, Research Associate • Samuel Rush, Research Assistant
  34. 34. Research – Practicing Nurses in Critical Care Consistent with the start up of the program is the integration of a research component The research questions will examine: • program success (academic and clinical success of students, attrition/graduate rate) • Satisfaction with program (curriculum, e-learning, simulation, integrated practicum) • Satisfaction with resources/services (library, IT, registration, availability of faculty support)
  35. 35. Research- Practicing Nurses in Critical Care (cont’d… • Contribution of the number of available/skilled critical care nurses graduated from the program at the 2 year time point • Differences in ranking of nurses’ self perception of critical care nursing competencies pre and post program
  36. 36. MOHLTC Critical Care Secretariat Nursing Secretariat DC - UOIT
  37. 37. Next steps Leading the Way and Staying Ahead of the Curve… • Application of the learning model (e- learning, simulation and integrated practicum) to other areas of nursing and health education • Explore the use of E-learning and/or “Second Life” to interdisciplinary education in the Bachelor of Allied Health Sciences degree completion program
  38. 38. Questions and Answers