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The NCSBN Na*onal Simula*on Study

Jennifer Hayden, MSN, RN

2

Review of Literature

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

3

Research Ques*ons-‐Part I

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

Research Ques*ons-‐Part II

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

Research Design

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

8

Study Groups

9

•  Tradi*onal clinical experiences as usual (up to 10% simula*on) Control Group

•  25% of clinical *me spent in simula*on •  75% spent in tradi*onal clinical 25% Group

•  50% of clinical *me spent in simula*on •  50% of *me in tradi*onal clinical 50% Group

10

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

11

INSTRUMENTS

12

Instruments •  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

Instruments •  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

Simula*on day

•  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

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

Determining the curriculum •  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

Round 1: Survey •  Link to electronic survey distributed to 2 nursing simula*on communi*es

•  Link ac*ve for 4 weeks October-‐November 2010

Round 2: Refine the list of topics

Round 3: Item ranking

•  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

THE SAMPLE

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Study Par*cipants (Fall 2011) •  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

Ajri*on Overall Control group 25% group 50% group

Number of students randomized 847 268 293 286

Number of students comple*ng the study 666 218 236 212

Rate of Comple,on 78.6% 81.3% 80.5% 74.1%

Number of students who failed a course during the study 66 25 22 19

Rate of Failure 7.8% 9.3% 7.5% 6.6%

Number of students who withdrew or were withdrawn from the study for any reason

115 25 35 55

Rate of Withdrawal 13.6% 9.3% 11.9% 19.2%**

27

FINDINGS

28

Research Ques*on 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?

29

Knowledge-‐End of Program ATI Comprehensive Predictor

30

69.1% 69.5% 70.1%

0%

20%

40%

60%

80%

100%

Control group 25% group 50% group

Total Score

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 SD Mean SD Mean SD

Clinical Knowledge 5.12 0.73 5.18 0.60 5.09 0.72 0.14 0.481

Technical Skills 5.06 0.76 5.09 0.64 5.01 0.86 0.11 0.659

Cri*cal Thinking 5.11 0.72 5.06 0.71 5.03 0.88 0.10 0.668

Communica*on 5.30 0.65 5.34 0.65 5.24 0.87 0.13 0.478

Professionalism 5.38 0.69 5.47 0.61 5.39 0.85 0.14 0.432

Management of Responsibili*es

5.22 0.71 5.20 0.70 5.17 0.85 0.06 0.849

31

1=lowest ra*ng, 6=highest ra*ng

Cri*cal Thinking-‐End of Program Preceptor Ra*ngs

CriTcal Thinking DiagnosTc (1-‐6 scale)


25% group (n=171)

50% group (n=136)

Effect size

P value


Problem Recogni*on 4.97 0.70 5.07 0.65 5.02 0.75 0.15 0.494

Clinical Decision Making 5.09 0.60 5.18 0.61 5.12 0.81 0.15 0.469

Priori*za*on 5.14 0.66 5.08 0.63 5.03 0.77 0.15 0.418

Clinical Implementa*on 5.10 0.61 5.19 0.60 5.10 0.76 0.15 0.361

Reflec*on 5.13 0.64 5.23 0.59 5.15 0.78 0.16 0.318

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Overall Clinical Competency-‐EOP Preceptor Ra*ngs

Global assessment of clinical competency & readiness for pracTce (1-‐10 scale)


25% group (n=168)

50% group (n=135)

Effect size P value


Overall ra*ng 8.20 1.34 8.29 1.48 8.34 1.44 0.10 0.688

33


Research Ques*on 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?

34

Fundamentals of Nursing Knowledge

35

68.1% 67.3% 68.6%

0%

20%

40%

60%

80%

100%


Total Score

ATI Assessment Total Score (n=800)

p=0.155

Fundamentals of Nursing Clinical Competency

36

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14

% of items s

cored as Com

petent

# of Weeks

CCEI Scores: Clinical Se\ng

Control group

25% group

50% group

Medical-‐Surgical Nursing Clinical Competency

37

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

% of items s

cored as Com

petent

# of Weeks

CCEI Scores: Clinical Environment

Control Group

25% Group

50% Group

Advanced Medical-‐Surgical Nursing Knowledge

38

62.7% 64.1% 65.5%

0%

20%

40%

60%

80%

100%


Total Score


p=0.005

Advanced Medical-‐Surgical Nursing Clinical Competency

39

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14

% of items S

cored as Com

petent

# of Weeks


Control Group

25% Group

50% Group

Maternal-‐Newborn Nursing Knowledge

40

68.4% 69.2% 71.1%

0%

20%

40%

60%

80%

100%


Total Score


p=0.011

Maternal-‐Newborn Nursing Clinical Competency

41

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9 10 11 12 13

% of items s

cored as Com

petent

# of Weeks


Control Group

25% Group

50% Group

Pediatric Nursing Knowledge

42

63.7% 65.0% 67.1%

0%

20%

40%

60%

80%

100%


Total Score

p=0.002


Pediatric Nursing Clinical Competency

43

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9 10 11

% of items s

cored as Com

petent

# of Weeks


Control Group

25% Group

50% Group

Mental Health Nursing Knowledge

44

63.4% 65.2% 66.3%

0%

20%

40%

60%

80%

100%


Total Score


p=0.011

Mental Health Nursing Clinical Competency

45

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

% of items s

cored as Com

petent

# of Weeks


Control Group

25% Group

50% Group

Community Health Nursing Knowledge

46

65.5% 65.5% 67.1%

0%

20%

40%

60%

80%

100%


Total Score


p=0.387

Community Health Nursing Clinical Competency

47

0.0

20.0

40.0

60.0

80.0

100.0

1 2 3 4 5 6 7 8 9

% of items S

cored as Com

petent

# of Weeks


Control Group

25% Group

50% Group

Learning Needs Met-‐End of Program Clinical Environment Comparison Survey (CLECS)


n Mean SD Effect Size n Mean SD Effect

Size n Mean SD Effect Size

Tradi*onal 197 3.50 0.42 1.23

202 3.41 0.41 0.28

187 3.26 0.53 0.57

Simula*on 174 2.82 0.67 202 3.28 0.51 187 3.54 0.45

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Scale 1-‐4 1=Learning needs not met 4=Learning needs well met

Research Ques*on 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?

49

NCLEX May-‐December 2013

50

88.4% 85.5% 87.1%

0%

20%

40%

60%

80%

100%


Pass Rate

NCLEX First Time Pass Rates

p=0.737

PART II: FOLLOW UP STUDY

51

Follow-‐up Surveys •  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)


25% group (n=86)

50% group (n=84)

Effect size

P value


Clinical Knowledge 5.21 0.63 5.07 0.92 5.21 0.66 0.17 0.376

Technical Skills 5.28 0.65 5.09 0.95 5.19 0.65 0.23 0.325

Cri*cal Thinking 5.11 0.78 5.06 0.92 5.15 0.72 0.11 0.741

Communica*on 5.40 0.66 5.22 0.95 5.42 0.70 0.24 0.203

Professionalism 5.54 0.58 5.30 0.95 5.50 0.65 0.30 0.096 Management of

Responsibili*es 5.26 0.73 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)


25% group (n=85) 50% group (n=84) Effect size

P value


Problem Recogni*on 5.36 0.60 5.17 0.88 5.28 0.57 0.25 0.251

Clinical Decision Making 5.40 0.53 5.28 0.88 5.36 0.53 0.16 0.491

Priori*za*on 5.36 0.68 5.25 0.90 5.35 0.57 0.14 0.559

Clinical Implementa*on 5.40 0.49 5.21 0.92 5.38 0.55 0.25 0.116

Reflec*on 5.42 0.53 5.26 0.92 5.39 0.58 0.21 0.325

56


Overall Clinical Competency 6 Month Manager Ra*ngs

Global assessment of clinical competency & readiness for pracTce (1-‐10 scale)


25% group (n=86)

50% group (n=84)

Effect size P value


Overall ra*ng 8.60 1.37 8.36 1.46 8.55 1.16 0.16 0.527

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

Prepara*on for Prac*ce 6 Week Survey

Control group (n=68) 25% group (n=99) 50% group

(n=99) Effect size P value

freq % freq % freq %

0.16 0.030**

Very well prepared 15 22% 20 20% 36 36%

Quite a bit prepared 25 37% 42 42% 36 36%

Somewhat prepared 26 38% 37 37% 27 27%

Not at all prepared 2 3% 0 0 0 0

6 Month Survey Control group

(n=98) 25% group (n=108) 50% group (n=109)

0.11 0.261 Very well prepared 14 14% 21 19% 29 27%

Quite a bit prepared 44 45% 40 37% 46 42%

Somewhat prepared 38 39% 46 43% 33 30%

Not at all prepared 2 2% 1 1% 1 1%

59

Lee First Nursing Posi*on 6 Month Survey


freq % freq % freq % Effect size

P value

Lee first posi*on 5 7.2% 9 7.3% 11 9.1% 0.07 0.462

60

Pa*ent Care Assignments 6 Month Survey


25% group (n=106)

50% group (n=105)

freq % freq % freq % Effect size P value

Not challenging enough 4 5% 5 5% 5 5%

0.01 0.999 Just right 73 83% 89 84% 87 83%

Too challenging 11 13% 12 11% 13 12%

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Workplace Stress

62

3.7% 4.4% 4.0% 3.0% 2.6% 3.8% 3.6% 3.0% 3.4% 3.8% 1.9%

32.3% 26.5% 36.6% 32.0%

25.2% 30.4% 26.4% 19.8% 19.7% 11.4%

25.5% 21.0%

50.9% 52.9%

47.5% 53.0% 54.7% 44.6%

54.7% 63.1% 63.5% 67.1%

57.6% 66.7%

13.0% 16.2% 11.9% 12.0% 17.5% 25.0%

15.1% 13.5% 13.7% 18.2% 13.2% 10.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total Contol Group

25% Group

50% Group

Total Contol Group

25% Group

50% Group

Total Contol Group

25% Group

50% Group

Strongly disagree Disagree Agree Strongly agree

I am experiencing stress at work 6 week 3 month 6 month

Workplace Stress

63

71.0% 72.1% 72.3% 69.0% 63.1% 57.6% 63.2% 67.6% 56.2%

47.7% 55.7%

63.8%

19.7% 20.6% 16.8% 22.0% 24.3%

25.0% 23.6%

24.3% 32.4%

39.8% 30.2% 28.6%

7.4% 5.9% 6.9% 9.0% 9.1% 12.0% 11.3% 4.5% 8.4% 8.0% 11.3%

5.7% 1.9% 1.5% 4.0% 3.6% 5.4% 1.9% 3.6% 3.0% 4.6% 2.8% 1.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total Contol Group

25% Group

50% Group

Total Contol Group

25% Group

50% Group

Total Contol Group

25% Group

50% Group

Almost never Some*mes Oeen Almost always

In the last week, I felt expectaTons of me were unrealisTc 6 week 3 month 6 month

Limita*ons

•  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

Limita*ons

•  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

Conclusions

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

Conclusions 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

Qualifiers

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

Recommenda*ons for BONs

•  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

Summary

70

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