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1 Multi-Center Development and Testing of a Simulation-Based Cardiovascular Assessment Curriculum f0r Advanced Practice Nurses PA M E L A R. J E F F R I E S, M I C H A E L B E A C H, S H A R O N I. D E C K E R, L U C I E D L U G A S C H, J E F F R E Y G R O O M, J U L I E S E T T L E S, A N D J O H N M. O D O N N E L L T HE EVER-CHANGING LANDSCAPE OF HEALTH CARE al. (2006) found no improvement in auscultation skills after the third H A S A F F E C T E D T H E T R A I N I N G O F H E A LT H C A RT year of medical school among medical students, residents, and faculty, PROFESSIONALS. Decreased access to patients, restrictions on student interventions, and economic constraints have driven educators to find novel and improved ways to train their students. Even without changes in the clinical environment, numerous studies have revealed that acquisition of clinical skills by experience alone is inadequate to obtain mastery (Barrett et al., 2006; Issenberg & McGaghie, 2002; Wayne, Barsuk, O Leary, Fudala, & McGaghie, 2008). In situations where mastery seems to have occurred by successful completion of a course, such as advanced cardiac life support, and the passing of clinical and didactic examinations, retention becomes a problem (Wayne et al., 2005). Inadequacies in clinical education result in knowledge and skills that are never fully developed or are lost over time, translating into errors during the delivery of patient care. Deliberate practice and the mastery learning model have shown promising results with regard to mastering and retaining knowledge and performance of clinical skills (Wayne et al., 2008). although cardiology fellows demonstrated superior skills. Results from studies by Issenberg & McGaghie (2002) and Wayne et al. (2008) have shown that simulation technology and deliberate, repetitive practice resulted in a large and significant improvement in the recognition of simulated heart sounds and recordings of actual human heart sounds. Issenberg and McGaghie found that practice with simulated heart sounds significantly improved performance compared to the usual clinical experience. Deliberate practice is an evidence-based teaching method grounded in information processing and behavioral theories of skill acquisition and maintenance (Ericsson, 2004, 2006; Ericsson & Charness, 1994; Ericsson, Krampe, & Tesch-Römer, 1993). The goal in a simulation learning context is constant skill, knowledge, or professional improvement, not just maintenance of the status quo. Several examples can be cited that demonstrate the power of deliberate practice in simulation-based education (Barrett et al., 2006; Issenberg, McGaghie, Petrusa, Lee, & Scalese, 2005; Background Cardiovascular assessment skills, including auscultation, McGaghie, Issenberg, Petrusa, & Scalese, 2006; Wayne et al., 2005). Several features of deliberate practice contribute to simulation-based are deficient among advanced practice nursing (APN) students and health care education: providers, and effective instructional methods to improve cardiovascular Highly motivated learners with good concentration assessment skills are needed (Mangione & Nieman, 1997). Prior stud- ies have shown that clinical experience often does not lead to improvement Engagement with a well-defined learning objective or task at an appropriate level of difficulty in skills. Mangione and Nieman found that medical students iden- Focused, repetitive practice that leads to rigorous, precise educa- tified only 20 percent of 12 cardiac events correctly, with the rate for tional measurements internal medicine residents 19 percent. A study by Vukanovic-Criley et Informative feedback from educational sources R E S E A R C H Abstract Cardiovascular assessment skills are deficient among advanced practice nursing students, and effective instructional methods to improve assessment skills are needed. The purpose of this study was to develop, implement, and evaluate outcomes of a cardiovascular assessment curriculum for advanced practice nurses at four institutions. Each institution used a one-group pre-to-post-intervention design. Educational interventions included faculty-led, simulation-based case presentations using the Harvey cardiopulmonary patient simulator (CPS), and independent learning sessions using the CPS and a multimedia, computer-based CD-ROM program. Outcome measures included a 31-item cognitive written exam, a 13-item skills checklist used in each of a three-station objective structured clinical exam, learner self-efficacy and satisfaction survey, instructor satisfaction and self-efficacy survey, and a participant logbook to record practice time using the self-learning materials. Thirty-six students who received the simulation-based training showed statistically significant pre-to-post-test improvement in cognitive knowledge and cardiovascular assessment skills. 316 Nursing Education Perspectives

2 Trainee monitoring of learning experiences, correcting strategies, errors, and levels of understanding, and engaging in more deliberate practice Evaluation to reach a mastery standard Advancement to another task. Features of the mastery learning model, introduced to health care education 30 years ago, complement the deliberate practice construct (McGaghie, Siddall, Mazmanian, & Meyers, 2009): Baseline (e.g., diagnostic) testing Clear learning objectives, sequenced as units ordered by increasing difficulty Engagement in learning activities (e.g., deliberate skills practice, data interpretation, reading) focused on reaching the objectives Setting a minimum passing mastery standard (e.g., test score) for each educational unit Formative testing to gauge unit completion at a preset mastery standard Advancing to the next educational unit given measured achievement at or above the mastery standard; or, continuing practice or study on an educational unit until the mastery standard is reached. A mastery model is congruent with recent trends in health care education favoring certification of achievement (outcome-based) over the delivery of an educational curriculum (process-based). While the goal is to ensure that all learners accomplish all educational objectives with little or no outcome variation, the amount of time needed to reach mastery standards for a unit s educational objectives varies among the learners. A mastery model in which learners acquire essential skills measured against fixed achievement standards has been employed in the teaching of advanced cardiac life support (ACLS) (Wayne et al., 2006). A standardized curriculum, with uniform outcomes ensured from rigorous measurements, is requisite, with learning outcomes gauged against high mastery achievement standards derived empirically by experts (Wayne, Barsuk, Cohen & McGaghie, 2007). As nursing professionals assume greater responsibility in the assessment and care of patients, they need to master skills previously expected only from physicians. For example, APNs must be able to carry out accurate and appropriate patient assessments, including the cardiovascular system. This article reports on the development and evaluation of a special cardiovascular curriculum that focuses on cardiovascular assessment skills for the nursing population by a national consortium of experts in simulation-based training. Five research questions were asked: 1. Is there a significant difference in APN students cardiovascular skill performance and clinical diagnostic reasoning and diagnosis after completing the deliberative practice curriculum (DPC) and simulation? 2. Do students perceive improved self-efficacy in their cardiovascular and clinical reasoning skills after completing the DPC and simulation? 3. Are students satisfied with the cardiovascular assessment instruction using the DPC and simulation? 4. Are nurse educators satisfied and confident with the instructional method for teaching cardiovascular assessment using the DPC and simulation? 5. What percentage of student participants need remediation in obtaining appropriate benchmarks in performing a cardiovascular assessment after going through the DPC and simulation? Curriculum Development An interprofessional team representing multiple specialties, teaching backgrounds, and institutions was formed from the Miami International Alliance for Medical Education Innovation (M.I.A.M.I.) Group based at the University of Miami Michael S. Gordon Center for Research in Medical Education. This collaborative model for health care education draws on the talents and expertise of individuals brought together to design innovative simulation curricula and devise evaluation methods to perform outcomes-based research. The collaboration ensures the validity and credibility of all programs that are developed and ensures that they are generalizable beyond a single institution. In 2007, the M.I.A.M.I. Group was expanded to include nursing experts. The team was then tasked with developing a comprehensive program of instruction for nurses using Harvey, a cardiopulmonary patient simulator that dates from Harvey, a full-size patient manikin with advanced digital technology that simulates 30 cardiac and pulmonary cases (Issenberg, 2006), has been adopted and used internationally. The manikin is supported by a complete curriculum package of audiovisual resources and learner and teacher manuals developed for the instruction of medical students and residents. More than 50 published studies demonstrate its effectiveness as a teaching, testing, and learning methodology (Issenberg & McGaghie, 2002; McGaghie et al., 2006). This article reports on the development and modification of the Harvey curriculum for basic and advanced nursing learners. GUIDING PRINCIPLES In 2007, having reviewed the existing Harvey curriculum as it was designed for medical students, the team modifying the curriculum identified teaching and learning materials that would be most applicable for nurses. A sample plan to integrate Harvey into both basic and advanced nursing curricula was developed. Two basic principles guided curriculum development for mastery of the bedside examination used in patient assessment and care. First, students must have an orderly examination technique together with knowledge of the hemodynamic correlations with bedside findings. Second, skills must be practiced repetitively. LEARNER MANUAL The team developed a learner manual that incorporates a systematic approach to cardiovascular assessment. The content is case-based and highlights assessment findings with underlying physiology. Twelve key cardiovascular cases were identified for basic and advanced nurses (Figure 1). September / October Vol. 32 No

3 Figure 1. Cardiovascular Curriculum Curriculum Evaluation Method STUDY DESIGN The study design was a multicenter, prospective, quasi-experimental intervention. Using the Angoff method (Downing, Tekian, & Yudowsky, 2006), an expert panel of judges devised minimum passing scores for the identification of essential cardiovascular bedside findings. SETTING AND PARTICIPANTS This study was performed at INTRODUCTORY PROGRAM A CD-ROM-based introductory four university schools of nursing that were geographically distributed across the nation. The University of Miami Gordon Center for Research in Medical Education provided coordinating and support services such as meeting facilities, statistical analysis, and Harvey technical support. Indiana University Purdue University in Indianapolis enrolls more than 30,000 students representing all 50 states and 122 countries. It is the largest multipurpose nursing school in the country. Nursing programs include master s and doctoral level programs. Clinical tracks include acute care, family, adult, pediatric, neonatal, and psychiatric nurse practitioner programs, clinical nurse specialty programs, education, and informatics. The University of Pittsburgh, located in western Pennsylvania, is an urban campus with 34,000 students. The School of Nursing has 550 undergraduate and 420 graduate students. Graduate programs include master s and doctoral level course work. Clinical tracks include acute care, family, adult, pediatric, neonatal, and psychiatric nurse practitioner programs, clinical nurse specialty programs, education, informatics, and nurse anesthetist programs. program was developed that incorporates PowerPoint slides on the basics of cardiac assessment. It is designed to be used in a variety of instructional formats, including traditional didactic lecture presentation, student self-learning, and small-group learning. An existing additional CD-ROM program, Essential Cardiac Auscultation, is available to students, and includes video instruction and practice of the 12 key cardiac auscultatory findings. Florida International University (FIU) is one of the largest urban public research universities serving South Florida, with more than 39,000 students enrolled. It is also one of the largest minority and Hispanic serving institutions in the United States. The Colleges of Nursing and Health Sciences offer master s and doctoral level graduate nursing programs. The master s programs include adult, pediatric, and family nurse practitioner tracks and a nurse anesthetist track. INSTRUCTOR GUIDE The instructor guide was developed to Texas Tech University Health Sciences Center (TTUHSC) is located complement the learner manual and CD-ROM and to highlight the case-based findings with Harvey. The guide provides features and capabilities of the simulator and practical tips to integrate Harvey-based instruction across nursing curricula. It also includes guidelines for using Harvey as an assessment tool for evaluation of performance and for incorporation into simulation-based research. CARDIOVASCULAR CASE DESIGN Twelve case-based presentations were developed that incorporate a presentation of physical findings, underlying physiology, and expected goals for the learner. The cases include nursing cardiovascular assessment findings and final diagnoses. The case scenarios were developed to be used in different teaching and learning settings including traditional didactic format, small-group in west Texas and has an enrollment of approximately 3,000 students. A six-school university, its service area is composed of 108 counties that are predominantly rural and underserved. The TTUHSC Anita Thigpen Perry School of Nursing has both undergraduate programs (traditional, second degree, and RN-BSN) and graduate programs (MSN, nurse practitioner program focusing on practice specializations in family, acute care geriatric, and pediatrics, and the Doctorate of Nursing Practice). Participants were recruited utilizing a convenience sample from the first year of advanced practice nursing programs at each university. None of the participants had previously taken a graduate level physical assessment course. Approximately 10 participants were recruited at each site. instruction, or self-learning for both basic and advanced nurses. Harvey PROCEDURE The Cardiovascular Curriculum was implemented is integrated for the identification of findings, correlation of physiology and pathophysiology, generation of differential diagnosis, correlation of severity, and clinical decision-making. across four sites starting in January 2009 and ending in July Institutional Review Board approval was obtained at each institution. Instructors and evaluators were recruited from experienced faculty at 318 Nursing Education Perspectives

4 Figure 2. Cardiopulmonary Assessment Skills Checklist each site; to reduce bias, each site used one evaluator and one instructor. Each instructor received an overview of the project and instruction on the cardiovascular curriculum and the use of the Harvey simulator; evaluators were provided with instructions on use of the evaluation tools. Participants signed an informed consent form and then completed two pretests designed to measure cardiovascular cognitive knowledge and physical assessment skills. Each participant also completed a demographic data survey and a pre-intervention self-confidence questionnaire. Each participant was given a logbook to record all time spent with Harvey and other learning materials. The educational intervention was divided into independent learner review and instructor-led sessions. The independent learner materials included the Essential Cardiac Auscultation CD-ROM, introductory PowerPoint slide set, and the learner manual. Participants were encouraged by faculty to engage in self-directed review and practice using all provided materials and document their time in the logbook. The instructor-led sessions consisted of eight hours of combined didactic and practice with Harvey. Within one to two weeks following the educational intervention, each participant completed two posttests measuring cardiovascular cognitive knowledge and physical assessment skills. Participants also completed post-intervention self-efficacy and course satisfaction questionnaires and turned in their logbooks. Instructors also completed a satisfaction and self-efficacy questionnaire. While each institution followed the same general procedure, certain variations in delivery of the educational intervention occurred. The faculty-led intervention was delivered in varying time blocks across the institutions. The shortest was eight hours in one day; the longest was four two-hour blocks over a two-week period. The length of time between the initiation of the educational interventions and the posttest varied from one to two weeks. EDUCATIONAL INTERVENTION The focused nurses curriculum is comprised of 12 conditions (Figure 1). The overall learning goals were to teach APN students to: a) identify key assessments when caring for a cardiopulmonary patient; and b) discuss the basic underlying pathophysiology associated with the assessment findings. Participants used Harvey to learn at their own rate, acquiring skills as well as cognitive information. They controlled the number of variables being taught, thus reducing the background noise that often overwhelms a student dealing with real patients. Use of a patient simulator exposes students to multiple pathological assessment findings that may not be available in real clinical situations. Simulators also address the lack of standardized assessment findings in patients with unstable disease. OUTCOME MEASUREMENTS Statistical analysis using SPSS was conducted on all instruments. Content validity of the instruments was determined by a group of six APN experts from the Miami Nursing Simulation Group. September / October Vol. 32 No

5 COGNITIVE KNOWLEDGE AND DIAGNOSTIC REASONING A 31-item, multiple-choice and matching written examination was developed and used for pre- and posttesting. The items covered key principles of cardiac bedside physiology and pathophysiology. CARDIOPULMONARY SKILLS PERFORMANCE A 13-item checklist, which included a section for qualitative comments, was developed for six different clinical scenarios (three for pretest, three for posttest) where critical skills could be demonstrated by the participant during objective structured clinical exams (OSCEs). The skills checklist was designed to measure: a) cardiopulmonary assessment technique using yes/no responses; and b) identification of cardiopulmonary findings (e.g., S1, S2, murmur, crackles, Figure 2). The development team identified two critical findings/skills that the participant needed to demonstrate for each scenario and assigned points to each skill, ranking the findings/skills in order of importance. Skills deemed to be of higher priority were assigned a higher score; those of a lower priority were assigned a lower score. Scores participants received reflected an overall percentage score of items identified, with higher scores equated with better skills performance. Remediation occurred when the participant did not identify both of the predetermined critical findings/skills for a given cardiopulmonary clinical scenario. TRAINING TIME ON THE HARVEY CURRICULUM Participants used their logbooks to track the amount of time in minutes and hours they spent using the Harvey simulator and learning materials. Instructions were provided by the researcher on how to use the journal and how to note the amount of time spent with the Harvey simulator and learning materials in class, hands-on training, and practice. Remediation time was measured by calculating the additional time (measured in hours/minutes) the instructor spent with the participant to remediate in order for the student to obtain the skill required. LEARNER SELF-EFFICACY (SELF-CONFIDENCE) Confidence in performing a cardiovascular assessment was measured with a threeitem, five-point Likert scale instrument. LEARNER SATISFACTION WITH CURRICULUM Participants satisfaction with the curriculum was measured using a five-item, fivepoint Likert scale. Included in the satisfaction scale were three openended evaluation questions regarding the teaching-learning practices, the overall curriculum, and what the participant liked best about the overall instruction. INSTRUCTOR SELF- EFFICACY ( SELF- CONFIDENCE) Instructors confidence in teaching the participants to perform a cardiovascular assessment was measured using a three-item, five-point Likertscale instrument. INSTRUCTOR SATISFACTION WITH CURRICULUM Instructor satisfaction with the Harvey curriculum and simulations to teach cardiovascular assessment and clinical diagnostic reasoning was measured using a five-item, five-point Likert scale instrument. Results The sample consisted of 36 participants from four institutions. Participants volunteered to be in the study; participation was limited due to section size or amount of available equipment to use for the teaching activity. Of the participants, 43 percent worked in a critical care area; 91 percent had their BSN and were currently enrolled in a master s program in either a nurse practitioner track (53 percent primary care; 22 percent acute care) or a nurse anesthesia program (25 percent). The majority of the participants (44 percent) were 26 to 35 years of age; 12 percent were ages 18 to 25, 19 percent were ages 35 to 45, and 25 percent were age 46 or older. The sample was 73 percent Caucasian, 14 percent Hispanic, 5 percent Asian, and 3 percent African American. Twenty-one percent of the sample had earned CCRN certification; 37 percent had no certification at the time. In this study, APN students were able to perform accurate cardiovascular assessments after completing the Harvey curriculum and simulation as described in the study. For cardiovascular knowledge, there was an overall 22 percentage point gain in knowledge from pre- to posttesting across all four groups. Table 1 shows a breakdown of the three clinical scenarios focused on normal heart sounds, third and fourth heart sound, systolic murmurs (innocent murmur and mitral valve prolapse), and diastolic murmurs (chronic and acute aortic regurgitation). There was statistically significant pre-to-post-test improvement in all clinical scenarios and in all assessment areas. Thirty of the 36 participants completed the training logbook and returned it prior to the posttests. Participants reported a mean practice time of 9.8 hours during the educational intervention period outside the formal instructional sessions. There was a wide range in self-reported practice time, from a low of 30 minutes to a high of 56 hours. Students had an increase in self-confidence in their ability to perform cardiovascular assessment and in their clinical diagnostic reasoning skills after participating in the Table 1. Mean Percentage Score by Clinical Scenario 320 Nursing Education Perspectives

6 Table 2. Learner Self-Efficacy (Confidence) Survey *All differences significant difference (p<0.05) Table 3. Learner Post-Intervention Satisfaction Survey Harvey curriculum and simulations, as shown in Table 2. Table 3 depicts very high learner satisfaction with the deliberate practice curriculum. On the five-item scale, mean scores ranged from 4.6 to 5.0 (5 = strongly agree), with the highest mean associated with simulation-based instruction motivated participants to learn. Tables 4 and 5 report the instructor findings reflecting high satisfaction and confidence with teaching cardiovascular assessment technique using this curriculum. All instructors believed this type of learning helped motivate their students to learn. Four out of the 36 participants (11 percent) did not initially reach the benchmark set for success and required remediation. Limitations Limitations of the study include the small number of participants at each of the four institutions. Another potential limitation is a resource issue; not all institutions have resources and funding to perform OSCEs such as was done in this study. In addition, finding a strong faculty member who is willing to embrace change and be a champion to introduce new teaching concepts, such as the deliberative practice curriculum and the use of high-fidelity simulations, can also be a challenge. Table 4. Learner Self-Efficacy (Confidence) Survey Table 5. Instructor Post-Intervention Self-Efficacy (Confidence) Survey Discussion Curricula that are grounded in deliberate practice have been found to provide a positive teaching strategy as demonstrated by previous studies involving medical students and residents (Issenberg & McGaghie, 2002; Wayne et al., 2008). The simulation-based curriculum was effective in helping APN students significantly improve their cardiovascular assessment and technique skills. The findings reported here support the deliberate practice model with eight hours of content and hands-on experiences with skills and techniques. Students increased their skills in cardiovascular bedside assessment and diagnostic reasoning. The combination of correlating realistic auscultatory findings with underlying pathophysiology, and providing opportunity for repetitive practice, resulted in mastery learning and acquisition of important clinical skills. Students indicated that they appreciated the opportunity to practice cardiovascular skills using the CD-ROM program at home so they could have unlimited access to the curriculum. After identifying the heart sounds and findings correctly in the majority of cases, student self-confidence increased through the practice of these skills. The curriculum promotes repetitive practice that ultimately facilitates the students knowledge and skills in this area. Chickering and Gamson (1987) state that when best practices are incorporated into one s teaching, student satisfaction and performance are promoted in the course or classroom. Having hands-on practice and relating the teaching strategy to real-life experiences exemplify the best practices in teaching as outlined by Chickering and Gamson, including active learning, prompt feedback, collaborative learning, faculty/student interaction, high expectations, and diverse ways of learning. Nurse educators were also found to be satisfied and confident with this method of teaching. They appreciated the instructor guide and the training they received in using the Harvey simulator. The item with the highest mean was the one reflecting faculty agreement that this method increases student September / October Vol. 32 No

7 motivation. In contrast to previous teaching methods, this strategy was found to be more interactive, realistic, and satisfying to both the instructors and students. Remediation overall was only required for 11 percent of the students. Realistically, the number is not high, considering the high-level skills and expectations for identifying the findings in the clinical scenarios. Students need to learn and practice to obtain the knowledge and skills needed for this requirement. Conclusion Use of the deliberate practice model and a simulation-based curriculum to learn cardiovascular assessment and diagnostic reasoning skills was found to be very important in this study. APN students acquired important cardiovascular clinical skills in a nonthreatening, interactive, and selfpaced learning environment. Since this teaching-learning activity works with learning cardiovascular knowledge and skills, the combination of deliberate practice and hands-on experience with simulators should be considered when teaching other nursing skills and clinical diagnostic reasoning abilities. Overall, the findings substantiate the benefit of incorporating the deliberate practice Harvey curriculum into a nursing program when cardiovascular knowledge and skills are required in advanced practice nursing roles. NLN About the Authors Pamela R. Jeffries, DNS, RN, FAAN, ANEF, is associate dean for academic affairs at Johns Hopkins University School of Nursing, Baltimore, Maryland. Michael Beach, DNP, ACNP-BC, PNP, is assistant professor at the University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania. Sharon I. Decker, PhD, RN, ANEF, is a professor at Texas Tech University Health Sciences Center School of Nursing, Lubbock. Lucie Dlugasch, PhD, ARNP, is a clinical professor, Florida International University College of Nursing and Health Sciences, Miami. Jeffrey Groom, PhD, CRNA, is director of anesthesiology and clinical associate professor at the Florida International University Anesthesiology Nursing Program. Julie Settles, MSN, ACNP- BC, RN, CEN, is adjunct faculty, Indiana University Southside Emergency Associates at Indiana University Purdue University School of Nursing, Indianapolis. John M. O Donnell, DrPH, CRNA, is associate director, Wiser Institute for Simulation, University of Pittsburgh Medical Center. For more information, contact Dr. Jeffries at pjeffri2@son.jhmi.edu. Key Words Cardiopulmonary Patient Simulator Deliberative Practice Harvey Simulation-Based Curriculum References Barrett, M. J., Kuzma, M., Seto, T. C., Richards, P., Mason, D., Barrett, D. M., et al. (2006). The power of repetition in mastering cardiac auscultation. 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