DECLINING PATIENT SITUATIONS: A Study with New RN Residents

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1 DECLINING PATIENT SITUATIONS: A Study with New RN Residents

2 RESEARCHERS Patricia Ravert PhD, RN, CNE, ANEF, FAAN Brigham Young University Provo, UT Janell Anderson RN, MSN, NEA-BC Intermountain Healthcare Provo, UT 2

3 SIMULATION AND NURSE ORIENTATION Integrate simulation technology into new nurse orientation and residency Large hospital system Urban facilities Rural facilities 3

4 OBJECTIVES Participants will: Understand how simulation program is integrated into orientation (new-nurse residency) Comprehend the new-nurses perceptions of the experiences (usefulness/satisfaction) Understand how the experiences affected their encounters with patients in declining or rapid response situations after completion of the orientation/residency 4

5 BACKGROUND/PURPOSE Ultimate goal of using simulation is to improve patient care However, it is unknown whether the clinical judgment learning that takes place in a simulation setting extends to the actual care of patients Project is early step to investigate transfer of learning 5

6 BUILDING SIMULATION INTO THE RN RESIDENCY PROGRAM RN Residency Program for Intermountain Healthcare new graduate RN s Simulation added (2011) to facilitate development clinical judgment/critical thinking skills for new RN s 10 hours of simulation 6

7 METHODOLOGY 7

8 UNDERLYING FRAMEWORK/MODEL NLN/Jeffries Simulation Framework Tanner s Clinical Judgment Model (Tanner, 2006) Lasater Clinical Judgment Rubric (2007) 8

9 INSTRUMENTS NLN simulation tools Educational Practices Simulation Design Satisfaction and Self-Confidence Debriefing Experience Scale (Reed, 2010) Post Nurse Residency Reflection (based on the Lasater Clinical Judgment Rubric) Ponder about an actual patient situation(s) when the Rapid Response Team (RRT) was called or if you have not been involved in a RRT, reflect on a patient situation when you were concerned and sought assistance in determining actions to take. 9

10 NLN INSTRUMENTS Permission to use Permission to change student to participant Permission to change teacher to facilitator 10

11 PROCEDURES Simulation experiences and associated learning activities regular part of the residency/ orientation program Cohort about every 2 months - Informed consent Those not consenting still participated in the simulation experiences - but did not complete the research instruments 2 half days of simulation (with 3-4 different scenarios each day) Instruments were completed after each half-day Post Nurse Residency Reflection - 2 months after completing the residency/orientation simulation experiences 11

12 ANALYSIS SPSS Determine demographics Determine means of responses to quantitative instruments Participant s evaluation of simulation experiences Determine the Reliability (Cronbach s Alpha for sub-scales and overall) Qualitative analysis of reflection responses Inductive analysis - locate themes 12

13 FINDINGS 13

14 DEMOGRAPHICS 66 participants Age years (mean 27.6) Gender - Female 68%, Male 32% Education Associate degree 71.2% Bachelor degree 28.8% Year of graduation %; % First RN position 86% Previous simulation experience 62% 85% in school 14

15 INSTRUMENT LIKERT SCALES Educational Practices, Simulation Design, & Debriefing Experience Scale Presence in the simulation experience 1= Strongly Disagree; 5= Strongly Agree Importance 1= Not important; 5= Very important Satisfaction & Self-Confidence 1= Strongly Disagree; 5= Strongly Agree 15

16 Instrument Time 1 M (SD) Time 2 M (SD) Educational Practices Questionnaire (Overall) 4.76 (.25) 4.82 (.25) Importance (Overall) 4.64 (.55) 4.75 (.34) Active Learning 4.75 (.27) 4.83 (.24) Importance 4.64 (.57) 4.75 (.38) Collaboration 4.92 (.30) 4.96 (.18) Importance 4.77 (.58) 4.82 (.41) Diverse Ways of Learning 4.62 (.50) 4.70 (.54) Importance 4.54 (.72) 4.71 (.42) High Expectations 4.82 (.39) 4.75 (.61) Importance 4.61 (.71) 4.70 (.48) 16

17 Instrument Time 1 M (SD) Time 2 M (SD) Simulation Design Scale 4.72 (.25) 4.78 (.25) Importance 4.72 (.54) 4.81 (.27) Objectives and Information 4.64 (.43) 4.74 (.38) Importance 4.76 (.57) 4.80 (.32) Support 4.77 (.32) 4.80 (.31) Importance 4.76 (.58) 4.81 (.34) Problem Solving 4.58 (.45) 4.66 (.37) Importance 4.58 (.62) 4.70 (.41) Feedback/Guided Reflection 4.92 (.22) 4.93 (.21) Importance 4.81 (.56) 4.92 (.25) Fidelity (Realism) 4.81 (.40) 4.89 (.25) Importance 4.80 (.37) 4.92 (.23) 17

18 Instrument Time 1 M (SD) Time 2 M (SD) Participant Satisfaction and Self-confidence in Learning 4.68 (.29) 4.71 (.31) Satisfaction with Current Learning 4.87 (.26) 4.86 (.28) Self-confidence in Learning 4.56 (.37) 4.62 (.38) 18

19 Instrument Time 1 M (SD) Time 2 M (SD) Debriefing Experience Scale 4.83 (.23) 4.81 (.31) Importance 4.79 (.31) 4.78 (.35) Analyzing Thoughts and Feelings 4.76 (.37) 4.68 (.64) Importance 4.74 (.38) 4.73 (.48) Learning and Making Connections 4.84 (.24) 4.88 (.25) Importance 4.81 (.31) 4.81 (.33) Facilitator Skill 4.86 (.28) 4.85 (.31) Importance 4.82 (.32) 4.78 (.42) Appropriate Facilitator Guidance 4.87 (.30) 4.73 (.61) Importance 4.80 (.37) 4.75 (.60) 19

20 POST NURSE RESIDENCY REFLECTION On a scale of 1-10 with 1 being the lowest and 10 being the highest, how calm or confident did you feel in caring for your patient? M (SD) Calm 6.04 (1.8) Confident 4.33 (2.1) 20

21 CRONBACH'S ALPHA SCORES Describe the reliability of items, scale, or subscale Cronbach s alpha scores range in value from 0 to 1 Higher the score, the more reliable the scale 0.7 is an acceptable reliability coefficient 21

22 ORIGINAL SCALE - PRESENCE = 0.86; IMPORTANCE = 0.91 Instrument Time 1 α Time 2 α Educational Practices Questionnaire (Overall) Importance (Overall) Active Learning Importance Collaboration Importance Diverse Ways of Learning Importance High Expectations Importance

23 ORIGINAL SCALE - PRESENCE = 0.92, IMPORTANCE = 0.96 Instrument Time 1 α Time 2 α Simulation Design Scale Importance Objectives and Information Importance Support Importance Problem Solving Importance Feedback/Guided Reflection Importance Fidelity (Realism) Importance

24 ORIGINAL SCALE - SATISFACTION =0.94; SELF-CONFIDENCE = 0.87 Time 1 α Time 2 α Instrument Participant Satisfaction and Self-confidence in Learning Satisfaction with Current Learning Self-confidence in Learning

25 ORIGINAL SCALE PRESENCE = 0.93; IMPORTANCE = 0.91 Time 1 α Time 2 α Instrument Debriefing Experience Scale Importance Analyzing Thoughts and Feelings Importance Learning and Making Connections Importance Facilitator Skill Importance Appropriate Facilitator Guidance Importance

26 QUALITATIVE DATA 2-month post reflection 12 questions to prompt responses regarding transfer of learning 11 from Lasater Clinical Judgment Rubric 1 asking if the simulation experiences better prepared them to care for the actual patient in the clinical setting Two themes emerged Knowledge Acquisition Confidence 26

27 SIMULATION EXPERIENCE BETTER PREPARATION FOR CLINICAL 96.66% participants believe the simulation experience helped them to care for an actual patient in a declining situation Better clinical judgment Knowledge of resources Knowledge of symptoms & common causes of declining patient conditions Increased their confidence in their clinical judgments Only 1 participant did not find the simulations helpful pediatric nurse (no pediatric simulations included) 27

28 THEME KNOWLEDGE ACQUISITION 30% of participants noted the simulation experience added to knowledge expanded my knowledge base of resources I learned the hypoglycemic protocol I think simulation helped me challenge and stretch what I had learned. I am glad it was on a manikin. 28

29 THEME CONFIDENCE 41% noted after the simulation experiences they were confident knew protocols and resources confident as a new nurse I felt like the simulations gave me more confidence and helped me think better on my feet. I think it will help me not feel so overwhelmed when I get into an emergent situation. 29

30 CONCLUSIONS/ IMPLICATIONS The new nurses Reported the simulation experiences helped them make informed decisions with patients experiencing a decline in their condition Reflected back to the simulation experiences Recalled the resources available to them Confident to seek assistance in a timely manner Possibly improved patient outcomes Include pediatric/l&d/neonatal simulations as appropriate to group 30

31 FUTURE RESEARCH Determine if simulation experiences decrease the number of code situations as nurses may recognize declining situations quicker and call for assistance Other indications of improvement in patient outcomes could be investigated as well 31

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