Transforming Nurse Residency Skills Training Using Simulation: A Deliberate Practice Approach

Background: New nurses perceive that they do not have sufficient practice time for technical and clinical skills prior to and during orientation in professional practice (Candela & Bowles, 2008; Hartigan, Murphy, Flynn, & Walshe, 2010).  Additionally, nurses have indicated that their preparation should be more reality based (Hartigan, Murphy, Flynn, & Walshe, 2010).  Since 2005, a National Cancer Institute-designated Comprehensive Cancer Center has implemented a Graduate Nurse Residency Program that is committed to building confidence in graduate nurses through a structured, professional transition-into-practice experience that is customized to individual developmental needs.  A review of participant evaluations from the Graduate Nurse Residency program over a 2-year period identified clinical skills that graduate nurses were least confident performing at the end of one year of practice.  It is believed that a combination of infrequency of exposure to these skills, coupled with insufficient practice and demonstration of these skills may have contributed to these responses. Graduate nurse responses indicated they were least comfortable performing the following clinical skills: set up of blood administration sets, use of a complex intravenous tubing set-up, peripheral intravenous (IV) insertion, Foley catheter insertion, nasogastric (NG) tube insertion, central venous catheter (CVC) dressing change, tracheostomy (trach) care/airway management, and chest tube management. 

The National Council State Boards of Nursing (NCSBN) Simulation Study recognizes the challenge for students to obtain high-quality clinical experiences (Hayden, Smiley, Alexander, & Kardong-Edgren, 2014). There are only seven Boards of Nursing that have a specific number of mandated clinical hours in their Bachelor of Science in Nursing (BSN) programs (NCSBN, 2009), which can lead to variability in the amount of clinical skills experience a graduate nurse obtains. Graduate nurses (GNs) hired from BSN programs across the nation participating in the Graduate Nurse Residency program have stated during debriefs that they had limited opportunities to perform some of these skills during nursing school. Clinical skills practice was dependent on type of clinical rotation sites available which has resulted in a wide range in level of preparedness of new graduates for preforming clinical skills on patients.

A committee was formed to review the identified skills and determine methods to increase confidence and competency in performance.  Healthcare simulation was selected as the instructional approach.  The Dick and Carey Systems Approach Model for Designing Instruction was selected as the guiding framework for the simulation based instruction.  Simulation of the skills identified above were planned strictly for practice and not for competency assessment.  

Aim: The aim of these simulation education sessions was to improve learner confidence in the performance of selected skills as measured by self-report.   

Intervention: The committee separated the skills into two skill sets: beginner (peripheral IV starts, Foley catheter insertion, NG tube insertion and CVC dressing change) and advanced (trach care/airway management, chest tube management and blood administration and intravenous tubing set-up).  Baseline learner knowledge and the instructional setting was considered.  Simulation skills sessions were designed in 2 four-hour segments during months two and three, respectively of the residency 12-month curriculum.  For each of the sessions, learner objectives were developed to guide instruction.  Institutional policies, procedures, and Mosby’s Nursing Procedures and Skills checklist were selected for content development and learner self-evaluation of performance.

Ericsson’s Deliberate Practice was selected as the theoretical foundation for the simulation methodology. Deliberate practice is continuous practice with a focus on competency mastery.  Deliberate practice encourages learner-centered and paced educational approaches where learners are provided supervised practice until mastery in a skill is achieved.  The goal is to move the learner from novice performance to mastery in a particular skill set (Ericcson, Krampe, Tesch-Romer, 1993; Ericsson, 2008).  Partial task trainer simulators in a low fidelity environment comprised the simulation technique. The focus of the technique is to increase the validity of the training by minimizing the effects of increased situational fidelity to teach skills that can be easily transported into a real world situation. In essence, we sought to ensure technical skills in the areas identified were mastered so in escalating patient situations learners have a strong appreciation of the skills to perform competently in their roles.  Skills were divided into stations.  Developers conducted practice runs of procedures and skills to determine flow and timing.  Subject matter experts (SME) for each skill were identified.  The SMEs provided the content for orientation of facilitators for each of the skills stations.  Additionally, an orientation for learners and facilitators was developed.

The first skills simulation day was implemented in May 2013. Nurse Educators and clinical staff with expertise in specific skills volunteered as facilitators for the stations.  The participants were provided an orientation to the simulation lab and expectations. Stations were set up for each skill and printed procedure guidelines were provided. The participants were divided into small groups and each group was given 30 minutes to rotate through each of the skills station.

The program was piloted with two residency groups who completed the beginner and advanced simulation days.  From feedback during this pilot period the developers identified that more didactic overview of chest tube and trach/airway stations was required.  Also, the advanced skills stations required additional time for completion.  It was identified that the blood administration sets and complex intravenous tubing set-up session could be moved to the beginner skills day and coupled with the peripheral IV start station. Port-a-cath accessing and de-accessing was added to the advanced day due to request from previous evaluations and recent past learners.

Outcomes: At the beginning of the nurse residency program, the GNs are asked which skills they feel uncomfortable performing.  After completion of the residency program 12-months later, their comfort with these skills is again assessed.  With two groups of residency classes attending the program, there was a reduction in request for skills by 86.3%. Only 13.7% of respondents said they were uncomfortable with the skills A further reduction in request for skills by 92.7% was noted after program revisions were made following the pilot period where only 7.3% of respondents said they were uncomfortable with the skills  Additionally, after each skills session, GNs attitude towards the benefits of the simulation experience was assessed.  99% of the survey respondents reported that they agreed or strongly agreed that the simulation was beneficial.

Conclusions:  Simulation can be introduced into the nurse residency period for new graduate nurses to successfully enhance participants’ comfort with both fundamental and advanced clinical skills.  Integrating a deliberate practice approach to this training can further enhance both participants comfort with performing these skills, and ultimately their efficacy in delivering safe, effective care at the bedside.