Enhancing Faculty Development and Student Clinical Learning Using Quality Simulation Through Innovative Technologies

A significant nursing shortage is driving nursing schools to increase enrollment, and ultimately, graduation of well-prepared students. Along with the increased enrollment, nursing schools across the state are simultaneously experiencing a decrease in the number of traditional clinical sites for student learning experiences, particularly for specialty nursing clinical sites such as community health, mental health, and older adult nursing. In addition to limited clinical sites, the quality of the learning experience can be unpredictable with fluctuating patient numbers and diagnoses which further diminishes the overall learning experience for the student. The evidence indicates that learning outcomes using simulation are similar to those in traditional clinical experiences. A recent study conducted by the National Council of State Boards of Nursing (NCSB) found that up to 50% of traditional clinical experiences can be substituted with simulation with no change in core course grades, grade point average (GPA), or National Licensure Exam (NCLEX) pass rates (Hayden, Smiley, Alexander, Kardong-Edgron, & Jeffries, 2014). Hayden et al., (2014) found that there was no significant difference in nursing knowledge, clinical competency, or readiness for practice at end-of-program with increased simulation use.

To be effective, high-quality simulation must incorporate best practices into the program (Hayden, et al., 2014). These best practices are defined by the International Nursing Association for Clinical Simulation and Learning (INACSL) and include participant objectives, facilitation, facilitator proficiency, debriefing process, and participant assessment and reflection (INACSL, 2013). This project will fund comprehensive training of a group of faculty, including faculty teaching in the Nursing Care of the Aged, Mental Health, and Care of Community Health Clients courses, to more fully incorporate the INACSL V-IX Standards across the program (INACSL, 2013). These standards focus on debriefing methods, the role of the facilitator, simulation enhanced interprofessional education (IPE), and simulation scenario creation (INACSL, 2013). The project is guided by principles articulated in the situated cognition model including the interaction of the community of learners, participation in authentic activities, and the incorporation of learning including tools, technology, images, and prior knowledge (Brown, Collins, & Durguild, 1989).

Specialty Course Simulations Faculty teaching in specialty courses are especially challenged by increasing enrollment and limited capacity in specialty clinical sites to accommodate nursing students’ clinical learning. High quality, realistic simulation experiences effectively augment traditional clinical learning and provide critical experiences that may otherwise be limited. Simulations in mental health have been used to increase student understanding of specific psychiatric conditions and the needed communication skills for engaging persons affected (Orr et. al., 2013). Scenarios that simulate obstetric and perinatal care have been successfully used to prepare students prior to clinical experience and to augment higher-risk care practices that may not be available to students in the clinical setting (Hogewood, Smith, Etheridge & Britt, 2015). Evidence indicates that both student empathy and understanding of the challenges and barriers to health care for the elderly, low-income individuals and families, and other vulnerable populations in the community increases with well-designed simulation experiences. As a consequence, community referrals and inter-professional collaboration increased in student nursing practice (Chen et al., 2015; Sawin et al., 2016; Wheeler & McNelis, 2014; Yang, et al., 2014). The increased use of advanced technology will be used as part of this project to augment the overall simulation experience, increase realism, and expand learning opportunities, particularly for students in the Nursing Care of the Aged, Mental Health, and Care of Community Health Clients courses. Previous funding awarded from the former THECB grant supported new technology and equipment used in simulation such as GoPro cameras, laptop computers, and SimScopes.

Standardized Patients To provide more realistic clinical experiences, the College of Nursing utilizes Standardized Patients (SPs) in all simulated learning. In addition to faculty evaluation, these “patients” provide valuable feedback to students about their care. In order to provide the high quality learning experience for students, SP’s are coupled with advanced technologies such as Ventrilocopes. These scopes allow students to hear life-like assessment sounds from SP’s that allow for real time progression of a pathological process or treatment within a given simulation scenario. The Ventriloscope technology purchased from this round of funding is more advanced and will be used in the subsequent courses, including the specialty courses, to create a high degree of realism in simulation scenarios. This level of realism in simulation is difficult to achieve without the use of this advanced technology.

Telehealth Texas is a state with large rural populations, often without access to quality specialty services. TAMU’s mission as a land grant university is to educate students to serve all the citizens of Texas. Telehealth can be used to provide health services to rural areas by allowing patients access to healthcare providers from a distance through the use of technology (Ali, Carlton, & Ali, 2015). Telehealth is the use of technology to deliver healthcare via distance in real time. With telehealth technology, providers can access patient information, charts, and visually see the patient across large distances. Ali, Carlton, & Ali (2015) found the integration of telehealth in nursing curricula, clinical experiences, and simulation to be lacking. Currently the CON has no capability to expose students to the use of distance healthcare technologies, such as telehealth. With funds from this grant, a robotic device will be purchased and incorporated into simulations designed to allow a student in the provider role at a distant site to join in the simulation via technology. This IPad on a mobile unit will allow for distance participation in simulation scenarios through a computer. This type of healthcare delivery provides the capability to simulate reaching a broader population that includes rural communities. In a survey of 130 accredited nursing schools, Nagia, Kay, and Omar (2015) found that only 42% of participants reported incorporating a telehealth learning experience through the use of remote technology. The TAMUHSC includes colleges of nursing, medicine, and pharmacy on multiple campuses across the state. Nursing students in the Care of Community Health Clients courses, along with students from these programs will be included in simulations, and using telehealth technology, will interact with multiple members of the healthcare team such as a nurse practitioner, physician, or pharmacy students at distance locations to add an interprofessional component to the learning experience.

Over the two-year period of the project, sixteen hours or approximately 10-25% of the traditional clinical hours in each of the Nursing Care of the Aged, Mental Health, and Community Health courses will be replaced by high-quality simulation experiences. Students will participate in simulation experiences that are consistent with skills that the nursing student would normally encounter in a traditional clinical setting in these courses. Additionally, students will be exposed to innovative pedagogical instruction to facilitate skill development and preparation for subsequent areas of study and clinical practice. Some simulations will include an interprofessional component in order to allow students to practice skill acquisition as part of a healthcare team. All simulations will be standardized in order to maintain consistency throughout the curriculum to provide each student with a holistic set of high quality simulation experiences.

The performance measures of Goal one aimed at the addition of technology enhanced simulation clinical hours in the Nursing Care of the Aged, Mental Health, and Community Health nursing courses include (1) evaluating the distribution (%) of simulated and actual patient clinical contact hours; (2) the addition of simulated clinical contact hours offered throughout the Nursing of the Aged, Mental Health, and Care of Community Health Clients courses.

It is hypothesized that through the associated pedagogical innovations, students’ knowledge, skills, and attitudes will be sustained if not improved. To evaluate the second goal, we will examine a comprehensive set of performance measures at the course and program level using focused assessments such as instructor evaluations of clinical nursing skills in addition to broad-based, norm-referenced assessments that include HESI exam scores and NCLEX pass rates. Baseline performance measures on nursing competence will be gathered using program data from TAMUHSC CON students from 2012 to 2016. Mean HESI data will be gathered to demonstrate a baseline for comparisons across the project period. To account for initial group differences, chi square tests on demographic variables such as race, ethnicity, gender, and socioeconomic status (SES) will be conducted. Additionally, entrance HESI scores will be used as a covariate for subsequent analyses if initial differences are determined.

Comparisons will also be made at the program level beyond the grant period. The average NCLEX pass rates for the 2011 to 2014 were 97%. A direct comparison of NCLEX pass rates following curricular changes will be conducted to examine the potential impact of the proposed change on national nursing certification rates compared with previous cohorts.