Today’s healthcare environment is largely focused on illness treatment in an aging population with increasingly complex health needs resulting in rising healthcare costs. To promote health and well-being, there must be a shift toward improving population health outcomes, enhancing the patient care experience, and reducing per capita costs (Institute for Healthcare Improvement, 2017). To address social determinants and health disparities in populations, nurses require sophisticated knowledge and skills in cultural competence, health promotion, self-management of chronic illnesses, care coordination, data translation, and use of technology (Cronenwett et al., 2007; Institute of Medicine, 2010; Interprofessional Education Collaborative Expert Panel, 2016).
Literature Review
There is a critical need to redesign baccalaureate curricula to promote better integration and attainment of essential population health competencies (American Association of Colleges of Nursing, 2008; Benner, Sutphen, Leonard, & Day, 2010; Cronenwett et al., 2007; Institute of Medicine, 2000, 2003; Interprofessional Education Collaborative Expert Panel, 2016). Simulation based learning provides realistic clinical experiences that promote competencies and readiness for professional nursing practice (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Flipped classroom assignments, online activities, and academic-practice partnerships have been reported to increase student population health learning (Ezeonwu, Berkowitz, & Vlasses, 2014; Randolph, Evans, & Bacon, 2016; Simpson & Richards, 2015). Research is lacking regarding effective strategies to promote baccalaureate population health competencies across the curriculum.
Purpose
The study aim was to evaluate use of high-fidelity patient simulation to redesign our baccalaureate nursing curriculum to address population health through an academic-practice partnership.
Method
Theoretical framework. Using the NLN Jeffries Simulation Theory as a framework (Jeffries, 2016), our academic-practice partner team developed two patient cases using de-identified patient data that unfolded over the adult health I/II, pediatrics, and community courses: 1) an 82-year-old African American female with heart failure, diabetes, and 2) a 9-year-old Hispanic Latino boy with chronic asthma. Multiple, innovative learning strategies comprised of five videotaped simulated patient encounters (VSE), five high-fidelity simulation (HFS) experiences, five faculty/student guides, flipped classroom activities, and population health resources were developed and implemented in didactic and simulation settings. Six population health competency based learning outcomes were addressed: delivers culturally competent care, advances self-management of chronic illnesses, facilitates transitions in care, promotes culture of health, collects meaningful use data to address care gaps, and utilizes an electronic health record for assessment.
Sample. A pretest/posttest, descriptive, electronic survey design was used to collect data from 585 baccalaureate students and 78 faculty on three statewide campuses at a large US public university in fall 2016 and spring 2017.
Outcomes measures. Investigator developed evaluation surveys were used by students and faculty to assess student attainment of population health competencies using a 4-point Likert scale. Qualitative themes were extracted from additional comments. Cultural competence was assessed using the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professions-Student Version (IAPCC-SV©) (Campinha-Bacote, 2007).
Procedure. University institutional review board exemption approval and informed consent were obtained. Didactic simulation activities involved a student guide pre-assignment (1-2 hrs) with a VSE (10-15 mins), activities (e.g., care plan), and resources. The faculty guide included the student assignments and resources along with a debriefing activity for a class VSE discussion (1.25-1.5 hours). The HFS experience with manikins or standardized patients occurred approximately one week later, and included: student guide pre-assignment (1-2 hrs) activities (e.g., online modules), and resources; and dedicated simulation team and clinical faculty guides for the pre-briefing (1 hour), simulation (2 hours), and debriefing (1 hour) activities. Students and faculty were allotted instructional time to complete the electronic surveys.
Results
Sample. There was a 100% student (n = 585) and 87% faculty (n = 68) response rate. Students were ethnically diverse (48%), predominantly female (81%), and mostly between 20-25 years-old (61% fall 2016, 68% spring 2017). Faculty were primarily white (59%), Asian (13%), Black/African American (12%), female (96%), and over age 40 (55%).
Population health competencies. Students overwhelmingly agreed/strongly agreed (90% to 100%) that they met the population health competencies for all VSE and HFS activities across all courses. Faculty also agreed/strongly agreed (89% to 100%) that student groups met four to six population health competencies for the VSE and HFS activities across all courses, with slightly less agreement/strong agreement (75% to 80%) that students improved outcomes through culturally competent care and facilitating connections to community resources for the patient in the unfolding pediatrics case. No difference in population health competencies was noted between VSE and HFS activity learning outcomes across courses.
Cultural competence. Reliabilities for the IAPCC-SV© showed excellent to good internal consistency (.93 overall, subscales .67 to .87). Students’ cultural competence increased in both fall 2016 [mean diff (SD) = 1.25 (7.62), t (df) = 2.996 (335), p = .003], and spring 2017 [mean diff (SD) = 1.64 (8.11), t (df) = 4.577 (510), p = .000]. ANOVA results showed no differences in outcomes based on ethnicity, race, gender, or course enrollment.
Student and faculty qualitative feedback. Four themes consistent with quantitative findings were revealed: student population health learning outcomes achievement, active/engaging collaborative learning experiences, skills gained, and faculty facilitator characteristics.
Discussion
Didactic VSE discussions and HFS experiences with flipped classroom pre-assignments and structured debriefing were equally effective in advancing student population health competencies. Rigorous, systematic study design enabled successful, large scale integration of population health competencies across the curriculum on all campuses. Benefits to students and faculty included: new opportunities to engage in culturally competent care in multiple settings across the continuum, collection of electronic health information to avoid care gaps, electronic health record documentation, increased understanding of big data, and a shift toward a population health focus. The clinical partner stated the realistic clinical experiences were enriched through our academic-clinical partnership and provided support to new nurses for a smoother transition to practice. Rapid cycle quality improvements were made to improve communication with students and faculty, and to address internal and external challenges (e.g., survey software and new email systems glitches).
Conclusions
Students and faculty perceived simulation based learning strategies to be effective in advancing baccalaureate students’ knowledge and skills to address population health. A strong project design and widespread support led to successful student outcomes. Enhanced academic-practice partnerships aimed at ongoing, collaborative efforts to integrate population health competencies into baccalaureate curricula and future research on actual patient outcomes are needed.