Hospitals and outpatient clinics are both seeing a rise in patient acuity as care shifts to the outpatient setting, leaving those most acutely ill as inpatients. The Institute of Medicine’s 2011 The Future of Nursing report highlights the need for changes in nursing to meet the needs of the evolving healthcare environment.1 Identifying and managing clinically complex or deteriorating patients are a primary and highly important challenge. Newly hired nurses need more advanced skills compared with the past.2 Although residency programs have partially filled this gap, more training programs are needed to practice clinical scenarios and skills,3 simulation may be the way to meet this need.
Simulated learning is the process of allowing trainees to perform skills and learn actively while replicating real-world scenarios.4 Simulation allows the learner to practice managing clinical situations, including critical thinking, in preparation for similar scenarios at the point of care. It allows for a safe space to sharpen clinical skills without the possibility of harming real patients. A systematic review on simulation-based learning in nursing education reported simulation as a valid teaching/learning strategy.5 In the critical care setting, simulation has also proven to produce higher levels of confidence in staff members after implementation.6
At this 492-bed National Cancer Institute–designated Comprehensive Cancer Center, several clinical units fall under the division of critical care and pediatrics. These units include the emergency department, intensive care unit (ICU), the medical and surgical advanced care unit (ie, step-down unit), mixed medical-surgical oncology and telemetry unit, and the pediatric unit, including the pediatric ICU. Collectively, these units see a large volume of emergencies, increasing numbers of central lines and indwelling urinary catheters, and many new-graduate nurses. Annually, the hospital experiences about 100 cardiopulmonary resuscitation attempts and more than 1000 rapid response calls. The units included in this training account for 22% of the organization’s rapid response calls.
In 2017, 42% of newly hired nurses (n = 214) across the care continuum were new-graduate nurses. Supporting these new-graduate nurses as they transitioned into practice was identified as an important priority for the clinical nurse specialist (CNS). This institution has robust general training programs including hospital orientation, nursing orientation, unit-based orientation, and a residency program to support new-graduate nurses. However, specialized skills training was needed to meet the needs of our high-acuity patients and complex clinical scenarios.
The CNS team and nursing leadership collectively identified a need to enhance new graduates’ knowledge and skills with the nursing-sensitive indicators (NSIs)–associated care bundles for falls, catheter-associated urinary tract infections (CAUTIs), and central line–associated bloodstream infections. A need also existed to address practice drift from CAUTI nurse-driven catheter discontinuation algorithm. A need for a standardized approach with smaller groups, more comprehensive content, and an opportunity for practicing hands-on skills was identified.
An 8-hour training program was proposed. In line with the CNS competency of leadership,7 2 CNSs led the mandatory program for all newly hired nurses from the clinical units that fall under the division of critical care and pediatrics. Of the newly hired nurses, 106 were new-graduate nurses, and 36 had varying amounts of prior clinical experience (Figure 1). Prior to this approach, each unit was teaching similar content individually. At the time of program inception, there were CNS vacancies in pediatrics and the ICU. Centralizing the program allowed the CNSs to influence nursing practice on units with a CNS vacancy and pool resources for increased efficiency. This article describes the impact of a hands-on critical care skills day led by CNSs to enhance newly hired or new-graduate nurses’ clinical skills.
The idea for the program and planning began in January 2016. To create the curriculum and meet the program goals, the team first examined the units’ collective NSI data and considered events logged in the event reporting system. As noted, continued and sustained improvement with NSI care bundles compliance was needed.
The first program goal was to reinforce background theory behind each NSI’s associated care bundle. When the bundles were initially implemented, staff received several hours of education on each topic, which had been consolidated over time to a much more condensed format. Additionally, as supported by the literature, the team wanted to offer simulation-based learning for the associated skills. This would allow for validation of competence. The CNS group focused on coaching through education and mentorship of staff nurses to acquire new knowledge and skills.
The second program goal was to provide staff with additional theoretical background information and skills on a variety of clinical topics seen with increased frequency in this high-acuity patient population. These topics were identified from the annual nursing learning needs assessment as areas the staff would like more training on.
The proposed content was shared at a nursing leadership meeting for feedback. The first program was held in June 2016 and continues to be offered quarterly. In total, 9 sessions have been offered at the time of writing. Content included a combination of didactic content and round-robin skills sessions (Table 1). Skills sessions are presented in smaller breakout groups with 4 nurses per group for 15 minutes each. Although the intent was to create a skills-heavy program, the team faced early challenges including room availability and the need to train many attendees at one time. These factors shifted the original content format to be more lecture based. Initially, the 8-hour day included 6.5 hours of classroom time broken up into 4 hours 15 minutes and 1 hour 45 minutes of hands-on skills time, or 71% lecture and 29% hands-on. Anecdotal staff feedback from the first 2 programs included requests for more hands-on practice and less lecture. We secured classroom space better suited for interactive skills practice and revamped the program format.
The revised course format included a total of 6.5 hours of classroom time with 2 hours 15 minutes of lecture and 3 hours 45 minutes of hands-on simulation, or 37% lecture and 63% hands-on simulation. Both the didactic and hands-on content also changed over time to reflect learning needs, feedback of attendees, and evolving organizational needs. For example, an organizational need existed to practice code cart content based on clinical adverse events and nurse feedback. Hands-on skills sessions were added and amplified in 2018 to support this need. After course revision, preprogram and postprogram metrics were integrated into the program.
Preintervention and postintervention survey and demographic information were collected during the 4 most recent sessions, inclusive of approximately 70 participants. These assessments demonstrate the CNS group’s focus on systems leadership by ensuring clinically competent staff.7 The assessments ask the user to rate their comfort with hands-on skills and applied knowledge for 18 different categories (Table 2), on a 5-point Likert Scale where 1 was not comfortable at all, 3 was neutral, and 5 was very comfortable. The team looked at effect size to measure the impact of the intervention due to the small sample size. Effect size was calculated using the SDs and means for the preintervention data set and the postintervention data set.
One primary intervention to reduce CAUTI rates is to reduce the number of indwelling urinary catheters. This program sought to do this through reinforcement of the nurse-driven catheter discontinuation algorithm, and success was to be measured by decreased rates of indwelling catheter utilization. Indwelling urinary catheter utilization accounts for changes in catheter days while also controlling for fluctuations in patient census.
It was decided that unit metrics related to catheter utilization would only be analyzed if participant volume from the unit was at least 15% or more of the staff. This is based on the Law of Diffusion theory that you must reach 15% to 18% of a group of individuals before the majority adopts the behavior or practice.8 Similarly, units without available data to be tracked (such as the emergency department) could not be followed.
Data showed that 89% (n = 16) of the assessed components were affected by the program (Table 2). A medium effect was noted in 44% of the measured components; with the biggest effect in defibrillator skills, retrieving items from the code cart, care of the suicidal patient, and sepsis screening (Figure 2). A small effect was seen in 33% of the assessment components (Figure 3). No effect was seen in management of feeding and nasogastric tubes or knowledge of falls prevention strategies.
To gauge qualitative feedback from attendees, a 3-question survey was distributed to all attendees via email at one time point. Fourteen percent (n = 20) of attendees replied. Consent was implied by completion of the survey. Seventy-five percent (n = 15) of the respondents answered that the skills day changed their practice. When asked how their practice changed, a response theme surrounding increased confidence was identified. Other feedback included overall feelings that the course was helpful, a desire to have course in the early part of orientation, and more code simulations.
Catheter utilization was measured on the step-down and medical-surgical telemetry units as participation exceeded the 15% benchmark. Because of the low number of new graduates hired into the ICU and pediatric settings, the participant volume did not meet the benchmark for data analysis.
Since implementation of the program, the step-down unit has seen a 29% decrease in indwelling catheter utilization, including an overall downward trend in utilization (Figure 4). While the overall trend in the medical-surgical telemetry unit has been stable, there has been a 15% decrease in utilization from baseline to quarter 1 of 2018 (Figure 4). When translating these improvements to actual CAUTI reductions, both units outperformed the CAUTI benchmarks in quarters 2 and 3 of 2017, with the medical-surgical telemetry unit going 9 straight months without a CAUTI.
In reviewing the collected data, the largest effect was seen in skills related to clinical emergencies. As noted, the units attending the program see a high volume of rapid response emergencies, but lower volumes of medical codes, and had insufficient training opportunities on high-risk skills such as use of the defibrillator in a code. Although this program partially filled the knowledge deficit, a separate program is being implemented to addresses emergency management skills for all inpatient nurses based on staff feedback.
It was noted that staff tended to rate themselves highly in the preassessment, despite observed deficits in the same areas, which may have underestimated the actual size of the program effect due to inflated baseline scores. There is a need to further explore the disconnect between self-perception of skills and actual skill level among attendees. In future sessions, the teaching team will also ask the nurses to self-report on the number of times they have performed a particular skill to cross reference frequency with self-reported confidence.
For topics that showed small or no effect, the team is further examining the data to consider changes to the program content for future offerings. Specifically, more in-depth content for interventional radiology drains will be added. Nurses on both day and night shifts consistently reach out to the CNSs for help managing and troubleshooting these drains, and there are frequent requests for additional education despite the program content, which is consistent with the low effect score. Detailed didactic background and patient case study photographs will now be integrated to further enhance this content. A hands-on pairing of interventional radiology drain content will continue to be presented during the skills round-robin. Currently, the program is offered quarterly to new-graduate hires, but attendee feedback indicates it may be more helpful to offer the course in the early part of orientation, which would require offering the program monthly.
Throughout the implementation phase of this training program, valuable opportunities for mentoring occurred. A core CNS competency, effective mentoring influences career advancement, job satisfaction, and development of leadership skills.9 The CNS influenced nursing practices and acted as mentors by reaching out to 5 senior staff nurses to become involved in teaching and further program planning. This formed a core teaching team that worked together to guide the program’s success. The senior staff reflected on their precepting experiences and assisted in tailoring the education to the specific knowledge deficits identified. Together, the core teaching team also provided input regarding individual needs for each unit in accordance with their respective NSI scores. The senior staff nurses were selected to teach content most applicable to their clinical area. While leading the team in education, the CNSs also provided support and mentorship to the senior nurses on curriculum development, PowerPoint skills, and public speaking and presentation skills. As the program evolved, CNS graduate students were invited to participate as well. Together, the senior nursing staff and graduate students were encouraged by the CNSs to become active participants in agenda development, metrics, and program logistics. This also provided for succession planning and sustainability of the program for the future. Finally, the program coordinators were mentored by senior nursing leadership on the analysis of metrics to ensure the selected teaching strategies were effective. Much of the success of this program stemmed from the teamwork and guidance that occurred at all levels.
It is evident that this project demonstrates numerous CNS competencies across the 3 spheres of influence: direct patient care, nurses and nursing practice, and organization/system. Our role as CNSs calls for us to ensure nursing practice is reflective of policy and current evidence and mentor others in dissemination of information. Doing so directly influences patient care, safety, and ultimately patient outcomes.7 Clinical nurse specialists facilitate best practice by designing and executing evidence-based programs aimed at giving staff the necessary knowledge, skills, and confidence to manage complex clinical scenarios. On a local, divisional, and organizational level, our program has impacted staff education, created mentoring opportunities, and elevated competency assessment.
The nursing feedback from the program demonstrates success in helping nurses feel better prepared when caring for highly complex patients. The emergency skills practiced in the program help the nurses feel confident in the large number of rapid response team calls experienced on these units. Using simulation has aided in addressing a learning need in an efficient manner reflective of evidence for effective teaching strategies. Other organizations looking to enhance new-graduate knowledge and skills could emulate this program with a reasonable expectation of success.
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