The current health care environment emphasizes the treatment of illness for an aging population with complex health needs, which has resulted in rising health care expenditures. Population health refers to health outcomes for a group of individuals and how they are distributed within that group.1 There needs to be a shift toward health promotion and disease prevention to improve population health outcomes, enhance the patient care experience, and reduce per capita costs.2 This shift requires nurses to demonstrate competencies that address social determinants and health disparities in diverse populations. To meet this need, nurses should have knowledge and skills related to cultural competence, health promotion, acute and chronic disease management, care coordination, patient and family engagement, interprofessional collaboration, evidence-based practice, quality and safety, data translation and application, and use of technology.3-5
Curricula in prelicensure nursing programs should be restructured to integrate and achieve key population health competencies.3-7 It is essential that nursing faculty prepare entry-level graduates to provide population-based care that improves the quality, cost, and safety of the patient experience through transitions across care levels and settings.2 Educators also should address the challenge of linking practice to population health and intentionally integrate population health across the nursing program.8 To achieve these goals, innovative teaching strategies are required that incorporate real-life clinical experiences to promote population health competencies that bridge the gap between education and practice.7
There is substantial evidence that high-fidelity simulation provides realistic clinical learning opportunities that promote competence and preparedness for nursing practice.9 Educators have been encouraged to expand the use of simulation beyond acute care to engage students in population-focused, community-based learning experiences.10 Integrative teaching and learning strategies have been suggested to foster baccalaureate student population health competencies that address health disparities and social determinants.11-13 Flipped classroom activities, online assignments, and academic-practice partnerships have led to increased student learning about population health.14-16
Research is needed to identify effective approaches that integrate population health competencies across the baccalaureate nursing curriculum. Existing literature focuses primarily on integration of these competencies into individual assignments, learning activities, projects, or courses, such as community health.10,12-17 The study purpose was to evaluate a simulation innovation developed through an academic-practice partnership to restructure our baccalaureate nursing curriculum to address population health.
Our project goal was to redesign our baccalaureate curriculum using a simulation innovation to (1) improve population health by providing culturally competent care to address social determinants and health disparities; (2) advance behavioral changes in self-management of chronic illnesses; (3) facilitate transitions in care; (4) promote a culture of health through health promotion, disease prevention, and utilization of community resources; (5) contribute to the collection and interpretation of meaningful use data to recognize care gaps; and (6) use the electronic health record (EHR) for documentation and reassessment as it relates to quality, safety, and evidence-based best practices. The simulation innovation included videotaped simulated patient encounter (VSE) didactic discussions and high-fidelity patient simulation (HFS) on-site clinical experiences. The NLN Jeffries Simulation Theory guided the project framework.18
In July 2016, an academic-practice partnership was initiated between our nursing school and a senior nurse administrator from a large health system to construct 2 unfolding patient cases to address population health needs of ethnically/racially diverse adults and children with prevalent chronic diseases: an 82-year-old African American woman with heart failure, hypertension, and diabetes and a 9-year-old Latino boy with chronic asthma. Our clinical partner had nursing informatics expertise that added significant knowledge and depth to our project team of faculty and simulation experts. An external consultant contributed outcomes evaluation and cultural competence expertise.
Faculty/student guides were developed for 4 courses across our upper division baccalaureate curriculum: adult health I and II, pediatrics, and community. The adult case unfolded across the adult health and community courses, whereas the pediatric case bridged the pediatrics and community courses. Multiple, innovative learning strategies composed of flipped classroom assignments, VSE didactic discussions, and HFS on-site clinical experiences were created and implemented as described in the Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A439. Flipped classroom assignments included content review (eg, textbook, quiz, video), completion of online Institute for Healthcare Improvement modules, review of evidence-based assessment tools and resources, development of nursing care plans, and analysis of population health data (eg, county databases, mortality and morbidity statistics). Each course included a VSE didactic discussion and an on-site clinical HFS experience for a specific patient case, whereas the community course applied these activities for both cases. The HFS occurred approximately 1 week after the VSE discussion.
Deidentified patient charts from our clinical partner shaped the faculty/student guides and VSE/HFS activities created collaboratively by our project team. Prebriefing and debriefing activities and questions were designed to prepare students and both didactic and clinical faculty for a collaborative exchange and discussion. Each high-fidelity VSE was 7 to 15 minutes with faculty/student actors as the patient, family, and providers. The VSE was filmed using an Apple iPad or iPhone (Apple Inc, Cupertino, California) in early August. Each VSE was placed on a video platform, and hyperlinks were included in the guides. The guides and schedules were placed on a unified project site within a course learning management system. Given their simulation and facilitation expertise, our dedicated simulation team members were lead facilitators for HFS on-site clinical experiences. Clinical faculty were HFS cofacilitators/actors who shared clinical knowledge and skills.
Setting and Participants
A pretest-posttest, descriptive survey design was used to collect data from 585 generic and second-degree baccalaureate students (n = 336 fall, n = 511 spring, n = 262 both semesters) and 78 faculty facilitators on 3 nursing school campuses (2 urban, 1 suburban) of a large US public university during the 2016-2017 academic year. Students were primarily female (81%), white (52%), Asian (26%), Hispanic Latino (12%), and black/African American (12%), ranging in age from 20 to 56 years. Student age was positively skewed for fall 2016 (mean, 27 [SD, 6.8] years) and spring 2017 (mean, 25.5 [SD, 6.4] years). Faculty were predominantly female (96%), white (59%), Asian (13%), and black/African American (12%), ranging in age from 31 to 57 years (mean, 44.71 [SD, 8.7] years). Some faculty declined to report their age (n = 21) or ethnicity (n = 6).
Population Health Learning Outcomes
Student learning outcomes were assessed by students/faculty on electronic evaluation surveys developed by the project director for each didactic VSE and HFS activity. Surveys assessed student learning using a 6- to 7-item Likert scale scored as 1 (strongly disagree) through 4 (strongly agree), and themes from additional comments. Student learning outcomes were met when student/faculty feedback reflected agreement or strong agreement.
To improve population health, students should become culturally competent so they may address social determinants and health disparities.4 Cultural competence was assessed using the electronic Inventory for Assessing the Process of Cultural Competence Among Healthcare Professions–Student Version (IAPCC-SV), which has been found to be reliable and valid.19 Students completed the pretest/posttest IAPCC-SV to assess their level of cultural proficiency, cultural competence, cultural awareness, or cultural incompetence. A 4-point Likert scale (strongly disagree to strongly agree) for 20 items measures overall cultural competence and 5 constructs: desire, awareness, knowledge, skill, and encounters. Total scores range from 20 to 80; subscale scores range from 3 to 20. Higher scores indicate a higher cultural competence level.
University institutional review board exemption approval was obtained. Students received an e-mail invitation with the electronic survey consent form and student outcome measures: the pretest-posttest IAPCC-SV and post-VSE discussion/HFS evaluation surveys. Faculty also received the electronic consent form and post-VSE discussion/HFS evaluation surveys via e-mail.
Data were analyzed using IBM SPSS Statistics version 24.0 (IBM Inc, Armonk, New York). Means, SDs, ranges, and frequencies of sample demographics, IAPCC-SV scores, and evaluation survey scores were assessed. The IAPCC-SV Cronbach’s α reliabilities were calculated. The IAPCC-SV scores were analyzed using paired t tests. Evaluation survey and IAPCC-SV scores were examined using analysis of variance (ANOVA). Multivariate canonical correlation analysis was used to assess changes in IAPCC-SV subscale scores over time. Level of significance was set at .05. A minimum of 198 students was required for a power of 0.80 with a small effect size (0.20) using a 2-tailed paired t test (α = .05) and the canonical correlations (r = 0.20, α = .05).
High response rates were obtained for students (100% [n = 585]) and faculty (87% [n = 68]). A few students in the fall (n = 9) and spring (n = 17) did not complete specific VSE and HFS activity evaluations because of absence.
Population Health Competencies
There was overwhelming student agreement/strong agreement (90%-100%) that population health competencies were achieved for all VSE and HFS activities across all courses. Similarly, faculty agreed/strongly agreed (89%-100%) that student groups met 4 to 6 population health competencies related to VSE and HFS activities across all courses. There was slightly less faculty agreement/strong agreement (75%-80%) that students improved patient outcomes through culturally competent care and facilitating connections to community resources for the unfolding pediatrics case. Paired t test and ANOVA results revealed no differences in population health competencies between VSE and HFS activity learning outcomes across courses.
The IAPCC-SV demonstrated excellent to very good internal consistency reliability (overall 0.93, subscales 0.67 to 0.87). ANOVA results showed no difference in cultural competence related to ethnicity, race, gender, or course enrollment. Overall cultural competence of students increased in fall 2016 (t 335 = 3.01, P = .003) and spring 2017 (t 510 = 4.58, P < .001). Moreover, overall mean scores indicated students deemed themselves culturally competent, and they had statistically significant increases in their cultural knowledge and skill in both semesters (Table 1). Cultural encounters decreased slightly in spring 2017 (t 510 = 2.13, P = .033). Items within this construct related to willingness to learn from others and frustration when values and beliefs clashed with a client revealed minimal declines (−0.12 and −0.39) that were statistically significant (P < .001). These changes may reflect a deeper self-awareness of cultural competence that became detectable in the larger spring group.
Students enrolled in adult health II, pediatrics, and/or community courses who participated in the simulation innovation across both fall and spring semesters (n = 262) assessed themselves as culturally competent overall and had significant increases in their cultural knowledge, skill, and overall scores over time (Table 2). One statistically significant canonical variate was produced (Wilks λ = 0.836, P = .007) that explained 8% of the variance in the relation between pretest and posttest cultural competency subscale scores for these students. While the overall explained variance was low, the redundancy analysis for the canonical variate accounted for 100% of the variance in overall cultural competence for both the pretest and posttest, showing it represented the cultural competence subscale constructs well.
Moderate to moderately high canonical loadings exhibited the importance of specific constructs in explaining changes in cultural competence over time: pretest cultural awareness (−0.49), knowledge (−0.72), skill (−0.64), and encounters (−0.53) and posttest cultural awareness (−0.31), knowledge (−0.52), and encounters (−0.44). In other words, lack of cultural awareness, knowledge, and encounters had a consistent, negative impact on overall cultural competence. However, this impact diminished over time. Meanwhile, the negative impact of lack of cultural skill was almost eliminated by the posttest (−0.04). These findings demonstrated that students who participated in the population health simulation innovation over 2 semesters had consistent improvement in their cultural awareness, knowledge, skill, and encounters over time.
Student, Faculty, and Clinical Partner Feedback
Student and faculty evaluation survey comments revealed 4 themes consistent with quantitative findings: student population health learning outcomes achievement, active/engaging collaborative learning experiences, skills gained, and faculty facilitator characteristics. Student population health learning outcomes achievement included recognizing the impact of social determinants on patient outcomes, increased awareness of disproportionate chronic illness rates among ethnic/racial groups, promoting health and facilitating care transitions to reduce hospital readmissions, coordinating interprofessional team care along the health continuum (eg, primary, acute, chronic, palliative), and engaging in new clinical learning experiences (eg, post–cardiac catheterization discharge teaching). Students recognized the need to improve health outcomes for patients living with chronic diseases by providing culturally competent care and discharge teaching to maintain optimum health at home.
The innovative simulation activities were valued as active/engaging collaborative learning experiences that enhanced students’ knowledge and understanding of key concepts. Skills gained included critical thinking, increased cultural competence, identifying patient needs in multiple settings, working with patients at home, and facilitating small and large group class discussions; for example, students examined patient cases from multiple angles and learned the importance of transitional care. Several community students requested more frequent, similar learning experiences earlier in the program. Finally, faculty facilitator characteristics were evident: being knowledgeable, engaging, and supportive of learning through helpful feedback, especially the dedicated simulation team members.
Our clinical partner deemed the population health simulation innovation enhanced the education of future nurses to better care for patients in acute, outpatient, and home care settings. Realistic clinical experiences were enriched through our academic-clinical alliance and access to an educational EHR, providing support to new nurses for a smoother transition to practice. Our clinical partner expressed a sense of accomplishment in helping to create a true clinical record focused on care coordination to help entry-level nurses provide high-quality, safe patient care and transitions. This relationship has laid the foundation for future collaborations and projects with an expanded academic-practice team.
Didactic VSE discussions and HFS experiences combined with flipped classroom preassignments and structured debriefing were effective, interactive strategies to increase student population health competencies. The VSE discussions and HFS were equally effective in achieving desired student outcomes. This result is consistent with the importance of postsimulation debriefing as an essential best practice.18 It may also further inform an earlier finding that watching a recorded simulation was inferior to engaging in a case study and lecture.20 In the current study, using a high-fidelity VSE in the context of an unfolding case with structured debriefing may have increased its educational value. This finding may also have implications for defining high-fidelity simulation and optimal group size because our didactic VSE classes had 28 to 68 students versus up to 10 for HFS. The didactic preassignment included previewing the VSE and prepared students to self-debrief in groups of 4 to 6 on assigned questions and participate in a larger discussion facilitated by the faculty member. Furthermore, these results demonstrate students attained several baccalaureate program outcomes: provides culturally competent care, communicates effectively, analyzes health data, and influences health outcomes through comprehensive patient and population health care delivery.
The rigorous, systematic study design facilitated assessment of competencies across students, courses, and campuses. Feedback showed students and faculty were engaged and felt supported. Despite significant scheduling and logistical challenges, the project scope facilitated curricular integration of the simulation innovation. Individuals were more likely to implement the innovation as all course sections and campuses were involved. Participation was enhanced by offering faculty and student orientations, standardized syllabus language about project requirements, structured learning activity guidelines, course credit for surveys, and time for on-site electronic survey completion with e-mail reminders.
Population health competencies were integrated throughout the baccalaureate curriculum through simulation-based learning activities that built upon one another and could also stand alone. Therefore, changes made to the unfolding cases, guides, and simulation scenarios required careful scrutiny to maintain consistency within and across courses. Realistic VSE and HFS scenarios addressed transitions across the health continuum and settings, with a focus on the application and flow of electronic health information. Our population health simulation innovation challenged students to optimize interprofessional teamwork and integrated patient care. Students and faculty appreciated the depth and breadth of the unfolding cases and wanted to delve deeper into patient cultural backgrounds. Frequent project team and faculty meetings led to rapid cycle quality improvements. For example, in spring 2017, the adult was identified as African American of Nigerian descent and the child as Latino and Dominican to elaborate on the patient’s heritage so students could explore more specific cultural practices.
Other benefits expressed by 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, EHR documentation, increased understanding of big data, and a shift to a population health focus. Throughout the project, reintroduction of the patient and health history allowed students to provide continuity of care often missing in current practice. Faculty required EHR training while students easily navigated the system with little to no instruction. Faculty and students were excited to use the EHR. They particularly appreciated its integration into the HFS experiences because this may often be an educational gap in traditional clinical settings. Flipped classroom assignments related to population health data analysis allowed students to build on basic assessments and grow more skilled over time. Moreover, these data helped facilitate discussions about social determinants and health disparities.
Throughout the curriculum integration, ongoing support was provided to faculty and students by the project team. An immediate enhancement was the creation of cue cards for students playing an HFS role to improve the flow of scenarios. Rapid cycle improvements were also implemented to improve communication with faculty and students. For instance, student orientation videos and checklists outlining the project requirements and resources for the adult health, pediatrics, and community courses were developed for spring 2017.
Internal and external challenges were experienced during the project. Our school had ongoing curricular, faculty, and systems issues following a recent merger of 2 nursing schools. The electronic survey software required some training and had intermittent glitches. We had several changes and gaps in research assistant personnel. Also, new university e-mail and budget systems were rolled out in early fall 2016 coinciding with the project implementation. This posed numerous hurdles that were overcome through ongoing communication, follow-up, and tremendous support from administration, faculty, and staff.
The results are from 1 baccalaureate nursing program in a single public institution and may have limited generalizability to other programs. There may be some response bias as student outcome measures used self-report instruments that may have elicited socially desirable answers. Reliability and validity have not been established for the investigator-generated didactic VSE discussion and HFS evaluation instruments.
Simulation-based learning strategies were perceived to be effective in advancing baccalaureate student knowledge and skills to address population health. Strong design, rigorous methods, rapid cycle quality improvements, and widespread cooperation from stakeholders supported successful curricular integration of the simulation innovation. Continued faculty development regarding innovative, active learning strategies, and population health resources is needed to further advance student competence and curricular integration in additional core courses, for example, maternity and psychiatric mental health. Improved academic-practice partnerships that target ongoing, collaborative efforts to integrate population health competencies into baccalaureate curricula are needed. Future research on the subsequent impact on patient outcomes using an experimental design is recommended.
The authors thank Dr Leslie Nicoll for her support in writing this article.
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