Increased acuity in hospitalized patients, combined with the worsening nursing shortage, makes it crucial to implement ways to ease the transition from student nurse (SN) to graduate nurse (GN). Research has shown how complex the transition from SN to GN can be, and how new nurses often feel ill prepared for real-world nursing.1–3 In the transition period, GNs encounter the gap between what is learned in school and what actually happens in practice, and the pressures, priorities, and responsibilities of the new staff role.4,5 For example, more GNs are being hired directly into specialty areas such as labor and delivery and intensive care units. These GNs may have had limited exposure to these specialty areas during their educational experiences.
Effective transition is about instilling patterns of adjustment so GNs learn to cope, knowing how and when to seek assistance and personal support, which is traditionally accomplished through an orientation period.6 Orientation typically involves classroom instruction and assignment to a nurse mentor. Because hospitals have acquired simulation equipment, orientation programs that incorporate patient case scenarios as a means to orient GNs are increasingly more common.4,7,8 Simulation provides GNs, who have had minimal clinical experience, exposure to patient scenarios that they are likely to encounter.9 Although research investigating the efficacy of simulation in nursing education shows that critical thinking, clinical judgment, and competencies among students is improved, there is little research examining the outcomes of simulation when used as a strategy in GN orientation.10–13 The purpose of this article is to provide a summary of current evidence related to the use of simulation in GN orientation. Findings from the literature are linked to the three themes and recommendations for future research are suggested.
An integrative review of the literature was conducted according to guidelines set forth by Ganong14 (Table 1). Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMED, and the Cochran Library were searched using the following terms: GN, simulation, transition, orientation, nursing, and nursing student. Although there is literature in other disciplines about the use of simulation during orientation, this search was limited to nursing to yield an accurate description of the evidence in nursing. Additional articles were obtained through citation chasing.
More than 4000 articles were identified using different combinations of the above search terms; however, not all were research articles. A large subset of literature supports the use of simulation as an educational strategy in nursing. Authors of many articles describe how useful simulation can be to review, update, or teach healthcare personnel new techniques or procedures. Only a small portion of the published research explores the effects of simulation on GN orientation.
After narrowing the search and removing duplicate items, 43 articles were further examined for inclusion in the sample using additional criteria: written in English, published within the past 10 years, and used simulation during GN orientation. Nonresearch articles and articles that addressed simulation for educating SNs in undergraduate or advanced practice nursing programs were excluded. Three studies were included in the final sample (Table 2).
BODY OF EVIDENCE
Ackermann et al8 examined how simulation could be used to enhance a preceptor-based orientation program and improve retention of new nurses. Preceptors served as mentors to new nurses. In this case study, 21 new graduates participated in the orientation. Learning objectives were developed that focused on clinical decision making, critical thinking, and professional development. High-fidelity human patient simulators (HPS) were used, and five patient scenarios were created. Each GN had an opportunity to review patient charts, listen to report about each patient, respond to a given situation, and document nursing actions and patient responses. Educators assessed a printout of each GN′s actions and subsequently led group discussions reviewing the experiences. Qualitative data were collected using an evaluation form. Authors found that simulation added to the quality of instruction and the hands-on experience facilitated learning and retention of information by GNs. Even though the HPS were stiff and complex, students had the opportunity to apply knowledge and see outcomes from their actions without risk to an actual patient. After participating in simulated case scenarios, GNs indicated that they had increased confidence to manage actual patient situations. Learning in a safe environment also supported the process of socialization.
Beyea et al.4 examined using high-fidelity HPS in a nurse residency program to improve development of GN competence, confidence, and readiness for practice. A descriptive pilot study was performed using a convenience sample of GNs (N = 42). A 12-week residency program included didactic sessions, simulation, and time in the clinical setting. Several aspects were emphasized in the simulations: professional development, quality improvement, collaboration and teamwork, patient safety, and self-directed learning. A wide variety of high risk, low frequency, and high frequency, common situations were used in the simulated experiences. Each simulated experience was designed to evaluate GN competence regarding patient safety, human factors, communication, resource management, and situational awareness. Both qualitative and quantitative data were collected through structured evaluations. Unit-based clinical and administrative leaders provided feedback about GN clinical performance. They reported that the use of simulation assisted them to identify performance concerns and structure clinical learning experiences for GNs to reinforce learning in the simulation laboratory. GNs also evaluated the simulation and overall orientation experience. They reported that using simulation allowed application of what they had learned to practice. Mean scores of GNs' perceptions of clinical competence, confidence, and readiness for independent practice increased over the course of the residency program. Overall, it was demonstrated that simulation strengthened GNs' assessment and clinical skills and enhanced critical thinking abilities.
Shepherd et al7 examined ways to enhance GNs' health assessment knowledge and skills. An experimental study was conducted to investigate the impact of three different learning strategies: (1) a self-directed learning package (SDLP) alone, (2) SDLP plus 2 scenario-based PowerPoint (PP) sessions, and (3) SDLP plus 2 scenario-based HPS sessions. It was hypothesized that simulation would enhance the learning of health assessment techniques. Eighty GNs were randomly assigned to one of the three groups. All GNs took a pretest measuring knowledge about respiratory assessment. When nearing completion of the orientation, GNs were individually tested using a systematic assessment involving an acute pulmonary edema scenario on low-fidelity HPS. Before testing, the PP and HPS groups completed scenarios for asthma and pneumonia. Data were analyzed using simple descriptive statistics and analysis of variance for comparison of mean scores among the groups. Although there were no significant differences among the three groups, the mean posttest simulation assessment scores were higher in the group that used simulation. This finding, although not significant, suggests a trend that should be further investigated. This research shows that simulation, when added to other educational activities, may be more effective than self- directed learning or PP scenarios for teaching specific assessment skills.
Although only three articles met the criteria for inclusion in this integrative review, there were some commonalties among them. All orientations had small convenience samples. Surveys and questionnaires were used in all of the orientations to collect both quantitative and qualitative data. There was only one study involving random assignment of subjects.
COMMON THEMES IDENTIFIED
In the Ganong14 approach, the analysis begins by creating a table summarizing the main details of each piece of evidence. Evidence is reviewed for similarities and differences in design, sample, instruments, and outcomes. A qualitative approach is used to identify commonalities and themes across the studies. In this integrative review, three themes emerged: socialization to the professional role, competence and confidence in self-performance, and learning in a safe and supportive environment. These themes are also supported by other articles involving the transition of SNs to GNs.5,6,15,16
Socialization to the Professional Role
Socialization to the professional role is facilitated by using simulation and role playing in either laboratory or actual patient care settings. Through simulation, GNs are able to experience controlled chaos while learning about healthcare systems, information management, and safety. Hospital policies and care procedures are incorporated into simulations to familiarize GNs with standards of care before arriving on the unit.4 When simulation is conducted in actual patient care settings, mentors and GNs are able to remain on the unit, thus reducing time away from patients.7
Simulation enables GNs to practice clear and effective communication techniques. Exposure to rare events in preprogrammed scenarios having different outcomes provides experience with teamwork and communication with other members of the healthcare team.4,7,8 Fostering collegiality facilitates the transition from novice to competent professional nurse.15
Competence and Confidence in Self-Performance
A second theme identified during the analysis was competence and confidence in self-performance. Research shows that during transition, GNs often suffer overwhelming feelings that they lack knowledge to make sound clinical judgments and respond appropriately. They often fear facing issues they do not understand, missing significant symptoms, or incorrectly performing procedures that ultimately result in unfavorable patient outcomes.6
Simulation functions as a highly effective approach for developing confidence and seems to be effective to develop competency. When learning involves the use of simulation, GNs can evaluate their competence, synthesis of knowledge, and abilities to manage critical events. Lessons learned during simulation can be applied to actual patient care situations. Researchers found that performance concerns could be identified during simulated scenarios. Unit-based mentors and educators were subsequently able to structure clinical education experiences to reinforce learning that had occurred in the simulation laboratory.4 Other researchers stated that GNs, after being involved in simulation exercises, felt more confident in emergency situations.8 The inclusion of simulation in orientation programs may decrease the time required to become clinically proficient. This could result in GNs who are more self-assured and work-ready practitioners.7
Some authors suggest that confidence of GNs may be compromised by an extended period of time between the conclusion of their undergraduate nursing studies and the beginning of employment.4,7 Therefore, it is critical that orientations be structured to build confidence. Orientation programs, whether mentor or residency focused, were built on senior student competencies. Simulation offers an extremely effective mechanism to immerse GNs into complex care situations, thus building confidence.
Learning in a Safe and Supportive Environment
An important aspect of transition for GNs is to continue learning in a safe and encouraging environment. Simulation provides the supportive and safe environment that GNs appreciate during transition to their professional role. They have opportunities to participate in commonly occurring clinical events or situations to develop their clinical reasoning and decision-making skills. Scenarios often include realistic, hands-on learning that allows GNs to assess and manage different clinical situations. Whether high risk or low risk, rare or common, scenarios are used in a planned and prescribed way to build skills needed to manage emergencies and unexpected events. Because cases can be repeated, GN′s can learn by correcting mistakes without harming actual patients. Self-evaluation and feedback from experienced nurses and peers aid in the learning process.4,7,8
The three themes identified are also consistent with other findings reported in the literature. For example, socialization to the role of professional nurse is imperative for a smooth transition from SN to GN. Most hospitals and other healthcare facilities include an extended GN orientation period that facilitates socialization. Orientations may last from a few months to a year, or more, depending on the specialty area. McNiesh5 found that most orientations incorporate preceptors/mentors who aid GNs as they adjust to the responsibilities of the new staff role and to changing pressures and priorities that accompany that role. Mentoring GNs most likely requires a blend of clinical expertise and organizational ability, as well as interpersonal skill.16 Mentors are charged with determining whether GNs are clinically competent to work independently and in teams. Orientations should be able to offer ongoing supportive clinical environments that foster safe practice by GNs.5 In two other studies, it was found that residency programs providing clinical education experiences increase GNs' awareness about healthcare services, resources, and challenges while fostering commitment to the profession and professional growth and development.15,16 Augmenting mentor and/or residency programs with simulation may assist GNs to move more quickly from novice to advanced beginner.
In the literature, there is substantial evidence supporting the need to foster competence and confidence in self- performance. Clinical judgment evolves over time and continues to develop well beyond orientation. As GNs become more experienced, they are more independent when providing safe, efficient holistic care. Studies of residency programs showed improvement of GNs' critical thinking skills and abilities to use outcome data to promote patient safety. Emphasis was placed on analysis of evidence and application for the purpose of improving patient care. GNs were assisted with honing clinical skills and refining communication skills, while evolving from a novice to a competent nurse.15,16 No studies of residency programs using simulation have been conducted to determine whether GN′s development of clinical judgment is affected.
Learning in a safe and supportive environment has also been identified as an important aspect of transitioning GNs. Having open and effective communication with supportive staff and strong leaders is essential to guide new nurses.16 It has been shown that GNs hold great respect for experienced mentors who give constructive and nonjudgmental feedback. GNs appreciate nurses who have realistic expectations about the skills and knowledge of novices. GNs enjoy being included as team members and having their contributions valued.6
Despite the exponential growth of simulation for preparation of nurses, the paucity of evidence is alarming. For the most part, the quality of research evidence is weak because there are a limited number of experimental studies. Evidence is also limited by a dependence on self-report measures rather than presentation of quantifiable objective outcomes. Despite limitations related to quality, there is high utility of the evidence. Authors provide detailed descriptions of the simulation intervention that can be replicated in other orientations. The extent and strength of the evidence is low because of self-report measures, lack of randomization, and diversity of the intervention. The target outcomes selected were appropriate for the purpose of evaluating the success of simulation during orientation; however, from a research perspective, the measurements lacked objectivity, consistency, and control. Many of the variables were measured using self-report. Furthermore, some authors created most of the measures, and there was little attempt to ascertain reliability and validity of the instruments. Some reported data were anecdotal. Although settings were limited to medical centers, the simulation intervention has applicability to various healthcare organizations because scenarios can be tailored to high risk or high-frequency situations commonly encountered in all healthcare settings. Because the articles were written by authors from two countries, it is evident that the topic is of concern internationally.
Several limitations of this integrative review should be noted. The evidence available in nursing is limited; therefore, only a small number of articles were reviewed. Because there was only one randomized clinical trial, articles involving pilots and case studies were included. The search was not extended to other disciplines because the focus of this article was to determine how much evidence is available regarding use of simulation in new GN orientations.
Recommendations for Future Research
Although existing data cannot demonstrate an indisputable connection to improved patient outcomes, the evidence indicates that exposing GNs to scenario-driven, problem-based learning using simulation should effectively prepare them to manage at-risk patients in a safe, confident, and competent manner.7 Simulation may also prove to be an important strategy for orienting nurses reentering the work force after a period of absence or international recruits who may have difficulty adjusting to nursing in a different milieu.7
More experimental research is needed to determine whether simulation causes new nurses to respond more effectively to actual patient situations. Further research could explore the possibility that simulation during orientation results in improved quality of patient care, increased nurse retention rates, and decreased costs. Also, studies investigating the use of simulation in nurse residency programs are warranted. For example, a random clinical trial to compare the use of high-fidelity HPS to low-fidelity HPS is warranted. Outcomes could include cost, length of orientation, and new graduate confidence, competence, and readiness to provide independent care. Another study could be designed to examine whether nurses who are oriented using simulation have greater retention rates and job satisfaction than nurses who are oriented in a more traditional manner. Given the importance of patient safety, studies could be designed to discover if the use of simulation during orientations is correlated with a reduction in the number of medication errors and sentinel events. Employers responsible for providing GN orientations need evidence about the efficacy of simulation and its effect on nurse retention, cost-effectiveness, and patient care to make decisions regarding simulation resources.
To assure that future research related to simulation in GN orientations is rigorous, a number of strategies should be implemented. Studies using randomization, control groups, and larger samples are necessary. Although it would be impossible and undesirable for researchers to standardize simulation interventions, detailed descriptions about the implementation of simulation would be beneficial so that consumers would know how to replicate the study. Outcomes need to be measured consistently across studies using valid and reliable instruments. Using these strategies will yield results that are more generalizable. A priority for research should be to determine what would be the most appropriate exposure to simulation to achieve the best GN orientation without wasting resources by over using this technique.
The addition of simulation to new graduate orientation programs presents the potential to impact the quality of nursing care. Socialization to the professional role, competence and confidence in self-ability, and learning in a safe and supportive environment are aspects that have been identified as being important when transitioning GNs to the role of the professional nurse. Simulation may be one way to facilitate this transition. Cost-effective orientation programs that efficiently prepare new GNs to care for at risk patients in a safe, confident, and competent manner may prove to be essential. The use of HPS provides a unique opportunity to mimic real world experiences in a safe and controlled environment. Simulation may contribute to socializing new GNs who are confident and competent professionals and who will be more likely to embrace nursing as a life long career.