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Using simulation learning through academic-practice partnership to promote transition to clinical practice: a qualitative evaluation Sok Ying Liaw, Sabrina Palham, Sally Wai-Chi Chan, Lai Fun Wong & Fui Ping Lim Accepted for publication 5 November 2014
Correspondence to S.Y. Liaw: e-mail: [email protected] Sok Ying Liaw PhD RN Assistant Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Sabrina Palham RN Master in Counselling, Lecturer Division of Family Medicine, National University of Singapore, Singapore Sally Wai-Chi Chan PhD RN Professor, Head of School School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia Lai Fun Wong BSc RN Research Assistant Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Fui Ping Lim MN RN Lecturer Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
L I A W S . Y . , P A L H A M S . , C H A N S . W . - C . , W O N G L . F . & L I M F . P . ( 2 0 1 5 ) Using simulation learning through academic-practice partnership to promote transition to clinical practice: a qualitative evaluation. Journal of Advanced Nursing 71(5), 1044–1054. doi: 10.1111/jan.12585
Abstract Aim. To explore the effect of an innovative simulation education programme on nursing students’ transition-to-practice experiences. Background. Academic-practice partnership is emerging as an important vehicle for improving nursing students’ transition-to-practice. Using existing university resources, academic educators and alumni developed an innovative simulation educational programme known as the Simulated Professional Learning Environment (SIMPLE) to align the educational process with the realities of nursing practice. Educators and alumni collaborated to create and facilitate 15 hours of simulation sessions that comprised the learning platform for the SIMPLE programme. Design. This was a descriptive qualitative study. Method. Focus groups were conducted in 2012 with 22 final-year nursing students completing their transition-to-practice clinical practicum. The interview transcripts were analysed using content analysis. Results. Three themes were identified from the analysis: ‘experiencing the role of staff nurse’; ‘knowing how to’; and ‘learning from the ‘seniors’. Experiencing the role of staff nurse in the programme showed the nursing students what to expect and how to prepare for their roles. Knowing how to focus on holistic patient care, manage ‘difficult’ clients and communicate with other healthcare professionals were the learning outcomes gained from the programme. Learning from the ‘seniors’ about hospital work processes positively influenced the nurses’ transition-to-practice experiences. Conclusion. This study provides support for introducing the simulation education programme as an enhancement during nursing students’ final year to improve their transition-to-practice experiences. A stronger collaborative relationship between academic educators and practising nurses could be further fostered by expanding this learning platform. Keywords: academic-practice partnerships, clinical practice, role of staff nurse, simulation, transition- to-practice
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Why is this research needed? ● Ensuring the work readiness of newly graduating nurses on entering the workforce remains a challenge for the nursing profession. ● Collaborative work between academic and service institutions has been highlighted as the key to the successful transition from students to professional nursing practice.
What are the key findings? ● An innovative simulation educational programme, known as the SIMPLE programme, was developed and implemented through an academic-practice partnership to enhance nursing students’ transition-to-practice experience. ● The qualitative study provides evidence of the SIMPLE programme’s effect on the students’ transition-to-practice experiences. ● A stronger collaboration between academic educators and practising nurses is needed to optimise the benefits of the SIMPLE programme.
How should the findings be used to influence practice/ education? ● The involvement of practising nurses in the design and implementation of a simulation learning programme could increase the ‘work readiness’ of future graduate nurses. ● Greater involvement could be fostered by expanding this learning platform to promote the professional growth of practising nurses in formal roles as clinical teachers.
Introduction The overall decline in the size of the nursing workforce has hampered its ability to meet the healthcare needs of a growing ageing population. It is becoming increasingly clear that nursing school enrolments need a boost and enhanced strategies are required to retain the nurses at their working place. The reported attrition rates of newly graduated nurses, which have been alarmingly high, are known to be related to the myriad difficulties and stressful experiences incurred during the transition from student to professional nurse (Duchscher & Cowin 2004, Pellico et al. 2004). Studies of new graduates’ transition-to-practice experiences have identified various reasons why nurses leave the profession. These include role ambiguity and conflict (Kelly & Ahern 2008), a lack of organization and time-management skills (O’Shea & Kelly 2007), high expectations from workplace staff (Mooney 2007), a lack of professional support (Zins© 2014 John Wiley & Sons Ltd
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meister & Schafer 2009) and poor interprofessional communication (Dyess & Sherman 2009). The increasing complexity of the healthcare system and acuity of patients, together with the growth in knowledge and advances in technology, have reinforced the importance of preparing new graduates for their transition into the nursing workforce (Duchscher 2009, Wolff et al. 2010). Both academic and healthcare institutions are responsible for developing nursing students’ clinical competencies for entry into practice to ensure patient safety and quality of care (Berkow et al. 2008). While academic institutions must consider pedagogies and curricula that prepare students for the realities of nursing, healthcare institutions need to consider orientation and preceptorship programmes (Teoh et al. 2012). However, collaborative work between academic and service institutions has been highlighted as the key to the successful transition from students to professional nursing practice (Duchscher & Cowin 2004, Murray et al. 2010).
Background Simulation is now firmly established in healthcare education as a crucial learning strategy for the development of clinical competency. Simuations ranging from part-task trainers to high-fidelity patient simulator have been widely used in nursing education, particularly for the acquisition of psychomotor and communication skills. Drawing on Kneebone’s concept of a patient-focused simulation, the use of a combination of real human beings with a high-fideltly simulated environment that reflects the contextual realities of clinical practice could allow learners to integrate and practise a full range of skills (e.g. technical skills, communication, decision-making and professionalism) in a safe environment (Kneebone et al. 2006). This patient-focused simulation has recently received statistically significant attention in pre-registration nursing programmes to prepare senior nursing students for learning work organization and management skills (Kaplan & Ura 2010, Warland 2011, Smith 2013, Sharpnack et al. 2013). By replicating a ward environment that reflects the complexity of real ward practices, the simulation can help nursing students to develop a wide range of clinical skills including teamwork, work organization, decision-making and prioritising (Reed et al. 2009, Kaplan & Ura 2010, McGrath et al. 2012). However, the evidence supporting the learning outcomes of such simulations has been generated by short rather than long-term studies. Whether students are able to transfer their learning into clinical practice thus remains uncertain. 1045
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With the collaboration of relevant healthcare institution partners, a consolidated clinical experience described as transition-to-practice was implemented in the final year of the undergraduate nursing curriculum to prepare senior nursing students for their roles as staff nurses. To improve this transition-to-practice experience, academic educators worked collaboratively with nursing alumni who are working as practising nurses to develop and implement an innovative simulation programme entitled, ‘SIMulated Professional Learning Environment (SIMPLE).’ The programme was implemented using simulations that mimicked real-world ward settings, which were conducted before the final-year nursing students commenced their transition to practising in a clinical setting.
The SIMPLE programme Academic educators and nursing alumni developed and facilitated the SIMPLE programme for final-year undergraduate nursing students. A total of 15 hours (3 hours per week over 5 weeks) of simulation sessions formed the programme’s learning platform. The learning outcomes were developed based on the role expectations of newly qualified staff nurses in the healthcare sector, with reference to reports taken from an employer survey conducted as part of the Bachelor of Science (Nursing) programme evaluation. The survey indicated the need to further develop newly qualified nurses’ abilities to prioritise their work, manage time, delegate work to other team members, work in teams and react to emergency situations. Thus, the identified learning outcomes (Table 1) go beyond clinical skills consolidation to focus on developing a comprehensive set of complex skills including communication, teamwork, care management and delegation. These outcomes build on from the standards of mastery accomplished by the students in their previous learning. The programme developer devised a list of themes according to the learning outcomes. The academic educators developed clinical scenarios related to common ward nursing practices based on these themes and clearly defined outcomes with inputs from nursing alumni. The outline of the SIMPLE programme is briefly described in Table 1. The SIMPLE programme took place in the National University of Singapore’s Centre for Healthcare Simulation – the layout of which resembles a hospital environment. Simulated patients (SPs) and patient simulators were used in the programme to present realistic clinical settings. While the SPs played the roles of conscious patients and relatives in the wards, the patient simulators were used to represent deteriorating and dying patients. Middle-aged and older 1046
male adults were recruited as SPs and trained by the centre’s SP educator. They trained in their roles before each simulation session using detailed script developed from clinical scenario. In addition to the SPs training, two hours of facilitator training was conducted before each simulation session. The cohort of 94 final-year nursing students of the Bachelor of Science (Nursing) programme was formed into small groups of six in accordance with the guidelines of the hospital where they were posted for their transition-to-practice. Two facilitators led each group, one from the faculty and the other an alumnus from the particular hospital. In each session, the students took turns participating in the scenarios by performing the roles of staff nurses. While one or two students undertook the roles in any particular scenario, the other students observed the scene from another room. Each simulation scenario commenced with the facilitator acting out the role of a staff nurse giving a verbal report of each patient’s condition during the previous shift. Each scenario lasted 20–30 minutes. A debriefing session was held immediately after each simulation scenario and was facilitated by both an academic educator and an alumnus. While the academic educator led the students to reflect on their simulation performance, the alumnus offered information about current hospital practices and protocols. An early study was conducted to evaluate the immediate outcomes of the SIMPLE programme and provided evidence of the programme’s effectiveness in enhancing the students’ preparedness for their transition-to-practice clinical practicum (Liaw et al. 2014). This paper reports on the follow-up outcome evaluation of the SIMPLE programme at the completion of the nine-week transition-to-practice clinical practicum.
The study Aim The aim of this study was to evaluate the effect of the SIMPLE programme on the students’ transition-to-practice experiences.
Design A qualitative approach was used in this study as this method seeks the deep understanding of a phenomenon (Greenhalgh & Taylor 1997) while allowing for the exploration of real-life behaviours (Kuper et al. 2008). This type of design is most appropriate when the study aims to discover how and why an intervention works (Cook et al. 2008). © 2014 John Wiley & Sons Ltd
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Theme
Admitting and preparing a patient for an operation
Communicating with an interprofessional team
Transferring a patient to another clinical setting
Delegating and supervising junior nurses
Discharge a ward patient and provide postmortem care
Session
1
2
3
4
5
The students were required to perform admission tasks for Mr Tan including nursing assessment (history taking, physical assessment); interventions (wound dressing, administration of medication); evaluation (documentation). In addition, they were required to perform pre-operative procedures to prepare him for surgery. This was an interprofessional simulation learning session where the nursing students learnt together with the medical students. They were introduced to communication strategies including SBAR (Situation, Background; Assessment, Recommendation); feedback to acknowledge call-out; check-back to enhance their teamwork and communication skills in providing safe care for Mr Tan. The students were required to transfer the acutely ill Mr Tan to an Intensive Care Unit (ICU). They were also required to receive a transfer patient, Mr Lim, from the ICU. The students were expected to apply effective hand-off strategy for unitto-unit reporting. In addition, they would have to deal with Mr Tan’s angry family. A list of follow-up plans and treatments were developed after a doctor’s ward round. The students were required to plan, organize and prioritise their workload, which included delegating tasks to the junior nurses. In addition, the students were required to perform the task of supervising a nursing student. Interruptions were incorporated into the scenarios to allow the students to deal with multiple ward demands and distractions. The students were required to break bad news to Mdm Tan’s family. They had to deal with the grieving and difficult family, while performing death procedures for Mdm Tan. Issues related to caregiving were presented to the students when preparing Mr Lim for discharge.
Mr Tan Ah Kow, a 60-year-old man, was admitted with a fractured right femur and stable head injury after a road traffic accident.
Mdm Tan, a 80-year-old woman, was admitted for acute subdural haemorrhage. She was on end-of-life care. Mr Lim, a 65-year-old postoperative patient with lung cancer had undergone right lung lobectomy.
Mr Tan Ah Kow who was in his third postoperative day presented with septic shock. Mr Lim, a 65-year-old postoperative patient with lung cancer had undergone right lung lobectomy.
Mr Tan Ah Kow who was in his third postoperative day presented with physiological signs of deteriorations.
Synopsis
Case scenario
Learning outcomes: 1 Demonstrate the ability to assess, plan, implement and evaluate care for a patient caseload 2 Recognize the importance of their role as a responsible, accountable, professional nurse. 3 Develop and apply strategies for time management and management of workload. 4 Demonstrate an understanding of the role of a preceptor and the role of the RN in supporting learning in the clinical setting. 5 Demonstrate an understanding of strategies to function effectively as a member of the healthcare team. 6 Demonstrate the role of critical reflection in professional development as a nurse and apply it in practice. 7 Demonstrate competency in the core clinical skills required of a RN at a beginning practitioner level.
Table 1 Outline of SIMPLE programme.
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Participants A purposive sampling strategy was used to recruit nursing students at a university in Singapore. The inclusion criteria were that the nursing students had completed the 9 weeks of their transition-to-practice clinical practicum after undertaking the SIMPLE programme. Twenty-two nursing students who met the sample criteria and were willing to share their experiences were recruited. Among the recruited participants, four were males and the overall ages ranged from 22–25 years.
Data collection Focus groups were conducted at the end of the participants’ transition-to-practice clinical practicum (May 2012). The focus groups provided a useful platform to explore the students’ experiences in developing knowledge and skills. The focus groups also helped to develop an understanding of the current factors affecting the students’ transitions into professional nursing roles. Unlike an individual interview, the synergistic nature of a focus group often provides access to social interactional dynamics amongst specific groups of people and to powerful interpretive insights that lead to rich qualitative descriptive findings (Kamberelis & Dimitriadis 2005). Three focus groups were conducted with six to eight participants in a group, each lasting 60–90 minutes. This duration is considered appropriate for effective focus groups (Wong 2008). An experienced research team member facilitated each group using an interview guide with four open-ended questions. All of the interviews were audio-recorded and transcribed.
Ethical considerations The institutional Review Board approved this study. All of the participants were recruited on a voluntary basis and assured that their decision to participate or not participate would not affect their grades. They received a participant information sheet that explained the purpose of the study and their involvement. The participants gave written consent before the focus group interview. The anonymity and confidentiality of the interview data were assured.
Data analysis The data were subjected to content analysis using inductive data analysis (Elo & Kyng€as 2008). Two researchers initially read the three transcipts to achieve immersion in the data and a sense of the whole. The researchers met 1048
to discuss their initial impressions and the steps of the content analysis before individually engaging in the process of data analysis. The steps undertaken by each researcher included re-reading the transcripts, identifying codes from significant phrases and sentences and grouping the codes into categories. The researchers met again to compare their coded texts and categories. The coded texts were merged and re-grouped into categories and themes.
Rigour Dependability was maintained in the study by having the same research team member facilitated the three focus groups. The credibility of the data was strengthened by: (1) using a structured interview guide to maintain a reliable approach to the focus groups interviews; (2) verifying the key points with the participants at the end of each focus group to ensure that their opinions were interpreted correctly (Guba & Lincoln 2005); and (3) having two researchers generating codes and uncovering key themes. The interpretations of these codes and themes were then discussed and challenged until a consensus on the final set of coded categories and themes was reached.
Findings The analysis yielded three main themes: ‘experiencing the role of staff nurse’, ‘knowing how to’ and ‘learning from the ‘seniors’’. Sub-themes were also identified.
Theme 1: Experiencing the role of staff nurse The opportunity to experience the role of staff nurse in the SIMPLE programme significantly influenced the participants’ transition-to-practice clinical experiences. The programme was not only identified as ‘a stepping stone’ to experiencing the actual roles of staff nurse but also allowed the participants to ‘know what to expect’ from this role. Despite all of these positive experiences, the ‘complex roles of staff nurses’ were one of the key challenges addressed by the participants in their experience. Sub-theme 1: A stepping stone The participants saw the SIMPLE programme as a good stepping stone towards experiencing the role of staff nurse in real clinical practice. It was perceived as a good initial learning exposure away from the clinical responsibilities and demands of actual clinical practice. For example, one participant reported: © 2014 John Wiley & Sons Ltd
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Simulation learning through academic-practice partnership
I found that the experience of simulation was helpful because we
clinical settings and helps us understand their context. However, in
were often pressed for time in the ward. We need to learn prioriti-
the clinical setting, it is of greater depth as everything occurs at the
sation and the experience of simulation was a stepping stone for us
same time.
to learn that. Things were different on the ward. We faced more pressure. In the simulation sessions, we learned how to deal with pressure in a gradual manner.
Some participants reported a sense of gaining confidence through experiencing the role of staff nurse in the programme. One participant succinctly stated:
Many of the participants reported the challenges that they faced surrounding the complexity of the nursing care. One participant described her difficulties in managing workflow and care delivery to an assigned group of patients: It was difficult to manage multiple patients. I started with nursing
It boosted my confidence when I know that I have performed simi-
two patients, then progressed to four and eventually six patients.
lar tasks previously.
Yet, I found it difficult to prioritise the care for each patient. After the receiving shift report, the enrolled nurse would start to perform
Sub-theme 2: Knowing what to expect The SIMPLE programme showed the participants what to expect of their roles as staff nurses. As one participant said: It exposed me to the common experiences encountered by ward nurses. With the SIMPLE programme, we were able to think beforehand and to know exactly what to expect.
Knowing what to expect from the roles of staff nurses reduced the participants’ fears of finding themselves in situations that would expose their lack of competence. The appraisal of their individual performance in the new role of staff nurse allowed them to assess their learning needs, identify knowledge or skills gaps and take responsibility for rectifying their shortcomings. One participant captured this by saying:
nursing care. We were supposed to follow them to perform the nursing care but at times other things cropped up and required our attention. I found that quite difficult to manage.
To prepare for their roles as staff nurses better, the participants highlighted the need to provide more complex simulation scenarios in the SIMPLE programme to match the real-world role complexity. One participant suggested starting the programme earlier in the nursing curriculum and progressively increasing the complexity throughout the training levels: The SIMPLE programme should be progressively introduced across the 3 years of our nursing programme. For instance, one part of the programme could be introduced in the second year of our studies and all parts could be consolidated and implemented during the third year of our studies before we go out to the clinical practicum.
The simulation allowed us to know our current level of competencies, helped us to realise our strengths and weaknesses. It enabled us to enhance our strengths and work on our weaknesses.
In another participant’s words: I think the simulation was useful as it provided me with various encounters and helped me to know what to expect. Also, I know in which areas I would need further help and can prepare myself accordingly.
Sub-theme 3: Complex roles of staff nurses Compared with the simulated learning environment in the SIMPLE programme, a real clinical situation is much more complex, making the work of nursing care very challenging. The role of staff nurses regarding the ‘what’, ‘how’ and ‘when’ of nursing care delivery is multifactorial and timepressured, requiring a variety of skills to be applied simultaneously or in quick succession. A participant explained: In the real clinical setting, we need to handle many things at one time. The SIMPLE programme has prepared and exposed us to © 2014 John Wiley & Sons Ltd
Theme 2: Knowing how to Knowing how to ‘focus on holistic patient care, manage ‘difficult’ clients’ and ‘communicate with other healthcare professionals’ were the positive learning outcomes gained from the SIMPLE programme, as described by the participants. The importance of knowing how to ‘apply clinical knowledge’ in preventing potential error was also recognized. Sub-theme 1: Focusing on holistic patient care The SIMPLE programme led the participants to focus beyond technical skills performance to holistic patient care. One participant said: I thought the SIMPLE programme was good because previously during our attachment, we tend to be very task oriented. . .The simulation made me see the importance of being patient oriented.
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care for the patient’s psychological needs during a transfer in the actual clinical setting: I think the session on transferring a patient to another clinical setting was helpful. We learnt that we need to assess our patients, communicate with our patients and reassure them that they will be in good hands. I think these are applicable in my ward.
Sub-theme 2: Managing ‘difficult’ clients The opportunity to deal with psychologically challenging situations in the SIMPLE programme, during which patients and relatives strongly express emotions such as anger and grief, enabled some participants to know what to do when confronted with similar situations in the clinical arena. One participant described how her learning experience in the programme helped her to manage an angry parent in a paediatric ward setting: There was a parent who requested for four cold packs for his child. We could not provide him with four packs at one time. He made a
a structured communication tool (Leonard et al. 2004), – that was practised during the interprofessional simulation session: I think the constant practice we had during simulation really prepared me to communicate with the doctors using the SBAR (Situation, Background, Assessment, Recommendation) mnemonics. Some of the participants stated that the interprofessional simulation learning made them much more prepared than other nursing students when communicating with doctors. One said: I realise that some of the nurses in the ward were not exposed to a similar programme. They had less opportunity to communicate with doctors, or even with medical students during their training. Hence, their first encounter in the ward was more difficult.
For greater benefits, the participants suggested broadening the interprofessional learning simulations to include other healthcare professionals. One participant said:
big fuss and shouted at some of the nurses. From the SIMPLE pro-
Maybe, apart from doctors, we could collaborate with other health
gramme, I learnt how to manage difficult situations, how to com-
care professionals such as pharmacists, dieticians and therapists.
municate with anxious parents. I remembered a similar scenario presented in the programme and I tried to apply what I have learnt, such as bringing the parent to a quieter place.
In addition, some of the participants reported that their simulation experiences helped them to be aware of and manage their own emotions and to moderate their behaviour in emotionally charged clinical situations. One participant said: Despite feeling very frustrated, I think it [the SIMPLE programme] prepared us for appropriate ways to control ourselves.
Sub-theme 3: Communicating with other healthcare professionals The opportunity to practise communication skills with medical students in the interprofessional simulation learning session made the participants more confident when communicating with doctors about patient care. One participant gave an account of how she confidently updated the doctor about the status of her patients during ward rounds: I think the programme really prepared us very well. It gave us con-
Sub-theme 4: Applying clinical decision-making The participants identified the importance of applying sound clinical decision-making principles in maintaining patient safety by preventing errors from affecting the patients. The potentially dire consequences of drug administration error as a result of not knowing how to apply clinical knowledge when serving medication during their transition-to-practice were highlighted by some of the participants. For example, one participant clearly identified the importance of understanding a patients’ condition and having requisite knowledge of the medication ordered for them to prevent medication error: It [a particular drug] was for a patient who has a past medical history of asthma. So, I really ensured that the anti-hypertensive was not beta-blockers, because it would worsen the asthma. . ..
Participants suggested they needed more opportunities to learn how to apply pharmacological knowledge in the simulation scenarios. One participant said:
fidence to communicate with other health care professionals, such
Maybe the SIMPLE programme could incorporate more pharma-
as doctors. . .Because I understand my patients well, I am able to
cology knowledge and link this knowledge to nursing practice.
share information on what my patients are going through. They (doctors) are then able to make the necessary adjustments to the treatment plan
Theme 3: Learning from the ‘seniors’
Another participant highlighted the application of Situation, Background, Assessment, Recommendation (SBAR) –
In the SIMPLE programme, learning from the ‘seniors’ (alumni working as practising nurses) during hospital work
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processes had positive outcomes for the participants’ transition-to-practice experiences. To further this positive effect, the deliberate involvement of the ‘seniors as nurse confederates’ in the simulation session could be scripted to achieve particular learning outcomes. Sub-theme 1: Hospital work processes Many of the participants highlighted the value of learning hospital work processes from their ‘seniors’ in preparing them for their roles as staff nurses. In one participant’s words: The senior [alumni] shared almost all of the procedures such as admission, transfer and discharge which prepared us quite well.
Another participant provided an example of how learning hospital protocol from a senior helped her with the process of performing a blood transfusion: We appreciate our seniors returning from the hospitals as they brought with them some forms (protocols) from the hospitals. We were able to look through these forms. This prepared me to nurse a patient receiving blood transfusion as I was already familiar with the work process. Sub-theme 2: ‘Seniors’ as confederate nurses The participants recommended more involvement by the seniors to enhance the complexity and realism of the simulation scenarios. Some suggested that the seniors could act as confederate nurses (people who play roles with specific tasks in a simulation scenario) to confront the learners with more of the challenges they may meet in actual clinical settings. One participant said: I think the SIMPLE programme could involve the seniors (alumni) in the simulation scenarios. They could role-play as ‘difficult nurse’ and do something that challenges us.
Discussion Various programmes have been developed to address the need for smoother transitions between academia and graduate practice (Philips 2007). Clinical settings can be used to implement orientation programmes (Cubit & Ryan 2011) and academic units can develop transitional clinical programmes (Nash et al. 2009). The academic educators and practising nurses collaborated to develop and implement the SIMPLE programme. The programme’s effectiveness in enhancing students’ experiences during their transition into practice was evaluated. This study supports the effectiveness of the SIMPLE programme as a ‘stepping stone’ to expose final-year student © 2014 John Wiley & Sons Ltd
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nurses to the reality of their work environment and, most importantly, their roles as staff nurses. A sense of unpreparedness in facing the responsibilities of a staff nurse and the weight of expectation in the professional working environment have been highlighted as typical concerns in many studies (Duchscher & Cowin 2004, Kelly & Ahern 2008). Ward nurses and managers have higher expectations of student clinical performance in this transition-to-practice period, because they know that students will soon graduate to become staff nurses. Student nurses, during their transition practicum, are given the responsibilities of a staff nurse to assume the total care of a group of patients. In the SIMPLE programme, they were given the opportunity to assume these responsibilities in a controlled positive learning environment that required them to multitask and cope with the managerial and organizational aspects of the job. Evidence suggests that when newly graduated nurses find themselves underprepared, they commonly identify feeling anxious and overwhelmed. They also have a low confidence in their ability and experience free-flowing stress and uncertainty regarding their self-perception of practice competency (Gerrish 2000, Dyess & Sherman 2009, Feng & Tsai 2012). This study highlights that through experiencing the role of a RN in the SIMPLE programme, the students gained a sense of confidence that helped them to cope with their roles in reality. Such confidence appeared to stem from the opportunity to know what to expect and how to prepare for their roles as staff nurses. Furthermore, it was evident from the data that an awareness of their current competency and areas of weakness and strength, were constructed from the experiential learning the SIMPLE programme offered. This self-awareness allowed student nurses to identify their own learning needs and seek further instruction to prepare themselves for their new professional roles. A study by Currie (2008) supported the positive effect of self-awareness on graduates’ sense of confidence in developing expert practice. A simulated clinical laboratory that focuses on technical skills is insufficient to prepare student nurses for transition to the work environment. Given the complexity of today’s health care, it is essential that student nurses be prepared with a broad scope of skills for caring holistically for a caseload of several patients (Hourican et al. 2008, Liaw et al. 2014). A simulation that reflected the reality of actual ward practices was used in the SIMPLE programme to allow nursing students to apply and practise communication, decision – making, collaborative practice, delegation and conflict management. The simulation was supported by the use of SPs and collaborative learning with medical students to allow nursing students to apply effective communi1051
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cation and decision-making skills and to cope with human emotions and other challenges. It is evident from the findings of this study that the learning experiences gained from the SIMPLE programme enabled the students to know how to focus on holistic patient care, deal with ‘difficult’ client and communicate with other healthcare professionals. This appeared to justify the learning gains from the SIMPLE programme that may have resulted in the transfer of learning to the actual clinical setting. In our study, context similarity between the simulation scenario and actual clinical situations was observed to facilitate the transfer of learning. The similarity between learning and the application context has been identified as a critical factor in the transfer of learning (Kulasegaram et al. 2012, Norman & Schmidt 1992). The simulation scenarios were developed through collaboration between academic educators and practising nurses to ensure that the scenarios were congruent with the realities of current nursing practice. To further enhance context similarity between learning and practice, the participants recommended building more scope and complexity into the simulation scenarios. This augmentation could allow participants to be involved with more challenging patient situations that require the application of complex clinical decision-making, particularly the safe administration of medication. Furthermore, to enhance the scenario complexity, the participants foresaw the benefits of increasing the involvement of the practising nurses by having them portray ward nurses in the simulation scenarios. By participating in the simulation scenarios, practising nurses could improve the realism by presenting challenges that would engage students in the veritable reality of ward practices. Two existing university resources – academic educators and alumni – were used in the SIMPLE programme to foster collaborative relationships between academia and practice. The academic-practice partnership provided opportunities for the students to learn from the practising nurses, who were familiar with the culture of the current nursing practice environment. The academic educators who served as experts in the educational process played a critical role in supporting student learning while also mentoring the practising nurses (Raines 2006). The findings of this study support the learning experienced by the student nurses regarding hospital work process, which greatly helped them to develop confidence in their roles as staff nurses. As Johnstone et al. (2008) noted, an understanding of the working knowledge of an organization’s systems and processes is considered important to support a graduate nurse’s transition from novice to advanced beginnerlevel practitioner. 1052
Limitation Although longitudinal studies have been conducted to examine the effect of the SIMPLE programme on the students’ transition-to-practice, these have been limited to the students’ perceptions and experiences. In addition, it is acknowledged that the findings are limited to those who were willing to participate in the study and thus, may not be reflective of all the other students’ experiences.
Conclusion Practising nurses from the universtiy’s alumni and the academic educators developed and implemented an innovative simulation education programme (SIMPLE) for final-year nursing students before their transition to practising in clinical settings. The programme was developed to align the educational process with the realities of nursing practice. The findings of this qualitative study highlight the beneficial effect of the SIMPLE programme on the students’ transition-to-practice experiences and ways of enhancing the programme to optimize learning. The results reflect the need for stronger collaboration between faculty members and practising nurses in the subsequent planning and development of the SIMPLE programme. We continue to partner with practising nurses to expand the programme by increasing the scope and complexity of the simulation scenarios. In addition to using the simulation experience to immerse students in the professional nurse role, we plan to use this programme to promote the professional growth of practising nurses in roles as clinical teachers. This would involve using the programme to complement a hospital preceptorship programme that supports and develops the roles of preceptors in facilitating an effective transition experience for final-year students. It is essential to equip academic educators with the resources to facilitate the teaching-learning process for alumni practising nurses and further research is clearly needed to examine the perspectives of practising nurses and academic educators and to strengthen the evidence for best practice to foster a smoother transition. Ensuring the work readiness of newly graduating nurses on entering the workforce remains a challenge for the nursing profession. Work readiness encompasses not only a wide range of clinical skills including teamwork, work organization, decision-making and prioritising but also an understanding of hospital systems and work processes (Johnstone et al. 2008). The involvement of practising nurses in the design and implementation of a simulation learning programme could increase the ‘work readiness’ of © 2014 John Wiley & Sons Ltd
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future graduate nurses. Expanding this learning platform to promote the professional growth of practising nurses in formal roles as clinical teachers would foster even greater involvement.
Acknowledgement The authors thank the nursing students of the National University of Singapore for participating the research study. We also thank the National University of Hospital System Medical Publications Support Unit, Singapore, for providing editing services for this manuscript.
Funding This research was supported by Alice Lee Centre for Nursing Studies at the University of Singapore.
Conflict of interest No conflict of interest has been declared by the authors.
Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:
• •
substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
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Sharpnack P.A., Goliat L. & Rogers K. (2013) Using standardized patients to teach leadership competencies. Clinical Simulation in Nursing 9(3), 95–102. Smith S.B. (2013) Integrating simulation in a BSN leadership and management course. Journal of Nursing Education and Practice 3(11), 121–131. Teoh Y.T.E., Pua L.H. & Chan M.F. (2012) Lost in transition: a review of qualitative literature of newly qualified registered nurses’ experiences in their transition to practice journey. Nurse Education Today 33(2), 143–147. Warland J. (2011) Using simulation to promote nursing students’ learning of work organization and people management skills: a case study. Nursing Education in Practice 11(3), 186–191. Wolff A.C., Pesut B. & Regan S. (2010) New graduate nurse practice readiness: perspectives on the context shaping our understanding and expectations. Nurse Education Today 30(2), 187–191. Wong L. (2008) Focus group discussion: a tool for health and medical research. Singapore Medical Journal 49(3), 256–261. Zinsmeister L.B. & Schafer D. (2009) The exploration of the lived experience of the graduate nurse making the transition to registered nurse during the first year of practice. Journal for Nurses in Staff Development 25(1), 28–34.
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Using simulation learning through academic-practice partnership to promote transition to clinical practice: a qualitative evaluation Sok Ying Liaw, Sabrina Palham, Sally Wai-Chi Chan, Lai Fun Wong & Fui Ping Lim Accepted for publication 5 November 2014
Correspondence to S.Y. Liaw: e-mail: [email protected] Sok Ying Liaw PhD RN Assistant Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Sabrina Palham RN Master in Counselling, Lecturer Division of Family Medicine, National University of Singapore, Singapore Sally Wai-Chi Chan PhD RN Professor, Head of School School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia Lai Fun Wong BSc RN Research Assistant Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Fui Ping Lim MN RN Lecturer Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
L I A W S . Y . , P A L H A M S . , C H A N S . W . - C . , W O N G L . F . & L I M F . P . ( 2 0 1 5 ) Using simulation learning through academic-practice partnership to promote transition to clinical practice: a qualitative evaluation. Journal of Advanced Nursing 71(5), 1044–1054. doi: 10.1111/jan.12585
Abstract Aim. To explore the effect of an innovative simulation education programme on nursing students’ transition-to-practice experiences. Background. Academic-practice partnership is emerging as an important vehicle for improving nursing students’ transition-to-practice. Using existing university resources, academic educators and alumni developed an innovative simulation educational programme known as the Simulated Professional Learning Environment (SIMPLE) to align the educational process with the realities of nursing practice. Educators and alumni collaborated to create and facilitate 15 hours of simulation sessions that comprised the learning platform for the SIMPLE programme. Design. This was a descriptive qualitative study. Method. Focus groups were conducted in 2012 with 22 final-year nursing students completing their transition-to-practice clinical practicum. The interview transcripts were analysed using content analysis. Results. Three themes were identified from the analysis: ‘experiencing the role of staff nurse’; ‘knowing how to’; and ‘learning from the ‘seniors’. Experiencing the role of staff nurse in the programme showed the nursing students what to expect and how to prepare for their roles. Knowing how to focus on holistic patient care, manage ‘difficult’ clients and communicate with other healthcare professionals were the learning outcomes gained from the programme. Learning from the ‘seniors’ about hospital work processes positively influenced the nurses’ transition-to-practice experiences. Conclusion. This study provides support for introducing the simulation education programme as an enhancement during nursing students’ final year to improve their transition-to-practice experiences. A stronger collaborative relationship between academic educators and practising nurses could be further fostered by expanding this learning platform. Keywords: academic-practice partnerships, clinical practice, role of staff nurse, simulation, transition- to-practice
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Why is this research needed? ● Ensuring the work readiness of newly graduating nurses on entering the workforce remains a challenge for the nursing profession. ● Collaborative work between academic and service institutions has been highlighted as the key to the successful transition from students to professional nursing practice.
What are the key findings? ● An innovative simulation educational programme, known as the SIMPLE programme, was developed and implemented through an academic-practice partnership to enhance nursing students’ transition-to-practice experience. ● The qualitative study provides evidence of the SIMPLE programme’s effect on the students’ transition-to-practice experiences. ● A stronger collaboration between academic educators and practising nurses is needed to optimise the benefits of the SIMPLE programme.
How should the findings be used to influence practice/ education? ● The involvement of practising nurses in the design and implementation of a simulation learning programme could increase the ‘work readiness’ of future graduate nurses. ● Greater involvement could be fostered by expanding this learning platform to promote the professional growth of practising nurses in formal roles as clinical teachers.
Introduction The overall decline in the size of the nursing workforce has hampered its ability to meet the healthcare needs of a growing ageing population. It is becoming increasingly clear that nursing school enrolments need a boost and enhanced strategies are required to retain the nurses at their working place. The reported attrition rates of newly graduated nurses, which have been alarmingly high, are known to be related to the myriad difficulties and stressful experiences incurred during the transition from student to professional nurse (Duchscher & Cowin 2004, Pellico et al. 2004). Studies of new graduates’ transition-to-practice experiences have identified various reasons why nurses leave the profession. These include role ambiguity and conflict (Kelly & Ahern 2008), a lack of organization and time-management skills (O’Shea & Kelly 2007), high expectations from workplace staff (Mooney 2007), a lack of professional support (Zins© 2014 John Wiley & Sons Ltd
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meister & Schafer 2009) and poor interprofessional communication (Dyess & Sherman 2009). The increasing complexity of the healthcare system and acuity of patients, together with the growth in knowledge and advances in technology, have reinforced the importance of preparing new graduates for their transition into the nursing workforce (Duchscher 2009, Wolff et al. 2010). Both academic and healthcare institutions are responsible for developing nursing students’ clinical competencies for entry into practice to ensure patient safety and quality of care (Berkow et al. 2008). While academic institutions must consider pedagogies and curricula that prepare students for the realities of nursing, healthcare institutions need to consider orientation and preceptorship programmes (Teoh et al. 2012). However, collaborative work between academic and service institutions has been highlighted as the key to the successful transition from students to professional nursing practice (Duchscher & Cowin 2004, Murray et al. 2010).
Background Simulation is now firmly established in healthcare education as a crucial learning strategy for the development of clinical competency. Simuations ranging from part-task trainers to high-fidelity patient simulator have been widely used in nursing education, particularly for the acquisition of psychomotor and communication skills. Drawing on Kneebone’s concept of a patient-focused simulation, the use of a combination of real human beings with a high-fideltly simulated environment that reflects the contextual realities of clinical practice could allow learners to integrate and practise a full range of skills (e.g. technical skills, communication, decision-making and professionalism) in a safe environment (Kneebone et al. 2006). This patient-focused simulation has recently received statistically significant attention in pre-registration nursing programmes to prepare senior nursing students for learning work organization and management skills (Kaplan & Ura 2010, Warland 2011, Smith 2013, Sharpnack et al. 2013). By replicating a ward environment that reflects the complexity of real ward practices, the simulation can help nursing students to develop a wide range of clinical skills including teamwork, work organization, decision-making and prioritising (Reed et al. 2009, Kaplan & Ura 2010, McGrath et al. 2012). However, the evidence supporting the learning outcomes of such simulations has been generated by short rather than long-term studies. Whether students are able to transfer their learning into clinical practice thus remains uncertain. 1045
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With the collaboration of relevant healthcare institution partners, a consolidated clinical experience described as transition-to-practice was implemented in the final year of the undergraduate nursing curriculum to prepare senior nursing students for their roles as staff nurses. To improve this transition-to-practice experience, academic educators worked collaboratively with nursing alumni who are working as practising nurses to develop and implement an innovative simulation programme entitled, ‘SIMulated Professional Learning Environment (SIMPLE).’ The programme was implemented using simulations that mimicked real-world ward settings, which were conducted before the final-year nursing students commenced their transition to practising in a clinical setting.
The SIMPLE programme Academic educators and nursing alumni developed and facilitated the SIMPLE programme for final-year undergraduate nursing students. A total of 15 hours (3 hours per week over 5 weeks) of simulation sessions formed the programme’s learning platform. The learning outcomes were developed based on the role expectations of newly qualified staff nurses in the healthcare sector, with reference to reports taken from an employer survey conducted as part of the Bachelor of Science (Nursing) programme evaluation. The survey indicated the need to further develop newly qualified nurses’ abilities to prioritise their work, manage time, delegate work to other team members, work in teams and react to emergency situations. Thus, the identified learning outcomes (Table 1) go beyond clinical skills consolidation to focus on developing a comprehensive set of complex skills including communication, teamwork, care management and delegation. These outcomes build on from the standards of mastery accomplished by the students in their previous learning. The programme developer devised a list of themes according to the learning outcomes. The academic educators developed clinical scenarios related to common ward nursing practices based on these themes and clearly defined outcomes with inputs from nursing alumni. The outline of the SIMPLE programme is briefly described in Table 1. The SIMPLE programme took place in the National University of Singapore’s Centre for Healthcare Simulation – the layout of which resembles a hospital environment. Simulated patients (SPs) and patient simulators were used in the programme to present realistic clinical settings. While the SPs played the roles of conscious patients and relatives in the wards, the patient simulators were used to represent deteriorating and dying patients. Middle-aged and older 1046
male adults were recruited as SPs and trained by the centre’s SP educator. They trained in their roles before each simulation session using detailed script developed from clinical scenario. In addition to the SPs training, two hours of facilitator training was conducted before each simulation session. The cohort of 94 final-year nursing students of the Bachelor of Science (Nursing) programme was formed into small groups of six in accordance with the guidelines of the hospital where they were posted for their transition-to-practice. Two facilitators led each group, one from the faculty and the other an alumnus from the particular hospital. In each session, the students took turns participating in the scenarios by performing the roles of staff nurses. While one or two students undertook the roles in any particular scenario, the other students observed the scene from another room. Each simulation scenario commenced with the facilitator acting out the role of a staff nurse giving a verbal report of each patient’s condition during the previous shift. Each scenario lasted 20–30 minutes. A debriefing session was held immediately after each simulation scenario and was facilitated by both an academic educator and an alumnus. While the academic educator led the students to reflect on their simulation performance, the alumnus offered information about current hospital practices and protocols. An early study was conducted to evaluate the immediate outcomes of the SIMPLE programme and provided evidence of the programme’s effectiveness in enhancing the students’ preparedness for their transition-to-practice clinical practicum (Liaw et al. 2014). This paper reports on the follow-up outcome evaluation of the SIMPLE programme at the completion of the nine-week transition-to-practice clinical practicum.
The study Aim The aim of this study was to evaluate the effect of the SIMPLE programme on the students’ transition-to-practice experiences.
Design A qualitative approach was used in this study as this method seeks the deep understanding of a phenomenon (Greenhalgh & Taylor 1997) while allowing for the exploration of real-life behaviours (Kuper et al. 2008). This type of design is most appropriate when the study aims to discover how and why an intervention works (Cook et al. 2008). © 2014 John Wiley & Sons Ltd
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Theme
Admitting and preparing a patient for an operation
Communicating with an interprofessional team
Transferring a patient to another clinical setting
Delegating and supervising junior nurses
Discharge a ward patient and provide postmortem care
Session
1
2
3
4
5
The students were required to perform admission tasks for Mr Tan including nursing assessment (history taking, physical assessment); interventions (wound dressing, administration of medication); evaluation (documentation). In addition, they were required to perform pre-operative procedures to prepare him for surgery. This was an interprofessional simulation learning session where the nursing students learnt together with the medical students. They were introduced to communication strategies including SBAR (Situation, Background; Assessment, Recommendation); feedback to acknowledge call-out; check-back to enhance their teamwork and communication skills in providing safe care for Mr Tan. The students were required to transfer the acutely ill Mr Tan to an Intensive Care Unit (ICU). They were also required to receive a transfer patient, Mr Lim, from the ICU. The students were expected to apply effective hand-off strategy for unitto-unit reporting. In addition, they would have to deal with Mr Tan’s angry family. A list of follow-up plans and treatments were developed after a doctor’s ward round. The students were required to plan, organize and prioritise their workload, which included delegating tasks to the junior nurses. In addition, the students were required to perform the task of supervising a nursing student. Interruptions were incorporated into the scenarios to allow the students to deal with multiple ward demands and distractions. The students were required to break bad news to Mdm Tan’s family. They had to deal with the grieving and difficult family, while performing death procedures for Mdm Tan. Issues related to caregiving were presented to the students when preparing Mr Lim for discharge.
Mr Tan Ah Kow, a 60-year-old man, was admitted with a fractured right femur and stable head injury after a road traffic accident.
Mdm Tan, a 80-year-old woman, was admitted for acute subdural haemorrhage. She was on end-of-life care. Mr Lim, a 65-year-old postoperative patient with lung cancer had undergone right lung lobectomy.
Mr Tan Ah Kow who was in his third postoperative day presented with septic shock. Mr Lim, a 65-year-old postoperative patient with lung cancer had undergone right lung lobectomy.
Mr Tan Ah Kow who was in his third postoperative day presented with physiological signs of deteriorations.
Synopsis
Case scenario
Learning outcomes: 1 Demonstrate the ability to assess, plan, implement and evaluate care for a patient caseload 2 Recognize the importance of their role as a responsible, accountable, professional nurse. 3 Develop and apply strategies for time management and management of workload. 4 Demonstrate an understanding of the role of a preceptor and the role of the RN in supporting learning in the clinical setting. 5 Demonstrate an understanding of strategies to function effectively as a member of the healthcare team. 6 Demonstrate the role of critical reflection in professional development as a nurse and apply it in practice. 7 Demonstrate competency in the core clinical skills required of a RN at a beginning practitioner level.
Table 1 Outline of SIMPLE programme.
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Participants A purposive sampling strategy was used to recruit nursing students at a university in Singapore. The inclusion criteria were that the nursing students had completed the 9 weeks of their transition-to-practice clinical practicum after undertaking the SIMPLE programme. Twenty-two nursing students who met the sample criteria and were willing to share their experiences were recruited. Among the recruited participants, four were males and the overall ages ranged from 22–25 years.
Data collection Focus groups were conducted at the end of the participants’ transition-to-practice clinical practicum (May 2012). The focus groups provided a useful platform to explore the students’ experiences in developing knowledge and skills. The focus groups also helped to develop an understanding of the current factors affecting the students’ transitions into professional nursing roles. Unlike an individual interview, the synergistic nature of a focus group often provides access to social interactional dynamics amongst specific groups of people and to powerful interpretive insights that lead to rich qualitative descriptive findings (Kamberelis & Dimitriadis 2005). Three focus groups were conducted with six to eight participants in a group, each lasting 60–90 minutes. This duration is considered appropriate for effective focus groups (Wong 2008). An experienced research team member facilitated each group using an interview guide with four open-ended questions. All of the interviews were audio-recorded and transcribed.
Ethical considerations The institutional Review Board approved this study. All of the participants were recruited on a voluntary basis and assured that their decision to participate or not participate would not affect their grades. They received a participant information sheet that explained the purpose of the study and their involvement. The participants gave written consent before the focus group interview. The anonymity and confidentiality of the interview data were assured.
Data analysis The data were subjected to content analysis using inductive data analysis (Elo & Kyng€as 2008). Two researchers initially read the three transcipts to achieve immersion in the data and a sense of the whole. The researchers met 1048
to discuss their initial impressions and the steps of the content analysis before individually engaging in the process of data analysis. The steps undertaken by each researcher included re-reading the transcripts, identifying codes from significant phrases and sentences and grouping the codes into categories. The researchers met again to compare their coded texts and categories. The coded texts were merged and re-grouped into categories and themes.
Rigour Dependability was maintained in the study by having the same research team member facilitated the three focus groups. The credibility of the data was strengthened by: (1) using a structured interview guide to maintain a reliable approach to the focus groups interviews; (2) verifying the key points with the participants at the end of each focus group to ensure that their opinions were interpreted correctly (Guba & Lincoln 2005); and (3) having two researchers generating codes and uncovering key themes. The interpretations of these codes and themes were then discussed and challenged until a consensus on the final set of coded categories and themes was reached.
Findings The analysis yielded three main themes: ‘experiencing the role of staff nurse’, ‘knowing how to’ and ‘learning from the ‘seniors’’. Sub-themes were also identified.
Theme 1: Experiencing the role of staff nurse The opportunity to experience the role of staff nurse in the SIMPLE programme significantly influenced the participants’ transition-to-practice clinical experiences. The programme was not only identified as ‘a stepping stone’ to experiencing the actual roles of staff nurse but also allowed the participants to ‘know what to expect’ from this role. Despite all of these positive experiences, the ‘complex roles of staff nurses’ were one of the key challenges addressed by the participants in their experience. Sub-theme 1: A stepping stone The participants saw the SIMPLE programme as a good stepping stone towards experiencing the role of staff nurse in real clinical practice. It was perceived as a good initial learning exposure away from the clinical responsibilities and demands of actual clinical practice. For example, one participant reported: © 2014 John Wiley & Sons Ltd
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I found that the experience of simulation was helpful because we
clinical settings and helps us understand their context. However, in
were often pressed for time in the ward. We need to learn prioriti-
the clinical setting, it is of greater depth as everything occurs at the
sation and the experience of simulation was a stepping stone for us
same time.
to learn that. Things were different on the ward. We faced more pressure. In the simulation sessions, we learned how to deal with pressure in a gradual manner.
Some participants reported a sense of gaining confidence through experiencing the role of staff nurse in the programme. One participant succinctly stated:
Many of the participants reported the challenges that they faced surrounding the complexity of the nursing care. One participant described her difficulties in managing workflow and care delivery to an assigned group of patients: It was difficult to manage multiple patients. I started with nursing
It boosted my confidence when I know that I have performed simi-
two patients, then progressed to four and eventually six patients.
lar tasks previously.
Yet, I found it difficult to prioritise the care for each patient. After the receiving shift report, the enrolled nurse would start to perform
Sub-theme 2: Knowing what to expect The SIMPLE programme showed the participants what to expect of their roles as staff nurses. As one participant said: It exposed me to the common experiences encountered by ward nurses. With the SIMPLE programme, we were able to think beforehand and to know exactly what to expect.
Knowing what to expect from the roles of staff nurses reduced the participants’ fears of finding themselves in situations that would expose their lack of competence. The appraisal of their individual performance in the new role of staff nurse allowed them to assess their learning needs, identify knowledge or skills gaps and take responsibility for rectifying their shortcomings. One participant captured this by saying:
nursing care. We were supposed to follow them to perform the nursing care but at times other things cropped up and required our attention. I found that quite difficult to manage.
To prepare for their roles as staff nurses better, the participants highlighted the need to provide more complex simulation scenarios in the SIMPLE programme to match the real-world role complexity. One participant suggested starting the programme earlier in the nursing curriculum and progressively increasing the complexity throughout the training levels: The SIMPLE programme should be progressively introduced across the 3 years of our nursing programme. For instance, one part of the programme could be introduced in the second year of our studies and all parts could be consolidated and implemented during the third year of our studies before we go out to the clinical practicum.
The simulation allowed us to know our current level of competencies, helped us to realise our strengths and weaknesses. It enabled us to enhance our strengths and work on our weaknesses.
In another participant’s words: I think the simulation was useful as it provided me with various encounters and helped me to know what to expect. Also, I know in which areas I would need further help and can prepare myself accordingly.
Sub-theme 3: Complex roles of staff nurses Compared with the simulated learning environment in the SIMPLE programme, a real clinical situation is much more complex, making the work of nursing care very challenging. The role of staff nurses regarding the ‘what’, ‘how’ and ‘when’ of nursing care delivery is multifactorial and timepressured, requiring a variety of skills to be applied simultaneously or in quick succession. A participant explained: In the real clinical setting, we need to handle many things at one time. The SIMPLE programme has prepared and exposed us to © 2014 John Wiley & Sons Ltd
Theme 2: Knowing how to Knowing how to ‘focus on holistic patient care, manage ‘difficult’ clients’ and ‘communicate with other healthcare professionals’ were the positive learning outcomes gained from the SIMPLE programme, as described by the participants. The importance of knowing how to ‘apply clinical knowledge’ in preventing potential error was also recognized. Sub-theme 1: Focusing on holistic patient care The SIMPLE programme led the participants to focus beyond technical skills performance to holistic patient care. One participant said: I thought the SIMPLE programme was good because previously during our attachment, we tend to be very task oriented. . .The simulation made me see the importance of being patient oriented.
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care for the patient’s psychological needs during a transfer in the actual clinical setting: I think the session on transferring a patient to another clinical setting was helpful. We learnt that we need to assess our patients, communicate with our patients and reassure them that they will be in good hands. I think these are applicable in my ward.
Sub-theme 2: Managing ‘difficult’ clients The opportunity to deal with psychologically challenging situations in the SIMPLE programme, during which patients and relatives strongly express emotions such as anger and grief, enabled some participants to know what to do when confronted with similar situations in the clinical arena. One participant described how her learning experience in the programme helped her to manage an angry parent in a paediatric ward setting: There was a parent who requested for four cold packs for his child. We could not provide him with four packs at one time. He made a
a structured communication tool (Leonard et al. 2004), – that was practised during the interprofessional simulation session: I think the constant practice we had during simulation really prepared me to communicate with the doctors using the SBAR (Situation, Background, Assessment, Recommendation) mnemonics. Some of the participants stated that the interprofessional simulation learning made them much more prepared than other nursing students when communicating with doctors. One said: I realise that some of the nurses in the ward were not exposed to a similar programme. They had less opportunity to communicate with doctors, or even with medical students during their training. Hence, their first encounter in the ward was more difficult.
For greater benefits, the participants suggested broadening the interprofessional learning simulations to include other healthcare professionals. One participant said:
big fuss and shouted at some of the nurses. From the SIMPLE pro-
Maybe, apart from doctors, we could collaborate with other health
gramme, I learnt how to manage difficult situations, how to com-
care professionals such as pharmacists, dieticians and therapists.
municate with anxious parents. I remembered a similar scenario presented in the programme and I tried to apply what I have learnt, such as bringing the parent to a quieter place.
In addition, some of the participants reported that their simulation experiences helped them to be aware of and manage their own emotions and to moderate their behaviour in emotionally charged clinical situations. One participant said: Despite feeling very frustrated, I think it [the SIMPLE programme] prepared us for appropriate ways to control ourselves.
Sub-theme 3: Communicating with other healthcare professionals The opportunity to practise communication skills with medical students in the interprofessional simulation learning session made the participants more confident when communicating with doctors about patient care. One participant gave an account of how she confidently updated the doctor about the status of her patients during ward rounds: I think the programme really prepared us very well. It gave us con-
Sub-theme 4: Applying clinical decision-making The participants identified the importance of applying sound clinical decision-making principles in maintaining patient safety by preventing errors from affecting the patients. The potentially dire consequences of drug administration error as a result of not knowing how to apply clinical knowledge when serving medication during their transition-to-practice were highlighted by some of the participants. For example, one participant clearly identified the importance of understanding a patients’ condition and having requisite knowledge of the medication ordered for them to prevent medication error: It [a particular drug] was for a patient who has a past medical history of asthma. So, I really ensured that the anti-hypertensive was not beta-blockers, because it would worsen the asthma. . ..
Participants suggested they needed more opportunities to learn how to apply pharmacological knowledge in the simulation scenarios. One participant said:
fidence to communicate with other health care professionals, such
Maybe the SIMPLE programme could incorporate more pharma-
as doctors. . .Because I understand my patients well, I am able to
cology knowledge and link this knowledge to nursing practice.
share information on what my patients are going through. They (doctors) are then able to make the necessary adjustments to the treatment plan
Theme 3: Learning from the ‘seniors’
Another participant highlighted the application of Situation, Background, Assessment, Recommendation (SBAR) –
In the SIMPLE programme, learning from the ‘seniors’ (alumni working as practising nurses) during hospital work
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processes had positive outcomes for the participants’ transition-to-practice experiences. To further this positive effect, the deliberate involvement of the ‘seniors as nurse confederates’ in the simulation session could be scripted to achieve particular learning outcomes. Sub-theme 1: Hospital work processes Many of the participants highlighted the value of learning hospital work processes from their ‘seniors’ in preparing them for their roles as staff nurses. In one participant’s words: The senior [alumni] shared almost all of the procedures such as admission, transfer and discharge which prepared us quite well.
Another participant provided an example of how learning hospital protocol from a senior helped her with the process of performing a blood transfusion: We appreciate our seniors returning from the hospitals as they brought with them some forms (protocols) from the hospitals. We were able to look through these forms. This prepared me to nurse a patient receiving blood transfusion as I was already familiar with the work process. Sub-theme 2: ‘Seniors’ as confederate nurses The participants recommended more involvement by the seniors to enhance the complexity and realism of the simulation scenarios. Some suggested that the seniors could act as confederate nurses (people who play roles with specific tasks in a simulation scenario) to confront the learners with more of the challenges they may meet in actual clinical settings. One participant said: I think the SIMPLE programme could involve the seniors (alumni) in the simulation scenarios. They could role-play as ‘difficult nurse’ and do something that challenges us.
Discussion Various programmes have been developed to address the need for smoother transitions between academia and graduate practice (Philips 2007). Clinical settings can be used to implement orientation programmes (Cubit & Ryan 2011) and academic units can develop transitional clinical programmes (Nash et al. 2009). The academic educators and practising nurses collaborated to develop and implement the SIMPLE programme. The programme’s effectiveness in enhancing students’ experiences during their transition into practice was evaluated. This study supports the effectiveness of the SIMPLE programme as a ‘stepping stone’ to expose final-year student © 2014 John Wiley & Sons Ltd
Simulation learning through academic-practice partnership
nurses to the reality of their work environment and, most importantly, their roles as staff nurses. A sense of unpreparedness in facing the responsibilities of a staff nurse and the weight of expectation in the professional working environment have been highlighted as typical concerns in many studies (Duchscher & Cowin 2004, Kelly & Ahern 2008). Ward nurses and managers have higher expectations of student clinical performance in this transition-to-practice period, because they know that students will soon graduate to become staff nurses. Student nurses, during their transition practicum, are given the responsibilities of a staff nurse to assume the total care of a group of patients. In the SIMPLE programme, they were given the opportunity to assume these responsibilities in a controlled positive learning environment that required them to multitask and cope with the managerial and organizational aspects of the job. Evidence suggests that when newly graduated nurses find themselves underprepared, they commonly identify feeling anxious and overwhelmed. They also have a low confidence in their ability and experience free-flowing stress and uncertainty regarding their self-perception of practice competency (Gerrish 2000, Dyess & Sherman 2009, Feng & Tsai 2012). This study highlights that through experiencing the role of a RN in the SIMPLE programme, the students gained a sense of confidence that helped them to cope with their roles in reality. Such confidence appeared to stem from the opportunity to know what to expect and how to prepare for their roles as staff nurses. Furthermore, it was evident from the data that an awareness of their current competency and areas of weakness and strength, were constructed from the experiential learning the SIMPLE programme offered. This self-awareness allowed student nurses to identify their own learning needs and seek further instruction to prepare themselves for their new professional roles. A study by Currie (2008) supported the positive effect of self-awareness on graduates’ sense of confidence in developing expert practice. A simulated clinical laboratory that focuses on technical skills is insufficient to prepare student nurses for transition to the work environment. Given the complexity of today’s health care, it is essential that student nurses be prepared with a broad scope of skills for caring holistically for a caseload of several patients (Hourican et al. 2008, Liaw et al. 2014). A simulation that reflected the reality of actual ward practices was used in the SIMPLE programme to allow nursing students to apply and practise communication, decision – making, collaborative practice, delegation and conflict management. The simulation was supported by the use of SPs and collaborative learning with medical students to allow nursing students to apply effective communi1051
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cation and decision-making skills and to cope with human emotions and other challenges. It is evident from the findings of this study that the learning experiences gained from the SIMPLE programme enabled the students to know how to focus on holistic patient care, deal with ‘difficult’ client and communicate with other healthcare professionals. This appeared to justify the learning gains from the SIMPLE programme that may have resulted in the transfer of learning to the actual clinical setting. In our study, context similarity between the simulation scenario and actual clinical situations was observed to facilitate the transfer of learning. The similarity between learning and the application context has been identified as a critical factor in the transfer of learning (Kulasegaram et al. 2012, Norman & Schmidt 1992). The simulation scenarios were developed through collaboration between academic educators and practising nurses to ensure that the scenarios were congruent with the realities of current nursing practice. To further enhance context similarity between learning and practice, the participants recommended building more scope and complexity into the simulation scenarios. This augmentation could allow participants to be involved with more challenging patient situations that require the application of complex clinical decision-making, particularly the safe administration of medication. Furthermore, to enhance the scenario complexity, the participants foresaw the benefits of increasing the involvement of the practising nurses by having them portray ward nurses in the simulation scenarios. By participating in the simulation scenarios, practising nurses could improve the realism by presenting challenges that would engage students in the veritable reality of ward practices. Two existing university resources – academic educators and alumni – were used in the SIMPLE programme to foster collaborative relationships between academia and practice. The academic-practice partnership provided opportunities for the students to learn from the practising nurses, who were familiar with the culture of the current nursing practice environment. The academic educators who served as experts in the educational process played a critical role in supporting student learning while also mentoring the practising nurses (Raines 2006). The findings of this study support the learning experienced by the student nurses regarding hospital work process, which greatly helped them to develop confidence in their roles as staff nurses. As Johnstone et al. (2008) noted, an understanding of the working knowledge of an organization’s systems and processes is considered important to support a graduate nurse’s transition from novice to advanced beginnerlevel practitioner. 1052
Limitation Although longitudinal studies have been conducted to examine the effect of the SIMPLE programme on the students’ transition-to-practice, these have been limited to the students’ perceptions and experiences. In addition, it is acknowledged that the findings are limited to those who were willing to participate in the study and thus, may not be reflective of all the other students’ experiences.
Conclusion Practising nurses from the universtiy’s alumni and the academic educators developed and implemented an innovative simulation education programme (SIMPLE) for final-year nursing students before their transition to practising in clinical settings. The programme was developed to align the educational process with the realities of nursing practice. The findings of this qualitative study highlight the beneficial effect of the SIMPLE programme on the students’ transition-to-practice experiences and ways of enhancing the programme to optimize learning. The results reflect the need for stronger collaboration between faculty members and practising nurses in the subsequent planning and development of the SIMPLE programme. We continue to partner with practising nurses to expand the programme by increasing the scope and complexity of the simulation scenarios. In addition to using the simulation experience to immerse students in the professional nurse role, we plan to use this programme to promote the professional growth of practising nurses in roles as clinical teachers. This would involve using the programme to complement a hospital preceptorship programme that supports and develops the roles of preceptors in facilitating an effective transition experience for final-year students. It is essential to equip academic educators with the resources to facilitate the teaching-learning process for alumni practising nurses and further research is clearly needed to examine the perspectives of practising nurses and academic educators and to strengthen the evidence for best practice to foster a smoother transition. Ensuring the work readiness of newly graduating nurses on entering the workforce remains a challenge for the nursing profession. Work readiness encompasses not only a wide range of clinical skills including teamwork, work organization, decision-making and prioritising but also an understanding of hospital systems and work processes (Johnstone et al. 2008). The involvement of practising nurses in the design and implementation of a simulation learning programme could increase the ‘work readiness’ of © 2014 John Wiley & Sons Ltd
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future graduate nurses. Expanding this learning platform to promote the professional growth of practising nurses in formal roles as clinical teachers would foster even greater involvement.
Acknowledgement The authors thank the nursing students of the National University of Singapore for participating the research study. We also thank the National University of Hospital System Medical Publications Support Unit, Singapore, for providing editing services for this manuscript.
Funding This research was supported by Alice Lee Centre for Nursing Studies at the University of Singapore.
Conflict of interest No conflict of interest has been declared by the authors.
Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:
• •
substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
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