Today, many nursing students graduate from educational programs without the clinical skills and judgment they need to handle a typical hospital caseload. At the same time, the number of new graduate nurses working in critical patient care areas, such as intensive care units (ICUs) and critical care units, has been increasing. In the past, new nurses were required to have many years of medical/surgical experience before transitioning into these areas.

In a recent survey by the Advisory Board Company, a healthcare consulting firm, only 10% of hospital nurse executives said they believe newly graduated nurses are fully prepared to provide safe care. Many novice nurses struggle to effectively manage one or two patients at a time, let alone the five or six commonly assigned. What’s more, some have little or no training in complex technology and lack the team skills they need to function effectively in a “live” patient-care environment.

To help bridge these gaps, many healthcare employers have established various educational and training programs. Banner Simulation Medical Center in Mesa, Arizona, grew out of a desire to train healthcare professionals to provide the highest quality of care while offering improved learning opportunities for new nurses. Occupying a former hospital, it provides a unique on-boarding experience to orient newly hired employees into the Banner System. Its simulated clinical environment integrates new healthcare delivery models and innovative equipment and technologies into the learning process.

“Virtual” hospital and orientation program

Opened in September 2009, Banner Simulation Medical Center is a 55,000-square-foot “virtual” hospital and orientation program that uses clinical scenarios and hands-on immersive curricula, training, and evaluation to improve and standardize on-boarding programs. Every nurse newly hired by Banner Health Arizona is required to attend the center and complete the orientation (including a simulation orientation) to ensure safety and competency regardless of their experience level. Tuition is free for all Banner Health employees. Banner covers the center’s operational and capital costs.

Traditionally, free-standing simulation centers have suffered by not being in the heart of a campus or medical center. At Banner, however, tremendous support from administration and senior leaders draws learners to the facility. The facility has:

• a 14-bed ICU/progressive care unit
• an 18-bed medical/surgical floor
• an eight-bed neonatal ICU/pediatric ICU/pediatrics area
• a 20-bed emergency department/labor and delivery unit
• two operating-room suites
• four dedicated classrooms
• a skills station wing.

Each unit is complete, with a full complement of simulated medical gases, computer charting stations, and all the other technology and equipment required (such as ventilators, defibrillators, feeding and infusion pumps, and physiologic monitors). The facility has at least 71 patient simulators and task trainers of various sizes, genders, ages, and fidelity levels.

The center operates 5 days a week and can train up to 75 to 100 learners weekly. On average, 50 nurse-learners are present at any given time, depending on the type of training being given. (Learners from other healthcare disciplines average about 25 per week.) The core staff of approximately 20 is split among simulation educators and simulation specialists, managers, administrative assistants, and data analysts representing almost every healthcare service line.

New graduate nurses spend 5 days at the center; experienced nurses spend 1½ days or 12 hours there. The center also has the capacity to provide remediation training to nurses and physicians. To date, it has provided complete training for nearly 300 nurses.

Nursing curricula

Collaborating with multiple interdisciplinary teams within Banner Health Arizona, the simulation center developed standardized nursing curricula for facility-based learning, simulation skills, and scenarios. The environment serves as a learning bridge, enabling newly hired nurse graduates to care for a more typical patient load—even though the patients are plastic! Participants also learn about computerized medical documentation, flow prioritization, team training, communication, and the other complex issues that healthcare professionals encounter daily.

On-boarding

On-boarding begins when new nurses learn about such topics as human relations and the insurance, health, and dental benefits available at their own Banner facility. All new employees in each of the nine Banner Arizona hospitals are placed through simulation orientation as part of their on-boarding experience. They continue to learn about clinical specifics that can be reinforced and demonstrated in simulations—professional practice concepts, chain of command, informed consent, advance directives, core measures, and national patient safety goals.

Once they arrive at Banner Simulation Medical Center, the nurses begin to practice a series of skills and scenarios, as defined by their professional service lines, until they reach a measurable level of competency. Until they’ve completed orientation, they don’t perform those same skills and services on “live” patients or in a real clinical environment.

Procedural skills

Banner teaches procedural skills based on the policies, procedures, regulations, and requirements set forth by healthcare facilities, medical equipment manufacturers, and state and national guidelines and professional boards. Mosby’s Nursing Skills, an online skills reference and competence management resource, serves as the procedural guideline. Tool kits used by learners incorporate the following:

• table of contents
• objectives
• equipment needed to perform each skill
• simulation equipment needed
• standardized content
• weighted checklists
• references
• policy
• reviewing team members
• date of last update
• comments.

To allow for different learning and educational styles, only the content of the skills—not their delivery—is standardized. The primary focus is on competency, not on time spent in a program or attendance relative to clinical learning.

Weighted checklists. The skills portion of learners’ competency evaluation uses weighted checklists. Weighting critical steps provides a specific educational focus, reducing redundant training in areas where the learner already performs adequately. New nurse graduates must participate in both didactic and hands-on skills training and evaluation; experienced nurses can choose to complete the hands-on portion for evaluation only.

Weighted checklists typically consist of five to seven steps. The learner’s performance in each step is given a weighted score determined by clinical experts. Also, each step is correlated to the new graduate practice readiness domains, as outlined in the recent Advisory Board survey. Every nurse is evaluated using a weighted checklist during a hands-on return demonstration of all required skills. Their performance dictates whether they can continue on to complete other skills or must receive remediation and complete another return demonstration. All scores and the number of return demonstration attempts are compiled in a report summary tool and database. The report is sent to the manager or unit preceptor, who individualizes the nurse’s focus to work on areas in which he or she may be weaker.

Below is an example of a weighted checklist used to evaluate nurse-learners’ skill competency at Banner Simulation Medical Center.

Simulation scenarios

After skills completion, learners move onto simulation scenarios, spending 3 days working with manikin patients in a simulated hospital setting. On each of the 3 days, they spend 4 to 5 hours in direct patient (manikin) care, completing all normal tasks required in a typical day of patient care. These tasks include:

• giving and receiving report
• completing assessments
• documenting in the electronic medical record
• giving medication
• providing appropriate patient care and treatments
• monitoring laboratory values
• calling physicians and ancillary staff as appropriate.

Scenarios are developed based on the specifics of the clinical service area (such as med/surg unit, ICU, or pediatrics.) They include patient history, clinical history, laboratory values, equipment, SBAR communication (Situation-Background-Assessment-Recommendation), handoffs, orders, and computerized charting components.

Scenarios allow for interaction and representation of a true multi- and interdisciplinary healthcare team. They incorporate previously learned procedural skills as well as the more complex skills involved in communication, documentation, critical thinking, time management, and decision making. All aspects of the scenarios (which are programmed into the manikins) are developed to encompass Banner’s initiatives, the Joint Commission’s National Patient Safety Goals, Centers for Medicare & Medicaid guidelines, and quality and core measures. When learners end their shift, they are debriefed by staff on what they think they did successfully and what they would choose to do differently. Individualized discussions also occur on issues throughout the patient-care day.

The learner’s assessment includes the consistency of such technical functions as infection control precautions, patient identification, and consent. Because these functions represent only a portion of the nurse’s role, performance standards or behavioral measures (such as attitude, communication, responsiveness, teamwork, and accountability) also are evaluated. A summary of the assessment is sent to facility educators and unit managers, who can further tailor the learner’s development plan or take action on potential concerns.

Accuracy and improvement

After didactic training, new graduate nurses are able to complete return skill demonstration with approximately 95% accuracy after the first demonstration and with 100% accuracy after remediation and the second demonstration. These numbers essentially mirror those of experienced nurses, except the latter don’t review didactic materials before the return demonstration.

New graduates show significant improvement from day 1 to day 3 of their immersive scenarios. All performance outcomes obtained from the learner’s return demonstration of psychomotor skills and performance in scenarios are entered into a comprehensive database, summarized, and given to the learner, manager, educator, and/or preceptor. An ongoing record is kept of each nurse’s needs and performance, helping Banner provide individualized support that sets up the learner for continued success.

At Banner Simulation Medical Center, centralization of education and learning provides the highest quality and consistency of care to patients within the nine hospitals the center primarily serves. Participants learn the skills they need to provide the highest quality of safe patient care—and learn them to an objective, measurable level of competence and proficiency. Later, they can use the facility for credentialing, accreditation, and skills maintenance.

The center mimics the real environment in complexity and leads to richer learning. Its ultimate goal is to produce more confident and competent healthcare providers and thereby reduce medical errors, improve patient safety and care, and enhance the entire patient experience throughout Banner Health.

Carol Noe Cheney is the director of simulation and innovation at Banner Health Arizona in Phoenix. Karen Josey is a simulation senior manager at Banner Simulation Education and Training Center in Phoenix. Terry Chavez is a simulation senior manager at Banner Simulation Medical Center in Mesa, Arizona.

References

Berkow S, Virkstis K., Stewart J, Conway L. Assessing new graduate performance. Nurse Educ. 2009;34(1):17-22.

Bridging the preparation-practice gap. Vol 1. Quantifying new graduate nurse improvement needs. Washington, DC: Advisory Board Company; 2008.

Del Bueno DJ. A crisis in critical thinking. Nurs Educ Perspect. 2005;26(5):278-282.

Li S, Kenward K. A national survey of nursing education and practice of newly licensed nurses. JONAS Healthc Law Ethics Regul. 2006;8(4):110-115.