2014 NCSBN Scientific Symposium

April 2014

Christine Szweda, MS, BSN, RN Senior Director, Operations

Office of Nursing Education and Professional Development

Objectives

•  Participants can state the rationale for the proposed research study

•  Participants can describe the intervention

•  Participants can identify one area for future study

Cleveland Clinic National Recognition

•  U.S. News & World Report -  #1 in heart care 19 consecutive years -  In top 4 hospitals nationally

H Fairview Hospital

Lakewood Hospital

H

Lutheran Hospital

H

Euclid Hospital

H

Hillcrest Hospital

H

South Pointe Hospital

H

Marymount Hospital

H

Cleveland Clinic

(main campus)

Integrated Health System serving 5.1 million patients

H Medina Hospital H Weston Hospital,

Florida

•  Total workforce >41,000 •  Nurses 11,000+

•  154 nursing units •  4,500 beds •  200 operating room settings •  ER visits (system wide) – 440,000

Cleveland Clinic Nursing

Annual RN Hires

2011

1750

2013

1250

2012

1500 Types of New Hires

18%

82%

ExperiencedInexperienced

40% New Graduate Nurses Hired into

an ICU Setting

Study Overview Evaluating the Use of Human Patient Simulation

(HPS) to Improve Critical Thinking Competencies and Perceived Self-Confidence of New Graduate Nurses in the Intensive Care

Unit (ICU)

•  Could an intensive educational program utilizing HPS scenarios significantly improve new

graduate RN’s critical thinking competencies and perceived self-confidence in managing patient

problems in the ICU setting?

Study Methods

•  Part A - A mixed methods study with double-blind randomized trial

•  Part B - A qualitative component utilizing individual interviews

•  Study Tools -  PBDS© Competency Assessment Tool -  Casey Fink Graduate Nurse Experience

Survey -  Qualitative Interview Tool

Expectations at Point of Hire

•  Recognition of Problem •  Recognition of Urgency

Expectation of New Graduate Nurses upon entry to CC Health System

PBDS Continuum Baseline Assessment

Unable to recognize

change problem or

urgency

Unable to manage basic

med/surg patient

problems

Acceptable

Percent of New Graduates in Each Category

35%*

54% 11%

Unsafe to transition to hospital unit

Expectations at End of Orientation

•  Management of Problem -  Communicate Relevant Info to MD -  Anticipate Orders from MD -  Implement Immediate Nursing

Interventions Expectation of New Graduate Nurses upon completion of orientation

PBDS Continuum Re-assessment

Unable to recognize

change problem or

urgency

Unable to manage patient

problems specific to their

unit

Acceptable

Percent of ICU Nurses in Each Category

15%

55% 30%

Percent of Med/Surg Nurses in Each Category

10% 20% 70%

Participants

•  Consented 65 -  31 intervention group -  25 control group

Intervention

•  Control Group -  Standard 12 weeks of orientation with

a coach/preceptor -  Critical care classes scheduled

throughout orientation

Intervention

•  Experimental Group -  Standard 12 weeks of orientation with

a coach/preceptor -  Critical care classes scheduled

throughout orientation •  Five day immersive experience focused

on ICU problem management

Day 1 Day 2 Day 3 Day 4 Day 5 Review week

Review critical thinking questions

Practice critical thinking questions with video scenarios

Intro to hi-fidelity simulation

HPS Scenario – Uncontrolled Pain

Debriefing

Equipment Review

Review Scenario SBAR

HPS Scenario – Hypovolemia

Debriefing

Equipment Review

Review Scenario SBAR

HPS Scenario – Sepsis

Debriefing

Equipment Review

Review Scenario SBAR

HPS Scenario – Obstucted Airway

Debriefing

Compare and Contrast with video scenarios and critical thinking questions

Debriefing

Equipment Review

Review Scenario SBAR

HPS Scenario – DKA

Debriefing

Review Scenario SBAR

HPS Scenario – Pulmonary Edema

Debriefing

Individual HPS Scenarios

Review video – self assess

Present video to cohort and debrief

Prioritization exercise (all scenarios from week)

Critical Thinking Questions

Review SBAR/Receive Handoff Report •  What complications is the patient at risk for? •  How will you know if that complication is occurring? •  What particular components of the assessment are

you going to focus on?

Critical Thinking Questions Assess the patient •  What signs/symptoms do you see? •  What problem/complication do you think is occurring

and why? •  Does this require any urgent action(s) and why? •  What immediate nursing interventions do I need to

take and why? •  What information do I need to communicate to the

physician? •  What orders am I going to anticipate from the

physician? •  What is the rationale for those orders? •  How will I know the interventions/orders implemented

have been effective?

PBDS Re-assessments Unable to recognize

change problem or

urgency

Unable to manage patient

problems specific to their unit

Acceptable

Pre-Study 15%

55% 30%

Control Group 4% 62% 44%

Experimental/ Intervention Group

0% 61% 39%

Qualitative Findings

•  Experimental/Intervention group identified 3 themes -  Improved their ability to see the

entire patient picture -  Taught them to anticipate problems

and/or complications and know what to expect

-  Communicate more effectively with the MD and anticipate appropriate orders.

Qualitative Findings

•  Top Lessons Learned -  Improved assessment skills -  Learned the why behind the

interventions -  Ability to prioritize -  Pattern of critical thinking to use

when approaching patients

Qualitative Interviews

•  Themes -  Learn best on unit with coach instead of in

classes -  Time away from unit increased stress in

some -  Even when practicing independently, did

not feel confident in understanding the entire patient picture

-  Coaches who asked questions preferred to those who just showed how things were done

Recommendations

•  Further study on an intervention that allows for time on unit with coach and minimal class content.

•  Compare relationship between perceived confidence and competency.