Int. J. Nurs. Educ. Scholarsh. 2015; 12(1): 1–9
Teresa N. Gore*, Tanya Looney Johnson and Chih-hsuan Wang
Teaching Nursing Leadership: Comparison of Simulation versus Traditional Inpatient Clinical Abstract: Nurse educators claim accountability to ensure their students are prepared to assume leadership responsibilities upon graduation. Although front-line nurse leaders and nurse executives feel new graduates are not adequately prepared to take on basic leadership roles, professional nursing organizations such as the American Nurses Association (ANA) and the Association of Colleges of Nursing (AACN) deem leadership skills are core competencies of new graduate nurses. This study includes comparison of a leadership-focused multi-patient simulation and the traditional leadership clinical experiences in a baccalaureate nursing leadership course. The results of this research show both environments contribute to student learning. There was no statistical difference in the overall score. Students perceived a statistically significant difference in communication with patients in the traditional inpatient environment. However, the students perceived a statistical significant difference in teaching–learning dyad toward simulation. Keywords: nursing leadership, multiple patient simulation, traditional in-patient clinical, senior BSN students DOI 10.1515/ijnes-2014-0054
Introduction In spite of the recognizable need to increase the nursing workforce, simply increasing the volume of nurses is not the answer (American Association of Colleges of Nursing [AACN], 2007). The American Nurses Association (ANA) embraces leadership as a core component in their standards of professional practice with clinical leadership as a key competency for nursing graduates (ANA, 2008). In efforts to accommodate the nation’s demand for nurses, as well as nurse leaders, universities are increasing enrollments in *Corresponding author: Teresa N. Gore, School of Nursing, Auburn University, 137 Miller Hall, Auburn, Alabama 36849, USA, E-mail: [email protected] Tanya Looney Johnson, School of Nursing, Auburn University, 139 Miller Hall, Auburn, Alabama 36849, USA, E-mail: [email protected] Chih-hsuan Wang, Department of Educational Foundations, Leadership, and Technology, Auburn University, Auburn, Alabama, USA, E-mail: [email protected]
their baccalaureate programs. Consequently, the growing enrollment of nursing students presents challenges for academic programs to effectively develop leadership abilities (Abdrbo, 2012). Clinical site demands (Curtis, Vries, & Sheerin, 2011) and increasing student–faculty ratios are problematic issues that may hamper effective leadership preparation of students (Chunta & Edwards, 2013). The AACN recommended nursing students be assessed for nursing leadership behaviors and competency throughout the curriculum. Responses to this recommendation include integrating nursing leadership content throughout the curriculum (Abdrbo, 2012). Some schools’ curricula only offer leadership content in one semester, which allows limited time for students to integrate these skills into clinical practice prior to graduation (Hendricks, Cope, & Harris, 2010). Nursing students may not be prepared to assume leadership roles in their nursing programs, and leadership should not be viewed as an optional competency (Curtis et al.). Health-care organizations and nursing educators recognize the broadening gap between the leadership ability of new graduate nurses as compared to actual clinical practice requirements (Lekan, Corazzini, Gilliss, & Bailey, 2011). The nursing curriculum is an additive program with more concepts and skills being added without removing obsolete practices that are not evidence-based. This can dilute the amount of time dedicated to each concept, without the opportunity for students to apply concepts into their clinical practice (Clapper & Kardong-Edgren, 2012). Hospitals are adamant they are in need of nurses who have acquired proficient clinical skills and leadership abilities. Nursing is central to effective leadership in health care (Lekan et al., 2011). Curtis et al. (2011) found that successful nursing leadership positively influenced patient safety outcomes, staff satisfaction, healthy work environments, and staff. As Curtis and colleagues reported, poor leadership among nursing has no place within organizations that strive for effective change and excellence in patient care. A recent survey demonstrated that only 25% of nurse managers and 10% of nurse executives were favorable toward new graduate preparedness with leadership skill. Unfortunately, new graduates are often placed in charge nurse roles within the first year of practice, creating a mismatch between new graduate educational skill set and employer expectations (Lekan et al.).
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2
T. N. Gore et al.: Teaching Nursing Leadership
It is difficult to connect specific educational activity to achieving competency, especially with an abstract concept such as nursing leadership (Abdrbo, 2012). However, research has shown that simulation is an effective teaching strategy (Aebersold, Tschannen, & Bathish, 2012; Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014; Kilgore, Goodwin, & Harding, 2013; McGrath, Lyng, & Hourican, 2012) for fundamental clinical skills, as well as nursing leadership, delegation, and prioritization skills (Chunta & Edwards, 2013; Thomas, Hodson-Carlton, & Ryan, 2011). Hayden and colleagues determined that simulation is an equitable learning experience for students without negative outcomes in grades and licensure pass rate. Chunta and Edwards provided evidence that multi-patient simulation during the final semester of nursing school provided students with the opportunity to effectively learn organization, prioritization, and delegation skills. McGrath and associates demonstrated effectiveness of simulation with students’ learning by integrating skills, such as critical thinking and decision making with case load management. Nursing leadership simulation has the potential to enhance the students’ leadership abilities, as well as build their self-confidence (Reed, Lancaster, & Musser, 2009). Additionally, simulation poses a safe environment for students to practice their skills with opportunity for immediate feedback and skill refinement (Aebersold et al.). Learner satisfaction is the level of satisfaction that is self-reported by the participants and the facilitators. Studies suggest both participants and facilitators have high levels of satisfaction with simulation as a teaching and learning strategy (Jeffries & Rogers, 2012; O’Donnell, Decker, Howard, Levett-Jones, & Miller, 2014). Lyle (2009) stated health-care providers are less likely to respond appropriately in a timely manner if they lack self-confidence. Simulation is a strategy used to provide participants with an opportunity to practice and build self-confidence (Jeffries & Rogers; O’Donnell et al.). Clinical experience has been recognized as the gold standard to prepare student nurses to critically think, problem-solve (Abdrbo, 2012), and observe and model leadership skills (Curtis et al., 2011). However, a variety of circumstances inhibit student application of learned leadership skills in the clinical setting. Clinical site availability is one of the major challenges for many nursing schools due to competition of increasing enrollment and numbers of nursing programs seeking clinical placement for students (Thomas et al., 2011). In addition, multi-patient assignments are essential for senior-level nursing students to adequately practice leadership concepts, such as delegation, critical thinking, and prioritization. Shorter hospital stays and decreasing opportunities are a constraint for developing
leadership skills in the traditional clinical environment. Due to these types of constraints and obstacles in clinical settings, the traditional inpatient clinical experiences may not offer the opportunity to develop necessary leadership skills (Chunta & Edwards, 2013). Hayden and colleagues (2014) used several tools for evaluation of the longitudinal, randomized, controlled study for replacing clinical hours with simulation in pre-licensure nursing education. One of the tools used was the Clinical Learning Environments Comparison Survey (CLECS; Leighton, 2015) for student perceived learning effectiveness at the end of each clinical course and the completion of curriculum for each group for simulation as clinical time: the control group used 10% simulation (n ¼ 197 traditional; n ¼ 174 simulation), 25% simulation (n ¼ 202) and 50% simulation (n ¼ 187). Hayden and colleagues found that students in the control group (10% simulation) preferred traditional clinical experiences and the 50% simulation group preferred the simulated clinical experiences. The 25% simulation group was in the middle with a tendency for preferring traditional clinical experiences. In this study, also evaluated were student outcomes for licensure pass rate and a 6-month follow-up after graduation. No statistical differences were noted between the groups (Hayden et al.).
Experiential learning theory The theoretical framework underpinning this study was Kolb’s Experiential Learning Theory (ELT, 1984). The ELT is a process of learning with an interactive relationship between the learner and the environment. The major components of ELT include occurrence of a concrete experience, reflective observation of the concrete experience, abstract conceptualization by learning and looking for identifiable patterns from the concrete experience, and active experimentation by applying what has been learned (Decker, Caballero, & McClanahan, 2014). Simulationbased learning is an experiential learning experience by means of providing the concrete experience in the scenario. The reflective observation of the concrete experience occurs in the debriefing session following the simulation. Through this reflection, participants can develop abstract concepts by linking actions and outcomes that can lead the participants to use active experimentation. Through reflection, the participants can gain confidence. During active experimentation participants can implement the concepts into clinical practice (Decker et al.; Kolb). This may lead to an increase in perceived ability to perform in a real-world environment that includes leadership skills.
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T. N. Gore et al.: Teaching Nursing Leadership
Purpose of the study Nurse educators are utilizing simulation more now than ever (Thomas et al., 2011), but there is a dearth of research comparing student perception of the effectiveness of teaching nursing leadership via multi-patient simulation versus the traditional leadership acute-care clinical experiences. The purpose of this study was to explore senior level nursing students’ perceptions of the effectiveness in leadership learning between simulated and traditional clinical environments. The authors hypothesized there will be no difference in perceived learning between simulated and clinical environments.
Methods Study design The descriptive, correlational study was implemented with a convenience sample of students in the leadership class over three semesters. Students’ clinical groups were kept intact from the previous semester. The rationale was that students needed a working knowledge of their team members’ strengths and weakness before performing the role of team leader and making patient assignments in the traditional leadership clinical environment. The clinical groups were also assigned to the same hospital because of the students’ familiarity and proficiency in charting and with hospital policy and procedures. Therefore, randomization did not occur; however, the students had been randomly assigned into clinical groups the previous semester. The order of participants’ engaging in either simulation or traditional clinical first was randomly assigned. Figure 1 shows the group assignments.
Fifth Semester Senior Leadership Course Cohort
Multiple Patient Leadership Clinical (n = 78)
Traditional Inpatient Leadership Clinical (n = 77)
Traditional Inpatient Leadership Clinical (n = 78)
Multiple Patient Leadership Clinical (n = 77)
Complete L-CLECS (n = 155)
Preceptorship (internship)
Figure 1: Study design.
3
All students enrolled in the course were required to participate in both the leadership simulation and traditional clinical acute-care experiences on a medical–surgical unit. Institutional Review Board (IRB) approval was obtained prior to the study. Participants were notified of this research and signed an informed consent to participate in the study. Only consenting students’ survey results were used. After students finished both the leadership simulation and traditional clinical experiences, students completed the Leighton CLECS (L-CLECS; Leighton, 2015) prior to beginning their preceptorship/internship.
Setting and participants The participants were fifth clinical semester baccalaureate of science in nursing (BSN) students (n ¼ 155) at a southeastern university and enrolled in a leadership didactic and clinical course. Fifth semester nursing students were selected for this study because they had experience with providing care to one to two patients in the clinical setting, and participated in at least one simulation per semester in all four semesters in their curriculum. The first semester students participated in one simulation day for a 3-h experience; second semester students participated in four simulation scenarios; third semester students participated in one simulation scenario and two interactive computerized case studies; fourth semester students participated in four simulation scenarios and fifth semester students participated in three simulation scenarios, in addition to the leadership simulation. The multiple patient leadership simulation is the students’ only simulation as an individual. Requirements for this course were student participation in leadership simulation conducted in the skills laboratory/ simulation center and 48 h of traditional inpatient nursing experience. The fifth semester leadership courses are: (1) three credit hours for didactic and two credit hours for clinical experiences and (2) two credit hours didactic leadership course. The clinical course includes 90 h of clinical experience with 2 h of simulation for multiple patient scenario and 3 h for the other three scenarios. The simulation policy for this school of nursing states 1 h of simulation is equal to 3 h of traditional clinical experience (Gore & Schuessler, 2013).
Instrument Permission to use the CLECS was obtained from the researcher/developer of the tool. The CLECS is a 29-item self-report survey based on pertinent topics from a
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T. N. Gore et al.: Teaching Nursing Leadership
literature review, and designed to compare how well undergraduate students perceived their learning needs were met in the simulated clinical environment and in the traditional clinical environment. Participants respond to each item using a Likert scale of 1–4, and a not applicable choice (0 ¼ not applicable; 1 ¼ not met; 2 ¼ partially met; 3 ¼ met, and 4 ¼ well met) with total possible scores from 0 to 116 (Leighton, 2015). The scale has been validated with good face and construct validity, and good reliability (Cronbach’s alpha for each subscale ranged from 0.73 to 0.97; Leighton, 2007, 2015). Leighton (2015) provided definitions of these subscales: Self-efficacy is the perceived capability to perform a behavior (Kear, 2000). Teaching–learning dyad is the interactive, collaborative relationship between teacher and student in which both have shared responsibility for the learning that occurs. Holism refers to the five dimensions people have that nurses care for: physiological, psychological, sociocultural, spiritual, and developmental (Neuman & Fawcett, 2011). Communication is verbal and nonverbal interactions between student, faculty, patient, patient’s family or significant others, and members of the health-care team. Interactions may occur between two or more parties. Nursing process is a systematic method of problem solving that is a deliberate, organized, and scientific approach to patient care involving five phases: assessment, nursing diagnosis, plan, implementation, and evaluation (Kozier, Erb, Berman, & Synder, 2004). Critical thinking is “the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion” (critical thinking, n. d., p. 46).
critically think and problem-solve. The venue allowed for up to 20 low-fidelity manikins and a medium-level environmental fidelity with the same number of hospital patient rooms being staged as a medical-surgical nursing unit for up to five nursing students (each student had the same four patients). The simulation experience occurred over a period of one and one half hours and was timed as follows: (1) Pre-brief and handoff shift report (20–25 min), (2) simulation exercise (30–40 min), and (3) debrief (20–25 min). Students were assigned presimulation readings and questions for each patient along with overview and objectives of the simulation. During the course orientation and described in the syllabus, students were informed of the simulation scenario, pre- and post-simulation assignments, and the guidelines of this simulation. Learning objections are defined in Table 1. Table 1: Learning objectives for multiple patient leadership simulation. . Implement effective communication techniques (SBAR [Situation, Background, Assessment, and Recommendation], closed loop communication, and therapeutic) among team members to enhance nursing leadership knowledge and skill. . Utilize time management techniques when caring for a group of patients. . Employ critical thinking, delegation, and prioritization skills into care of patients in simulation. . Assimilate theory and practice to influence actions as a nurse leader in preparation for preceptorship/internship.
Pre-briefing
Multiple patient leadership simulation The purpose of this simulation was to prepare students to care for multiple patients, prioritize, improve critical thinking and delegation, practice time management, and demonstrate leadership skills prior to preceptorship/internship. The multiple patient simulation scenario was a “thinking” simulation with students verbalizing their thought processes without performing all of the psychomotor skills, such as auscultation, vital signs, and charting. The students had to verbalize and request assessment information needed in their decision-making process. Some skills were required, such as calculating the amount of morphine sulfate required for pain management, and the amount of dextrose 50% to be given based on the blood glucose level. These skills were required to demonstrate the ability to
Students were randomly assigned to simulation times based on clinical groups and reported to the simulation center in groups of three to five students. As a group, they were pre-briefed on expectations and received a verbal Situation, Background, Assessment, and Recommendation (SBAR) shift handoff report from the charge nurse (faculty member) on the same four patients: (1) an unresponsive hypoglycemic diabetic patient, (2) a second day post-op hip replacement patient experiencing excruciating pain, (3) an elderly – high fall risk – and hypotensive patient who has voiding urgency, and (4) a patient with pneumococcal pneumonia experiencing respiratory difficulty. Following pre-briefing and shift report, the students were instructed to individually organize a plan to provide care for their group of patients just as they would if they were beginning a clinical shift. Faculty allowed the students five minutes for planning
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T. N. Gore et al.: Teaching Nursing Leadership
since they were familiar with the patients’ history from their pre-simulation exercises. Emphasis was placed on critical thinking with regard to “thinking out loud” versus psychomotor performance. The students were taken to the simulation unit after shift report, oriented to the location of the medications, patients, and introduced to their facilitator and nursing care technician.
5
Table 2: Examples of debriefing questions. “How did this scenario make your feel?” “What made you chose the actions/interventions that you chose?” “Discuss your knowledge, skills, attitudes, and previous experiences that provided you the ability to provide evidenced base care to these patients.” “What are the five rights of delegation and which ones did you use?” “Speak to how your personal beliefs and values influenced the care provided to this team.”
Simulation experience
“Which patient should have been seen first and why?”
As the simulation experience began and students attempted to initiate patient assessments and care, a series of interruptions began to occur. Each patient had a flip chart on his/her chest where the facilitator would turn the pages to provide additional information regarding patient assessment and response to interventions. Over the 40 min of the simulation, the students were faced with acutely ill and demanding patients, an argumentative patient care technician (faculty member) while challenged to implement prioritization and delegation, and critically think from a staff nurse’s perspective.
“If you could re-do this scenario now, what would you change and why?” “What is your leadership style and what leadership style did you use today?”
Table 3: Questions on student reflection assignment. . Explain your decisions and interventions during the simulation – particularly what you felt you performed correctly right and what you could have performed better. . How do you think this experience will influence your nursing care in the future? . Based on your learning experience, discuss what you will change or perform differently in the clinical setting during Leadership Clinical and Preceptorship (depending on sequencing of simulation and clinical).
Debriefing Immediately after the simulation experience, the charge nurse (faculty member) who had viewed the simulation facilitated guided reflection to prompt students’ discussion of their performance, potential for improvements, and concepts that could be transferred to clinical practice. Debriefing has been shown to promote reflective thinking and Standards of Best Practice includes guidance for planning debriefing sessions (Decker et al., 2013; Diaz & Nowicki, 2013). Facilitators used personal, empirical, ethical, and reflective questions to lead discussions. Each student participated in reflective journaling following the debriefing session as the final component of the multiple patient leadership simulation. The journals were completed within a week of the simulation experience and submitted via email to the Simulation Learning Coordinator. Samples of questions for debriefing and student reflection assignment are included in Tables 2 and 3 consecutively.
Faculty facilitation The simulation experience used student-led facilitation with faculty members’ role playing in one of three roles: (1) facilitator, (2) nursing care technician, (3)
. How did this experience make you feel?
pre/debrief/charge nurse. As each student was assigned a (faculty) facilitator, the nursing care technician and pre/debrief/charge nurse were shared among the other three to five students and their patients. The facilitator provided patient assessment details by changing the pages of the flip chart for each patient, and minimal verbal cues when prompted by the student, while the role of the patient care technician was to provide the student with opportunities to practice delegation and conflict resolution.
Traditional leadership clinical The traditional Leadership Clinical was comprised of four 12-h shifts completed in inpatient medical–surgical nursing units in local hospitals. The overall purpose was to place emphasis on students’ enhancing skills (organization, time management, delegation, and critical thinking) and teamwork required to deliver quality patient care. Students functioned in roles of the staff nurse for three shifts and charge nurse for one shift. Clinical activities
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T. N. Gore et al.: Teaching Nursing Leadership
such as medication administration, assessments, and other treatments were supervised by the nursing instructor and/or hospital staff nurse. Students were expected to document all care provided. Documentation was reviewed by the clinical instructor and the staff nurse assigned to the patient. Students worked in two teams of four – one charge nurse and three staff nurses for each team. While functioning in the staff nurse role, students assumed care for two to four patients by the end of the clinical rotation. Table 4 demonstrates student responsibilities while in the staff nurse role and the student charge nurse responsibilities are outlined in Table 5.
Data analysis The Statistical Package for Social Science (SPSS) 22.0 was used to analyze the data to determine students’ perception of how well their learning needs were met in the multiple patient simulation and leadership clinical. Exploratory factor analysis (EFA) and internal consistency Cronbach’s alpha were used to validate the construct validity and reliability of the measure in the current study. Demographic information was analyzed via descriptive statistical procedure, whereas data to answer the research questions were analyzed using a series of paired-samples t-tests.
Table 4: AUSON student staff nurse responsibilities for traditional clinical experience. . . . .
Arrive to unit by : am. Receive assignment from your charge nurse. Receive patient report via walking rounds with your nurse and the off going nurse. Check charts for medication and times. Review vital signs and accuchecks a. Your clinical instructor or nurse may pull medications from Pyxis b. You may administer PO meds with your student charge nurse, c. IV medications must be administered with a RN –including flush d. Prior to asking for help with pulling/administering medications, you must know: . the medication and reason for use . allergies . vital signs and blood sugar, and labs (if applicable).
. . . . .
Document nursing assessments, Excellence of Care, and all other care given in the electronic medical record. Notify your hospital nurse immediately if you note a change in your patient. Review documentation of the patient care technicians to ensure completion. If there is an error while documenting – notify your clinical instructor. Keep your charge nurse updated with where you are in your patient care and patient information as it changes and/or is updated. . Before a patient is discharged, inform your student charge nurse.
Table 5: AUSON student charge nurse responsibilities for traditional clinical experience. . .
Arrive to the nursing by : am. Assign student staff nurses after receiving patient work sheets. i. assign patients keeping one student to one hospital nurse. ii. assign lunch times to students.
. . . .
Complete Student Assignment Sheet for hospital nurses and place at the nursing desks. Round on patients. Receive report from your students after they have rounded (may have to find them). Review MARs for medication times – check EMAR throughout the day and end of shift- remind student if something has not been completed. . Throughout the day review students’ documentation/medications/excellence of care and continue to round on students. . Provide assistance to students as needed. . Know patient diagnosis, plan of care, vital signs, accuchecks and other pertinent information. . Keep the clinical instructor updated throughout the shift. . Go with students to give PO medications (IV medications, including flushes, must be done with the staff RN or clinical instructor).
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T. N. Gore et al.: Teaching Nursing Leadership
Results Demographics of the participants were female (92%), Caucasian (96%), and between the ages of 19–25 years old (96%). There were no statistically significant demographic differences between participants who took the traditional clinical environment first and those who took simulated clinical environment first. After EFA with principal component extraction and an oblique rotation, three factors, nursing leadership (18 items), communication (6 items), and teaching–learning dyad (5 items), were obtained from the original 29 items in CLECS. These three factors accounted for 60.10% of variance of the total variance. Table 6 indicates the scores for each CLECS subscale were reliable. Table 6: Reliabilities for each subscale in CLECS (Cronbach’s alpha). Scales
Traditional clinical environment
Simulated clinical environment
.
.
.
.
.
.
.
.
Nursing leadership ( items) Communication ( items) Teaching–learning dyad ( items) Overall scale
Table 7 presents the descriptive information and pairedsamples t-test results for each subscale and the entire scale. Paired-samples t-test results indicated that students perceived their learning needs for communication were better met in the traditional clinical environment rather than the simulated clinical environment when the issues were related to discussing patient’s needs, not communication between team members (t(154) ¼ 4.51, p < 0.001). The effect size Cohen’s d was small to
moderate, d ¼ 0.36. However, students experienced better teaching–learning dyad in simulated clinical environment than in traditional clinical environment with a small effect size (t(154) ¼ 2.89, p ¼ 0.004, d ¼ 0.23).
Discussion It was hypothesized that there would be no difference in perceived learning between simulated and clinical environments. This hypothesis was supported. The students’ overall perceived learning needs were met equally in the simulated and traditional clinical environments. However, communication needs were better met in the traditional clinical environment, and their teaching-learning needs were better met in the simulated clinical environment. The communication needs difference may be explained by considering the use of low-fidelity mannequins with communication expressed as information on flip cards on the mannequins’ bed. This limited the interaction with the patient. The researchers determined the focus of this study was on delegation, prioritization, time management and conflict resolution in order to practice leadership qualities. However, in the traditional clinical, the students communicate and interact with human patients. The teaching–learning needs were better met in the simulated clinical environment more than in the traditional clinical environment. This may be due to the interaction with and the availability of a facilitator during the simulation. One facilitator was assigned and followed each student during the entire simulation allowing the facilitator to understand the student’s thinking and leadership skills. The facilitator provided minimal verbal cues to the student at critical points allowing the student an opportunity to refocus on the tasks and a chance to think out loud. The opportunity to pause, refocus and think out loud is not always possible in the traditional clinical setting during urgent situations. By providing a
Table 7: Descriptive information and paired-samples t-test results for each subscale and CLECS (n ¼ 155). Scales
Nursing leadership Communication Teaching–learning dyad Total
Traditional clinical environment
7
Simulated clinical environment
Paired-samples t-test (df ¼ )
M
SD
M
SD
t
p
d
. . . .
. . . .
. . . .
. . . .
. −. . −.
.
Teresa N. Gore*, Tanya Looney Johnson and Chih-hsuan Wang
Teaching Nursing Leadership: Comparison of Simulation versus Traditional Inpatient Clinical Abstract: Nurse educators claim accountability to ensure their students are prepared to assume leadership responsibilities upon graduation. Although front-line nurse leaders and nurse executives feel new graduates are not adequately prepared to take on basic leadership roles, professional nursing organizations such as the American Nurses Association (ANA) and the Association of Colleges of Nursing (AACN) deem leadership skills are core competencies of new graduate nurses. This study includes comparison of a leadership-focused multi-patient simulation and the traditional leadership clinical experiences in a baccalaureate nursing leadership course. The results of this research show both environments contribute to student learning. There was no statistical difference in the overall score. Students perceived a statistically significant difference in communication with patients in the traditional inpatient environment. However, the students perceived a statistical significant difference in teaching–learning dyad toward simulation. Keywords: nursing leadership, multiple patient simulation, traditional in-patient clinical, senior BSN students DOI 10.1515/ijnes-2014-0054
Introduction In spite of the recognizable need to increase the nursing workforce, simply increasing the volume of nurses is not the answer (American Association of Colleges of Nursing [AACN], 2007). The American Nurses Association (ANA) embraces leadership as a core component in their standards of professional practice with clinical leadership as a key competency for nursing graduates (ANA, 2008). In efforts to accommodate the nation’s demand for nurses, as well as nurse leaders, universities are increasing enrollments in *Corresponding author: Teresa N. Gore, School of Nursing, Auburn University, 137 Miller Hall, Auburn, Alabama 36849, USA, E-mail: [email protected] Tanya Looney Johnson, School of Nursing, Auburn University, 139 Miller Hall, Auburn, Alabama 36849, USA, E-mail: [email protected] Chih-hsuan Wang, Department of Educational Foundations, Leadership, and Technology, Auburn University, Auburn, Alabama, USA, E-mail: [email protected]
their baccalaureate programs. Consequently, the growing enrollment of nursing students presents challenges for academic programs to effectively develop leadership abilities (Abdrbo, 2012). Clinical site demands (Curtis, Vries, & Sheerin, 2011) and increasing student–faculty ratios are problematic issues that may hamper effective leadership preparation of students (Chunta & Edwards, 2013). The AACN recommended nursing students be assessed for nursing leadership behaviors and competency throughout the curriculum. Responses to this recommendation include integrating nursing leadership content throughout the curriculum (Abdrbo, 2012). Some schools’ curricula only offer leadership content in one semester, which allows limited time for students to integrate these skills into clinical practice prior to graduation (Hendricks, Cope, & Harris, 2010). Nursing students may not be prepared to assume leadership roles in their nursing programs, and leadership should not be viewed as an optional competency (Curtis et al.). Health-care organizations and nursing educators recognize the broadening gap between the leadership ability of new graduate nurses as compared to actual clinical practice requirements (Lekan, Corazzini, Gilliss, & Bailey, 2011). The nursing curriculum is an additive program with more concepts and skills being added without removing obsolete practices that are not evidence-based. This can dilute the amount of time dedicated to each concept, without the opportunity for students to apply concepts into their clinical practice (Clapper & Kardong-Edgren, 2012). Hospitals are adamant they are in need of nurses who have acquired proficient clinical skills and leadership abilities. Nursing is central to effective leadership in health care (Lekan et al., 2011). Curtis et al. (2011) found that successful nursing leadership positively influenced patient safety outcomes, staff satisfaction, healthy work environments, and staff. As Curtis and colleagues reported, poor leadership among nursing has no place within organizations that strive for effective change and excellence in patient care. A recent survey demonstrated that only 25% of nurse managers and 10% of nurse executives were favorable toward new graduate preparedness with leadership skill. Unfortunately, new graduates are often placed in charge nurse roles within the first year of practice, creating a mismatch between new graduate educational skill set and employer expectations (Lekan et al.).
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2
T. N. Gore et al.: Teaching Nursing Leadership
It is difficult to connect specific educational activity to achieving competency, especially with an abstract concept such as nursing leadership (Abdrbo, 2012). However, research has shown that simulation is an effective teaching strategy (Aebersold, Tschannen, & Bathish, 2012; Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014; Kilgore, Goodwin, & Harding, 2013; McGrath, Lyng, & Hourican, 2012) for fundamental clinical skills, as well as nursing leadership, delegation, and prioritization skills (Chunta & Edwards, 2013; Thomas, Hodson-Carlton, & Ryan, 2011). Hayden and colleagues determined that simulation is an equitable learning experience for students without negative outcomes in grades and licensure pass rate. Chunta and Edwards provided evidence that multi-patient simulation during the final semester of nursing school provided students with the opportunity to effectively learn organization, prioritization, and delegation skills. McGrath and associates demonstrated effectiveness of simulation with students’ learning by integrating skills, such as critical thinking and decision making with case load management. Nursing leadership simulation has the potential to enhance the students’ leadership abilities, as well as build their self-confidence (Reed, Lancaster, & Musser, 2009). Additionally, simulation poses a safe environment for students to practice their skills with opportunity for immediate feedback and skill refinement (Aebersold et al.). Learner satisfaction is the level of satisfaction that is self-reported by the participants and the facilitators. Studies suggest both participants and facilitators have high levels of satisfaction with simulation as a teaching and learning strategy (Jeffries & Rogers, 2012; O’Donnell, Decker, Howard, Levett-Jones, & Miller, 2014). Lyle (2009) stated health-care providers are less likely to respond appropriately in a timely manner if they lack self-confidence. Simulation is a strategy used to provide participants with an opportunity to practice and build self-confidence (Jeffries & Rogers; O’Donnell et al.). Clinical experience has been recognized as the gold standard to prepare student nurses to critically think, problem-solve (Abdrbo, 2012), and observe and model leadership skills (Curtis et al., 2011). However, a variety of circumstances inhibit student application of learned leadership skills in the clinical setting. Clinical site availability is one of the major challenges for many nursing schools due to competition of increasing enrollment and numbers of nursing programs seeking clinical placement for students (Thomas et al., 2011). In addition, multi-patient assignments are essential for senior-level nursing students to adequately practice leadership concepts, such as delegation, critical thinking, and prioritization. Shorter hospital stays and decreasing opportunities are a constraint for developing
leadership skills in the traditional clinical environment. Due to these types of constraints and obstacles in clinical settings, the traditional inpatient clinical experiences may not offer the opportunity to develop necessary leadership skills (Chunta & Edwards, 2013). Hayden and colleagues (2014) used several tools for evaluation of the longitudinal, randomized, controlled study for replacing clinical hours with simulation in pre-licensure nursing education. One of the tools used was the Clinical Learning Environments Comparison Survey (CLECS; Leighton, 2015) for student perceived learning effectiveness at the end of each clinical course and the completion of curriculum for each group for simulation as clinical time: the control group used 10% simulation (n ¼ 197 traditional; n ¼ 174 simulation), 25% simulation (n ¼ 202) and 50% simulation (n ¼ 187). Hayden and colleagues found that students in the control group (10% simulation) preferred traditional clinical experiences and the 50% simulation group preferred the simulated clinical experiences. The 25% simulation group was in the middle with a tendency for preferring traditional clinical experiences. In this study, also evaluated were student outcomes for licensure pass rate and a 6-month follow-up after graduation. No statistical differences were noted between the groups (Hayden et al.).
Experiential learning theory The theoretical framework underpinning this study was Kolb’s Experiential Learning Theory (ELT, 1984). The ELT is a process of learning with an interactive relationship between the learner and the environment. The major components of ELT include occurrence of a concrete experience, reflective observation of the concrete experience, abstract conceptualization by learning and looking for identifiable patterns from the concrete experience, and active experimentation by applying what has been learned (Decker, Caballero, & McClanahan, 2014). Simulationbased learning is an experiential learning experience by means of providing the concrete experience in the scenario. The reflective observation of the concrete experience occurs in the debriefing session following the simulation. Through this reflection, participants can develop abstract concepts by linking actions and outcomes that can lead the participants to use active experimentation. Through reflection, the participants can gain confidence. During active experimentation participants can implement the concepts into clinical practice (Decker et al.; Kolb). This may lead to an increase in perceived ability to perform in a real-world environment that includes leadership skills.
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T. N. Gore et al.: Teaching Nursing Leadership
Purpose of the study Nurse educators are utilizing simulation more now than ever (Thomas et al., 2011), but there is a dearth of research comparing student perception of the effectiveness of teaching nursing leadership via multi-patient simulation versus the traditional leadership acute-care clinical experiences. The purpose of this study was to explore senior level nursing students’ perceptions of the effectiveness in leadership learning between simulated and traditional clinical environments. The authors hypothesized there will be no difference in perceived learning between simulated and clinical environments.
Methods Study design The descriptive, correlational study was implemented with a convenience sample of students in the leadership class over three semesters. Students’ clinical groups were kept intact from the previous semester. The rationale was that students needed a working knowledge of their team members’ strengths and weakness before performing the role of team leader and making patient assignments in the traditional leadership clinical environment. The clinical groups were also assigned to the same hospital because of the students’ familiarity and proficiency in charting and with hospital policy and procedures. Therefore, randomization did not occur; however, the students had been randomly assigned into clinical groups the previous semester. The order of participants’ engaging in either simulation or traditional clinical first was randomly assigned. Figure 1 shows the group assignments.
Fifth Semester Senior Leadership Course Cohort
Multiple Patient Leadership Clinical (n = 78)
Traditional Inpatient Leadership Clinical (n = 77)
Traditional Inpatient Leadership Clinical (n = 78)
Multiple Patient Leadership Clinical (n = 77)
Complete L-CLECS (n = 155)
Preceptorship (internship)
Figure 1: Study design.
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All students enrolled in the course were required to participate in both the leadership simulation and traditional clinical acute-care experiences on a medical–surgical unit. Institutional Review Board (IRB) approval was obtained prior to the study. Participants were notified of this research and signed an informed consent to participate in the study. Only consenting students’ survey results were used. After students finished both the leadership simulation and traditional clinical experiences, students completed the Leighton CLECS (L-CLECS; Leighton, 2015) prior to beginning their preceptorship/internship.
Setting and participants The participants were fifth clinical semester baccalaureate of science in nursing (BSN) students (n ¼ 155) at a southeastern university and enrolled in a leadership didactic and clinical course. Fifth semester nursing students were selected for this study because they had experience with providing care to one to two patients in the clinical setting, and participated in at least one simulation per semester in all four semesters in their curriculum. The first semester students participated in one simulation day for a 3-h experience; second semester students participated in four simulation scenarios; third semester students participated in one simulation scenario and two interactive computerized case studies; fourth semester students participated in four simulation scenarios and fifth semester students participated in three simulation scenarios, in addition to the leadership simulation. The multiple patient leadership simulation is the students’ only simulation as an individual. Requirements for this course were student participation in leadership simulation conducted in the skills laboratory/ simulation center and 48 h of traditional inpatient nursing experience. The fifth semester leadership courses are: (1) three credit hours for didactic and two credit hours for clinical experiences and (2) two credit hours didactic leadership course. The clinical course includes 90 h of clinical experience with 2 h of simulation for multiple patient scenario and 3 h for the other three scenarios. The simulation policy for this school of nursing states 1 h of simulation is equal to 3 h of traditional clinical experience (Gore & Schuessler, 2013).
Instrument Permission to use the CLECS was obtained from the researcher/developer of the tool. The CLECS is a 29-item self-report survey based on pertinent topics from a
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T. N. Gore et al.: Teaching Nursing Leadership
literature review, and designed to compare how well undergraduate students perceived their learning needs were met in the simulated clinical environment and in the traditional clinical environment. Participants respond to each item using a Likert scale of 1–4, and a not applicable choice (0 ¼ not applicable; 1 ¼ not met; 2 ¼ partially met; 3 ¼ met, and 4 ¼ well met) with total possible scores from 0 to 116 (Leighton, 2015). The scale has been validated with good face and construct validity, and good reliability (Cronbach’s alpha for each subscale ranged from 0.73 to 0.97; Leighton, 2007, 2015). Leighton (2015) provided definitions of these subscales: Self-efficacy is the perceived capability to perform a behavior (Kear, 2000). Teaching–learning dyad is the interactive, collaborative relationship between teacher and student in which both have shared responsibility for the learning that occurs. Holism refers to the five dimensions people have that nurses care for: physiological, psychological, sociocultural, spiritual, and developmental (Neuman & Fawcett, 2011). Communication is verbal and nonverbal interactions between student, faculty, patient, patient’s family or significant others, and members of the health-care team. Interactions may occur between two or more parties. Nursing process is a systematic method of problem solving that is a deliberate, organized, and scientific approach to patient care involving five phases: assessment, nursing diagnosis, plan, implementation, and evaluation (Kozier, Erb, Berman, & Synder, 2004). Critical thinking is “the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion” (critical thinking, n. d., p. 46).
critically think and problem-solve. The venue allowed for up to 20 low-fidelity manikins and a medium-level environmental fidelity with the same number of hospital patient rooms being staged as a medical-surgical nursing unit for up to five nursing students (each student had the same four patients). The simulation experience occurred over a period of one and one half hours and was timed as follows: (1) Pre-brief and handoff shift report (20–25 min), (2) simulation exercise (30–40 min), and (3) debrief (20–25 min). Students were assigned presimulation readings and questions for each patient along with overview and objectives of the simulation. During the course orientation and described in the syllabus, students were informed of the simulation scenario, pre- and post-simulation assignments, and the guidelines of this simulation. Learning objections are defined in Table 1. Table 1: Learning objectives for multiple patient leadership simulation. . Implement effective communication techniques (SBAR [Situation, Background, Assessment, and Recommendation], closed loop communication, and therapeutic) among team members to enhance nursing leadership knowledge and skill. . Utilize time management techniques when caring for a group of patients. . Employ critical thinking, delegation, and prioritization skills into care of patients in simulation. . Assimilate theory and practice to influence actions as a nurse leader in preparation for preceptorship/internship.
Pre-briefing
Multiple patient leadership simulation The purpose of this simulation was to prepare students to care for multiple patients, prioritize, improve critical thinking and delegation, practice time management, and demonstrate leadership skills prior to preceptorship/internship. The multiple patient simulation scenario was a “thinking” simulation with students verbalizing their thought processes without performing all of the psychomotor skills, such as auscultation, vital signs, and charting. The students had to verbalize and request assessment information needed in their decision-making process. Some skills were required, such as calculating the amount of morphine sulfate required for pain management, and the amount of dextrose 50% to be given based on the blood glucose level. These skills were required to demonstrate the ability to
Students were randomly assigned to simulation times based on clinical groups and reported to the simulation center in groups of three to five students. As a group, they were pre-briefed on expectations and received a verbal Situation, Background, Assessment, and Recommendation (SBAR) shift handoff report from the charge nurse (faculty member) on the same four patients: (1) an unresponsive hypoglycemic diabetic patient, (2) a second day post-op hip replacement patient experiencing excruciating pain, (3) an elderly – high fall risk – and hypotensive patient who has voiding urgency, and (4) a patient with pneumococcal pneumonia experiencing respiratory difficulty. Following pre-briefing and shift report, the students were instructed to individually organize a plan to provide care for their group of patients just as they would if they were beginning a clinical shift. Faculty allowed the students five minutes for planning
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T. N. Gore et al.: Teaching Nursing Leadership
since they were familiar with the patients’ history from their pre-simulation exercises. Emphasis was placed on critical thinking with regard to “thinking out loud” versus psychomotor performance. The students were taken to the simulation unit after shift report, oriented to the location of the medications, patients, and introduced to their facilitator and nursing care technician.
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Table 2: Examples of debriefing questions. “How did this scenario make your feel?” “What made you chose the actions/interventions that you chose?” “Discuss your knowledge, skills, attitudes, and previous experiences that provided you the ability to provide evidenced base care to these patients.” “What are the five rights of delegation and which ones did you use?” “Speak to how your personal beliefs and values influenced the care provided to this team.”
Simulation experience
“Which patient should have been seen first and why?”
As the simulation experience began and students attempted to initiate patient assessments and care, a series of interruptions began to occur. Each patient had a flip chart on his/her chest where the facilitator would turn the pages to provide additional information regarding patient assessment and response to interventions. Over the 40 min of the simulation, the students were faced with acutely ill and demanding patients, an argumentative patient care technician (faculty member) while challenged to implement prioritization and delegation, and critically think from a staff nurse’s perspective.
“If you could re-do this scenario now, what would you change and why?” “What is your leadership style and what leadership style did you use today?”
Table 3: Questions on student reflection assignment. . Explain your decisions and interventions during the simulation – particularly what you felt you performed correctly right and what you could have performed better. . How do you think this experience will influence your nursing care in the future? . Based on your learning experience, discuss what you will change or perform differently in the clinical setting during Leadership Clinical and Preceptorship (depending on sequencing of simulation and clinical).
Debriefing Immediately after the simulation experience, the charge nurse (faculty member) who had viewed the simulation facilitated guided reflection to prompt students’ discussion of their performance, potential for improvements, and concepts that could be transferred to clinical practice. Debriefing has been shown to promote reflective thinking and Standards of Best Practice includes guidance for planning debriefing sessions (Decker et al., 2013; Diaz & Nowicki, 2013). Facilitators used personal, empirical, ethical, and reflective questions to lead discussions. Each student participated in reflective journaling following the debriefing session as the final component of the multiple patient leadership simulation. The journals were completed within a week of the simulation experience and submitted via email to the Simulation Learning Coordinator. Samples of questions for debriefing and student reflection assignment are included in Tables 2 and 3 consecutively.
Faculty facilitation The simulation experience used student-led facilitation with faculty members’ role playing in one of three roles: (1) facilitator, (2) nursing care technician, (3)
. How did this experience make you feel?
pre/debrief/charge nurse. As each student was assigned a (faculty) facilitator, the nursing care technician and pre/debrief/charge nurse were shared among the other three to five students and their patients. The facilitator provided patient assessment details by changing the pages of the flip chart for each patient, and minimal verbal cues when prompted by the student, while the role of the patient care technician was to provide the student with opportunities to practice delegation and conflict resolution.
Traditional leadership clinical The traditional Leadership Clinical was comprised of four 12-h shifts completed in inpatient medical–surgical nursing units in local hospitals. The overall purpose was to place emphasis on students’ enhancing skills (organization, time management, delegation, and critical thinking) and teamwork required to deliver quality patient care. Students functioned in roles of the staff nurse for three shifts and charge nurse for one shift. Clinical activities
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T. N. Gore et al.: Teaching Nursing Leadership
such as medication administration, assessments, and other treatments were supervised by the nursing instructor and/or hospital staff nurse. Students were expected to document all care provided. Documentation was reviewed by the clinical instructor and the staff nurse assigned to the patient. Students worked in two teams of four – one charge nurse and three staff nurses for each team. While functioning in the staff nurse role, students assumed care for two to four patients by the end of the clinical rotation. Table 4 demonstrates student responsibilities while in the staff nurse role and the student charge nurse responsibilities are outlined in Table 5.
Data analysis The Statistical Package for Social Science (SPSS) 22.0 was used to analyze the data to determine students’ perception of how well their learning needs were met in the multiple patient simulation and leadership clinical. Exploratory factor analysis (EFA) and internal consistency Cronbach’s alpha were used to validate the construct validity and reliability of the measure in the current study. Demographic information was analyzed via descriptive statistical procedure, whereas data to answer the research questions were analyzed using a series of paired-samples t-tests.
Table 4: AUSON student staff nurse responsibilities for traditional clinical experience. . . . .
Arrive to unit by : am. Receive assignment from your charge nurse. Receive patient report via walking rounds with your nurse and the off going nurse. Check charts for medication and times. Review vital signs and accuchecks a. Your clinical instructor or nurse may pull medications from Pyxis b. You may administer PO meds with your student charge nurse, c. IV medications must be administered with a RN –including flush d. Prior to asking for help with pulling/administering medications, you must know: . the medication and reason for use . allergies . vital signs and blood sugar, and labs (if applicable).
. . . . .
Document nursing assessments, Excellence of Care, and all other care given in the electronic medical record. Notify your hospital nurse immediately if you note a change in your patient. Review documentation of the patient care technicians to ensure completion. If there is an error while documenting – notify your clinical instructor. Keep your charge nurse updated with where you are in your patient care and patient information as it changes and/or is updated. . Before a patient is discharged, inform your student charge nurse.
Table 5: AUSON student charge nurse responsibilities for traditional clinical experience. . .
Arrive to the nursing by : am. Assign student staff nurses after receiving patient work sheets. i. assign patients keeping one student to one hospital nurse. ii. assign lunch times to students.
. . . .
Complete Student Assignment Sheet for hospital nurses and place at the nursing desks. Round on patients. Receive report from your students after they have rounded (may have to find them). Review MARs for medication times – check EMAR throughout the day and end of shift- remind student if something has not been completed. . Throughout the day review students’ documentation/medications/excellence of care and continue to round on students. . Provide assistance to students as needed. . Know patient diagnosis, plan of care, vital signs, accuchecks and other pertinent information. . Keep the clinical instructor updated throughout the shift. . Go with students to give PO medications (IV medications, including flushes, must be done with the staff RN or clinical instructor).
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T. N. Gore et al.: Teaching Nursing Leadership
Results Demographics of the participants were female (92%), Caucasian (96%), and between the ages of 19–25 years old (96%). There were no statistically significant demographic differences between participants who took the traditional clinical environment first and those who took simulated clinical environment first. After EFA with principal component extraction and an oblique rotation, three factors, nursing leadership (18 items), communication (6 items), and teaching–learning dyad (5 items), were obtained from the original 29 items in CLECS. These three factors accounted for 60.10% of variance of the total variance. Table 6 indicates the scores for each CLECS subscale were reliable. Table 6: Reliabilities for each subscale in CLECS (Cronbach’s alpha). Scales
Traditional clinical environment
Simulated clinical environment
.
.
.
.
.
.
.
.
Nursing leadership ( items) Communication ( items) Teaching–learning dyad ( items) Overall scale
Table 7 presents the descriptive information and pairedsamples t-test results for each subscale and the entire scale. Paired-samples t-test results indicated that students perceived their learning needs for communication were better met in the traditional clinical environment rather than the simulated clinical environment when the issues were related to discussing patient’s needs, not communication between team members (t(154) ¼ 4.51, p < 0.001). The effect size Cohen’s d was small to
moderate, d ¼ 0.36. However, students experienced better teaching–learning dyad in simulated clinical environment than in traditional clinical environment with a small effect size (t(154) ¼ 2.89, p ¼ 0.004, d ¼ 0.23).
Discussion It was hypothesized that there would be no difference in perceived learning between simulated and clinical environments. This hypothesis was supported. The students’ overall perceived learning needs were met equally in the simulated and traditional clinical environments. However, communication needs were better met in the traditional clinical environment, and their teaching-learning needs were better met in the simulated clinical environment. The communication needs difference may be explained by considering the use of low-fidelity mannequins with communication expressed as information on flip cards on the mannequins’ bed. This limited the interaction with the patient. The researchers determined the focus of this study was on delegation, prioritization, time management and conflict resolution in order to practice leadership qualities. However, in the traditional clinical, the students communicate and interact with human patients. The teaching–learning needs were better met in the simulated clinical environment more than in the traditional clinical environment. This may be due to the interaction with and the availability of a facilitator during the simulation. One facilitator was assigned and followed each student during the entire simulation allowing the facilitator to understand the student’s thinking and leadership skills. The facilitator provided minimal verbal cues to the student at critical points allowing the student an opportunity to refocus on the tasks and a chance to think out loud. The opportunity to pause, refocus and think out loud is not always possible in the traditional clinical setting during urgent situations. By providing a
Table 7: Descriptive information and paired-samples t-test results for each subscale and CLECS (n ¼ 155). Scales
Nursing leadership Communication Teaching–learning dyad Total
Traditional clinical environment
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Simulated clinical environment
Paired-samples t-test (df ¼ )
M
SD
M
SD
t
p
d
. . . .
. . . .
. . . .
. . . .
. −. . −.
.
