The heart and science of medicine. UVMHealth.org/CVPH Evaluation of an Experiential Learning and Simulation Based Clinical Orientation at UVMHN-CVPH Tracy Coleman, RN, BS, BSN, Stephanie Drown, RN, BS, BSN, Med, CMSRN, Carlyn Haag, RN, BSN, CCRN, Rachael Hite, RN, BA, OCN, CHPN, CMSRN, Cathy Patnode, RN, BSN, CCRN, Karen Phillips, RN, BSN, MSN, CMSRN
Objectives Discuss the development of an experiential and simulation based orientation. Discuss how increased Clinical Education Manager time on clinical units strengthens orientation for registered nurses. 2
UVMHealth.org/CVPH The development of an experiential and simulation based orientation. 3
Purpose of Study To strengthen the orientation for all Registered Nurses (RN s) hired at UVHN-CVPH through the utilization of experiential learning, simulated clinical orientation experiences and increased Clinical Education Manager time on the units.
Our Journey 5
Rationale and Significance JumpStart Program Jason Zigmont, PhD, CHSE-A 2 years of work in development of program First pilot included 153 RN s New and experienced RN s had over a 3 1/2 week reduction in orientation time. Gross savings of $702,270. Zigmont, J. J.; Wade, A., Edwards, T., Hayes, K., Mitchell, J., Oocumma, N. (2015). Utilization of Experiential Learning, The Learning Outcomes Model Reduces RN Orientation Time by More than 35%. Clinical Simulation in Nursing, 11, 79-94. http://dx.doi.org/10.1016/j.ecns.2014.11.001 6
Blooms Taxonomy Diagram retrieved from www.laerdal.com/.../13/indianapolis/zigmont_objectives_outcomes.ppt on October 25, 2015 7
Learning Outcomes Model Well-Tuned Learning Orientation Mental Models Analogical Reasoning Improved Patient Outcomes Experiences Challenging Emotionally Charged Mistakes or Errors Skilled Mentors Evidence Based Medicine Products and Protocols Environment Zigmont, J. J., Kappus, L., Sudikoff, S. N., (2011a). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47-51. Diagram retrieved from www.laerdal.com/.../13/indianapolis/zigmont_objectives_outcomes.ppt on October 25, 2015 8
Learning Outcomes Model Individualized online competency based orientation, electronic CBO Experiential Learning/MBTI Improved Patient Outcomes Preceptor Class Policies and Protocols Unit Based Changes Environment Experiences Five days of skills and scenarios Focus on the what and how Critical Care Course Zigmont, J. J., Kappus, L., Sudikoff, S. N., (2011a). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47-51. Diagram retrieved from www.laerdal.com/.../13/indianapolis/zigmont_objectives_outcomes.ppt on October 25, 2015 9
JumpStart/UVHN CVPH Orientation Experienced and new graduate nurses Small groups (maximum of 7 students to 1 facilitator) UVHN-CVPH maximum of 4-5 students to 1 facilitator, ideal is 2-3 students. Experiential Learning Based Program Individual assessed at mid-point and end of their orientation UVHN-CVPH consistent regular weekly meetings with Shared Mental Model Use of 3D Model of Defusing, Discovering, Deepening for Debriefing UVHN-CVPH mixture of + Delta, Good Judgement, 3D 10
What did we want to accomplish? Provide a smoother transition into the workplace Improve graduate nurses' work ready skills and attributes Focus on teamwork and communication skills Clinical competence Relationship building 11
Essential Practice Elements JumpStart Rhythm Recognition Oxygen Therapy Waive test Clinical Applications IV Pumps Peripheral IV Med Administration Blood Administration Safe Patient Handling Restraints Defibrillation Central Line Dressings/Blood Draw UVHN-CVPH Peripheral IV Therapy Oxygen Therapy Waive Test Clinical Applications IV Pumps MAK Blood Administration Safe Patient Handling Central Line Blood Draw/TPA Administration Pain Identification Pressure Ulcer Prevention Ostomy/Wound Care Sepsis Fall Equipment Hypoglycemia Treatments Foley Care Central Line Care and Maintenance Zigmont, J., Cavalieri, A., Edwards, T., Rees, T., Wade, A. (2015). Create a Simulation-enhanced RN Orientation Program. 4 hour Pre-conference course at the International Meeting for Simulation in Healthcare, New Orleans, Louisiana, January 11, 2015. 12
Simulations JumpStart CHF Find the Wound STEMI IDDM Fall Pre-op Preparation/Sepsis End of Life Stroke Clinical Institute Withdrawal Assessment Central Line UVHN-CVPH Hourly Rounding Hypoglycemia Falls Sepsis Pain and PUPS Zigmont, J., Cavalieri, A., Edwards, T., Rees, T., Wade, A. (2015). Create a Simulation-enhanced RN Orientation Program. 4 hour Pre-conference course at the International Meeting for Simulation in Healthcare, New Orleans, Louisiana, January 11, 2015. 13
UVHN-CVPH 2015 Clinical Orientation June December 2015 General Orientation Day 2 Clinical Orientation Day 1 Clinical Orientation Day 2 Clinical Orientation Day 3 Clinical Orientation Day 4 Clinical Orientation Day 5 CPR & Waive Test Competencies 12-2pm Clinical & Non-Clinical Staff 8-1pm Clinical Staff 8-1pm Clinical Staff 8-1230 Clinical Staff 8-1630 Clinical Staff 8-1630 Welcome Patient Advocate Program Patient Centered Care/AIDET Communication Team STEPPS Infection Control The Perception Experience Striving for Excellence Dietary Presentation Who Am I? Tips for Being a Successful Preceptee PUPS/Wound Ostomy Hourly Rounding & Simulation HR Check-In RN Documentation/Care Plan/Order Entry 1230-1630 Skill Sessions & Simulations Pharmacy Presentation Skill Sessions & Simulations Transfusion Education Code 99/Rapid Response Policy Review HealthStream Peripheral IV Therapy Central Line Blood Draws TPA Competency 1230-1pm Lunch 1-430 Safe Patient Handling & Mobility Program 1-230pm RN/CA Documentation 230-430pm CA s EKG Class/Phlebotomy 230-430pm MAK/Order Entry 14
Staff Satisfaction Descriptive evaluations were distributed to participants on the simulations days to get immediate feedback. Take extra care in checking the events when the patient fell. Follow protocol for different fall levels. Make sure Star is up for high risk. I will advocate for my patients and stop the pain! And follow protocol. I will look for signs of sepsis and use the protocol. Ensure SBAR model is followed. Rely more on protocols and keep them with me. I found the protocols very helpful, and it s great to know I can pull them up as a reference. I will always remember to look down to the next step to see if it applies to the situation. 15
Staff Satisfaction Descriptive evaluations were given after orientation was complete. Thirteen evaluations were distributed, nice were completed and returned from the first group. Favorable emphasis on learning Pain, Pressure Ulcer Prevention, Falls, Sepsis and Hypoglycemia Protocols, assessment, document standards, and equipment. An average overall score of 4.2 (1-5 Likert scale) demonstrated how participants felt the simulations/skills helped them care for patients. 16
Lessons Learned Orientation binders with policies were a huge success. With large groups it is okay to have simulations before skills sessions. Schedule more time between the skills sessions and simulations for instructor debriefing and setting up for next group. Coordinate distribution of the Clinical Simulation Evaluations prior to the end of their orientation. 17
The heart and science of medicine. UVMHealth.org/CVPH How increased Clinical Education Manager time on clinical units strengthens orientation for registered nurses. 18
Clinical units orientation UVMHealth.org/CVPH
2015 New Graduate Nurses 16 Med/Surg 10 night shift 6 evening shift 10 resource pool 2 R5 2 R6 2 R7 14 Critical Care 6 night shift 7 evening shift 1 day shift 8 progressive care 6 short stay unit. 20
What did we know? Graduate nurses experience significant stress: professional role adjustment and adaptation difficulty managing the social and work environment role conflict..student vs registered nurse perceptions of a lack of clinical competence (Ramritu and Barnard, 2001) 21
What did we do? Preceptor workshop Critical Care Course Electronic Clinical Based Orientation (CBO) document Schedules Unit presence of Clinical Education Managers 22
Preceptor Workshop Began in 2015 for all disciplines Focuses on: Sustaining Safe Practice Engaging Communication & Diversity Developing Performance & Critical Thinking Experiences in Precepting: Coaching & Conflict Management 23
Critical Care Course 5 days, total of forty hours Scheduled during the middle to end of orientation Days divided by topics/systems Topics Covered Cardiac (MI, Post-PCI care, HF), Respiratory (COPD, ARF, etc), Multisystem (Severe Sepsis), Endocrine (DKA, Hyperglycemia), Renal (Renal Failure, Dialysis), Gastrointestinal (Pancreatitis, Cirrhosis), ETOH withdrawal, Neurologic(Stroke Recognition and Intervention), Patient Safety/TeamSTEPPS Included a total of 6 simulations Chest Pain/Heart Failure exacerbation Respiratory Distress/Chest Tube troubleshooting Sepsis Recognition/Sepsis Intervention with transfer to HLOC Included skills testing and case scenarios Arterial Puncture (ABG Collection) Chest Tube Set-up/Troubleshooting Groin Management (Femostop/TR-Band) Insulin Drip Management Case Scenarios CIWA Scoring Case Scenarios Staff content experts guest lectured during each topic Diabetic Educator, Respiratory Therapist, Pharmacist, Progressive Care RN, ICU RN, Dialysis RN 24
Electronic CBO Document Historically, paper document was 18 pages long (front and back). Required preceptors to fill out and sign before end of orientation. Electronic version Flipped the focus from preceptor ownership to orient ownership. Working document. 25
Schedules 2013/2014 Nurse Residency survey results. Orientations begin on hired shifts Limited off the unit classes. Telemetry class scheduled once off orientation. Exception: Critical Care orients received 3 day telemetry class prior to coming off orientation. Resource pool orienting with resource pool preceptors. 26
Educators Presence on Clinical Units Weekly schedule of clinical time for orients Shoulder-to-shoulder support Real-time learning opportunities Frequent preceptor/orient meetings Build relationships 27
Lessons Learned Preceptor guidance and education Expanding instructional time between CEMs and preceptors prior to the new GN s orientation. Formalize a system for preceptor knowledge of new GN s education and work history. Resource pool preceptors and scheduling Scheduling new Resource Pool GNs with a Resource Pool preceptor and following their schedule. Increasing our preceptor pool to decrease burnout Preparing unit staff for the influx of new nurses during the prime GN season (June-Aug) Looking at knowledge gaps and competency completion 28
UVMHealth.org/CVPH Our Data 29
2013-2014 New Graduate Nurses 2013 15 Med/Surg Nurses Average 7.18 Weeks 15 Critical Care Nurses Average 10.05 Weeks 2014 1 Med/Surg Nurse Average 8.12 Weeks 4 Critical Care Nurses Average 11.74 Weeks 15 11.75 10 10.05 7.18 8.12 Med/Surg 5 Critical Care 0 2013 2014 30
2015 New Graduate Nurses 2015 16 Med/Surg Nurses Average 5.46 Weeks 14 Critical Care Nurses Average 8.75 Weeks 15 10 5 10.05 7.18 11.74 8.12 8.75 5.46 Med/Surg Critical Care 0 2013 2014 2015. 31
Estimated Cost Savings 2013 Cost for Orientation 15 Med/Surg RN s at 7.18 weeks = 287.2 hours 15 Critical Care RN s at 10.5 weeks = 420 hours 2014 Cost for Orientation 1 Med/Surg RN at 8.12 weeks = 324.8 hours 4 Critical Care RN s at 11.74 weeks = 469.6 hours 2015 Cost for Orientation 15 Med/Surg RN s at 5.46 weeks at 218.4 hours 13 Critical Care RN s at 8.75 weeks at 350 hours 32
Orientation Cost in $$ 14000 12000 11424 13027 10000 8000 6000 7812 9010 9901 6178 Med/Surg Critical Care 4000 2000 0 2013 2014 2015 33
Outcome The utilization of: Preceptor classes Feedback from previous Nurse Residency Classes Experiential learning, skills training, and simulations Increased educator time on the units Has helped to strengthened the orientation of graduate nurses and decrease overall orientation time at UVHN- CVPH. 34
Retention As of October 29, 2015, all Graduate Nurses hired are currently still employed at UVHN-CVPH. 35
UVMHealth.org/CVPH Questions 36
References Ramritu, P., & Barnard, A. (2001). New nurse graduates' understanding of competence. International Nursing Review, 48, 47 57. Zigmont, J., Cavalieri, A., Edwards, T., Rees, T., Wade, A. (2015). Create a Simulation-enhanced RN Orientation Program. 4 hour Pre-conference course at the International Meeting for Simulation in Healthcare, New Orleans, Louisiana, January 11, 2015. Zigmont, J. J.; Wade, A., Edwards, T., Hayes, K., Mitchell, J., Oocumma, N. (2015). Utilization of Experiential Learning, The Learning Outcomes Model Reduces RN Orientation Time by More than 35%. Clinical Simulation in Nursing, 11, 79-94. Zigmont, J. J., Kappus, L., Sudikoff, S. N., (2011b). The 3D model of debriefing: Defusing, discovering, and deepening. Seminars in Perinatology, 35(2), 52-58. Zigmont, J. J., Kappus, L., Sudikoff, S. N., (2011a). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35(2), 47-5. 37