COLLABORATIVE SOLUTIONS: IMPLEMENTING INNOVATIVE STRATEGIES

Texas Board of Nursing Innovative Professional Education Pilot Programs Robbin Wilson, MSN, RN Nursing Education Consultant Texas Board of Nursing

Historical Background Texas Nurses Association Redesign of Nursing Education Task Force Texas Higher Education Coordinating Board Nursing Innovation Grant Program

Texas Nursing Practice Act Statutory Authority for Pilot Programs Patient Safety Pilot Program – University of Texas M.D. Anderson Cancer Center Texas Board of Nursing Rules Freedom in Existing Rules for Innovation Waivers for Existing Rules New Rules

Pilot Programs

Request for Proposals Midwestern State University Partnerships Regional Interdisciplinary Simulation Center BSN-prepared Utilized as Lab Mentors Request for Applications Victoria College BSN-prepared Nurses Utilized as Certified Clinical Instructors (CCIs) Must Complete 7 Specified Graduate Hours in Nursing Education

Legislative Actions

Sunset Review Issues/Recommendations Passage of Texas House Bill 2426 Revised the Texas Nursing Practice Act Renamed the Board of Nurse Examiners as the Texas Board of Nursing; and

Collaborate with Nursing Educators Texas Higher Education Coordinating Board Texas Health Care Policy Council Implement, Monitor, & Evaluate a Statewide Plan for Creation of Innovative Nursing Education Models Promote Increased Enrollments in Texas Nursing Programs Address Nursing Shortage Mandated that the Texas Board of Nursing:

What comes next? Encourage Nursing Programs to Increase Enrollment/Retention/Graduation Consultant Expertise & Assistance Website Showcase Workshops Suggest Models Clearinghouse Research Findings Evaluate Enrollment, Retention & Graduation Rates NCLEX Examination Pass Rates

Collaborative Solutions: An Example Susan Sportsman, RN, Ph.D. Dean, College of Health Sciences and Human Services

North Central Texas Health Care Consortium Midwestern State University (MSU) Vernon College (VC) United Regional Health Care System (350 bed regional hospital) (URHCS) $1.27 million grant to develop a regional simulation center

Primary Purpose of the RSC: To Increase admissions to Nursing Programs Goal: Increase admission at MSU and VC by 56 over grant period. Outcome: Increased admissions of the two schools by 57 MSU 41 (77 additional) VC 16

Structure of Regional Simulation Center (RSC) 3,410 square feet renovated nursing unit at URHCS 7 high fidelity patient simulators (4 adults and 3 infants/child manikins) 4 clinically strong BSN lab mentors, supervised by a MSN director Responsible for providing competency education and validation to BSN, ADN, and hospital clinicians.

Relationship between Faculty and Lab Mentors Faculty developed/approved scenario template Faculty developed learning objectives for all simulations consistent with course objectives Faculty & Lab mentors developed/revised simulation scenarios Lab mentors implemented learning activities Lab mentors communicated to faculty student progress

Opened January, 2005, providing scenario-based high fidelity patient simulation for competency education/validation Opportunity for students to integrate clinical decision-making into the development of psychomotor skills Clinical scenarios as the basis for learning. As students progress in the curriculum, scenarios become more complex

Student Schedules MSU and VC course coordinators work with RSC Director each semester to schedule student time, according to course objectives. Blocks of time assigned to each course prior to the beginning of the semester. Students are allowed to sign up in class for their Sims experience at times convenient to them, as long as it falls in the appropriate class block. Once schedule is made, students must call the RSC secretary to make changes to their schedule.

Student Learning Process Scheduled blocks of time typically during the students expected clinical day. The first week of class and finals week avoided. Students not allowed to sign up for sims time during regularly scheduled classes. RSC staff blocks out additional times during the semester for make-up times

Substitution of RSC for Some Clinical Hours Examples of MSU clinical experience assignments in the RSC: Health Assessment-100% of clinical experience Fundamentals:50% Med-Surg courses: 25% Pedi; OB:10-14%

Outcomes of the 32-Month Grant 20,074 duplicated learner visits 13,444-MSU 4,042 VC 2,688 URHCS 44,963 duplicated learner hours 34,116 MSU 7742 VC 3,105 URHCS 900 members of URHCS Clinical Staff participated in annual competency validation through the RSC

What impact does the use of the RSC have on the quality of the education for the nurse? RSC Allows More Students to be Admitted

Research Question What is the impact of participation in scenario-based simulation throughout their course of study on students sense of clinical competence, anxiety, and satisfaction with clinical learning environment, as well as GPA and HESI-E2 exit exam scores?

Development of a Model to Explain/Predict Factors which Influence Clinical Competency in New Graduates

Three Year Data Collection Process January 2005, 2006, & 2007: Juniors April 2005,2006 & 2007: Seniors 2005 Seniors-Little or no simulation experience 2005 Juniors/2006 seniors-3 semesters of simulation experience 2006 Juniors/2007 seniors-5 semesters of simulation experience

Data Collection Clinical Competence Appraisal Scale (PSP, Leadership, Teaching/Collaboration, Interpersonal Relations/Communication, Planning/Evaluation) LASSI (Motivation, Attitude, Concentration, Anxiety) PSVIII-R (Hardiness) Clinical Learning Environment Demographic Data Sheet GPA Scores on HESI d

Demographics: Significant Difference A large majority of the respondents in both schools were between the ages of 19 and 39 years of age MSU students younger than VC

Comparison of Previous and Current Health Care Experience by Schools Variable SchoolNMeanSt.D.fDfp Previous Health Care Experience VC MSU Current Health Care Experience VC MSU

Comparison Among Years – Juniors 2005 juniors (no simulation experience before completing the CCAS) rated their competence in psychomotor skills performance significantly higher (p=.0001) than juniors in 2006 and 2007 (participated in simulation before they responded to the CCAS). Participating in simulation early in their clinical experience may provide a dose of realism for students in their clinical courses.

Comparison Across Years - Seniors No significant difference in mean score of the PSP, teaching/collaboration, planning/evaluation or interpersonal relations/communications subscales among the three groups of seniors in the study. Substituting clinical experience in the RSC for a portion of the time required in clinical agencies does not make a difference in students perception of their clinical competence. Argues for the substitution of simulation experience for some clinical experiences as a strategy for increasing student admissions when there are limited clinical experiences available to schools.

Only CCAS subscale for which there was significant difference in the mean scores of the seniors =Leadership subscale. The 2005 Seniors (little or no experience in the RSC) perceived themselves to be less competent in leadership skills than the 2006 and 2007 Seniors (participated in simulation). During the teaching scenarios, small groups of students worked together to provide care in the simulation. Students played various roles during these experiences, including charge nurse, recorder, family member, and/or primary nurse. Perhaps this opportunity to role play enhanced students sense of their competence in leadership activities.

Comparison by Year (LASSI) NO significant difference among mean scores on the attitude, concentration and motivation subscales of the LASSI in the three groups of seniors. The higher the mean score on the LASSI subscale, the lower the level of anxiety: 2005 seniors had significantly less anxiety than the seniors in 2006 and seniors had a significantly higher mean anxiety score (p=.015) than the seniors in 2006 and 2007 did, although the 2007 mean score rose above the 2006 score. Increased participation in simulation experiences may have contributed to the increase in the 2006 and 2007 senior students anxiety.

Comparison by Year: Clinical Learning Environment The mean scores on the CLE Scale for the 2005 seniors were significantly lower than the mean scores for seniors in 2006 and Simulation may positively influence students perceptions of the clinical environment where they are assigned during the last semester of their course of study.

Comparison among Years: Graduating GPA & HESI E2 Exit Exam No significant difference in graduating GPA or HESI E2 Exit Exam for seniors in 2005, 2006 and Participation in scenario-based simulation does not negatively impact the students performance on the HESI exam, the results of which is highly correlated with success on the NCLEX-RN licensing exam (Morrison, et. al, 2004).

Positive Factors Negative Factors Competence in Nursing Role Lack of Competence in Nursing Role Effect of RSC Mimics the real world. Too many scenarios assigned Critical thinkingTechnical skillsMakes you realize you know more than you think you do Provides collaboration opportunities. Lack of realism in some scenarios Ability to plan patient care Caring for multiple patients Emphasis on the processes of care Provides connection between class and clinical experience Frustrating virtual IV Organizational Skills Delegation Provides opportunity for safe mistakes Putting it all together Qualitative Evaluation: Focus Groups

Hardiness (HRD) Student Effort (SEFFT) Clinical Learning Environment (CLE) Grade Point Average (GPA) Clinical Competence (CCAS) Model of Factors Influencing New Graduate Competence