The heart and science of medicine.

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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.

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UVMHealth.org/CVPH

The development of an experiential and simulation based orientation.

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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

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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

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Blooms Taxonomy

7 Diagram retrieved from www.laerdal.com/.../13/indianapolis/zigmont_objectives_outcomes.ppt on October 25, 2015

Learning Outcomes Model

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

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•Well-Tuned Learning

Orientation

•Mental Models

•Analogical

Reasoning

Experiences

•Challenging

•Emotionally Charged

•Mistakes or Errors

Environment

•Skilled Mentors

•Evidence Based Medicine

•Products and Protocols

Improved

Patient

Outcomes

Learning Outcomes Model

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

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•Individualized online

competency based

orientation, electronic

CBO

•Experiential

Learning/MBTI

Experiences

•Five days of skills and

scenarios

•Focus on the what

and how

•Critical Care Course

Environment

•Preceptor Class

•Policies and Protocols

•Unit Based Changes

Improved

Patient

Outcomes

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

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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

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• 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

Essential Practice Elements

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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.

• 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.

Simulations

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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

Welcome

Patient Advocate

Program

Patient Centered

Care/AIDET

Communication –

Team STEPPS

Infection Control

The Perception

Experience

1230-1pm

Lunch

1-430

Safe Patient Handling

& Mobility Program

Clinical Staff

8-1pm

Striving for Excellence

Dietary Presentation

Who Am I? Tips for

Being a Successful

Preceptee

PUPS/Wound Ostomy

Hourly Rounding &

Simulation

HR Check-In

1-230pm

RN/CA Documentation

230-430pm

CA’s EKG

Class/Phlebotomy

230-430pm

MAK/Order Entry

Clinical Staff

8-1230

RN Documentation/Care

Plan/Order Entry

1230-1630

Skill Sessions &

Simulations

Clinical Staff

8-1630

Pharmacy

Presentation

Skill Sessions &

Simulations

Transfusion Education

Code 99/Rapid

Response

Policy Review

HealthStream

Clinical Staff

8-1630

Peripheral IV Therapy

Central Line Blood

Draws

TPA Competency

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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.

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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.

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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.

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The heart and science of medicine.

UVMHealth.org/CVPH

How increased Clinical Education Manager time on clinical units strengthens orientation for registered nurses.

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UVMHealth.org/CVPH

Clinical units orientation

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

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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)

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What did we do?

• Preceptor workshop

• Critical Care Course

• Electronic Clinical Based Orientation (CBO) document

• Schedules

• Unit presence of Clinical Education Managers

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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

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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

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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.

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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.

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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

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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

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Our Data

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• 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

2013-2014 New Graduate Nurses

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7.18 8.12 10.05

11.75

0

5

10

15

2013 2014

Med/Surg

Critical Care

2015 New Graduate Nurses

• 2015

– 16 Med/Surg Nurses

• Average 5.46 Weeks

– 14 Critical Care Nurses

• Average 8.75 Weeks

31 .

7.18 8.12 5.46

10.05 11.74

8.75

0

5

10

15

2013 2014 2015

Med/Surg

Critical Care

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

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Orientation Cost in $$

7812

9010

6178

11424

13027

9901

0

2000

4000

6000

8000

10000

12000

14000

2013 2014 2015

Med/Surg

Critical Care

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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.

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Retention

• As of October 29, 2015, all Graduate Nurses hired are

currently still employed at UVHN-CVPH.

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Questions

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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.

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