Simulation in New York State Nursing Education

memorandum

 

TO:	Regent Wade Norwood
FROM:	Jeanine Santelli, PhD, RN, AGPCNP-BC, FAAN, Executive Director, ANA-NY in collaboration with the New York State Council of Deans
DATE:	January 31, 2020
RE:	Simulation in New York State Nursing Education

OVERVIEW

Nurse educators across New York State are facing challenges in finding quality, hands-on clinical experiences for nursing students. Clinical experiences are critical in nursing education. These experiences provide opportunities for students to assess, diagnose, plan, implement, and evaluate nursing care in a variety of practice settings. Unfortunately, in the current clinical environment, student experiences are being limited in most health care settings. Faculty report that the numbers of students allowed on specialty units are shrinking and the allowable activities are being restricted (i.e., starting IVs, taking blood sugar readings, passing medications, documenting in the health care record).  It has even been reported that some settings are only allowing observation with no direct patient contact. 

The key to any nursing education program is direct patient contact and direct practice and experience treating a patient.  However, with these new limitations that have arisen, faculty are forced to seek alternative settings to provide high-quality clinical experiences.  Additionally, enrollment numbers in nursing education programs across the state are being limited based on the availability of clinical placements. As these challenges continue to escalate, we must explore the appropriate role of simulation scenarios.

 SIMULATION EXERCISES EXPLAINED

            Simulation exercises are scenarios that unfold in ways that are not always known or predictable to the learner. They can be conducted on mannequins or virtually, on a computer. Simulation provides realistic, context-rich experiential learning in a safe environment. Students can be involved in critical situations that they would be removed from in actual clinical settings for patient safety, such as a postpartum hemorrhage, prolapsed cord, cardiac arrest, or diabetic emergency. Students can also directly experience the results of their decisions when in a simulation setting; whereas, indirect care clinical settings, students are not allowed to make bad/harmful decisions. An important part of any educational program is training the student on what happens when bad/harmful decisions are made, and this cannot be done on actual patients, but it can be effectively done in simulation.           

CURRENT ENVIRONMENT

     NYSED allows simulation as a supplement to nursing education only to replace laboratory experiences. Low fidelity, hybrid, standardized patients, and role-play have been successfully used to enhance laboratory experiences as students familiarize themselves with professional roles and technical skills. However, the current regulations do not allow for medium and high-fidelity simulations to count towards anything other than laboratory experiences. Programs “can’t replace clinical with simulation” (report by Renee Gescedi, Associate in Nursing Education, NYSED, January 15, 2020).

 ARGUMENTS FOR REGULATORY CHANGES

      As external pressures are limiting student clinical experiences, we must look to how medium and high-fidelity simulation scenarios can help fill this clinical void.  It is mutually agreed that simulation is not a replacement for all direct patient care; however, clinical simulation provides opportunities for students to develop their professional skills and critical thinking abilities.  This has been proven in numerous studies.  For example, one study found that simulation exercises allow students to “develop effective non-technical skills, practice rare emergency situations, and [provide] a variety of authentic life-threatening situations” (Kim, Park, & Shin, 2016) without compromising the patient’s well-being (Sanford, 2010).

      While some may argue that simulation exercises are not the same as direct care clinical experiences, it is important to note that it has always been the quality of an experience that dictates what the student learns.  We know that the quality of the simulation experience from student preparation and scenario through debrief is critical to the value of the experience (Alinier, Hunt, & Gordon, n.d.).  However, this same statement also applies to direct care clinical settings. “Experts agree that it is not the number of hours, but the quality of the experience. If students are going to be placed in clinical settings where there is inadequate opportunity for hands-on experience, employment of simulation by capable faculty with meaningful debriefing may offer a better alternative” (NCSBN, 2020). If a student is only allowed to observe in a clinical setting, or their ability to provide care is limited to assistance in activities of daily living, the clinical hours are merely “time served” and a higher quality educational experience would be provided in a simulation environment.

 Following the 2014 landmark study conducted by the National Council of State Boards of Nursing (NCSBN), that demonstrated that up to 50% of clinical in simulation has the same outcomes as in the clinical environment, more than half of Boards of Nursing reported having regulations to address the use of simulation (Bradley, et al, 2019). Several state boards for nursing allow up to 25% of clinical time to be simulation-based experiences (Jeffries, 2009). This blend of clinical practice opportunities provides the opportunity for students to develop their professional skills and critical thinking abilities. Use of simulation scenarios provide clinical practice experience thus preparing students to function at a higher level.  This level of preparation results in the students providing better care and having a richer experience in the limited time that they are able to provide direct patient care in a traditional clinical setting.

 RECOMMENDATION

      It is very important to keep in mind that nursing programs vary in their preparation of nursing professionals. A one-size-fits-all approach is neither safe nor appropriate. We are requesting that the NYSED regulatory guidelines, based on the best evidence, allow up to 25% of traditional clinical experiences to be replaced by simulation in programs in good standing with sufficient direct care clinical hours. Programs should also be held to the following NCSBN (2020) criteria:

1. Overall number of clinical hours required by the program
2. NCLEX-RN pass rates of students
3. Availability of clinical sites
4. Turnover of faculty/program director
5. Complaints from students
6. Retention rates

      Additional guidelines to consider were developed by an expert panel consisting of representatives from the International Nursing Association for Clinical Simulation and Learning (INACSL), American Association for Colleges of Nursing (AACN), National League for Nursing (NLN), Society for Simulation in Healthcare (SSH), Boards of Nursing, and NCSBN. An extensive literature review was conducted by this group, which laid the basis for the following guidelines:

1. There is a commitment on the part of the school for the simulation program
2. The program has appropriate facilities for conducting simulation
3. The program has the educational and technological resources and equipment to meet the intended objectives
4. The program has lead faculty and sim lab personnel who are qualified to conduct simulation
5. Faculty are prepared to lead simulations
6. The program has an understanding of policies and processes that are a part of the simulation experiences.

 

     We believe that this percentage, combined with these objective criteria, will allow for a better quality education for nursing students in New York State and will better prepare them for practice when they graduate and begin working in direct care. 

  REFERENCES

           Below is a list of references that support our position and arguments.

 

Alinier, G., Hunt, W.B., & Gordon, R. (n.d.). Determining the value of simulation in nursing education: Study design and initial results. Retrieved from https://uhra.herts.ac.uk/bitstream/handle/2299/392/103692?sequence=1

Bradley, C. S., Johnson, B. K., Dreifuerst, K. T., White, P., Conde, S. K., Meakim, C. H., Curry-Lourenco, K., & Childress, R. M. (2019, August). Regulation of simulation use in united states prelicensure nursing programs. Clinical Simulation in Nursing, 33(C), 17-25.

Hayden, J.K., Alexander, M., Karlong-Edgren, Jeffries, P.R. (2014). The NCSBN national simulation survey: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2 Supplement July 14), S3-S64. (https://www.ncsbn.org/JNR_Simulation_Supplement.pdf)

INACSL Simulation Regulations Committee. (2019, October) INACSL Simulation Regulation Map. Retrieved from https://www.inacsl.org/simulation-regulations/

Jeffries, P. R. (2009). Dreams for the future of clinical simulation. Nursing Education Perspectives, 30(2), 71.

Kim, J., Park, J-H., & Shin, S. (2016). Effectiveness of simulation-based nursing education depending on fidelity: A meta-analysis. BMC Medical Education, 16, 152. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877810

National Council State Boards of Nursing (NCSBN). (2020). National simulation guidelines for prelicensure nursing programs. Retrieved from https://www.ncsbn.org/9535.htm

Sanford, P. G. (2010). Simulation in Nursing Education: A Review of the Research. The Qualitative Report, 15(4), 1006-1011. Retrieved from https://nsuworks.nova.edu/tqr/vol15/iss4/17