Simulation and Clinical Competency in Undergraduate Nursing Programs: A Multisite Prospective Study.

BACKGROUND: In prelicensure nursing education, there is a need to better understand the roles that simulation and traditional clinical instruction play in the development of clinical competence. METHOD: A prospective cohort study was conducted across four prelicensure nursing programs. Four undergraduate nursing programs tested an intervention cohort with a redesign of the use of simulation, a redistribution of clinical hours, and an implementation of these new educational approaches into simulation experiences. RESULTS: The final sample consisted of 271 control students and 315 intervention students who were assessed at the end of five clinical courses. There was no significant difference between the control and intervention groups on licensure examination pass rates and no uniform differences in clinical competency. CONCLUSION: These findings suggest that the redistribution of clinical hours from traditional to simulation did not affect clinical competency or licensure examination results. Such redistributions have the potential to yield comparable results. [J Nurs Educ. 2019;58(10):561-568.].

Educational Changes to Support Advanced Practice Nursing Education.

Educational factors limit the number of advanced practice registered nurse (APRN) graduates to meet the growing workforce demands. Healthcare dynamics are necessitating a shift in how nursing education envisions, creates, and implements clinical learning opportunities. The current clinical education model in APRN programs continues to be the same as it was 45 years ago when the student numbers were much smaller. New approaches in graduate nursing education are needed to address the shortage of APRNs in primary and acute care areas. Determining competency based on the number of clinical hours can be inefficient, ineffective, and costly and limits the ability to increase capacity. Little research exists in graduate nursing education to support the effectiveness and efficiency of current hours of clinical required for nurse practitioner students. Simulation and academic-practice partnership models can offer innovative approaches to nurse practitioner education for clinical training, with the goal of producing graduates who can provide safe, quality care within the complex practice-based environment of the nation's evolving healthcare system.

Can a virtual patient trainer teach student nurses how to save lives--teaching nursing students about pediatric respiratory diseases.

INTRODUCTION: Virtual environments offer a variety of benefits and may be a powerful medium with which to provide nursing education. The objective of this study was to compare the achievement of learning outcomes of undergraduate nursing students when a virtual patient trainer or a traditional lecture was used to teach pediatric respiratory content. METHODS: This was a randomized, controlled, posttest design. A virtual pediatric hospital unit was populated with four virtual pediatric patients having different respiratory diseases that were designed to meet the same learning objectives as a traditional lecture. The study began in Spring 2010 with 93 Senior I, baccalaureate nursing students. Students were randomized to receive either a traditional lecture or an experience with a virtual patient trainer. Students' knowledge acquisition was evaluated using multiple-choice questions, and knowledge application was measured as timeliness of care in two simulated clinical scenarios using high-fidelity mannequins and standardized patients. RESULTS: Ninety-three students participated in the study, of which 46 were in the experimental group that received content using the virtual patient trainer. After the intervention, students in the experimental group had significantly higher knowledge acquisition (P = 0.004) and better knowledge application (P = 0.001) for each of the two scenarios than students in the control group. CONCLUSIONS: The purpose of this project was to compare a virtual patient trainer to a traditional lecture for the achievement of learning outcomes for pediatric respiratory content. Although the virtual patient trainer experience produced statistically better outcomes, the differences may not be clinically significant. The results suggest that a virtual patient trainer may be an effective substitute for the achievement of learning outcomes that are typically met using a traditional lecture format. Further research is needed to understand how best to integrate a virtual patient trainer into undergraduate nursing education.

Growth and neurodevelopment in extremely low-birth-weight neonates exposed to postnatal steroid therapy.

We compared postnatal growth and neurodevelopment in extremely low-birth-weight (<1000 g) neonates who did or did not receive postnatal steroid (PNS) therapy for bronchopulmonary dysplasia (BPD). One hundred seventy-three neonates with Bayley Scales of Infant Development II (BSID II) testing performed at 18- to 22-month adjusted age were studied. Growth parameters and BSID II scales were compared among three groups: group I, no BPD; group II, BPD, no PNS; group III, BPD and PNS exposure. A subset of 77 neonates' growth parameters were retrieved at 12-month adjusted age. Psychomotor Development Index (PDI) and Mental Development Index (MDI) scales were lower in group III versus groups I and II. Growth velocity (GV) was lower in group III versus group I and II during the initial hospital stay. In the subset, GV from birth to 1-year adjusted age and weight, length, and head circumference determined at 1-year adjusted age were similar among the groups. Multivariate analysis revealed a significant effect of group membership and cystic periventricular leukomalacia on PDI. These results suggest that a deleterious effect of PNS therapy on neurodevelopment can occur by a mechanism that does not impair overall growth or growth of head circumference.

Alternative educational models for interdisciplinary student teams.

BACKGROUND: Few studies compare instructor-modeled learning with modified debriefing to self-directed learning with facilitated debriefing during team-simulated clinical scenarios. OBJECTIVE: : To determine whether self-directed learning with facilitated debriefing during team-simulated clinical scenarios (group A) has better outcomes compared with instructor-modeled learning with modified debriefing (group B). METHODS: This study used a convenience sample of students. The four tools used assessed pre/post knowledge, satisfaction, technical, and team behaviors. Thirteen interdisciplinary student teams participated: seven in group A and six in group B. Student teams consisted of one nurse practitioner student, one registered nurse student, one social work student, and one respiratory therapy student. The Knowledge Assessment Tool was analyzed by student profession. RESULTS: There were no statistically significant differences within each student profession group on the Knowledge Assessment Tool. Group B was significantly more satisfied than group A (P = 0.01). Group B registered nurses and social worker students were significantly more satisfied than group A (30.0 +/- 0.50 vs. 26.2 +/- 3.0, P = 0.03 and 28.0 +/- 2.0 vs. 24.0 +/- 3.3, P = 0.04, respectively). Group B had significantly better scores than group A on 8 of the 11 components of the Technical Evaluation Tool; group B intervened more quickly. Group B had significantly higher scores on 8 of 10 components of the Behavioral Assessment Tool and overall team scores. CONCLUSION: The data suggest that instructor-modeling learning with modified debriefing is more effective than self-directed learning with facilitated debriefing during team-simulated clinical scenarios.

Effectiveness of 2 methods to teach and evaluate new content to neonatal transport personnel using high-fidelity simulation.

Neonatal transport team members undergo initial and periodic training to ensure knowledge and performance competencies. Given that various methods can be employed in this effort, it is important to evaluate how well new knowledge is learned and applied by transport team members and assess learner satisfaction. Self-paced modular learning and expert-modeled learning using high-fidelity simulations (HFSs) are 2 teaching/learning/evaluation tools for content application for team members. This article describes 2 educational approaches using simulated scenarios and evaluations. These experiences occurred in 2006, summer I (self-paced modular learning) and in 2007 for the same participants, summer II (expert-modeled learning). A group of experienced nurses, respiratory therapists, emergency medical technicians, and paramedics participated. Satisfaction was measured using a 5-point Likert scale. Effectiveness of HFS was evaluated using the Technical Evaluation Tool. Behavioral performance was assessed using the Behavioral Assessment Tool. The Technical Evaluation Tool showed that expert-modeled learning using HFS as a teaching/ learning/evaluation tool for application of content was effective as self-paced modular learning. Experienced participants appear to be satisfied with the use of HFS scenarios.

Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience.

BACKGROUND: There are no reports in the literature that compare instructor-modeled learning to self-directed learning when simulation is used. Therefore, no evidence exists to know which approach is superior. This study aims to test the hypothesis that instructor-modeled learning is more effective compared with self-directed learning during a simulated clinical experience. METHODS: This is a descriptive pilot study to compare instructor-modeled learning with self-directed learning during a clinical simulated experience. Four evaluation tools were used at three time points to evaluate knowledge, self-efficacy (self confidence), and behaviors. RESULTS: Sixteen students participated. There were no statistically significant differences between the groups on the Knowledge Assessment Test. There were significant differences between the groups in the Self-Efficacy Tool (SET) at three times (time 1: P = 0.006, time 2: P = 0.008, time 3: P = 0.012). The only significance between the groups on the Technical Evaluation Tool was time to start Albuterol. The Behavioral Assessment Tool (BAT) showed significant differences between the groups in 8 out of 10 components of the tool. A strong correlation was observed between the overall score of the BAT and the SET Score. CONCLUSION: Although the small sample size prohibits definitive conclusions, the data suggest that instructor-modeled learning may be more effective than self-directed learning for some aspects of learning during a clinical simulated experience.

Capillary refill time is an unreliable indicator of cardiovascular status in term neonates.

PURPOSE: Decisions regarding the need for volume replacement in neonates often are made in the immediate newborn period. Capillary refill time (CRT) is used as an indicator of circulatory status; however, recent data show that CRT varies considerably with age, ambient and skin temperature, anatomical site of measurement, and duration of pressure. The purpose of this study was to (1) examine the relationship between CRT and heart rate (HR) and blood pressure (BP) in term neonates, and (2) evaluate the differences among CRT values measured at 3 body sites and with varying duration of cutaneous pressure. DESIGN: This was a prospective, cross-sectional, correlational study. Subjects Forty-two appropriate-weight-for-gestational-age (AGA) neonates with birthweights, (M = 3407; SD = +/- 540 g), gestational ages (M = 39 weeks; SD = +/- 1 week), and sex (21 males, 21 females). Infants had no history of perinatal distress or maternal chorioamnionitis. METHODS: Each neonate was studied prospectively 1 to 4 hours after birth. The infants were clothed with only a diaper and evaluated on a radiant warmer bed set to achieve an axillary temperature of 36.5 degrees to 37.0 degrees C. Capillary refill time was measured with a digital stopwatch at 3 sites: volar surface of finger (F), plantar surface of heel (H), and lower sternum (St), using brief (1- to 2-second) and extended (3- to 4-second) pressure. Heart rate was auscultated and counted for 60 seconds, and BP was measured by oscillometry. Relationships among variables were assessed by Pearson correlation coefficient, analysis of variance, and multiple regression analysis. The Bonferroni correction for multiple comparisons was applied. MAIN OUTCOME MEASURES: Capillary refill time, blood pressure, and heart rate. PRINCIPAL RESULTS: There was no significant site variation for CRT for either brief (2.4 +/- 0.6 to 2.9 +/- 1.0 seconds) or extended (3.8 +/- 0.8 to 4.3 +/- 0.8 seconds) pressure. However, regardless of site, CRT was greater when extended versus brief pressure was used (P < 0.001). There were no significant correlations between HR and CRT. There was a moderate, direct relationship between BP and CRT observed in the following anatomic sites: (1) sternum/extended pressure and systolic BP (SBP), diastolic BP, and mean BP (r = 0.35, P = 0.02; r = 0.49, P = 0.001; and r = 0.43, P = 0.005, respectively); (2) sternum/brief pressure and SBP (r = 0.31, P = 0.05); and (3) finger/extended pressure and SBP (r = 0.30, P = 0.05). CONCLUSIONS: An unanticipated moderate, direct correlation between BP and CRT was observed; prolongation of CRT occurred with elevated blood pressure. This finding may have been secondary to increased circulating vasoactive substances in the newborn period; measurement of these substances was beyond the scope of this study. In addition, CRT was highly dependent on the duration of cutaneous pressure, regardless of the site. These 2 findings indicate that CRT may be an unreliable indicator of cardiovascular status in the term neonate during the first 4 hours after birth.

Value of neurosonography in predicting subsequent cognitive and motor development in extremely low birth weight neonates.

OBJECTIVE: To compare the results of neurosonography (NSG) with subsequent neurodevelopmental testing in extremely low birth weight (ELBW; < or =1000 g) neonates. STUDY DESIGN: NSG at hospital discharge was available in 164 neonates and Bayley Scores of Infant Development (BSID II) evaluations (MDI and PDI) were performed in 158 of these infants at 18 to 22 months. Neurosonographic studies obtained prior to the discharge study also were evaluated. Neurosonograms were interpreted by pediatric radiologists, and BSID II examinations were performed by certified examiners masked to the results of the neurosonographic studies. RESULTS: A normal sonographic study at discharge was observed in 44% (14/32) of neonates with MDI <70 and 29% (7/24) with PDI <70. Furthermore, the sonographic study at discharge was normal in 59% (36/61) of neonates with MDI 70 to 84 and 56% (31/55) with PDI 70 to 84. Conversely, approximately 30 to 40% of those with an abnormality noted on neurosonogram at discharge, or at any time during hospitalization, had MDI and/or PDI scores > or =85. The association between abnormal NSG at discharge and low BSID II results was stronger for the PDI exam compared with the MDI exam. CONCLUSION: These results emphasize the limitations of NSG in predicting subsequent neurodevelopmental outcome in ELBW neonates. The primary role for NSG in ELBW neonates may be in the diagnosis and management of acute problems, such as intraventricular hemorrhage and posthemorrhagic hydrocephalus, and not as a tool to predict subsequent outcome.

Association of antenatal and postnatal dexamethasone exposure with outcomes in extremely low birth weight neonates.

BACKGROUND: Recent studies of preterm neonates have indicated that antenatal dexamethasone (ADX) may have adverse effects on cranial ultrasound findings at the time of hospital discharge, including periventricular leukomalacia. Furthermore, both ADX and postnatal dexamethasone (PDX) may have adverse effects on subsequent neurodevelopmental outcome. OBJECTIVES: 1) To assess the effects of ADX exposure on cranial ultrasound findings at the time of hospital discharge and 2) to evaluate the individual effects of ADX and/or PDX exposure on subsequent neurodevelopmental outcome in extremely low birth weight (ELBW) neonates in whom confounding risk factors known to influence outcome were controlled. METHODS: One hundred seventy-three ELBW (< or =1000 g) neonates were studied using a prospectively collected database and hospital and clinic records. Study patients were assigned to 1 of 4 groups according to dexamethasone exposure: group I, no dexamethasone exposure; group II, ADX exposure to hasten fetal lung maturity; group III, PDX exposure for chronic lung disease; group IV, both ADX and PDX exposure. The 4 groups were compared using multinomial logistic regression or analysis of covariance to control for confounding variables. Primary outcome variables were cranial ultrasound findings at hospital discharge and results of developmental testing at 18 to 22 months' corrected age (Bayley Scales of Infant Development). RESULTS: Cranial ultrasound results as well as Bayley Scales of Infant Development scores were similar in groups I and II and in groups III and IV. The likelihood of abnormal cranial ultrasound studies and lower scores on neurodevelopmental testing was greater in groups III and IV versus groups I and II. In this study, ADX did not seem to increase the risk of periventricular leukomalacia. CONCLUSIONS: ADX exposure is not associated with an increase in abnormal cranial ultrasound findings in ELBW neonates. PDX exposure, but not ADX exposure, is associated with worse neurodevelopmental outcome in this population. These results are supportive of the recent statement by the American Academy of Pediatrics (Committee on Fetus and Newborn) and the Canadian Paediatric Society (Fetus and Newborn Committee) and emphasize that PDX should be used with caution in ELBW neonates.