Simulation Training Makes New Grads Better Nurses

What's the best way to train new graduate nurses? Ten hospitals will give you 10 different answers. Every organization has its own system to move new nurses through orientation quickly and successfully.

Phoenix-based Banner Health System found itself asking that question last year, says Carol Cheney, MS, Banner's director of simulation and innovation.

"We did an audit and [found that] all units trained in different ways," says Cheney. "We wondered who produces the better nurse? And no one had an answer."

The question came up as Banner Health was opening a state-of-the-art simulated medical center, where the health system will send new nurses in the Arizona region for training.

The center is the lynchpin for the whole project. Banner has operated a simulation center since 2006, which quickly outgrew its allotted space. When Banner's Mesa Hospital moved to a new building, the health system turned the empty hospital into a sophisticated simulation training center that is now used by all its hospitals in Arizona.

The training center could pass for a real hospital. It includes a 20-bed ED, 18-bed med-surg unit, 14-bed ICU, and two ORs. It's filled with high- and low-tech simulation devices and virtual training, and there are plans to add virtual avatars to facilitate behavioral health training.

All new nurses, whether experienced or new graduates, pass through the center after a brief time at their home hospitals to receive facility-specific orientation.

Cheney and her colleagues examined orientation throughout Banner to see what everyone was doing, what needed to be included in orientation, what was required by regulation, and what problems were common in all hospitals.

"We created comprehensive curricula surrounding these topics," says Cheney. "We double checked all polices and procedure guidelines against AHRQ, IHI, so we could bring forward the best evidence-based practice standards."

The resulting orientation at the simulated medical center combines skills training and scenario training. Nurses are put through four-hour scenarios set in the department in which they will work. If they are in the ICU, they'll get an ICU setting with a one- to two-patient ratio.

"The real goal is to immerse them in that environment—on a somewhat simplistic level, we're not trying to scare them—to show them the reality of the unit they will be on," says Cheney.

The training is more interesting for new graduate nurses, as it allows them to experience life on their new unit. "And the beauty is that their patients are essentially plastic," says Cheney.

Facilitators set the scenario and provide coaching and guidance specific to that new nurse. When scenarios are completed, new nurses receive debriefing and talk through the experience. "We do it in a non-punitive way," Cheney says. "We don't say 'Susie you didn't do this.' What we'll do is talk about the patients and what was happening with the patients."

The scenarios let new nurses practice patient care in a safe environment and makes their time with preceptors on their real-life unit more productive. "They don't want new nurses' time with preceptors to be spent learning tasks, such as how to hook up an IV pump, which can be done in the simulation lab," says Cheney. "Time with a preceptor should be an opportunity to develop critical thinking skills and focus on learning clinically-advanced knowledge."

Cheney can create a report on each new graduate and his or her skills and competence. "Orientation used to be really arbitrary," she says. "Now we're saying, 'let's not look at time [spent in orientation]. Let's look at competence.'"

Report summaries identifying new nurses' competence are given to the trainees, their managers, preceptors, and educators, allowing them to individualize training and know which nurses are ready for a greater patient load and which nurses are struggling.

Cheney continues to refine the training. "We're able to see 'where do people make their errors? Are they procedural errors or are they decision making errors?'" she says.