Orientation is an overwhelming time for new nursing employees, who are faced with learning many systems, processes, and people as quickly as possible. The situation is even more difficult for new graduate nurses, who must overcome the transition from school to practice.
New grads have a tricky balancing act to perform involving learning new skills, committing policies and procedures to memory, prioritizing patients' needs, and even remembering where the supply closet is. Wouldn't it be nice if they had a safe environment in which to practice those skills before being thrust onto the unit and dealing with real patients?
That's the idea behind Phoenix-based Banner Health System's new simulation center. The organization is hoping that simulation holds the key to successfully onboarding new nurses and helping them transition swiftly to become competent, confident nurses.
Waste not, want not
Banner Health opened its first simulation center in 2006 at Banner Good Samaritan Medical Center in Phoenix. The facility proved so popular with the nine Banner facilities in the state that it soon became too small.
Around this time, Banner's Mesa Hospital was moving into a new facility, leaving the organization wondering what to do with an empty medical center. It decided to turn the building into a state-of-the-art simulation training center to be used by all of Banner's facilities in Arizona.
The center was extensively renovated to house the largest simulation center in the country, which passes for a real-life hospital. It includes a 20-bed ED, an 18-bed med-surg unit, a 14-bed ICU, and two ORs. It is filled with a variety of high- and low-fidelity simulation modalities and offers some virtual training. It also hopes to develop virtual avatars to facilitate behavioral health training.
Standardizing training
Carol Cheney, MS, director of simulation and innovation at Banner Health, says the organization decided to create a standardized onboarding program for all nursing staff in the Arizona region, which would involve time at the new simulated medical center.
Previously, each facility had its own orientation and precepting structures. "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."
Cheney spearheaded a project to create a standardized orientation for all new nursing employees and ushered everyone through the program at the simulated medical center.
She brought teams together to examine what needed to be part of orientation, what was required by regulation, as well as problem areas that could be identified as common across Banner facilities.
"We created a comprehensive curricula surrounding these topics," says Cheney. "We double-checked all policies and procedure guidelines against [Agency for Healthcare Research and Policy and Institute for Healthcare Improvement], so we could bring forward the best evidence-based practice standards."
Skills and scenario-based training
All new hires, whether experienced nurses or new graduates, first go to their own facilities to receive facility-specific orientation. Afterward, they go to the simulation medical center, where they participate in skills training and scenario-based training.
The experienced nurses are guided through short scenarios, but the new nurses must experience four-hour scenarios that are set in the department in which they will work. For example, if they will be working in the ICU, new nurses have a one-to-two patient ratio just like they will have in reality.
The four-hour scenarios involve all aspects of unit life that new nurses will experience. For example, they:
- Learn how to perform patient handoffs
- Practice patient assessments
- Distribute medications
- Contact physicians or ancillary services for items their patients need or for patient orders
- Enter their documentation in the electronic medical record
"We have a facilitator on the floor to help them," says Cheney. "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." After the scenario is complete, the new nurses are debriefed and encouraged to talk through the scenario and what happened. Because the facilitators know exactly what occurred, they can provide coaching and guidance specific to each nurse.
"We do it in a nonpunitive way," notes Cheney. "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."
In essence, the scenarios allow new nurses to practice patient care, critical-thinking skills, documentation, and all of their new responsibilities in a safe environment. "And the beauty is that their [fictional] patients are essentially plastic," laughs Cheney.
Measuring outcomes
Before the program began, Banner surveyed preceptors to identify common problems they were seeing among new graduates. The facility turned these common issues into scenarios for new grads to practice at the simulation center.
Cheney says Banner doesn't want new nurses' time with preceptors to be spent on learning tasks such as how to hook up an IV pump, which can be done in the simulation lab.
Banner wants time spent with the preceptor to be an opportunity for new nurses to develop critical thinking and focus on learning clinically advanced knowledge. The new simulation training center also allows Banner to create a report on each new graduate and his or her particular skills and competence.
"Orientation used to be really arbitrary," Cheney says. "Now we're saying, 'Let's not look at time; let's look at competence.' "
Report summaries based on a series of measurements help identify new nurses' competence level. The reports are provided to each learner and his or her manager, preceptor, and educators, which allows units to individualize training.
The simulation medical center identifies new nurses who are ready to take on a greater patient load, as well as those who struggled with suctioning or tracheotomy care so the unit can help them in that area.
Cheney is also collecting data to refine the training for the long term. "We're able to see, where do people make their errors? Are they procedural errors or are they decision-making errors?" she says.
Cheney plans to examine the data Banner is collecting to identify what really needs attention and what does not. This will allow the organization to refine the program over time and continually work to ensure that new nurses receive the best orientation possible.
This article was adapted from one that originally appeared in the January issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.