How can simulation help with new nurse onboarding?

Jared M. Kutzin, DNP, MS, MPH, RN, FSSH
Associate Professor, Emergency Medicine & Medical Education
Icahn School of Medicine at Mount Sinai
Senior Director of Simulation, Emergency Medicine
Mount Sinai Hospital

Jared: The transition of nurses from school into clinical practice is one of the most tumultuous times in their career. That first year that nurse is in practice is really “make or break” for them. If they aren’t successful in that transition, they’re going to leave the profession – and we can’t afford that. But what makes them unsuccessful in that first year? A lot of it is the interpersonal relationships that they have with other staff members, especially other nurses. But a lot of it is the comfort and confidence in their own skills and abilities. And a lot of nurses are leaving nursing school with the foundational education to pass the NCLEX, which is super important. But when you are entering a highly specialized area – the emergency department, obstetrics, the operating room, pediatrics, outpatient oncology care – the nurses in those environments need so much intensive training. 
 
I have an emergency nurse background. I work a lot with our emergency nurses and onboarding them. And what we see and what we hear is that the classroom education that they’re being provided is good – but it’s not sufficient. They’re coming to work worried about seeing any of the conditions that may walk through the door – and not having that basic competency is what really is scaring them. We see that there are programs out there like the AACN’s nurse residency program, which really tries to assimilate nurses into the culture of the organization and give them the tools to be involved with process improvement projects and navigate the difficult situations they may be involved with. But the simulations that we can do is really what makes all that content come alive. And so we need to do more simulations with our onboarding staff members that is not just the clinical simulations – they need a lot more of that – but also the really difficult patient interactions: managing up, patient satisfaction simulations. The breadth and depth of simulation that we can do with new nurses is really endless. And we just need the resources to be able to do that. And we need the policy to go along to help support that. And we need our organizations to support us in doing that.  
 
I think the old adage, the definition of insanity, really comes to fruition here, right? The definition of insanity is doing the same thing over and over again and expecting a different result. What are we doing different with onboarding nurses today than we have in the past? Not much. We need a paradigm shift. We need more high-quality simulation by people who are credentialed to do it, in facilities that are accredited to do simulation, to really make a change, to get our nurses onboarded in a way for them to stay in the profession long term.

Sarah L. Beebe, PhD, APRN, CNM, WHNPr, CHSE
Graduate Medical Education Simulation Lab Program Manager
PCOM Simulation Center at Bayhealth
Bayhealth Medical Center

Sarah: At our hospital, we use simulation in our accredited nurse residency program and with all of our new nurses … They do lots of classroom learning, but we use simulation for them to practice the communication skills that they need. As a new nurse, it’s often difficult for new nurses to speak up or to talk to doctors or advanced practice providers. And so using simulation, you can practice those skills in a safe setting with feedback and debriefing. And we also use simulation to practice the high acuity, low-frequency skills that a new nurse may not see for a couple of years or but we still need them to know how to do it. And so it’s helpful to use simulation for things like mock codes or a deteriorating patient or something like that. 
 
It is vital in the new nurse population, not to mention new nurses are coming out of school. We’re still dealing with some of the limitations that COVID put on academic nursing. And so some of them have varied skills coming out of hands-on skills coming out of nursing school. They may have all the didactic skills, but they may not have gotten as many robust clinical opportunities. Or they live in an area where finding good, robust clinical opportunities is limited. So when they come to whatever hospital it is that they’re working in, we need to ensure that all new nurses come in at the same level. Using simulation, you can bridge those gaps that they might have, making that transition from academic nursing to clinical nursing.

Roxane Gardner, MD, MSHPEd, DSc
Executive Director, Center for Medical Simulation
Assistant Professor-Obstetrics, Gynecology at Harvard Medical School
Department of OB/GYN at Brigham and Women’s Hospital
Division of Adolescent Gynecology at Boston Children’s Hospital
Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital

Roxane: There’s a lot more turnover. And with the turnover, there’s new nurses that are being pushed through their educational system – and they may or not be ready to jump into a ward and start taking care of patients. So if you set them up in that way and they’re encountering things that they’re really not comfortable dealing with, and their higher ups, their more experienced nurse clinician colleagues, are stressed because they’re doing more work themselves, then everybody quits a little bit more frequently, right? They get burnout, they get frustrated, they don’t feel valued, etc.  
 
I think the onboarding is really important and simulation has a really integral role. So you can, with simulation, standardize some scenarios that reflect whatever it is that’s the acuity of that particular ward. The new nurses who are coming on board can gain some more familiarity and comfort – and not only just with the situation medically, but how their system works. Where is their medication device? Where do you call for help? Just helping them familiarize themselves with their environment and what resources are available. With simulation, you can do that in a standardized way and have people go through and then be able to give them feedback on their progress, their improvement, how well they’re doing and give them opportunities to try again if they’re still not getting some aspect of that care pathway.

Connie M. Lopez, MSN, CNS, CPHRM, CHSEA, FSSH
Quality and Safety Improvement Consultant, Maternal Child Health Patient Safety
Patient Safety (KFH/HP), Northern California Region
Kaiser Permanente

Connie: Simulation can help with new nurses tremendously. So one of my experiences as a manager in an OB unit was to bring new nurses on board and team them with an experienced nurse. And I had a checklist of all the experiences that they should encounter in their 12-week orientation. And if they didn’t have the opportunity to encounter the actual experience, such as a hemorrhage or a shoulder dystocia or an emergency C-section, or even a diabetic patient, I would set up a simulation. 
 
And so the teams – the experienced nurse and the new nurse – would meet with me weekly, we would go through their encounters and then I would just circle the areas in which we would then need to set up a simulation. So it’s a great opportunity to set up something that doesn’t always happen on demand, and so we can make it happen in a simulated setting and give them that experience.