How can simulation help with new nurse onboarding?

Jared M. Kutzin, DNP, MS, MPH, RN, FSSH
Professore associato, Medicina d'urgenza e formazione medica
Icahn School of Medicine at Mount Sinai
Direttore senior di simulazione, Medicina d'urgenza
Mount Sinai Hospital

Jared: Il passaggio degli infermieri dalla scuola alla pratica clinica è uno dei momenti più tumultuosi della loro carriera. Il primo anno in cui l'infermiere esercita è davvero “decisivo” per lui. Se non hanno successo in questa transizione, lasceranno la professione, e noi non possiamo permettercelo. Ma cosa li porta a non avere successo nel primo anno? In gran parte sono le relazioni interpersonali con gli altri membri del personale, soprattutto con gli altri infermieri. Ma in gran parte si tratta del comfort e della fiducia nelle proprie capacità e abilità.E molti infermieri escono dalla scuola per infermieri con la formazione di base per superare l'NCLEX, che è importantissima. Ma quando si entra in un'area altamente specializzata - il pronto soccorso, l'ostetricia, la sala operatoria, la pediatria, l'oncologia ambulatoriale - gli infermieri di questi ambienti hanno bisogno di una formazione molto intensa.
 
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: La simulazione può aiutare enormemente i nuovi infermieri. Una delle mie esperienze come manager in un'unità di ostetricia è stata quella di inserire nuove infermiere e di affiancarle a un'infermiera esperta. Avevo una lista di controllo di tutte le esperienze che avrebbero dovuto affrontare durante le 12 settimane di orientamento. E se non avevano l'opportunità di vivere un'esperienza reale, come un'emorragia o una distocia di spalla o un cesareo d'emergenza, o persino un paziente diabetico, organizzavo una simulazione. 

Così i team - l'infermiere esperto e il nuovo infermiere - si incontravano con me settimanalmente, esaminavano i loro incontri e poi io cerchiavo le aree in cui avremmo dovuto organizzare una simulazione. Si tratta quindi di una grande opportunità per organizzare qualcosa che non sempre avviene su richiesta e che possiamo far accadere in un ambiente simulato e far fare loro questa esperienza.