The New York University College of Nursing

Using a Simulation Clinical Teaching Model to Increase Faculty Capacity in an Undergraduate Nursing Education Program

Principal Investigator: Hila Richardson, R.N., Dr.PH, FAAN, Professor and Associate Dean for Undergraduate Program
Program Evaluator: Lloyd Goldsamt, Ph.D., National Development of Research Institutes

The study team is evaluating the impact of substituting clinical simulation experiences for half of the traditional clinical days in the hospital for the medical surgical rotation for all nursing students at NYU (approximately 200 per year). Dr. Lloyd Goldsamt of the National Development of Research Institutes is conducting the mixed quantitative/qualitative evaluation to assess the overall impact of simulation on teaching productivity, quality of faculty work-life, and student educational measures. An appropriate university nursing school has been incorporated as the comparison group in the quasi-experimental design.

Read Here for principal research project findings.

EIN Grantee Spotlight: New York University (NYU) College of Nursing and National Development and Research Institutes (NDRI)

INTRODUCTION

EIN awarded a two-year grant to researchers at New York University (NYU) and their evaluator team at National Development and Research Institutes (NDRI) to conduct a controlled evaluation of their undergraduate clinical teaching intervention – the Clinical Simulation/Clinical Experience (CSCE) Model—adopted to address the shortage of clinical faculty and sites. The purpose of this project was to document how the NYU simulation substitution model has an impact on faculty capacity for clinical supervision.  In this project, the researchers calculated “faculty capacity” (as distinct from “faculty workload”) as the number of students per “faculty day[i]” for medical surgical courses at each school. The research team also examined faculty quality of work life and student experience. While all of the measures of the NYU model of simulation were compared to those at the Johns Hopkins University (JHU) School of Nursing, the researchers underscore that this study was not intended to be an overall comparison of the two programs (NYU and JHU). Rather, the aim of the study (with key findings summarized below) is confined to study the effect of two different doses of simulation, one much more intensive than the other, reflecting differences in local contexts, and different stages in the implementation of their simulation programs.

BACKGROUND AND PURPOSE

Historically, the literature has pointed to the lack of empirical studies validating simulation methods and systems as teaching tools (Schiavenato, 2009; Ward et al, 2006). Findings from this study – which focused on the impact of simulation on faculty capacity – will contribute to the evidence and knowledge base related to the use of simulation as a clinical teaching model.

In their research project proposal, the study team pointed out that the projected demand for nurses with increased education levels amidst a faculty and clinical teaching shortage that extends globally requires the nursing education community to embrace models that move beyond traditional modes of clinical education of the past decades. The changes in the clinical teaching environments, the need for highly educated and technical nurses, the diversification of the workforce and the work nurses will do calls for the re-thinking and re-designing the of clinical teaching model.

NYU initiated its CSCE model in 2005 – primarily for the purpose of addressing a local shortage of both clinical faculty and traditional clinical placements – and it has been fully in effect in four of the school’s core medical-surgical nursing courses since 2009. In New York City, multiple nursing programs “compete” for clinical instructors and student placements in hospital and healthcare agency settings, and the program at NYU was faced with a shortage of both resources, particularly for hospital settings.  Utilizing this model has allowed NYU to substantially increase student enrollment and educate new nurses beyond the degree possible without the clinical simulation model. Since the program’s 2005 implementation, NYU student enrollments increased from 600 to 990 (in 2011).

NYU was selected as the primary site for these analyses because the program uses a 50% substitution model (in which 50% of clinical education is provided using simulation, representing a high dose of simulation). The CSCE program is defined as a “mature” program as the high dose model of simulation is fully operational. Students in the program alternate weeks in a traditional clinical placement with weeks in the clinical simulation laboratory. This model allows for fewer students to be in traditional and simulation settings each week; however, an overall larger number of students are provided clinical and simulation supervision during the semester because each group meets biweekly.

JHU was selected as a comparison site because at the time the JHU program used a much lower dose of simulation (between 0% and 25% depending on class and semester).  At JHU, simulation was introduced as a supplement to traditional clinical supervision, and was being implemented without the external constraints of limited traditional clinical placements.  JHU had not formally substituted simulation for traditional clinical education. This model was implemented in 2010 and represented a new and evolving model of simulation as it is actively being developed and implemented.

DATA COLLECTION

The study team collected a substantial amount of both quantitative and qualitative data over a nearly two-year period at the two sites. Quantitative data included program statistics from each school, a faculty survey administered annually to faculty members in each school, and a student survey (consisting of multiple measures) administered to students in classroom settings at each school. Qualitative data included semi-structured interviews conducted with faculty members and students in each school.

SELECTED FINDINGS – FACULTY OUTCOMES

ON FACULTY CAPACITY:

Use of simulation can substantially increase faculty capacity without negative impact on quality of work life

The introduction of a high “dose” of clinical simulation education as a substitute for traditional clinical education resulted in a nearly 50% increase in faculty capacity at NYU. At JHU, where clinical simulation was not used as a substitution for traditional clinical education, no change in capacity was seen. The second major finding with significance for nursing education is that faculty quality of work life and student confidence and competence are not affected by increasing doses of simulation whether as an adjunct to or substitution for hospital- based clinical learning. Based on this finding, nursing schools can undertake with more confidence the use of simulation as a substitution for traditional clinical hours.  The findings have important significance for the future of nursing education.

ON FACULTY QUALITY OF LIFE

By analyzing satisfaction ratings from an annual faculty survey, the study team was able to assess the impact of clinical simulation on faculty quality of life. Although data using this instrument were not available prior to 2010, the study team used independent sample t-tests to compare ratings from faculty members who were involved with simulation at each program with those who were not involved. These comparisons included 12 items that asked respondents to endorse specific positive statements about their jobs and 17 items in which respondents rated their satisfaction with various aspects of their work life.

Overall, ratings were higher among NYU faculty; however, it was not clear that these between-program differences reflect a comparison between high-dose and low-dose simulation, or other factors that likely differ across institutions. For the 12 items related to quality of work life, significant differences were seen in five items, all of which were rated more highly by NYU faculty than by JHU faculty:

  • I have adequate school travel funds for professional development
  • I have sufficient internal funds to conduct my research
  • I have sufficient teaching support
  • I have confidence in the current direction in which my department or school of nursing is heading
  • My school offers adequate opportunities for fitness and recreation

For the 17 satisfaction ratings, significant differences were seen on six items, all of which were again rated more highly by NYU faculty. The six items rated most highly regarding satisfaction were about:  workload; work schedule; flexibility to balance work and family life; opportunity to use skills and abilities; quality of your relationship with school administration and opportunities for career advancement.

ON SIMULATION vs. NON-SIMULATION FACULTY

At NYU, virtually no differences were seen between simulation and non-simulation faculty members on job satisfaction. Simulation faculty were significantly less likely to indicate that their office space was sufficient, which likely reflects that fact that all full-time faculty at the instructor level have shared offices and the clinical part-time faculty do not have offices on campus.  Simulation activities take place in the simulation lab. Simulation faculty members did however report significantly stronger levels of a sense of community in the school. At JHU, very few differences in job satisfaction were seen between simulation and non-simulation faculty members. JHU simulation faculty members were significantly more likely to have confidence in the direction their school of nursing was heading and to report that they had the opportunity to influence important decisions at the school.

Based on the qualitative survey data collected from NYU and JHU, researchers found that the innovation of simulation as a new pedagogy did not influence faculty quality of work life, except during initial start-up when faculty development and course revisions are needed.  This is true regardless of “dose” (50% or 10%). Faculty members were most concerned that quality of instruction and patient care be maintained in simulation. Simulation learning was viewed as an acceptable instructional innovation, especially by those who were most experienced teaching and learning via simulation. Simulation lab provided quality as long as the instructor was clinically competent in the area of expertise required by the scenario and was sensitive to student performance anxiety. Nonetheless, not all faculty and students were “on board” with simulation and many believed the innovation was still new and improvements are necessary.

SELECTED FINDINGS: STUDENT OUTCOMES

Use of simulation can substantially increase student confidence and competence

The evaluation team administered surveys to students at baseline, mid- and end-program. Qualitative interviews were administered continuously. Findings from student surveys showed that students rated traditional learning highest, followed by simulation and didactic learning (Student Expectations/Experience Measure). Student self-confidence increased from mid- to end-program, and student satisfaction and self-confidence in learning remained stable from mid- to end-program (Assessment of Nursing Education – ANE)[ii] (Learner Satisfaction and Self-Confidence – LSSCL)[iii].  As they progressed through the program, students increasingly reported positive perceptions about collaboration, high expectations of the program and the faculty, and active and diverse ways of learning (Educational Practices Questionnaire – EPQ)[iv].

THE QUESTION OF COST

An independent cost analysis showed the model to be cost-efficient in clinical faculty salaries when the implementation of the model also includes an increase in enrollment of students as occurred at NYU. There were four times (238 to 1,134) as many students in 2011 as in 2006 in the three courses studied in this project. The faculty salaries required to teach this number of students increased less than two-fold. However, in implementing this model, nursing schools may need to consider the start-up and maintenance costs for the simulation labs. The costs of staffing and supplying simulation laboratory students as well as the investment in construction, equipment and faculty development that is initially required are among the costs to be included. In adopting this model, nursing schools will have to calculate their institution’s policies related to paying clinical faculty, accounting for space and facilities, availability of capital expansion and how costs are off-set by increasing student tuition to determine the cost efficiency for any one school.

ADDITIONAL COMMENTS FROM THE RESEARCHERS

At the conclusion of their submitted technical report to the EIN NPO, the NYU and NDRI research team averred that their findings (as summarized above) have important significance for the future of nursing education. “The major finding related to faculty capacity provides evidence for the use of simulation to substitute for up to 50 percent of the traditional hospital clinical experience as an effective and efficient use of scarce faculty and clinical placement resources to increase faculty capacity by 50 percent.” Another significant finding in this EIN-funded evaluation that carries implications for nursing education is that faculty quality of work life and student confidence and competence are not affected by the use of simulation whether as an adjunct to or substitution for hospital-based clinical learning. The study team pointed out that in the American Association of Colleges of Nursing’s most recent survey, respondent schools reported that the top two reasons for not accepting qualified students into entry-level baccalaureate programs were: 1) insufficient clinical sites (65.2%) and 2) lack of faculty (62.5%).

The study team also noted that: “…[I]n addition to a demand for larger numbers of entry level baccalaureate nurses, there will be a demand for nurses who are prepared for highly technical care whether they work in a hospital, home or ambulatory care. Simulation is essential to providing a safe way to practice technical protocols for complex patient care as the opportunity to practice skills on a patient has become superseded by concerns for patient safety.”

Based on this evidence, it is believed by the researchers that nursing schools can undertake with more confidence the use of simulation as a workable option for nursing schools that turn away qualified students due to insufficient clinical sites and/or lack of faculty.

The NYU-NDRI study included the publication of an Implementation Guide (which can be accessed HERE) for potential replicators. In the introduction to the Guide, the authors write that although there are financial, administrative and educational challenges when introducing simulation as an integral part of a clinical education program, those challenges can be worked out with explicit planning and leadership support.

REFERENCES:

Richardson, H., Goldsamt, L.  and Jeffries, P. (2013). “Clinical Simulation: Issues, outcomes and Future Directions”, presented at the American Association of Colleges of Nursing, 2013 Spring Annual Meeting: Guiding Change: Technology in Nursing Higher Education, March 16-19, 2013, Washington, D.C. Proceedings available at http://www.aacn.nche.edu/membership/members-only/presentations/2013/13spring/Richardson-Goldsamt-Jeffries.pdf

Richardson, H., Gilmartin, M. J. and Fulmer, T. (2012). “Shifting the clinical teaching paradigm in undergraduate nursing education to address the nursing faculty shortage.” Journal of Nursing Education, 51(4), 226-31. doi:http://dx.doi.org/10.3928/01484834-20120210-04

Richardson, H., Gilmartin, M. J., Jeffries, P. and Verzzano, J. (2011). “The Clinical Simulation/Clinical Experience Model: Expanding Faculty Capacity”, presented at the American Association of Colleges of Nursing, Hot Issues Conference: Beyond the Rhetoric: The Impact of Technology on the Transformation of Nursing Education, April 14-16, 2011, Baltimore, MD.

Schiavenato, M. (2009). Reevaluating simulation in nursing education: Beyond the human patient simulator. Journal of Nursing Education, 48, 388–394.

Ward, P., Williams, A.M. & Hancock, P.A. (2006). Simulation for performance and training. In Ericsson, K.A., Charness, N., Feltovich, P.J. & Hoffman, R.R. (Eds.), The Cambridge handbook of expertise and expert performance (pp. 243–262). Cambridge, UK: Cambridge University Press.




[i] A “faculty day” refers to a full day of clinical supervision, either in a traditional hospital setting or in a laboratory. In the laboratory, a “faculty day” may be more than one laboratory session.

[ii] The ANE is a 43-item measure that assesses student confidence in performing specific nursing-related tasks.

[iii] The LSSCL is a 13-item measure that asks students to indicate the degree to which they agree or disagree with specific statements about their personal attitudes toward the instruction they receive in simulation.

[iv] The EPQ is a 16-item questionnaire that asks students to indicate the degree to which they agree or disagree with specific statements related to their experiences in simulation. The measure also asks students to indicate how important each item is to them. Items represent four specific domains: Active Learning (10 items), Collaboration (2 items), Diverse Ways of Learning (2 items) and High Expectations (2 items). Items are rated on a 5-pointscale ranging from “strongly disagree” to “strongly agree.”