The Impact of a Sequential Simulation Experience on the Clinical Decision Making of Novice Nurses related to the Care of the Morbidly Obese Post-operative Patient: A Pilot Project

Abstract

Problem: Errors in healthcare have been linked to new nurses' inability to apply sound clinical decision making/clinical judgment (Dunton, Gajewski, Klaus & Peirson, 2007; Smith & Crawford, 2003; NCSBN, 2009). As more demands are being placed on nurses in the current health care environment, particularly the novice nurse, there is an even greater need for nursing educational strategies that integrate theory and practice for nurses, particularly related to the development of sound clinical judgment, which is often illustrated by the appropriate application of clinical nursing skills. The use of clinical simulation has been proposed as a method that integrates theory, clinical skills application and clinical decision making, thus enhancing novice nurses' clinical judgment.

Purpose: The purpose of this Capstone was to implement a program evaluation project that assessed the impact a change in program delivery, the use of a sequential simulation experience, had on the competence of novice nurses' clinical decision making during a nurse residency program in an acute care facility. A sequential simulation experience was created and implemented, and its impact on novice nurses' clinical decision making skills was evaluated. Tanner's Model of Clinical Judgment (2006) was used as the guiding framework and the context was holistic patient care for the morbidly obese post-operative patient.

Methods: This project was conducted in three phases:

Phase I: Simulation scenarios, case studies, participant surveys, simulation checklists and decision trees, related to the nursing care and associated clinical decision making with the morbidly obese post-operative patient, were developed and reviewed by content experts, with revisions as indicated. Simulation scenarios were piloted with senior nursing students enrolled in an Associate degree nursing program. Phase II: Implementation of project occurred during scheduled nurse residency program. Participants were randomly assigned to one of two groups: simulation or case study. Sequential simulation scenarios were run with eight participants in the morning session of the nurse residency program. Case study group presentation/discussion occurred in the afternoon session with remaining seven participants. All program participants completed surveys prior to and immediately after the teaching intervention.

Phase III: Ten novice nurse participants returned two weeks later to complete a simulation scenario related to the clinical decision making of the morbidly obese post-operative patient to assess competence. Competence was individually assessed using a clinical skills checklist and decision tree.

Results: Survey results for both subgroups were similar with all participants indicating an increase in knowledge and a majority indicating confidence in their confidence in their clinical decision making skills after educational intervention. Mean score on the assessment checklist for the simulation subgroup participants was 8 versus a mean score of 7.8 for the case study group, indicative of a slight enhancement in skill for simulation group. Decision tree results were also similar for both subgroups.

Implications: A summary of program evaluation results was presented to the acute care facility and all materials created were provided for future use. Although the sample size was small, participant self-assessment related to knowledge and confidence, and the slight improvement in the checklist/decision tree results for the simulation subgroup support the conclusion that simulation may be a valuable tool for enhancing the clinical decision making skills of novice

nurses.