Using clinical simulations in geriatric nursing continuing education

Article Outline

• Abstract
• • Rationale for Geriatric Nursing Clinical Simulations
• Method
  • Overview of the Program
  • Participants
  • Procedure
    • Workshop Descriptions
    • Geriatric Nursing Content
    • Geriatric Clinical Simulations
    • Evaluation Process
• Results
• Discussion
• Conclusions
• Acknowledgment
• References
• Biography
• Copyright

Accompanying an increased number of older adults in the population is the need for knowledgeable and clinically competent nurses to provide care for this group, especially those experiencing sudden changes in health status. A continuing education program was designed to improve geriatric nursing competencies through the use of clinical simulations. Three-day nurse educator institutes and one-day workshops for registered and licensed practical nurses were offered to 312 nurses. The clinical simulations that were developed specifically focused on acute health events or conditions. Specific geriatric clinical competencies were also emphasized. Different types of clinical simulations included unfolding cases, use of a human patient simulator, and online case studies. Geriatric nursing knowledge significantly increased and clinical simulations were well-received. Clinical simulations involving the human patient simulator were highly rated. Clinical simulations are an excellent teaching strategy to help nurses increase knowledge and skill in caring for older adults.

An urgent need for knowledgeable nurses to work with older adults exists.¹ A major driving force for this need is the rapid growth of the aging population.² By 2020, there will be 54.6 million Americans > 65 years of age; by 2030, approximately 71.5 million will be > 65 years old.³ Many will be living with complex chronic functional and medical conditions.

Older adults are heavy consumers of acute hospital care and extended health care services. Approximately 50% of older adults have at least 2 chronic conditions.⁴ Twenty-three percent of Medicare beneficiaries have ≥ 5 chronic conditions and take multiple prescribed medications.⁵ The combination of physiologic aging changes, coexisting chronic diseases, physical and cognitive impairments, and altered physiologic responses to pharmacological and other medical treatments can create certain health vulnerabilities. These include: (1) developing infections with atypical symptoms; (2) experiencing subtle changes in chronic disease states and other health conditions that can be overlooked by nurses and nursing assistants; (3) incurring negative consequences of hospitalization; and (4) worsening of cognitive and functional status.

Up to half of hospitalized older adults experience functional decline during hospitalization,⁶ yet few advanced practice geriatric nurses are employed in acute care settings.⁷ Hospital care has been cited as failing older adults⁸ and efforts are underway to meet the needs of medically complex older adults.⁶, ⁷

Older adults need age-specific acute and critical care services during the course of their hospitalization and recovery, regardless of the care setting. This care must be provided by nurses knowledgeable about normal physiologic changes occurring with age that can modify or compromise the body's response to acute illness in the presence of prevalent chronic conditions.

In the basic social contract with society, the nursing profession agrees to provide competent care in return for remuneration and status.⁹ As a consequence, nurses need to refine and update their clinical geriatric nursing skills in the identification and treatment of acute illnesses and conditions that can lead to deterioration of function. Besides geriatric age-specific care, nurses must also be aware of the racial and ethnic disparities of chronic illnesses. For example, 68.4% of black, non-Hispanic older adults in the United States are reported to have high blood pressure, as opposed to 49.7% of white, non-Hispanic older adults.¹⁰

Even for schools of nursing with an adequate number of faculty members prepared in gerontological nursing, significant and growing difficulties exist using the traditional method of clinical instruction with students at all levels of nursing involving acutely ill older adults. High patient acuity, short length of hospitalization, and lack of ready access to older patients with specific conditions or illnesses are some factors that challenge clinical practice educators' ability to provide adequate supervision and facilitate problem-solving in the clinical setting.¹¹ In addition, patient safety issues and a limited number of prepared nurse preceptors in critical care units can further exacerbate the challenge of providing learners with realistic clinical experiences.¹² Thus, alternate methods to assist staff nurses and nursing students in learning the competencies to work with critically ill older adults must be devised.

Unless academic nursing takes the lead in providing innovative models to prepare nurses in geriatrics, health outcomes of older adults will be undermined.⁷ This effort is made more challenging and the need more critical given the limited pool of nursing faculty prepared to teach geriatric nursing and given the projections of worsening nursing faculty shortages.

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Rationale for Geriatric Nursing Clinical Simulations 

The use of clinical simulations provides an innovative milieu to practice geriatric nursing skills that include high level problem-solving and multi-task performance in a risk-free environment.¹³ According to constructivist learning theory, all learning is individually constructed from one's experience during interaction with the physical, mental, and social world by building and adjusting current knowledge structures.¹⁴ This suggests that the focus of learning should be on constructing active learning environments and less on the delivery of content.¹⁵ The use of in-depth analysis of a case study allows learners to consider multiple facets of a clinical situation, expand their knowledge base, and develop problem-solving and critical thinking skills.¹², ¹³ These skills are particularly important with geriatric patients who have complex health issues, such as a frail, cognitively impaired person who fractures a hip in the long-term care setting and is subsequently transferred to an acute care facility. In this example, as in many real-life cases, multiple health needs exist concurrently and compete for nurses' attention and action. An unfolding case study adds the dimension of time, thus allowing the learner to experience the clinical situation as it progresses.¹⁶ Thus, both the novice and experienced nurse have the opportunity to critically examine clinical situations that are likely similar to ones they have already encountered. They are also able to share their perspective and expertise with other learners, refine critical thinking skills, and develop confidence in communicating with other healthcare providers as they analyze the unfolding case.

Focused questions guide the initial discussion of the situation, and more information is provided to the learner as the case unfolds. The additional information may include changes in physical or psychological symptoms, emergence of other symptoms or complications, physical assessment data, laboratory values, and changes in illness trajectory. Information regarding family circumstances, cultural practices, and emotional response to the clinical situation is also incorporated. As additional information is accumulated, focused questions lead the learner to further refine a patient-focused nursing care plan. Unfolding cases can also include the use of a simulated patient—a trained individual who uses a prepared script to respond to questions about health history, life circumstances, presenting physical and emotional symptoms, and other necessary details. Learners, with a facilitator, interview the simulated patient and devise a nursing care plan.

Another type of clinical simulation involves high fidelity, life-size human patient simulators (HPSs) that can be programmed and operated by a skilled technician to demonstrate key physiological parameters, such as respiratory rate, cardiac function, and pupillary response, with real-time responses to nursing interventions. These simulations facilitate the integration of the knowledge and skills essential for nursing assessment and management of the physiologically unstable and complex older patient. Evidence exists that the HPS is an effective clinical teaching and learning tool.¹¹

The purpose of this article is to describe an innovative continuing education program to improve geriatric nursing competencies in the care of older adults who experience an acute medical event or a sudden exacerbation of a chronic condition through the use of clinical simulations.

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Method 

Overview of the Program 

In 2003, the University of North Carolina at Chapel Hill School of Nursing was awarded a 3-year Comprehensive Geriatric Education Program grant by the Health Resources and Services Administration (HRSA, grant number D62HP01913). The specific purposes of this grant were to: (1) develop peer-reviewed geriatric clinical simulations in the long-term care and acute care settings appropriate for 3 levels of learner: registered nurses, licensed practical nurses and nursing assistants; (2) offer continuing education workshops using these simulations; and (3) develop an online library of these clinical simulations. An Advisory Board of clinical and academic nurse leaders (both registered and licensed practical nurses) was formed and met twice yearly to provide feedback about development of promotional materials, recruitment for the continuing education workshops, and strategies for sustainability of grant activities, including updating the clinical simulations developed over the course of the grant.

Clinical simulations were developed by members of the School of Nursing faculty and adjunct faculty members who are experts in geriatric nursing and clinical simulation. The clinical simulation writers initially met as a group to select the topics for the simulations. A topics list was generated from an earlier survey of nurses working in the long-term care setting who were asked to list conditions or illnesses that could go undetected and result in hospitalization, further comorbidity or death. Members of the Advisory Board also made suggestions for clinical simulation topics, and these topics were added to the list.

Geriatric nursing competencies from the American Association of Colleges of Nursing (AACN) and the John A. Hartford Foundation Institute for Geriatric Nursing, Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care were identified to be integrated into each clinical simulation.¹⁷ For example, urinary incontinence in the long-term care setting was selected as a topic, and assessment and critical thinking were selected as the target competencies. Besides clinical competencies, the care delivery setting for the clinical simulation was also selected so there would be a variety of cases set in the hospital, nursing home, or community setting. Cultural diversity was also emphasized in a number of clinical simulations. Examples of other clinical simulations include delirium in the acute care setting with the focus on communication and critical thinking competencies and development of transient urinary incontinence in the long-term care setting with a focus on assessment. See Figure 1 for a grid created to systematically direct case development.

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• Figure 1. 

  Examples of Topics, Geriatric Nursing Competencies, and Care Settings for Clinical Simulations.

Each clinical simulation was peer-reviewed by at least 2 content experts and an expert in instructional design. After revision, the clinical simulations were used in the workshops and were adapted to be posted on the online library to facilitate distance learning.

Participants 

Registered nurses (RNs), RN students, and licensed practical nurses (LPNs) attending 7 one-day RN Workshops and 4 one-day LPN Workshops, and RNs attending 3 three-day Nurse Educator Institutes (all workshops/institutes focused on Improving the Nursing Care of Acutely Ill Elders) were recruited to participate in the program evaluation. The School of Nursing's Department of Continuing Education used a variety of strategies to recruit participants to these programs: mass mailings of brochures, personal contact, telephone recruitment by grant staff and Advisory Board members, and postings about the workshops on the School of Nursing website (www.nursing.unc.edu). At the request of faculty members at a local community college, 32 nursing students, enrolled in an associate degree nursing program, attended one of the LPN and one of the RN one-day workshops.

Because detailed evaluations were requested of the participants, Institutional Review Board approval was obtained and nurses participating in the evaluation signed written informed consent forms. Even if nurses did not provide informed consent, they were able to participate in the workshops. All workshop participants received continuing education credits upon completion of the workshop.

Procedure 

One-day continuing education workshops were designed for 2 levels of learners: RNs and LPNs. In addition, nurse educators desiring to learn how to use clinical simulations in their home agencies attended a 3-day nurse educator institute (NEI). During this institute, the nurse educators learned the theoretical basis for use of clinical simulations in nursing education and how to develop unfolding geriatric clinical case simulations. The format for the didactic geriatric nursing content and actual hands-on use of clinical simulations was the same for the RN and LPN workshops and the NEIs.

During the first part of the RN and LPN workshops and NEIs, nurses received current scientific information on epidemiology and etiology for common geriatric conditions or events that frequently lead to acute exacerbations or acute adverse reactions (such as heart failure and falls). They also received related information about evidence-based nursing practice. This material provided the foundational information needed for the geriatric clinical simulations on the same topics used later during the RN and LPN workshops and NEIs. A component on cultural diversity was also included for all participants.

The second half of the RN and LPN workshops and NEIs involved small groups rotating through 4–5 interactive clinical simulations of varying types, dependent upon the number of participants. For example, an unfolding case study involving an acute urinary tract infection in a hospitalized older woman was included. The geriatric clinical competencies stressed in this simulation were disease management and communication. Another unfolding case study involved the use of a simulated female patient with depression and it addressed communication, disease management, and leadership competencies. The clinical simulation that used the HPS addressed acute exacerbation of chronic heart failure and pulmonary edema in the emergency department and addressed disease management and communication competencies. An online clinical simulation explored the use of physical restraints with a cognitively impaired older adult and focused on communication and technical skills competencies. Other clinical simulations were used over the course of the grant, including topics such as sepsis in the geriatric patient and providing culturally appropriate care to older adults with pneumonia.

Nurse educators participating in the NEI also learned how to address differences in learning styles, develop geriatric clinical simulations, effectively use resource materials, and use clinical simulations in their home agencies. NEI participants also had the opportunity to write and present their own unfolding geriatric clinical simulation.

All RN and LPN workshop and NEI attendees participating in the evaluation component took the same short geriatric nursing knowledge quiz on the content covered in the clinical simulations prior to the start (pre-test) and at the conclusion (post-test) of the RN and LPN workshops (1-day) and NEIs (3-day). During the first year, the test consisted of open-ended questions and reliable grading was difficult. Multiple choice tests, consisting of 4 questions for each of the clinical simulations (for example, urinary tract infections, chronic heart failure, depression in older adults) used during the RN and LPN workshops and NEIs were used in the following years; only those results will be presented.

Nurses were also asked to evaluate: (1) each component of the didactic geriatric nursing portion of the workshop; (2) each clinical simulation based on the following elements: clarity, realism, accuracy and flow of the case, promotion of information integration, and the clinical simulation's relevance to practice; (3) whether they increased their skills in each area covered by the simulations; and (4) whether they increased their skills in providing care to diverse populations.

All data entered were double-checked by a second person to ensure accuracy. Statistical Package for Social Sciences (SPSS) was used for statistical analyses. Paired t-tests were used to compare pre-test and post-test scores. Krushkal-Wallis tests for k-independent samples were used to compare the non-parametric data. For continuous variables, analysis of variance was used to test statistical differences among types of workshops (NEI, RN, LPN) and t-tests were used to compare RNs and LPNs.

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Results 

A total of 312 nurses participated in 14 continuing education (CE) offerings: 7 RN workshops, 4 LPN workshops, and 3 NEIs. Informed consents were signed by 283 participants (90.7%). The 29 participants who did not sign informed consent forms were scattered across the CE offerings except for the last LPN workshop, in which only 7 of 15 informed consent forms were submitted. This may have been due to a personnel change in the CE department prior to the workshop and the person was unaware to draw attention to the consent form. Of the 283 volunteers participating in the evaluation, 159 attended the RN workshops, 80 attended the LPN Workshops, and 44 attended the NEIs. Only data from consented participants were included in the research analyses.

Demographic data were not collected at the first NEI and RN workshop; therefore, the demographic results represent responses for 243 attendees at 6 RN workshops (n = 139), 4 LPN workshops (n = 81), and 2 NEIs (n = 23). Attendees across all workshops included: 141 RNs, 68 LPNs, and 32 nursing students. Two attendees did not indicate their professional status.

The average age of the participants (n = 243) was 43.5 years (standard deviation = 12.04 years). The majority were women (94%); 70% were white and 23% were black. When RN participants and LPN participants were compared (nursing students omitted) across all CE offerings, statistical differences in ethnicity (χ² = 4.406, df = 1, n = 208, P < .05) and age (t = 2.135, df = 205, n = 139:68, P < .05) were obtained, with 75% of the RNs identifying themselves as white as compared to 56% of the LPNs. Registered nurses, on average, were older than LPNs, 46.9 years (sd = 10.8) vs 43.4 years (sd = 11.25) respectively. Only 9.3% of participants had certification from AACN in gerontological nursing or were working on certification.

The majority of participants, excluding nursing students, at the RN and LPN workshops were staff nurses (54.3% and 92.6% respectively). No students attended NEIs. The majority of NEI participants identified their role as staff development (39.1%), supervisors, managers, or directors of nursing (21.7%), or instructors (21.7%), with 52.3% of them spending > 50% of their time teaching. Participants in each work role expected to use their experiences from the conference both in clinical practice (91.6%) and to teach others (67.7%). The NEI attendees were focused on teaching others (95.7%).

The differences between pre-test and post-test geriatric nursing knowledge scores were statistically significant. Overall the pre-test average score was 62.7% and post-test score was 76.8% (P < .01) (Table 1). Over 90% of participants agreed or strongly agreed that they had increased their skills in each of the content areas covered in the RN and LPN workshops and NEIs. When further explored by type of workshop, no statistical differences (χ² tests) were obtained.

Table 1. Differences in Mean Pre-test and Post-test Scores

	LPN (n = 39) % (SD)⁎	RN (n = 66) % (SD)	NEI (n = 18) % (SD)	ALL (n = 123) % (SD)
Pre-test	67.7(10.3)	59.8(11.3)	62.8(8.5)	62.7(11.1)
Post-test	78.6(9.1)	75.0(8.0)	79.4(7.5)	76.8(8.4)
t-statistic	6.774	10.448	5.978	13.653
df†	38	65	17	122
P-value	<.001	<.001	<.001	<.001

Overwhelmingly, each component of the workshops was highly rated by the participants. For example, 91% of NEI, 94% of RN, and 96% LPN workshop participants rated the didactic geriatric nursing portion as good or excellent (data not shown). Every unfolding case used in the RN and LPN workshops and NEIs was rated as very good or excellent by ≥ 80% of the participants. Clinical simulations using the HPS were very popular and consistently had the highest ratings across the evaluation items. Over 95% of participants rated the reality of the HPS case very good or excellent. The participants also rated the online cases highly. Table 2 shows the results from the evaluations completed during all 14 CE offerings across the 3 years of the study. As previously noted, for each workshop, one HPS case, at least 2 unfolding cases, and 1 online case were used. Thus, attendees participated in more unfolding cases than in HPS and online cases, therefore more evaluations for unfolding cases were completed. In addition, a high proportion of participants agreed or strongly agreed on the overall evaluation of the workshops that the simulations helped them to integrate information presented (range of scores: 96.1%–97.2%) and that they will use the information in their clinical settings (range of scores: 95.3%–96.9%).

Table 2. Percentage of Respondents Strongly Agreeing or Agreeing that the Clinical Simulations Increased Their Skill Level for Each Clinical Simulation Used in the Workshops

Many nurses provided open-ended comments on their evaluation forms. Comments about the HPS cases were clearly enthusiastic, such as “loved this! Great to work as a team in a realistic emergency situation. The use of the roles with designated duties was very helpful”; “very impressed with how case could be made easier or more difficult depending upon the audience and need”; “excellent hands-on learning. Immediate feedback!” Similar enthusiasm was expressed for other hands-on methods, such as the use of simulated patients: “role play with actor was a great experience”; “using an ‘actor’ was great. This was something new to me”; “excellent, will be able to duplicate in my setting.” Comments on the online case demonstrated a positive reaction to the use of technology, such as “can be used in any setting”; “flexibility of doing case at home, school, etc.”; “excellent—wish we had this at our institution”; “very complete; loved it”; “kept my interest, informational.” Comments on the unfolding cases reflected less enthusiasm, but a positive experience: “role play participation is good”; “good for group discussions.”

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Discussion 

There is great need for nurses with geriatric nursing competencies in assessing and treating acute exacerbations of chronic conditions, new acute illnesses or sentinel events such as hip fractures. Evidence of nurse shortages, especially those with geriatric expertise, is alarming to nurse educators and clinicians desiring to improve geriatric nursing care. Many initiatives in schools of nursing¹⁸ and in hospitals¹⁹ are underway. Increasing geriatric competencies in already-practicing nurses can be challenging in CE venues. The grant from the Health Services and Resources Administration funded the development of geriatric clinical simulations that can be used in CE offerings as unfolding case studies, human patient simulations, case studies with simulated patients, and as online clinical cases.

The participants in the NEIs and RN and LPN workshops are similar to the national profile of nurses. In 2004, the average age of RNs was 46.8 years and 81.8% were estimated to be white.²⁰ The average age of LPNs nationally was 42.1 years and 69.9% were reported to be white.²¹ Post-test geriatric nursing knowledge scores of both RNs and LPNs increased significantly, on average, improving from 62.7% to 76.7%. The pre and post tests were based on the latest available evidence-based geriatric nursing literature. Because the average post-test score was < 80%, nurses need to continue to increase their level of geriatric nursing knowledge and to keep it current through journal reading and attending CE offerings. The participants also reported that their clinical and communication skills increased through the interactive venue of the offerings. Formal measurement of skill improvement would have been ideal, but it was beyond the scope of this project. Thus, caution in interpreting self-report skill acquisition or improvement is necessary.

The geriatric nursing content provided was intentionally similar to other educational programs,²² as nurses need foundational knowledge to inform their practice. The geriatric clinical simulations were developed to be used as in-person group exercises and independent online venues to increase their usability as a learning strategy for practicing nurses. Incorporating geriatric competencies into nursing curricula is not new; however, disseminating this information to all nurses in various practice settings so that baseline geriatric competency is achieved is an essential goal for nurse educators.²³ In addition, because older adults can and do experience sudden and often subtle changes in their health status, nurses need to be aware of how to identify and communicate these changes to other health care providers to initiate swift and effective care. The clinical simulations developed as a part of this federal grant address the needs of older adults experiencing sudden changes in health due to worsening of a chronic condition or development of new comorbidities. Most curricula are aimed at the general care of older adults, such as cognitive needs, functional assessment, and physiologic response to medications, and do not focus on the knowledge and skills needed in specific acute situations.

One lesson learned from this project is that writing geriatric clinical simulations in which an older adult's health status is undergoing an abrupt change is a challenging and labor-intensive endeavor. More work was required in leveling the cases to be appropriate for the scope of practice for each group of learners (RNs, LPNs, and nursing assistants) than had been expected. It is, however, a doable project. Clinical and academic nurses joined in this venture as workshop faculty, case writers, and reviewers, creating stronger bonds and partnerships between clinical and academic nurses. Besides these close partnerships, working with experts in evaluation, simulation, instructional design, and web development is crucial. Proactive planning regarding the content to use for workshops, including PowerPoint slides, reference resource materials, and clinical props to provide realism for the HPS, was essential to the success of the programs.

This project provides evidence that nurses readily learn about acute changes in the health of older adults using clinical simulations, and that they enjoy the process. An additional benefit has been faculty requests to use these simulations with their undergraduate nursing students. A limitation of this study was the reliance on nurses' self-reports of changes in their skill level. Ideally, observation of the nurses in their home agencies would assist in determining the impact of this type of educational offering on patient care.

Because traveling to CE venues can be challenging to nurses working and living in rural areas, a competing continuation application was submitted to and awarded by Health Services and Resources Administration to implement a “train the trainer” model with nurse educators in North Carolina's Area Health Education Centers (AHEC). The faculty at UNC-Chapel Hill will train nurse educators at 4 AHECs in the state to implement these successful workshops in their local communities. Nurses will travel to CE offerings in their locality, as will nursing assistants who are often the primary providers of direct care to older adults in many healthcare delivery settings. A virtual Center of Geriatric Clinical Simulations is currently being developed to address the needs of acutely ill older adults and will be available for RNs, LPNs, and nursing assistants.

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Conclusions 

Clinical simulations are effective in increasing geriatric nursing knowledge. Nurse participants enjoyed the interactive nature of clinical simulations, especially those that used a HPS. Research is needed to determine if the self-reported increase in skills levels translate into better patient care.

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The authors would like to acknowledge Carolyn Davenport, Kevin Morgan, Kay Hengeveld, Dr. Judy Miller, the Advisory Board and peer reviewers of the clinical simulations for their assistance with this study.

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