Every day, on every shift, rural nurses experience geographic and professional isolation. Confined by geography, staff in rural hospitals practice as generalists by necessity, seeing illness and injury in patients across the lifespan. Challenged by lack of equipment, poor access to consistent continuing education and training, and lack of clinical resource mentors, they rarely have the chance to practice low-volume, high-risk skills in a safe, controlled environment.
Yet to provide safe patient care and demonstrate clinical competence, they need to acquire and apply new knowledge. Many rural nurses have limited opportunities to become “expert generalists” with regard to specialty nursing content, credentialing, or certification. Without nurse-to-nurse mentoring, registered nurses (RNs) in many rural healthcare settings are expected to practice in a self-sufficient, autonomous manner. Additional knowledge, skills, and training would advance their careers as they develop their expert generalist practice.
Duke TEAM: Supporting rural nurses’ learning needs
To address these issues, project educators in the education and professional development department of Duke University in Durham, North Carolina saw an opportunity to use their expertise to support nurses’ learning needs in four rural hospitals that had established relationships with their organization. Titled the Duke TEAM (Training, Educating, and Mobile), the project was developed to bring blended learning educational activities to these rural areas, using human simulation as a modality.
The purpose of the project, as authorized in Public Health Service Act, Title VIII, and the American Recovery and Reinvestment Act of 2009, was to strengthen the capacity for basic nursing education, practice, and retention. The EETHP-NEPR initiative (Equipment to Enhance Training for Health Professionals—Nursing Education, Practice, and Retention) supported equipment purchase for projects designed to strengthen the nursing workforce.
RNs practicing in rural and underserved settings across North Carolina provide accessible nursing care to patients and families in their own communities. According to the Health Resources and Services Administration (HRSA), 68 of 100 North Carolina counties are medically underserved areas (MUAs) and 26 are partial MUAs. Emergency departments are filled to capacity with patients and families seeking primary care or care for life-threatening emergencies.
To determine the needs of the community, four regional community hospitals were chosen based on their location relative to the education department and potential patient transfers between organizations. Chief nursing officers (CNOs) from each hospital were surveyed through a written needs assessment. Two important responses were clear:
- All respondents answered “yes” when asked if they would participate in a mobile simulation/education program.
- All four CNOs said their hospitals didn’t own high-fidelity simulation equipment but stated they would be interested in simulating low-volume, high-risk skills. Each also said they had sent nurses to courses offered at outside facilities. However, this was no longer an option, as travel dollars, staffing schedules, and patient volumes posed unique barriers. With this in mind, an educational plan was created to meet the needs of the rural RN learners.
Project educators, already familiar with human simulation as a teaching modality, would now provide this modality as the project’s cornerstone. An education wheel was created to capture this plan and travel schedule for the target hospitals so that everyone involved would know what to expect. (See the box below.)
Identifying required resources
The next step was to identify resources needed to implement the plan. The education wheel was used to make decisions about the number of instructors needed and additional equipment purchases. With federal grant money totaling $294,155, three high-fidelity and eight moderate-fidelity simulators were obtained from various vendors. These simulators were added to a previously purchased SimMan® 3G and several partial task trainers used for life support classes.
Developing learning scenarios
Once these steps were complete, Duke educators were ready to develop learning scenarios in partnership and collaboration with staff educators in the rural hospitals. A follow-up needs assessment was completed. Final educational priorities for the hospitals consisted of mock codes, recognition of the decompensating patient, and development of critical-thinking skills. Not surprisingly, specific content requested included shock states, heart-rhythm recognition, and low-volume, high-risk specialty topics, such as pediatric assessment, obstetric emergencies, and neonatal resuscitation.
Content was developed using a nurse-to-nurse partnership with staff educators at each hospital to individualize and confirm that their needs would be addressed. The result was a blended learning approach of interactive case studies, audience response, and simulated experiences. Once more, the education wheel provided clarity as educators began to implement their activities.
Overall, 480 individuals participated in the training over a 1-year period. Participants included staff nurses at rural sites, academic health system staff, and allied health professionals in participating rural hospitals. To promote high-quality care, patient safety, and optimal clinical outcomes, it was essential to include interprofessional cross-team training in the care of complex med-surg and trauma patients.
To determine project outcomes, two instruments were chosen to document staff satisfaction with simulation and confidence in using simulation during a learning activity. The National League for Nursing/Laerdal Medical developed tools for a national study of nursing students and simulation. Using the instruments in this project demonstrated that the tools could be used with practicing nurses across settings. (See the box below.)
Instruments to determine project outcomes
The Educational Practices in Simulation Scale measures the educational practices of active learning, collaboration, diverse learning methods, and high expectations present in instructor-developed simulation, as well as their worth and merit to the learner.
The Self-Confidence in Learning Using Simulation Scale measures students’ confidence in the skills they practiced and their knowledge about caring for the specific type of patient in the simulation. Participants found simulation enhanced learning, satisfaction, and confidence with low-volume, high-risk skills. No differences were found among rural and urban populations.
Class evaluations and anecdotal comments made during the activities offered additional evidence that the project and the team’s expertise were well-received. Participants evaluated each class and gave written feedback on their experience.
Nurse-to-nurse mentoring between project educators and rural educators led to several positive outcomes. The project gave rural educators access to experienced educators well-versed in clinical practice guidelines and organizational standards. Cross-coaching in applying standards to the development of critical thinking proved beneficial for staff educators. In addition, the collaborative process used to develop the educational activities provided mentoring experiences mutually beneficial to all. This included planning and program development, starting with a needs assessment and ending in a blended learning approach.
All activities were designed to capitalize on the use of resources currently available at each hospital to meet future needs, including low-fidelity simulation and task trainers that would achieve similar results. For instance, staff educators at one rural hospital changed their method for running mock codes to a more interactive approach. The interactive blended learning modalities used to teach content across all age spans resulted in staff confidence and satisfaction.
Simulation-enhanced education and nurse-to-nurse mentoring led to positive clinical practice outcomes. Follow-up contact with each hospital revealed a positive impact on practice and the care of patients and families. At one hospital, staff nurses who’d attended a class focused on adolescent patients undergoing orthopedic surgery for scoliosis verbalized the comfort level they felt with that patient population after training. They recommended including the activity for future unit hires. An emergency department nurse attending a class on obstetric emergencies stayed after class to practice skills on the high-fidelity mannequin, including fundal assessment, fetal heart tones, cervical dilation, and assisting with childbirth. A month later, she reported she’d put these skills into practice and felt comfortable using them in a real situation.
A great equalizer
At the start of the project, the team had predicted differences in learning, satisfaction, and self-confidence with low-volume, high-risk skills for nurses who lived and practiced in rural areas. They also had questions about the level of education and experience, as well as the perception that the nurses had different levels of continuing educational exposure and technology experience.
Despite these preconceived notions, the team discovered that simulation as a teaching and learning method was a great equalizer. No differences occurred in participant learning, satisfaction, or self-confidence. Participants expressed high satisfaction with learning and high confidence with skills. Appropriate use of the educational strategy and the collegial relationships established from the nurse-to-nurse mentoring had formed a strong foundation for success.
Pamela B. Edwards is associate chief nursing officer for Education at the Duke University Health System in Durham, North Carolina, and director of Duke’s Clinical Education & Professional Development. She is also an associate consulting professor at the Duke University School of Nursing and deputy director of the Duke Area Health Education Center.