Dr. Halstead is Executive Associate Dean for Academic Affairs and Dr. Phillips is Director RN to BSN Consortium and Clinical Assistant Professor, Indiana University School of Nursing, Indianapolis, Indiana. Ms. Koller is Dean and Associate Professor, Ivy Tech Community College-Central Indiana, Indianapolis, Indiana. Ms. Hardin is Director, BSN Programs, Marian University, Indianapolis, Indiana. Dr. Porter is Associate Professor, University of Indianapolis, Indianapolis, Indiana. Ms. Dwyer is Alumnus CCRN, Indiana University Health, Indianapolis, Indiana.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This project was generously funded by the Richard M. Fairbanks Foundation, Indianapolis, Indiana.
Presented at the National League for Nursing Education Summit, September 26, 2009, Philadelphia, Pennsylvania.
Address correspondence to Judith A. Halstead, PhD, RN, ANEF, Executive Associate Dean for Academic Affairs, Indiana University School of Nursing, 1111 Middle Drive–NU 120, Indianapolis, IN 46202. E-mail: firstname.lastname@example.org.
The complexity of caring for acutely ill patients safely in today’s health care environment continues to cause critical concern for health care providers. The educational implications associated with the challenges of these patient care demands require that nurse educators consider new ways to practice and provide education to collaborate to best prepare nurses to function in this environment. Academic institutions are seeking “best practices” by which to instill the knowledge, skills, and attitudes needed for safe practice; practice settings are seeking ways to validate and maintain up-to-date competencies among nurses (Halstead, 2009).
In recent years, simulation technology, especially high-fidelity human patient simulation technology, which simulates realistic patient responses to treatment, has assumed an increasingly prominent role in the education of nursing students and staff nurses. The use of simulation technology provides learners with a safe environment in which to develop the requisite practice competencies and clinical reasoning skills for delivery of safe patient care. Critical events, such as emergency resuscitation, that occur relatively infrequently yet require astute and prompt clinical intervention can be simulated through the use of technology, allowing health care providers the opportunity to maintain their clinical skills (Fort, 2010). It is assumed that acquiring such skills in a controlled environment will foster the transition of the same skills into the practice setting and thereby improve patient safety. Many schools of nursing and acute care health care agencies are seeking ways to acquire and integrate the use of clinical simulations into their programs.
However, the integration of simulation technology into the curriculum of any institution involved in nursing education requires a significant investment of resources—human, financial, and physical (equipment and space). Acquiring and maintaining the equipment is only one expense; developing and supporting the expertise needed by nurse educators to develop simulated clinical scenarios, integrate simulations into the curriculum, and evaluate learner outcomes is another significant resource demand. Many institutions, both academic and practice, lack the resources and expertise needed to implement simulation technology into their educational curricula. This is especially true in practice settings where nurse educators have multiple responsibilities for staff education and little time is allocated for their own skill development in new pedagogical strategies, such as simulation.
One way to address these resource issues is to form partnerships between schools of nursing and health care agencies that allow for institutional collaboration to train educators in the use of simulation technology. This article describes one such partnership that emerged between schools of nursing and health care agencies through the use of a consortium model. Academic and practice institutions can replicate this consortium model in their own regional communities to foster educator development in the use of simulations.
Purpose of the Consortium
The initial purpose of the consortium was to facilitate faculty development in the use of simulation technology as well as to develop and evaluate best practices in the integration of simulation into undergraduate nursing curricula. Funding for this project came from a private foundation in the form of a 3-year grant, with each school receiving funding proportional to its size. The private foundation approached the schools’ deans specifically seeking a project that would benefit the faculty and students of the four regional schools of nursing and improve health care. The need to integrate simulation technology into the curriculum was identified by all four schools, and thus it became the focus of the grant. In the first year, development activities were limited to the faculty of the four schools to develop a core group of faculty experts who could serve as simulation champions within their own institutions. It quickly became apparent, however, that health care agency staff development educators had an equally acute need for preparation in the use of simulation technology. Therefore, with the strong endorsement of the funding foundation, the grant’s original goals were expanded, and staff development nurse educators from three area health care agencies were invited to participate in the grant activities in the remaining 2 years of the grant, along with their academic colleagues. This academic-practice partnership served to strengthen the outcomes of the grant and increased the speed with which the technology has been integrated into the health care institutions.
One unique aspect of this consortium model was the variety of missions of the institutions involved. Although the academic institutions had historically enjoyed positive relationships, this project marked the first time that they had actively collaborated around a singular purpose. The academic institutions included a state-supported community college nursing program; two nursing programs in moderately sized, private, comprehensive liberal arts universities; and one public university nursing program based in a large, research-intensive, academic health center. The health care agencies were also diverse and included a large urban teaching hospital system located in an academic health center, a 1,000-bed community-based hospital network, and a large, religiously affiliated health care system.
A consortium model enhances relationships among institutions by reducing competition and promoting collaboration with shared goals (Ciesielka, Conway, Penrose, & Risco, 2005). Sustainable partnerships can also provide a common frame of reference and understanding about what is needed to expand the delivery of goals between the institutional members (Long, 2007). To achieve a sustainable partnership in this consortium, the partners developed consortium model principles to guide their activities.
Consortium Model Principles
The consortium model initially evolved from discussions that were held with the four academic deans of the schools of nursing. Because the consortium was initially conceived to meet the development needs of the faculty of the four area schools of nursing, the funds were awarded directly to the schools and the deans remained accountable for the expenditures and outcomes associated with the grant for the 3-year grant period. To ensure that the input of the area health care employers was sought, the deans invited the senior nursing leaders of the area health care facilities to serve on an advisory board that included national experts to guide implementation of the project. In this manner, work force development needs were addressed and incorporated into the grant activities.
Because of the significant variation in mission and size of the academic institutions, the academic leaders believed that it was essential for all consortium model partners to agree to a set of principles that would guide decisions made by the consortium and respect the different missions of the institutions. The overriding principle was that all institutions involved were equal partners in the consortium, so all decisions were to be made collaboratively by the deans of the four schools. To demonstrate this equitable relationship, the project funding was awarded directly to each individual school by the funding agency, with each school responsible for managing its own grant budget.
Another principle of the consortium was that all learning objects (clinical simulation scenarios) developed through the consortium were to be made available to all consortium partners for their use in the nursing curricula. Because most of the learning objects were created by teams of educators from all four schools, with health care agency nurse educators participating in the scenario development activities, all academic and practice institutions enjoyed free and unlimited access to the developed learning objects for educational purposes.
A final principle of the consortium was built on the concept of a faculty “champion” model. Because a limited number of educators could participate in the grant activities due to space and funding restrictions, implementing this principle meant that the nurse educators selected to participate were expected to return to their respective academic and practice institutions and help to train their colleagues in the use of simulation technology. In this manner, the effect of the consortium was significantly extended beyond the educators who actually participated in the training.
For institutions considering such collaborative ventures, the importance of the time spent in dialogue about guiding principles for the partnership cannot be overstated. The open discussions that the consortium partners had about their responsibilities and expectations as the consortium was initially formed established a common frame of reference, helped to ensure respect for differences in institutional missions, and thus contributed to the long-term sustainability of the consortium.
Curriculum Model for Consortium Activities
The curriculum model used to guide consortium activities was based on the National League for Nursing simulation model (Jeffries, 2007). This model is adaptable not only to academic settings but also to staff development and continuing education settings because of its foundation in the seven principles of good practice in education. These principles include active learning, feedback, student-faculty interaction, collaboration, high expectations, diverse ways of learning, and time on task (Chickering & Gamson, 1991). The seven principles were threaded throughout the consortium curriculum, with the goal of fostering best practices in using simulation.
Implementation of the curriculum model was designed with an initial immersion experience followed by monthly meetings of the participants during the academic year. The program commenced with a face-to-face week-long intensive workshop conducted by simulation technology experts. Participants from the schools of nursing and health care agencies were chosen by their administrators to participate based on their willingness to champion simulation in their respective institutions. The champion model allowed each institution to send educators who committed to train additional educators in their institutions and serve as resources on the best practices of simulation.
Topics and activities in the week-long immersion workshop included an overview of the different types of simulators, how to program high-fidelity mannequins, strategies for integrating simulations into the curriculum, evidence-based findings associated with simulations, development of an institutional implementation plan for simulations, the art of debriefing, evaluation methods, and application of the seven principles of good practice in education. In subsequent annual immersion workshops, the nurse educators who had attended in previous years were invited back to participate as facilitators. This approach helped to foster continuity between past and current participants and further strengthened the skills of regional area nurse educators who were learning to use simulations effectively.
During the immersion experience, all participants worked in small groups to develop a simulated clinical scenario that they could use in their collective curricula. Group members were specifically divided so that participants from the various institutions were intermingled. The scenarios that were developed were demonstrated to the entire group on the final day of the workshop, followed by feedback from experienced consortium faculty. In addition, using an easily accessible course management system, an online repository was set up to share information and resources about planning, implementing, and evaluating the simulations. Sidebar 1 contains examples of the simulated clinical scenarios developed through the consortium and shared by all institutions.
Examples of Clinical Simulation Scenarios
Care of the neurologically impaired patient
Care of the patient experiencing postpartum hemorrhage
Admission assessment of the patient in labor
Postoperative care for the patient undergoing open-heart surgery
Care of the patient in preterm labor
Care of the patient experiencing preeclampsia
Care of the patient with atrial fibrillation
Community health care: assessment of the home
Implementation of standing orders
Community health care: patient with acute infectious respiratory illness and mental health issues
Care of the patient with pediatric sepsis
End-of-life pain management
Fundamentals of pain assessment
After participation in the immersion workshop, participants returned to their individual institutions and implemented the simulations in their curricula. Monthly follow-up meetings of the participants, lasting approximately 1 to 2 hours, were held. The meetings emphasized collegiality, networking, and sharing information about successes and challenges in implementing simulations. Additional teaching-learning sessions also occurred during these monthly meetings on selected topics, as requested by the participants. Topics included scheduling simulated learning experiences for large numbers of learners, advanced programming of equipment, acquiring resources for simulation facilities, and evaluating learner outcomes. The monthly meetings provided opportunities to reinforce best practices in the use of simulations and generated feedback as the educators shared their experiences.
Resources for Consortium Implementation
Institutions contemplating forming a consortium arrangement to facilitate nurse educator adoption of simulation technology need to identify the resources required for successful implementation. In this consortium model, resources were required for equipment acquisition, educator training, project implementation, and evaluation of project outcomes. A collaborative approach to such initiatives is viewed positively by potential funding partners and will increase the likelihood of garnering financial support from the external community.
A consortium steering committee, consisting of academic leadership from the four funded schools of nursing that had agreed to partner for the grant, guided consortium activities. Health care agency representation was not included on the steering committee because the grant was not initially conceived as an academic-practice partnership and grant funds were awarded directly to the four schools. After the grant was awarded, the academic deans remained fiscally accountable and responsible for reporting grant outcomes to the foundation for the duration of the project. The steering committee decided to obtain input and feedback from health care agency representatives in an advisory capacity. This approach worked well for the purposes of this project.
The steering committee met quarterly, held fiscal responsibility for implementation of the project activities, provided overall direction for project activities, and also assumed responsibility for developing guidelines for the protection of intellectual property rights for the clinical scenarios developed by the educators within consortium activities. The committee consulted with a copyright and intellectual property law expert. The main principle regarding intellectual property rights that was adopted by the consortium partners was that all clinical simulation scenarios developed within the consortium remained the joint property of the partners for unlimited use for educational purposes.
An eight-member national advisory board was appointed to guide the development, implementation, and dissemination of the consortium’s activities. Area clinical agency partners, national clinical simulation experts, academic and business leaders, and other stakeholders were invited to be members. The board met annually and helped the consortium partners to develop a plan for sustainability of the consortium.
Resources for supporting faculty participants included funds to provide “scholarships” to cover the registration costs to attend the 5-day workshop as well as a modest stipend for attendance during the summer, when most faculty were not on contract. All participants were awarded continuing nursing education credits for workshop attendance. Funding from the grant provided a partial reduction in the registration fees for the clinical agency staff development educators who attended the immersion workshop. Because their time commitment to attend the workshop was integrated into their workweek, they did not receive a stipend to attend the workshop.
Faculty, who were designated as “simulation scholars” within their institutions by virtue of their participation in the project, were also given release time to integrate simulation technology into their programs’ curricula and train additional faculty colleagues in the use of simulation technology. The release was equal to one course for one semester. Faculty considered this course release a crucial element of their success in integrating the use of simulations within their institutions. This has implications for staff development nurse educators in clinical settings who are charged with championing simulations because release time typically is not provided in those settings. For successful implementation into clinical agencies, it is important for administration to consider means by which responsibilities for integrating simulations can be accounted for in the workload of staff development educators and not simply considered an “add-on” to their other responsibilities.
Before the formation of the consortium, the extent of simulation equipment available at each school varied from none to high-fidelity human patient simulators. Limited funds for purchasing simulation equipment were built into the grant during the first year of the project, and schools purchased equipment based on their individual needs. This approach ensured that each school would have the basic equipment resources necessary to incorporate clinical simulation into their curricula. Health care agencies made decisions to purchase their own simulation equipment as the staff development educators became more knowledgeable about how to best integrate the technology into educational programs. Although this project did not support the purchase of “shared” simulation technology equipment between institutions, for many communities, developing and jointly operating a community-based simulation center that is shared by academic and practice partners represents the best use of resources and can be an attractive proposal to potential funders.
Evaluation of the effectiveness of the consortium model in changing educator and learner outcomes was also supported through the consortium grant. Learner outcomes were evaluated by a number of measures, including psychomotor skills checklists, student satisfaction with learning and perceived knowledge of clinical decision-making, standardized testing, course grades, and National Council Licensure Examination results. Evaluation of educator outcomes included measurement of knowledge acquisition about the use of simulations, self-efficacy with using simulations, and satisfaction with integrating simulation technology into teaching strategies. Long-term plans include collaborating with clinical agency partners to evaluate students’ transfer of clinical decision-making skills to their practice environments after graduation.
Consortium Model Outcomes
The use of a consortium model to prepare nurse educators to use simulation technology produced a multitude of positive outcomes in academic and practice settings. During the 3-year grant period, a total of 41 nurse educators (33 nursing faculty and 8 staff development nurse educators) participated in the grant activities and were trained in the use of simulation technology.
Through the immersion workshop, 15 clinical scenarios were developed for use by all partners. However, after their participation in the workshop, educators have continued to develop an estimated additional 38 clinical simulations. The simulation scenarios that are being developed address clinical situations that have been collaboratively deemed by faculty and clinical practice partners as important for nursing students to experience during their nursing education.
Integrating the use of simulations and serving as nurse educator champions within their institutions was an expectation of the simulation scholars. Individual participants were charged with the task of taking the simulation experience back to their respective institutions to foster further implementation and educator development. This champion approach has been effective in creating a critical mass of nurse educators in the region who are competent in the use of clinical simulations. To date, it is estimated that more than 5,700 students across all four schools of nursing have participated in the simulations that educators have created over the last 3 years. In addition, two of the clinical agency partners that participated in the workshop reported that 478 staff nurses have experienced simulations as one means of validating their clinical skills.
Nurse educators also indicated an increased sense of self-efficacy related to the use of clinical simulations, helping to ensure continued integration of simulations into the curricula (Milgrom & Halstead, 2009). Simulations have been embraced as a teaching strategy across all levels of curriculum. A repository of simulation scenarios was created for sharing across institutions, and the issue of intellectual property rights was addressed with the intent of ensuring joint ownership by all participants.
The emphasis on developing best practices for the use of simulations provided a new framework for nurse educators to use with a number of teaching strategies. It also provided a means to re-energize teaching using new technology. Whether one teaches in an academic or a practice setting, letting go of old paradigms regarding teacher-centered versus student-centered learning is both challenging and liberating. The common experience of working together in groups with representation from different institutions and freely sharing developed scenarios contributed to the high level of collaboration in this project.
One of the most effective strategies for developing collaboration was the regular monthly meetings of the participants held throughout the course of the year. Simulation interest groups led by the nurse educator champions were also formed at each institution for all educators with an interest in simulation. The simulation interest groups promoted the long-term integration of simulation into the various program curricula and allowed educators to continue to act as change agents within their institutions.
To further contribute to the development of best practices in the use of simulation technology, the participants have been encouraged to join professional organizations and present outcomes related to their work. Data have been collected on simulation design, student satisfaction, confidence, attitudes toward instructional methods (simulation), and demographics. One group of educators developed a simulation project for a multiple-site study that focused on learner outcomes across institutions. Additional single-site research projects at the various consortium institutions have also been implemented. Dissemination of outcomes has occurred through local, national, and international presentations, and several groups are preparing manuscripts for publication. Dissemination of outcomes will be valuable to nursing practice, nursing education, and other health professions as investigators continue to develop an evidence base on the effectiveness of simulation technology in education and practice.
In addition, many participants reported that the ongoing networking and collaborative relationships provided the single most important outcome (Milgrom & Halstead, 2009). Relationships among a statewide community college, two private universities, a public university, and their clinical agency partners have been strengthened. The consortium model has offered a means for sharing resources and promoting the development of nurse educators within the community, and this model can be used to address other shared educator development needs. Although the project was not initially developed as an academic-practice partnership, but instead evolved into one, the relationships that it fostered have reinforced the importance of collaboration between academia and practice to further common goals. Sidebar 2 further describes outcomes identified by a staff development nurse educator as a result of participating in the consortium in collaboration with educators from the academic setting.
Benefits of Participating in the Simulation Consortium From the Perspective of a Staff Development Nurse Educator
The opportunity given to me, as a service partner, to participate in the intensive week-long simulation institute advanced my knowledge of the methodology whereby I could then share this knowledge with educators, across disciplines in our service setting, through education, coaching, and mentoring. Colleagues have been very open to learning and embracing the simulation methodology to enhance content and procedural experiences, and our staff have been the beneficiaries of this innovative teaching strategy. Because of the freedom given to develop cases that focused on an area of need, I considered events that were not associated with pathologies yet more focused toward work flow, prioritization, and delegation. The collaboration and networking between academia and service institutions for the common goal of safe patient outcomes that began at the institute grew exponentially over the next 7 months as we gathered to share our successes and lessons learned.
The annual simulation immersion workshop is now self-sustaining and continues to prepare nurse educators from academic and clinical settings in the use of simulation technology. The applicability of the consortium model for future collaborative projects is under discussion by consortium partners.
Simulation technology, if used effectively, has the potential to promote the development of nurses’ clinical decision-making skills in complex environments and ultimately to improve the quality of patient care. Learning to use the technology effectively can be time-consuming and resource-intensive. Many staff development nurse educators lack the time, resources, and expertise within their institutions to implement simulation technology. Partnering with other academic and health care institutions in the community, however, can provide a synergistic experience that promotes educator development and fosters collaborative relationships. This article described a consortium model that provided collaborative development opportunities for nurse educators in academic and practice settings and successfully created a critical mass of educators who can now implement clinical simulations in their educational settings. Other nurse leaders and educators can learn from this experience and use the consortium model to achieve similar results in their own communities.
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