Nurses practicing in rural health care settings require a broad skill set to provide care to diverse patient populations, and to be successful in doing so they must be autonomous, competent, and expert practitioners (Pavloff, Farthing, & Duff, 2017). However, rural nurses often practice in settings with limited access to continuing education resources. In their integrative review, Pavloff et al. (2017) identified the continuing education needs of rural nurses. These included specialty-focused nursing practice, such as pediatrics, obstetrics, postoperative, and neurology; the handling of unanticipated events, such as emergency preparedness and triage; nondirect patient care content inclusive of technology, leadership, and management; and advanced specialty courses, such as a trauma nursing core course and pediatric advanced life support (Pavloff et al., 2017). Despite their challenging geographical locations, rural nurses must maintain a level of competency and autonomy that supports delivery of safe patient care.
In 1991, the Coastal Carolinas Health Alliance (CCHA) was formed to strengthen relationships between regional hospitals to improve quality and operational efficiencies ( https://coastalalliance.org/about-us/). The CCHA is a nonprofit organization owned entirely by member health care organizations—90% of which are in rural settings. There are 13 affiliated hospitals across 11 counties, and 13 nonacute health care organizations in 95 locations in 29 counties.
Member hospitals employ an estimated 5,800 nurses who are required to demonstrate continued competency in order to maintain an active license. In 2005, the CCHA's chief nurse executives identified the education and professional development of their nurses as a priority. To accomplish this, the nurse executives conceptualized a CCHA-owned mobile simulation resource. Specifically, they believed that an onsite mobile training solution would help nurses meet the competency requirements for continued licensure. Another advantage of the onsite solution would be the reduced costs associated with travel and the lost productivity that resulted when staff needed to travel for continuing education.
The challenges facing rural facilities often need creative solutions and in this case required creating both inter-hospital collaborations and the innovative use of mobile simulation technology. This article describes the creation of that program and its development as a best-value and high-quality resource for critical access, rural hospitals, and their nurses. Additionally, recommendations for others who may desire to develop a similar program are discussed.
The CCHA's chief nurse executives designed the mobile simulation program (MSP) using a hub-and-spoke model. This model placed the MSP staff and resources at the CCHA's central administration office with the expectation that they would deliver education and training onsite at member hospitals. The hub-and-spoke model arranges service delivery assets into a network consisting of an anchor establishment (hub) that offers an array of services, complemented by secondary organizations (spokes)—thereby yielding a more efficient network of services and eliminating the need to replicate operations across multiple sites (Elrod & Fortenberry, 2017).
A search of the recent literature on mobile simulation and education yielded 12 articles. Although the majority addressed simulation as online education (Chang, Su, Lin, & Huang, 2015; Kaleekai et al., 2016; Kyriakoulis et al., 2016; Radhakrishnan et al., 2016; Sanger et al., 2017; Santhi & Sadasasivam, 2015; Tobase et al., 2017), five articles focused on mobile simulation that provided education outside of a simulation center, similar to the CCHA program described here.
In situ simulations are one form of mobile simulation that provides a potential solution to the barriers of cost, space, and equipment and keeps staff in their unit (Kellish, 2015). In situ simulations have been used for neonatal and obstetric emergencies (Vail et al., 2018) and for pediatric emergency response training (Kellish, 2015; Spence & Chatfield, 2018). In some studies, in situ simulations improved the quality of simulated and live resuscitations for neonates in Bihar, India (Vail et al., 2018) and increased the frequency of emergency response training for a U.S. children's hospital (Kellish, 2015) and for 30 rural sites in Alberta, California, in conjunction with telehealth (Spence & Chatfield, 2018).
Other forms of mobile simulation are the modified motorhomes or trucks equipped to provide emergency response training outside of a brick-and-mortar facility (Ferenc, 2017; Martin, Bekiaris, & Hansen, 2017). These units provide emergency response training to rural health care providers to develop clinical reasoning, decision making, and recognition of patient emergencies (Martin et al., 2017). Despite limited publications, mobile simulation was shown to be a viable, creative solution for providing health care education to facilities that may not have access otherwise. Of interest, none of the articles discussed a program using the hub-and-spoke model for program delivery.
Mobile Simulation Program Implementation
In 2009, the CCHA was awarded a $1,100,214 endowment grant, which provided start-up funds and supported the initial implementation of the MSP. This award funded the hiring of a CCHA nurse educator who served as the program's clinical coordinator and instructional designer. The grant also provided funding to purchase patient simulators (low, medium, and high fidelity) and a mobile simulation laboratory truck. A subsequent grant in 2015 funded the purchase of a van, adding to the CCHA staff's mobility to reach rural hospital nursing staff. The CCHA's MSP continues as a shared resource, delivering evidence-based programs via mobile staff and resources.
Integral to the program's design was the establishment of a nurse educator liaison at each of the CCHA member organizations. These liaisons work with the CCHA nurse educator to plan and deliver targeted continuing education events at the individual hospitals. As the MSP evolved, hospitals requested that simulation training take place in patient care units using the hospital's equipment in order to increase realism and staff participation. The MSP responded by providing in situ simulations in addition to simulation training within the mobile simulation truck.
Rural, critical access hospitals represent the largest percentage of CCHA members who participate in the MSP. In the initial design of the MSP, CCHA staff provided training via a stand-alone, specially designed truck, which was parked in the member hospital's lot. The MSP truck came equipped with the necessary simulation resources (e.g., high-fidelity manikins), including a patient care area, control room, and debriefing room. The training used evidence-based, preprogrammed scenarios that were purchased with the high-fidelity simulation manikins. The hospital nurse liaisons collaborated with the CCHA nurse educator to tailor simulations to meet the respective hospital's unique needs. The CCHA nurse educator planned the trainings and provided technical support (e.g., running the manikins from the control room), whereas the hospital's nurse liaison served as facilitator for the simulation and debrief.
In 2013, as demand for MSP services increased, a second CCHA nurse educator was hired. However, unanticipated turnover in that position created challenges when the remaining nurse educator was tasked with planning and coordinating simulations for all regional member hospitals. Additionally, because of their time limitations, staff nurses at the member hospitals experienced difficulty completing presimulation online education modules. As a result, nursing staff were unprepared for the scheduled simulation activity that occurred during their shift. In response to the staff's limited preparation and training, the lone MSP nurse educator had to provide didactic content simultaneous with the simulation activity. Thus, a necessary compromise resulted: beginning in 2014, the sole MSP nurse educator no longer used the preprogrammed scenarios for trainings. Education shifted from the use of high-fidelity simulation to a more informal, in-service training experience using low-fidelity simulation. Although these sessions were based on best evidence, training was delivered in a modified format to meet staff and time availability and did not follow an accredited, approved continuing education plan. Thus, the shift from high-fidelity simulation programs to informal, in-service training compromised the CCHA's ability to offer continuing education credit. The implications of this did not become apparent until 3 years later when the MSP's application as a continuing education provider was scheduled for renewal. Gaps in required documentation were noted in conflict of interest forms, education activity disclosure forms, and templates for learning activities. Until the MSP was reinstated as a continuing education provider, a contract with a local area health education center provided the continuing education credit. This partnership, coupled with the hiring of a second MSP nurse educator to assist with training and documentation, was key to the MSP's reinstatement as a continuing education provider.
CCHA member hospitals complete an annual evaluation of the MSP. Not surprisingly, the previously discussed staffing issue and resulting accommodation resulted in decreased satisfaction with the quality of MSP training. Specifically, evaluations from the member hospital education directors indicated that simulation was not being used to its fullest capacity. The less than satisfactory 2016 survey results triggered an in-depth evaluation of the MSP, resulting in the development of a quality performance improvement plan.
The performance improvement plan was implemented in 2017 and focused on the use of professional standards, real-time feedback, and nurse educator retention. This intense, renewed focus on quality programming proved to be a turning point for the CCHA's MSP and staff. First, the CCHA nurse educators adopted the state's professional organization standards for continuing education, and the International Nursing Association for Clinical Simulation and Learning standards for simulation-guided program development. These strategies improved program quality and participant experience. Second, the MSP staff and hospital nurse liaisons began to meet monthly to monitor performance improvement and to provide timely feedback. Finally, to improve the retention of MSP nurse educators, CCHA orientation routinely included the use of simulation curriculum and a simulation mentoring program.
The CCHA's MSP staff also modernized the continuing education documentation and reporting processes, which resulted in the cataloguing of 60 simulation learning activities for continuing education contact hours. Participant evaluations and certificates were provided electronically (versus the existing paper and pencil), making evaluation results easy to track and analyze, and facilitated retrieval of MSP productivity data. After these changes were in place, satisfaction with the quality of the MSP's programs increased. Currently, the mobile simulation program provides continuing education programs to member organizations within a 10-county region in southeastern North Carolina.
Establishing an MSP within the CCHA was a novel approach to meeting staff education needs in rural, critical access hospitals. Several facilitators and challenges influenced the structuring of this hub-and-spoke model of education delivery (Table 1). The following provides an overview of those.
Facilitators and Barriers in Setting Up a Mobile Simulation Program Within the Alliance
The core measure of the CCHA's MSP success is utilization, meaning the number of staff attending the training when the mobile simulation truck and nurse educators are onsite. Several system and program elements facilitated the CCHA's MSP success (Table 2). Securing funding for start-up costs such as personnel, capital equipment, and simulation supplies provided the foundation for implementing this shared resource program. Developing effective communication and coordination processes with member hospitals directly affected the program's success. Additionally, the MSP staff continued to nurture a customer service culture, important when designing and implementing a shared resource in a geographically distant and rural environment.
Key System and Program Elements for Successful Implementation
Achieving early successes during the grant-funded period highlighted the value of the CCHA's MSP to member organizations and provided the impetus to develop a sustainment strategy. In 2011, the CCHA's financial model was based on member hospitals purchasing training hours. Since that time, the number of hours purchased for simulation has increased 53% from 548 hours in 2011 to 840 hours in 2017. The type of education provided and the diversity of the providers receiving the education has grown exponentially. Although nursing constitutes the highest percentage of participating hospital staff, the CCHA's mobile simulation program has expanded to include resident, respiratory, emergency medical services, nurse aides, and surgical scrub technician training.
Since the program's inception, utilization has increased by an average of 22% every year. This growth is attributed to the program's commitment to evaluating and achieving targeted quality improvement (Table 3), the continued development of evidence-based trainings that meet the competency requirements of member hospital staff, and demonstrating to member hospitals a positive return on their investment.
Recommendations for Resolving Program Quality Issues
Overall, the CCHA mobile simulation program—a creative merger of meeting an identified need with technology—serves as a model for providing education to rural hospitals. Its uniqueness lies in the structure of the program as a nurse-led, mobile, and shared regional asset that is not affiliated or physically attached to a large medical center. The program has proven to be cost effective and ensures that rural nurses and their patients can benefit from a key shared resource. By incorporating International Nursing Association for Clinical Simulation and Learning standards of best practice for simulation, and working with on-site nurse educator liaisons, satisfaction with the CCHA's MSP has increased. The MSP staff have demonstrated their ability to provide quality simulation education while meeting the specific needs of nurses practicing in rural hospitals.
The creation of a financial model where member hospitals “buy” simulation time for their staff nurses proved essential to the MSP's sustainability as a regional asset. Additionally, the MSP's ability to award continuing education credit as an approved provider unit was central to the program's viability and return on investment for member hospitals. Most importantly, the nurse liaisons at member hospitals reported a significant improvement in staff confidence, especially when caring for patients with high-risk, low-volume medical conditions.
Mobile simulation shows promise as an effective mode for delivering continuing and just-in-time education for rural health professionals. The success of this regional, hub-and-spoke model, in both education delivery and financial sustainability, may prove useful for future projects focused on rural health.
- Chang, W.H., Su, Y.C., Lin, A.P. & Huang, M.Y. (2015). Using a mobile application to facilitate post-simulation debriefing. Medical Education, 49, 1163–1164.
- Elrod, J.K. & Fortenberry, J.L. (2017). The hub-and-spoke organization design: An avenue for serving patients well. BMC Health Services Research, 17(Suppl. 1), 457.
- Ferenc, J. (2017). Mobile simulation trucks help bring EMS training home. Retrieved from https://www.hfmmagazine.com/articles/3198-mobile-simulation-trucks-help-bring-ems-training-home
- Kaleekai, N., Schuster, C.A., Murray, C.L., King, M.A., Stahl, B., Labrozzi, L.J. & Glover, K.R. (2016). Improving nurses' peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation-based blended learning program: A randomized trial. Simulation in Healthcare, 11, 376–384.
- Kellish, A., (2015). Mobile simulation: High-stakes emergency training at a budget-friendly price. Critical Care Nurse, 35(2), e61.
- Kyriakoulis, K., Patelarou, A., Laliotis, A., Wan, A., Matalliotakis, M., Tsiou, C. & Patelarou, E. (2016). Educational strategies for teaching evidence-based practice to undergraduate health students: Systematic review. Journal of Education Evaluation for Health Professions, 13, 34.
- Martin, D., Bekiaris, B. & Hansen, G. (2017). Mobile emergency simulation training for rural health providers. Rural and Remote Health, 17(3), 4057.
- Pavloff, M., Farthing, P.M. & Duff, E. (2017). Rural and remote continuing nursing education: An integrative literature review. Online Journal of Rural Nursing & Health Care, 17, 88–102 doi:10.14574/ojrnhc.v17i2.450 [CrossRef]
- Radhakrishnan, K., Toprac, P., O'Hair, M., Bias, R., Kim, M., Bradley, P. & Mackert, M. (2016). Interactive digital e-health game for heart failure self-management: A feasibility study. Games for Health Journal, 5, 366–374.
- Sanger, P.C., Simianu, V.V., Gaskill, C.E., Armstrong, C.A., Hartzler, A., Lordon, R.J. & Evans, H.L. (2017). Diagnosing surgical site infection using wound photography: A scenario-based study. Journal of the American College of Surgeons, 224, 8–15.
- Santhi, S. & Sadasasivam, G. (2015). Design and development of compact monitoring system for disaster remote health centers. Indian Journal of Medical Microbiology, 33(Suppl.), S11–S14.
- Spence, T. & Chatfield, J. (2018). Dummies on the go: Utilizing tele-health during pediatric outreach education. Canadian Journal of Critical Care Nursing, 29, 30–31.
- Tobase, L., Peres, H.H.C., Gianotto-Oliveira, R., Smith, N., Polastri, T.F. & Timerman, S. (2017). The effects of an online basic life support course on undergraduate nursing students' learning. International Journal of Medical Education, 8, 309–313.
- Vail, B., Morgan, M., Spindler, H., Christmas, A., Cohen, S. & Walker, D. (2018). The power of practice: Simulation training improving the quality of neonatal resuscitation skills in Bihar, India. BMC Pediatrics, 18, 291.
Facilitators and Barriers in Setting Up a Mobile Simulation Program Within the Alliance
|The Coastal Carolinas Health Alliance (CCHA) had an established and positive reputation serving southeastern North and South Carolina, which was beneficial when establishing a regional approach to education through a mobile program.||Clinical support
The education directors/nurse educators from the member hospitals provide guidance to the mobile simulation program (MSP). The hospital nurse liaisons often expressed difficulty of the added responsibility of the MSP liaison nurse role (i.e., coordinating the simulation schedule and assuring that staff attend the scheduled training).|
|Existing local collaborations with the CCHA staff (e.g., chief nursing officers, nurse educators) proved beneficial during program improvement.||Scheduling
A challenge for the MSP staff as an outside entity attempting to accommodate the schedules of working hospital nurses who also needed to attend the simulation training.|
|Program attributes of being mobile with the ability to deliver education programs tailored to the individual needs of each facility was foundational in designing the mobile simulation program.||Communication
A constant challenge given the stakeholders involved (MSP staff, hospital nurse educators, unit nurse managers, and nursing staff) in identifying staff education needs and coordinating staff availability.|
Key System and Program Elements for Successful Implementation
|Secure funding for a start up, (e.g., grants, member organizations, financial commitments, partner investment)||Staffing model to support outreach within the program's geographic boundaries|
|Identify organizational liaisons whose role includes communication and coordination of activities with program staff||Adopt best practices relevant to educational program design, delivery, and evaluation|
|Establish stakeholder council for feedback and program evaluation||Actively engage in quality improvement with stakeholders|
|Develop model for financial sustainment beyond grant funding||Demonstrate value/return on investment to member organizations or partners|
Recommendations for Resolving Program Quality Issues
|Adhere to INACSL simulation standards and guidelines from the approved provider's source of continuing education credit.|
|Develop and implement a systematic plan to monitor and improve programs.|
|Ensure program outcomes are collaboratively defined by stakeholders.|
|Ensure there is a right fit between program growth and structure.|
|Maintain open communication with accrediting body/office for continuing education.|
|Establish process for stakeholder group meetings, communication, and feedback.|