Nursing students need to anticipate and confront the challenges that may be presented in the real world upon graduation (Bambini, Washburn, & Perkins, 2009). However, students reported having little to no exposure to deteriorating patient conditions during their pediatric inpatient clinical rotation (Pauly-O’Neill, Prion, & Lambton, 2011). Exposure to stable pediatric patients is not sufficient to confer competence in caring for children with acute illness; therefore, nurse educators have begun to substitute some of the required patient care hours with high-fidelity simulated scenarios. Although state regulations often dictate the maximum time allowed in simulation, it is vital for nurse educators to create a model of simulation that fills the gap between the competencies required of new nurse graduates and what the clinical setting provides for nursing students. The first step in creating the ideal blend of authentic clinical and simulation experience is an exploration of the experiences currently available in both settings.
This pilot observational study was conducted to answer the following two questions:
- Do the pediatric clinical and simulation settings offer the opportunity to practice the six competencies set forth by the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007): patient-centered care, teamwork and collaboration, safety, evidence-based practice, quality improvement, and informatics?
- Are the activities available in each setting comparable?
The findings may also help to answer the commonly asked question: Does 1 hour in the simulation laboratory equate to 1 hour of clinical time?
Observation Tool Development
To categorize what students accomplish in each arena, the QSEN competencies were used as a guide by the authors to create the time-on-task/clinical observation tool (TOT-COT). Although the QSEN competencies operationalize the knowledge, skills, and attitudes (KSAs) needed to demonstrate competence in six main areas (Cronenwett et al., 2007), measurable behaviors that demonstrate application of those competencies were included in the TOT-COT instrument (Table 1). Easily observable QSEN behaviors were selected to confirm the feasibility of the TOT-COT instrument in capturing student experiences in clinical and simulation settings. The results of this pilot study will inform further development and testing of the TOT-COT instrument.
Table 1: Observed Clinical Skills by Quality and Safety Education for Nurses (QSEN) Competency Category
The TOT-COT checklist was used to assess minutes spent by students in nursing care during assigned shifts. The tool was reviewed for content validity by five pediatric nurse experts before its first use to ensure that the nursing activities list demonstrated a reasonable outline of potential interventions. In this pilot study, the tool was used in more than 30 observations, comprising more than 105 hours, and the faculty observers thought it captured all the targeted competencies without need to use the “other” category.
Junior-level baccalaureate students enrolled in the Child Health Nursing didactic course were asked to participate in the study. Fifteen students consented to be observed for one shift in both their inpatient site and in the pediatric simulation laboratory. Students were informed that the collected data were not to be used for evaluation of their performance but rather “for use in improving the pediatric clinical rotation.”
Using the TOT-COT checklist, the nurse investigators observed students in each setting for 210 minutes, which is the time allotted for each pediatric simulation experience. The equivalent time in the inpatient area was deemed to be 7:00 a.m. to 10:30 a.m., capturing shift report, morning medication administration, and morning nursing care. The simulation laboratory experience is a structured, scripted learning experience for which preparation and debriefing are required components. The clinical prelaboratory and postconference structure is individualized by each instructor in the clinical setting and varies greatly. Although in the clinical rotation the care needs vary by patient, the student expectations for the actual clinical experience component are highly structured. Therefore, the measure of student experiences in the two structured sections of the simulation and clinical experience was deemed the most equivalent for comparison.
Observers used the tool to account for the 3.5 hours of time, attributing each minute as “on-task” in various nursing and nonnursing activities. Student activities included collecting patient history, conducting physical assessments, listening to the change-of-shift report, communicating with other health care providers, and performing procedures. In the clinical setting, the faculty–student preconference prior to the beginning of the shift was not observed, nor was the postclinical conference. However, during simulation, these activities were included in the simulation session and were therefore included in the 210-minute observation.
Institutional review board approval was obtained from two large, urban, tertiary care children’s hospitals with a variety of pediatric subspecialty units. University institutional review board approval was garnered for the observation done in the simulation laboratory on campus.
The data were analyzed for two sets of observations with a total of 13 prelicensure nursing students. Each participant was observed in both a pediatric clinical rotation at Hospital A (n = 9) or Hospital B (n = 4) and in the simulation laboratory setting for a total of 210 minutes in each place. Observers carefully noted how many minutes each student was engaged in the defined QSEN activities. The mean number of minutes spent in each QSEN activity was calculated and compared between clinical rotation and simulation laboratory settings. An effect size (Cohen’s d) was computed to quantify the magnitude of difference in time spent in QSEN activities between these two learning environments (Table 2).
Table 2: Descriptives of Time (Minutes) Spent in Clinical Activities During the 210-Minute Observation (N = 13)
The most significant effect size difference was observed for the QSEN competency, patient-centered care. Table 3 elaborates on the specific activities that comprise this competency. Not surprising, students spend more time in the hospital providing patient-centered care than in the simulation laboratory. The primary activities were, in order of total time, (a) patient education, (b) documenting, (c) establishing rapport with the patient and patient’s family, and (d) assessment. It is important to provide some needed context for these results. Each of the six students in the clinical rotation were assigned one patient, whereas the six students in the simulation laboratory rotation essentially shared a single patient. In addition, the authors recognize a limitation to the research methodology, as the observers had difficulty making the distinction between establishing rapport (i.e., “How are things today?”), patient education (i.e., “Do you have any questions about the care?”), and conducting a patient assessment (i.e., “Is there anything wrong today?” and “How are you feeling?”).
Table 3: Descriptives for Patient-Centered Care Activities (N = 13)
In all aggregated categories, students spent more time on the QSEN activities in the hospital than in the simulation laboratory, but the variability of the time students spent in each activity was significantly greater in the hospital than in the laboratory. In other words, students were more consistent in the amounts of time spent on a given activity in the laboratory. This is likely due to the more structured nature of a simulation laboratory.
However, it is interesting to note the variety of QSEN competencies that did not receive significant amounts of time in either the clinical or simulation settings. Students spent less than 10 minutes during a 3.5-hour clinical period or simulation laboratory engaged in (a) quality improvement (2.31 and 0.62 minutes, respectively), (b) evidence-based practice (5.92 and 0.54 minutes, respectively), and (c) informatics (2.96 and 0 minutes, respectively). This is an important finding, as it indicates that the common thinking that students are sufficiently developing these skills in the clinical experience may not be true. Unfortunately, students have limited opportunity to practice these skills in the simulation laboratory.
To better quantify what students were doing in both the clinical and simulation laboratory rotations, the observers also calculated the amount of time students were unengaged in patient-related work and the amount of time spent in observation. Table 4 displays the results of the observed unengaged and observation times. Unengaged was defined as any time that the student was engaged in any nonpatient care–related activity. Observation was defined as the purposeful watching of the clinical activities of another student, another nurse, or the instructor.
Table 4: Descriptives of Time (Minutes) Spent in Observation or Not Engaged in Patient-Related Activities During the 210-Minute Observation (N = 13)
Students were more engaged in meaningful work in the simulation laboratory than in the clinical setting (8.77 unengaged minutes in the simulation laboratory versus 25.04 unengaged minutes in the clinical setting). Engagement is a key characteristic of the learning environment, and it is important to recognize that there was a moderate effect size difference (0.62) between the two settings. Also noted is the large variability of unengaged time (mean = 25.05, SD = 35.86) in the clinical setting compared with the simulation laboratory (mean = 8.77, SD = 9.81). Students in the simulation laboratory also spend more time observing other students (mean = 48.62 minutes, SD = 22.58) compared with the same students in the clinical setting (mean = 11.04 minutes, SD = 22.40). According to Bandura (1986), learning through observation can be effective if the four principles of attention, retention, production, and motivation are included in the instructional experience. The observer role in the simulation laboratory is carefully planned to maximize these principles, and the authors of the current study believe research supports that students in the simulation laboratory are indeed learning through careful and purposeful observation of their peers during a simulation experience (Lambton & Prion, 2009).
This small exploratory study attempted to compare the amount of time spent on QSEN-related activities in the clinical and simulation laboratory settings. Because this is one of the first studies to attempt this comparison, several significant limitations exist.
Students were observed for an arbitrary amount of time in both the clinical and simulation rotations. It is possible that important activities were overrepresented or underrepresented because of the times chosen to observe the students. This results artifact occurred because the simulation and clinical experiences take different amounts of time to complete, and it was methodologically impossible to observe the students for 8 hours in the clinical setting and only 3 to 4 hours in the simulation laboratory. Another significant limitation is the possibility of a Hawthorne effect (Franke & Kaul, 1978). The trained observers accompanied the students into the patient’s room and could have influenced the student–patient–family interactions. Students could have behaved differently in the presence of the observer, and they could have performed activities that were thought to be socially or professionally desirable to the observer. The QSEN competencies were selected as the organizing framework for the observations, and it is possible that some student-initiated nursing actions were missed because they did not conform to the QSEN model. It is also clear that the instrument requires additional work, but there was no way to assess the validity of the tool, beyond construct by experts, without actually putting it into use. Based on the results, the instrument revision and refinement process will be actively continued.
Due to the intensive nature of gathering observational data, the sample size is small. Because of the limited sample size and great variability, any conclusions should be made with caution. The TOT-COT tool was untested, and further use will assist in determining validity. Some phenomena reported are due to the different periods of time during which students were observed. Students were observed for the entire 210-minute simulation laboratory period, but only for the morning part of the hospital shift. Activities surely took place before the shift began, and likely the evening before, as students consulted textbooks and online resources to develop a plan of care. Postconference, which traditionally occurs at the end of the shift, would add another dimension of learning but was not observed in this pilot study.
This pilot observational study was conducted to answer whether clinical and simulation settings offer equal opportunity to practice the six competencies set forth by the QSEN initiative and, further, whether the time spent in those activities in each setting were comparable. Students in this study completed a traditional pediatric clinical assignment of one patient. Our observations indicate there is significant unengaged time with this assignment and that students busy themselves with activities they can regulate, such as talking to patients and their families and talking to each other. Without control over the more important clinical activities, such as fulfilling medication and treatment orders, students fill their time to the best of their limited clinical abilities. In contrast, the simulation laboratory provides a structured environment in which students can develop skills that are not available or appropriate in the traditional clinical setting.
Table 5 summarizes some of the results of this pilot study. It seems that this particular clinical rotation integrated with simulation is helping students to develop at least three of the QSEN competencies—patient-centered care, teamwork and collaboration, and safety—but are not as focused on evidence-based practice, quality improvement, and informatics. Furthermore, although students have more opportunities in their clinical rotation for patient-centered care and developing effective communication skills, there is still time wasted in nonpurposeful interactions.
Table 5: Suggested Use of Clinical and Simulation Experiences
QSEN competencies are acknowledged as key proficiencies for quality care and patient safety that should be attained during the student’s education in the nursing program (Brown, Feller, & Benedict, 2010; Chenot & Daniel, 2010; Cronenwett et al., 2007; Forbes & Hickey, 2009; Schlar, Ostendorf, & Kinner, 2012). This pilot study seems to demonstrate that students had the opportunity to practice nursing care activities in both settings that correspond with three of the six QSEN competencies: patient-centered care, teamwork and collaboration, and safety. In both the hospital setting and in the simulation laboratory, students were observed to spend little time engaging in the other three QSEN category activities: evidence-based practice, quality improvement, and informatics. It is difficult to conclude from these preliminary results that the clinical and simulation laboratory settings were comparable, except that both environments did not provide experiences that developed all of the QSEN competencies. Our findings are congruent with those of Smith, Cronenwett, and Sherwood (2007) and may represent actual limited opportunities for students or the weakness of the tool in capturing behaviors that signify student opportunity to develop certain QSEN competencies.
If employers expect students to have minimal competency in these important activities, then nurse educators must ensure that current teaching–learning strategies are, in fact, helping students to develop these skills. A mixed educational approach integrating simulation, classroom, and clinical experiences offers significant promise for meeting these expectations.
The potential lack of practice with all six QSEN competencies in both the clinical and simulation settings is not altogether surprising but does cause concern. This presents additional cause for nurse educators and agency leaders to join in meaningful academic–service partnerships and develop integrated learning activities that help students develop all of the QSEN competencies. Educators may use the results of this pilot study to intentionally manage clinical experiences to help students acquire these important quality care and safety competencies.
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Observed Clinical Skills by Quality and Safety Education for Nurses (QSEN) Competency Category
|QSEN Competency||Observed Skills Related to Competency|
|Patient-centered care||Collects history|
|Establishes rapport with patient and patient’s family|
|Performs physical assessment|
|Develops plan of care|
|Implements nursing care|
|Performs patient education|
|Contacts health care team regarding patient status|
|Documents on flow sheets and in nursing notes|
|Teamwork and collaboration||Asks questions to clarify|
|Receives and provides information|
|Safety||Assesses emergency equipment|
|Adheres to infection control|
|Performs “rights method” in medication administration|
|Evaluates medication effects|
|Maintains safe environment|
|Quality improvement||Follow up|
|Evidence-based practice||Locates or reviews policies or protocols|
|Informatics||Navigates electronic medical record|
|Records data on electronic medical record|
Descriptives of Time (Minutes) Spent in Clinical Activities During the 210-Minute Observation (N = 13)
|QSEN Competency||Hospital, Mean (SD)||Simulation Laboratory, Mean (SD)||Cohen’s d (Effect Size)|
|Patient-centered care||98.12 (36.03)||33.31 (15.26)||2.34*|
|Teamwork and collaboration||28.23 (19.38)||18.92 (12.33)||0.28|
|Safety||36.38 (24.40)||21.46 (15.97)||0.72|
|Quality improvement||2.31 (4.84)||0.62 (1.61)||0.48|
|Evidence-based practice||5.92 (9.89)||0.54 (1.51)||0.76|
|Informatics||2.96 (5.79)||0 (0)||0.70|
|Preconference–postconference||0 (0)||77.77 (17.96)||6.12*|
|Unengaged||25.04 (35.86)||8.77 (9.81)||0.62|
|Observe||11.04 (22.40)||48.62 (22.58)||−1.67*|
Descriptives for Patient-Centered Care Activities (N = 13)
|QSEN Competency||Hospital, Mean (SD)||Simulation Laboratory, Mean (SD)||Cohen’s d (Effect Size)|
|History||12.23 (5.09)||2.00 (1.41)||−2.74|
|Rapport||18.80 (12.50)||7.88 (9.69)||−0.98|
|Assessment||18.08 (9.01)||6.5 (5.13)||−1.58|
|Developing plan of care||7.50 (6.72)||0 (0)||−1.56|
|Implementing plan of care||14.88 (6.64)||21.25 (14.19)||0.58|
|Evaluating plan of care||11.00 (4.00)||1.0 (0)||−3.53|
|Patient education||31.43 (19.52)||2.71 (1.60)||−2.074|
|Contacts||6.67 (2.89)||1.67 (1.15)||−2.20|
|Documenting||19.55 (10.62)||1.25 (0.50)||−2.43|
Descriptives of Time (Minutes) Spent in Observation or Not Engaged in Patient-Related Activities During the 210-Minute Observation (N = 13)
|QSEN Competency||Hospital, Mean (SD)||Simulation Laboratory, Mean (SD)||Cohen’s d (Effect Size)|
|Unengaged in patient-related activities||25.04 (35.86)||8.77 (9.81)||0.62|
|Observing patient-related activities by other students or instructor||11.04 (22.40)||48.62 (22.58)||−1.67*|
Suggested Use of Clinical and Simulation Experiences
|Rotation||Effective for||Not Effective for|
|Clinical||Teamwork and collaboration||Quality improvement|
|Simulation laboratory||Teamwork and collaboration||Quality improvement|