In the United States, the number of deaths associated with preventable patient harm is estimated at more than 400,000 per year (James, 2013). Health care leaders have recognized that reducing these numbers requires investment in best practices from all stakeholders within health care systems and use of a systems approach to health care delivery and problem solving (de Savigny & Adam, 2009). Nursing leaders in academia and practice have collaborated to create quality and safety practice competencies rooted in systems thinking (Quality and Safety Education for Nurses [QSEN], 2017) for students and practicing nurses.
Nurse educators use multiple learning activities to aid students in the development of the quality and safety competences and system thinking skills they will need as practicing clinicians. Using active cooperative learning through simulations and games is an effective vehicle to teach the systems thinking skills necessary for the transfer and use of classroom-acquired knowledge in the clinical setting, and is linked to increased student learning and satisfaction (Boctor, 2013). The Friday Night at the ER® game is a simulated learning exercise designed to promote quality care through systems thinking, collaboration, effective problem solving, and application of fiscal concepts (Breakthrough Learning, Inc., 2018; Young, 2018). This article describes the use of the Friday Night at the ER game to simulate complex problem solving and provide students with an opportunity to promote systems thinking through practice of complex, databased decision making in an undergraduate leadership course. The game was used by the educators to assess student learning through examination of their scores on pre- and post-Systems Thinking Scale (STS) surveys and assessment of student perceptions of their proficiency with the six QSEN competencies.
Systems thinking considers the relationships among the building blocks that make up the systems, the interactions between them, and the results of the interactions (de Savigny & Adam, 2009). With systems thinking as a structural underpinning to nursing practice, nurses move from an individual level to a system level (Dolansky & Moore, 2013) when making decisions about the provision of health care services. A systems thinking approach to problem solving allows nurses to consider options in relation to other system stakeholders, manage and coordinate system resources, and make decisions that incorporate the larger context that surrounds the problem.
A systems-level perspective enables nurses to identify issues and problems within the complex structures encompassing health care and effectively apply the QSEN principles in their own nursing practice (Phillips, Stalter, Dolansky, & Lopez, 2016; Stalter & Mota, 2017). The QSEN project was established to provide students with the tools to improve the quality and safety of the health care systems in which they work (QSEN, 2017); six competency areas were identified. Patient-centered care involves incorporating patients as full partners in care that includes consideration of their preferences, values, and needs (QSEN, 2017). Teamwork and collaboration promotes the use of open communication and participation in shared decision making. Evidence-based practice integrates current best practices with clinical expertise in the provision of patient care. Quality improvement involves nurses' use of data to make informed decisions, monitor the outcomes of care processes, and make changes to continuously improve the quality and safety of health care systems (QSEN, 2017). Safety includes nurses practicing in a manner that minimizes the risk of harm to their patients and also evaluating system factors that contribute to error and safety risk and report any variances. Finally, informatics describes nurses' use of information and technology to manage patient care and support their decision making (QSEN, 2017). Competence in these six areas provide students with the tools to address problems in complex health care systems (QSEN, 2017).
The Friday Night at the ER gaming simulation allows learners to progress through 24 hours in the ER assuming roles as nurse leaders facing real-life situations that require complex problem solving. Learners practice handling high-stakes problems at a rapid pace. Learners are evaluated and scored on cost and quality outcomes based on the decisions made during the game play. Learners complete a set number of activities that require collaboration and the use of data to make decisions. Simulation of real-life scenarios allows learners to develop and practice essential skills in a controlled learning environment without compromising patient safety. Young (2018) reported that when using the game with one group of undergraduates, the students shared in the debriefing session that they felt empathy for the leader-manager role and better understood the interactions among system components. Our Bachelor of Science in Nursing (BSN) program incorporates quality and safety concepts throughout the curriculum. Completing the Friday Night at the ER simulation in the senior year provides an opportunity for students to build on these foundational concepts. The Friday Night at the ER game aptly simulates the challenges of the complex hospital environment. The game play, coupled with the debriefing, provides a rigorous challenge for students and an opportunity to positively influence their knowledge related to systems thinking and the QSEN concepts. For these reasons, we expected students to have higher self-reported scores on the STS and higher self-perceived competence in applying the QSEN concepts in their practice after participating in Friday Night at the ER.
All students in four sections of an undergraduate leadership course participated in the Friday Night at the ER game simulation. Two sections consisted of prelicensure, senior-level students, and the other two sections were RN-to-BSN students. All students were encouraged to complete the identical pre- and postevaluation surveys, which consisted of demographic questions, the 37-item STS, and an assessment of their self-perceived competency with the six QSEN concepts. The final sample contained 164 students, with 104 prelicen-sure and 60 RN-to-BSN students, and 164 matched surveys pre- and postintervention.
The STS is a 37-item instrument that assesses individuals' ability to “recognize, understand, and synthesize the interactions and interdependencies in a set of components designed for a specific purpose” (Moore, Dolansky, Singh, Palmieri, & Alemi, 2010, p. 5). Respondents rank items from 0 to 4 on a Likert-type scale ranging from 0 = never to 4 = most of the time. Scores can range from 0 to 80, with higher scores indicating higher levels of systems thinking. Sample items include “I consider the cause and effect that is occurring in a situation” and “I consider the relationships among co-workers in the work unit.” QSEN competency was assessed, with students indicating their frequency of agreement with six statements outlining each QSEN competency. For example, the QSEN Informatics Competency statement is “I use information and technology to communicate, manage knowledge, mitigate error and support decision making.” The student then chose the frequency, which ranged from never to most of the time, that applied to them.
Each section of students completed the Friday Night at the ER game in a separate 3-hour session. Students worked in self-assigned groups of four and each assumed the role of a nurse leader in simulated nursing units within a simulated hospital. Game play was scheduled for 1 hour. Each group progressed through simulated hourly events that required complex problem solving, data-based decision making, and communication across departments to complete the activities. For each event, students made decisions that affected quality, safety, and cost. At the end of the game play, students calculated their scores based on these decisions. Game play was followed by a 2-hour faculty-led debriefing that addressed group performance on cost, quality, and reflected on learning. As Young (2018) described, the debriefing process consists of two steps. In step one, students review group performance related to quality outcomes achieved and share their justifications about costs incurred due to the decisions made. In step two, students discuss strategies used during the game and factors that influenced decision making. They also discuss their feelings about the simulated situations—for example, responses to the question “What felt real?”
STS scores were created as specified by Moore et al. (2010), with a 20-item STS score (α = .91), 7-item personal effort subscale (α = .67), and 10-item reliance on authority subscale (α =.75). Linear regression using a generalized estimating equations approach adjusting for repeated measures was used to analyze STS while controlling for student gender, time to completion, and RN-to-BSN versus prelicensure status with a Bonferroni correction of 0.05/3 = 0.0167 significance level. Repeated measures ordinal logistic regression was performed to analyze QSEN competencies for pre- versus postsimulation exercise comparisons with a Bonferroni correction of 0.05/6 = 0.0083 significance level. Differences in STS at presimulation for comparing RN-to-BSN versus prelicensure students was performed with independent samples t tests. Differences in QSEN competences for similar comparisons were performed using Mann-Whitney nonparametric tests. All analyses were performed in Stata v14.2.
There was a significantly higher average STS score after participating in the Friday Night at the ER simulation exercise (b = 3.24, 95% CI for b = [1.76, 4.73]; p < .001), adjusting for student gender, time to completion, and RN-to-BSN versus prelicensure status. There were also significantly higher average subscale scores for Personal Effort (b = 1.25, 95% CI for b = [0.71, 1.80]; p < .001) and Reliance on Authority (b = 3.15, 95% CI for b = [2.48, 3.83]; p < .001).
The only QSEN competency associated with significantly increased odds postcompletion was “I use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (OR = 1.50, 95% CI for OR = [1.11, 2.02]; p = .008). Other competencies were not significantly different postcompletion (all p ≥ .05), but this may be due to ceiling effects presimulation (range of means = 4.29 to 4.65 on a 1 to 5 rating scale, with range of SD = 0.56 to 0.74).
RN-to-BSN students were not significantly different presimulation on STS scores (p = .327), Personal Effort (p = .787), Reliance on Authority (p = .080), or any of the QSEN competencies (all p ≥ .05) except for “I minimize risk of harm to patients and providers through both system effectiveness and individual performance” (md = 0.191, p = .025). RN-to-BSN and prelicensure students had similar adjusted mean levels on STS scores (p = .931), Personal Effort (p = .503), Reliance on Authority (p = .219), and all six of the QSEN competencies (all p ≥ .05) from pre- to postintervention from regression modeling adjusting for repeated measures and other covariates. Overall, 64% (118 of 185) of students reported being satisfied with the Friday Night at the ER simulation exercise, 15% (28 of 185) were neutral, and three students reported not being satisfied (2%; 3 of 185). We did not have satisfaction data for 36 of 185.
The Friday Night at the ER activity is a useful teaching strategy in advancing students' competency in complex problem solving, increasing their exposure to systems thinking, and allowing them to apply these concepts to situations, as well as broadening their knowledge of and proficiency related to the QSEN competencies. The Friday Night at the ER learning activity provided students with the opportunity to practice real-life problem solving. The faculty-led discussion and reflection promoted synthesis of knowledge gained. This conclusion is supported by the fact that students had significantly higher scores on the STS and reported increased self-perceived proficiency with the quality improvement QSEN competency after the game.
The hourly simulated challenges in the Friday Night at the ER game helped students to recognize the multiple inputs and outputs that occur within a system, their interdependencies, and the many components that factor into complex decisions. Students were able to weigh the pros and cons of their complex decisions and receive immediate feedback on how their decisions translated into quality and costs outcomes for their patients. For example, many challenges in the game involved immediate time-sensitive staffing decisions, such as a sudden large increase in patient volume in the emergency department. The students had to weigh options such as the financial costs of bringing in off-duty nurses at overtime wages versus closing beds or diverting patients, and providing safe and quality care for their patients. The Friday Night at the ER game actively engaged students in the learning process. The discussions with students during the game and in the debriefing sessions were robust, and students eagerly shared positive feedback about the benefits of participating in the activity. Students gained an understanding of key systems thinking principles and strengthened their understanding that everyone in the system was responsible for patient care delivery and throughout.
Nurse educators should consider incorporating complex problem-solving exercises, such as Friday Night at the ER, into their undergraduate curriculum to challenge and strengthen students' critical and systems thinking. Nurse leaders may also wish to use this intervention with their work teams to assist practicing nurses and other members of their interdisciplinary teams in bolstering their critical and systems thinking.
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