Mind the Gap: Using Simulation to Bridge Didactic and Practice in Ambulatory Care for BSN Students

Background: The challenge of preparing BSN student nurses with skills and competencies needed for practice in an increasingly complex healthcare system has been noted. Healthcare facilities describe new graduates who lack the expected skills and competencies even at a beginning nurse level, and schools of nursing find that the limited availability of clinical sites increases the obstacles to helping students make the clinical-didactic connection. One method for addressing this challenge is through simulation that allows students to practice and demonstrate clinical competencies in a safe environment. In our accelerated BSN nursing program, we provide ambulatory care simulations that exemplify three key components of ambulatory care nursing: telehealth, primary care, and home health. For these simulations, we evaluate our students in alignment with the American Association of Colleges of Nursing Essentials, using a modified Lasater scale used by our primary clinical partner in new graduate residency. The Essentials: Core Competencies for Professional Nursing Education detail the domains, competencies, and sub-competencies needed for pre-licensure students to advance to practice. The modified Lasater scale is used to evaluate new graduates for clinical readiness. The combination of these resources allows us to evaluate these last-semester pre-licensure students for significant gaps in competency.

Method: Students are single or in pairs for each simulation. Prior to the simulation, they are provided with resources and an overview of expectations based on the Lasater framework of noticing, interpreting, responding, and reflecting. As they proceed through the simulation, clinical faculty from the ambulatory care setting and/or standardized patients interact as patients. Separate faculty are designated as observers only. Observer faculty use the Lasater tool as modified by our clinical partner and the students are rated as beginning, developing, accomplished, or exemplary in both physical skills and clinical judgment. After the simulation, both faculty and standardized patients provide immediate feedback and review of the students’ performance. The students submit a post-simulation analysis/reflection on their perceived strengths and weaknesses and ways they expect or intend to improve. If remediation is necessary, it is in the form of video review, faculty discussion, and possibly repeated simulation.

Evaluation: Scores from the faculty evaluation are used in post-simulation discussion with the students of areas needing improvement. They also are reviewed to identify students who, in any category, do not meet the beginning level. These students receive a written evaluation, taking into consideration their comments in the self-reflection assignment. This provides a tool for the student to address areas of concern. If students fall below beginning level on multiple categories, clinical faculty may assign remediation. Analysis of the percentages of students needing remediation or follow-up also will inform potential curricular modifications to meet the needs of our clinical partners who receive new graduates.

Implications: Communication, prioritization, and clinical reasoning are approached in a different manner in ambulatory care and require guided direction toward competency. In collaborating with practice partners, ambulatory care faculty and clinical instructors can develop simulation experiences and evaluation that will inform academic preparation and assist in clinical competency for newly graduated students.