Simulation and Confidence in the PICU Newly Licensed Registered Nurse

Background: Communication and critical thinking are essential practice competencies for every registered nurse. However, newly licensed registered nurses (NLRN) often lack these skills on entry into practice contributing to low levels of clinical confidence (Fisher & King, 2013; Hommes, 2014). An association has been demonstrated between limited NLRN clinical confidence and increased medication error rates, self-doubt, and lack of interprofessional collaboration, ultimately impacting patient safety and quality of care as well as role satisfaction (Pfaff, Baxter, Jack, & Ploeg, 2014).

Purpose: The purpose of this quality improvement (QI) project is to implement and evaluate the effectiveness of simulation on clinical confidence among NLRNs.

Methods: This QI project is a mixed methods, pre-test and post-test design, targeting NLRNs in a 19-bed pediatric intensive care unit within an urban academic teaching hospital. Eligible participants were baccalaureate-prepared NLRNs who graduated within the last year and were either currently enrolled in the institution’s nurse residency program (NRP) or completed the residency program within the last year. During the QI project, NLRNs participated in two clinical simulations in small groups of three, utilizing dedicated simulation space and high-fidelity equipment at the project site. The clinical simulations reflected common PICU clinical practice and were developed by the project lead and two doctoral-prepared clinical simulation content-matter experts, utilizing the simulation module for assessment of resident’s targeted event responses (SMARTER) and the behavior assessment tool (BAT). The clinical simulations were delivered and debriefed by the project lead, certified clinical simulation educators, and facilitators at the project site. Newly licensed registered nurse confidence data were collected immediately pre-simulation and post-simulation, as well as one-month post-simulation using the self-report C-scale instrument of clinical confidence. Additionally, each NLRN was observed by a preceptor at project baseline, and again one-month post simulation, while engaged in routine nursing care. Qualitative data was collected by the preceptor using the C-scale instrument of clinical confidence. Paired sample t-tests will be used to determine if there is a significant change in confidence after each simulation, and at the completion of the project. Content analysis will be performed by two evaluators on the qualitative data derived from the C-scale observations to identify confidence themes and patterns.

Results: Paired sample t-tests revealed a significance increase in clinical confidence immediately after each of the three simulations and sustained one-month post simulation. Qualitative data collection of preceptor observations is still in progress.

Conclusions: Preliminary data indicates that simulation is an effective strategy to increase clinical confidence as perceived by the NLRNs and based on the observations of preceptors. Incorporation of simulation into transition-to-practice programs such as nurse residency or facility orientation is an evidence-based recommendation to improve development of clinical confidence and communication abilities in this population.