1. Kindl, Heather BSN, RN, CPEN
  2. Martin, Angela MSN, RN, CNE, CHSE
  3. Spade, Kathy MSN, RN, CNE, CHSE
  4. Williams, Felecia PhD, RN, CCRN
  5. Clarke, Kim MSN, RN


New graduate nurses (NGNs) are not fully prepared to recognize and react to rapidly declining patient conditions. Academic curricula typically do not target education related to rapid response events. A study was conducted to evaluate if a collaborative simulation between senior nursing students and NGNs would develop and improve the knowledge and skills needed to recognize and react to a patient who is rapidly deteriorating. Outcomes showed that participants made gains in the areas of competence, prioritization, and communication. This model can be used by other nurses in professional development to increase NGN competence, confidence, and safety.


Article Content

Nursing professional development (NPD) practitioners are in a unique position to positively impact the transition of a new graduate nurse (NGN) to practice. The identification of potential problem areas and collaboration with other educators can foster an environment that creates solutions for enhancing the transition experience and contributing to safe patient care (Burns & Poster, 2008). The NPD practitioner who is the NGN transition-to-practice coordinator received frequent anecdotal feedback from NGNs about a lack of confidence and competence regarding emergency events. A literature search that was conducted in between late 2012 and early 2013 is consistent with this feedback (Ulrich et al., 2010).



Recognizing this practice gap, an NPD practitioner from a hospital met with faculty from a local community college to investigate the feasibility of a partnership. The concerns expressed by the NGN were found to be similar to those experienced by senior nursing students. A needs assessment was conducted in early 2013. Results revealed a lack of knowledge and confidence in recognizing and responding to rapidly deteriorating patients. The NPD practitioner and faculty collaborated to design an educational program involving simulation, which has been shown to foster knowledge and skills development in a safe environment (Hoffart, Waddell, & Young, 2011; Kaddoura, 2010; Sittner, Schmaderer, Zimmerman, Hertzog, & George, 2009). The purpose of this educational initiative was to bridge the gap between nursing students and NGNs in the areas of recognizing and responding to patient deterioration. Organizers hypothesized that, by including senior nursing students and NGNs in the same simulation experience, the NGNs would gain confidence by seeing how much they had learned. Nursing students would gain knowledge that they could bring to the hospital as an NGN. An additional goal was that the class would provide a networking opportunity for the senior nursing students to meet the NGNs and the NGN transition-to-practice coordinator. The partnership between the NPD practitioner and nursing school faculty was a natural association because both institutions have a long-standing relationship and adjacent campuses.



Facilitators of the initiative included an NPD practitioner from the hospital, who led the initiative; two nursing simulation faculty from the college; and two clinical nurse educators, one each from the college and the hospital. Nursing students in their final semester at the community college and NGNs employed by the hospital for 6-12 months participated in the simulation. Other stakeholders included the Director of Nursing Education, unit management within the hospital, and academic nurse educators at the community college, who all anticipated positive educational outcomes. Required resources included a simulation facility including high-fidelity manikins and audiovisual recording equipment, a crash cart with defibrillator, patient-controlled analgesia pumps, intravenous pumps, a stretcher, and a slide board.



Each class included four nursing students and four NGNs. Classes were capped at eight participants to optimize the simulation experience and learning opportunities. The institutional review boards at both facilities deemed the project exempt, but requested informed consent to be obtained before each class offering. Each class offering included a preclass survey, prebriefing, a simulation scenario, debriefing, didactic content, skills stations, a second simulation scenario with debriefing, and a summative evaluation. The skills stations afforded participants the opportunity to rotate through stations featuring an overview of the crash cart contents, review of basic defibrillator use, operation of the patient-controlled analgesia pumps, and review of a pain management protocol including the use of reversal agents. Upon completion of the class, participants earned 4.5 contact hours. Three months postsession, all participants were asked to complete a follow-up survey to evaluate for behavior change. Each simulation was recorded, compared, and evaluated for length of time to recognize a patient's decline in status and implementation of actions while awaiting the rapid response team (RRT).



Outcomes of the initiative included decreased time to recognition of a decline in patient status and decreased time to offering appropriate interventions while waiting for the RRT responders to arrive, when comparing how participants performed in the predidactic and postdidactic simulations. Students commented on how far the NGNs had progressed in clinical knowledge and decision making within a year of practice. Survey results from both groups revealed significant gains in confidence, competence, and prioritization skills immediately after the simulation experience.


Results from the 3-month follow-up revealed a slight decrease in perceived knowledge and skill attainment compared with the immediate postclass results. However, perceptions of confidence, competence, and prioritization remained greater than preclass levels. Qualitative data included statements from NGNs such as "I left feeling confident about how far I've come"; "Much of the time at work I feel my inexperience, and it can be a drain on me emotionally"; and "I gained a bit of confidence, and I really needed it right now." Results also included the formation of a collegial relationship among all participants and facilitators.



Challenges in NGN participant recruitment included higher-than-usual hospital census attributed to flu season and implementation of a new electronic health record. These factors made it challenging for the NGN to attend the classes. Future efforts to increase participation could include increased advertisement through electronic and social media. Meeting with nurse managers and presenting at nursing leadership forums could increase program awareness.



Many positive lessons were gained during the project. Collaboration between the nursing school and the hospital allowed sharing of equipment, facilitator's time, and physical space. This permitted the project to remain budget neutral. During the orientation time, participants were asked to describe their experience with RRT/code situations. It was discovered that many participants needed to debrief their previous hospital RRT/code blue experiences. The professional expertise and guidance from the facilitators assisted participants in reflection/debriefing. Finally, facilitators in the partnership learned from one another and gained exposure to a variety of teaching strategies, which resulted in professional growth.


Next steps of the project first included incorporating the RRT simulation into the curriculum for senior nursing students at the college. The class was expanded to include training in calling a code blue, providing the necessary steps while waiting for the code team to arrive, and performing effective CPR. The NPD planner is exploring opportunities to incorporate simulation into the NGN standard programming. This process will entail compiling support including literature and project outcomes to gain endorsement from hospital and college leadership for expanded collaboration.




Burns P., & Poster E. C. (2008). Competency development in new registered nurse graduates: Closing the gap between education and practice. The Journal of Continuing Education in Nursing, 39(2), 67-73. doi:10.3928/00220124-20080201-03 [Context Link]


Hoffart N., Waddell A., & Young M. B. (2011). A model of new nurse transition. Journal of Professional Nursing, 27(6), 334-343. doi:10.1016/j.profnurs.2011.04.011 [Context Link]


Kaddoura M. A. (2010). New graduate nurses' perceptions of the effects of clinical simulation on their critical thinking, learning, and confidence. Journal of Continuing Education in Nursing, 41(11), 506-516. doi:10.3928/00220124-20100701-02 [Context Link]


Sittner B. J., Schmaderer M., Zimmerman L., Hertzog M., & George B. (2009). Rapid response team simulated training for enhancing patient safety (STEPS). Clinical Simulation in Nursing, 41(11), 506-516. doi:10.1016/j.ecns.2009.02.007 [Context Link]


Ulrich B., Krozek C., Early S., Ashlock C. H., Africa L. M., & Carman M. L. (2010). Improving retention, confidence, and competence of new graduate nurses: Results from a 10-year longitudinal database. Nursing Economics, 28(6), 363-375. [Context Link]