The technological transformation of nursing education

The patient seemed fine. A few minutes ago, he was sitting upright, talking to nurses in the emergency room of an American hospital. Yet in a moment, his vital signs take an inexplicable nosedive. Soon, he’s non-responsive. Breathing becomes labored and then stops altogether. Eventually, there is no pulse.

The man is dying under the watch of graduate students from the University of Florida College of Nursing. They must think and act quickly amid a crescendo of alarms. Dr Michael Bumbach, a clinical assistant professor of nursing, watches the scene closely to see how they respond.

Fortunately, the patient involved in this simulation is actually a high-fidelity mannequin, powered by artificial intelligence and delivered courtesy of augmented reality.

Dr Bumbach witnesses all of this within a specialist centre at the University of Florida. The Thomas M. and Irene B. Kirbo Innovation and Learning Laboratory represents a $2.9m overhaul of the college’s previous teaching lab and creates a true-to-life clinical setting. The facility houses patient care rooms, debriefing rooms and a control center that powers all of its technology. The learning lab officially opened in Spring 2021.

This investment is happening as a part of a larger shift taking place within American nursing education, which like its global counterparts, is facing challenging times.

Prior to the Covid-19 outbreak, the United States faced a nursing shortage of nearly half a million licensed caregivers. Globally, the shortage was about 6m. The average new graduate nurse turnover rate was 35 percent and it cost between $32,000 and $67,000 to onboard a newly licensed nurse. If the nursing profession was bleeding in 2019, the 2020 global pandemic triggered a hemorrhage.

Nursing schools are at the epicenter of the Covid-19 pandemic. First, they need to develop capacity so they can accept and educate more students. Next, they need to do more to ensure a greater percentage of those students actually graduate. In the US, they are attempting to fast-track graduate pass rates of the National Council Licensure Examination (NCLEX-RN), which has been the nationwide examination for licensing nurses in the United States, Canada and Australia since 1982.

A real concern for higher education institutions is how to effectively prepare students for the next generation NCLEX exam – students seasoned in lifelike clinical situations so they enter the workforce ready to deliver excellent patient outcomes from their very first round on the job.

To do that, schools are transforming themselves by adopting digital technology ranging from e-learning to virtual reality simulations.

Dr Michael Bumbach of the University of Florida runs the patient simulator in the control room of the newly renovated Kirbo Innovation and Learning Laboratory.

Passing exams

Critical to setting students up for career success as health professionals is the curriculum to prepare nurses for the licensure exam, the National Council Licensure Examination (NCLEX).

“When our faculty looked at our NCLEX-RN pass rates, they hovered between 86-92 percent. They identified it as a major gap in our program outcomes. Our graduate performance did not match the academic potential of our students,” says Dr Anna McDaniel, dean of the University of Florida’s College of Nursing.

To increase the student NCLEX-RN pass rate, McDaniel and her team began working with Elsevier, an information and analytics provider which is part of RELX, to implement HESI, a review and testing solution that helps students stay on track with their test preparation. The University of Florida had already leveraged HESI in its legacy curriculum for mid-curricular and program exit assessments but saw its full adoption as the potential answer to their problem.

“We integrated HESI educational products, including standardized exams and remediation, into each level of our upper division nursing courses. Faculty embraced the move and students used the exams to assess competency and mastery of course material,” said McDaniel. “After implementing the comprehensive curriculum transformation, which included HESI as a component, we observed an immediate improvement in our NCLEX-RN rate.”

The University of Florida College of Nursing improved its annual pass rate to 96 percent, representing a 4 to 10 percentage point increase year over year. Its quarterly pass rates now range from 95-100 percent.

This level of pass rate improvement isn’t limited to the University of Florida. Caldwell University, based in New Jersey, had NCLEX-RN pass rates hovering under 60 percent. After implementing Elsevier's HESI tool across its curriculum, Caldwell exam scores rose into the high 90s. In May 2018 it achieved a 98 percent overall pass rate, 100 percent for bachelor’s of science in nursing (BSN) graduates and 94.7 percent for nursing as second degree. This represented an improvement of over 30 percentage points, 20 percentage points over the national average when compared with a pass rate for all candidates of 73 percent.

Under the leadership of Dr Kathleen Kelley, director of undergraduate nursing education, the faculty is now able to use HESI to test and analyze the data to make sure its program outcomes are constantly adapted and on track to reach the highest possible pass rates.

HESI not only helps to prepare students to pass the critical NCLEX exam, but the data also help faculty understand how they can improve the program by finding the gaps in the curriculum based on students’ performance. For example, at Caldwell, HESI was instrumental in identifying that knowledge retention was their biggest challenge, enabling faculty to prioritize and address the issue. Having identified these gaps, the faculty was also able to use other tools from Elsevier to develop a remediation strategy. Retention activities were developed for students during term breaks to help students achieve better test outcomes.

Caldwell was recently named as one of New Jersey’s top nursing schools.

Near real-life simulation

“Nursing students are graduating and passing the licensure exam faster, but they are not job-ready by day one. The job has become increasingly complex: there are time pressures, there is a need for more immediate clinical readiness and decisions must be made faster and better,” says Brent Gordon, managing director of Elsevier.

Today's novice nurses are often likely to transition to practice feeling isolated, unsure, frustrated and overwhelmed. In fact, 50 per cent of them report missing signs of life-threatening conditions and 40 percent report making medication errors.

Simulations of near real-life experience are critical to student preparation. This is where Elsevier provides additional support to nursing programs through its digital clinical practice offering. Shadow Health is one of these tools. Students engage with a state-of-the-art conversation engine and interactive 3D imagery to perform assessments, practice documentation, and demonstrate critical thinking. “The virtual simulations offer me an initial take on how a student would perform in that situation,” says Dr Bumbach at the University of Florida. “I can evaluate which students are calm, cool and collected and will thrive in an emergency room (ER) environment and which are more cut out for a pediatric office. And what’s really great is the ability to then take them into a room and watch the scenario once more and critique performance. It’s so necessary.”

“Face it, it would be great if we could safely facilitate 100 percent human simulations, but that’s utopian and it’s always been utopian,” says Dr Bumbach. “What usually ends up happening is what you see on TV or in the movies: pods of students moving in clumps around a health care facility. It’s not particularly effective. By leveraging digital technology, we are able to give students a safe space to learn prior to human clinical interaction. And these simulation cases have been prepared with great care and precision so that we can really measure all of the processes they need to go through to evaluate a given patient.”

“The ability to critique students through their approach and cognition is so pivotal,” says Dr Bumbach. “What if they’re in a hospital next week and they have a patient who actually stops breathing? You want them to pre-think their way through these kinds of incidents. And there’s data that reveals if caregivers are more comfortable, they will act and react in ways that result in better outcomes for patients. It results in self-efficacy as they move into a physical clinical setting.”

Jamil George-Abdullah, a third-year student in the university’s traditional undergraduate nursing program, attests to the authenticity of these live, unraveling case studies and the urgency and adrenaline rush they evoke. He was amazed by the realism.

“I can tell you during my first time, there was a mannequin sitting there and its eyes were blinking and he was talking to you, and the breathing is life-like – in this case it was an older adult,” he says. “I was startled and nervous. And I was really grateful, too, because I knew that I could really get the practice that I needed and if I made a mistake, we could start over. You can’t start over with a human.”

George-Abdullah says the simulations are vesting him with a level of confidence he is applying to his job in the emergency room at the Malcom Randall Veterans Affairs Medical Center in Gainesville, Florida.

Dr Jane Gannon, assistant dean of simulation-based learning at the University of Florida, describes this approach as taking the cognitive knowledge harvested in the classroom and layering it with the psychomotor skills students require to become world-class nurses. The Kirbo Lab enables that blend to flourish through experiential learning that can only happen in the moment with a patient. Along the way, the high-powered technology brought to bear by Elsevier is allowing for deeper immersion in the clinical experience that scales across UFCN’s student body.

“Before, it was tough to expose all of the students to a clinical simulation, and to move a hundred students through a simulation would take weeks,” explains Gannon. “Now we can move up to 120 students through a set of simulations in a couple of days. We’re impressed with how well the system is working, giving our students an edge.”

Image from the Elsevier Simulation Learning System with VR

Nursing students using the Simulation Learning System with VR

Simulation learning system with VR

Partnering with Elsevier, McDaniel adapted the University of Florida’s pedagogical approach to evidence-based clinical simulation. Through its collaboration on the Kirbo Lab, Elsevier delivered a tailored deployment of its Simulation Learning System, or SLS for short, that delivers hands-on practice. More than 160 real-world scenarios help to gauge a student’s temperament, thought process and an ability to act and react with appropriate, precision-based clinical judgment leveraging leading-edge digital tools.

Josh Schoeller, president of Clinical Solutions at Elsevier, sees this as an essential pathway for nursing regardless of geography, particularly in terms of making sure good students become excellent professionals.

“Transition to practice is a universal problem worldwide,” says Schoeller. “When you begin looking at nursing care around the world, whether it’s in the US, the UK, India, Japan or Pakistan, you’re looking at a whole set of cultural nuances and approaches to care that define nursing education, country by country. We are sensitive to this, and with a solution like our Simulated Learning System we can ensure that more people get the practice they need in the cultural context that is appropriate. Whether it’s sepsis or treating a wound, they can make the critical thinking decisions necessary for the greatest outcomes possible.”

It’s a difference-making outlook that is impacting aspiring nurses, one student at a time.

Nicholas Slimick is one such student. Slimick took a non-traditional route to nursing school. Previously, he was a circus performer, touring with world-renowned aerialist and acrobat Nik Wallenda. “There is a team aspect of the circus and an intensity that is profound,” says Slimick. “It’s that aspect that also attracted me to nursing – without hanging by my ankles, connected to a motorcycle one hundred feet up on a tightrope.”

Slimick is completing a bachelor’s of science in nursing (BSN) within the University of Florida’s accelerated program, which requires 60 credits and more than 750 clinical hours over a single calendar year. “It’s like drinking from a fire hose,” says Slimick. “It’s intense and it’s no joke.”

For Slimick, knowledge retention is driven by what he characterizes as consistently challenging situations where a life is on the line.

“I hadn't even heard of Elsevier a few months ago,” says Slimick. “But now I’m on Evolve, the Elsevier student portal, every day. I’ve bookmarked it to death. I’ve used the simulated learning system with virtual reality numerous times. I’ve immersed myself in the HESI benchmarks. I graduate in the next month and I will be taking the NCLEX-RN as soon as possible. So, Elsevier is like an extension of this amazing team of faculty and these amazing hospitals at the University of Florida who’ve equipped me with what I need.”

Slimick is already making his transition to practice, starting as an Intensive Care Unit nurse at the University of Florida Health Shands Hospital in Gainesville, Florida. The dual-threat caregiver and high-wire act feels incredibly prepared for what’s next. “A professor suggested I immediately tackle Elsevier’s Saunders Comprehensive Review for the NCLEX,” says Slimick. “With all my studies and preparation, I hope to pass the NCLEX very soon."

Nicholas Slimick, right, in a 7-person pyramid. Photo by Cliff Roles.

Facing Covid-19

Nurses are at the front line of the battle against Covid-19. However, in California, the state has faced significant capacity constraints in its Intensive Care Units (ICU) during the pandemic. Nursing is the largest health profession in the state with more than 500,000 registered nurses.

The Emergency Medical Services Agency (EMSA) explored different ways to increase the number of nurses able to work in ICU units. The EMSA needed to provide the latest Covid-19 training in the fastest way possible so that nurses from other units could work in ICU.

After visiting Elsevier's Covid-19 healthcare hub, the EMSA contacted Elsevier and expressed interest in using its curated content to provide its nurses an advanced training programme, with specialized tools and guidelines to help them fight the pandemic.

A programme specific to nurses was developed in collaboration with the American Association of Critical Care Nursing (AACN) to provide ICU care. It includes 15 skills and 11 e-learning lessons. The two-day online curriculum of skills and learning provides the most critical things for a nurse to know when supporting ICU-based Covid care. A new module was also created for their specific need around use of a high-flow nasal cannula, which is becoming commonly adopted in California. The education is free for all registered nurses practicing in the state and is delivered through Elsevier’s Learning Management System found on the EMSA website. Users self-register for the education and complete skills and lessons for continuing education credit.

To date, hundreds of practicing nurses in the state have received additional training and preparation on caring for patients in the intensive care units diagnosed with Covid.