Development and Implementation of Hybrid

Medical/Surgical Simulation Clinical Experiences in an

A.D.N. Program

Christina C. Olson RN, MSNPamela Gonzales RN, MSN

Today’s Nursing Education Challenges

Increased demand for nurses Shortages in clinical sites Shortages of nursing faculty Lack of facilities for classroom and

lab instruction space. Increased patient acuity.

Beginnings

Grant Funding – Methodist Healthcare Ministries Goals• Increase nursing faculty• Develop new clinical experiences• Increase student enrollment• Increase number of qualified nurse in

community.

Solutions begin with definitions….. “the art and science of recreating

clinical scenarios in artificial setting.” Jeffries, 2005

a strategy, not technology, to mirror , anticipate or amplify real situations with guided experiences in a fully interactive way.”

Lassiter, 2007

Goals for implementation of simulation into clinical courses…

Blending tradition with simulation Varying learning opportunities Encouraging critical thinking Creating a safe environment Providing opportunities not always

available – like the RN role Be creative.

Faculty tasks…. Medical/Surgical nursing faculty were

tasked with development of :• High fidelity clinical simulation scenarios• Using various scenario products• Or developing them from scratch• Specifying them to our course outcomes• Specifying clinical grading tools, templates

and agendas

Defining these developmental responsibilities…

“best outcomes occur when a theoretical framework is used for structure and integrated across entire curriculums.”

Starkweather & Karding-Edgren, 2008

Other essentials…

SIRCI Training http://sirc.nln.org/ Laerdal training http://www.laerdal.com/us/ Audio/visual equipment training

Scenarios were developed according to…..

Quality Safety Education for Nurses Guidelines(QSEN)

And the proposed targets for Acquisition of Knowledge, Skills, Attitudes (KSA’s) in all scenarios.• http://www.qsen.org/ksas_prelicensure.php

• NLN SIRCI guidelines

Simulation Course Faculty (SCF) teams….

Med./Surg. course faculty member.

BSN Clinical Teaching Assistant – also a graduate nursing student.

Grant set-up

Faculty Responsibilities… Develop scenario templates from

nursing clinical knowledge and experience.

Tailor clinical situations/diagnoses to content theory taught in co-requisite clinical, typical diagnoses found in clinical area and incorporate competencies specific to course leveling.

Write new or adapt existing scenario products (such as NLN or Elsevier).

Faculty Responsibilities… Develop scenario template..described in

greater detail later. Develop daily student clinical grading tool

based on clinical course tool but adapted to simulation experiences.

Develop daily student clinical worksheets also based on those used in clinical setting.

Develop clinical rotation schedule for the 15 student groups.

Faculty Responsibilities… Develop virtual patient medical

records needed for each scenario, in keeping with adult medical/surgical, hospital records.

Loading all student course tools on accessible Blackboard Vista learning modules.

SAC Student Support BBV pre-work which contains:

• Required-directed reading/videos.• Pre-worksheets to be completed• Simulation specific learning objectives• Simulation specific daily grading tool.• Orientation to San Antonio Hospital

Simulation Experience• Orientation to “roles” assigned.

San Antonio CollegeRNSG 1262 Daily Simulation Grading Tool

Role of the NurseConcepts

ObjectivePerformance Criteria SIM Day 1

Osteo ClientDate ______

SIM Day 2CHF Client

Date ______

SIM Day 3Bowel ClientDate ______

SIM Day 4CVA

ClientDate ______

Provider of CareNursing Process

Uses patho-physiology and psychosocial theories to explain complex medical surgical health care need and treatment response across the adult life span.Demonstrates in a plan of care, psycho-social, developmental and cultural factors which impact the family and client with complex medical surgical health care needs.

Performs a systematic physical, psycho-social, cultural and developmental assessment on the simulation client. (10 pts)

Correlates patho-physiology and psychopathology with assessments and establishes nursing diagnoses for the simulation client. (10 pts)

Develop criteria based outcomes for the simulation client. (5 pts.)

Plans nursing interventions for the simulation client based on client needs. (10 pts.)

Therapeutic Nursing InterventionsDemonstrate the appropriate use of cognitive, psychomotor and communication skills in the implementation of therapeutic nursing interventions.

Provides scientific rationale for therapeutic nursing interventions required by the simulation client. (10 pts.)

San Antonio CollegeRNSG 1262 Daily Simulation Grading Tool

CommunicationDemonstrates the appropriate use of cognitive psychomotor and communication skills in the implementation of therapeutic nursing interventions.

Participates and communicates effectively with student peers during simulation. (5 pts.)

CaringDemonstrates professional attributes of caring when providing nursing care to adult clients with complex medical-surgical health care needs and their families.

Demonstrates comportment to all fellow student members involved in the simulation experience. (5 pts.)

Teaching/Learning ProcessImplement a teaching and or discharge plan for promotion of health maintenance, rehabilitation and restoration of health.

Determines teaching needs to address simulation client/family learning needs. (5 pts)

Critical ThinkingUses nursing process and critical thinking skills to prioritize and organize nursing care of clients with complex medical-surgical healthcare needs.

Prioritizes nursing diagnoses for the simulation client. (5 pts.)

Therapeutic ModalitiesUses therapeutic modalities to promote adaptation for adult clients with complex healthcare needs.Coordinator of Care

CommunicationUses therapeutic modalities in collaboration with the interdisciplinary health care team, to promote adaptation for adult clients with complex health care needs.

Documents simulation client’s prescribed therapeutic modalities in daily careplan kardex. (5 pts. )

Documents significance of simulation client’s diagnostic finding, correlating them to underlying patho-physiology. (5 pts)Uses appropriate medical terminology and charting technique in communicating simulation client data.(5 pts.)

Therapeutic ModalitiesUses therapeutic modalities to promote adaptation for adult clients with complex healthcare needs.Coordinator of Care

CommunicationUses therapeutic modalities in collaboration with the interdisciplinary health care team, to promote adaptation for adult clients with complex health care needs.

Documents simulation client’s prescribed therapeutic modalities in daily careplan kardex. (5 pts. )

 

Documents significance of simulation client’s diagnostic finding, correlating them to underlying patho-physiology. (5 pts)Uses appropriate medical terminology and charting technique in communicating simulation client data.(5 pts.)

 

Critical ThinkingUtilizes community resources that assist clients and families in adapting to complex health care needs in collaboration with the inter-disciplinary health care team.

Designates appropriate community resources and referrals in the daily clinical worksheet. (5 pts.)

 

CaringDemonstrates the advocacy role of the nurse in caring for clients with complex health care needs and their families.

Identifies key attributes of the advocacy role in caring for simulation clients and their families during de-briefing sessions. (5 pts.)

 

Member of ProfessionCaring

Demonstrates accountability and responsibility for the quality of nursing care provided

Demonstrates accountability and responsibility during clinical simulation day. (5 pts.)  

Reflects a professional image in dress and manner during clinical simulation day. (5 pts.)  

Critical Thinking & CommunicationIdentifies political, economic, ethical and legal issues associated with the nursing care of clients with complex health care needs.

Communicates external issues impacting the simulation client/family health care needs during de-briefing sessions. (5 pts.)

 

Maximum Points Possible 120 120 120 120  Accumulated Points  

Daily Numerical Grade(caluculated by ration/proportion)

San Antonio CollegeRNSG 1262 Daily Simulation Grading Tool

Scenario Development In the Beginning

• Pediatrics – 4 Scenarios developed Acetaminophen Overdose Asthma Pyloric Stenosis VSD

Developed by Simulation Grant Committee15 Students in SimulationScenarios ran 45 minutesDebriefing 1 to 1.5 hours

Sim Newbie

Scenario Development Current Scenarios Developed

• Fundamentals• OB• Pediatrics• Medical Surgical

Medical Surgical 1 Medical Surgical 2 Critical CareCurrently 195 students in SimulationScenarios run from 1.0 to 2 hours in lengthDebriefing run from 1.5 to 2.5 hours in length

Critical Care

Network Engineer

CTA Role Greet students Check Pre-work and grading criteria

pertaining to role of “Member of the Profession.”

Assign roles Run Simulation scenario either trended or

spontaneous-script based

Guidelines for CTA’s Board of Nursing

Requirements

http://www.bon.state.tx.us/practice/position.html#15.26

MHM Grant Requirements

Simulation Faculty Meetings

Simulation Coordinator

Nurses Station in SIM LAB

Patient Hallways

Pre-work Example  Modules on Blackboard Vista  Setting: SICU Past Medical History: DM, CHF, HTN, CHF, Depression History of Present Illness: CHI S/P MVC Primary Medical Diagnosis: CHI with HA Surgeries/Procedures & Dates: Gallbladder removal Cognitive

Activities Required prior to Simulation: Independent Reading (Lewis)

• Acute Intracranial Problems, including management of ICP monitor. ( pg 1467-87)

• Describe the pathophysiology of Cushings Triad pg 1469• Full Neurological Assessment pg. 1456-1461• Adult IV insertion and assessment• Foley insertion• Five rights of medication administration• Adult assessment• Documentation- Glascow Coma Scale pg 1476

Pre Work QuestionsDescribe nursing considerations of a patient on a vent with an ICP monitor?What are the two types of posturing that can occur and describe how they appear?What are the potential complications of a patient with an ICP monitor?What is the normal range for ICP and CPP?What daily diagnostic tests would you expect to see ordered for this client?What are the primary nursing considerations for caring for a client with an ICP monitor?How would the client’s development task and/or psychosocial needs affect his/her nursing care:What are the safety considerations when administering the following medications:

Control Room

Sample Scenario CTA Guide SheetTiming (approximate)

Manikin Actions Expected Interventions May use the Following Cues

Faculty/Staff Notes

5-10 min In room on bed supine; Nurse gives verbal report utilizing SABRQ format;accepting nurse receives report

5-10 min Day shift RN gives report to Evening shift RN and Student Nurse (SN).Manikin PresentationManikin lying flat in bed. Monitor settings:T = 100.2BP = 135/86P = 128RR = 36O2 Sat = 85%

1. Day shift RN gives verbal report utilizing SBARQ format.

2. Evening shift RN, SN, and CNA receive report.3. Evening shift RN & SN review order set 4. Day shift RN will now assume role of observer.5. Elevate HOB.6. Patient's temperature has decreased since Tylenol

was given earlier7. Patient had an uneventful night and slept okay.

5 minutes Speech clear, Intermittent coughing and confusion. BBS with crackles.Right-sided pleural friction rub. Manikin states: “It was nice to get out of the room.”

Performs a focused respiratory assessment.

Identifies pertinent abnormal assessment findings:

Increased respiratory rate

Decreased oxygen saturation

Increased heart rate

Confused/disoriented

Crackles bilaterally

Check Oxygen tubing and connect to wall unit properly

Neighbor at bedside.

Sample CTA Guide SheetTiming (approximate)

Manikin Actions Expected Interventions May use the Following Cues

Faculty/Staff Notes

15-20 minutes Manikin presentation as above:Manikin states:“My chest hurts when I cough or breath too deep.”

1. RN and SN introduce themselves, wash hands, and put on gloves.

2. Check ID band.3. RN/SN begins to take vital signs and perform

assessment.4. RN and SN will review orders and labs 5. RN and SN recognize incorrect IV fluids

hanging. RN obtains and hangs correct fluids. Makes note of patient hydration status (↑Hgb, ↑Hct, and ↑BUN, ↑sp.gr.)

6. RN and SN identify abnormal assessment findings and need for medication. RN states that he/she will obtain medication.

7. RN will check orders against MAR.8. RN will recognize the presence of both

Tylenol and Vicodin on MAR and will review orders for clarification.

9. RN will administer the appropriate medication for elevated temp and pain.

10. RN and SN will teach client how to splint rib cage when coughing of deep breathing.

Cue: If RN and SN do not introduce themselves, manikin will ask, “Who are you?”Cue: If RN or SN does not pick up on hydration status, patient states “I’m really thirsty,” and neighbor states “she has not gone to the bathroom since being admitted.”

Scenario CoversheetPsychomotor Skills Required Prior toSimulationPhysical assessment skillsPain assessmentGiving and receiving report using SBARQ methodTaking vital signsMedication administrationIV Care and maintenanceDocumentationSetting/ Simulator Manikin/s Needed: Vital SimMan Props: hospital gown, blanket, telephone, bedside computer for nurses notes, chair, chart, bedside tableEquipment attached to manikin:

ID band Allergy band Equipment available: IV insertion Supplies Standard Sim Man Room Setup Standard Sim Man Monitor Setup Oxygen delivery devices

Fidelity: HighIV Fluids:Normal SalineMedications: Diagnostics Available: Labs: X-rays (Images): Documentation Forms: online Physician orders

Medication administration recordFlow SheetNurses notes

Roles / Guidelines for Roles: Nurses (student)

Parent (student) Off-going RN/observer (student )MD (instructor)

REQUIRED SKILLS AND EQUIPMENT

Roles During Scenario Primary RN Student Nurse LVN Family member Observer

Miscellaneous samples MAR http://practicefusion.com/ Lab reports Diagnostic reports Hard patient medical record,

computerized charting available and Blackboard Vista module specific to complete pre-work for scenario assigned.

Documentation now required of students in every scenario.

MED ADMINISTRATION RECORD

Patient Name : Julia Parker Allergies : NKDADATE MEDICATION REFILLS

StartStop

Dosage/Direction/Amount Date/Amount/InitialsRoutine meds 7-3 3-11 11-7

10/xx/2010

Aspirin 81mg po tablets Q Day 08

10/xx/2010

Nitroglycerine paste 1 inch now and Q 6 hrs 06 12

18

24 06

IV PRN Meds

10/xx/2010

Morphine sulfate IV 2mg Q 1 hr PRN chest pain

10/xx/2010

Metoprolol tartrate 5mg IV now Q 2 hrs

IV Meds

10/xx/2010

IV fluids: D51/2 N.S. with 20 mEq KCL at 100ml/hr

10/xx/2010

Heparin 25,000u in 250ml D5W @ 18 units/hr

10/xx/2010

Nitroglycerin IV drip 100mg in 250ml D5W titrate to keep pain free, start at 5mg/min

10/xx/2010

Dopamine 400mg/ 500mlNS

PRN Meds

10/xx/2010

Nitroglycerin 0.4mg SL tablets

10/xx/2010

Medication Room and Medication Cart

LAB Normal Values Patient

Results

CBCHgb 9 Gm/dl – 14 Gm/dl Gm/dl

Hct 28 % – 42 % %

WBC 5 mm3 – 10mm3 mm3

Platelets 150 X 103 /mm3 – 400 X 103 /mm3

CMPPotassium 3.5 mEq/L – 5.2 mEq/L mEq/L

CHLORIDE 98 mEq/L – 106 mEq/L mEq/L

Calcium 8.7 - 10.7 mg/dL mg/dl

Carbon dioxide 20 - 28 mmol/L mmol/L

Creatinine 0.5 - 1.1 mg/dL mg/dl

Protein, total 5.6 - 8.5 g/dL g/dl

Sodium 135- 145 mmol/L mmol/L

Urea Nitrogen (BUN) 5 - 18 mg/dL mg/dL

Blood Glucose 80 mg/dL – 100 mg/dL mg/dL

SAN ANTONIO HOSPITAL Laboratory Report

DRAWN DATE: TODAY TIME: 15 MIN AGO

DIAGNOSTIC REPORTSRadiology

DATE: today TIME: 15 minutes agoTest: chest PA/Lateral Findings: Atelectasis RUL

Student assessing patient (SIM MAN)

View scenarios….

CTA/TNT Role in Debriefing Most critical time in this

learning experience Length should be 2-3 times

the length of the simulation itself.

Must include the guided reflection questions.

Facilitator views videotape with students and directs conversation, questions and learning in a positive manner

Scenario specific discussion questions.

DEBRIEFING General Guided Reflection Questions for This Simulation How did you feel throughout the simulation experience? Describe the objectives you were able to achieve? Which ones were you unable to achieve (if any) and why? Did you feel you had the knowledge and skills to meet objectives? Were you satisfied with your ability to work through the simulation? To Observer: Could the nurses have handled any aspects of the

simulation differently? If you were able to do this again, what would you have done

differently? What did the group do well? What did the team feel was the primary nursing diagnosis? What were the key assessments and interventions? Is there anything else you would like to discuss?  

 

Debriefing after scenario

QUESTIONS?????