Download Development and Implementation of Hybrid

Christina C. Olson RN, MSN
Pamela Gonzales RN, MSN
 Increased
demand for nurses
 Shortages in clinical sites
 Shortages of nursing faculty
 Lack of facilities for classroom and lab
instruction space.
 Increased patient acuity.
 Grant
Funding – Methodist Healthcare
Ministries Goals
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Increase nursing faculty
Develop new clinical experiences
Increase student enrollment
Increase number of qualified nurse in
community.
 “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
 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.
 Medical/Surgical
nursing faculty were
tasked with development of :
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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
 “best
outcomes occur when a theoretical
framework is used for structure and
integrated across entire curriculums.”
 Starkweather & Karding-Edgren, 2008
 SIRCI Training
 http://sirc.nln.org/
 Laerdal
training
 http://www.laerdal.com/us/
 Audio/visual equipment training
 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
Med./Surg. course
faculty member.
 BSN Clinical Teaching
Assistant – also a
graduate nursing student.
 Grant set-up
 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).
 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.
 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.
 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.
Role of the Nurse
Concepts
Performance Criteria
Nursing 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)
Objective
Provider of Care
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 Interventions
Demonstrate 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.)
SIM Day 1
Osteo Client
Date ______
SIM Day 2
CHF
Client
Date ______
SIM Day 3
Bowel Client
Date ______
SIM Day 4
CVA
Client
Date ______
Communication
Demonstrates the appropriate use of cognitive
psychomotor and communication skills in the
implementation of therapeutic nursing interventions.
Caring
Demonstrates professional attributes of caring when
providing nursing care to adult clients with complex
medical-surgical health care needs and their families.
Participates and communicates effectively with student
peers during simulation. (5 pts.)
Demonstrates comportment to all fellow student
members involved in the simulation experience.
(5 pts.)
Teaching/Learning Process
Implement 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 Thinking
Uses 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 Modalities
Uses therapeutic modalities to promote adaptation for
adult clients with complex healthcare needs.
Coordinator of Care
Communication
Uses 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 Modalities
Uses therapeutic modalities to promote adaptation for
adult clients with complex healthcare needs.
Coordinator of Care
Communication
Uses therapeutic modalities in collaboration with the
interdisciplinary health care team, to promote
adaptation for adult clients with complex health care
needs.
Critical Thinking
Utilizes community resources that assist clients and
families in adapting to complex health care needs in
collaboration with the inter-disciplinary health care
team.
Caring
Demonstrates the advocacy role of the nurse in caring
for clients with complex health care needs and their
families.
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.)
Designates appropriate community resources and
referrals in the daily clinical worksheet. (5 pts.)
Identifies key attributes of the advocacy role in caring
for simulation clients and their families during debriefing sessions. (5 pts.)
Member of Profession
Caring
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 & Communication
Identifies 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 debriefing sessions. (5 pts.)
Maximum Points Possible
Accumulated Points
Daily Numerical Grade
(caluculated by ration/proportion)
120
120
120
120
 In
the Beginning
• Pediatrics – 4 Scenarios developed
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Acetaminophen Overdose
Asthma
Pyloric Stenosis
VSD
Developed by Simulation Grant Committee
 15 Students in Simulation
 Scenarios ran 45 minutes
 Debriefing 1 to 1.5 hours
Sim Newbie
 Current Scenarios
• Fundamentals
• OB
• Pediatrics
• Medical Surgical
 Medical Surgical 1
 Medical Surgical 2
 Critical Care
Developed
Currently 195 students in Simulation
Scenarios run from 1.0 to 2 hours in length
Debriefing run from 1.5 to 2.5 hours in length
Critical Care
Network Engineer
 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
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Board of Nursing
Requirements
http://www.bon.state.t
x.us/practice/position.
html#15.26
MHM Grant
Requirements
 Simulation Faculty
Meetings
 Simulation Coordinator

Patient Hallways
 Modules on Blackboard Vista
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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
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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
Describe 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
Timing
(approximate)
5-10 min
Manikin Actions
Expected Interventions
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 Presentation
Manikin lying flat in bed.
Monitor settings:
T = 100.2
BP = 135/86
P = 128
RR = 36
O2 Sat = 85%
1.
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.
5 minutes
2.
3.
4.
5.
6.
7.
May use the Following
Cues
Day shift RN gives verbal report utilizing SBARQ
format.
Evening shift RN, SN, and CNA receive report.
Evening shift RN & SN review order set
Day shift RN will now assume role of observer.
Elevate HOB.
Patient's temperature has decreased since Tylenol
was given earlier
Patient had an uneventful night and slept okay.
Identifies pertinent abnormal assessment findings:
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Increased respiratory rate
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Decreased oxygen saturation
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Increased heart rate
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Confused/disoriented
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Crackles bilaterally
Check Oxygen tubing and connect to wall unit properly
Neighbor at bedside.
Faculty/Staff Notes
Timing
(approximate)
Manikin Actions
Expected Interventions
May use the
Following Cues
15-20 minutes
Manikin presentation as
above:
Manikin states:
“My chest hurts when I
cough or breath too deep.”
1.
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.”
2.
3.
4.
5.
6.
7.
8.
9.
10.
RN and SN introduce themselves, wash
hands, and put on gloves.
Check ID band.
RN/SN begins to take vital signs and perform
assessment.
RN and SN will review orders and labs
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.)
RN and SN identify abnormal assessment
findings and need for medication. RN states
that he/she will obtain medication.
RN will check orders against MAR.
RN will recognize the presence of both
Tylenol and Vicodin on MAR and will review
orders for clarification.
RN will administer the appropriate medication
for elevated temp and pain.
RN and SN will teach client how to splint rib
cage when coughing of deep breathing.
Faculty/Staff Notes
REQUIRED SKILLS AND EQUIPMENT
Psychomotor Skills Required Prior to
Simulation
Physical assessment skills
Pain assessment
Giving and receiving report using SBARQ
method
Taking vital signs
Medication administration
IV Care and maintenance
Documentation
Setting/
Simulator Manikin/s Needed: Vital SimMan
Props: hospital gown, blanket, telephone,
bedside computer for nurses notes, chair, chart,
bedside table
Equipment 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: High
IV Fluids:
Normal Saline
Medications:
Diagnostics Available:
Labs:
X-rays (Images):
Documentation Forms: online
Physician orders
Medication administration record
Flow Sheet
Nurses notes
Roles / Guidelines for Roles:
Nurses (student)
Parent (student)
Off-going RN/observer (student )
MD (instructor)
 Primary
RN
 Student Nurse
 LVN
 Family member
 Observer
 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.
Patient Name : Julia Parker
Allergies : NKDA
DATE
REFILLS
MEDICATION
Start
Stop
Dosage/Direction/Amount
Routine meds
Date/Amount/Initials
7-3
10/xx/2010 Aspirin 81mg po tablets Q Day
08
10/xx/2010 Nitroglycerine paste 1 inch now and Q 6 hrs
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
3-11
11-7
12
24
18
06
Medication Room and Medication Cart
SAN ANTONIO HOSPITAL Laboratory Report
DRAWN DATE: TODAY
TIME: 15 MIN AGO
Normal Values
Patient
Results
CBC
Hgb
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
CMP
Potassium
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
Radiology
DATE: today
Test: chest PA/Lateral
TIME: 15 minutes ago
Findings: Atelectasis RUL
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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.
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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?