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Nursing Essays - Staff Nurses Hospital

Info: 2737 words (11 pages) Essay
Published: 9th Mar 2016 in Nursing

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Staff Nurses Hospital

Abstract

This article outlines a simulation project developed and implemented by staff nurses at a specialty rehabilitation hospital.   The project was designed to educate nurses on proper care, protocol, and policy when caring for patients post laminectomy and spinal cord untethering surgery. 

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This surgery is unique to patients with spinal cord injury and this center is one of a few in the country that perform it; because of the complicated nature of the surgery, these patients are highly acute and may present with specific complications that need to be addressed for positive patient outcomes.

While simulation technology is not new to nursing education it is new to this facility.  By tapping into the experience of staff nurses, who parlayed their knowledge and expertise of caring for patients after this unique surgery, an involved 30 minute scenario was developed. 

The scenario emphasized some common and also unusual patient presentations post surgery and required the participating nurse to follow policy and protocol in order to successfully care for the patient.  Once the scenario was developed it was implemented as a teaching exercise for new graduate nurses. 

This process allowed experienced staff nurses to facilitate new graduate learning in a safe, non-threatening environment.  After the exercise a debriefing session was held providing feedback from the participants about the experience.  The feedback was overwhelmingly positive with the new graduate nurses reporting an increased confidence in taking care of these patients post surgically because of an increased knowledge of policy, protocol, and standard of care related to this surgery.

Article

Simulation education is becoming a routine teaching strategy for undergraduate nursing students, but is not yet used routinely in the clinical arena for practicing nurses. Effective for teaching nursing students new skills as well as enhancing their decision making ability (Baldwin, 2007), simulation is slowly being integrated into clinical practice for the purpose of demonstrating competency and enhancing safe patient care (Decker, Sportsman, Puetz and Billings, 2008; Anderson and Leflore, 2008).

Our world renowned rehabilitation hospital is exclusively dedicated to the specialty rehabilitation and research for patients with spinal cord injury and traumatic brain injury. As one of the leaders in spinal cord injury care, our nurses often care for patients after unique spinal cord specific surgeries including laminectomy and spinal cord untethering.

Due to the unique nature of these surgeries, post operative care of these patients is not part of a standard undergraduate nursing curriculum. As a result, many of our new graduate nurses learn “on the job” about seemingly inconsequential findings that may prove fatal in the spinal cord population undergoing this unique surgery.

Learning under duress in a situation in which mistakes may be critical to a patient’s outcome is neither ideal nor in the best interest of patient safety (Long, 2005). Simulation education offers an ideal teaching strategy for high-risk/low volume events for which new graduate nurses lack experience (Anderson & Leflore, 2008). Outcomes of simulation education with nursing students are speculated to include knowledge acquisition, skill performance, increasing confidence and enhanced critical thinking (Jeffries, 2006).

Some experts posit that new graduate nurses are expected to be advanced beginners or at the competent level based on the underpinnings of the theoretical framework of Novice to Expert (Long, 2005; Rhodes & Curran, 2005; Benner, 1984). Due to the specialization of spinal cord and traumatic brain injury rehabilitation at our facility, new graduate nurses are expected to be advanced beginners upon hire.

Waldner and Olson (2007) point out that simulators can play an important role in skill acquisition, both in decreasing anxiety and in increasing exposure to ‘abnormal’ or ‘unusual’ experiences that nursing students may otherwise not be exposed to in their clinical practicum. Simulation education may enhance new graduate nurses’ confidence, knowledge acquisition and critical thinking skills, similar to that experienced with nursing students.

Simulations can provide excellent experiences, both planned and spontaneous, for advanced beginners to immerse in the consequences of flawed decisions, without causing patient harm. These simulated experiences may, therefore, be helpful for advanced beginners to start making the transition to the competent level.

While simulation technology is not new to nursing education it is new to the education department at this world renowned rehabilitation facility. Developing simulation scenarios is time and resource-intensive (Radhakrishnan, Roche and Cunningham, 2007; Waldner & Olson, 2007) and requires knowledge of standards of nursing practice for a specific patient population. To address this need for education the Nursing Staff Development Coordinator at this facility brought together a group of staff nurses who understood the nuances of care specific to the hospital and this population.

This group of self selected experienced nurses identified several patient care situations that stemmed from personal experience, standards of care, policy, protocol, and essential critical thinking skills and judgment specific to the population of spinal cord injury. By parlaying their knowledge and expertise of spinal cord injury a complex 30 minute simulation scenario was developed by the staff nurses to educate staff on proper care, protocol, and policy when caring for patients post laminectomy and spinal cord untethering surgery.

While this scenario was specific to the spinal cord population after a unique surgery, the process of drawing on the expertise of the clinical nurse to develop simulation scenarios for peer education is easy to adopt. The Nursing Staff Development Coordinator invited all nurses to participate in this new opportunity to learn simulation development and implementation. An initial meeting was arranged where all interested nurses learned the goals of simulation and the process of simulation development. In a subsequent training session, the nurses experienced simulation scenarios and were introduced to the many elements involved in scenario development.

Later that same day, the development nurses brainstormed possible scenarios based on experience in caring for rehabilitation patients with spinal cord injuries. Many of the scenarios identified stemmed from personal experience with complicated patients or observations of deviations of care between nurses working on the same unit. Scenarios were then written with teams of 2 to 4 nurses, each team drawing on personal experience, standards of care, policy, protocol, and essential critical thinking skills.

Once the scenarios were written each team transferred their scenario into the simulation software and pulled together all the elements to create a “real” environment including mocked up doctor’s orders and medications. Staff nurse scenario developers collaborated with the Nursing Staff Development Coordinator to facilitate the scenarios for new graduate nurses. Finally, implementation and debriefing occurred with participants leading to evaluation of the scenario and adjustments, as needed, to improve the learning process.

The simulation scenario was developed around a surgery unique to patients with spinal cord injury, who experience pain and decreased functionality and sensation when, through the initial healing process, the spinal cord inappropriately tethers to surrounding lamina and structures. This surgery is often performed at our hospital resulting in complicated and highly acute patients.

New graduate nurses have not been exposed to the nursing care for the patient undergoing this unique surgical procedure in their undergraduate nursing programs. This specific scenario was developed due to the uncommon knowledge of this specialized intervention and the atypical patient presentations associated with complications post surgically.

The scenario emphasizes some common and also unusual patient presentations post surgery requiring the participating nurse to synthesize policy and protocol with critical thinking in order to make timely clinical decisions and improve the patient outcome.

  • Per hospital protocol, vital signs are monitored every 15 minutes for the first hour post-operatively. In the scenario, blood pressure and heart rate increase requiring the nurse to identify that the patient is experiencing pain although the patient can not feel the pain related to the spinal cord paralysis. If the nurse does not appropriately address the pain, the patient deteriorates into autonomic dysreflexia which can be a life threatening complication, stimulated as a result of underlying pain.
  • The patient complains of an intense headache indicating a cerebrospinal fluid leak or autonomic dysreflexia related to the surgery; the nurse must recognize these signs as possible complications and implement interventions to resolve the situation.
  • The nurse must work to control the patient’s pain. The scenario incorporates psychomotor skills including intravenous medication administration or setting up a patient controlled analgesia (PCA) infusion.
  • Neurological checks are completed every 30 minutes for the first two hours post-operatively. In the scenario, the nurse must make quick clinical decisions related to subtle changes in the patient’s mental status.
  • The scenario ends with the nurse identifying a complication related to profuse serosanguinous drainage at the surgical incision and taking appropriate action.

Once the scenario was developed it was implemented as a learning exercise for new graduate nurses, as part of the monthly new graduate program, utilizing high fidelity simulation in the hospital simulation lab. This space within the education department is set up as a patient room to enhance the reality of caring for a real patient.  This process allowed experienced staff nurses to facilitate new graduate learning, where the new nurses were encouraged to develop their decision making capabilities in a safe, non-threatening environment.

After the exercise a debriefing session was held in which the staff nurses who facilitated the scenario discussed the experience with the participants. For learning to take place, students need to be able to go through the process of reflection and conceptualization to adapt and reconstruct their cognitive frameworks (Waldner & Olson, 2007). Talking about the experience with the facilitators and their peers allowed for deeper understanding of the scenario and of care for these patients.

Participants were encouraged to vent their emotions and share insights related to the experience in addition to reflect on positive and negative patient outcomes. Self-assessments help clarify for students where they are in the development of nursing skills (Waldner & Olson, 2007). Additionally, feedback from the participants allowed the facilitators to identify areas of weakness and strength in the implementation in order to make future experiences more useful to the learner.

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The new graduate nurses reported an increased confidence in taking care of these patients post surgically because of enhanced knowledge and application of standards of care, policy, and protocol related to this surgery. Since the scenario emphasized common and unique findings post surgically, the nurse’s critical thinking skills and ability to synthesize seemingly inconsequential yet life threatening findings increased their autonomy and trust in their assessment skills at the bedside.

These findings are consistent with other reports about simulation experiences requiring integration of didactic education with clinical experience to develop confidence and competence into clinical judgment (Alinier et al., 2004; Jeffries, 2007; Mole & McLaffery, 2004; Rhodes & Curan, 2005; Rystedt & Lindstrom, 2001; Schoening, 2006) (Lasater, 2007;).

Current research showing the efficacy of simulation exercises resulting in increased clinical competence is insufficient. This simulation project highlights the need for enhanced evaluation. Although participants reported increased confidence in their assessments and clinical judgment skills through a post simulation evaluation we have only anecdotal evidence that this transpires to changes in patient outcomes as a result of simulation education.

One new graduate reiterated increased confidence and knowledge at the bedside when he cared for his first post-operative patient one week after the simulation exercise. Ongoing evaluation is needed in order to demonstrate the efficacy of simulation education in assisting new graduate nurses to move from advanced beginners to experts in their field. Based on the anecdotal evidence and participant self reports this initial simulation project has inspired future projects studying the efficacy and value of simulation education in the clinical setting

References

Alinier, G., Hunt, W.B., Gordon, R., (2004). Determining the value of simulation in nurse education: Study design and initial results. Nurse Education in Practice, 4: 200-207.

Anderson, M. and Leflore, J. (2008). Playing it safe: Simulated team training in the OR. AORN Journal, 87(4), 772-778.

Baldwin, K. B. (2007). Friday night in the pediatric emergency department: A simulated exercise to promote clinical reasoning in the classroom. Nurse Educator, 32(1), 24-20.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Co., Nursing Division.

Craig Hospital. (2008). Post-traumatic syringomyelia and post-traumatic tethered spinal cord. Craig Hospital. Downloaded February 20, 2008 from http://craighospital.org/SCI/rehabNeurosurgery.asp.

Decker, S., Sportsman, S., Puetz, L. and Billings, L. (2008). The evolution of simulation and its contribution to competency. The Journal of Continuing Education in Nursing, 39(2), 74-80.

Jeffries, P.R. (Ed.). (2007). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nursing.

Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students’ experiences. Journal of Nursing Education, 46(6): 269-276.

Long, R.E. (2005). Using simulation to teach resuscitation: an important patient safety tool. Critical Care Nursing Clinics of North America, 17: 1-8.

Mole, L.J., McLaffery, I.H.R., (2004). Evaluating a simulated ward exercise for third year student nurses. Nurse Education in Practice, 4: 91-99.

Radhakrishnan, K., Roche, J. P. and Cunningham, H. (2007). Measuring clinical practice parameters with human patient simulation: A pilot study. International Journal of Nursing Education Scholarship, 4(1), 1-10.

Rhodes, M., Curran, C. (2005). Simulation as a teaching strategy for nursing education and orientation in cardiac surgery. Cardiovascular Surgery, 24(3), 46-51.

Rystedt, H., Lindstrom, B. (2001). Introducing simulation technologies in nurse education: A nursing practice perspective. Nurse Education in Practice, 1: 134-141.

Schoening, A.M. (2006). Simulated clinical experience: Nursing students’ perceptions and the educators’ role. Nurse Educator 31(6): 253-258).

Waldner, M.H., Olson, J.K. (2007). Taking the patient to the classroom: Applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship, 4(1): article 18, 1-14).

 

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