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 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 : 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   Laerdal training   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. 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 Objective Performance Criteria SIM Day 1 Osteo Client Date ______ SIM Day 2 CHF Client Date ______ SIM Day 3 Bowel Client Date ______ SIM Day 4 CVA Client Date ______ Provider of Care 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) 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.)

Communication Demonstrates 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.) Caring Demonstrates 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 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. 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 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. Designates appropriate community resources and referrals in the daily clinical worksheet. (5 pts.) Caring Demonstrates 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 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 de- briefing sessions. (5 pts.) Maximum Points Possible 120 Accumulated Points Daily Numerical Grade (caluculated by ration/proportion)

 In the Beginning Pediatrics – 4 Scenarios developed  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 Developed Fundamentals OB Pediatrics Medical Surgical  Medical Surgical 1  Medical Surgical 2  Critical Care 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

 Board of Nursing Requirements  x.us/practice/position. html# x.us/practice/position. html#15.26  MHM Grant Requirements  Simulation Faculty Meetings  Simulation Coordinator

Patient Hallways

 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 ) Describe the pathophysiology of Cushings Triad pg 1469 Full Neurological Assessment pg 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) Manikin ActionsExpected Interventions May use the Following Cues Faculty/Staff Notes 5-10 minIn 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 = BP = 135/86 P = 128 RR = 36 O 2 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 earlier 7.Patient had an uneventful night and slept okay. 5 minutesSpeech 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.

Timing (approximate) Manikin ActionsExpected Interventions May use the Following Cues Faculty/Staff Notes minutesManikin 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.”

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) REQUIRED SKILLS AND EQUIPMENT

 Primary RN  Student Nurse  LVN  Family member  Observer

 MAR  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 DATEMEDICATIONREFILLS Start Stop Dosage/Direction/AmountDate/Amount/Initials Routine meds /xx/2010 Aspirin 81mg po tablets Q Day 08 10/xx/2010 Nitroglycerine paste 1 inch now and Q 6 hrs 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 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 CBC Hgb9 Gm/dl – 14 Gm/dlGm/dl Hct28 % – 42 % WBC5 mm 3 – 10mm 3 mm 3 Platelets 150 X 10 3 /mm 3 – 400 X 10 3 /mm 3 CMP Potassium3.5 mEq/L – 5.2 mEq/LmEq/L CHLORIDE98 mEq/L – 106 mEq/LmEq/L Calcium mg/dL mg/dl Carbon dioxide mmol/L mmol/L Creatinine mg/dL mg/dl Protein, total g/dL g/dl Sodium mmol/L mmol/L Urea Nitrogen (BUN) mg/dLmg/dL Blood Glucose80 mg/dL – 100 mg/dLmg/dL SAN ANTONIO HOSPITAL Laboratory Report DRAWN DATE: TODAY TIME: 15 MIN AGO

Radiology DATE: today TIME: 15 minutes ago Test:chest PA/LateralFindings: Atelectasis RUL

 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.

 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? 