- Email: [email protected]
Adult simulation and demonstration of nurse competency with neurological assessment
PAGE 38
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
MARCH 2017
Clinical Column Adult simulation and demonstration of nurse competency with neurological assessment Pamela J. Mahaffey, DNP, RN, ACNS-BC, and Megan Robertson, BSN, RN
Nurses work in challenging environments and vast amounts of information are shared on a continual basis. Changes in health care and bedside nursing are constant which make maintaining competency in this dynamic environment challenging. In addition, as documentation has transitioned to electronic medical records, new challenges have been created. The purpose of this paper is to describe an educational intervention using a live standardized patient (actor) simulation with staff nurses that care for patients after a stroke or carotid intervention. Staff nurses at a large Midwestern Level 1 trauma center were preparing for stroke recertification from The Joint Commission. During the preparation period, it was recommended to create an educational opportunity for nurses that would allow them to demonstrate competency with both the neurological assessment and bedside swallow screen that they perform. The American Heart Association Stroke guidelines provide recommendations for frequent neurological assessments in the first 24 hours of admission after stroke as well as bedside swallow screening to assess for dysphagia.1 The neurological assessment and close monitoring for stroke patients is so that any changes in neurological status can be detected and managed in a timely manner. The neurological assessment in the electronic medical record (EMR) was used as a guide for the simulation and included an evaluation of: mental status, Glasgow coma scale, pupil reaction and accommodation, speech, motor function of arms and legs, facial symmetry, pronator drift, and shoulder shrug. In order to establish consistency and assess competency for all staff, educational didactic review sessions for the neurological assessment were conducted, and a checklist for the neurological assessment and the bedside nurse swallow screen using the EMR were created (Table 1.)
From the Grant Medical Center, OhioHealth, Columbus, Ohio; College of Nursing at Capital University, Bexley, Ohio. Corresponding author: Pamela J. Mahaffey, DNP, RN, ACNS-BC, Grant Medical Center, Ohio Health, 2339 Walnut Creek Pike, Circleville, OH 43113 (E-mail: [email protected]). 1062-0303/$36.00 Copyright Ó2016 by the Society for Vascular Nursing, Inc. http://dx.doi.org/10.1016/j.jvn.2016.12.001
The checklists were used during the simulation to assure that all components were being consistently assessed, evaluated, and documented.
BACKGROUND/LITERATURE REVIEW FOR SIMULATION Simulation is an educational technique that can be used in the clinical setting that can be developed to teach new concepts as well as assess competency with complex procedures including physical assessment, codes, and sterile technique.2–4 Simulation is an effective education method which can be used to educate and assess health care provider competency for various skills and provide an opportunity for debriefing and feedback in a one-one setting.2 Simulation can be done in a formalized setting with high fidelity computerized mannequins, in a setting using live (actor) standardized patients or a combination of both.5,6 In addition, simulation with adult volunteers provides an opportunity for health care providers to practice technical and nontechnical skills in a safe practice environment.2,3 A simulation experiential program for nurses working with the acute stroke population was developed and implemented to allow staff nurses the opportunity to practice neurological assessment skills for the acute stroke population and was shown to enhance skills and confidence for staff.7,8 In another study, mannequins and standardized patients were used to educate and evaluate nurses performing bedside swallow screens and found that nurses were able to transfer knowledge they learned with mannequins to a live patient scenario.6 Nurses who participated in simulation-based training demonstrated the ability to improve sterile technique and competency in managing central lines in critical care.9,10 Clinical simulation for health care providers using standardized patients can enhance knowledge, while allowing for practice and evaluation of both clinical skills and technology in a safe environment.
EDUCATIONAL INTERVENTION Nurses chose one of several case studies (Table 2) and demonstrated a complete neurological assessment on a live adult standardized (simulated) patient and described how and where they would document the data in the EMR. In addition, nurses
Vol. XXXV No. 1
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
PAGE 39
TABLE 1 NEURO ASSESSMENT CHECK-OFF Associate: ______________________________________ Skill Assessed:
Performed:
Not Performed:
1. 2. 3. 4. 5. 6.
Level of consciousness Orientation level Cognition Speech Pupil assessment (size, shape, reaction) Motor function/sensation assessment (grip, dorsiflexion, plantar flexion, motor response, sensation, strength) 7. Tongue deviation/lip sensation 8. Facial symmetry/sensation 9. Pronator drift assessment 10. Shoulder shrug 11. Sedation scale (POSS) 12. Glasgow coma scale Documentation of above reviewed in CareConnect?
Yes
Date ________________ Educator signature ______________________________________________ Associate signature ______________________________________________ BEDSIDE SWALLOW ASSESSMENT CHECK-OFF
Associate: ______________________________________ Skill Assessed:
Performed:
Not Performed:
Preswallow screen, including: 1. Observing the patient 2. Able to sit upright 3. Able to follow commands 4. Tolerates nasal cannula, if impaired O2 5. Facial droop assessed 6. Vocal quality assessed 7. Speech assessed 8. Cough and throat assessed 9. Drooling assessed 10. Clearance of foods assessed 11. Signs of dysphagia assessed 12. History of dysphagia assessed 13. Pass/fail indicated Swallow screen, including: 1. Swallow 2–3 ice chips 2. Swallow 2 Tsp. H20 3. Drink 1/3 cup H20 (Continued )
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JOURNAL OF VASCULAR NURSING www.jvascnurs.net
MARCH 2017
CONTINUED Associate: ______________________________________ Skill Assessed:
Performed:
Not Performed:
4. Assess for signs and symptoms of dysphagia 5. Pass/fail indicated Documentation of above reviewed in CareConnect?
Yes
Date ________________ Educator signature ______________________________________________ Associate signature ______________________________________________
performed a bedside swallow screen during the live simulation to assure that all steps were followed and that the appropriate consults or diet was ordered for stroke patients. During the simulation experience, nurse participants were encouraged to utilize the EMR to guide their assessment and they were encouraged to be systematic and to conduct their assessment in a head to toe format. Emphasis was placed on both the consistency in performing the neurological examination and the documentation of the neurological assessment including the bedside nursing swallow screen. In addition, the case studies included the question
‘‘what else might you do for this patient?’’ This question was intended to inspire critical thinking and problem solving for the specific patient described in the case study. Each session lasted 10–15 minutes and was scored by the unit educator.
CONCLUSION There were 35 clinical bedside nurses who participated in the simulation experience with a few nurses completing the entire examination without any prompting or coaching. Some nurses
TABLE 2 CASE STUDIES Neuro case study Case study 1: A 65-year-old woman looks much younger than stated age.was up at 4 AM to go to the bathroom and then when awakened at 6 AM had weakness and tingling on the right side of her body. She is having difficulty with speech— she is unable to form her words and is becoming frustrated as you try to communicate with her. 1. Perform a neuro assessment 2. Perform a swallow screen 3. What else might you do for this patient? Neuro case study Case study 2: A 50-year-old female admitted with an acute CVA. She is asking for some food because it has been many hours since she has anything to eat or drink. She also has a history of COPD and complains of frequent coughing spells. She is asking when she can leave the unit to smoke. 1. Perform a neuro assessment 2. Perform a swallow screen 3. What else might you do for this patient? Case study 3: A 60-year-old female admitted with an acute CVA and status post-TPA 48 hours ago. She is complaining of weakness in her right arm and feels unsteady when she gets up to walk. Her speech is ok, but she is feeling a little forgetful. She has numbness of her feet related to diabetic neuropathy. She has had type 2 diabetes for 20 years. Her blood glucose is not well controlled. 1. Perform a neuro assessment 2. Perform a swallow screen 3. What else might you do for this patient? CVA = cerebral vascular accident; COPD = chronic obstructive lung disease; TPA = tissue plasminogen activator.
Vol. XXXV No. 1
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
required prompting for various components of the assessment but completed all components with coaching during the simulation exercise. Only seven participants chose to use the EMR to guide their examination to confirm that all aspects were being included during the assessment. The majority of staff completed the entire neurological assessment and then reviewed how they would document their findings in the EMR. The importance of bedside reports and review of any patient deficiencies and mutual agreement during hand-offs was also reinforced, to assure that assessments were congruent in regard to the evaluation of extremity weakness, numbness, or deficit. The simulation was a good method to evaluate and provide immediate feedback to nurse participants. Nurses commented that participating in the simulation provided a good opportunity for learning and their personal confidence for performing the neurological assessment and swallow screen as well as properly documenting their assessment in EMR. Simulation is an educational method that can be used in multiple ways to teach and assess competency.
REFERENCES 1. Jauch E, Saver JL, Adams HP, et al. Guidelines for the early management of patients with ischemic stroke. Stroke 2013; 44:870-947. 2. Lewis R, Strachan A, Smith MM. Is high fidelity simulation the most effective method for the development of nontechnical skills in nursing? A review if current evidence. Open Nurs J 2012;6:82-9.
PAGE 41
3. Kesten KS, Brown HF, Meeker MC. Assessment of APRN student competency using simulation: a pilot study. Nurs Educ Perspect 2015;36(5):332-334. 4. Munroe B, Curtis K, Murphy M, et al. A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation. J Clin Nurs 2016;25:2262-74. 5. Freeland TR, Pathak S, Garett RR, et al. Using Medical Mannequins to train nurses in stroke swallowing screening. New York: Springer Science +Business Media; 2015:104-10. 6. Liaw SY, Chan SW, Chen F, et al. Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: randomized controlled trial. J Med Internet Res 2014;16(9):e214. 7. Ross AJ, Reedy GB, Roots A, et al. Evaluating multisite multiprofessional simulation training for a hyperacute stroke service using the behavior change wheel. BMC Med Educ 2015; 15:143. 8. Roots A, Thomas L, Jaye P, et al. Simulation training for hyperacute stroke unit nurses. Br J Nurs 2011;20(21): 1352-6. 9. Barsuk JH, Cohen ER, Mikolajczak A, Seburn S, Slade M, Wayne DB. Simulation-based mastery learning improves central line maintenance skills of ICU nurses. J Nurs Admin 2015;45(10):511-517. 10. Gerolemou L, Fidellaga A, Rose K, et al. Simulation-based training for nurses in sterile techniques during central vein catheterization. Am J Crit Care 2014;23(1):40-8.
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
MARCH 2017
Clinical Column Adult simulation and demonstration of nurse competency with neurological assessment Pamela J. Mahaffey, DNP, RN, ACNS-BC, and Megan Robertson, BSN, RN
Nurses work in challenging environments and vast amounts of information are shared on a continual basis. Changes in health care and bedside nursing are constant which make maintaining competency in this dynamic environment challenging. In addition, as documentation has transitioned to electronic medical records, new challenges have been created. The purpose of this paper is to describe an educational intervention using a live standardized patient (actor) simulation with staff nurses that care for patients after a stroke or carotid intervention. Staff nurses at a large Midwestern Level 1 trauma center were preparing for stroke recertification from The Joint Commission. During the preparation period, it was recommended to create an educational opportunity for nurses that would allow them to demonstrate competency with both the neurological assessment and bedside swallow screen that they perform. The American Heart Association Stroke guidelines provide recommendations for frequent neurological assessments in the first 24 hours of admission after stroke as well as bedside swallow screening to assess for dysphagia.1 The neurological assessment and close monitoring for stroke patients is so that any changes in neurological status can be detected and managed in a timely manner. The neurological assessment in the electronic medical record (EMR) was used as a guide for the simulation and included an evaluation of: mental status, Glasgow coma scale, pupil reaction and accommodation, speech, motor function of arms and legs, facial symmetry, pronator drift, and shoulder shrug. In order to establish consistency and assess competency for all staff, educational didactic review sessions for the neurological assessment were conducted, and a checklist for the neurological assessment and the bedside nurse swallow screen using the EMR were created (Table 1.)
From the Grant Medical Center, OhioHealth, Columbus, Ohio; College of Nursing at Capital University, Bexley, Ohio. Corresponding author: Pamela J. Mahaffey, DNP, RN, ACNS-BC, Grant Medical Center, Ohio Health, 2339 Walnut Creek Pike, Circleville, OH 43113 (E-mail: [email protected]). 1062-0303/$36.00 Copyright Ó2016 by the Society for Vascular Nursing, Inc. http://dx.doi.org/10.1016/j.jvn.2016.12.001
The checklists were used during the simulation to assure that all components were being consistently assessed, evaluated, and documented.
BACKGROUND/LITERATURE REVIEW FOR SIMULATION Simulation is an educational technique that can be used in the clinical setting that can be developed to teach new concepts as well as assess competency with complex procedures including physical assessment, codes, and sterile technique.2–4 Simulation is an effective education method which can be used to educate and assess health care provider competency for various skills and provide an opportunity for debriefing and feedback in a one-one setting.2 Simulation can be done in a formalized setting with high fidelity computerized mannequins, in a setting using live (actor) standardized patients or a combination of both.5,6 In addition, simulation with adult volunteers provides an opportunity for health care providers to practice technical and nontechnical skills in a safe practice environment.2,3 A simulation experiential program for nurses working with the acute stroke population was developed and implemented to allow staff nurses the opportunity to practice neurological assessment skills for the acute stroke population and was shown to enhance skills and confidence for staff.7,8 In another study, mannequins and standardized patients were used to educate and evaluate nurses performing bedside swallow screens and found that nurses were able to transfer knowledge they learned with mannequins to a live patient scenario.6 Nurses who participated in simulation-based training demonstrated the ability to improve sterile technique and competency in managing central lines in critical care.9,10 Clinical simulation for health care providers using standardized patients can enhance knowledge, while allowing for practice and evaluation of both clinical skills and technology in a safe environment.
EDUCATIONAL INTERVENTION Nurses chose one of several case studies (Table 2) and demonstrated a complete neurological assessment on a live adult standardized (simulated) patient and described how and where they would document the data in the EMR. In addition, nurses
Vol. XXXV No. 1
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
PAGE 39
TABLE 1 NEURO ASSESSMENT CHECK-OFF Associate: ______________________________________ Skill Assessed:
Performed:
Not Performed:
1. 2. 3. 4. 5. 6.
Level of consciousness Orientation level Cognition Speech Pupil assessment (size, shape, reaction) Motor function/sensation assessment (grip, dorsiflexion, plantar flexion, motor response, sensation, strength) 7. Tongue deviation/lip sensation 8. Facial symmetry/sensation 9. Pronator drift assessment 10. Shoulder shrug 11. Sedation scale (POSS) 12. Glasgow coma scale Documentation of above reviewed in CareConnect?
Yes
Date ________________ Educator signature ______________________________________________ Associate signature ______________________________________________ BEDSIDE SWALLOW ASSESSMENT CHECK-OFF
Associate: ______________________________________ Skill Assessed:
Performed:
Not Performed:
Preswallow screen, including: 1. Observing the patient 2. Able to sit upright 3. Able to follow commands 4. Tolerates nasal cannula, if impaired O2 5. Facial droop assessed 6. Vocal quality assessed 7. Speech assessed 8. Cough and throat assessed 9. Drooling assessed 10. Clearance of foods assessed 11. Signs of dysphagia assessed 12. History of dysphagia assessed 13. Pass/fail indicated Swallow screen, including: 1. Swallow 2–3 ice chips 2. Swallow 2 Tsp. H20 3. Drink 1/3 cup H20 (Continued )
PAGE 40
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
MARCH 2017
CONTINUED Associate: ______________________________________ Skill Assessed:
Performed:
Not Performed:
4. Assess for signs and symptoms of dysphagia 5. Pass/fail indicated Documentation of above reviewed in CareConnect?
Yes
Date ________________ Educator signature ______________________________________________ Associate signature ______________________________________________
performed a bedside swallow screen during the live simulation to assure that all steps were followed and that the appropriate consults or diet was ordered for stroke patients. During the simulation experience, nurse participants were encouraged to utilize the EMR to guide their assessment and they were encouraged to be systematic and to conduct their assessment in a head to toe format. Emphasis was placed on both the consistency in performing the neurological examination and the documentation of the neurological assessment including the bedside nursing swallow screen. In addition, the case studies included the question
‘‘what else might you do for this patient?’’ This question was intended to inspire critical thinking and problem solving for the specific patient described in the case study. Each session lasted 10–15 minutes and was scored by the unit educator.
CONCLUSION There were 35 clinical bedside nurses who participated in the simulation experience with a few nurses completing the entire examination without any prompting or coaching. Some nurses
TABLE 2 CASE STUDIES Neuro case study Case study 1: A 65-year-old woman looks much younger than stated age.was up at 4 AM to go to the bathroom and then when awakened at 6 AM had weakness and tingling on the right side of her body. She is having difficulty with speech— she is unable to form her words and is becoming frustrated as you try to communicate with her. 1. Perform a neuro assessment 2. Perform a swallow screen 3. What else might you do for this patient? Neuro case study Case study 2: A 50-year-old female admitted with an acute CVA. She is asking for some food because it has been many hours since she has anything to eat or drink. She also has a history of COPD and complains of frequent coughing spells. She is asking when she can leave the unit to smoke. 1. Perform a neuro assessment 2. Perform a swallow screen 3. What else might you do for this patient? Case study 3: A 60-year-old female admitted with an acute CVA and status post-TPA 48 hours ago. She is complaining of weakness in her right arm and feels unsteady when she gets up to walk. Her speech is ok, but she is feeling a little forgetful. She has numbness of her feet related to diabetic neuropathy. She has had type 2 diabetes for 20 years. Her blood glucose is not well controlled. 1. Perform a neuro assessment 2. Perform a swallow screen 3. What else might you do for this patient? CVA = cerebral vascular accident; COPD = chronic obstructive lung disease; TPA = tissue plasminogen activator.
Vol. XXXV No. 1
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
required prompting for various components of the assessment but completed all components with coaching during the simulation exercise. Only seven participants chose to use the EMR to guide their examination to confirm that all aspects were being included during the assessment. The majority of staff completed the entire neurological assessment and then reviewed how they would document their findings in the EMR. The importance of bedside reports and review of any patient deficiencies and mutual agreement during hand-offs was also reinforced, to assure that assessments were congruent in regard to the evaluation of extremity weakness, numbness, or deficit. The simulation was a good method to evaluate and provide immediate feedback to nurse participants. Nurses commented that participating in the simulation provided a good opportunity for learning and their personal confidence for performing the neurological assessment and swallow screen as well as properly documenting their assessment in EMR. Simulation is an educational method that can be used in multiple ways to teach and assess competency.
REFERENCES 1. Jauch E, Saver JL, Adams HP, et al. Guidelines for the early management of patients with ischemic stroke. Stroke 2013; 44:870-947. 2. Lewis R, Strachan A, Smith MM. Is high fidelity simulation the most effective method for the development of nontechnical skills in nursing? A review if current evidence. Open Nurs J 2012;6:82-9.
PAGE 41
3. Kesten KS, Brown HF, Meeker MC. Assessment of APRN student competency using simulation: a pilot study. Nurs Educ Perspect 2015;36(5):332-334. 4. Munroe B, Curtis K, Murphy M, et al. A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation. J Clin Nurs 2016;25:2262-74. 5. Freeland TR, Pathak S, Garett RR, et al. Using Medical Mannequins to train nurses in stroke swallowing screening. New York: Springer Science +Business Media; 2015:104-10. 6. Liaw SY, Chan SW, Chen F, et al. Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: randomized controlled trial. J Med Internet Res 2014;16(9):e214. 7. Ross AJ, Reedy GB, Roots A, et al. Evaluating multisite multiprofessional simulation training for a hyperacute stroke service using the behavior change wheel. BMC Med Educ 2015; 15:143. 8. Roots A, Thomas L, Jaye P, et al. Simulation training for hyperacute stroke unit nurses. Br J Nurs 2011;20(21): 1352-6. 9. Barsuk JH, Cohen ER, Mikolajczak A, Seburn S, Slade M, Wayne DB. Simulation-based mastery learning improves central line maintenance skills of ICU nurses. J Nurs Admin 2015;45(10):511-517. 10. Gerolemou L, Fidellaga A, Rose K, et al. Simulation-based training for nurses in sterile techniques during central vein catheterization. Am J Crit Care 2014;23(1):40-8.