- Email: [email protected]
Innovative Varied-Fidelity Simulation Mobile Teaching Cart and Education Project
CLINICAL NURSES FORUM
INNOVATIVE VARIED-FIDELITY SIMULATION MOBILE TEACHING CART AND EDUCATION PROJECT Authors: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, Kathryn Cullinane Whalen, DNP, RN, FAHA, and Bradley S. Silverman, BS, New Bedford and Milton, MA Section Editors: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, and Kathryn Cullinane Whalen, DNP, RN, FAHA
The use of a varied-fidelity simulation mobile teaching cart is a teaching tool that offers unique advantages in the acute care setting. The cart is used to demonstrate the use of patient monitoring devices, and there are a variety of software tools available with the monitoring technology to ensure
that the outputs, including electrocardiographic waves, are analyzed appropriately by nursing staff using this variedfidelity simulation mobile teaching cart. Bringing variedfidelity simulation to the nurses’ work area is a unique application setting.
sing electrocardiogram (ECG) rhythm strips on paper or on PowerPoint slides (Microsoft, Redmond, WA) is a traditional method for assessing a nurse’s ability to interpret ECGs. An opportunity to provide an enhanced innovative simulation using the ECG monitors and affiliated technology available at a community health system in the nurses’ work area, not in the classroom or an off-campus simulation laboratory, was pursued. A process of a product development partnership was used with a manufacturer. A best-practices teaching modality review was undertaken to meet the educational needs of registered nurses responsible for patient ECG monitoring. This article will review the product development and acquisition process along with the descriptive rollout of this innovative teaching modality.
Background and Significance
U
Andrew D. Harding, Member, Mayflower Chapter, is Associate Chief Nursing Officer, Charlton Memorial Hospital, Southcoast Health System, New Bedford, MA. Kathryn Cullinane Whalen, Member, Mayflower Chapter, is Assistant Professor, Curry College, Milton, MA, and Nurse Educator, Southcoast Health System, New Bedford, MA. Bradley S. Silverman is Director of Business Operations, Southcoast Health System, New Bedford, MA. For correspondence, write: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, Charlton Memorial Hospital, Southcoast Health System, 101 Page St, New Bedford, MA 02470; E-mail: [email protected]. J Emerg Nurs 2015;41:423-7. Available online 19 June 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.05.009
September 2015
VOLUME 41 • ISSUE 5
Cardiology physicians brought their clinical care concerns forward to nursing administration about the nurses’ ability to interpret ECGs. Although the cardiology physicians acknowledged that there was a range of nurses’ capabilities to interpret ECGs, they were concerned about both overand under-appreciation of significant ECG abnormalities. Education for nurses responsible for ECG rhythm monitoring included a 3-day basic ECG telemetry class on orientation to the unit, the American Heart Association Basic Life Support program, the American Heart Association Advanced Cardiac Life Support program, annual computer-based learning modules for ECG telemetry rhythm interpretation, annual in-services on cardiology medications, and mock codes. Despite this solid foundation of cardiac dysrhythmia education, there was an added consideration by the interprofessional team to develop increased proficiency in cardiac monitoring by using cognitive, technical, psychomotor, and interactive skills with the equipment through case-based scenarios.
Patient Safety
Since 2000, Institute of Medicine publications have focused on patient safety. In the pivotal report To Err Is Human: Building a Safer Health System, 1 the needed emphasis on patient safety was detailed in the authors’ reports of numerous fatal medical errors involving hospitalized patients. In the report summary, simulation training was specifically recommended to mitigate harm to patients. 1
WWW.JENONLINE.ORG
423
CLINICAL NURSES FORUM/Harding et al
FIGURE 1 Initial sketch of mobile teaching simulation cart. (Source: Gary Brayton, JACO.)
The health system and nursing administration responded to the physicians’ concerns and fulfilled its obligation to assess staff competence. 2 In brainstorming to determine better ways to teach nurses about ECG interpretation and the use of the technology available within the hospital system, a vision for a mobile cart that would contain these devices was promoted, developed, and implemented (Figure 1). The on-site unit-based educational action plan was collaboratively developed and subsequently executed.
424
JOURNAL OF EMERGENCY NURSING
The use of mobile teaching carts allow for in-the-moment in-services using the equipment that staff nurses currently use to monitor their patients’ ECG, therefore making the education timely, accurate, and immediately applicable. Using this teaching strategy allowed the nursing educators to include simulation of a critical event within the framework of a case study, incorporating familiar and potential scenario elements that would require the nurse to identify, interpret, and explore the critical thinking needed to deal with the clinical dilemma described in the case
VOLUME 41 • ISSUE 5
September 2015
Harding et al/CLINICAL NURSES FORUM
the emergency department to support the availability of nurse participants. Once the simulation begins, the commitment of the participants to complete the session is essential for the interactive team experience and the follow-up debriefing. The agenda for each drop-in simulation session is goal oriented with well-designed case studies and a follow-up checklist for the technical cardiac monitor skills from simple to complex. Each nurse leaves the session with resource-rich fact sheets and information on upcoming basic, intermediate, and advanced cardiac dysrhythmia nursing education. The nurse participant also has the ability to return for any recommended remediation or self-directed supplementary reviews. 2,7,8 Lastly, because this form of mobile cardiac monitoring instruction is not at the patient’s bedside, our goal was to decrease the risk of exposing the learner to any embarrassment or humiliation resulting from lack of expertise and to enhance his or her ability to draw on this knowledge for future safe practice. FIGURE 2 Mobile teaching simulation cart. (Source: Andrew D. Harding.)
3,4
study. Adult learners have different learning styles, and the literature provides us with instructional methodology that recounts optimal retention of learning from demonstration, from hands-on practice, and by teaching others. 2,5 As an applied science, nursing education has acknowledged the benefits of psychomotor skills with infusion pumps, as well as other adjunctive devices, in the environment of care. This “hands-on” approach for the return demonstration and the acquisition of technical skills has been a foundation of safe clinical practice. 2,6 Moreover, the benefits and rewards of simulation allow the sharing of nursing experiences—a place to acknowledge and demonstrate to the nurse the relevance of the case studies to everyday practice.
Cost of Nursing Simulation Education and Pilot Intervention
A consideration of the fiscal expense of creating the simulation laboratory is significant especially in today’s environment of reduced reimbursement from third-party payers. The challenge associated with implementation of a structured simulation laboratory holds a substantial commitment of capital funding and continuous human resources. With knowledge of the burden of scheduling classes along with staffing a busy clinical unit, the feasibility of conducting meaningful educational experiences requires an advanced partnership with the local nursing leadership of
September 2015
VOLUME 41 • ISSUE 5
The Teaching Method: In-Person Varied-Fidelity True Technology
Teaching with simulation permits the instructor to modify the content from facts and procedures to enhanced clinical decision making. A critical component of simulation is fidelity. Fidelity has been described in the literature as low, medium, or high. 3Low fidelity is practice for a single skill, medium fidelity is more convincing yet missing indications for the learner, and high fidelity is processing of the full situational experience. 9 With respect to all of these descriptions, our goal was to incorporate each level and establish true-to-life cardiac situations to meet the varied learning objectives of our nurses. This was realized with a convenient customized mobile teaching simulation cart. This use of technology integrating realistic situations for the patient within the nurses’ clinical work environment remains the focus of this project. As stated earlier, structured case scenarios were initially built. We then learned to modify and to add cases specific to the nurses’ feedback to achieve customized learning opportunities. For example, after a specific patient simulation was played out, during the debriefing session, a recent reference to a specific patient case would then be an example for the subsequent simulation. This adaptable strategy requires flexibility and dexterity of the educator to enhance the learners’ experience. The information is then rapidly applied during the course of the clinical day. Typically, in simulation, we can control realism by orchestrating complex patient experiences through a
WWW.JENONLINE.ORG
425
CLINICAL NURSES FORUM/Harding et al
scenario-based program. This flexible approach allowed the nurses to analyze selected ECG cases as they related to actual patient clinical scenarios. Using this adaptive approach brought the simulation education experience to the nurses’ work area and facilitated access to the education. Knowing that simulation methodology poses no risk to patients and allows for mistakes, the nurses are prepared for a real-life event, which translates to improved patient outcomes. Another goal for the nurses remains to increase their confidence, cognitive reasoning, and technical skill acquisition because this pedagogy is likely to have a positive effect on both performance and patient care. 10 Bloom’s taxonomy of the cognitive domain teaches us the 6 classifications for knowledge development; knowledge, comprehension, application, analysis, synthesis, and finally, evaluation—the ability to defend one’s judgments based on evidence. 11 Building an education program for clinical nurses must be dynamic so that the nurse is equipped to not only distinguish and understand the content but also synthesize and discriminate to act in the patient’s best interest in an actual complex environment of care.
Interprofessional Team for Innovation and Business Acquisition Process
It is important to reflect on the retrospective development and process work for this innovation. To speak to a step-wise process, an initial interprofessional team was developed by the associate chief nursing officer, who approached the director of business operations for recommendations about obtaining a cart that had an ECG monitor, interactive abilities, a simulator, and a computer to conduct education. STEP 1
The first step was to conduct a search for a commercially available product, which included reaching out to our monitor manufacturer; the search was futile and ended up at a dead end. STEP 2
The next step was to investigate a custom-fabricated solution. Fortunately, we do business with an innovative local company, JACO (Franklin, MA), a leading manufacturer of wireless laptop carts. The vice president of sales was contacted to see if our project would be one in which the company would be interested, which it was. STEP 3
In step 3, time was spent interviewing clinical nursing staff, professional development educators, and clinical engineer-
426
JOURNAL OF EMERGENCY NURSING
ing staff to determine where and how the training cart would be used and what type of hardware, along with which inputs and outputs, should be included. The wish list included a 17-inch display connected to a central station computer running demonstration software, a critical care monitor, a standard telemetry monitor, a computer, and an advanced cardiac rhythm simulator. STEP 4
In step 4, the engineering industry experts were invited to a site visit, which included observing how staff interacted with monitors and central stations in the actual work environment. A subsequent meeting was conducted with clinical engineering staff to discuss wiring requirements for each device. A cocktail napkin sketch (Figure 1) was produced at this meeting, which served as the starting point for the engineering team. The manufacturer produced a concept drawing and estimated pricing and the timeline required for the process. STEP 5
The next step involved a series of communications—first, with clinical staff and professional development staff to review the concept and seek their approval to continue with the project and, second, with the senior administrative team to garner its support and financial resources to custom build 3 cardiac training carts, 1 for each hospital campus. STEP 6
In step 6, with funding secured for the project, all of the monitors, computers, simulators, and mounting brackets were ordered. One set of each was delivered to the manufacturing company with our approval for the company to move forward to the next phase in the design process. STEP 7
Step 7 included 2 site visits to the manufacturing facility in Franklin, Massachusetts; the first visit was to tour the facility and review the cart base the company proposed using. The company assured us that the cart would be tip tested to meet Occupational Safety and Health Administration standards, and we had the opportunity to wheel it over elevator thresholds, through doorways, and from carpeting to hard flooring. During this visit, we determined the optimum height and mounting configuration for the monitors and displays. Participants in the second visit included a member of our clinical engineering staff and an ergonomist. At this meeting, we reviewed wiring specifications and the best ergonomic positioning for the keyboard, the mouse, and the handle that would be used to move the cart. Finally, a formalized quote was prepared and a purchase order was prepared, and we are now using this
VOLUME 41 • ISSUE 5
September 2015
Harding et al/CLINICAL NURSES FORUM
product for education in the nurses’ clinical settings at 3 community hospitals within the health care system. Seeking an interprofessional solution and partnering with industry engineers brought to life the original-concept hand sketches by creating 3-dimensional computer-aided design models to develop a comprehensive product blueprint for fabrication, complete with high-resolution images of what the final product would look like. These photorealistic images provided a great opportunity for engineers to collaborate with actual end users to discuss design enhancements that would help improve the product fit, form, and function.
REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System, Washington, DC: The National Academies Press; 2000. 2. Harding AD, Walker-Cillo G, Duke A, Campos G, Stapleton S. A framework for creating and evaluating competencies for emergency nurses. J Emerg Nurs. 2013;39(3):252-264. 3. Jeffries PR. A frame work for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96-103. 4. Rodgers DL, Securro SJr., Pauley RD. The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course. Simul Healthc. 2009;4(4):200-206.
Outcomes and Evaluation
5. Leigh G. The simulation revolution: what are the implications for nurses in staff development? J Nurses Staff Dev. 2011;27(2):54-57.
Anecdotally, staff participants have stated that they have an increased confidence in rhythm interpretation and use of the technology. A follow-up qualitative study is planned to further understand the experiences and perceptions of the nurses who participated in the ECG simulation education program on the pilot units. The benefits and challenges of the ethnographic ECG simulation education program regarding perceived barriers or the impact of simulation-based training on confidence in practice will also be explored.
6. Harding A. Use IV, smart pumps for patient safety. J Emerg Nurs. 2011;37(1):71-72.
Conclusion
The use of a mobile teaching simulation cart is unique and a privilege in the acute care setting (Figure 2). Varied-fidelity simulation is typically used in academic settings in rooms designed for teaching with simulation, not in the acute care practice setting. A rolling customized simulation cart with the actual monitoring tools used by the registered nurses with an advanced level simulator has not been described in the literature at this time. This tool has been effective in allowing professional development nurses to help staff nurses—responsible for patients using ECG telemetry for patient monitoring—to hone their skills, review competencies, and improve teamwork.
September 2015
VOLUME 41 • ISSUE 5
7. Walker-Cillo G, Harding A. Emergency department remediation provided by the clinical nurse specialist. Adv Emerg Nurs J. 2013;35(2):129-142. 8. Harding A, Connolly M. Remediation: a necessary function for employers to correct incompetence regarding clinical professional registered nurse practice. JONAS Healthc Law Ethics Regul. 2012;14(2):48-52. 9. Yaeger KA, Halamek LP, Coyle M, et al. High-fidelity simulation based training in neonatal nursing. Adv Neonatal Care. 2004;4(6):326-331. 10. Brown D, Chronister C. The effect of simulation learning on critical thinking and self-confidence when incorporated into an electrocardiogram nursing course. Clin Simul Nurs. 2009;5(1):e45-e52. 11. Bloom BS, Krathwohl DR, Englehart M, Furst E, Hill W. Taxonomy of Educational Objectives: The Classification of Educational Goals—Handbook I: Cognitive Domain, New York, NY: Longmans Green; 1956.
Submissions to this column are encouraged and may be sent to Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN [email protected] or Kathryn Cullinane Whalen, DNP, RN, FAHA [email protected]
WWW.JENONLINE.ORG
427
INNOVATIVE VARIED-FIDELITY SIMULATION MOBILE TEACHING CART AND EDUCATION PROJECT Authors: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, Kathryn Cullinane Whalen, DNP, RN, FAHA, and Bradley S. Silverman, BS, New Bedford and Milton, MA Section Editors: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, and Kathryn Cullinane Whalen, DNP, RN, FAHA
The use of a varied-fidelity simulation mobile teaching cart is a teaching tool that offers unique advantages in the acute care setting. The cart is used to demonstrate the use of patient monitoring devices, and there are a variety of software tools available with the monitoring technology to ensure
that the outputs, including electrocardiographic waves, are analyzed appropriately by nursing staff using this variedfidelity simulation mobile teaching cart. Bringing variedfidelity simulation to the nurses’ work area is a unique application setting.
sing electrocardiogram (ECG) rhythm strips on paper or on PowerPoint slides (Microsoft, Redmond, WA) is a traditional method for assessing a nurse’s ability to interpret ECGs. An opportunity to provide an enhanced innovative simulation using the ECG monitors and affiliated technology available at a community health system in the nurses’ work area, not in the classroom or an off-campus simulation laboratory, was pursued. A process of a product development partnership was used with a manufacturer. A best-practices teaching modality review was undertaken to meet the educational needs of registered nurses responsible for patient ECG monitoring. This article will review the product development and acquisition process along with the descriptive rollout of this innovative teaching modality.
Background and Significance
U
Andrew D. Harding, Member, Mayflower Chapter, is Associate Chief Nursing Officer, Charlton Memorial Hospital, Southcoast Health System, New Bedford, MA. Kathryn Cullinane Whalen, Member, Mayflower Chapter, is Assistant Professor, Curry College, Milton, MA, and Nurse Educator, Southcoast Health System, New Bedford, MA. Bradley S. Silverman is Director of Business Operations, Southcoast Health System, New Bedford, MA. For correspondence, write: Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN, Charlton Memorial Hospital, Southcoast Health System, 101 Page St, New Bedford, MA 02470; E-mail: [email protected]. J Emerg Nurs 2015;41:423-7. Available online 19 June 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.05.009
September 2015
VOLUME 41 • ISSUE 5
Cardiology physicians brought their clinical care concerns forward to nursing administration about the nurses’ ability to interpret ECGs. Although the cardiology physicians acknowledged that there was a range of nurses’ capabilities to interpret ECGs, they were concerned about both overand under-appreciation of significant ECG abnormalities. Education for nurses responsible for ECG rhythm monitoring included a 3-day basic ECG telemetry class on orientation to the unit, the American Heart Association Basic Life Support program, the American Heart Association Advanced Cardiac Life Support program, annual computer-based learning modules for ECG telemetry rhythm interpretation, annual in-services on cardiology medications, and mock codes. Despite this solid foundation of cardiac dysrhythmia education, there was an added consideration by the interprofessional team to develop increased proficiency in cardiac monitoring by using cognitive, technical, psychomotor, and interactive skills with the equipment through case-based scenarios.
Patient Safety
Since 2000, Institute of Medicine publications have focused on patient safety. In the pivotal report To Err Is Human: Building a Safer Health System, 1 the needed emphasis on patient safety was detailed in the authors’ reports of numerous fatal medical errors involving hospitalized patients. In the report summary, simulation training was specifically recommended to mitigate harm to patients. 1
WWW.JENONLINE.ORG
423
CLINICAL NURSES FORUM/Harding et al
FIGURE 1 Initial sketch of mobile teaching simulation cart. (Source: Gary Brayton, JACO.)
The health system and nursing administration responded to the physicians’ concerns and fulfilled its obligation to assess staff competence. 2 In brainstorming to determine better ways to teach nurses about ECG interpretation and the use of the technology available within the hospital system, a vision for a mobile cart that would contain these devices was promoted, developed, and implemented (Figure 1). The on-site unit-based educational action plan was collaboratively developed and subsequently executed.
424
JOURNAL OF EMERGENCY NURSING
The use of mobile teaching carts allow for in-the-moment in-services using the equipment that staff nurses currently use to monitor their patients’ ECG, therefore making the education timely, accurate, and immediately applicable. Using this teaching strategy allowed the nursing educators to include simulation of a critical event within the framework of a case study, incorporating familiar and potential scenario elements that would require the nurse to identify, interpret, and explore the critical thinking needed to deal with the clinical dilemma described in the case
VOLUME 41 • ISSUE 5
September 2015
Harding et al/CLINICAL NURSES FORUM
the emergency department to support the availability of nurse participants. Once the simulation begins, the commitment of the participants to complete the session is essential for the interactive team experience and the follow-up debriefing. The agenda for each drop-in simulation session is goal oriented with well-designed case studies and a follow-up checklist for the technical cardiac monitor skills from simple to complex. Each nurse leaves the session with resource-rich fact sheets and information on upcoming basic, intermediate, and advanced cardiac dysrhythmia nursing education. The nurse participant also has the ability to return for any recommended remediation or self-directed supplementary reviews. 2,7,8 Lastly, because this form of mobile cardiac monitoring instruction is not at the patient’s bedside, our goal was to decrease the risk of exposing the learner to any embarrassment or humiliation resulting from lack of expertise and to enhance his or her ability to draw on this knowledge for future safe practice. FIGURE 2 Mobile teaching simulation cart. (Source: Andrew D. Harding.)
3,4
study. Adult learners have different learning styles, and the literature provides us with instructional methodology that recounts optimal retention of learning from demonstration, from hands-on practice, and by teaching others. 2,5 As an applied science, nursing education has acknowledged the benefits of psychomotor skills with infusion pumps, as well as other adjunctive devices, in the environment of care. This “hands-on” approach for the return demonstration and the acquisition of technical skills has been a foundation of safe clinical practice. 2,6 Moreover, the benefits and rewards of simulation allow the sharing of nursing experiences—a place to acknowledge and demonstrate to the nurse the relevance of the case studies to everyday practice.
Cost of Nursing Simulation Education and Pilot Intervention
A consideration of the fiscal expense of creating the simulation laboratory is significant especially in today’s environment of reduced reimbursement from third-party payers. The challenge associated with implementation of a structured simulation laboratory holds a substantial commitment of capital funding and continuous human resources. With knowledge of the burden of scheduling classes along with staffing a busy clinical unit, the feasibility of conducting meaningful educational experiences requires an advanced partnership with the local nursing leadership of
September 2015
VOLUME 41 • ISSUE 5
The Teaching Method: In-Person Varied-Fidelity True Technology
Teaching with simulation permits the instructor to modify the content from facts and procedures to enhanced clinical decision making. A critical component of simulation is fidelity. Fidelity has been described in the literature as low, medium, or high. 3Low fidelity is practice for a single skill, medium fidelity is more convincing yet missing indications for the learner, and high fidelity is processing of the full situational experience. 9 With respect to all of these descriptions, our goal was to incorporate each level and establish true-to-life cardiac situations to meet the varied learning objectives of our nurses. This was realized with a convenient customized mobile teaching simulation cart. This use of technology integrating realistic situations for the patient within the nurses’ clinical work environment remains the focus of this project. As stated earlier, structured case scenarios were initially built. We then learned to modify and to add cases specific to the nurses’ feedback to achieve customized learning opportunities. For example, after a specific patient simulation was played out, during the debriefing session, a recent reference to a specific patient case would then be an example for the subsequent simulation. This adaptable strategy requires flexibility and dexterity of the educator to enhance the learners’ experience. The information is then rapidly applied during the course of the clinical day. Typically, in simulation, we can control realism by orchestrating complex patient experiences through a
WWW.JENONLINE.ORG
425
CLINICAL NURSES FORUM/Harding et al
scenario-based program. This flexible approach allowed the nurses to analyze selected ECG cases as they related to actual patient clinical scenarios. Using this adaptive approach brought the simulation education experience to the nurses’ work area and facilitated access to the education. Knowing that simulation methodology poses no risk to patients and allows for mistakes, the nurses are prepared for a real-life event, which translates to improved patient outcomes. Another goal for the nurses remains to increase their confidence, cognitive reasoning, and technical skill acquisition because this pedagogy is likely to have a positive effect on both performance and patient care. 10 Bloom’s taxonomy of the cognitive domain teaches us the 6 classifications for knowledge development; knowledge, comprehension, application, analysis, synthesis, and finally, evaluation—the ability to defend one’s judgments based on evidence. 11 Building an education program for clinical nurses must be dynamic so that the nurse is equipped to not only distinguish and understand the content but also synthesize and discriminate to act in the patient’s best interest in an actual complex environment of care.
Interprofessional Team for Innovation and Business Acquisition Process
It is important to reflect on the retrospective development and process work for this innovation. To speak to a step-wise process, an initial interprofessional team was developed by the associate chief nursing officer, who approached the director of business operations for recommendations about obtaining a cart that had an ECG monitor, interactive abilities, a simulator, and a computer to conduct education. STEP 1
The first step was to conduct a search for a commercially available product, which included reaching out to our monitor manufacturer; the search was futile and ended up at a dead end. STEP 2
The next step was to investigate a custom-fabricated solution. Fortunately, we do business with an innovative local company, JACO (Franklin, MA), a leading manufacturer of wireless laptop carts. The vice president of sales was contacted to see if our project would be one in which the company would be interested, which it was. STEP 3
In step 3, time was spent interviewing clinical nursing staff, professional development educators, and clinical engineer-
426
JOURNAL OF EMERGENCY NURSING
ing staff to determine where and how the training cart would be used and what type of hardware, along with which inputs and outputs, should be included. The wish list included a 17-inch display connected to a central station computer running demonstration software, a critical care monitor, a standard telemetry monitor, a computer, and an advanced cardiac rhythm simulator. STEP 4
In step 4, the engineering industry experts were invited to a site visit, which included observing how staff interacted with monitors and central stations in the actual work environment. A subsequent meeting was conducted with clinical engineering staff to discuss wiring requirements for each device. A cocktail napkin sketch (Figure 1) was produced at this meeting, which served as the starting point for the engineering team. The manufacturer produced a concept drawing and estimated pricing and the timeline required for the process. STEP 5
The next step involved a series of communications—first, with clinical staff and professional development staff to review the concept and seek their approval to continue with the project and, second, with the senior administrative team to garner its support and financial resources to custom build 3 cardiac training carts, 1 for each hospital campus. STEP 6
In step 6, with funding secured for the project, all of the monitors, computers, simulators, and mounting brackets were ordered. One set of each was delivered to the manufacturing company with our approval for the company to move forward to the next phase in the design process. STEP 7
Step 7 included 2 site visits to the manufacturing facility in Franklin, Massachusetts; the first visit was to tour the facility and review the cart base the company proposed using. The company assured us that the cart would be tip tested to meet Occupational Safety and Health Administration standards, and we had the opportunity to wheel it over elevator thresholds, through doorways, and from carpeting to hard flooring. During this visit, we determined the optimum height and mounting configuration for the monitors and displays. Participants in the second visit included a member of our clinical engineering staff and an ergonomist. At this meeting, we reviewed wiring specifications and the best ergonomic positioning for the keyboard, the mouse, and the handle that would be used to move the cart. Finally, a formalized quote was prepared and a purchase order was prepared, and we are now using this
VOLUME 41 • ISSUE 5
September 2015
Harding et al/CLINICAL NURSES FORUM
product for education in the nurses’ clinical settings at 3 community hospitals within the health care system. Seeking an interprofessional solution and partnering with industry engineers brought to life the original-concept hand sketches by creating 3-dimensional computer-aided design models to develop a comprehensive product blueprint for fabrication, complete with high-resolution images of what the final product would look like. These photorealistic images provided a great opportunity for engineers to collaborate with actual end users to discuss design enhancements that would help improve the product fit, form, and function.
REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System, Washington, DC: The National Academies Press; 2000. 2. Harding AD, Walker-Cillo G, Duke A, Campos G, Stapleton S. A framework for creating and evaluating competencies for emergency nurses. J Emerg Nurs. 2013;39(3):252-264. 3. Jeffries PR. A frame work for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96-103. 4. Rodgers DL, Securro SJr., Pauley RD. The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course. Simul Healthc. 2009;4(4):200-206.
Outcomes and Evaluation
5. Leigh G. The simulation revolution: what are the implications for nurses in staff development? J Nurses Staff Dev. 2011;27(2):54-57.
Anecdotally, staff participants have stated that they have an increased confidence in rhythm interpretation and use of the technology. A follow-up qualitative study is planned to further understand the experiences and perceptions of the nurses who participated in the ECG simulation education program on the pilot units. The benefits and challenges of the ethnographic ECG simulation education program regarding perceived barriers or the impact of simulation-based training on confidence in practice will also be explored.
6. Harding A. Use IV, smart pumps for patient safety. J Emerg Nurs. 2011;37(1):71-72.
Conclusion
The use of a mobile teaching simulation cart is unique and a privilege in the acute care setting (Figure 2). Varied-fidelity simulation is typically used in academic settings in rooms designed for teaching with simulation, not in the acute care practice setting. A rolling customized simulation cart with the actual monitoring tools used by the registered nurses with an advanced level simulator has not been described in the literature at this time. This tool has been effective in allowing professional development nurses to help staff nurses—responsible for patients using ECG telemetry for patient monitoring—to hone their skills, review competencies, and improve teamwork.
September 2015
VOLUME 41 • ISSUE 5
7. Walker-Cillo G, Harding A. Emergency department remediation provided by the clinical nurse specialist. Adv Emerg Nurs J. 2013;35(2):129-142. 8. Harding A, Connolly M. Remediation: a necessary function for employers to correct incompetence regarding clinical professional registered nurse practice. JONAS Healthc Law Ethics Regul. 2012;14(2):48-52. 9. Yaeger KA, Halamek LP, Coyle M, et al. High-fidelity simulation based training in neonatal nursing. Adv Neonatal Care. 2004;4(6):326-331. 10. Brown D, Chronister C. The effect of simulation learning on critical thinking and self-confidence when incorporated into an electrocardiogram nursing course. Clin Simul Nurs. 2009;5(1):e45-e52. 11. Bloom BS, Krathwohl DR, Englehart M, Furst E, Hill W. Taxonomy of Educational Objectives: The Classification of Educational Goals—Handbook I: Cognitive Domain, New York, NY: Longmans Green; 1956.
Submissions to this column are encouraged and may be sent to Andrew D. Harding, MS, RN, NEA-BC, FACHE, FAHA, FAEN [email protected] or Kathryn Cullinane Whalen, DNP, RN, FAHA [email protected]
WWW.JENONLINE.ORG
427