- Email: [email protected]
Simulation to Improve Pediatric Patient Outcomes: University and Hospital Collaborative
Clinical Simulation in Nursing (2013) 9, e243-e247
www.elsevier.com/locate/ecsn
Featured Article
Simulation to Improve Pediatric Patient Outcomes: University and Hospital Collaborative Kimberly P. Stephens, DNP, RNa,*, Nancy R. Mosser, EdD, RNb a b
Graduate Programs in Nursing, Waynesburg University, Waynesburg, PA 15370, USA Department of Nursing, Waynesburg University, Waynesburg, PA 15370, USA KEYWORDS collaboration; intravenous therapy; nursing education; pediatric; simulation; staff development; registered nurses
Abstract: A collaborative venture between a local university in southwestern Pennsylvania and a rural community hospital enhanced learning and improved pediatric patient outcomes. The partnership led to the development and implementation of an evidence-based pediatric peripheral intravenous (PIV) insertion program. Through the use of simulation technology and debriefing techniques at the pediatric PIV insertion program, pediatric PIV insertion skills of the medicalesurgical nursing staff improved, as evidenced by a decreased number of pediatric PIV insertion attempts. Cite this article: Stephens, K. P., & Mosser, N. R. (2013, July). Simulation to improve pediatric patient outcomes: University and hospital collaborative. Clinical Simulation in Nursing, 9(7), e243-e247. doi:10.1016/ j.ecns.2011.11.010. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Improving the quality of patient care is a concept that has been discussed with increasing frequency in the literature (Boxer & Goldfarb, 2011; Cronenwett et al., 2007). In 2003, the Institute of Medicine developed an entire report, Institute of Medicine 2003, addressing the essential areas in which health care professionals should be educated in order to improve quality and patient care outcomes. The document emphasizes five core competencies in which all health care professionals should be equipped: deliver patient-centered care, practice in interdisciplinary teams, use evidence-based practice, apply quality improvement initiatives, and use informatics. The competency of applying quality improvement initiatives addresses the importance of identifying and preventing errors, as well as
* Corresponding author: [email protected] (K. P. Stephens).
designing, implementing, and evaluating projects in order to improve health care outcomes (Long, 2003). Collaborative skills are indispensable to developing and establishing quality patient care (American Association of Colleges of Nursing, 2006a). The newest Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2010), recommends the expansion of nurse-led collaborative improvement opportunities between educational and practice settings; however, collaborative efforts between these two arenas have been limited (American Association of Colleges of Nursing, 2006b, Institute of Medicine, 2010). Historically, the two domains of academe and practice have existed in separate silos, thus limiting the sharing of research and evidence-based scholarship that can be translated into improving quality care outcomes. When academice practice relationships do develop, they generally occur between large academic health care centers and universities,
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2011.11.010
Simulation to Improve Pediatric Patient Outcomes
e244
institutions that tend to have greater faculty and physical resources than small community hospitals. However, relationships are beginning to emerge between universities and smaller health care institutions (Jones, 2009). The purpose of this article is to describe the collaborative relationship between a university and a small rural Key Points community hospital that re Nurses were able to sulted in the development of insert a PIV in one ata project that affected the tempt on all 9 patients. quality of health care deliv The partnership led to ery at the hospital. The qualthe development and ity improvement initiative implementation of an that developed between the evidenced-based peditwo institutions involved the atric PIV insertion chairperson of the nursing program. department at the university, The simulation techthe CEO of the hospital, the nology used in this staff education coordinator project permitted the at the hospital, a doctoral staff nurses to practice student in the nursing prothe pediatric PIV ingram, and a member of the sertion skill, learn the hospital foundation. procedure, make and correct mistakes, and fine-tune PIV skills The Quality Improvein a safe environment ment Initiative without harming a patient or risking safety. The university and community hospital are located approximately 3 miles from each other in rural Pennsylvania, 50 miles from a large urban area. The nursing department’s baccalaureate program is on the main campus, and RN-to-BSN, MSN, and doctor of nursing practice (DNP) programs are located at three other sites near the large city, still within 50 miles of the main campus. Enrollment across the various nursing programs totals approximately 800 students. The department chair serves on the hospital’s board of trustees, and the CEO of the hospital, a graduate of the baccalaureate program, serves on the community advisory board of the nursing program at the university. The 68-bed community hospital includes a medicale surgical unit with four pediatric beds, an intensive care unit, a behavioral health unit, a sleep center, home health services, and an emergency express care service. The hospital is accredited by the Joint Commission Center for Transforming Healthcare. Inpatient admissions have increased since the hospital came under new management in 2007, and emergency department visits have grown by 25%. In response to emergency department growth, the hospital added an emergency express care service in 2008; as the result, pediatric visits and acuity levels increased. With the increase in pediatric acuity levels, a staff nurse educational needs assessment revealed that the institution’s RNs lacked experience and skills in pediatric peripheral intravenous
(PIV) insertion. Pediatric patients differ physiologically from adult patients (Jones, 2009), and pediatric PIV access can be difficult (Etzel-Hardman, 2008). It was not unusual for nurses to make several attempts at PIV insertion, resulting in a delay in the administration of fluids and medications and a painful experience for the patient. The delay in PIV treatment could adversely affect patient care outcomes. The problem was identified by the administration of the hospital and was presented to the department chair of the nursing program at the local university. A team was formed, and key personnel were invited from both institutions. Team members included the CEO, the chief nursing officer, the staff educator from the hospital, the department chair, the simulation laboratory coordinator, a DNP student with patient simulation expertise from the university, and a certified pediatric nurse practitioner. The DNP student was the project leader and expedited university institutional review board approval for the project. The goal of the collaborative project was to decrease the number of pediatric PIV attempts, improve the start time of PIV therapy, and therefore improve patient safety outcomes for the pediatric population. The focus of the project was to create a safe learning environment for staff nurses at the community hospital through the development and delivery of didactic content, PIV skill training, and a pediatric simulation scenario requiring a PIV insertion.
Theoretical Underpinning Nursing educators have long incorporated simulation in some form or another to teach skills and principles of patient care. Simulation techniques used in the past included use of a fresh orange to instruct proper technique of subcutaneous injection administration and role-playing of therapeutic and nontherapeutic communication. A literature review was conducted, and the search term phrase simulation in nursing education resulted in an extensive number of articles that included scientific theory supporting simulation in nursing education as a teaching strategy; however, similar to the findings of Durham & Alden (2008), only a limited number of these studies addressed the use of clinical simulation by hospitals to educate RNs. Studies have found that senior-level nursing students using high fidelity simulation acquired skills faster and demonstrated higher performance than did participants who acquired skills through traditional educational approaches (Durham & Alden, 2008). Research indicates simulation methodology is more realistic, enhances both acquisition and retention of knowledge, sharpens critical-thinking and psychomotor skills, and is more enjoyable for the learner (Garrett, MacPhee, & Jackson, 2010). Nurse educators are using simulators in the adult acute care setting to introduce new equipment, instruct on new procedures, and assess competencies of nurses. Simulation as an educational strategy offers the absence of risk to a live patient; the ability to
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provide standardization of cases; the promotion of criticalthinking, clinical decision-making, and psychomotor skills; the provision of immediate feedback; and the integration of knowledge and behavior (Lamagna & MacPhee, 2004). Simulation permits learners to fully immerse themselves and to participate in a high-risk, low-incidence patient scenario, making and correcting mistakes without harming an actual patient. Clinical simulation as a teaching strategy is consistent with adult learning theory (Gaberson & Oermann, 2010; Rauen, 2004). Malcolm Knowles’s theory of andragogy emphasizes that adult learners are self-directed and are motivated to learn when they are actively involved in the process, can draw from personal experiences, are able to ‘‘problem-solve,’’ and can immediately apply what they have learned. Clinical simulation is a learner-centered approach to education and builds on previous knowledge and experience (Lamagna & MacPhee, 2004). Simulation as a teaching tool engages learners, provides a realistic environment, permits hands-on learning, focuses on application of knowledge, shifts from subject-centeredness to problem-centeredness, incorporates and appeals to all learning styles (auditory, visual, kinesthetic, and tactile), and meets the needs of the adult learner (Gaberson & Oermann, 2010; Rauen, 2004). Simulation scenarios can provide a safe environment for cognitive conflict for the adult learner. According to Liu (2010), cognitive conflict is considered a premise for conceptual change. Cognitive conflict occurs when individuals cannot apply their existing knowledge to solve a problem and are thus confronted with a situation that motivates the learning of new concepts (Knowles, 1978). Cognitive theory involves higher-order mental activities such as memory, perception, thinking, problem solving, reasoning, and concept formation (Liu, 2010). The cognitive conflict learning theory supports clinical simulation as a teaching strategy because it allows the learner to acquire new knowledge and improve skills in a safe, nonthreatening experimental environment and provides the opportunity for decision making, critical thinking, and team building. Crimlisk, Jonhstone, & Sanchez (2009) reported that RNs who participated in simulation acknowledged that evidence-based practice education is imperative and revealed that clinical simulation was their preferred training method to promote critical thinking and decision making.
Barriers After the team defined the scope of the project, they identified barriers. The hospital’s lack of an infant simulator and the space to house one was the No. 1 barrier. The university did not have an infant simulator but had the space to house one in its laboratory. The CEO suggested that the university submit a proposal to the hospital foundation to purchase a simulator for the pediatric PIV insertion program. The foundation is a nonprofit organization that strives to
provide resources for programs that target health care initiatives with measurable outcomes. The chairperson and the DNP student wrote a proposal for an infant simulator and submitted it to the hospital foundation. Subsequently, the university was awarded the funds to purchase an infant and pediatric simulator (Laerdal SimBabyÒ) for hospital staff and community education. Other barriers included compensation and lack of time off for nurses to attend the program. The infant and patient simulator is portable, so the team decided to offer the sessions on-site at the hospital. Full-time employment for nursing staff at the community hospital is 72 hours per 2-week pay period. A 36-hour workweek allowed staff to attend meetings and educational programs 4 hours or less per week without being paid an overtime wage.
Program Development The population criterion was defined as any patient from 1 day to 18 years of age, admitted to the hospital, and requiring IV therapy. Pediatric PIV insertion was defined as an initial placement and replacement cannula. Data collection consisted of age, admission diagnosis, and the number of IV attempts to sucessfully achieve access. The team decided to pilot the pediatric PIV insertion program on the 31-bed medicalesurgical unit that included four designated pediatric beds. The nursing staff and unit manager on this unit identified pediatric PIV insertions as a high-risk, low-incidence skill. The DNP student coordinated activities and collaborated with the staff education coordinator to develop a pediatric PIV insertion program using the infant and pediatric simulator (Laerdal SimBaby) as teaching tool. The pediatric PIV insertion program was developed specifically for nurses and provided a comprehensive evidence-based overview of nursing care of the pediatric patient requiring a PIV insertion. The DNP student arranged practicum hours at a large metropolitan children’s hospital so that program participants could shadow pediatric nurses in the radiology department while observing best practice and reviewing hospital policy. The didactic content included a review of anatomy and physiology, pediatric equipment, pediatric specific interventions such as distraction therapy, safety positioning for children, and review of hospital policy and procedure. The program was based on professional reviewer recommendations by a certified pediatric nurse practitioner, an advanced practice nurse educator, and a simulation education consultant for readability and content appropriateness.
Program Implementation A total of 37 staff nurses participated in the mandatory 2-hour pediatric PIV insertion program. Six program sessions were offered on-site at the hospital during
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a 30-day period; this schedule optimized flexibility, allowing nurses to attend the session most convenient to their work schedule, thus yielding 100% attendance. Class size varied from 4 to 12 participants in each session. The program began with the project leader’s presenting didactic content, followed by a patient simulation scenario and a debriefing session. The patient scenario was an 18-month-old admitted from the physician’s office with the diagnosis of dehydration. Assessment findings included irritability, no interest in oral fluids, tachycardia, dry mucous membranes, and a history of vomiting and fever for a 24-hour period. The physician ordered 0.9% NaCl IV fluids immediately. Mom, Dad, 5-year-old sibling, and grandparents were present. Debriefing sessions were conducted at the end of each patient scenario session.
Debriefing Debriefing, an essential element of simulation, encompasses critique, correction and evaluation of learners’ performance, discussion of the experience (Crimlisk, Jonhstone, & Sanchez, 2009), and correction of misinformation or improper practice techniques that the students may demonstrate (Lamagna & MacPhee, 2004). Conducted after the patient simulation is performed, debriefing is an important part of learning because it provides the learners with direct feedback on what they have successfully accomplished, insight into what they can change, and pearls of wisdom to carry with them into the future. Conversation, observations by the project leader, and reflective thinking are the teaching strategies used in debriefing. Debriefing can lead to the development of self-correcting practice habits when a facilitator assists the learner to recognize and resolve clinical and behavioral dilemmas that occur during simulations (Dreifuerst, 2009). Conversation brings participants’ clinical decisions into the open, but a nonjudgmental framework is important to keep motivation active and provide psychological safety (Rudolph, Simon, Dufresne, & Raemer, 2006). In one study, the majority of learners reported that the debriefing session was an engaging and realistic learning experience that increased their confidence and critical thinking skills (Kuiper, Heinrich, Matthias, Graham, & Kotwall, 2008). An important aspect is that debriefing should be conducted in an area that is quiet and free from distraction in order to permit the facilitator to guide participants through a reflective process regarding the scenario and to help them learn from the experience. During the debriefing sessions, staff nurses shared their thoughts, concerns, fears, and personal experiences of starting a PIV insertion on a pediatric patient. They identified what went well in the simulation scenario and what they could improve. They critically appraised the pediatric PIV insertion process and offered suggestions to improve patient outcomes that led to a systemwide change in PIV insertion policy within the organization.
Results A total of 17 patients met the criterion for this project. Patients ranged in age from 11 months to 18 years, with a mean age of 10.3 years. Baseline data were collected on 8 patients 2 months before the pediatric PIV insertion program was offered. Of those 8 patients, 3 required one PIVattempt, 3 required two attempts, and 2 required three attempts. Postprogram data collection was completed during 2 consecutive months after the pediatric PIV insertion program and involved a total of 9 patients who were admitted to the medicalesurgical unit and required PIV insertions. Nurses were able to insert a PIV in one attempt on all 9 patients.
Limitations The sample size was small, with limited variability in patients’ ages. The initial data collection period was limited to 2 months because of practicability of the project.
Conclusion A collaborative venture between a local university in southwestern Pennsylvania and a rural community hospital enhanced learning and improved pediatric patient outcomes. The partnership led to the development and implementation of an evidenced-based pediatric PIV insertion program. Simulation technology and debriefing techniques were used to improve pediatric PIV insertion skills of the medicalesurgical nursing staff through attendance at a pediatric PIV insertion program, leading to the decreased number pediatric PIV insertion attempts. The simulation technology used in this project permitted the staff nurses to practice the pediatric PIV insertion skill, learn the procedure, make and correct mistakes, and finetune PIV skills in a safe environment without harming a patient or risking safety. In addition, it allowed the staff nurse to gain experience with pediatric patients and function in an environment that was as close as possible to an actual situation. The debriefing session that immediately followed the simulation experience was an essential element; it provided the learners with the opportunity to reflect and evaluate on their performance and practice. The pediatric PIV insertion program evaluations were positive, with staff nurses requesting more evidence-based practice simulation programs. The expansion of this pilot program is planned for the emergency room staff nurses in the future.
References American Association of Colleges of Nursing. (2006a). The essentials of doctoral education for advanced nursing practice. Retrieved January 6, 2010, from http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf.
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American Association of Colleges of Nursing. (2006b). Doctor of nursing practice roadmap task force report. Retrieved December 4, 2010, from www.aacn.nche.edu/dnp/roadmapreport.pdf. Boxer, A., & Goldfarb, E. (2011). Creative solutions to enhancing nursing quality. Sudbury, MA: Jones & Bartlett Learning. Crimlisk, J., Johnstone, D., & Sanchez, G. (2009). Evidence-based practice, clinical simulations workshop, and intravenous medication: Moving toward safer practice. MEDSURG Nursing Journal, 18(3), 153-160. Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. doi:10.1016/j.outlook.2009.07.009. Dreifuerst, K. (2009). The essentials of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives, 30(2), 109-114. doi:10.1043/1536-5026-030.002.0109. Durham, C., & Alden, K. (2008). Enhancing patient safety in nursing education through patient simulation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (chap. 51). Rockville, Md: Agency for Healthcare Research and Quality. Retrieved December 14, 2011, from http://www.ahrg.gov/qual/nurseshdbk.pdf. Etzel-Hardman, D. (2008). Continuing education: Teaching IV therapy to pediatric nurses. ModernMedicine. Retrieved November 24, 2010, from http://www.modernmedicine.com/modernmedicine/article/articleDetail. jsp?id¼561171. Gaberson, K., & Oermann, M. (2010). Clinical teaching strategies in nursing (3rd ed.). New York, NY: Springer. Garrett, B., MacPhee, M., & Jackson, C. (2010). High-fidelity patient simulation: Considerations for effective learning. Nursing Education Perspectives, 31(5), 309-313.
Institute of Medicine. (2003). Health professions education: a bridge to quality. Washington, DC: National Academies Press. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Jones, A. L. (2009). Developing a collaborative relationship between a rural hospital and a university. Clinical Simulation in Nursing, 5(4), e155e159. doi:10.1016/j.ecns.2009.02.003. Knowles, M. (1978). Andragogy: Adult learning theory in perspective. Community College Review, 5(3), 9-20. Kuiper, R., Heinrich, C., Matthias, A., Graham, M., & Kotwall, L. (2008). Debriefing with the OPT model of clinical reasoning during high fidelity patient simulation. International Journal of Nursing Education Scholarship, 5(1), 2. doi:10.2202/1548-923X.1466. Lamagna, P., & MacPhee, M. (2004). Troubleshooting pediatric peripheral IV, phlebitis and infiltration. Nursing Spectrum. Retrieved December 9, 2010, from http://news.nurse.com/apps/pbcs.dll/article?AID=2004407010305. Liu, T. C. (2010). Developing simulation-based computer assisted learning to correct students’ statistical misconceptions based on cognitive conflict theory, using ‘‘correlation’’ as an example. Journal of Educational Technology & Society, 13(2), 180-192. Long, K. A. (2003). The Institute of Medicine report: Health professions education: A bridge to quality. Policy, Politics & Nursing Practice, 4(4), 259-262. doi:10.1177/1527154403258304. Rauen, C. (2004). Simulation as a teaching strategy for nursing education and orientation in cardiac surgery. Critical Care Nurse, 24(3), 46-51. Rudolph, J., Simon, R., Dufresne, R., & Raemer, D. (2006). There’s no such thing as ‘‘nonjudgmental’’ debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), 49-55.
pp e243-e247 Clinical Simulation in Nursing Volume 9 Issue 7
www.elsevier.com/locate/ecsn
Featured Article
Simulation to Improve Pediatric Patient Outcomes: University and Hospital Collaborative Kimberly P. Stephens, DNP, RNa,*, Nancy R. Mosser, EdD, RNb a b
Graduate Programs in Nursing, Waynesburg University, Waynesburg, PA 15370, USA Department of Nursing, Waynesburg University, Waynesburg, PA 15370, USA KEYWORDS collaboration; intravenous therapy; nursing education; pediatric; simulation; staff development; registered nurses
Abstract: A collaborative venture between a local university in southwestern Pennsylvania and a rural community hospital enhanced learning and improved pediatric patient outcomes. The partnership led to the development and implementation of an evidence-based pediatric peripheral intravenous (PIV) insertion program. Through the use of simulation technology and debriefing techniques at the pediatric PIV insertion program, pediatric PIV insertion skills of the medicalesurgical nursing staff improved, as evidenced by a decreased number of pediatric PIV insertion attempts. Cite this article: Stephens, K. P., & Mosser, N. R. (2013, July). Simulation to improve pediatric patient outcomes: University and hospital collaborative. Clinical Simulation in Nursing, 9(7), e243-e247. doi:10.1016/ j.ecns.2011.11.010. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Improving the quality of patient care is a concept that has been discussed with increasing frequency in the literature (Boxer & Goldfarb, 2011; Cronenwett et al., 2007). In 2003, the Institute of Medicine developed an entire report, Institute of Medicine 2003, addressing the essential areas in which health care professionals should be educated in order to improve quality and patient care outcomes. The document emphasizes five core competencies in which all health care professionals should be equipped: deliver patient-centered care, practice in interdisciplinary teams, use evidence-based practice, apply quality improvement initiatives, and use informatics. The competency of applying quality improvement initiatives addresses the importance of identifying and preventing errors, as well as
* Corresponding author: [email protected] (K. P. Stephens).
designing, implementing, and evaluating projects in order to improve health care outcomes (Long, 2003). Collaborative skills are indispensable to developing and establishing quality patient care (American Association of Colleges of Nursing, 2006a). The newest Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2010), recommends the expansion of nurse-led collaborative improvement opportunities between educational and practice settings; however, collaborative efforts between these two arenas have been limited (American Association of Colleges of Nursing, 2006b, Institute of Medicine, 2010). Historically, the two domains of academe and practice have existed in separate silos, thus limiting the sharing of research and evidence-based scholarship that can be translated into improving quality care outcomes. When academice practice relationships do develop, they generally occur between large academic health care centers and universities,
1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2011.11.010
Simulation to Improve Pediatric Patient Outcomes
e244
institutions that tend to have greater faculty and physical resources than small community hospitals. However, relationships are beginning to emerge between universities and smaller health care institutions (Jones, 2009). The purpose of this article is to describe the collaborative relationship between a university and a small rural Key Points community hospital that re Nurses were able to sulted in the development of insert a PIV in one ata project that affected the tempt on all 9 patients. quality of health care deliv The partnership led to ery at the hospital. The qualthe development and ity improvement initiative implementation of an that developed between the evidenced-based peditwo institutions involved the atric PIV insertion chairperson of the nursing program. department at the university, The simulation techthe CEO of the hospital, the nology used in this staff education coordinator project permitted the at the hospital, a doctoral staff nurses to practice student in the nursing prothe pediatric PIV ingram, and a member of the sertion skill, learn the hospital foundation. procedure, make and correct mistakes, and fine-tune PIV skills The Quality Improvein a safe environment ment Initiative without harming a patient or risking safety. The university and community hospital are located approximately 3 miles from each other in rural Pennsylvania, 50 miles from a large urban area. The nursing department’s baccalaureate program is on the main campus, and RN-to-BSN, MSN, and doctor of nursing practice (DNP) programs are located at three other sites near the large city, still within 50 miles of the main campus. Enrollment across the various nursing programs totals approximately 800 students. The department chair serves on the hospital’s board of trustees, and the CEO of the hospital, a graduate of the baccalaureate program, serves on the community advisory board of the nursing program at the university. The 68-bed community hospital includes a medicale surgical unit with four pediatric beds, an intensive care unit, a behavioral health unit, a sleep center, home health services, and an emergency express care service. The hospital is accredited by the Joint Commission Center for Transforming Healthcare. Inpatient admissions have increased since the hospital came under new management in 2007, and emergency department visits have grown by 25%. In response to emergency department growth, the hospital added an emergency express care service in 2008; as the result, pediatric visits and acuity levels increased. With the increase in pediatric acuity levels, a staff nurse educational needs assessment revealed that the institution’s RNs lacked experience and skills in pediatric peripheral intravenous
(PIV) insertion. Pediatric patients differ physiologically from adult patients (Jones, 2009), and pediatric PIV access can be difficult (Etzel-Hardman, 2008). It was not unusual for nurses to make several attempts at PIV insertion, resulting in a delay in the administration of fluids and medications and a painful experience for the patient. The delay in PIV treatment could adversely affect patient care outcomes. The problem was identified by the administration of the hospital and was presented to the department chair of the nursing program at the local university. A team was formed, and key personnel were invited from both institutions. Team members included the CEO, the chief nursing officer, the staff educator from the hospital, the department chair, the simulation laboratory coordinator, a DNP student with patient simulation expertise from the university, and a certified pediatric nurse practitioner. The DNP student was the project leader and expedited university institutional review board approval for the project. The goal of the collaborative project was to decrease the number of pediatric PIV attempts, improve the start time of PIV therapy, and therefore improve patient safety outcomes for the pediatric population. The focus of the project was to create a safe learning environment for staff nurses at the community hospital through the development and delivery of didactic content, PIV skill training, and a pediatric simulation scenario requiring a PIV insertion.
Theoretical Underpinning Nursing educators have long incorporated simulation in some form or another to teach skills and principles of patient care. Simulation techniques used in the past included use of a fresh orange to instruct proper technique of subcutaneous injection administration and role-playing of therapeutic and nontherapeutic communication. A literature review was conducted, and the search term phrase simulation in nursing education resulted in an extensive number of articles that included scientific theory supporting simulation in nursing education as a teaching strategy; however, similar to the findings of Durham & Alden (2008), only a limited number of these studies addressed the use of clinical simulation by hospitals to educate RNs. Studies have found that senior-level nursing students using high fidelity simulation acquired skills faster and demonstrated higher performance than did participants who acquired skills through traditional educational approaches (Durham & Alden, 2008). Research indicates simulation methodology is more realistic, enhances both acquisition and retention of knowledge, sharpens critical-thinking and psychomotor skills, and is more enjoyable for the learner (Garrett, MacPhee, & Jackson, 2010). Nurse educators are using simulators in the adult acute care setting to introduce new equipment, instruct on new procedures, and assess competencies of nurses. Simulation as an educational strategy offers the absence of risk to a live patient; the ability to
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provide standardization of cases; the promotion of criticalthinking, clinical decision-making, and psychomotor skills; the provision of immediate feedback; and the integration of knowledge and behavior (Lamagna & MacPhee, 2004). Simulation permits learners to fully immerse themselves and to participate in a high-risk, low-incidence patient scenario, making and correcting mistakes without harming an actual patient. Clinical simulation as a teaching strategy is consistent with adult learning theory (Gaberson & Oermann, 2010; Rauen, 2004). Malcolm Knowles’s theory of andragogy emphasizes that adult learners are self-directed and are motivated to learn when they are actively involved in the process, can draw from personal experiences, are able to ‘‘problem-solve,’’ and can immediately apply what they have learned. Clinical simulation is a learner-centered approach to education and builds on previous knowledge and experience (Lamagna & MacPhee, 2004). Simulation as a teaching tool engages learners, provides a realistic environment, permits hands-on learning, focuses on application of knowledge, shifts from subject-centeredness to problem-centeredness, incorporates and appeals to all learning styles (auditory, visual, kinesthetic, and tactile), and meets the needs of the adult learner (Gaberson & Oermann, 2010; Rauen, 2004). Simulation scenarios can provide a safe environment for cognitive conflict for the adult learner. According to Liu (2010), cognitive conflict is considered a premise for conceptual change. Cognitive conflict occurs when individuals cannot apply their existing knowledge to solve a problem and are thus confronted with a situation that motivates the learning of new concepts (Knowles, 1978). Cognitive theory involves higher-order mental activities such as memory, perception, thinking, problem solving, reasoning, and concept formation (Liu, 2010). The cognitive conflict learning theory supports clinical simulation as a teaching strategy because it allows the learner to acquire new knowledge and improve skills in a safe, nonthreatening experimental environment and provides the opportunity for decision making, critical thinking, and team building. Crimlisk, Jonhstone, & Sanchez (2009) reported that RNs who participated in simulation acknowledged that evidence-based practice education is imperative and revealed that clinical simulation was their preferred training method to promote critical thinking and decision making.
Barriers After the team defined the scope of the project, they identified barriers. The hospital’s lack of an infant simulator and the space to house one was the No. 1 barrier. The university did not have an infant simulator but had the space to house one in its laboratory. The CEO suggested that the university submit a proposal to the hospital foundation to purchase a simulator for the pediatric PIV insertion program. The foundation is a nonprofit organization that strives to
provide resources for programs that target health care initiatives with measurable outcomes. The chairperson and the DNP student wrote a proposal for an infant simulator and submitted it to the hospital foundation. Subsequently, the university was awarded the funds to purchase an infant and pediatric simulator (Laerdal SimBabyÒ) for hospital staff and community education. Other barriers included compensation and lack of time off for nurses to attend the program. The infant and patient simulator is portable, so the team decided to offer the sessions on-site at the hospital. Full-time employment for nursing staff at the community hospital is 72 hours per 2-week pay period. A 36-hour workweek allowed staff to attend meetings and educational programs 4 hours or less per week without being paid an overtime wage.
Program Development The population criterion was defined as any patient from 1 day to 18 years of age, admitted to the hospital, and requiring IV therapy. Pediatric PIV insertion was defined as an initial placement and replacement cannula. Data collection consisted of age, admission diagnosis, and the number of IV attempts to sucessfully achieve access. The team decided to pilot the pediatric PIV insertion program on the 31-bed medicalesurgical unit that included four designated pediatric beds. The nursing staff and unit manager on this unit identified pediatric PIV insertions as a high-risk, low-incidence skill. The DNP student coordinated activities and collaborated with the staff education coordinator to develop a pediatric PIV insertion program using the infant and pediatric simulator (Laerdal SimBaby) as teaching tool. The pediatric PIV insertion program was developed specifically for nurses and provided a comprehensive evidence-based overview of nursing care of the pediatric patient requiring a PIV insertion. The DNP student arranged practicum hours at a large metropolitan children’s hospital so that program participants could shadow pediatric nurses in the radiology department while observing best practice and reviewing hospital policy. The didactic content included a review of anatomy and physiology, pediatric equipment, pediatric specific interventions such as distraction therapy, safety positioning for children, and review of hospital policy and procedure. The program was based on professional reviewer recommendations by a certified pediatric nurse practitioner, an advanced practice nurse educator, and a simulation education consultant for readability and content appropriateness.
Program Implementation A total of 37 staff nurses participated in the mandatory 2-hour pediatric PIV insertion program. Six program sessions were offered on-site at the hospital during
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a 30-day period; this schedule optimized flexibility, allowing nurses to attend the session most convenient to their work schedule, thus yielding 100% attendance. Class size varied from 4 to 12 participants in each session. The program began with the project leader’s presenting didactic content, followed by a patient simulation scenario and a debriefing session. The patient scenario was an 18-month-old admitted from the physician’s office with the diagnosis of dehydration. Assessment findings included irritability, no interest in oral fluids, tachycardia, dry mucous membranes, and a history of vomiting and fever for a 24-hour period. The physician ordered 0.9% NaCl IV fluids immediately. Mom, Dad, 5-year-old sibling, and grandparents were present. Debriefing sessions were conducted at the end of each patient scenario session.
Debriefing Debriefing, an essential element of simulation, encompasses critique, correction and evaluation of learners’ performance, discussion of the experience (Crimlisk, Jonhstone, & Sanchez, 2009), and correction of misinformation or improper practice techniques that the students may demonstrate (Lamagna & MacPhee, 2004). Conducted after the patient simulation is performed, debriefing is an important part of learning because it provides the learners with direct feedback on what they have successfully accomplished, insight into what they can change, and pearls of wisdom to carry with them into the future. Conversation, observations by the project leader, and reflective thinking are the teaching strategies used in debriefing. Debriefing can lead to the development of self-correcting practice habits when a facilitator assists the learner to recognize and resolve clinical and behavioral dilemmas that occur during simulations (Dreifuerst, 2009). Conversation brings participants’ clinical decisions into the open, but a nonjudgmental framework is important to keep motivation active and provide psychological safety (Rudolph, Simon, Dufresne, & Raemer, 2006). In one study, the majority of learners reported that the debriefing session was an engaging and realistic learning experience that increased their confidence and critical thinking skills (Kuiper, Heinrich, Matthias, Graham, & Kotwall, 2008). An important aspect is that debriefing should be conducted in an area that is quiet and free from distraction in order to permit the facilitator to guide participants through a reflective process regarding the scenario and to help them learn from the experience. During the debriefing sessions, staff nurses shared their thoughts, concerns, fears, and personal experiences of starting a PIV insertion on a pediatric patient. They identified what went well in the simulation scenario and what they could improve. They critically appraised the pediatric PIV insertion process and offered suggestions to improve patient outcomes that led to a systemwide change in PIV insertion policy within the organization.
Results A total of 17 patients met the criterion for this project. Patients ranged in age from 11 months to 18 years, with a mean age of 10.3 years. Baseline data were collected on 8 patients 2 months before the pediatric PIV insertion program was offered. Of those 8 patients, 3 required one PIVattempt, 3 required two attempts, and 2 required three attempts. Postprogram data collection was completed during 2 consecutive months after the pediatric PIV insertion program and involved a total of 9 patients who were admitted to the medicalesurgical unit and required PIV insertions. Nurses were able to insert a PIV in one attempt on all 9 patients.
Limitations The sample size was small, with limited variability in patients’ ages. The initial data collection period was limited to 2 months because of practicability of the project.
Conclusion A collaborative venture between a local university in southwestern Pennsylvania and a rural community hospital enhanced learning and improved pediatric patient outcomes. The partnership led to the development and implementation of an evidenced-based pediatric PIV insertion program. Simulation technology and debriefing techniques were used to improve pediatric PIV insertion skills of the medicalesurgical nursing staff through attendance at a pediatric PIV insertion program, leading to the decreased number pediatric PIV insertion attempts. The simulation technology used in this project permitted the staff nurses to practice the pediatric PIV insertion skill, learn the procedure, make and correct mistakes, and finetune PIV skills in a safe environment without harming a patient or risking safety. In addition, it allowed the staff nurse to gain experience with pediatric patients and function in an environment that was as close as possible to an actual situation. The debriefing session that immediately followed the simulation experience was an essential element; it provided the learners with the opportunity to reflect and evaluate on their performance and practice. The pediatric PIV insertion program evaluations were positive, with staff nurses requesting more evidence-based practice simulation programs. The expansion of this pilot program is planned for the emergency room staff nurses in the future.
References American Association of Colleges of Nursing. (2006a). The essentials of doctoral education for advanced nursing practice. Retrieved January 6, 2010, from http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf.
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American Association of Colleges of Nursing. (2006b). Doctor of nursing practice roadmap task force report. Retrieved December 4, 2010, from www.aacn.nche.edu/dnp/roadmapreport.pdf. Boxer, A., & Goldfarb, E. (2011). Creative solutions to enhancing nursing quality. Sudbury, MA: Jones & Bartlett Learning. Crimlisk, J., Johnstone, D., & Sanchez, G. (2009). Evidence-based practice, clinical simulations workshop, and intravenous medication: Moving toward safer practice. MEDSURG Nursing Journal, 18(3), 153-160. Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. doi:10.1016/j.outlook.2009.07.009. Dreifuerst, K. (2009). The essentials of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives, 30(2), 109-114. doi:10.1043/1536-5026-030.002.0109. Durham, C., & Alden, K. (2008). Enhancing patient safety in nursing education through patient simulation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (chap. 51). Rockville, Md: Agency for Healthcare Research and Quality. Retrieved December 14, 2011, from http://www.ahrg.gov/qual/nurseshdbk.pdf. Etzel-Hardman, D. (2008). Continuing education: Teaching IV therapy to pediatric nurses. ModernMedicine. Retrieved November 24, 2010, from http://www.modernmedicine.com/modernmedicine/article/articleDetail. jsp?id¼561171. Gaberson, K., & Oermann, M. (2010). Clinical teaching strategies in nursing (3rd ed.). New York, NY: Springer. Garrett, B., MacPhee, M., & Jackson, C. (2010). High-fidelity patient simulation: Considerations for effective learning. Nursing Education Perspectives, 31(5), 309-313.
Institute of Medicine. (2003). Health professions education: a bridge to quality. Washington, DC: National Academies Press. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Jones, A. L. (2009). Developing a collaborative relationship between a rural hospital and a university. Clinical Simulation in Nursing, 5(4), e155e159. doi:10.1016/j.ecns.2009.02.003. Knowles, M. (1978). Andragogy: Adult learning theory in perspective. Community College Review, 5(3), 9-20. Kuiper, R., Heinrich, C., Matthias, A., Graham, M., & Kotwall, L. (2008). Debriefing with the OPT model of clinical reasoning during high fidelity patient simulation. International Journal of Nursing Education Scholarship, 5(1), 2. doi:10.2202/1548-923X.1466. Lamagna, P., & MacPhee, M. (2004). Troubleshooting pediatric peripheral IV, phlebitis and infiltration. Nursing Spectrum. Retrieved December 9, 2010, from http://news.nurse.com/apps/pbcs.dll/article?AID=2004407010305. Liu, T. C. (2010). Developing simulation-based computer assisted learning to correct students’ statistical misconceptions based on cognitive conflict theory, using ‘‘correlation’’ as an example. Journal of Educational Technology & Society, 13(2), 180-192. Long, K. A. (2003). The Institute of Medicine report: Health professions education: A bridge to quality. Policy, Politics & Nursing Practice, 4(4), 259-262. doi:10.1177/1527154403258304. Rauen, C. (2004). Simulation as a teaching strategy for nursing education and orientation in cardiac surgery. Critical Care Nurse, 24(3), 46-51. Rudolph, J., Simon, R., Dufresne, R., & Raemer, D. (2006). There’s no such thing as ‘‘nonjudgmental’’ debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), 49-55.
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