Obstetrical Nursing Experience Simulation

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2 Obstetrical Nursing Experience Simulation Filling the Gap Teaching nurses to care for the woman and fetus during the intrapartal period presents unique challenges for educators in both the academic and clinical setting. Understanding nursing care needs and developing the professional judgment needed to provide safe care don t happen in a single moment or through the discrete event of hearing, reading or watching. Responding to a complex phenomenon requires learning opportunities that are cumulative, integrative and multifaceted. Limits of the Clinical Setting The hospital-based intrapartal clinical setting is inherently limited as a setting for learning how to provide safe and effective nursing care. The unpredictability of the birth process and the nature of the intrapartal setting challenge the educator to find situations for safe and effective learning without putting the patient at risk. The availability of patient care experiences are influenced by factors such as the workplace culture, patient satisfaction targets and liability issues. These factors may have a negative impact on the quality of the learning experience and limit the learner s ability to be immersed in the patient care situation. In a study of nurse midwives, Haigh (2007) found that opposing priorities between the learning needs of the student and nurses and the patient care needs of women created a source of tension and resulted in an environment not conducive to learning. In the practice setting, the needs of the patient establish the context of the learning opportunities. A student or a new labor and delivery nurse could potentially complete an entire clinical rotation or orientation period and not experience some of the common or high-acuity events that a nurse needs to come into contact with to be prepared to provide safe and effective care. Therefore, nurse educators, clinical leaders and unit directors are continually searching for strategies to provide nurses and students learning opportunities to develop and enhance their skills as competent and safe care providers. This paper outlines the use of simulation with a high-fidelity birthing simulator as a teaching strategy for nursing students and staff learning to care for patients in the intrapartum setting. Deborah A. Raines, PhD, RN, ANEF

3 Simulation as a Teaching Strategy Traditional teaching methods emphasize linear thinking, with a single concept being taught at a time. Although this method helps learners to dissect complex information, organ systems don t function in isolation. This is especially true in the intrapartal setting. Nurses need to recognize that when there is a change in maternal status, such as a change in vital signs, the onset of vomiting or a reaction to medication, there is a potential impact on fetal well-being. Grasping the complexities of Bottom Line Simulation is a teaching method that facilitates application of theory to practice in an integrated manner. It provides a safe environment for nurses to learn intrapartum care in high-risk, high-acuity scenarios. The cost for investing in simulation may be outweighed by the benefits of nurse competence and lack of harm to patients. Deborah A. Raines, PhD, RN, ANEF, is director of the Scholarship of Teaching and a professor at Florida Atlantic University in Boca Raton, FL. Address correspondence to: draines@fau.edu. Opening image: Reprinted with permission from the University of South Florida College of Nursing. nursing care for the intrapartal patient requires an integrative or circular type of thinking and acting because priorities are interrelated. Simulation is a method that facilitates application of theory to practice in an integrated manner. An important element in learning is experiential learning (Kolb, 1984). Simulation promotes experiential learning by providing opportunities for the learner to apply knowledge and skills used to assess and intervene in patient care situations. Simulation has been used outside of the health care setting for decades. Aviation, the nuclear power industry and the behavioral sciences have all used simulation to allow riskfree practice as well as to teach critical thinking skills. Gredler (2004) defines simulation as a deliberate approach to learning in which the goal for all participants is to each take a particular role, address the issues, threats or problems that are in the situation and experience the effects of their decisions (p. 571). Today technologic advances have resulted in sophisticated, computer-driven, full-body interactive simulators that perform the basic movements of human birth and individual variations in the human response to the progression of labor and birth. A simulated nursing situation adds a dimension not found in traditional didactic or clinical learning experience. The use of simulation removes the potential of risk to the patient and lets learners experience the outcomes of their actions or inactions. There are several advantages of a simulated nursing situation as a learning modality for the care of the intrapartal patient (see Box 1). Simulation allows events to occur simultaneously and the nurse learns to identify relationships essential and common to safe and effective practice in a setting. Unlike a classroom setting, simulation allows learners to function in an environment similar to the clinical setting and to think on their feet and to act as the nurse without the constraints of potential harm to the patient or liability issues. Simulation allows the integration of technical skills with the knowledge and the application of professional judgment foundational to safe and effective nursing care. Simulations are optimized for learning. With the use of simulation, the educational experience is determined by the needs of the learner and not the needs of the patient. Learners have permission to fail and to learn from the negative consequences of the failure to recognize and act. This isn t feasible in the clinical setting. Example of a Simulation The simulated nursing situation learning experience described below was designed to be used with nursing students in a prelicensure BSN program and with labor and delivery nurse orientees at a university medical center. A simulated nursing situation of a woman admitted for intrapartal care was created. The first step was to create an environment resembling the labor and birth rooms in the surrounding hospitals. Therefore, the simulation area was equipped with a birthing bed, electronic fetal monitor (EFM), IV pumps and other equipment and supplies usually found in the clinical setting. A Noelle Birthing simulator was used as the patient, known as Ms. Kane. Before the learners arrival, faculty position Ms. Kane in the bed, connect and initiate the flow of the IV fluids and pitocin and apply and turn on the EFM. Ms. Kane s position in bed varies from supine to left-sided to high fowlers and sometimes the BOX 1 Advantages of a Simulated Nursing Situation A realistic clinical setting No threat to patient safety Nurse is actively involved in the learning process Specific events can be simulated Errors in performance can be explored and then corrected Team work and delegation can be simulated DOI: /j X x , AWHONN

4 The use of simulation removes the potential of risk to the patient and lets learners experience the outcomes of their actions or inactions EFM is not correctly placed or the IV infusion is at the wrong rate. Personal items, such as a family photo, music or colorful socks, and hospital supplies, such as emesis basins, bedpans, lubricant and other supplies found in the clinical setting, are added to each simulation in a random pattern. These variations in patient presentation and the surrounding environment create a unique look and feel to the experience for each learner. A speaker attached to a wireless microphone was placed on the neck of the simulator to give the patient a voice. The voice of Ms. Kane was scripted to keep the responses consistent with the focus of the simulation. However, the person behind Ms. Kane s voice was familiar with the focus of the simulated nursing situation and the concerns and needs expressed by women during labor. The voice of Ms. Kane is essential to facilitate the nursepatient communication component of the simulation activity. The next step was to design the nursing situation scenario to be enacted during the simulation experience. High-frequency, high-acuity events associated with the care of women during labor and birth were embedded into the scenario. The scenario was developed to include didactic knowledge, assessment skills and recognition of variations in the patient s response and the implementation and evaluation of a plan of nursing care. Learners were expected to demonstrate the practice of universal precautions, therapeutic communication skills, communications with members of the health care team and documentation of nursing care and patient responses throughout the simulation scenario. This simulation required additional personnel in the roles of the nurse going off-duty, who also became the voice of Ms. Kane, the charge nurse and the physician. The nurse learners worked in pairs. Roles were determined at the beginning of the simulation by random draw. One learner was the labor nurse (nurse #1) and the second nurse was the birth nurse (nurse #2). Learners were instructed that they were to take the lead during their portion of the scenario, but that their peer was to assist and collaborate to provide optimal care to the patient. BOX 2 Simulation Script: Change of Shift Report Good morning. Let s see, you are going to be with Alice Kane in room 4. Ms. Kane is a 32-year-old gravida 3 para 0, admitted about 10:00 p.m. yesterday with contractions and a small amount of vaginal bleeding. A neighbor brought her to the hospital because her husband is out of town on business. She is currently 38 weeks. Her previous pregnancies ended with a preterm birth at 26 weeks of a girl who died within a couple of hours and a stillbirth at 30 weeks. She was very anxious about the vaginal bleeding, so we admitted her. She was started on an IV of RL (Ringers Lactate) at 125 ml/hour and routine labs were drawn. There has been no active bleeding since admission. By 2:00 a.m. her contractions were coming about every 7 minutes, so we started her on pitocin. The pitocin was increased per protocol and reached the maximum at 6:00 a.m. Her contractions are now coming every 4 to 5 minutes and are 60 seconds in duration. She is a little uncomfortable with the contractions and expressing concern about the baby s well-beings. She is refusing an epidural, because she thinks it could hurt the baby. Her vitals are on the flowsheet. She has an IV of RL at 125 ml/hr; her last void was at about 4:00 a.m. She has slept a little between contractions, but really hasn t had any good sleep since being admitted. I think that s it. Do you have any questions? April May 2010 Nursing for Women s Health 115

5 BOX 3 Scenario for Nurse #1 Care of the Patient in Labor (Ms. Kane) Learner-Initiated Action Ms. Kane s Response/Findings Variations Enters room, initiates a nurse-patient relationship Complete an individualized patient assessment Level of consciousness/ awareness Cardiac, respiratory, GI, neuromuscular assessment Ms. Kane responds and interacts with the nurse. Ms. Kane is able to tell the nurse her OB history, the story of this pregnancy, and what has happened since her admission last night. She also shares that she has previously loss two babies, and she really hopes the third time is the charm. Assessment data within normal limits Urinary assessment Abdominal assessment Ms. Kane denies feeling the need to void. She says she went to the bathroom early this morning. If the learner palpates the bladder, it is found to be slightly distended and when the nurse applies pressure, Ms. Kane says, when you press there is feels like I might need to go to the bathroom. Ms. Kane asks, Is there something wrong? Is the baby OK? What is the heart-rate now? Ms. Kane described her contractions as getting really strong and quite painful. Checks equipment in the room IV fluids, pitocin infusion, fetal monitoring equipment, availability of oxygen equipment and emergency equipment Nursing Care Explore pain management options with Ms. Kane Continue to discuss pain management options and find an option acceptable to the patient IV and pitocin infusions are running without problems. The fetal monitor is showing a reassuring FHR patterns and a pattern consistent with active labor. Ms. Kane puts on call light. It really hurts. I don t know how much more of this I can take. I wanted to do this all natural so I don t hurt the baby. And I definitely don t want that epidural in my back. Can you give me a couple of Tylenol or something? OK I ll try some of that pain medicine. Item is missing from the room or amount of IV fluids differs from what was reported. Increased maternal pulse rate, and BP. 116 Nursing for Women s Health Volume 14 Issue 2

6 Learner-Initiated Action Ms. Kane s Response/Findings Variations Calls physician. Gives report of patient s status and requests order for pain medicine. Administers pain medicine using all safety and patient identifier measures. Follows up with patient to evaluate effectiveness of pain relief techniques Nursing care Focused assessment of Ms. Kane: Identify and implement actions for correct problem. Assess fetal status as a result of the problem and the actions implemented Ms. Kane calls out to the nurse, Something s wrong. I don t feel right. I don t know what s happening to me. Ms. Kane reports relief and feeling better. Medication ordered and dosage varies. Variation #1: Complains of dizziness and tingling in fingers and legs, increased respiratory rate, difficulty talking Problem: hyperventilation Actions: Calm patient, breathe into cupped hands/paper bag Variation #2 Complains of headache, stomach pain, and feeling nauseated Problem: vomiting Action: Cool cloth, slow breathing, check for perineal bulging. Nursing care Correctly identifies the deceleration pattern and takes appropriate action including notifying charge nurse/ physician The baby s heart doesn t sound right. What s wrong? Variation in pattern of change in fetal heart rate on monitor tracing: Late Variable Early At this point the physician comes; the patient is checked and found to be completely dilated. Nurse #1 hands off the patient to nurse #2, who then assumes care of the patient through the birth and immediate postpartum period. Scenario continues through the birth and first hour postpartum with nurse #2 taking the lead in caring for Ms. Kane. April May 2010 Nursing for Women s Health 117

7 After the learners roles were established, they entered the simulation unit and nurse #1 was given report on the patient by the nurse going off duty. The learners had been told they were arriving for work at 7:00 a.m. The patient hand-off-report was scripted (see Box 2 for text). By design, some critical information such as cervical effacement and dilatation and status of the amniotic membranes are intentionally missing from the report. These deficiencies require the learner to process the information received and to recognize that important information is missing. The learners have an opportunity to ask for the missing information and it will be supplied. After receiving report, nurse #1 has the opportunity to briefly review the patient s chart, including the flow sheets, medical orders and lab results. The learner is asked to think out loud while reviewing the medical record. In other words, the learner states, I want to look at the flow sheet to see her vital signs, and when the flow sheet is located the learner thinks out loud that her temperature is OK, but her BP is on the low side, except for right after the Pitocin was started, when her systolic went up a little. The rationale for having the learner think out loud is to allow the observers to see and know what the learner is looking for and how she is processing the information being reviewed. Nurse #1 proceeds to the patient s room. If the nurse spends too much time reading the chart, the patient s call bell goes off and the charge nurse directs the nurse to see what her patient needs. Once the learner enters the patient s room, the scenario begins. A portion of the scenario is outlined in Box 3. Observation and Assessment During the simulation, learner performance is assessed by an observer. The observer may be an educator or experienced nurse. Observation of the learner s behaviors during the simulated nursing situation is assessed using predetermined criteria. The comparison of the learners activities to a predetermined level of performance, based on the standard of care for the intrapartum setting, allows assessment of components of clinical competence in a planned and structured format. An example of the performance assessment form is included as Box 4. Debriefing At the conclusion of the simulated nursing situation experience, the learners, observers and individuals who participated in the roles of charge nurse and physician all participate in a reflective debriefing session. Using a roundtable format, each participant shares things that went well, something he or she would do differently the next time, something he or she was uncomfortable with, something that felt good and something he or she would like to know more about. Learners also meet individually with the educator/observer to review their individual performance during the simulated nursing situation and to develop a plan for progression in their individual role development. Conclusion Overall, the response to the simulated learning experience has been positive. Nurses in unit-specific orientation appreciate the opportunity to learn their new role without putting the patient at risk, whereas the student nurses had the opportunity to document care, administer medications and communicate with the physician experiences often not available to students in the clinical setting. One disadvantage often cited in discussions about the use of simulated learning experiences is the cost. While simulation may be more costly and time-intensive than the ad hoc clinical experiences available in the practice setting, the lack of risk to patient well-being, lack of liability and ability to explore the impact of failure to act may outweigh the financial investment in the simulator and development time. The potential benefits of nurse competence and safe patient care outweigh the cost associated with the use of simulated nursing situations as learning opportunities. NWH References Gredler, M. E., (2004). Games and simulations and their relationships to learning. In D.H. Jonassen (Ed.), Handbook of research on educational communication and technology (2nd ed.). New York: MacMillan Library Reference. Haigh, J. (2007). Expansive learning in the university setting: The case for simulated experience. Nurse Education in Practice 7(2), Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice-Hall. Image courtesy of UCF College of Nursing 118 Nursing for Women s Health Volume 14 Issue 2

8 BOX 4 Performance Assessment Criteria Sheet Nurse #1: Observer: Expected behavior (critical behaviors are BOLD) YES NO N/A Comments Demonstrates Hand-washing/ Universal precautions At beginning of simulation When administering medications At other times as appropriate Uses standard patient identifiers At beginning of simulation When administering medications At other times as appropriate Demonstrates therapeutic nurse-patient communications. At beginning of simulation When patient expresses a concern or need At other times as appropriate Documents nursing care and patient responses throughout the simulation Communicates changes in patient s status with members of the healthcare team Completes initial assessment of the patient Provides education or support to patient related to the progress of her labor Intervenes appropriately to changes in the patient s status Recognizes changes in the FHR pattern Responds to changes in the FHR pattern Administers medications consistent with standards of practice. Manages IV fluids and Pitocin infusion consistent with standards of practice. Recognizes behavioral changes consistent with the progression of labor Gives complete and concise report to nurse taking over care of patient. Reflection on performance: Plan for progression of individual role development: April May 2010 Nursing for Women s Health 119