Patient deterioration simulation experiences: Impact on teaching and learning

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1 Collegian (2012) 19, Available online at jo ur nal homep age: Patient deterioration simulation experiences: Impact on teaching and learning Penny Buykx, PhD, GradDipAppPsych, BBSc a,, Simon Cooper, PhD, MEd, BA, RGN, FHEA b, Leigh Kinsman, PhD, MHSc, BHSc, RN c, Ruth Endacott, PhD, RN d,e, Julie Scholes, D.Phil, MSc (Nursing), DANS DipN, RN f, Tracy McConnell-Henry, MHSc (NseEd), GradDipCritCare, BN, RN g, Robyn Cant, PhD, MHSc, GradDipHEd h a School of Rural Health, Monash University, PO Box 666 Bendigo, Victoria 3552, Australia b School of Nursing & Midwifery (Berwick), Monash University, Australia c School of Rural Health, Monash University, Australia d School of Nursing and Midwifery, University of Plymouth, UK e School of Nursing and Midwifery, Monash University, Australia f Centre for Health Research, University of Brighton, UK g School of Nursing (Gippsland), Monash University, Australia h School of Nursing and Midwifery (Gippsland & Clayton), Monash University, Australia Received 14 September 2011; received in revised form 29 March 2012; accepted 30 March 2012 KEYWORDS Nurse education; Clinical performance; Simulation; Emergency; Australia Summary Early recognition and management of patient deterioration are essential nursing skills, and can be improved through education and experience. However, both nursing students and registered nurses may have few opportunities to develop and maintain the emergency management skills necessary to ensure patient safety. Using both theory and empirical evidence, we have developed a simulation-based educational model, FIRST 2 ACT (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends), to provide nurses with a highfidelity learning experience. The model has been tested in three different settings: it is highly acceptable to learners, adaptable to different training needs, and shows promise in improving actual clinical performance Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. Introduction Corresponding author. Tel.: ; fax: address: penny.buykx@monash.edu (P. Buykx). At some point in their career, most nurses will find themselves in the midst of an emergency, where a previously stable patient rapidly deteriorates. In many cases it is /$ see front matter 2012 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

2 126 P. Buykx et al. possible to halt the patient s further deterioration by the early recognition of changes in key physiological cues (e.g. blood pressure, temperature, respiratory rate) and responding appropriately. The ability of nurses to intervene effectively in such circumstances has been shown to improve with targeted education and relevant clinical experience (Cioffi, 2001; Clarke, Abbenbroek, & Hardy, 1996; Odell, Victor, & Oliver, 2009). In this paper we outline our program of research to develop and implement a simulation-based educational model to improve nurses emergency management skills. We describe the educational model and how it has evolved over time through research with three separate groups; undergraduate nursing students, under- and postgraduate midwifery students, and registered nurses working in a rural hospital. Key results of the FIRST 2 ACT (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends) research program are briefly summarised. The FIRST 2 ACT educational model To ensure our educational model was evidence-based we drew on both learning theory and empirical literature in designing the FIRST 2 ACT a five step educational cycle (Buykx et al., 2011). The first step of the model developing core knowledge is preparatory and takes place over months or years, whereas steps 2 5 (assessment, simulation, reflective self-review, performance feedback) occur on a single simulation day. 1. Developing core knowledge involves ensuring that the nurse has the appropriate building blocks of knowledge to put together an accurate clinical picture and to determine an appropriate course of action when faced with a set of patient observations. For nursing students, this core knowledge development occurs through exposure to a comprehensive curriculum, while registered nurses may be assumed to already possess such core knowledge from both their own training and subsequent practice experience. Classroom teaching has a place in the development of knowledge (Lisko & O Dell, 2010) but clinical critical thinking skills need to be developed through practice and experience. Experiential learning theory (Kolb & Kolb, 2005) suggests that concrete experience, reflective observation and active participation are essential with the learner moving through phases of experiencing, reflecting, thinking and acting to assimilate new knowledge and skills. 2. On simulation day, participants complete an assessment of their core knowledge, that is, a brief multiple choice questionnaire (MCQ) of items relevant to the patient simulated emergency and developed from a peer reviewed question set (Endacott, Jevon, & Cooper, 2009). It is not intended that participants knowledge be comprehensively assessed on every relevant aspect of the underlying medical condition, but rather that a general indication be given of academic preparedness for the simulation tasks. Boud and Falchikov (2006) argue that this form of formative assessment drives learning as it focuses learners on the tasks to come and encourages them to consider the critical issues within each problem. Knowledge testing on its own tends to develop superficial surface learning (Tiwari et al., 2005) so a combination of knowledge and skills tests are therefore more likely to enhance deep learning. 3. The simulation component of the educational model involves immersion in two consecutive scenarios, both of 7 8 min duration. We chose high-fidelity simulation as the mode of delivery because it allows for a large number of participants to have a realistic experience a specific emergency without actual risk to patients (Alinier, Hunt, Gordon, & Harwood, 2006; Decker, Sportsman, Puetz, & Billings, 2008); has been shown to have a positive effect on knowledge, critical thinking ability and confidence (Cant & Cooper, 2010); and the consolidation of theory into practice, with immediate feedback (Decker et al., 2008). These scenarios or Objective Structured Clinical Examinations were developed by an expert panel of six clinicians and academics and contained nominal item ratings which were summed for participant comparison. At the outset of each scenario, participants are given a brief handover of the patient, and then invited to explore the scenario, undertaking whatever observations or actions they consider necessary. Some subtle signs of patient deterioration are present from the outset and the patient begins to rapidly deteriorate from the midpoint of each scenario. Participant performance in the scenarios is scored in real-time by two assessors to ensure accuracy and to measure inter-rater reliability. Situation awareness of key features of the environment is also assessed by using the Situation Awareness Global Assessment Technique (SA Technologies, 2007) posing questions in four domains: global perception (e.g. is suction available?), physiological cues (e.g. what is the heart rate?), comprehension of the meaning of cues (e.g. what do you think is wrong?), and projection of likely outcome (e.g. what do you think may happen to the heart rate?). After completing the scenarios, participants progress through the final two steps of the educational model with a clinical expert. 4. Each participant is invited to watch a video recording of their own performance and to engage in reflective self-review. While watching the video participants are encouraged to verbalise what they were thinking at each stage and to reflect on their own decision making and actions. The intention is that by actually seeing their performance and having the opportunity to identify some of their own strengths and weaknesses, participants may develop a more realistic impression of their work (Fanning & Gaba, 2007). Zick et al. argue that this reflection and self assessment are essential components of skill-building (Zick, Granieri, & Makoul, 2007; p. 162). 5. Lastly, participants are provided with specific performance feedback by the clinical expert. The feedback, while clearly identifying gaps in knowledge and performance, is delivered in a constructive manner to emphasise the opportunity for learning inherent in the exercise, rather than reinforcing deficiencies. Such interactive feedback has been identified as a crucial factor in engaging students in learning (Cant & Cooper, 2011).

3 Patient deterioration simulation experiences 127 Implementing FIRST 2 ACT how has it evolved and what have we learnt? We have thus far used FIRST 2 ACT in three different settings, with three different participant groups and with three different pairs of scenarios. The model has been successful in each case (see below), but we have continued to refine it over time to test different questions in the varying contexts. Overall benefits to participants were positive with participants from all the studies completing an evaluation form on completion. Levels of satisfaction were rated, and before/after judgements of knowledge and confidence (all on a 5 point scale). Average satisfaction ratings were high for all three studies (4.4 5) with significant improvements in self rated knowledge levels (p 0.001) and confidence and competence ratings (Buykx et al., 2011). Suggestions for improving the program included better orientations to each scenario and improving the realism (or fidelity). [The latter was resolved by moving from manikin based scenarios to standardized patient actors.] In the third study with registered nurses we also undertook a patient notes review (times series analysis) before and after FIRST 2 ACT training identifying significant improvements in the applicable frequency of observations (p = 0.025), pain score charting (p = 0.001), and improvements in oxygen therapy. Final year undergraduate nursing students (Cooper, Buykx, McConnell-Henry, Kinsman, & McDermott, 2011; Cooper et al., 2010; Endacott et al., 2010). In 2008 the Nurses Board of Victoria funded the implementation of the FIRST 2 ACT model with a group of final year nursing students (n = 51). Simulated scenarios were conducted within a University skills education laboratory using a computerised manikin. The first scenario presented to each participant was considered the easier as participants were provided with a greater amount of patient information and there was less uncertainty about what was wrong with the patient. The second harder scenario involved the provision of less patient information and greater uncertainty. While the average level of knowledge as assessed by the MCQ was adequate (74%; range %) (Table 1), a knowledgepractice gap was evident, with skill performance averaging only 60% (range 30 78%) and declining as the condition of the patient worsened (p 0.012). However, skill performance improved significantly by the second scenario i.e. with practice (p 0.01). Average situation awareness scores were 59% (range 38 82%) and were particularly poor in the comprehension domain. Performance anxiety was common among participants with about a tenth remaining frozen to the spot well into the scenario. Errors in clinical reasoning were also common, notably fixating on a single cue and neglecting to search for other relevant information. In some cases this tunnel vision led to inappropriate actions, such as sitting up a patient with low blood pressure, and commencing CPR on a patient with a pulse. Many participants did not call for help, even when the patient s condition clearly demanded emergency intervention, however this may be an outcome related to the simulated nature of the study. Despite the anxiety provoking nature of the simulation exercises and some mediocre performances, participant Picture 1 Undergraduate student assesses the deteriorating patient computerised manikin. feedback about the experience was largely positive, particularly about the opportunity to review and reflect upon their basic assessment and observation skills; prioritisation and decision making skills; and personal coping strategies (e.g. anxiety management and communication). While this study did not measure actual change in knowledge, self-reported knowledge significantly improved following participation. A small proportion of participants felt the realism of the experience would be improved by using patient actors rather than manikins (Picture 1). Undergraduate and postgraduate midwifery students (Cooper, Bulle, et al., 2011). After the apparent success of implementing FIRST 2 ACT using two general nursing scenarios and computerised manikins, we were keen to see whether the model was sufficiently flexible to adapt to other emergencies and using a different simulation modality. In 2010 funding from Equity Trustees (Walter Cottman Endowment Fund) enabled us to test the appropriateness of the model in rehearsing obstetric emergency management. Thirty five under- and post graduate midwifery students participated in the simulation exercises. Importantly, patient actors wearing birthing suits were used instead of manikins. This allowed participants to interact far more realistically with the patient, including being able to seek additional information directly from the patient. In all other respects the simulation proceeded as for the study above. Very similar results were achieved, with average MCQ scores (75%; range 46 91%) (Table 1) well exceeding actual clinical performance (54%; range 39 70%) and performance decreasing significantly as the patient deteriorated (p 0.023). Average situation awareness was also only 54% (range 40 70%), although in this study perception of physiological cues was the weakest domain, probably due to lack of assessment and recording of the patient s vital signs by participants. Again, although calling for emergency backup was clearly warranted in each scenario, only about

4 128 P. Buykx et al. Table 1 Mean MCQ, clinical skills and situation awareness scores by group. Final year undergraduate nursing students (n = 51) Under and post graduate midwifery students (n = 35) Registered nurses in rural hospital (n = 35) Mean % (range) Mean % (range) Mean % (range) MCQ score 74 (46 100) 75 (46 91) 67 (27 91) Clinical skills 60 (30 78) 54 (39 70) 50 (26 74) Situation awareness 59 (38 82) 54 (40 70) 50 (25 83) half the participants actually did so. Of those who called for help, some participants clearly fully comprehended the situation, but many others appeared to have simply exhausted all other ideas for action. Participant feedback was once again very positive about the learning experience, indicating students found the model to be highly acceptable. Informal feedback from teaching staff suggests that for some students, participation in the simulation-based learning marked an encouraging turning point in their progress towards clinical competence. Overall, this study was important in demonstrating the adaptability of FIRST 2 ACT to different scenarios and different simulation modalities (Picture 2). Registered nurses in a rural hospital (Cooper, McConnell- Henry, et al., 2011). The above two studies gave us confidence in FIRST 2 ACT as an effective and acceptable educational tool for use in under- and post-graduate nursing courses as an adjunct to traditional clinical placements. However, we also wanted to test whether the model had utility as a real-world continuing professional development (CPD) program for practising nurses. We therefore implemented the model in a rural hospital to investigate whether there were measurable improvements in actual clinical practice assessing patient notes before and after the intervention for time series analysis. The simulations again used patient actors but were conducted in the hospital setting. Time series analysis was conducted for five fortnightly blocks before and after the delivery of the FIRST 2 ACT training to assess change in key outcome variables, including frequency of vital signs recording and charting of pain scores. Results followed a similar theme to our previous studies with implementation of practice issues identified for the 35 nurse participants. Using the same MCQ as in our first study with student nurses (see above) knowledge levels averaged 67% (range 27 91%) which was significantly lower (p = 0.006) for this qualified cohort compared to third year students. Situation awareness was low (50%) with many important actions and observations missed with, as in previous studies, a significant decline in performance as the patient deteriorated and the participant became more anxious (p 0.003). An important finding in this study related to the impact that the FIRST 2 ACT intervention had on clinical practice 258 patient records were audited for the ten weeks before the intervention and 242 records for the ten weeks after. As reported above staff were significantly more likely to record observations at applicable intervals after the intervention (e.g. shifting from four hourly to one hourly observations), and much more likely to record pain scores and to deliver/apply oxygen therapy correctly (Picture 3). Discussion and conclusion Our FIRST 2 ACT research program has shown a knowledgepractice gap in emergency management, not only for nursing and midwifery students nearing the completion of their Picture 2 Patient actor in the ModelMed Birth Simulation Suit. Picture 3 Registered nurses at a rural hospital administer oxygen to the deteriorating patient patient actor.

5 Patient deterioration simulation experiences 129 studies, but also for registered nurses working in a clinical environment. This consistent finding suggests that while nurse education may provide sufficient coverage of the academic material underpinning nurse practice, both students and qualified nurses may benefit from further learning opportunities which encourage them to correctly apply their knowledge under the pressure of an emergency situation. Our first study demonstrated the feasibility of FIRST 2 ACT as an educational tool, both in terms of implementation and also student satisfaction. Following applicable adaptations our second study showed that the model can meet a range of learning requirements through the use of different emergency management scenarios. Our third study greatly extends the evidence base for the model by investigating the impact of participating in the program on learning as evidenced by positive changes to clinical practice. The eventual outcome for a deteriorating patient may depend on the initial response of hospital staff to the early stages of the medical or obstetric emergency; however, students (nurse/midwives) and registered nurses may have infrequent exposure to such events through their clinical placements or work. The FIRST 2 ACT educational model provides a high fidelity opportunity to practice the necessary emergency management skills without risk to actual patients. Based on existing evidence and tested in three different studies, FIRST 2 ACT can be adapted to meet the particular training needs of different groups, is highly acceptable to students, and shows promise in improving the actual clinical practice of nurses. Acknowledgements Our thanks to the research teams on all the projects: Mary- Anne Biro, Rosemary Bolland, Bree Bulle, Robert Champion, Carole Gilmour, Jan Jones, Maureen Miles, Karen Missen, and Jo Porter. Thanks also to the hospital partners involved in the project. 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