Posted by on Apr 12, 2017 in News |

Submitter Information

Author: Randi Flexner, DNP, APN, FNP-BC, RN
Title: Clinical Assistant Professor
Institution: Rutgers, the State University of New Jersey
Email: Flexner13@gmail.com
Coauthors: No co-authors, but acknowledgment contributions: Course Leader, Carol Carofiglio, PhD, RN providing PPH lecture material & simulation lab set up and Dawn Geller BSN, MEd, RN, for contributions to rubric and lab simulation activities. Similar PPH teaching strategy initially posted on QSEN.org by Mary Lou Gies, Ed.D, RN (2013).

Competency Category(s)
Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration

Learner Level(s)
Continuing Education, Graduate Students, New Graduates/Transition to Practice, Pre-Licensure BSN, Staff Development

Learner Setting(s)
Clinical Setting, Skills or Simulation Laboratories

Strategy Type
Simulation Exercises

Learning Objectives

1. Identify signs and symptoms of postpartum hemorrhage and patient safety concerns. (Knowledge)
2. Perform non-invasive initial steps to remedy symptoms and evaluate results. (Knowledge, Skills)
3. Understand the value of teamwork and demonstrate collaboration to improve patient safety in emergency setting. (Attitude)
4. Utilize communication and delegation to meet necessary actions in emergency setting. (Attitude)
5. Utilize critical reasoning skills with the evolving patient status changes and apply necessary actions. (Knowledge, Skills)
6. Synthesize unfolding patient demise and urgency of more invasive interventions, collaborating with peers and interdisciplinary team. (Knowledge, Skills, Attitude)
7. Analyze and reflect on self and peer contribution to care of patient and family. (Attitude)
8. Acknowledge patient and family’s lack of knowledge and escalated fear, while providing them education and support. (Knowledge, Attitude)
9. Conduct SBAR communication for verbal report and transfer of patient. (Knowledge, Skills, Attitude)
10. Identify areas of one’s strength and areas of needed improvement with each cycle debriefing phase and audio/video recording, demonstrating increased confidence and action in subsequent cycle. (Knowledge, Skills, Attitude)
11. Utilize the model for improvement PDSA questions: What are we trying to accomplish? How do we know that a change is an improvement? What changes can we make that will result in the improvements we seek with each cycle to enhance learning? (Knowledge, Skills, Attitude)

Knowledge: Incorporates the knowledge of postpartum hemorrhage complication following delivery. The nurse’s role in identifying signs and symptoms and role of providing safe care to patient and family.

Skills: The ability to perform assessment skills, provide appropriate interventions based on assessment findings, collaborate and communicate with others, perform calmly during an urgent situation.

Attitude: Demonstrate confidence in oneself, promote patient safety, be patient advocate, provide emotional support to patient and family, recognize need for assistance, delegate to others, self-reflect and identify areas of improvement.

Strategy Overview

Preparation: Students are to complete the assigned textbook reading and a case study article provided prior to the exercise on PPH; etiology, signs and symptoms, nursing assessments, and treatment options. They should also be introduced to Kolb’s Change Theory of Learning, the Plan-Do-Study-Act cycle for change, and rapid cycle learning.
Pre-briefing: Students are instructed how the rapid cycle learning will be performed in the simulation lab. Students are told they will conduct an initial assessment of their patient collectively as “one’ nurse in a group format. They will be guided by the faculty facilitator in regards to vital signs with student request. Following a pre-determined time limit (approximately 10-15 minutes) the cycle will end and there will be an immediate debriefing. The students are either audio or video taped during the simulation which is reviewed together immediately following the cycle. The students are then instructed that they will proceed to the next repeat simulation cycle paired together in varied nursing roles, rather than working collectively as “one”. Lastly in the final cycle, students will individually assume an assigned nursing role as the case study continues to evolve. By utilizing rapid cycle learning, students are expected to navigate through a process of reflection and growth within a short time frame, increasing their knowledge, critical reasoning skills, collaboration, confidence, and safety in practice. A predetermined time is established for each action cycle. The cycles can be equal in time or elongated as the scenario evolves with additional complications and necessary interventions. A specified amount of time promotes the urgency of the situation and encourages the students to think and act in a more efficient manner.
Lab environment set up: The simulation scenario includes a mannequin with a soft uterus and a large amount of blood on a perineal pad hidden by a coversheet. A family member, played by faculty or another student is present by the bedside. The patient has an intravenous access in upper limb. A medication cart and oxygen delivery source is available in the simulation area.
Clinical groups of 4-8 students are recommended.
Strategy: The Plan-Do-Study-Act model and Kolb Theory of change demonstrates how learning evolves through phases. Rapid cycle learning is a similar method that provides students the opportunity to perform simulation, debrief and reflect immediately, then repeat the prior simulation multiple times along with an evolving scenario. This allows the student to incorporate what was and was not previously effective (Plan-Do-Study-Act) and further provides an option to build upon the prior experience with enhanced learning in each new cycle. The scoring rubric is recorded following each rapid cycle phase and the aim is that ultimately by the last cycle, all sections are completed. The scoring at each phase may vary depending on the student’s baseline actions, but should demonstrate evidence of progress with each new cycle.
Step 1: Action – Students are prompted on entry to simulation room that the group would initially operate as “one nurse” collectively to perform a postpartum assessment. By working synergistically as “one” students are less intimidated with new application of skills assessment. The mannequin has large amounts of blood on perineal pad, soft uterus, and intravenous fluid infusing at slow rate. Students are told to brainstorm and shout out all thoughts as to what their assessment should entail (basic ABCs) and why. Faculty can utilize a video and/or audio device to capture student’s real time performance. Faculty allows the students to conduct initial assessments without instruction.
Step 2: Initial Debriefing – Students and faculty facilitator view recording together and utilize a rubric check off list to award points of areas addressed during the first action cycle.
Further Debriefing – reflective process, discussion of rationale for actions taken and not taken, and areas of needed improvement.
Step 3: Action Cycle #2 – Repeat cycle of entry into patient’s room and initial assessments. Student are assigned roles working as pairs, rather than collectively as “one” nurse. Faculty facilitator evolves case with patient change of vital signs, increased uterine bleeding, and level of consciousness. Faculty records second cycle on recording device/or video.
Step 4: Debriefing – Together faculty facilitator and students review recording and revisit grading rubric, new point total calculated with improved patient care measures.
Further Debriefing – reflective process, discussion of rationale for actions taken and not taken, and areas of needed improvement.
Step 5: Action Cycle #3 – Faculty facilitator advances students in their roles at this stage and assigns specific student roles, no longer collectively being “one” nurse or “paired”, but assigned independent roles. This is to promote further accountability for student participation. Students along with the facilitator identify before role playing, anticipatory nursing roles in caring for the patient in this PPH scenario. Together, the facilitator and students pre-select their role for this cycle before it begins. Such examples are, but not limited to; (1) nurse to care for family member, (2) primary nurse for patient, (3) additional unit staff nurse for assistance (4) a charge nurse for staff support upon request, (5) an operating room nurse to receive SBAR. Faculty facilitator role plays the practitioner and provides new patient care orders at this stage of the evolving case. ie: Medications to stop bleeding, oxygen, blood transfusion, increased intravenous fluids, & urinary catheter insertion.
During this cycle, the faculty facilitator determines that the patient should be prepared for surgery. The student nurse caring for the patient should utilize critical reasoning skills to collaborate and delegate necessary nursing care assistance from her peers who are acting in their pre-assigned nursing roles mentioned above. The patient’s primary care nurse should inform the charge nurse of the patient’s negative status change, seek assistance from additional staff to console spouse and keep him well informed, and assist in patient care. Ie: If patient receives blood transfusion, two person RN verification required. The patient’s primary nurse or charge nurse should contact the Operating room nurse and communicate the need for an immediate available OR and provide the SBAR report, including pertinent information such as blood type, medications received, vital signs, and recent lab values. Each student is actively participating in the simulation exercise working as a team.
Step 6: Debriefing – Students and faculty facilitator review recording together as the final debriefing. Facilitator encourages student reflective process on areas of knowledge, safety, interdisciplinary collaboration of care, SBAR communication, critical reasoning, anticipation of events unfolding, prioritizing areas of care, student’s confidence, the various nursing roles with responsibilities and actions associated to that role, and family/patient centered care. Rubric scoring is recorded.

Submitted Materials

Rapid-Cycle-Scoring-Rubric.docx
Rapid-Cycle-PDSA.docx
195.-SBAR-form.docx
Simulation-Exercise-PPH-RCL-3-2-2-3.docx
Pre-reading-postpartum-hemorrage-article-1.pdf

Additional Materials

Utilize current classroom textbook, NCLEX material, and evidence based practice content information on topic (postpartum hemorrhage)
Provide content reading ahead of simulation experience.
Incorporate QSEN competencies, and KSA into the curricula and simulation.

Evaluation Description

At the conclusion of the activity, the instructor should perform a final debriefing.
The instructor should compare the prior cycle rubric scores to the final rubric score to determine improved performance. At the conclusion, allow students the opportunity to self-reflect on the model for improvement PDSA questions, and discuss collectively their perception of the rapid cycle learning process and the end results. Data collection: Combine all rubric data scores for cumulative tally and note areas of improvement. Analyze student’s shared verbal reflection comments for common themes.