Author: Randi Flexner, DNP, APN, FNP-BC, RN
Title: Clinical Assistant Professor
Institution: Rutgers,the State University of New Jersey
Coauthors: Robert Strayer, PhD, APN
Skills or Simulation Laboratories
1. Identify actual and potential safety risks at patient bedside-environment.
2. Application of self-reflection and peer evaluation in group debriefing
3. Demonstrate knowledge and skills of peri-operative experience: (1) identify various nursing roles, (2) clean verses aseptic environment, and (3) patient safety during peri-operative experience.
4. Maintain sterility in operating room. (Knowledge and skills)
5. Collaborate with interdisciplinary team in operating room. (KSA)
6. Utilize SBAR communication appropriately and efficiently. (KSA)
7. Preparation of content completed in advance to facilitate skills application, deploy critical thinking, and accountability during simulation. (KSA)
8. Demonstrate teamwork and collaboration by establishing specific roles during emergency mock code to effectively perform skills and patient outcome. (KSA)
9. Identify various interdisciplinary roles in mock code, demonstrate respect, professionalism, and collaboration for efficiency and patient safety. (Attitude, confidence, professionalism)
10. Recognize family stress during emergency mock code and intervene effectively. (Attitude, respect, professionalism)
At conclusion of junior year, students completed course theory in Nursing Foundations and Adult Health and Illness pertaining to but not limited to peri-operative nursing, SBAR communication, patient safety risks, cardiopulmonary resuscitation, and medication delivery. Students had one semester of medical surgical clinical and also completed their foundation skills competencies through-out the year in labs. Safety Bundle Day was constructed to apply a full day simulation experience in lieu of the last clinical day for the entire junior class. The purpose was to apply the culmination of content learned to clinical practice in a safe controlled environment, provide an opportunity to apply new skills in the mock code, collaborate with one another and with interdisciplinary persons. In a cost effective planning approach, faculty organized the simulation utilizing available materials in lab, and resources within the college at large, and personnel, i.e.: simulation operating room facility
The activity ran multiple times through-out the day with student groups pre-assigned.
1. Operating room: Surgeon (interdisciplinary teamwork and collaboration) provided group of students’ discussion on various nursing roles in operating room, circulating nurse, scrub nurse, nurse anesthetist and/or anesthesiologist. Students scrubbed and gowned, maintaining sterility (safety and QI) Students opened sterile drapes and equipment, identified safety concerns in operating room, patient positioning, oxygenation, and fluid volume. Surgeon role play of time out procedure (QI and EBP) and discussed sutures, dressings, specimen collection, and blood loss. Students role played SBAR report to one another for recovery room transport (Communication, Safety). Recommend utilization of unique resource opportunities, facilities, and interdisciplinary care providers to enrich simulation experience and student interaction. This exercise can be basic or further developed according to available resources and learning objectives. Additional interdisciplinary roles could include medical techs, surgical techs, medical residents, physician assistants, nurse practitioners, certified nurse anesthetists, anesthesiologist, for further elaborate simulation scenario.
2. Patient Bedside Environment: Similar to “House of Horror, or “Little Room of Errors” students enter lab to find 4 patient rooms with various safety risks for patient, self, and others. One section relates to intravenous tubing, central line dressing, oxygen, and tracheostomy risks on a mannequin. Another section has basic patient safety risks related to side-rails, bed height, Foley bag placement, improper ted stockings, non-labeled intravenous bags, etc. Last section has environmental risks, dirty commode, overflowing trash, uncapped needles and specimens on nightstand, etc. Student navigate silently from bed to bed and write down all actual and potential safety risks identified. This is individual work, in a set time limit. Group debriefing is done immediately, faculty silent facilitator and allows students to peer review findings and rationale (communication). Students compare total number of findings, utilize self-reflection, and critical thinking skills by thinking beyond actual safety concerns to potential safety concerns.
3. Mock Code: Students are provided a code packet 2 weeks prior to review roles of nurse, crash cart supplies, CPR, basic EKG strip rhythms and associated medications utilized, two current EPB articles on running a code. Students randomly select their individual role during the code with 3×5 card upon entry to lab. The patient assigned nurse finds mannequin unresponsive and calls Code Blue (communication, safety, collaboration). Role playing begins and students assume their roles. Faculty members are present and facilitate the code. The roles are provided and can vary in number ie: one with a script as the provider calling the code, one nurse anesthetist, or any individual certified in advanced cardiac life support (ACLS) training to assist with airway and one observer utilizing a check off rubric to identify actions taken and those omitted, and facilitate debriefing. Students assume roles such as code delegating charge nurse, family member, nurse manager, recording nurse, crash cart-medicine delivery, additional staff nurses – tending to nurse anesthetist and intubation, tending to family, assisting charge nurse, tending to remaining patients on unit floor during code. Immediate debriefing is done post simulation. Students and faculty identify “urgency” feeling during code, value of communication and teamwork, value of skills operating equipment and crash cart, interdisciplinary care, critical thinking, and accountability. Faculty addresses rubric, areas of strengths and weakness. Mock Code is repeated a second time (quality improvement), students randomly choose roles again for additional learning.
*Special Acknowledgment of ongoing annual simulation development contributions by Rutgers, Clinical Lab Instructors and assigned course leaders.
EKG rhythm strips (samples provided)
Commonly used medications during a cardiac arrest/code status (sample provided)
ANY current articles on nurses’ role during a code event & current EBP: *recommendations:
Bryce, W (2014) The Novice Nurse’s Guide to Calling “Code Blue” The Journal of Continuing Education in Nursing · Vol 45, No 3, 2014doi:10.3928/00220124-20140219-01
O’Donoghue et al (2015). Nurses’ Perceptions of Role, Team Performance, and Education Regarding Resuscitation in the Adult Medical-Surgical Patient Med Surg Nursing September-October 2015 • Vol. 24/No. 5
Mock Code Rubric (provided)
Mock Code Roles (provided)
Evaluation Tool (provided)
Additional recommended content knowledge prior to exercise:
Fundamentals of Nursing Skills completion on asepsis and sterile technique
Stages of the operative process, and nurse roles (pre-op, operative, post-op)
Various types of anesthesia methods
Additional supplemental documents available upon request
The students received a post exercise evaluation survey which inquired to student’s perception of the overall activity, meeting the learning objectives, role of faculty, and suggestions for future use. Overwhelmingly, the surveys were positive and students expressed satisfaction, learning, increased confidence, and continued use, plus MORE simulation exercises throughout the curriculum. Major themes identified were increased confidence, exercise provided additional learning opportunity and skill application not previously found in their actual clinical rotation, safe environment, appreciated emphasis on QSEN competencies, value of debriefing and opportunity to improve with immediate repetition of Mock Code. Students valued the interdisciplinary practice exposure and operating room simulation experience. The Mock Code check off rubric allowed for comparing objective outcome measures of initial performance, and secondary performance following immediate debriefing. The second application also provided student with increased confidence in their role performance, delegation and communication skills, collaboration, and patient safety.