Integrating QSEN Competencies into a Capstone Simulation

Submitter Information

Author: Nancy Lenaghan, MSN, APRN, CNE
Title: Professor
Institution: Brookdale Community College
Email: nlenaghan@brookdalecc.edu

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

Learner Level(s)
New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s)
Skills or Simulation Laboratories

Strategy Type

Learning Objectives

Evidence Based Practice

Demonstrate knowledge of basic scientific methods and processes (K).  Describe reliable sources for locating scientific evidence about Systemic Inflammatory Response Syndrome and sepsis (K).    Explain how the validity and relevance of available evidence influences the interventions (K).    Locate evidence based reports related to clinical practice/topics (S)  Value the need for continuous improvement in clinical practice based on new knowledge (A).

 Patient Centered Care

Integrate multiple dimensions of patient centered care (K).   Value seeing health care through the patient’s eyes (A).   Communicate patient values, preferences and needs to other members of the health team (S).  Value the active participation with patients or designated surrogates in planning, implementing and evaluating care (A).   Provide patient centered care with sensitivity and respect for human diversity (S)  Assess own level of communication skill in encounters with the patient and family (S).

 Safety

Examine environmental factors that impact patient safety (K).    Use strategies to reduce reliance on memory (S).    Use error reporting systems for reporting errors (S).    Participate in root cause analysis to analyze errors (S)    Implement specific interventions addressed in the National Patient Safety Goals (S). Communicate observations or concerns related hazards or errors to members of the health care team (S).   Describe factors that create a culture of safety (K).    Demonstrate effective use of standard practices to support patient safety (S) (recognize and intervene when patient’s status changes).

  Teamwork and Collaboration

Describe the scope of practice and roles of health team members (K).    Function competently within own scope of practice as a member of the health care team (S).   Initiate requests for help when appropriate to the situation(S).    Collaborate and communicate with health team members to ensure continuity of care (S).  Initiate actions to resolve conflict (S).

Quality Improvement

Identify gaps between actual and best practices in this simulation (S).    Identify tools that can be used to collect data to understand variations in care (K).   Describe approaches for changing processes of care (K).   Seek information about Quality Improvement projects in the care setting (S).

Strategy Overview

This teaching strategy is a capstone simulation conducted in the nursing skills laboratory with a small group of senior nursing students in the last course before they enter their preceptor experience.  Students complete this simulation when they are studying about urinary tract infections, sepsis and multiple organ dysfunction syndrome.   Using a high fidelity mannequin, students progress through the various complexities and unpredictable events that occur when caring for a geriatric patient whose condition changes dramatically.  Students are selected randomly to fill the five primary roles in the scenario:  Nurse A, Nurse B, an unlicensed assistant, the patient’s daughter, and a medical resident.  Later in the simulation, students from the radiologic technology and respiratory therapy programs join the scenario to collaborate with nursing students in managing their unstable patient.   Three student observers answer key questions designed to encourage clinical reasoning, and they contribute their impressions during the debriefing.

The simulated patient is an 85 year old Italian female who is transferred from a long term care facility to an acute care hospital with a urinary tract infection that rapidly progresses to sepsis followed by multiple organ dysfunction.  Within two hours of admission, the patient becomes hypotensive, oliguric, tachycardic, and tachypneic. The student identifies signs of Systemic Inflammatory Response Syndrome and calls a Rapid Response.  The Sepsis Bundle Protocol is implemented, but the patient continues to progress to septic shock and is transferred to ICU.

During the course of the simulation and the debriefing that follows, students apply the knowledge, skills and attitudes for five of the QSEN competencies.

Patient Centered Care is emphasized when students consider the patient’s individualized cultural and developmental needs. During the scenario, the student demonstrates therapeutic communication with the patient’s family, considering caregiver role strain and psychosocial concerns.    When the patient’s condition worsens, the student informs the ICU nurse about the patient’s wishes related to end of life care. Throughout the simulation, the nurse answers the family member’s questions and elicits input about patient’s care.

Teamwork and Collaboration comes alive in this simulation when students from the Respiratory Therapy and Radiologic Technology programs collaborate with nursing students and participate in the plan of care as the patient’s condition deteriorates.   The scenario also includes the opportunity to delegate to an unlicensed person and to intervene when the care does not meet appropriate standards. When the medical resident asks the patient’s daughter to leave, the student manages this conflict proactively and advocates for the patient and family.   When the patient’s condition becomes unstable, the student communicates critical information to the rapid response team and the ICU nurse, using an organized format

Prior the simulation experience, students identify a clinical question about Multiple Organ Dysfunction syndrome and locate Evidence Based Practice to answer their question.  They also research an article to explain the rationale for the components of the Sepsis Bundle Protocol and then they compare their findings in an online discussion forum.   Faculty can provide the students with specific criteria to evaluate the validity and reliability of the article they choose.   During the simulation, when the patient develops an unexpected outcome (pulmonary edema), the nursing must modify the protocol for administering IV fluid .

The Safety Competency is threaded throughout the simulation, with incorporation of several of the National Patient Safety Goals, including medication reconciliation, hand off communication, reporting and managing critical lab results and initiation of a rapid response. When discovering an incorrect IV solution, the students must respond by reporting the incident and analyzing potential root causes of the error.

Following the simulation, students participate in a small group project either in the classroom or online, to create a simulated Quality Improvement plan to reduce the incidence of nosocomial urinary tract infections.  Students discuss the process of collecting data, designing a plan for change and evaluating the outcomes.

Submitted Materials

112.Patient-Information-Sheet.docx
112.PCP-orders.docx
112.QSEN-Competencies-table.docx
112.Simulation-Chronology.docx

Additional Materials

Evaluation Description

The following is the result of students’ opinion in response to the following question.

Please describe how this simulation improved your understanding of:  (out of a possible score of 4.0)

 

 

 

 

 

 

 

Patient Centered Care     (3.60)     Patient Safety  (4.0)     Quality Improvement (4.0)   

Teamwork and Collaboration   (4.0)  Evidence Based Practice ( 4.0 )

(The relatively lower score on Patient Centered Care may be related to students’ lack of understanding

of the importance of interacting with the family, especially when the patient is confused or unstable.)

           

____________________________________________________________________________

The following narrative comments were in response to these two questions: 

Please describe the ways in which this simulation was most beneficial to your learning needs. 

How do you feel this simulation could be improved?

  • Fine tuned my critical thinking skills.
  • The real time possibilities were crucial and gave me a broader understanding of sepsis and how it can result in multiple organ dysfunction.
  • The simulation was extremely helpful in learning how to communicate and report to other members of the health care team.  It also helped with learning about delegation.  
  • This scenario was definitely a reinforcement of our learning, and it made you have to really think on your feet because the patient’s health situation can deteriorate very quickly.
  • The case study was accurate so we could recognize changes that can develop so quickly.     
  • I felt I we could have used more time for this simulation