307CHAPTER 26
Communication With an Elderly Client
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Simulation and guided reflection are used throughout the curriculum at Three Rivers Community College (TRCC). Role-playing in the classroom and nursing laboratory helps students make meaning of clinical content for proficiency in examinations and clinical practice. Students learn to collect cues, process information, consider alternative actions, and implement and evaluate outcomes. Reflective writing through carefully crafted prompts and directed questions strengthens the practice (Rafeldt et al., 2014). Faculty strive to remove obstacles of fear and inflexibility so that critical thinking becomes clinical reasoning. It is easy to carry out rote procedures rather than assessing and “thinking out” what to do in a situation. When students learn how to use broad concepts, they can perform procedures long after graduation (Nosich, 2008). Currently, standardized patients and static and high-fidelity human patient simulators (HPSs) are the “patients” in actual and video nursing simulation exercises.
Under the leadership of previous nursing directors, simulation has grown. Edith Ouellet, RN, MSN, now leads the work in which all faculty have been trained in debriefing, scenario, and equipment use. Two faculty members, Suzanne Turner, RN, MSN, and Joan Graham, RN, MSN, participated in a National League for Nursing simulation grant. Joan is completing her dissertation work in student simulation outcomes. Students complete dedicated simulation days with gerontologic, postpartum, and medical–surgical patients, reporting increased confidence and ability to practice in clinical. A multifaceted approach in the creation of laboratory classwork, independent study material, clinical experiences, and presentation of theory supports increased retention rates without depleting resources.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
Some of the first successful simulation experiences included students who demonstrated clinical reasoning ability while caring for clients with orthopedic conditions. After completing the learning unit, students signed up in groups of three to four to care for “Mr. Bili Rubin,” who had a right total hip replacement. He had one of eight complications; the students had to identify the complication correctly and then implement appropriate care. Because there were eight possible complications, students could not listen to “the grapevine” to prepare their actual care. Critical thinking skills within the moment in the discipline of nursing were required. Students rated this 308experience as an extremely positive activity. Now simulation activities are used in lab and active learning within the classrooms.
Another successful simulation experience included students who were returning or transferring into the program at varying levels. Simulation exercises were constructed to include outcomes from previous program levels. Students completed the simulations with laboratory staff, and were debriefed and evaluated by faculty to determine course placements. Simulation was not the only criterion for placement level.
Simulation and reflection in nursing education provide a foundation for knowledge, skill performance, collaboration, clinical reasoning, and development of self-confidence. Dewey (1944), an educational reformer, suggested that activity with purposeful reflection supports learning as a “moving force” toward positive change. In this simulation scenario, communication with an elderly client, students have the opportunity to reinforce previously learned content and explore principles used in communication with the older adult. Vygotsky (1978) defined scaffolding as an instruction technique whereby scaffolds facilitate a student’s ability to build on previous knowledge and internalize new information. Reflection and scaffolding approaches enrich the following scenario.
C. SPECIFIC OBJECTIVES OF SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Nurses assess, interview, examine, and gather data to develop plans and implement and evaluate care. Nurses of the 21st century use critical thinking when communicating with elders—the most rapidly expanding group of the population. Development of expert skills in communication facilitates efficient client-centered care, resolution of illness, and promotion of health. This scenario focuses on communication with an elderly client in the hospital. A generalist nurse provides direct and indirect care.
The scenario can be used in an introduction-to-nursing or gerontologic nursing course or as a tutoring tool for students who desire reinforcement of learning to support clinical practice. It may be used as an individual or group exercise. This scenario builds on previous learning, using the principles of scaffolding while focusing on achievement of new outcomes. Standard nursing behaviors when interacting with a client are expected in each scenario; new outcomes are added. The scenario can be enhanced in advanced nursing courses when the client becomes deaf, aphasic, or visually impaired, or is diagnosed with dementia. The scenario can be extended to develop nursing diagnoses and plans of care.
D. INTRODUCTION OF SCENARIO
Students enter a “nursing lab.” Evaluators can predetermine whether a uniform or any other equipment from home is required to care for the client. At the bedside, the student or students will find Mrs. Anderson, as described in the scenario description that follows. Choices are provided for high-fidelity or live role-play scenarios. Consider 20 students entering the lab: Five students could be assigned to act as the “active scenario participants,” while the other 15 students could be assigned to be observers using the evaluative checklists. The student observers could watch the scenario within the same room or in an observation classroom, depending on the constructed environment. Principles of teamwork can be fostered. Multiple simulations are required throughout a semester, so roles can be rotated. The simulations can be recorded and used as tools in active learning classrooms. For specifics regarding setting the scene, technology used, and description of participants with their roles and scripts, see Exhibit 26.1.
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E. RUNNING OF THE SCENARIO
Frames within high-fidelity simulation can be used to assist progression of the simulation. Student actions can drive progression toward new frames, or check boxes completed by the controller can be used. The controller would identify “done,” “not done,” or “done with prompt” within the program. The use of evaluative checklists by multiple observers encourages assessment, reflection, and professional growth for all participating in the process. Complexity in feedback and active learning can be embraced by using evaluative checklists for primary objectives as well as for standard nursing behaviors when interacting with a client.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Communication With an Elderly Client
Scenario Level and Focus Area
First-year nursing course or gerontology course
Scenario Description
An 85-year-old woman is admitted to a medical–surgical unit with a suspected urinary tract infection. She is a widow of 3 years, was married for 62 years, has three adult children, and lives in her own home 312with an unmarried son. She has a history of two incidents of congestive heart failure (CHF) 4 years ago, a total hysterectomy 22 years ago, a left total knee replacement (LTK) 15 years ago, and situational depression when her husband passed away. The “nurse” or participant in this scenario will practice principles of communication with the elderly woman.
The woman presents with the following vital signs (VS): blood pressure (BP): 140/88 mmHg, pulse (P): 90 beats/minute, respiratory rate (RR): 22 breaths/minute, and temperature (T): 99°F. She complains of falling into her chair at home, dribbling when trying to get to the bathroom, fatigue, and not being hungry for 1 week. Her physician evaluated her urine (urinalysis [UA]) and complete blood count (CBC) with differential and recommended admission to the hospital for further evaluation and treatment. She is 5 feet, 5 inches tall and weighs 160 pounds.
The scenario starts with the “nurse” entering the room.
Scenario Objectives
The National Council of State Boards of Nursing National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan categories and subcategories (NCSBN, 2015) included in this scenario are as follows:
Safe and effective care environment: Management of care (client rights), Safety and infection control (safe use of equipment); Health promotion and maintenance: Aging process; Psychosocial integrity: Therapeutic communications; Physiological integrity: Basic care and comfort (elimination, personal hygiene), Pharmacological and parenteral therapies (dosage calculation, medication administration, parenteral/intravenous therapies), Reduction of risk potential (potential for complications from surgical procedures and health alterations, vital signs), Physiological adaptation (illness management).
For this scenario, the American Association of Colleges of Nursing’s (AACN; 2008) Essentials of Baccalaureate Education for Professional Nursing Practice items addressed include:
Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety
Essential IV: Information Management and Application of Patient Care Technology
Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes
Essential VIII: Professionalism and Professional Values
Learning Method
Active learning is used within the cognitive, psychomotor, and affective domains through high-fidelity simulator, standardized patient, role-play, or case study.
Primary Learning Outcomes
During and after completing the simulation experience, the student will be able to do the following:
1. Identify intrinsic and extrinsic factors that affect communication with an elderly client
2. Identify, perform, and discuss strategies that can increase communication with an elderly client
3. Identify client conditions that can contribute to impaired communication
4. Perform and discuss therapeutic communication skills in phases of the nurse–client relationship
5. Discuss how attitudes affect behavior and propose changes that could be made in future interactions with elderly clients.
Student Preparation for the Simulation
Required Readings and Websites to Explore
Required readings relate to communication and the elderly in your curriculum. Chapters from a fundamentals of nursing or gerontology text or a journal article would be listed.
313Websites: John A. Hartford Foundation (2016),
Refer to med–surg text.
Urinary tract infection (University of Maryland, 2012),
umm.edu/health/medical/reports/articles/urinary-tract-infection
Materials to Prepare
Completed medication sheet/card: Information sheet/card for ciprofloxin 200 mg (IV) every 12 hours, nystatin (Mycostatin) 400,000 U orally once a day, furosemide (Lasix) 60 mg orally once a day, potassium supplement (K-Dur) 40 mEqs orally once a day, digoxin (Lanoxin) 0.25 mg orally once a day.
Review of standard nursing behaviors when interacting with a client: Verification of client orders and plan of care, identification of client, introduction of self and explanation of reason there, asepsis as appropriate, preparation and gathering of equipment/supplies needed, maintenance of privacy and Health Insurance Portability and Accountability Act (HIPAA) standards, appropriate ergonomic/body mechanics when assessing or performing care, maintenance of a safe environment (bed position, call bell, and equipment placement), and documentation. Use of the evaluative criteria for standard nursing behaviors when interacting with a client (as shown later in this chapter) succinctly identifies the behaviors.
Completion of survey: Beliefs about the elderly—answer the following statement with a yes or no. Bring this to the simulation. Highlights will be discussed in debriefing.
1. Most old people are sick.
2. Most old people are in nursing homes.
3. Most old people are retired.
4. Most old people would like to live in a warm climate.
5. Most old people live in poverty.
6. Most old people cannot learn as easily as when they were young.
7. Most old people are hard of hearing.
8. Most old people have no interest in sex.
9. Most old people are more religious than young people.
Setting the Scene
Equipment Needed
___Female wig on head
___Peripheral IV in left arm (nondominant)—IV catheter, tape, ordered IV fluid on infusion pump
___Female genitalia
___Sequential compression devices (SCDs), bilaterally on lower extremities
___Equipment to measure VS (thermometer, stethoscope, sphygmomanometer)
___Hospital gown
___ID bracelet with name, age, physician, medical record number, and allergies
___Collection container for routine UA and culture and sensitivity test
___Curtain or ability to create private assessment area
___Oxygen available via nasal cannula tubing
___Medication administration tools: drug handbook or personal digital assistant with medication program, measuring cup, intravenous piggyback (IVPB) tubing, simulated ordered medications, water pitcher with glass
___Client medical record that includes orders, history and physical, medication administration record, input and output (I&O) record, and progress documentation forms
___Telephone (for access to admitting nurse and physician)
314Participants Needed
1. Transfer assistant (if needed)
2. Lab member (if role-play used)
3. Voice of admitting nurse (can be simulation controller, other student, or preprogrammed handler)
4. Voice of physician (can be simulation controller, other student, or preprogrammed handler)
5. Simulation controller (if high-fidelity HPS is used)
6. Mrs. Anderson (other prepped student nurse)
7. Observers to participate in debriefing (if used as a group exercise)
Scenario Implementation
Expected run time is 15 to 20 minutes. The “nurse” is given a report from the admitting nurse via the telephone as the client is transported to the unit via stretcher. The medical record is brought to the unit with the client. Another student can assist with transfer, or this step can be eliminated by having the client in the bed to begin the scenario.
The report given is as follows: Mrs. Anderson, age 85 years. VS: BP: 140/88 mmHg, P: 90 beats/minute, RR: 22 breaths/minute, T: 99°F. She complained of falling into her chair at home, dribbling when trying to get to the bathroom, being tired, and not being hungry for 1 week. Dr. Smith evaluated a UA and complete blood count (CBC) with differential and recommended admission to rule out sepsis and urinary tract infection. Mrs. Anderson also has a fungal infection within her mouth. She is 5 feet, 5 inches tall and weighs 160 pounds.
Mrs. Anderson is a widow of 3 years, was married for 62 years, has three adult children, and lives in her own home with an unmarried son. She has a history of two incidents of CHF 4 years ago, a hysterectomy 22 years ago, an LTK replacement 15 years ago, and situational depression when her husband passed away.
Physician/provider orders include the following:
Admit to 1 South
Activity level: Bed rest today
Diet: Low NA (sodium), low cholesterol
D5 1/2 NS at 100 mL per hour
UA and urine culture and sensitivity (C/S)
Ciprofloxin 200 mg IVPB stat
SCDs
VS q 4 hr
Oxygen 2 L via nasal cannula titrated to maintain and PaO2 of 92% prn
Lasix 40 mg PO qd
KDur tab 40 mEqs PO qd
Digoxin 0.25 mg PO qd
Mycostatin 400,000 U qid swish 1/2 of dose in each side of mouth; hold
Tylenol 650 mg PO q 4 h prn for temperature higher than 101°F
The student begins the scenario by transferring Mrs. Anderson from the stretcher to the bed and assessing her. The student will be expected to focus on primary learning outcomes; however, basic principles of safety and infection control as nurse–client behaviors will also be expected.
Three frames are constructed within a high-simulation program. Frame 1 lasts 5 minutes, frame 2 lasts 10 minutes, and frame 3 occurs only if interventions are not done within frames 1 and 2. A microphone can be used during the exercise, or voice handlers can be built into the scenario. Exhibit 26.1 shows the scenario for a high-simulation program (such as SimMan by Laerdal) but can be adapted for role-play.
The simulation controller concludes the scenario and allows the students (and observers of group exercise) to reflect on behaviors within the scenario for 5 to 10 minutes. A 12-item “communication with the elderly” true–false quiz is given and will be self-evaluated by the student(s) in the debriefing.
315Evaluative Criteria for Standard Nursing Behaviors When Interacting With a Client
Students will be given feedback based on the degree to which they, in the appropriate order and with or without coaching, perform the actions as listed in Exhibit 26.2.
Evaluative Criteria for Communication With an Elderly Client
Students will be given feedback based on the degree to which they, in the appropriate order and with or without coaching, perform the actions outlined in Exhibit 26.3.
G. DEBRIEFING GUIDELINES
The estimated session time is 30 minutes for groups. A general discussion ensues related to the basic skills performed in this scenario. The evaluative criteria in Exhibits 26.2 and 26.3 are used as the foundation. Questions related to technique are encouraged. If videotape is available, the scenario can be reviewed. This is conducive to participation by all (either by the group; in a circle; or direct, one-to-one seating for an individual and facilitator). The discussion leader is the simulation controller or faculty member. A projector, screen, overhead projector, or computer is used.
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Completed surveys related to beliefs about the elderly are reviewed. This can be done in a number of ways: via individual presentation, surveys handed in before the scenario and tabulated as group data, or automated response anonymous clickers used during the actual discussion. Inferences are solicited about beliefs, assumptions, and resulting behaviors. The discussion leader gives examples of how a belief that “older people are hard of hearing” may lead to shouting or the belief that “older people have no interest in sex” may lead to a disregard in assessment questions. The student or group is guided to focus on positive themes and facts of today’s elderly. Stories may be shared as appropriate to objectives and time. The criteria detailed in Exhibit 26.3 are reinforced.
Finally, a review of the 12-item “communication with the elderly” quiz (similar to the survey review style used earlier) is done. Implicit bias is identified and ageism is discussed.
1. Shouting is required when speaking with older adults. (F)
2. Elderly people hear high-pitch tones easily. (F)
3. Background noise will enhance hearing ability. (F)
4. Light will promote communication. (T)
5. Fatigue, pain, and physical discomfort will influence communication. (T)
6. Hearing aids may need to be turned on, adjusted, or have the battery changed if communication is impaired. (T)
7. Standing off to the side in a shadow facilitates communication. (F)
8. The three-item recall screening asks the assessor to “tell the client to remember three items: apple, table, and dime. Then, a distracting activity is done, and 2 to 3 minutes later, the assessor asks the client what the three items were.” (T)
9. Active listening involves reflecting on what a patient has said while listening. (T)
10. Consonants such as ch, sw, or th are not heard well as one ages. (T)
31711. Attitudes and beliefs influence interactions with elders. (T)
12. Asking elderly clients to bring in their medications (prescription and nonprescription)—the “drug bag”—facilitates accurate assessment of medication intake. (T)
The discussion leader facilitates a review of the answers. Rationales are discussed, and participants are encouraged to share what they would continue to do and what they would do differently in future interactions with elderly clients.
Reinforce Standard Nursing Behaviors When Interacting With a Client
These standard behaviors are verification of client orders and plan of care, identification of client, introduction of self and explanation of reason there, asepsis as appropriate, preparation and gathering of equipment/supplies needed, maintenance of privacy and HIPAA standards, appropriate ergonomic/body mechanics used when assessing or performing care, maintenance of a safe environment (bed position, call bell, and equipment placement), documentation.
H. SUGGESTIONS/KEY FEATURES TO REPLICATE OR IMPROVE
Continue to reinforce learning through constructivist methods such as scaffolding. Use of standard nursing behaviors reinforces and develops confidence in student ability. Refer to Exhibit 26.2.
I. RECOMMENDATIONS FOR FURTHER USE
Complexity can increase in this scenario. Students can develop diagnoses and nursing care plans, and peer evaluation can be done in relation to outcome attainment and use of the nursing process.
In senior-level courses this scenario can be adapted for use with clients who have neurologic conditions or any type of progressive dementia. Clients with psychiatric conditions may also use this scenario with specific adaptations.
J. HOW SIMULATION-BASED PEDAGOGY HAS CONTRIBUTED TO IMPROVED STUDENT OUTCOMES
Active learning can promote greater understanding of concepts (Nosich, 2008), higher retention of information (Stice, 1987), and the opportunity to apply knowledge gained through action (Florea, Rafeldt, & Youngblood, 2011). Constructivist learning theory supports simulation in both high and low fidelity. Although debriefing is critical to facilitate desired outcomes, educators must remember that incorporation of surveys, discussion, and the NCLEX style questions will also contribute to efficient internalization of content and resulting practice as a student nurse and future RN.
K. EXPERT RECOMMENDATIONS AND WORDS OF WISDOM
Simulation experiences guide student learning. Particularly important is the creation of a safe environment where students can express their thoughts. All questions are encouraged by facilitators 318for development and adoption of the RN role. The way in which the facilitator gives feedback fosters students’ ability to use medical words, remove their own biases and make connections in new situations. With this experience, some students realize their need to learn more about aging, alternate presentations of disorders, and biases they may have. When those students go into a community senior center they listen to the stories of an older adult with curiosity and joy. Nursing practice becomes holistic, professional, safe, and competent.
L. EVALUATION OF BEST PRACTICE STANDARDS AND USE OF CREDENTIALED SIMULATION FACULTY
The International Nursing Association for Clinical Simulation and Learning (INACSL, 2013/2016) has guided simulation learning and curriculum development at TRCC. Standard II Professional Integrity (of participants) and Standard V Facilitation drove establishment of guidelines for students, participants, and faculty. All educators participate in professional development through company and nurse educator conferences. It has been helpful to have onsight Laerdal workshops for all. Standard III Outcomes and Objectives supported our continued focus on measured experience and curricular outcomes. We have a strong history of curricular development within our college and as a member of the Connecticut Community College Nursing Program. Standard VI Debriefing and Standard VII Participant Evaluation were validated through the clear statements. TRCC developed a foundation in reflective practice through the Connecticut Distance Learning Consortium (CTDLC) and National ePortfolio/Catalyst for Learning grants with Bret Eynon and LaGuardia Community College, New York City, New York.
Areas in which we are growing through the leadership of Edith Ouellet, Joan Graham, and champion super-users from each course are: terminology, Standard I, faculty simulation credentialing, Standard VII, overall assessment and evaluation beyond a specific experience, Standard VIII, interprofessional simulation experiences, and Standard IX, simulation design. Quality review continues through the lens of program outcomes, graduate and employer surveys, and professional organizations such as INACSL.
REFERENCES
Dewey, J. (1944). Democracy and education. New York, NY: Free Press.
International Nursing Association for Clinical Simulation and Learning. (2013, updated 2016). INACSL standards of best practice: Simulation. Retrieved from https://www.inacsl.org/i4a/pages/index.cfm?pageID=3407
John A. Hartford Foundation. (2016). Resources for aging. Retrieved from http://www.johnahartford.org/grants-strategy/current-strategies/age-friendly-hospitals
National Council of State Boards of Nursing. (2015). NCLEX-RN examination: Test plan for the National Council Licensure Examination for Registered Nurses. Retrieved from https://www.ncsbn.org/RN_Test_Plan_2016_Web.pdf
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