217CHAPTER 20
High-Risk Infant of a Diabetic Mother: Hypoglycemia
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
University of São Paulo, Brazil, School of Nursing of Ribeirão Preto
The School of Nursing has been interested in active methods of learning, including simulation as a core strategy, which was first implemented in child health in 2010. One of the major challenges of implementing simulation pedagogy into the curriculum was the ratio of students to professors, which was solved by including trained graduate students in the process to assist faculty. These students were enrolled in masters, or doctoral-level courses; registered nurses matriculated in an internship for pedagogy in nursing and researching in teaching, simulation, or child health areas. Thus, we started to have volunteer actors assume diverse roles in the scenarios and more partners to prepare new cases, participate in running the scenarios in lab, and collaboratively conduct debriefing.
We use simulation to develop scenarios that are consistent with the emerging issues in public health; thereby better preparing students to deal with challenges in the context of the Brazilian public health system. Students report that simulated practice has helped them solve similar problems in the clinical setting after training and discussing with peers and facilitators. Therefore, we have found simulation to be an excellent strategy to improve skills in cognitive, procedural, and attitudinal learning—stimulating helps the students to apply the knowledge built into clinical situations and respond appropriately. Subsequent steps include to fully integrate simulation throughout the curriculum, to expand multiprofessional simulation, and to stimulate collaborative communication and practice among physicians, nurses, physiotherapists, nutritionists, and others.
University of British Columbia School of Nursing, Vancouver, BC, Canada
Given the constraints on practice sites for specialty areas, including pediatric and neonatal intensive care, the University of British Columbia (UBC) School of Nursing in Vancouver, BC, Canada, has developed flexible learning options, including clinical practice and learning with the use of simulation, that cover potential high-risk situations that all students need to be aware of and have 218some practical knowledge to provide safe care. In the present curriculum, some students take an advanced maternity course that covers the topic of high-risk newborn care. As they do not have an opportunity to practice in the neonatal intensive care unit (NICU) during the clinical rotation for this course, a scenario like this can provide students with the foundational knowledge and skill set needed to manage similar circumstances in the clinical area.
British Columbia’s Women’s Hospital and Health Centre, Vancouver, BC, Canada
British Columbia’s Women’s Hospital (BCWH) is the provincial referral and academic center for high-risk maternal–fetal medicine and advanced neonatal intensive care. In collaboration with UBC Faculty of Medicine and BC Children’s Hospital, BCWH provides interdisciplinary and discipline-specific teams a variety of simulation learning experiences in our Simulation Center. Simulations are planned both with and without the use of the human patient simulators (HPS) to prepare the teams for a variety of complex care scenarios, for example, those that may require obstetrical, surgical, neonatal, and pediatric specialists at delivery.
BCWH recognizes that patients’ optimal experience of health care services is one in which team communication is consistent, accurate, effective, and supports best outcomes. Communication errors are the most common cause of adverse patient events and have been linked to the differences in which health care providers learn to communicate, the embedded hierarchical power imbalances in the clinical setting, and a culture and approach to mistakes that may not support a “safe” learning environment (M. Leonard, Graham, & Bonacum, 2004; B. Leonard, Shuhaibar, & Chen, 2010). Focusing team learning on interdisciplinary communication and promoting a culture of safety may improve teamwork in both critical and routine care (Haller et al., 2008), and thus positively influence patient care outcomes. Simulation supports our interdisciplinary teams to gain situational awareness, determine critical language, and learn from and with each other through facilitated debriefing with the goal of preventing harm and promoting optimal care standards.
BCWH uses simulation to support standardized learning programs, such as the Neonatal Resuscitation Program (NRP; 2016) and the Advanced Care of the at-Risk Newborn (AcORN; 2016), to test and evaluate new clinical services, and to validate postpartum and neonatal nursing education such as managed postpartum hemorrhage, maternal escalation of care, and neonatal hypoglycemia scenarios. The growing complexity of perinatal health care requires attention to both technical skills and nontechnical skills; team interactions can benefit from intentional rehearsal and reflection (Freeth, Ayida, Berridge, Sadler, & Strachan, 2006). Simulation-based learning requires an organizational commitment that supports a clinician’s time, equipment and space, team training, as well as support for the education of team members who facilitate the simulation debriefs. It has been shown to be an effective learning strategy in obstetrical emergency knowledge translation for midwives and obstetricians (Crofts et al., 2007) and in nursing education (Cant & Cooper, 2010). There is a limited understanding of the full impact of interdisciplinary education (Malt, 2015) on practice outcomes in simulation-based nursing education (Cant & Cooper, 2010) because of the heterogeneity of the various programs and outcome measures.
BCWH draws on a crisis resource management approach (Murray & Foster, 2000) in which trained facilitators are believed to be a key component to effective simulation learning. Facilitator development focuses on the development of knowledge and skills in order to provide interdisciplinary teams with feedback and an opportunity to reflect in a safe and supportive learning environment (Murray & Foster, 2000). A scripted debrief supports the facilitator in managing the complexity the debriefing by ensuring a standardized and practical approach (Eppich & Cheng, 2015), which has been shown to improve facilitator performance (Cheng et al., 2013).
219B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The UBC School of Nursing
As described in Chapter 18, the UBC SON has several rooms set up for simulation. This simulation scenario was initially developed at Fairfield University School of Nursing and used from 2008 to 2012 with third- and fourth-year baccalaureate students during their obstetrical/maternal–child rotation. A room set up as a neonatal intensive care unit (NICU) with a high-fidelity infant–patient simulator (HFIPS—Laerdal’s SimBaby®) under a warmer, with oxygen/suction wall mounts, and vital signs displayed on the monitor. Four students participated in the scenario while their classmates viewed live-streaming video in the classroom next door. The faculty communicated with students from the control room as needed. Students prepared for the simulation by completing a number of readings and videos available on their learning management system.
British Columbia Women’s Hospital and Health Center
The Simulation Center at BCWH and Health Centre (BCWHHC) includes innovative educational space with more than 20 rooms for running team-based simulation scenarios, clinical skills rooms, and classrooms. The fully equipped simulation environments are designed to closely resemble the current clinical care environment in an effort to assist staff to “suspend” disbelief in order to promote the most “true-to-life” learning experiences. There are nine high-fidelity HPSs, including premature and term infants and pregnant mothers. In addition to clinical practice, our Perinatal Research Imaging Center provides researchers, clinicians, and educators access to a computerized ultrasound pregnant-woman simulator that is programmed to reveal fetal anomalies and normal findings in pregnancy. In addition to high-fidelity, facilitated simulation scenarios, BCWHHC engages learners in a variety of related learning activities that include workshops, in situ simulations, or “mock codes.”
University of Sao Paulo
The Simulation Center of Nursing Practice includes five rooms prepared for running hospital scenarios and a simulated house for running home visits in the context of primary care. One of the simulation rooms is prepared for high-fidelity scenarios and includes videoconference capabilities and a control room. There are three adult high-fidelity and several medium-fidelity simulators, including adults, a high-fidelity obstetric simulator, and infants (including preterm babies) or children. Simulation has been used as an effective strategy for teaching and learning in a variety of disciplines within nursing at this university. This method of teaching has created spaces to focus on cognitive, attitudinal, and procedural skills and to discuss clinical reasoning in health care situations. In addition to their focus on nursing practice, the labs have been used to implement multiprofessional simulation and team training as well.
C. SPECIFIC OBJECTIVES of SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Learning Objectives
This scenario prepares students for newborn assessment, especially related to high-risk situations like the development of hypoglycemia. It is expected that students identify the condition early so as to avoid invasive interventions and respiratory distress, using nonpharmacological methods to solve the clinical problem, if possible.
220Research shows a 60% increased risk of excessive fetal weight gain (large-for-gestational age [LGA]) and a fourfold increased risk of neonatal hypoglycemia among the infants of diabetic women, including women with gestational diabetes mellitus (GDM; Maayan-Metzger, Lubin, & Kuint, 2009). This increase in number of large newborns in this population is explained by maternal hyperglycemia leading to fetal hyperinsulinemia, increased glucose usage, and adipocyte accumulation in the fetus (Amaral, Silva, Ferreira, Silva, & Bertini, 2015). The reasons that infants of diabetic mothers (IDMs) are admitted to the NICU include neonatal hypoglycemia, macrosomia, respiratory distress syndrome, electrolyte imbalance, and trauma (Amaral et al., 2015). In addition, hypoglycemia can cause and aggravate tachypnea, leading to respiratory distress (Hermansen & Mahajan, 2015).
Learning objectives for this simulation include maintenance of postnatal glucose homeostasis in IDMs (Adamkin, 2011), with prioritization of minimizing mother–infant separation and promoting successful breastfeeding. Adopting a standardized approach that identifies infants at risk of low blood sugar, coupled with early and structured breastfeeding approaches, has been shown to be an effective strategy to manage hypoglycemia and reduce admissions to the NICU (Csont, Groth, Hopkins, & Guillet, 2014). However, the exact blood glucose (BG) levels in infants that lead to central nervous system (CNS) damage and long-term outcomes (Straussman & Levitsky, 2010) remains unknown. Therefore, it is necessary to educate students to properly assess, monitor, and respond to both asymptomatic and symptomatic infants based on up-to-date evidence-based practices (Adamkin, 2011; Thornton et al., 2015).
Research indicates that mothers cite percieved inadequate milk supply as one of the main reasons for stopping breastfeeding (Hill & Aldag, 2007; Li, Fein, Chen, & Grummer-Strawn, 2008). What message do we send to students working with mothers if breastfeeding is not the first intervention in the asymptomatic at-risk infant, especially when we recognize that health information related to breastfeeding when delivered by physicians and nurses increases the intiation of breastfeeding (Dyson, McCormick, & Renfrew, 2005). The use of simulation to support breastfeeding for mothers and their newborns at risk of hypoglycemia could support long-term breastfeeding outcomes and the education of the next generation of health professionals on the importance of breastfeeding for mother and infant, as a possible alternative to pharmacological and invasive health procedures in asymptomatic IDMs.
For this reason, there is an option with this scenario to take more than one approach—as an unfolding case or two separate scenarios. In the first version, there is an asymptomatic IDM, who is at risk of developing hypoglycemia. The student can act with early feeds (especially within the first hour of life), monitor the infant’s vital signs, and encourage frequent feeding, informing the mother and educating her as care is provided. This monitoring would occur for the first hour and also encourage skin-to-skin contact and rooming in, according to Baby-Friendly Initiative (BFI) guidelines (Breast Feeding Committee for Canada, 2012). As the case unfolds or as a second scenario, the student arrives on the scene with a symptomatic infant who is cold, which would require feeding the infant (use donor breast milk if unable to breastfeed), warming the infant, and finally, if these actions do not relieve the symptoms, interventions, such as dextrose infusion and oxygen support, would be provided. In both endpoints, the students have the opportunity to learn more about newborn assessment, clinical reasoning in hypoglycemia, therapeutic communication and education to the mother, and critical thinking regarding association between gestational history and symptoms to assess, given the infant’s clinical status. A “stop and freeze” approach could be used, especially if the participants are team practitioners in situ in the clinical setting. If actions are significantly different from the suggested care pathway, the facilitator could use questions to guide the team back.
This scenario provides an opportunity to reinforce the importance of the mother–infant dyad, breastfeeding, and skin-to-skin contact; to support the health outcomes of mother and infant; and to illustrate the relevance of early identification of signs and symptoms reinforcing critical thinking and clinical reasoning/decision making in everyday practice.
221Student Learning Activities
• Perform an accurate newborn assessment.
• Identify the risk factors for the infant of a diabetic mother.
• Assess patient’s physiologic changes for risks of hypoglycemia and respond to findings.
• Perform BG monitoring and prepare to treat the patient’s condition.
• Communicate with mother regarding the newborn’s status and with other team members to develop a plan of care, using an integrated approach with the parents.
D. INTRODUCTION OF SCENARIO
Setting the Scene
Identification and Initial Response
The mother and infant are in the immediate postdelivery area, either a delivery suite or single room maternity care. The mother is a 35-year-old White woman with insulin-dependent gestational diabetes who had a vacuum-assisted delivery 1 hour ago after a long, difficult labor. Shift handover has occurred. The nurse enters the room and the mother is supported to breastfeed the asymptomatic infant and given information about frequent feeding and need for BG monitoring in the first 12 hours of life. She is told that some IDMs will need an intravenous (IV) line in addition to feeding in the first 12 hours (Adamkin, 2011; Aziz et al., 2004, reaffirmed 2015).
Decompensation
The infant’s blood sugar is low at 2 hours and the infant is now exhibiting symptoms that require the newborn to be admitted into the tertiary-level NICU.
Technology Used
Laerdal SimBaby® is in the room with mother initially and may transition to a pale infant under a radiant warmer. Mother’s role is acted by faculty, another student, or standardized patient.
Objectives
1. Describe the assessment of the newborn who is at risk for postdelivery complications related to maternal history gestational diabetes.
2. Incorporate preventive measures in the care of the newborn delivered to a gestational diabetic mother, specifically at risk for hypoglycemia.
3. Obtain a maternal and delivery history to determine factors that may have put the newborn at risk for hypoglycemia and other complications.
4. Perform an accurate newborn assessment.
5. Examine the newborn for signs of hypoglycemia and other complications.
6. Perform interventions according to newborn health status using critical thinking and clinical reasoning.
7. Educate parents regarding the newborn’s status and plan of care.
Description of Participants
Participants’ roles: One night-shift nurse reporting to the day-shift nurse; 1 day-shift nurse, getting a report and examining the patient, 1 nurse assisting the examining nurse as a licensed practical nurse (LPN) or health care aide (HCA)—all of whom work with the registered nurse to complete tasks; one family member (mother of the patient), the mother, should ask a lot of questions and demonstrate interest and genuine emotional concern for the welfare of the baby during the simulation; and one observer documents the communication, body language, and interventions.
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