117CHAPTER 12
Medical–Surgical Skill-Based Scenarios
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
At Western Connecticut State University, nursing students complete three levels of medical–surgical courses, each with an increasing breadth and complexity. The first course introduces common medical diagnoses found in chronic illness, long-term care, and restorative subacute care. In the middle medical–surgical course, students are introduced to common diagnoses requiring surgical intervention. In the third course, nursing care and interventions for complex patients, such as those in an intensive care unit (ICU), are studied within the context of the nursing process. Although the theory has been introduced in the foundation course, the second course is the first to include task and skill training related to acute care. Although medical–surgical experience has traditionally been performed on static task trainers, current nursing students have begun using a multipronged approach to task training. In the seminar portion of this middle surgical course, students are given the opportunity to read and review these skills in text and video. Instructors then demonstrate these skills in seminars and allow students to practice on static task trainers and manikins. In evaluations of the courses in the past, students did not seem to make the theory–seminar–clinical connections needed to transfer this knowledge as an integrated whole to their nursing practice. With a multipronged approach to read/study, view, and practice, however, we have found that the embedding of skills within a scenario or a case study that has been transformed into a scenario for use with a human patient simulator (HPS) was beneficial and increased their confidence in performing the skill on actual patients.
In addressing this need within a traditional nursing laboratory, an eight-bed nursing lab without computer or Internet access was renovated into a computer projection and instructor station with four student-use computers with Internet access and four beds with manikins. Videos of skills available online could then be projected and discussed by instructors and teachers, then reaccessed by students during open lab practice. In addition, these skill videos are available for students to view from home computers.
With the purchase of the department of nursing’s first HPS, a section of the lab was designated as the simulation area and, over time, equipment was purchased to enhance the “realness” and usability of the area for simulation. A bed was taken out and replaced with a stretcher to make the HPS more mobile. Several small grants and summer curriculum funds provided both the equipment organization and time for constructing skill-based scenarios to match the existing skill-training modules. In addition, several more grants allowed updates and upgrades to the HPS as the technology became available. Although not used consistently by all faculty teaching the course, the availability of this high-fidelity learning tool gives each instructor the flexibility to teach at different levels of technology to meet student needs.
118B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY AREA
As described previously, the simulation area used for these simulations is embedded in an existing nursing lab. It is an open area, with the HPS residing on a stretcher with an intravenous (IV) machine and pole nearby. In addition, this area even has a treatment cart that has become the simulation cart. In this cart are all the supplies needed for mock up of the scenarios and exclusively for use with the HPS. There are three hospital beds with static manikins and multiple partial task trainer manikins available, such as a pelvic model for urinary catheter insertion. Weekly objectives for the modules direct students and instructors to the equipment needed for each scheduled seminar. Each seminar coincides with a nursing concept being taught in the theory portion of the course. For example, when teaching about pain and comfort concepts in theory/class, students are asked in the seminar to review pain assessments, interventions to enhance a patient’s comfort level, and evaluative criteria by which to judge the success of nursing interventions for the surgical patient. When taught as individual tasks, students learn how to administer shots and give IV pain medications. On the HPS within a scenario, students can interact with the HPS, assess the pain level of the “patient,” decide which medication is appropriate, and measure the effectiveness of the medication. Unlike the static task training, the use of the HPS allows for practice with therapeutic communication and may involve contacting other health care professionals and possibly dealing with a patient with varying levels of pain relief. Safety techniques can be overlaid as well by asking the student to check the five rights of medication administration, put up side rails for the sedated patient, and concurrently assess the effects of the narcotic medications on the patient’s respiratory system.
Five scenarios were created to supplement and complement learning within the seminar portion of the medical–surgical course (Nursing 255). This chapter presents these scenarios. Scenarios have similar objectives and expected outcomes based on the nursing process. Initially written as computerized scenarios with computer programming, each was rewritten with additional summer curriculum funds to better reflect the need of instructors and students for flexibility in implementing the scenarios. Currently, these scenarios are written as “on the fly,” with the instructor running the scenario. Each scenario is simple and task oriented and is written to bring to life the common surgical nursing interventions.
At Western Connecticut State University, lab personnel may not be available, so each simulation must be run by an instructor who is trained in simulation. In some instances, this has resulted in the instructor enthusiastically jumping in with both feet to learn and use simulation. For others, lack of time and training opportunities are most often cited for nonuse of simulation. In addition, the classic task-training method is still a tried-and-true technique of effective teaching for most students, although students are requesting more simulation in this course each year.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
1. Student uses the nursing process to assess and intervene in a common surgical nursing problem.
2. Student develops a basic-level competency in performing a surgical nursing intervention.
D. INTRODUCTION OF SCENARIO
Setting the Scene
Each scenario includes a list of necessary equipment and supplies to mock up the HPS. These supplies are available in the simulation cart.
119Technology Used
High-fidelity HPS
Objectives
1. Student uses the nursing process to identify a surgical nursing problem that needs intervention.
2. Student practices a selected skill within a scenario that integrates maintaining a standard of care, therapeutic communication, safety precautions, and psychosocial care.
In these simulations, The American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008) addresses Essential IX: Baccalaureate Generalist Nursing Practice. The National Council of State Boards of Nursing’s (NCSBN) National Council Licensure Examination for Registered Nurses test plan categories and subcategories (NCSBN, 2016) are addressed in the simulation:
Safe and effective care environment: Management of care (establishing priorities, ethical practice, informed consent, legal rights and responsibilities), Safety and infection control (standard/transmission-based/other precautions/surgical asepsis, safe use of equipment); Health promotion and maintenance: Techniques of physical assessment; Psychosocial integrity: Coping mechanisms, therapeutic communications; Physiological integrity: Basic care and comfort (elimination, nonpharmacological comfort interventions, personal hygiene, rest and sleep), Pharmacological and parenteral therapies (dosage calculation, expected actions/outcomes, medication administration, parenteral/IV therapies, pharmacological pain management), Reduction of risk potential (diagnostic tests, laboratory values, potential for complications of diagnostic tests/treatments/procedures, system specific assessments, therapeutic procedures, vital signs), Physiological adaptation (hemodynamics, illness management).
Description of Participants
In these simple scenarios, the only participants are a small group of three to four nursing students and the HPS. Students seem to prefer this in contrast to be being “put on the spot” one by one. Students can portray a team of nurses using a group process to decide on care of the patients. Staff, or family members played by additional nursing students or faculty.
E. RUNNING OF THE SCENARIO
Each seminar topic area runs either 1 or 2 weeks for 3 hours each. The first hour usually involves discussion and application of the surgical concept being taught in class. The discussion involves taking that concept through the nursing process by integrating previously learned concepts with the new ones and reviewing common nursing interventions needed for the surgical patient in that topic area. During the second hour, the associated tasks are demonstrated, and the remaining time is given to the students for supervised practice. Students arrive ready to practice, having reviewed the skill content, viewed the associated videos, and, in the best case, having already tried to practice at home with their nursing kit.
During the designated practice time, two instructors are available to help with skills. When one is trained in the use of the HPS, that instructor works with the students who are ready to embed the skill into a scenario. The HPS is set up before the beginning of the scenario, and the scenario begins just as if the student were going to walk into a room to care for a patient. Students should identify and introduce themselves, check the identity of the patient, and begin a surgical assessment. During the assessment, a common surgical problem is found and interventions are needed to address the problem. A skill has to be performed to alleviate the problem and evaluation of the intervention follows.
120F. PRESENTATION OF COMPLETED TEMPLATE
The following five medical–surgical skill-based scenarios have been included based on those written for this course. The scenario template is somewhat different from the templates used throughout the book in order to show the original “as written” format that is currently in use at the university.
Nursing 255—Scenario #1
Surgical Pain (Skill: Administration of Pain Medication)
A 63-year-old man was admitted yesterday for a left knee replacement. He is 1 day postop. During the student’s morning assessment, he complains of pain.
Equipment Needed
___IV setup
___Syringe for pain meds
___Stethoscope
___Ace wrap for left knee
Objectives
1. Student will be able to identify source and level of pain.
2. Student will perform appropriate assessments in order to accurately assess pain level.
3. Student will correctly intervene to treat pain.
Settings for the Patient
Heart rate (HR): 108 beats/minute
Oxygen saturation (SpO2): 93%
CO2: 34%
Temperature (T): 37.2°C
Respiratory rate (RR): 20 breaths/minute
Blood pressure (BP): 96/64 mmHg
Vocals: “I’ve never had pain like this before!”
Interventions
___Identify self and patient
___Identify purpose of visit
___Perform surgical assessment
___Check incision
___Check vital signs
___Change BP to 110/80
___Vocals: “I don’t feel well!”
___Assess pain on pain scale
___Check doctor’s orders; select and administer IV pain meds
___Evaluate effectiveness
___Reposition patient with safety precautions for sedation
121Settings
HR: 80 beats/minute
SpO2: 98%
RR: 12 breaths/minute
BP: 120/80 mmHg
Vocals: “I feel better now.” Repeat × 1
Evaluation
Patient states, “I feel better now.” Level of pain is less than 5.
Nursing 255—Scenario #2
Hypovolemia
A 55-year-old woman, 2 days postop abdominal surgery with a large open wound. Wound is draining large amounts of serosanguinous fluid; patient is NPO (nothing by mouth) with a nasogastric tube (NG) tube.
Equipment Needed
___IV setup
___Stethoscope
___Red-soaked abdominal wound dressing with drainage
___NG tube
Objectives
1. Student will recognize need for overall assessment of patient and then recognize the signs and symptoms of hypovolemia.
2. Student will choose correct IV fluid and recognize need to hydrate patient.
3. Student will evaluate interventions appropriately.
Settings for the Patient
HR: 80 beats/minute
SpO2: 98%
T: 37.2°C
BP: 100/80 mmHg
Interventions
___Identify self and patient
___Identify purpose of visit
___Perform surgical assessment
___Check IV
___O2 in place
___Cardiac monitor on
___Check tubes/wound
___Increase HR to 92 beats/minute
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