95CHAPTER 10
Tune Into Simulation Through Physical Examination Using Your Five Senses
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
During the past several years, simulation pedagogy has taken off in leaps and bounds. The breadth of simulation design and implementation has become woven into the fabric of the majority of nursing education in the United States and beyond. As faculty members who teach in both graduate and undergraduate courses, we find that simulation can be challenging to both the novice and seasoned educator. Whether you are a novice or experienced educator remember that Rome was not built in a day and it is okay to move slowly through the simulation experience. Just as you can feel overwhelmed with changes in technology and have a hard time keeping abreast of all the latest and greatest “best practice” methodology, be aware that students also need time, patience, and practice to build their foundational skills. This particular chapter focuses on the use of simulation in the fundamental physical assessment course. We have found simulation to be quite useful in this setting as students can be quite hesitant to touch their student partners. We have had the opportunity to educate many students regarding how essential it is for them to learn, develop, and eventually master the skills of inspection, palpation, percussion, and auscultation. We try to instill in them a vivid awareness of the need to create an assessment environment that allows the nurse to maximize the accuracy of this assessment process while also instilling patient confidence in that process. As such, we emphasize the need to ensure that each student follows a structured, well-organized, and comprehensive preparation and execution process before and during each assessment activity. We explain to the students that this requirement is just as important when they use simulation technology as when dealing with real patients in order to establish a routine they will consistently use to ensure that each step of this process is consistently followed. The use of simulation technology is especially useful in creating the equivalent of “muscle memory” for the students because of the ability to do frequent and repetitive exercises using this technology. It is especially useful in assisting students to learn, develop, and mature their assessment skills.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The nursing department program offerings include a BS, RN to BS, and MS degree. The university nursing laboratories are each tailored for specific patient environments, which are equipped with high-fidelity simulators. Each simulation area is equipped with scenario-appropriate 96equipment and SMART Board technology. Items, such as hospital beds, stretchers, fluid infusion devices, fluid drainage systems, monitoring systems, crash carts, ventilators, medication dispensing system, and bedside tables, are available for creating a tailored scenario. Properties, such as clothing, eyeglasses, dentures, wigs, splints, wounds, compression boots, and miscellaneous other items, are readily available to allow the instructor to create a wide range of different patient dispositions. A video-recording device is available to capture student performance and is subsequently used to debrief students regarding their performance.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The overall objective of this simulation scenario is to define parameters of physical assessment for faculty in the context of simulation technology and create an awareness of the need to develop and nurture these skills through the use of simulation technology. Traditionally, physical assessment has been taught in the classroom through a variety of techniques, including lectures, videos, faculty demonstrations, student partnering, and such, and generally it gets concluded with the students demonstrating accurate assessment skills on completion of each module. In an era of evolving technology, nursing graduates must be introduced to and equipped to manage the complexities of the technologic environment they encounter. During each physical assessment module, simulation technology can be a valuable educational tool for both faculty and students. Although we may rely on technology to provide health care personnel with useful patient information (such as heart rhythm using an EKG reading), it is important for students to recognize that although the EKG looks perfect in rhythm, rate, form, and amplitude, the patient could be dead. Students are taught that a diagnosis of “pulseless electrical activity,” or PEA, means that the patient is clinically dead. It must be stressed to students that technology, although useful, is limited and is only one of many tools that should be accessed from their assessment tool kit. In fact, it is essential that students first develop and mature their personal assessment skills of inspection, palpation, percussion, and auscultation and then use technology to validate and refine the effectiveness of these skills.
To teach the art of assessment skills (inspection, palpation, percussion, and auscultation), faculty can direct students to think of themselves as “instruments” to be “tuned” into the process of assessment techniques. Early in the assessment process students are instructed to palpate a radial pulse and count the pulsations for 60 seconds. Depending on the amount of pressure the student uses he or she may report that he or she cannot feel anything. As musicians learn to tune their instruments, so, too, must student nurses learn to tune into physical assessment and quickly adjust their approach, or in this case depress more firmly on the artery.
A second objective of this simulation scenario is to provide a generic teaching template for each physical assessment module that can be tailored by the individual faculty member and includes structured, supportive, and evaluative elements. Learning modules are developed to be prescriptive in nature and are designed with the intent that the student master simple components of the assessment process in a step-by-step sequence before progressing to more complex assessment techniques. Students who successfully complete individual learning modules advance, whereas those who are unsuccessful are offered additional learning opportunities or experiences and remediation activities within an agreeable time frame. Before initiation of the module, students are provided with an evaluative/assessment rubric. On mastery of the module, the student may receive a “satisfactory” or “pass” as a part of a credentialing process. If the student is unsuccessful and unable to perform the assessment, the instructor advises the student in the following manner:
1. Have the student self-evaluate his or her performance using the corresponding skill performance checklist.
2. Instructor provides feedback on student evaluation to identify areas of strength and areas requiring improvement.
3. Instructor and student develop an individualized remedial plan, to include the following:
a. A review of specific scenario requirements and expectations
b. Student practicing specific skills in a nonrisk environment
c. Student reperforms the required assessment skills for validation by the instructor
The timing of each module must be carefully planned and flow from the course content. In addition, the student who attends to the readings and corresponding available media (video demonstrations, etc.) tends to move quickly and efficiently through the learning process. Students should be counseled, however, as to the need to review and reflect on their performance regardless of how rapidly they appear to be progressing.
A formalized reflection process creates an opportunity for students to identify and articulate positive behaviors, areas for improvement, and methods to enhance or address these areas. Weekly reflections, however brief, serve to demonstrate to the student his or her unique development and provide positive reinforcement of the progress being made. Having students identify what they do that contributes to improving their own performance and then having these students share, anonymously, this information with their fellow students can foster a positive communal learning experience.
D. INTRODUCTION OF SCENARIO
Setting the Scene
The scene takes place in a long-term care nursing facility. The patient is an 84-year-old female with a past medical history of coronary artery disease, hypertension, and mild dementia. The patient’s chief complaint is dizziness that began after waking this morning. The student nurse is assigned to conduct a general health assessment followed by a physical examination. On completion of the assessments, the student nurse prioritizes an individualized plan of care.
Technology Used
The patient is a high-fidelity human patient simulator (HPS). She is dressed in her nightgown, lying on her hospital bed, covered to her chest with a sheet, and in a semiprivate room with a female roommate of similar age in an accompanying bed. There is a wheelchair next to her bed, an overbed table, a telephone, a call bell, and a water pitcher with a plastic cup. The patient’s head of bed is elevated 15°, only one side rail is raised, the bed is in the lowest position with locks secured, and the patient is sleeping on student arrival. The privacy curtain between the beds is open and the lights are dimmed. The person operating the simulator is allowed to answer questions and speak for the patient.
The student is provided with an opportunity to obtain all necessary equipment and forms before entering the patient’s room. Equipment needed includes the following: simulator, video recording device, assessment tools such as alcohol hand sanitizer, clean gloves, blood pressure cuff, stethoscope, medical record, and so forth.
Objectives
1. Conduct a general survey of the patient
2. Obtain a health history and complete a physical examination
Description of Participants
Student nurse in long-term care rotation: The student should be prepared in patient assessment techniques, including inspection, palpation, percussion, and auscultation. The student should be knowledgeable about the equipment and forms necessary to accomplish this task. The student should obtain the necessary tools and forms from the instructor before entering the patient’s room.
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