Procedural Sedation Simulation
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This presentation is an overview of a Clinical Simulation I created for Procedural Sedation for my graduate student clinical.
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Procedural Sedation Simulation
- 1. S Procedural Sedation Simulation Stephanie Ricketts NURS 693 Summer 2015
- 2. OBJECTIVES S Recap of last semester S Constructivism philosophical theory of learning S Standards of simulation S Simulation pilot
- 3. Knowledge without experience is just information-Mark Twain
- 4. EVENT BASED APPROACH TO LEARNING Simulation is a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion.
- 5. RECAP S Subjective • Director of Perioperative Services, OR Manager and Sedation Educator all endorse the need for further procedural sedation training S Objective • Kaiser’s Procedural Training takes place on anesthesia patients NOT procedural sedation patients • No national guidelines for training of personnel S Assessment • “Hands on” competency is not measurable and not enforced S Plan • Create a clinical simulation tailored to procedural sedation for realistic & consistent training
- 6. PROJECT TIMELINE Identified problem: inconsistent & unrealistic training Participated in training Identified project: clinical simulation Created evidenced based scenarios for simulation Consulted Simulation technician Studied simulation software and EBP of scenarios Observed specific procedural sedation scenario in real life: Kyphoplasty Inputted kyphoplasty scenario into software with successful trial run
- 7. Constructivism Philosophical Theory of Learning S Individuals construct knowledge for themselves through their interaction with their environment. S Learning is contextual and occurs when situated in a realistic setting. Simulation is based on constructivist theorie
- 8. Standards of Best Practice S Standard I: Terminology S Standard II: Professional Integrity of Participants S Standard III: Participant Objectives S Standard IV: Facilitation S Standard V: Facilitator S Standard VI: The Debriefing Process S Standard VII: Participant Assessment and Evaluation -The International Nursing Association for Clinical Simulation and Learning (INACSL), 2013
- 9. Standard Specific Focuses Consistent terminology Pre-briefing Confidentiality to preserve integrity of scenarios Incorporate EBP Achievable in time frame Who will facilitate? Correspond to RN knowledge level & experience Who can facilitate? Promoting learner-centered reflective conversation Summative evaluations
- 11. CNS COMPETENCIES Competency Sphere of Influence Nurse Characteristics Detailed Actions performed Consultation Nurse & System Facilitation of Learning, collaboration & clinical judgment Initiated consultation with CRNAs, clinical educators & RNs while collecting resources Systems Leadership Nurse & System Collaboration & systems thinking Created clinical simulation objectives & scenarios Collaboration Nurse & System Clinical Inquiry & Collaboration Collaborated with CRNAs, physicians, RNs and simulation technicians to ensure all needs are addressed in training. Coaching Nurse Facilitator of learning & clinical inquiry Promoted professional development through presentation & application of EB care Research Nurse & System Clinical Inquiry, systems thinking Analyzed research findings, national standards & clinical facts for integration to SIM
- 14. TEAMWORK!
- 15. REFERENCES American Association of Nurse Anesthetists. Qualified Providers of Conscious Sedation Position Statement 2.2. Park Ridge, IL: American Association of Nurse Anesthetists; 1996. American Association of Nurse Anesthetists. Qualified Providers of Conscious Sedation Position Statement 2.2. Park Ridge, IL: American Association of Nurse Anesthetists; 1996. Bailey, M. (2002). Constuctivist Foundations of Teaching For Learning. Retrieved July 10, 2015, from http://education.ed.pacificu.edu/aacu/workshop/constructivism.html Caperelli-White, L., & Urman, R. D. (2014). Developing a Moderate Sedation Policy: Essential Elements and Evidence-Based Considerations. AORN Journal, 99(3), 416-430. doi:10.1016/j.aorn.2013.09.015 Conway, A., Rolley, J., Page, K., & Fulbrook, P. (2014). Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory: a modified Delphi study. Journal Of Advanced Nursing, 70(5), 1040-1053. doi:10.1111/jan.12337 Conway, A., Rolley, J., Page, K., & Fulbrook, P. (2014). Issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a qualitative study. Journal Of Clinical Nursing, 23(3/4), 374-384. doi:10.1111/jocn.12147 Ketcham, E., Ketcham, C., & Bushnell, F. L. (2013). Patient safety and nurses' role in procedural sedation. Emergency Nurse,21(6), 20-24. doi:10.7748/en2013.10.21.6.20.e1218 Murphy, J. M. (2013). Credentialing Process for Nurse Providers of Moderate Sedation. Journal Of Radiology Nursing, 32(1), 10-18. doi:10.1016/j.jradnu.2012.06.002 Ogg, M. (2008). Clinical issues. Recommended practices for moderate sedation/analgesia. AORN Journal, 88(2), 275-277. Registered Nurses Engaged in the Administration of Sedation and Analgesia. (2005, November 1). Retrieved May 7, 2015, from http://www.aana.com/resources2/professionalpractice/Documents/PPM Consid 4.2 RNs Engaged in Sedation Analgesia.pdf Spruce, L. (2015). Back to Basics: Procedural Sedation. AORN Journal, 101(3), 345-353. doi:10.1016/j.aorn.2014.09.011 Wunder L, Glymph D, Newman J, Gonzalez V, Gonzalez J, Groom J. Objective Structured Clinical Examination as an Educational Initiative for Summative Simulation Competency Evaluation of First-Year Student Registered Nurse Anesthetists’ Clinical Skills. AANA Journal [serial online]. December 2014;82(6):419-425. Available from: CINAHL with Full Text, Ipswich, MA. Accessed April 5, 2015.
Editor's Notes
- Aloha everyone! This is Stephanie Ricketts speaking and I will be presenting my final presentation via voiceover because I have moved to California. I was fortunate enough to have completed clinical hours in two separate areas this semester. I continued my clinical from last semester at Kaiser Moanalua in the perioperative areas and I had a short 45hour clinical with our instructor Claire at Queens. So let’s get started
- Here are some brief objectives for this presentation. First I will recap my time at Kaiser last semester before I begin speaking to the secondary phase of my project which was I completed this semester. I will discuss the constructivism philosophical theory of learning as the foundation for my intervention before I go into the national standards of simulation and my final simulation.
- I felt that this quote by Mark Twain and illustration are the perfect opening to this presentation because often times we get caught up in school or work and think knowledge gained from a book or module equals proficiency. Nurses are inundated with online competencies, in-services, certifications and even grad student’s projects so it is easy to truly feel you know something because you passed a test. However we have to be careful not to overload our nurses with information because some things are best learned through experience. We want to make sure they can remember what was on that test months later. For example, CPR is a skill that we all hopefully know and all have the BLS card to prove it. To this day, every time I am asked to perform CPR or recite the steps of it, a mental image pops into my head of the 2nd floor of Webster Hall at UH where I first took a CPR class and practiced the 30 chest compressions to 2 rescue breaths. This experience is ingrained in my memory as just that: an experience not simply information.
- The perfect intervention that can safely give our nurses experience instead of merely knowledge is through clinical simulation. One of the main things I want to teach people is that simulation is a technique not a technology. Technology can give us us tools to learn by and technology can be the knowledge of techniques however simulation is a technique that is very specific approach to learning. As most of us know simulation in a sim lab can give the learner or learners a safe environment to make mistakes and critically think in a realistic environment so that when the scenario does arise in real life, there is more than mere knowledge hopefully there is a experience. The guided experiences this quote speaks to is the ability we have to control each simulation to account for specific progressions of disease or injury we also have the ability to record and re-watch each simulation with allows the learner to learn from their own mistakes and see first-hand how to improve upon their critical thinking, reasoning & judgment. I loved participating in simulations during undergrad and then re-watching myself on the videos. I was able to see things clearer than I had experienced them and picking up on my own mistakes enhanced my learning more than say being passively told what common learner mistakes were.
- This slide is just a quick recap of my presentation and progress from last semester since this is a two semester capstone I wanted you all to be able to see where we came from. I used SOAP note form because this summer semester focused on the PLAN portion where as last semester was a lot of research and project managing. When I began last Spring semester my preceptor Gary Kienbaum explained to me that there was a need for hands on procedural sedation training because at the time the floor nurses who wished to be trained in procedural sedation were taking an online competency then going into the OR for a type of hands on training and this hands on training was not very well controlled. Gary’s main concern was that he wanted to make sure everyone got the same training. I then met with Barbara Horton, the OR manager and a CRNA who agreed with Gary’s concern but also had a concern that the training these RNs were receiving was not realistic enough. The RNs came in to observe a general anesthesia patient when in reality procedural sedation patients would be awake and responsive. And finally I spoke with the OR clinical educator Belinda Lujan whose main concern was that the training needed to be consistent with the online competency and national standards and she did not have any way to truly enforce this. These conversations lead me into taking part in the procedural training and confirming that the hands-on portion is very passive learning. Additionally I had two no-show RNs for the training I was trying to observe. We concluded that a simulation course would allow us to create a realistic scenario for procedural sedation that RNs could schedule and come into together which would help us enforce the consistency & success of the training.
- This slide is just a visual representation of the progression of this project which relied heavily on my project managing. Once the scenarios were solidified throughout last semester after much research we hit an obstacle. The SIM Lab Coordinator at Kaiser retired, leaving no one able to run the scenarios or help to teach us the software. After realizing this we did brainstorm changing our training from a simulation to a different tool however the research done last semester had ingrained in my mind that simulation was the best way to for RNs to gain experience in procedural sedation safely.
- One of the reasons we stuck with the simulation was because of the constructivism philosophical theory of learning which is (based on observation and scientific study) and speaks to how people construct their own understanding and knowledge of the world, through experiencing things and reflecting on those experiences. Galileo once said “You cannot teach a man anything you can only help him find it within himself.” And in healthcare this type of teaching is so important because often times reacting & thinking back to experience is faster and more efficient than merely thinking back on passive knowledge. In Constructivism the educator is a facilitator. In this image is shows the foundation of this theory. You can see each representation of active manipulation & authentic experiences and how they form a foundation for powerful, memorable learning. So you can see that reading & hearing words allows for less knowledge recall than an active type of learning such as simulation. This is why we decided that simulation was definitely the route to go for procedural sedation training due to the amount of memory it provided.
- The standards of best practice for simulation were released in 2011 by the International Nursing Association for Clinical Simulation and Learning, the most recent revision occurred in 2013. These seven standards outline the best practices in health care disciplines & health science education. The INACSL included rationales, outcomes, criteria and guidelines for each that we needed to follow for our simulation. Now for someone not trained in Simulation it took me a while to research & compare each of these seven standards to my scenarios. Eventually I ended up working solely on a Kyphoplasty scenario for the simulation and this next slide will show a few of the focuses or obstacles I faced in trying to meet each standards for our simulation.
- This is a lengthy slide but it gives a very brief synopsis of each standard necessary to fulfill for a successful simulation. My focus for terminology was to use terminology consistent with education, practice, research & publications in our prebriefing and throughout the scenario to enhance learning understanding, It was decided that the professional Integrity of participants wasto be covered in the prebriefing of the course so that we could preserve the integrity of the scenarios. For our SIM Objectives we wanted to make sure that we were using evidenced based practices in the scenarios which was confirmed through the research project last semester and through observing real life procedures for the scenarios we would be running. I also had to cut down my objectives for the SIM class to make sure that they could fit into the time frame which would be about 2 hours. I handled much of the facilitation scripting for this simulation because I wanted to ensure that the educator of this SIM to be a facilitator of learning. I typed up the cues to redirect each scenario and and guide participants down the path of discovery while also developing a list of expected behaviors to ensure the learning objectives were met. Our biggest problem was finding a facilitator because I needed to find someone to actually run the pre-briefing and de-briefing who was more proficient than I at procedural sedation. After drafting the scenarios I was asked to find a physician to run these scenarios but I felt that this might threaten the safe learning environment and wanted the facilitator to be someone who could correspond to the knowledge & experience level of the learners. Eventually we found the perfect educator in Reese Bush who is a procedural sedation RN at Kaiser in the Diagnostic Imaging Department and was recently hired as a clinical educator in sedation which helped us tremendously. The focus for our debriefing process was being able to utilize the cameras in the Kaiser SIM lab to help us get deeper reflection & reaction before we jumped into the analysis & summary of the SIM. And finally for the participant assessment & evaluation we decided to keep online competency test and add in a self-assessment by the participant about their critical thinking & reasoning throughout the scenario as well as a short SIM evaluation on how we could improve as well as what they liked about our simulation.
- These are just a few pictures of what most of my semester looked like in the Kaiser Sim Lab and in the right picture is the manual I had to read to teach myself how to actually input our information into the software. Since there was no SIM Coodinator and there was no SIM Certification Class offered anyplace this summer I had to learn how to use this technology on my own. Thankfully I have a good friend who is a simulation technician at the UH Sim Lab and he came in to help me our for a day and answered a lot of my questions and helped me tremendously. I was able to successfully pilot the simulation running a colleague through it and asked my team members to do the same. When I moved we were still shuffling the schedule around to run the first real class but I am confident that my team members now have everything they need to run the scenarios easily and successfully which was their biggest concern.
- Here is a chart of the CNS competencies utilized while working on this capstone. Clinical thinking, research and collaboration were huge in managing this project and creating a effective simulation.
- In closing I want to reflect upon my clinical journey in this graduate program and my personal progression to graduation. I chose to show my clinical progression in a circle because I began doing direct patient care with Dr. Hobbs in the Queens Emergency Department and then ended doing direct patient care with Claire and the Pain & Palliative Care team also at Queens. In between these two I spent time in both the Queens and Kaiser operating room and anasthesia departments doing mostly project managing and less patient care. Being able to begin and end with such great CNS preceptors with unique roles allowed me to see how much more advanced my comprehensive assessment became as well as how much my confidence grew in caring for complex patients.
- Here is a infographic of all of my intervention focuses in each clinical I had and the final project I ended presenting. The most important lesson I have learned from my clinical journey is teamwork.
- I was able to work with many fantastic preceptors & educators in completing my various projects and am so grateful for their patience and willingness to help. As I go forth and apply my education I will value working with others to reach a common goal because there is strength in numbers when it comes to getting things done.