viewcsa rev template (12/15/08; 5/09; 12/09; 4/11; 1/14) revised coupn january 2014

Enhancing Registered Nurse Job Readiness and Patient Safety Outcomes Through Clinical Simulation

Simulation Scenario Template

Adaptation of California Simulation Alliance (CSA)

Draft 1

January 13, 2014

CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)Revised COUPN January 2014

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SECTION I SCENARIO OVERVIEW

A. TitleB. SummaryC. Evidence Base

SECTION II CURRICULUM INTEGRATION

A. Learning Objectives1. Primary2. Secondary3. Critical Elements

B. Pre-scenario learner activities

SECTION III SCENARIO SCRIPT

A. Case SummaryB. Key Contextual DetailsC. Scenario CastD. Patient/Client ProfileE. Baseline patient/client simulator stateF. Environment / equipment / essential propsG. Case flow /triggers / scenario development

SECTION IV APPENDICES

A.B.C.

Health Care Provider OrdersB. Digital Images of Manikin / Milieu

Debriefing Guide


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SECTION I: SCENARIO OVERVIEW

Scenario Title: Pneumonia and Family CommunicationOriginal Scenario Developer(s): McMaster University: Joanna Pierazzo, Amy Palma

Date - original scenario Fall 2010Validation: Fall 2010Revision Dates:Pilot testing: Pre-run in Fall 2010 and used each semester thereafter QSEN revision:

Estimated Scenario Time: Debriefing time:13-15 min depending on group 30-40 min (again in depending on issues that unfold)interaction with patient and family

Target group: Level 4 student in pediatric inpatient acute unit

Core case: Acute Pneumonia, Family Communication

CNO/ CPSI/CIHC

The following CNO entry-to-practice competencies are addressed in this scenario:

The student nurse: develops a therapeutic relationship with the client identifies client health needs and autonomously performs nursing interventions demonstrates knowledge in critical-thinking and problem-solving

Best Practice Guidelines

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, 2011, Oct, 53(7).

Thomas, S.P.(2003). Anger: The mismanaged emotion. MedSurg Nursing, 12(2), 103-110.

Brief Summary of Case:

Patient is a 2 year old, admitted with pneumonia. Mom has left to go home and attend to younger sibling. Grandmother is at bedside and upset and concerned about grand-daughter’s condition. Nursing students (2-3) will need to manage care of child who begins to cough and describe shortness of breath, as well as grandmother whose emotional state escalates to one of anger as she observes her grand-daughter’s condition.


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EVIDENCE BASE / REFERENCES (APA Format)References listed aboveD. Price and J. Gwin, Pediatric Nursing (2011). Chapter 11 Respiratory Disorders.Hockenberry, M.J., and Wilson, D. (2009). Wong’s Essentials of Pediatric Nursing, Chapter 21 Family-Centered care of the child during illness and hospitalization.

SECTION II: CURRICULUM INTEGRATION

A. SCENARIO LEARNING OBJECTIVESDo What With What For What

Enhance understanding of pediatric respiratory assessment

utilizing a clinical assessment framework

to ensure adequate care for a 2 year old with pneumonia

Provide appropriate nursing intervention

utilizing the process of clinical judgment

to maintain patient comfort and effective airway management

Demonstrate skill in assessing and interacting with an angry, upset family member

utilizing therapeutic communication knowledge and skill

in order to provide effective relational responses during a difficult interaction

B. Learning Outcome Assessment / Rubric

Competency

(based on “What For”)

Demonstrated attributes align with required competency

Demonstrated attributes need some improvement to align with required competency

Demonstrated attributes need major improvement to align with required competency

Respiratory assessment and intervention

Through assessment techniques, the student is able to attain a full understanding of the child’s clinical status with a specific focus on oxygenation.

The student’s assessment will include VS, lung assessment, oxygen saturation, and general head to toe to determine fluid volume and circulatory

The student has been able to capture components of all assessments, but has missed some data.

The student is still able to recognize what may be happening, but response is slow with possible hesitancy. It is evident that process of clinical judgment is present, although not smoothly enacted.

The student is missing significant elements of assessment and intervention in the care of this patient.

There is concern regarding the student’s lack of knowledge and understanding, with a potential impact on patient and family safety.


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status.

The student is able to effectively intervene and ensure adequate oxygenation and comfort. This may include patient positioning, oxygen deliver, chest physiotherapy, deep breathing and coughing and administration of ventolin as ordered.

The student has missed some interventions, although patient safety is still maintained.

The flow of clinical judgment in managing this patient is a concern and requires greater development.

Relational skill and therapeutic interaction with an upset family member

Through knowledge of effective relational skill and therapeutic communication, the student is able to create a working relationship with the family member and maintain a calm working dialogue.

The student is able to integrate effective strategies and knowledge in order for the grandmother to feel more comfortable with her grand-daughter’s care, and to discuss her condition in a positive manner.

The student has been able to mildly calm the interaction between the nurse and the grandmother. Unfortunately, there are moments when the grandmother still demonstrates anger. In addition, the student requires greater skill in utilizing therapeutic strategies to maintain the working relationship.

The interaction between the student and the grandmother is ineffective. The student has demonstrated minimal understanding of how to effectively engage in a situation of emotional distress.Finally, the student utilizes only basic communication skill and has not integrated advanced techniques.

C. PRE-SCENARIO LEARNER ACTIVITIES Prerequisite Competencies

Knowledge Skills/ Attitudes Physical assessment of a pediatric patient,

including a focused respiratory assessment Performs a focused respiratory assessment in a

situation of abnormal symptoms Pneumonia in the pediatric patient Utilizes effective interventions to care for a child

with pneumonia Therapeutic communication with angry person Demonstrates effective skill in advanced therapeutic

communication


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SECTION III: SCENARIO SCRIPT

A. Case summaryMaya Gordon is a 2 year old, weighing 12 kg. For the last 3 days, she has had a productive cough, runny nose, and fever, which mom had been treating at home. Yesterday her mother noticed she was more tired, breathing faster, short of breath with activity and looked unwell, so she brought her to the ER. A chest x-ray showed left lower lobe pneumonia. She was admitted to the pediatric inpatient unit and started on IV antibiotics.

Once the student(s) attains morning report, s/he will enter Maya’s room to begin interaction and care. Maya is away and alert, but more tired and quiet than usual. On inspection, she displays subcostal and intercostals in-drawing. Her oxygen saturation is 93% on room air. On auscultation, there are bilateral crackles in both lung fields, although left > right, and air entry decreased to the left lower lobe. She will need ongoing chest physio, and ventolin PRN today. Her vitals this morning are HR 108, BP 110/60, RR 44, T 37.8. She is taking sips of milk or juice, but needs encouragement. IV of D5NS continues at 30 ml/hr. A chest xray, routine blood work, and sputum sample for culture and sensitivity (C&S) have been ordered.

Maya’s mother went home for the night for a break and to care for her one year old son. Patricia, Maya’s grandmother has been at the bedside all night and is quite concerned about her condition.

The learner outcomes as identified earlier.

B. Key contextual detailsScenario takes place on a pediatric in-patient unit at the beginning of morning shift. The student group has attained transfer of accountability/report and enters the room to begin interaction and nursing care.

The students have negotiated their roles prior to entering the room.

C. Scenario CastPatient/ Client High fidelity simulator

Mid-level simulator Task trainerX Hybrid (Blended simulator) – includes the use of high fidelity pediatric simulator and a standardized patient Standardized patient

Role Brief Descriptor(Optional)

Confederate/Actor (C/A) or Learner (L)

Level 4 Student Nurses(2-3)

It is the beginning of a morning shift. The students will enter the patient room after receiving report and begin interaction and care. The students negotiate their roles (ie. primary, secondary, runner).

Learners


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Grandmother of patient Patricia Gordon is the grandmother of Maya Gordon. Patricia is upset and concerned about her grand-daughter’s care. She exhibits moments of anger as a result of concern.

Grandmother of patient Maya

D. Patient/Client ProfileLast name: Gordon First name: MayaGender: F Age: 2 Ht: 65 in Wt: 13 kg Code Status: fullSpiritual Practice: Roman Catholic

Ethnicity: Canadian

Primary Language spoken: English

1. Past history

Not significant. Achieving developmental milestonesNKDA to medications or environmentalImmunizations are up-to-date

Primary Medical Diagnosis Pneumonia affecting left lower lobe

2. Review of SystemsCNS awake and alert, weepy, responds to questions, more quiet and tired than usualCardiovascular HR 108 reg, BP 110/60, cap refill+2 sec., pallor, skin warm to touch, peripheral pulses

present and equal bilaterallyPulmonary RR 44, T 37.8, mild subcostal and intercostals indrawing, Oxygen sat 93% RA. Bilateral

crackles to bases, decreased air entry LLLRenal/Hepatic ?hydration, last void 6 hrs, mom unable to recallGastrointestinal Abdomen soft, non-distended, BS active, LBM this am, no N/V, tolerating small sips of

fluids po Endocrine nilHeme/Coag nilMusculoskeletal fatigued, active movement, limb strengthIntegument nilDevelopmental Hx achievingPsychiatric Hx nilSocial Hx Mother Angela, father David, 1 year old brother MarkAlternative/ Complementary Medicine Hx nil

Medication allergies: NKDA Reaction:Food/other allergies: NKDA Reaction:

3.

Cur Drug Dose Route Frequency

Nil on admission


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rent

m

edic

ation

s Current as follows on admission:CefuroximeAmpicillinTylenolVentolin

425 mg 500 mg160 mg1-2 puffs

IVIVPoaerochamber

Q 8 hrQ 6 hrQ 4hr Q 4hr prn

4. Laboratory, Diagnostic Study ResultsNa: K: Cl: HCO3: BUN: Cr: Ca: Mg: Phos: Glucose: HgA1C:Hgb: Hct: Plt: WBC: ABO Blood Type: PT PTT INR Troponin: BNP:ABG-pH: paO2: paCO2: HCO3/BE: SaO2: VDRL: GBS: Herpes: HIV: Cxr: EKG

E. Baseline Simulator/Standardized Patient State(This may vary from the baseline data provided to learners)

1. Initial physical appearance Gender: female Attire: peds hospital gownAlterations in appearance (moulage):

X ID band present, accurate ID band present, inaccurate ID band absent or not applicable

X Allergy band present, accurate Allergy band inaccurate Allergy band absent or N/A

2. Initial Vital Signs Monitor display in simulation action room:X No monitor display; NB:

display VS when student takesMonitor on, but no data displayed Monitor on, standard display

BP: 110/60 HR: 104 RR: 44 T: 38.9 SpO²: 93% room airCVP: PAS: PAD: PCWP: CO:AIRWAY: ETC0²: FHR:

Lungs:Sounds/mechanics

Left: Right: Crackles bilateral, decreased left lower

Heart: Sounds:ECG rhythm: regular sinusOther:

Bowel sounds: normal Other:

3. Initial Intravenous line set upSaline lock #1

Site: IV patent (Y/N)


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X IV #1 Site: Fluid type:D5/NS

Initial rate: IV patent (Y/N)MainPiggybackIV #2 Site: Fluid type: Initial rate: IV patent (Y/N)MainPiggyback

4. Initial Non-invasive monitors set upNIBP ECG First lead: ECG Second lead:Pulse oximeter Temp monitor/type Other:

5. Initial Hemodynamic monitors set upA-line Site: Catheter/tubing Patency (Y/N) CVP Site: PAC Site:

6. Other monitors/devicesFoley catheter Amount: Appearance of urine:Epidural catheter Infusion pump: Pump settings: Fetal Heart rate monitor/tocometer Internal External

Environment, Equipment, Essential props Recommend standardized set ups for each commonly simulated environment

1. Scenario setting: (example: patient room, home, ED, lobby)acute in-pt pediatric unit, private room, child in bed

2. Equipment, supplies, monitors(In simulation action room or available in adjacent core storage rooms)

Bedpan/ Urinal Foley catheter kit Straight cath. kit Incentive spirometerIV Infusion pump Feeding pump Pressure bag Wall suction Nasogastric tube ETT suction catheters Oral suction catheters Chest tube kitDefibrillator Code Cart 12-lead ECG Chest tube equipPCA infusion pump Epidural infusion

pumpCentral line Insertion Kit

Dressing ∆ equipment

X IV fluid Type:

D5/NS IV fluid additives: Blood productABO Type:# of units:

3. Respiratory therapy equipment/devicesX Nasal cannula

avail in rmFace tent X Simple Face Mask Non re-breather mask

BVM/Ambu bag Nebulizer tx kit X Flowmeters (extra supply) oxygen adapters in rm


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4. Documentation and Order FormsX Health Care

Provider orders X Med Admin

RecordX H & P Lab Results

X Progress Notes X Graphic record Anesthesia/PACU record

ED Record

Medication reconciliation

Transfer orders Standing (protocol) orders

ICU flow sheet

X Nurses’ Notes X Dx test reports Code Record Prenatal recordX Actual medical record binder, constructed

per institutional guidelinesOther Describe:

5. Medications (to be available in sim action room)# Medication Dosage Route # Medication Dosage Route

Cefuroxime

Ampicillin

Tylenol

Ventolin

425 mg

500 mg

160 mg

1-2 puffs

IV

IV

Po

aerochamber

Q 8 hrs

Q 6 hrs

Q 4 4hrs

Q 4hr prn


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CASE FLOW / TRIGGERS/ SCENARIO DEVELOPMENT STATESInitiation of Scenario : Maya Gordon is a 2 year old, weighing 12 kg. For the last 3 days, she has had a productive cough, runny nose, and fever, which mom had been treating at home. Yesterday her mother noticed she was more tired, breathing faster, short of breath with activity and looked unwell, so she brought her to the ER. A chest x-ray showed left lower lobe pneumonia. She was admitted to the pediatric inpatient unit and started on IV antibiotics

Once student(s) attains morning report, s/he will enter Maya’s room to begin interaction and care. Maya is away and alert, but more tired and quiet than usual. On inspection, she displays subcostal and intercostals in-drawing. Her oxygen saturation is 93% on room air. On auscultation, there are bilateral crackles in both lung fields, although left > right, and air entry decreased to the left lower lobe. She will need ongoing chest physio, and ventolin PRN today. Her vitals this morning are HR 108, BP 110/60, RR 44, T 37.8. She is taking sips of milk or juice, but needs encouragement. IV of D5NS continues at 30 ml/hr. A chest xray, routine blood work, and sputum sample for culture and sensitivity (C&S) have been ordered.

Maya’s mother went home for the night for a break and to care for her one year old son. Patricia, Maya’s grandmother has been at the bedside all night and is quite concerned about her condition.

STATE / PATIENT STATUS DESIRED LEARNER ACTIONS & TRIGGERS TO MOVE TO NEXT STATE1. Baseline

Patient is resting in bed, tearful and tired. Talking quietly to grandmother when she asks questions.

HR 104, BP 110/60, O2 sat 93% r/a, T- 38.9

Lungs: crackles, decreased air entry to LLL

Operator

Display vitals when student has attained, otherwise monitor has a blank screen

Triggers:

If learners do not assess systems appropriately, will need prompting. If respiratory findings missed, patient coughs and move on to next segment.

Learner Actions

- Student groups organize themselves with roles and collaborate to ensure the following:- Introduces self and begin to create a working relationship with patient and grandmother. - Washes hands before beginning with VS and general head to toe assessment.- Checks morning meds, IV med for 0800 is due.- Once VS and assessments are

Debriefing Points:

Primary: pediatric general head to toe assessment, with focus on respiratory symptoms; therapeutic communication to begin working relationship with patient and family member

Secondary: management of fever in pediatric child; organizing a team and collaborating


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complete, Tylenol for fever.-Ensures documentation is completed.

STATE / PATIENT STATUS DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE2.HR 110, BP 112/68, O2 sat 90% r/a, T- 39

Child is crying, coughing, upset. Displays shortness of breath and decreased air entry.

Grandmother very concerned, becoming angry about grand-daughter’s condition. Escalating emotion.

Operator:Display vitals when student has attained, otherwise monitor has a blank screen

Triggers:

If learners do not assess and intervene appropriately, gentle prompting needed, otherwise will be discussed in debrief.

Grandmother gently escalates to challenge students, but not to a point where students feel overwhelmed. Will need to establish word cues to guide the standardized patient who is playing the grandmother. This should be done in the training of the SP.

Learner Actions:

- respiratory assessment continues- intervention may include: patient positioning, administration of oxygen, chest physio, deep breathing and coughing, ventolin as ordered- VS are monitored- patient comfort is attended to during crying, coughing- Therapeutic communication with grandmother with advanced strategies to de-escalate emotions

Debriefing Points:

Primary: respiratory intervention with decreased oxygen saturation, shortness of breath in pediatric patient with pneumonia; integration of therapeutic strategies to maintain working relationship with grandmother;


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STATE / PATIENT STATUS DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE3.

Depending on student interventions in segment 2, patient is feeling somewhat better and displays the following:

HR 96, BP 110/60, O2 sat 95%, T- 38.5

Child settling with less crying, coughing. No evidence of shortness of breath.

Grandmother calm and in control of emotions – communicating with the student nurses.

Operator:

Display vitals when student has attained, otherwise monitor has a blank screen

Triggers:

Learner Actions:

- continues to assess and comfort child- continues to be therapeutic with grandmother, providing comfort and information as needed

Debriefing Points:

Primary: explore clinical judgment process as a whole in the management of this child’s respiratory status and communication with the grandmother; reflect on own performance, sharing perceptions and opportunities for growth

Scenario End Point: Child settling with less crying, coughing. No evidence of shortness of breath. Grandmother calm and in control of emotions – communicating with the student nurses. Suggestions to decrease complexity: This scenario can be altered to focus only one component, that is respiratory status OR communication with grandmother. If the merging of both as currently developed in this scenario is too complex, then it is recommended to break down and perhaps layer the scenario into 2 parts.Suggestions to increase complexity: This scenario has the potential to further advance in two directions: child’s respiratory status worsens OR grandmother’s emotional status escalates.


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APPENDIX A: HEALTH CARE PROVIDER ORDERS

Patient Name: Maya Gordon

DOB: Jan 2, 2012

Age: 2 MR#:

Diagnosis: Pneumonia, Left Lower Lobe

No Known Allergies Allergies & SensitivitiesDate Time HEALTH CARE PROVIDER ORDERS AND SIGNATURE

VS q 4 hrOxygen via NP to keep sats >93%IV of D5/NS at 30 ml/hrDATAATChest physio consultation

Cefuroxime 425 mg IV q 8hrAmpicillin 500 mg IV q 6 hrTylenol 160 mg po q 4hr prnVentolin 1-2 puffs q4hr prn

Signature

CSA REV template (12/15/08; 5/09; 12/09; 4/11)Revised COUPN January 2014

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APPENDIX B: Digital images of manikin and/or scenario milieu


Insert digital photo of initial scenario set up here

Insert digital photo here Insert digital photo here

Insert digital photo hereInsert digital photo here

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APPENDIX C: DEBRIEFING GUIDE

General Debriefing PlanIndividual Group X With Video Without Video

Debriefing MaterialsDebriefing Guide X Objectives X Debriefing Points QSEN

CPSI Competencies to consider for debriefing scenarios Culture X Teamwork/Collaboration Identify safety risk

X Communication Issues in environment Respond to safety risk

Sample Questions for DebriefingSee below. The focus is the learning goals identified at the forefront.

Interprofessional Competencies to consider for debriefing scenariosRole Clarification Interprofessional Teamwork Functioning

Patient/Family /Client ? Community centred care

Collaborative Leadership

Interprofessional CommunicationSample Questions for Debriefing

1. Reflect on how the experience of caring for this patient/grandmother feel for you and the team?2. Did you feel you had the knowledge and skill to care for this child and communicate with the grandmother? How did the pre-readings assist you with this?3. Are there any learning gaps you feel you need to address and why?4. Was there anything missing in the scenario as it unfolded or in the simulation room that impacted your performance?5. Let’s move our discussion to the primary goals of this scenario (see debriefing points listed above).6. Summarize as a group, how you might handle this situation differently in the future. 7. Identify as a group 3 key learning points to take away from this experience.


viewcsa rev template (12/15/08; 5/09; 12/09; 4/11; 1/14) revised coupn january 2014

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