improving care for pediatric patients mindi anderson, phd, rn, cpnp-pc, cne, anef copyright© m....

Improving Care for Pediatric Patients

Mindi Anderson, PhD, RN, CPNP-PC, CNE, ANEF

Copyright© M. Anderson 2012

Disclosures

• Current research funding:– Laerdal Foundation for Acute

Medicine, National League for Nursing (NLN), UT Arlington, HRSA

• Previous/current consultant:–NLN/Laerdal

• Teach CE course/sim courses• Smart Hospital™

Copyright M. Anderson 2012

Objectives

• 1. Discuss the medical/legal environment in the pediatrics area.

• 2. Identify issues specific to pediatrics care.

• 3. Discuss the history of pediatric simulation.

• 4. Describe the role of simulation in providing quality (adequate) pediatric education.


Objectives Continued

• 5. Discuss collaboration with multidisciplinary leadership.

• 6. Describe how to plan and implement pediatric simulations.

• 7. Define measurable objectives for success.


Medical/Legal Environment

• Can not use actual patients for skills = safety

• Policies and procedures = students

(Nishisaki et al., 2012)


Legal Care

• Adolescents (case example)– Inconsistent laws–Considerations• Confidentiality• Consent by minors• Emancipated minor

(Hicks & Rome, 2011)


Ethics

• Providers need training• Survey of physicians (n = 88)

found ethics (pediatrics) problems related to:–Relationships –End-of-life–Conduct of professionals–Economics/policies–Educational process

(Guedert & Grosseman, 2012)


Issues in Pediatrics

• Decreased clinical sites; decreased procedures

• Decreased unit time• Worsening morbidity/mortality• Higher acuity; but students may

not get to care for• Low-volume but high-risk

(Birkhoff & Donner, 2010; Bultas, 2011; Schneider Sarver, Senczakowicz, & Murphy Slovensky, 2010)



• Decreased skills• Seasonality• Shift = outpatient care• Graduate = site issues,

decreased preceptors• Missing curricular pieces

(Cook, 2012; Schneider Sarver et al., 2010)



• Assessment-–Need for competency validation–Skills/performance (eg.

anesthesia)• “Children are not little adults”

(McQueen, Mitchell, & Joseph-Griffin, 2011, p. 780)

• Anatomy changes with age; need to know appropriate equipment

(Birkhoff & Donner, 2010; Fehr et al., 2011; McQueen et al., 2011)



• Balancing patient/family needs• Increased emotions = end-of-life–Often not covered– Lecture does not teach feeling–Are students prepared?

(Cheng, Donoghue, Gilfoyle, & Eppich, 2012; Lindsay, 2010)


History of Pediatric Simulation

• Study = “Standardized” mothers, gave history via telephone to interns/residents (Brown & Eberle, 1974)

• First pediatric simulator – 90’s (Rosen, 2008)

• “Pediatric clinical skills assessment” – SPs (Lane, Ziv, & Boulet, 1999, p. 640)


History of Pediatric Simulation

• Virtual = clinics in Second Life® (SL) (Cook, 2012)


Role of Simulation – Quality Education

• Skills–Communication–Medication

dosage/administration–Assessment–Procedures–Charting

• Clinical judgment(Bultas, 2011; McQueen et al., 2011)



• Orientation – students/new hires• Meet important

objectives/outcomes• Competency/performance–Eg. Clinical check-offs–OSCEs

• Preparation = Continuing Education (ICU areas)

(Broussard, Myers, & Lemoine, 2009; Bultas, 2011; Cazzell & Rodriguez, 2011)



• A way to teach EBP• Incorporate core concepts

(Aebersold, 2011; Waxman, 2010)


• Need for coordinated teams• Activities are often team-based

(airway)• Want students to learn roles

prior to graduation

(Birkhoff & Donner, 2010; Nishisaki et al., 2012)

Interdisciplinary Simulations


Interprofessional Education Defined

• Interprofessional education: “When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010)

(Interprofessional Education Collaborative Expert Panel, 2011, p.2)


Interdisciplinary Competencies

• Interprofessional Education Collaborative Expert Panel (2011)

• 4 categories competencies:–Values/ethics–Roles/responsibilities–Communication–Working as a team


Collaboration – Multidisciplinary

Leadership • Bring disciplines to the table• Leaders/stakeholders from

each• Who can you collaborate with?


Who is Available/Willing?

• Medicine• Nursing• Social Work• Chaplains• Radiology

• Respiratory Therapy

• Pharmacy• OT/PT• Phlebotomy


Consider

• Who else?• Think about hurdles prior



• Death/dying = child (Youngblood, Zinkan, Tofil, & White, 2012)

– Purpose = Communication–Mannequins/actors– Participants:• Fellows• Nurses• Social workers• Chaplain



• One study (n = 105) = increased collaboration between physician-nurse with each scenario (Messmer, 2008)


Topic Areas

• Interview/survey stakeholders• Look at trends/region/season/

M&M/competencies• Inpatient (survey)–Codes–Managing an airway/airway

issues(Deutsch, Olivieri, Hossain, & Sobolewski, 2010; Interprofessional Education Collaborative Expert Panel, 2011)


Interdisciplinary

• What are your shared goals/content/competencies?


Scenario Time

• Use pre-written versus write your own?

• Pre-written:–Ex.• http://www.mysimcenter.com/en-US/SimStoreHome.aspx

• Pre-written = may need to tweak

(Durham & Alden, 2008 )


http://www.mysimcenter.com/en-US/SimStoreHome.aspx




Template - Writing

• Find/create scenario template• Use consistently• May vary according to type of sim• Examples (Must join – FREE):– Laerdal (2010)http://simulation.laerdal.com/forum/files/folders/checklists__worksheets/entry2459.aspx

–NLN(2010); Childs, Sepple & Chambers, 2007

http://sirc.nln.org


http://simulation.laerdal.com/forum/files/folders/checklists__worksheets/entry2459.aspx

http://simulation.laerdal.com/forum/files/folders/checklists__worksheets/entry2459.aspx

http://sirc.nln.org/



Planning - Write Scenario

• Target group/population–Multiple?

• Year/experience• Formulate:–Overall goal–Specific objectives (1◦, 2◦)–Based on topic

(Anderson & LeFlore, 2008 ; Childs et al., 2007; Durham & Alden, 2008; Hwang & Bencken, 2008; Laerdal, 2010; Smith, 2009; Stillsmoking, 2008; Waxman, 2010)


What is Your Goal?


• Purpose• Ex.–Skills• Learning• Practicing

–Competency–Team training/teamwork• Every scenario vs. specific focus

(Cheng et al., 2012; Stillsmoking, 2008)

Considerations

• Do not “throw them the kitchen sink”

• “Save the world”• Start with a code


Considerations

• Maintain reality• Do not “trick” participants(Cheng et al., 2012)


Topic

• Dog or zebra?


Characteristics

• Focus–Ex. • Simple versus complex• Procedures vs. critical thinking (putting it all together)

(Anderson & LeFlore, 2008)


Choose Teaching Strategy

1. Observing2. Diagnosing3. Treating/Intervening4. Interacting5. Practicing- pass/competent

(Murray, 2004)

Choose How You Will Run

• Pre-program vs. “on-the-fly”

(Childs et al., 2007)


Objectives

• “Statement of cognitive (knowledge), affective (attitude), and/or psychomotor (skills) goal(s)”

(The International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011a, p. S4)


Measureable Objectives = Success

• Objectives = guide scenario/outcome

• Remember:–Should be able to meet–Reflect different domains–Correlate to course/program

outcomes–Be based on evidence

(Alinier, 2011; The INACSL Board of Directors, 2011b; Jeffries & Rogers, 2007; Smith, 2009; Waxman, 2010)


Remember- Objectives

• This is the most important step!

(Waxman, 2010)


Write Objectives

• Number–1-6 (depends)

• Formulate prior • Check with stakeholders• Make measureable, clear!• Utilize your resources• Provide to participants?

(Alinier, 2010; Anderson & LeFlore, 2008; Jeffries & Rogers, 2007; Smith, 2009; Stillsmoking, 2008; Waxman, 2010)


Objectives

• Use appropriate verb (action)• Bloom’s (higher levels?) -

cognitive

(Overbaugh & Schultz, n.d.)


Remember

• As you are writing objectives, how will you evaluate?

• Remember critical behaviors

(Anderson & LeFlore, 2008; Smith, 2000; Waxman, 2010)


Let’s Write Some Objectives

• Let’s take a look at the following situation


Type of Simulation

• Pick type = match objectives• Fidelity• Let’s go back to our situation

(Anderson & LeFlore, 2008; Jeffries & Rogers, 2007; Smith, 2009; Stillsmoking, 2008; Waxman, 2010)


Let’s Write Some Objectives

• Let’s try another scenario


Type of Simulation?


Develop Scenario/Script

• Name, concepts, demographics• Patient- Newborn/preemie,

infant, child, or adolescent?• Diagnosis/es and differentials

= reinforce objectives• Describe; summarize• What will you report?(Alinier, 2011; Anderson & LeFlore, 2008; Aebersold, 2011; Childs et al., 2007; Hwang & Bencken, 2008; Laerdal, 2010)


Skills

• What skills/knowledge do participants need to come with?

(Anderson & LeFlore, 2008; Childs et al., 2007; Laerdal, 2010)


Writing the Scenario

• Follow your template• Describe environment – where is

your patient?–Unit?–PICU?–Healthcare provider’s office?–Home?

(Anderson & LeFlore, 2008; Childs et al., 2007; Durham & Alden, 2008; Laerdal, 2010; Stillsmoking, 2008)


Patient

• What will he/she look like at the beginning?

• Monitor should match

(Laerdal, 2010; Stillsmoking, 2008)


Events

• List events that will happen – how will scenario progress?

• Flowchart• Think about cues/prompts

(Alinier, 2011; Childs et al., 2007; Laerdal, 2010; Waxman, 2010)



• Equipment• Moulage/supplies/props

(Alinier, 2011; Childs et al., 2007; Laerdal, 2010)


Writing Scenario

• Length?• Number of participants/scenario

(grouping)• Roles• Actors/confederates

(Alinier, 2011; Anderson & LeFlore, 2008; Childs et al., 2007; Durham & Alden, 2008; Hwang & Bencken, 2008; Waxman, 2010)



• Debriefing questions–Remember objectives

• Use/keep references

(Alinier, 2011; Anderson & LeFlore, 2008; Childs et al., 2007; Durham & Alden, 2008; Jeffries & Rogers, 2007; Laerdal, 2010; Smith, 2009; Waxman, 2010)


Ending

• How/when will it end?

(Alinier, 2011; Murray, 2004; Stillsmoking, 2008)


Complexity

• Suggestions scenario more complex

• Example: culture (Spanish-speaking only), co-morbidity (preemie)

(Childs et al., 2007)

Plan/Implement Pediatric Simulations

• Think about pre-assignments– Increases effectiveness of

simulation time• Directions for participants• Make sure you have enough help• Videotape?

(Bultas, 2011; Durham & Alden, 2008; Waxman, 2010)


Implement

• Set-up• Practice!• Orient–Roles–Scenario objectives–Type of simulation/simulator–Simulated environment

(Alinier, 2011; Childs et al., 2007; Durham & Alden, 2008 ; Horn & Carter, 2007, Smith, 2009)


Keys to Success

• P’s for Success–Passion–Plan (Personnel, Participants,

Props)–Prep (Patient, Participants)–Practice–Proceed–Process (Debrief)

(Alinier, 2011; Horn & Carter, 2007)


Form Collaborations

• Helps with resources• Ex.–Canadian Pediatric Simulation

Network–EXPRESS - research

(Cheng et al., 2011; Grant & Cheng, 2010)


Research Needs

• Whether simulation improves outcomes with patients

(Birkhoff & Donner, 2010)


References

• See provided reference list


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