Managing deteriorating patients: rural registered nurses’ performance in a simulated setting.

The FIRST2ACT Patient Deterioration Program

• A/Professor Dr Simon Cooper – Director of Research. School of Nursing and Midwifery, Monash University, Victoria, Australia

And McConnel-Henry T. Cant R. Porter J. Kinsman L. Endacott R. Scholes J.

Managing deteriorating patients Background

• Patient deterioration– High acuity – general wards– ‘Failure to rescue’ – Suboptimal care (SOCCER)– Medical Emergency Teams– De-skilling

• Situation awareness– cockpit crews – perception, understanding, projection

• Simulation – Safe repetition of skills– Matching reality– Scarcity of student placements

Study series1. A systematic review of simulation in nursing – Cant &

Cooper 20102. Nursing students’ knowledge, skill, and situation

awareness. Cooper et al 2010 – NBV funded3. Management of deteriorating women – Cooper et al –

current. Equity Trustees: Walter Cottman Fund4. Management of deterioration in rural hospitals. Cooper

et al – current. Gippsland – Monash University Grant5. Simulation in midwifery – a national review – Bogossian

et al – current. Health Workforce Australia6. Team management of deterioration in rural hospitals.

Cooper et al – Contract research funding7. Current: Development of on line/DVD patient

deterioration simulated learning program. ALTC

Managing deteriorating patients

Study 4: Management of deterioration in a rural hospital setting

Aim• To assess registered nurses’ ability to manage

patient deterioration using measures of:

– Knowledge

– Situation awareness

– Skill performance.

– Pre-post intervention notes review to assess the impact of the intervention (FIRST2ACT)

Previous simulated settings

Current simulated setting

Managing deteriorating patients

Instruments

Managing deteriorating patients

• Participants: registered nurses from a rural hospital ward (n=41) – 35 were recruited (1.5 hour session)

• Instruments and intervention1. Validated MCQ focussing on ‘ABCs’

Managing deteriorating patients

Instruments:2. Two videoed simulations (for each participant)

• AMI – high information low uncertainty (easiest)

• COPD – low information – high uncertainty (hardest)

• Both patients deteriorated significantly at the 4 minute mark and ran for 8 minutes

Managing deteriorating patients

Instruments3. Situation awareness (17 questions at end of scenario using

SAGAT)> Global e.g. is suction available?> Physiological e.g. what is the heart rate?> Comprehension e.g. what do you think is wrong?

> Projection e.g. what do you think may happen to the heart rate?

4. Video review ‘photo elicitation’ (to elicit decision points and strategies)

5. Performance feedback6. Evaluation7. And to assess the impact of the training intervention -

time series analysis –examining vital signs documentation, and frequency and oxygen delivery . Notes review included 258 before 242 after intervention.

Managing deteriorating patients

Results

Managing deteriorating patients

Results• MCQ: The average total score was 67%

(range 27 – 91%)

• Skill performance: an average score of 50% (range 26-74%).

– However skill performance decreased significantly between the first and second halves of each scenario (p=0.003) despite the obvious cues in the later stage of each scenario.

Results

• Situation awareness scores also averaged 50% with poor perception of the situation especially recall of vital signs

Overall• A wide range of performance in line with previous

study of student nurses (however knowledge scores were significantly lower than students p=0.006)

Results

– Notes review (time series analysis). Post intervention significant improvements in

> appropriate frequency of observations (p=0.025)

> administration of oxygen (p=0.05) > and charting of pain scores (p=0.001)

Managing deteriorating patients

Summary• Application of knowledge was an issue• Performance decreased as patients deteriorated

(including fewer vital sign measurements)• Situation awareness was generally low• However the training FIRST2ACT did have a

significant impact on performance

FIRST2ACT (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends)

1. Developing core knowledge - classroom based learning 2. Assessment:

stimulus for learning- Knowledge test

3. SimulationHigh fidelity kinestheticskills development

4. Reflective ReviewPhoto elicitation

5. Performance FeedbackDebriefing

Summary• Application of knowledge issues:

– Failures to practice in realistic settings (clinical skills teaching)

– Workplace culture – ‘we don’t do it like that here’

– Performance decrement when anxious

– Skill decline issues• Repetitive high fidelity and high stakes simulation, including

teaching of inductive and comparative clinical reasoning, (chunking/trends) are essential

• The FIRST2ACT program does have an impact on practice.

ANY QUESTIONS

• Cooper S. Cant R. Porter J. Bogossian F. McKenna L. Brady S. Fox-Young S. Simulated based learning in midwifery education: a systematic review. Women and Birth. In Press

• Buykx, P., Kinsman, L., Cooper, T., McConnell-Henry, T., Cant, R., Endacott, R. & Scholes, J. FIRST2ACT: Educating nurses to identify patient deterioration - a theory-based model for best practice simulation education. Nurse Education Today. In Press

• McKenna, Cooper et al. Is simulation a substitute for real life clinical experience in midwifery? A qualitative examination of the perceptions of educational leaders. Nurse Education Today. In Press

• Bogossian F, Cooper S et al. Simulation based learning in Australian midwifery curricula: Results of a national electronic survey. Women and Birth. In Press

• Cooper S. Buykx P. McConnell-Henry T. Kinsman L. McDermott S. (2011) Simulation: can it eliminate failure to rescue Nursing Times. 107; 3; Jan 25-31.

• Endacott R. Cooper S. Scholes J. Kinsman L. McConnell-Henry T. (2010) When do patient signs become cues? Detecting clinical cues of deterioration in a simulated environment. Journal of Advanced Nursing. 66(12), 2722–2731

• Cant R. & Cooper S. (2010) Simulation-based learning in nurse education: systematic review. Journal of Advanced Nursing. 66, 1, 3-15.

• Cooper S. Kinsman L. Buykx P. McConnell-Henry T. Endacott R. Scholes J. (2010) Managing the Deteriorating Patient in a Simulated Environment: Nursing Students’ Knowledge, Skill, And Situation Awareness. Journal of Clinical Nursing. Vol 19, Issue 15, 2309-2318