I am writing this from the perspective of a college professor who teaches mental health nursing, transcultural nursing, and pharmacology math. I also continue to practice as a nurse in the clinical setting, most recently in acute care on pulmonary step-down, adult psychiatry, and geropsychiatry units. It truly is a marvelous existence because I am fortunate enough to work with my former students while refreshing and maintaining the clinical skills I worked so hard to obtain all those years ago. My clinical practice often permits me to easily assess the effectiveness or, at least, retention of my teaching efforts and those of my peers as I observe our students' transitions from academia into beginning clinical practice.
We faculty consciously endeavor to instill a strong sense of professional pride and accountability along with the nursing knowledge. I'd even go so far as to admit nursing educators do indeed try to cultivate students who feel guilt or shame when their nursing performance fails to meet the quality thresholds fixed by our professional standards and practice guidelines.
My clinical role allows me to witness the interminable challenges my new professional peers daily confront. And I see a long-recognized disconnect arise: the one between what is taught and "real-world" pragmatism.
That incongruity, it seems to me, is even more conspicuous in these days due to an increased reconsideration of care delivery methods. Providers are reshaping delivery methods to be congruent with the Institute of Medicine's Six Aims of High-Quality Health Care (IOM, 2006). The Aims assert care should be:
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
I would like to focus our present discussion on effective care. The IOM describes effectiveness in part as being evidence-based, meaning interventions for which there is objective empirical support. Effectiveness also includes avoiding continued use, or at least questioning the use, of interventions lacking scientific confirmation. Let's consider a clinical example.
For many years, nurses and respiratory therapists have instilled small amounts of sterile normal saline into tracheostomy or endotracheal tubes prior to suctioning. The purpose was to loosen thick secretions and aid airway clearance. It seemed a good idea at the time but research hadn't been done. The practice continues. In one descriptive comparative study (Sole, Byers, Ludy & Ostrow, 2002), 95 nurses and 37 respiratory therapists working in adult critical care units at four different sites were surveyed regarding their suctioning techniques. Thirty percent of all nurses and 78% of respiratory therapists reported routinely instilling saline prior to suctioning.
Is this practice supported by evidence? One very recent randomized clinical trial (Caruso, Denari, Ruiz, Demarzo, & Deheninzelin, 2009) using 264 subjects in a single surgical intensive care unit of an oncologic hospital found instilling saline before tracheal suctioning decreased the microbiology proven incidence of ventilator-associated pneumonia (VAP). In the results discussion, the investigators do wonder if the effect was in any way due to shallow sedation levels that permitted the saline to produce sputum clearing coughs (think "water-boarding" here). Also, the authors agree that there was no difference in suspected VAP rates between the intervention group patients who received saline instillation and the control patients who didn't. The researchers urge further studies before recommending saline instillation as a regular step in the suctioning procedure.
The preponderance of the evidence, however, suggests routine saline instillation can be harmful and ought to be avoided. Pedersen, Rosendahl-Nielson, Hjermind, and Egerod (2008) reviewed the available literature regarding endotracheal suctioning. The authors searched literature from 1962 through the present. A total of 77 papers were included in the final review, four studies describing patient personal experiences, 19 literature reviews, two meta-analyses, and 52 clinical trials. Their analysis findings include recommending nurses should suction only when necessary, use a catheter occluding less than half of the lumen of the endotracheal tube, use the lowest possible suction pressure, and avoid saline instillation.
At this point, envision one of my graduates being directed by a nurse mentor during orientation to squirt 5 or 10 mL of sterile normal saline into the tracheostomy tube before suctioning. The student recalls being taught differently and remembers the evidence, but often abjectly yields to confident assertions of the mentor: "I've been doing this for 26 years and it works." The outmoded, unsupported, and potentially harmful practices continue.
Saline instillation is merely an illustration of a more pervasive problem. There are similar current nursing practice versus evidence-based practice conflicts. So, here are some questions for us all. How can nursing educators in colleges and healthcare systems create an environment that fosters the introduction of evidence-based practice? How can we empower new graduates to feel confident and assertive about what they've learned while being respectful of their professional 'elders'? How can we convince, co-opt, or even coerce long-time nurses to quit unsafe and ineffective interventions? Any suggestions?
References
Caruso, P., Denari, S., Ruiz, S., Demarzo, S., & Deheinzelin, D. (2009). "Saline instillation before tracheal suctioning decreases incidence of ventilator-associated pneumonia." Critical Care Medicine 37(1): 32-38.
Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.
Pedersen, C., Rosendahl-Nielsen, M., Hjermind, J. & Egerod, I. (2008). "Endotracheal suctioning of the adult intubated patient—What is the evidence?" Intensive and Critical Care Nursing 25(1): 21-30.
Sole, M., Byers, J., Ludy, J. & Ostrow, L. (2002). "Suctioning techniques and airway management practices: Pilot study and instrument evaluation." American Journal of Critical Care 11(4): 363-368.
Richard Freedberg, RN, MSN, MPA, is professor of mental health nursing at Lansing Community College in Lansing, MI. He continues to practice in a clinical setting, and has experience that includes staff nursing and management roles in medical-surgical and mental health acute-care settings, home-care nursing, and medical intermediate care.
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The phrase "simulation modalities" may conjure up a variety of images. For example, some nursing staff development professionals think of a sophisticated training mannequin that produces computer-generated EKG printouts, responds to intubation efforts, and virtually behaves in ways similar to an actual patient. Others may think of an IV arm used solely for learning how to start IVs.
The point is, there is a wide range of simulation modalities, but many staff development specialists know of only a few, and still more are as of yet unaware of the vast potential for providing education via simulation.
Low-fidelity simulation modalities
Low-fidelity simulations are described as those that feel the least real to the learner (Holtschneider, 2009; Mt. Hood Community College, 2009). These simulations can be paper- or computer-based and are generally static models that allow for very little learner interaction within the simulation. Examples include computer- or paper-based tasks, mannequins that do not have the capability for providing feedback (e.g., a Resusci Anne that only offers computer printouts that evaluate the accuracy of breaths and compressions), or an IV arm that allows students to practice IV insertion techniques without feedback devices (Holtschneider, Mt. Hood Community College).
Low-fidelity simulation modalities are relatively easy to implement and transport and less expensive to implement than more sophisticated modalities. However, they are the least real of the modalities and therefore do not provide learners with the experience or the feeling of actually working in real-life settings.
High-fidelity simulation modalities
Also referred to as a high-fidelity human patient simulators (HPS), these are often the first thing people think about when we say simulation. When using an HPS, educators can implement a variety of scenarios that they can tape and play back for debriefing or guided reflection, as well as create blended simulations, incorporating actors assuming the role of patients with low-fidelity task trainers.
HPS is usually dependent on some type of computerized mannequin that allows the re-creation of the physical patient in a realistic physical clinical environment. Mannequin-based simulators have become increasingly common in areas such as the OR, emergency department, and critical care units, where life-threatening situations that require recognition and treatment often occur. Some simulators can even mimic the effects of various drugs, track the distribution of the drug in the body, and determine the exact effects that a specific amount of the drug will have on the human body.
The costs associated with these types of simulation generally increase with the level of sophistication of the simulator. Complex simulators may also be more of a challenge to set up and transport than more simple simulation techniques. However, the level of realism introduced by high-fidelity simulation modalities truly brings the learner into an interactive, genuine work environment.
Standardized patient educators
A tactic that adds to the high-fidelity simulation modalities is the use of standardized patient educators (SP). SPs are educators who are specially trained to portray patients, family members, and, at times, even members of the hospital staff.
Using SPs lets learners engage in mock conversations with patients, deal with family members who are frightened and questioning, and cope with colleagues who may not be acting professionally.
SPs are used in a variety of academic settings, such as medical and nursing schools. However, their use is now becoming more common in clinical environments because they add another dimension of reality. However, they also add to the cost. Organizations hiring these educators must screen them carefully and hire only those persons qualified to assume such roles.
Serious gaming
The term "serious gaming" involves the use of video game technology to add another dimension to the learning process. Learners function within specific rules and guidelines while playing interactive computer-based games. These games generally present a complex healthcare situation (e.g., multiple casualties from a terrorist attack arriving at an emergency department) that requires the learner to intervene appropriately.
Although the game format is viewed as a fun way to learn, the games offer deadly serious scenarios. Serious gaming is an increasingly popular training mechanism.
Video and computer games can be developed fairly quickly and can simulate functional entities in various clinical settings. However, they can be expensive to develop and learners must have appropriate training in their use. In addition, they require the availability of adequate equipment for learners.
Desktop simulations and virtual worlds
Desktop simulations and virtual worlds can be run on a desktop computer and only need a screen, mouse, and audio inputs and outputs. The learner can view data, see the patient via animation, perform diagnostic or treatment interventions, and interact with the patient by typing or, in some cases, actually speaking with the patient.
An advanced approach to this type of simulation allows several participants to participate in a virtual world simultaneously. Learners can interact with each other, the patient, and others in this world. A distinct advantage of this type of simulation is the ability to interact with various healthcare team members as well as the patient and family.
Virtual reality and visualization
Virtual reality is a computer-generated world that allows the learner or group of learners to experience various stimuli, often in a 3-D presentation. Learners typically wear head-mounted displays to receive visual and auditory cues. They can interact in the computer-generated world from various sites or be in a physical space in which they can interact with others.
Virtual reality is a rapidly developing field and gives a true sense of realism. However, the creation of a complex virtual patient and treatment setting can be time-consuming and expensive. It requires a complete computer model of the patient environment; a way to track visual, audio, and touch fields; adequate hardware for all sensory modalities; and hardware to compute all models, track inputs, and produce outputs in real time.
Mt. Hood Community College (2009). "Fidelity simulators." Retrieved October 1, 2009, from www.mhcc.edu/pages/493.asp.
National Nursing Staff Development Organization (2008). "Collaborative efforts across organizations: Building a simulation alliance." Journal for Nurses in Staff Development 24(6): 303–304.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Staff Educator, an HCPro publication.
The nation's largest nurses' union and professional organization reached tentative agreement on a new contract with one of the biggest hospital systems in the country. The deal includes a collaborative effort to contain the spread of pandemics such as H1N1. The California Nurses Association/National Nurses Organizing Committee and Catholic Healthcare West agreed to establish a systemwide emergency task force of nurses and hospital representatives to monitor preparedness and set uniform standards that meet federal, state, and local government guidelines.
Tens of thousands of California healthcare workers are scrambling to get vaccinated for the H1N1 flu. Federal officials, who list healthcare workers among those at greatest risk for H1N1 flu, had promised California 6.2 million doses by now. But the state has received just 2.7 million doses due to manufacturing shortages, said Mike Sicilia, a spokesman for the California Department of Public Health. Nationwide, only about 27 million of an expected 40 million doses are available. With so few doses in hand, doctors and nurses say they have been forced to wait in line or volunteer at public clinics to get vaccinated, the Los Angeles Times reports.
Future doctors and nurses are learning about alternative medicine along with anatomy and physiology at a growing number of medical schools, the Associated Press reports. The government has spent more than $22 million to help medical and nursing schools start teaching about alternative medicine. Additional tax money has been spent to recruit and train young doctors to do research in this field, launching some into careers as alternative medicine providers.
A nursing union locked in contentious contract negotiations says Philadelphia-based Temple University Hospital is trying to infringe on the free-speech rights of the union and its members. The Pennsylvania Association of Staff Nurses and Allied Professionals, which represents 1,500 nurses at Temple, said it had filed a complaint with the Pennsylvania Labor Relations Board claiming the hospital was demanding that a gag clause limiting public criticism of Temple or its managers be included in the new contract.