Recognizing the findings in a patient with an impending myocardial infarction (MI) and intervening appropriately is essential for healthcare providers in improving patient outcomes. How this recognition best occurs depends not only on the underlying informative knowledge, but one’s experiences in applying this knowledge. A Doctorate of Nursing Practice (DNP) quality improvement, evidence-based project was implemented by the DNP student. The project provided a foundation for a change in the educational practices in a small community college nursing school, in an effort to better prepare students to positively affect patient outcomes as they enter the workforce. The system of change is identified as a community college school of nursing in rural Alabama, which has a state-mandated curriculum. A high-fidelity simulation exercise of impending MI was introduced. The scenario of a hospitalized patient was presented who experienced chest pain. High-fidelity simulation allowed mannequin-student verbal communication, physical findings, and EKG monitor changes which occur in this population of patients. Prompt recognition of this high-risk patient scenario and action taken is imperative for optimal patient outcomes. The exercise allowed students to experience and practice this high-risk finding in a safe environment. Evaluation and findings from the project suggest that the nursing students feel more confident in developing skills and knowledge of patients experiencing an MI and feel better prepared to intervene in the actual clinical setting.
Key words: simulation, active learning, myocardial infarction
Improving patient outcomes is the fundamental goal of all disciplines of healthcare, whether it is medicine, rehabilitation, nursing, or any of the many other providers of care. Core to the ability to providing optimal care is an understanding of human performance and the effects of disorder on this performance. This understanding comes at varying times throughout a healthcare provider’s lifetime. In the case of a patient experiencing an acute myocardial infarction (MI), it is detrimental to the patient outcome for the caregiver to promptly recognize this disease process’s effects on human performance and intervene appropriately and safely.
It is reported by Hand, Keenan, Ruggiero, and Simmons (2000) that approximately 1.1 million Americans experience an acute myocardial infarction every year with nearly 500,000 of them dying, one-half of which occur with 60 minutes of symptom onset. Medical science has provided treatment plans aimed at reducing cardiac muscle damage. Patient outcomes, however, depend on how quickly the impending MI is recognized and treatments initiated. The shorter the period of time between symptom onset, recognition and treatment, the greater number of lives saved.
Improving the outcomes of patients experiencing an impending MI by preparing nursing students to recognize the important findings in these patients, interact therapeutically with the patient, and initiate treatments in a timely manner was the focus of the DNP project.
While traditional lecture methods dominate most nursing school classrooms, it does not usually provide an avenue for active learning and yet, many students repeatedly explain that they “learn best by doing”. According to Kane (2004), active learning may be described as a theory, but it is also associated with implementing teaching methodologies that provide numerous examples of activities that educators can use in different learning environments. In considering clinical practice opportunities, many nursing students may not have the occurrence to care for a patient experiencing an impending MI. A need for change in teaching methods is recognized.
In the past several years, simulation has gained much popularity in nursing education and review of literature reveals much discussion on the topic. The literature gives account of the evolution of simulation activities and their impact on bridging theory with practice. This is readily evidenced by reviewing how flight simulators have improved aviation and space program activities. In healthcare, the development of Resusci-Anne began the movement towards simulation activities as a plausible way of teaching. Within medical-education, simulation-based learning has been found to be superior for acquiring critical assessment and management skills, (Steadman, Coates, Huang, Matevosian, Larman, McCullough and Ariel, 2006). In an effort to assist students in learning and thereby, better improve their ability to impact patient outcomes, a change in teaching methods was undertaken.
Newhouse, Pettit, Poe, and Rocco (2006) describe quality improvement projects as means to understand and improve processes, where individuals work together to improve outcomes, in order to benefit individuals served by the organization. Roueche, Baker, and Rose (1989) stress the importance of an organization knowing “what business it is in” and conclude that community colleges should, among other qualities, build relationships with learners, and be adaptable to new conditions or circumstances, with ever awareness of its community. The DNP student’s project was likened to a “microsystem in health care”, described by Godfrey, Nelson, Wasson, Mohr, and Batalden (2003) where a small functional unit became the focus for improvement. The system was called upon by the project’s focus to remember what business it’s in, accommodate diverse learning needs of students, and increase success for the student and program as a whole, and impact patient outcomes.
Duke University Medical Center (2005) presented The FADE Model, a method of quality improvement (QI), which provided the approach used to assess the present system targeted for change, and implement the proposed plan for change. The four steps of the FADE QI model include: 1) focus, 2) analyze, 3) develop, and 4) execute and evaluate.
The Iowa Model of Evidenced-Based Practice to Promote Quality Care provided the standard framework for the DNP project while the Nursing Education Simulation Framework allowed the best practices to become executable processes within the chosen system. The Iowa Model of Evidence-Based Practice to Promote Quality Care was chosen as the research model for the project as Titler (2007) reports that this model approaches evidence based practice from an organizational perspective rather than from the perspective of an individual provider. The Nursing Education Simulation Framework was developed and tested for the National League for Nursing/Laerdal Simulation Study (Jefferies, 2005) and has five conceptual components which include 1) teacher factors, 2) student factors, 3) educational practices that need to be incorporated into the instruction, 4) simulation design characteristics, and 5) expected student outcomes.
The project was implemented into a second year medical-surgical nursing course. The activity was offered as a supplemental learning activity. Participation was optional to students as the activity had not been formally addressed in the course syllabus. A total of 29 students (47%) chose to participate in the activity. Following the classroom presentation of the material, a high-fidelity simulation exercise of impending MI was introduced. The scenario of a hospitalized patient was presented who experienced chest pain. High-fidelity simulation allowed mannequin-student verbal communication, physical findings, and EKG monitor changes which occur in this population of patients. Prompt recognition of this high-risk patient scenario and action taken is imperative for optimal patient outcomes. The exercise allowed students to experience and practice this high-risk finding in a safe environment.
The DNP student chose to model the project design and evaluation from the leader in nursing educational standards. Jefferies (2007) discusses the tools developed by the National League of Nursing (NLN) in evaluating simulation activities. After approval from NLN, four of the tools were used in evaluating the project.
The Educational Practices in Simulation Scale (EPSS), a 16-item instrument designed to measure four educational practices: active learning, collaboration, diverse ways of learning, and expectations was obtained after simulation experience from the learners. The Student Satisfaction with Learning Scale and the Self-Confidence in Learning Using Simulations Scale, which measures student confidence in skills practiced and knowledge about caring for the type of patient presented in the simulation, was obtained after the simulation experience from the learners. The Simulation Design Scale (SDS), a 20-item tool that measures objectives, student support, problem solving, fidelity, and guided reflection/debriefing was obtained after simulation experience from the learners. The SDS, which is designed to evaluate specific features of the simulation, was utilized to provide feedback for future simulation designs. A debriefing exercise followed the simulation exercise to allow for student reflection of the experience and help promote learning from the activity. Observation of the simulation exercise by instructors also provided appraisal of group dynamics, and attitude and communication skills, as they related to the scenario presented.
Overall findings from students suggest that 1) learning time was perceived to be more productive, 2) the teaching methods were useful, motivating and effective, and most importantly, 3) helped students become more confident in developing skills and knowledge to perform necessary tasks in a clinical setting.
Assisting nursing students, novice nurses, or seasoned nurses who encounter unfamiliar territory to understand the practices of nursing is a responsibility of educators, mentors, and leaders of nursing. As technology enables more effective teaching activities to be utilized, it is important to evaluate their effectiveness. Results from this project suggest that students feel better prepared and more confident in caring for future patients. The project represents the beginning of changes in the teaching methods used at the institution. Based on the results from the project, the institution will incorporate additional simulation activities into the curriculum in an effort to increase student confidence and competency.
Duke University Medical Center (2005) Patient Safety-Quality Improvement- Methods of Quality Improvement. Retrieved June 2, 2008, fromhttp://patientsafetyed.duhs.duke.edu/module_a/module_overview.html
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