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 series
1. A systematic review of simulation in nursing – Cant &
Cooper 2010
2. Nursing students’ knowledge, skill, and situation
awareness. Cooper et al 2010 – NBV funded
3. Management of deteriorating women – Cooper et al –
current. Equity Trustees: Walter Cottman Fund
4. Management of deterioration in rural hospitals. Cooper
et al – current. Gippsland – Monash University Grant
5. Simulation in midwifery – a national review – Bogossian
et al – current. Health Workforce Australia
6. Team management of deterioration in rural hospitals.
Cooper et al – Contract research funding
7. 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 intervention
1. 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
Instruments
3. Situation awareness (17 questions at end of scenario using
SAGAT)
4.
>
>
>
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?
Video review ‘photo elicitation’ (to elicit decision points and
strategies)
5.
6.
7.
Performance feedback
Evaluation
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
5.
Performance
Feedback
Debriefing
4. Reflective
Review
Photo elicitation
2. Assessment:
stimulus for
learningKnowledge test
3. Simulation
High fidelity
kinesthetic
skills development
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
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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