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.
Copyright M. Anderson 2012
Objectives Continued
• 5. Discuss collaboration with
multidisciplinary leadership.
• 6. Describe how to plan and
implement pediatric simulations.
• 7. Define measurable objectives
for success.
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Medical/Legal
Environment
• Can not use actual patients for
skills = safety
• Policies and procedures =
students
(Nishisaki et al., 2012)
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Legal Care
• Adolescents (case example)
– Inconsistent laws
– Considerations
• Confidentiality
• Consent by minors
• Emancipated minor
(Hicks & Rome, 2011)
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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)
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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)
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Issues in Pediatrics
Decreased skills
Seasonality
Shift = outpatient care
Graduate = site issues, decreased
preceptors
• Missing curricular pieces
•
•
•
•
(Cook, 2012; Schneider Sarver et al., 2010)
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Issues in Pediatrics
• 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)
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Issues in Pediatrics
• 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)
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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)
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History of Pediatric
Simulation
• Virtual = clinics in Second
Life® (SL) (Cook, 2012)
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Role of Simulation –
Quality Education
• Skills
– Communication
– Medication
dosage/administration
– Assessment
– Procedures
– Charting
• Clinical judgment
(Bultas, 2011; McQueen et al., 2011)
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Role of Simulation –
Quality Education
• 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)
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Role of Simulation –
Quality Education
• A way to teach EBP
• Incorporate core concepts
(Aebersold, 2011; Waxman, 2010)
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Interdisciplinary
Simulations
• 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)
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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)
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Interdisciplinary
Competencies
• Interprofessional Education
Collaborative Expert Panel (2011)
• 4 categories competencies:
– Values/ethics
– Roles/responsibilities
– Communication
– Working as a team
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Collaboration –
Multidisciplinary Leadership
• Bring disciplines to the table
• Leaders/stakeholders from
each
• Who can you collaborate with?
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Who is
Available/Willing?
•
•
•
•
•
Medicine
Nursing
Social Work
Chaplains
Radiology
• Respiratory
Therapy
• Pharmacy
• OT/PT
• Phlebotomy
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Consider
• Who else?
• Think about hurdles prior
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Interdisciplinary
Simulations
• Death/dying = child
(Youngblood, Zinkan,
Tofil, & White, 2012)
– Purpose = Communication
– Mannequins/actors
– Participants:
• Fellows
• Nurses
• Social workers
• Chaplain
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Interdisciplinary
Simulations
• One study (n = 105) = increased
collaboration between physiciannurse with each scenario (Messmer,
2008)
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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)
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Interdisciplinary
• What are your shared
goals/content/competencies?
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Scenario Time
• Use pre-written versus write your
own?
• Pre-written:
– Ex.
• http://www.mysimcenter.co
m/enUS/SimStoreHome.aspx
• Pre-written = may need to tweak
(Durham & Alden, 2008 )
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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/checkl
ists__worksheets/entry2459.aspx
– NLN(2010); Childs, Sepple &
Chambers, 2007
http://sirc.nln.org
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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)
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What is Your Goal?
• Purpose
• Ex.
– Skills
• Learning
• Practicing
– Competency
– Team training/teamwork
• Every scenario vs. specific
focus
(Cheng et al., 2012; Stillsmoking, 2008)
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Considerations
• Do not “throw them the kitchen
sink”
• “Save the world”
• Start with a code
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Considerations
• Maintain reality
• Do not “trick” participants
(Cheng et al., 2012)
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Topic
• Dog or zebra?
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Characteristics
• Focus
– Ex.
• Simple versus complex
• Procedures vs. critical
thinking (putting it all
together)
(Anderson & LeFlore, 2008)
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Choose Teaching
Strategy
1. Observing
2. Diagnosing
3. Treating/Intervening
4. Interacting
5. Practicing- pass/competent
(Murray, 2004)
Choose How You Will
Run
• Pre-program vs. “on-the-fly”
(Childs et al., 2007)
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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)
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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)
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Remember- Objectives
• This is the most important step!
(Waxman, 2010)
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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)
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Objectives
• Use appropriate verb (action)
• Bloom’s (higher levels?) cognitive
(Overbaugh & Schultz, n.d.)
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Remember
• As you are writing objectives,
how will you evaluate?
• Remember critical behaviors
(Anderson & LeFlore, 2008; Smith, 2000; Waxman, 2010)
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Let’s Write Some
Objectives
• Let’s take a look at the following
situation
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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)
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Let’s Write Some
Objectives
• Let’s try another scenario
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Type of Simulation?
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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)
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Skills
• What skills/knowledge do
participants need to come
with?
(Anderson & LeFlore, 2008; Childs et al., 2007;
Laerdal, 2010)
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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)
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Patient
• What will he/she look like at the
beginning?
• Monitor should match
(Laerdal, 2010; Stillsmoking, 2008)
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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)
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Writing the Scenario
• Equipment
• Moulage/supplies/props
(Alinier, 2011; Childs et al., 2007; Laerdal, 2010)
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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)
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Writing the Scenario
• 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)
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Ending
• How/when will it end?
(Alinier, 2011; Murray, 2004; Stillsmoking, 2008)
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Complexity
• Suggestions
scenario
more complex
• Example: culture (Spanishspeaking only), comorbidity (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)
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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)
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Keys to Success
• P’s for Success
– Passion
– Plan (Personnel, Participants,
Props)
– Prep (Patient, Participants)
– Practice
– Proceed
– Process (Debrief)
(Alinier, 2011; Horn & Carter, 2007)
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Form Collaborations
• Helps with resources
• Ex.
– Canadian Pediatric Simulation
Network
– EXPRESS - research
(Cheng et al., 2011; Grant & Cheng, 2010)
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Research Needs
• Whether simulation improves
outcomes with patients
(Birkhoff & Donner, 2010)
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References
• See provided reference list
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