Leading Nursing Education: Building Patient Safety Into Clinical Care

Sunday, November 1, 2009

Ellen Cram, PhD, RN1
Teri Boese, MSN, RN2
Anita Nicholson, MSN, RN3
Anita Stineman, PhD, RN2
Elizabeth Swanson, PhD, RN2
1College of Nursing, University of Iowa, Iowa CIty, IA
2College of Nursing, University of Iowa, Iowa City, IA
3Department of Nursing, Coe College, Cedar Rapids, IA

Learning Objective 1: describe educational strategies to enhance student demonstration of patient safety behaviors.

Learning Objective 2: identify ways these strategies could be incorporated into other educational settings.

Leading nursing education: Building patient safety into clinical care         

Patient safety is dependent upon individual nurses routinely behaving in ways that have been demonstrated to contribute to error reduction. If these behaviors can become habit for students, when they enter practice, they can help lead organizations in patient safety culture transformational efforts. Specific behaviors we are attempting to “hardwire” into students’  practice are 1) use of two patient identifiers 2) use of standardized communication tools 3) verification of verbal orders and 4) methods to reduce common medication errors.

Learning strategies used to teach these behaviors include assigned readings, discussion and active participation in clinical simulation to demonstrate integration of these behaviors into clinical care and written personal reflection. Safety strategies desired are the use of patient name and birth date to confirm accurate identity prior to delivering medication or other interventions, use of the Situation Background Assessment Recommendation (SBAR) tool for nurse-physician communication and standardized hand-off tools for nurse-nurse report, read back and verify (RBAV) for any verbal orders, two nurse checking using a proved script for high risk medications and systems to minimize medication error such as stocking only one concentration of a drug and labeling strategies.  Use of checklists, time outs and “common sense” testing prior to deploying high risk interventions is practiced.

Students in the baccalaureate nursing program and the second degree entry into master’s nursing program are required to participate in a minimum of 10 clinical simulations during their educational program.  For each simulation, students use a high fidelity human patient simulator located in a setting that realistically resembles a hospital room complete with current bedside equipment. Each simulation includes background patient history, clinical data such as vital signs and laboratory data.  In small groups of 3-4, students plan and provide care to this patient. The simulated patient mannequin is programmable to have audible breath and heart sounds, palpable pulses and other physiologic responses. The instructor provides other input as the student requests information. For example, if the student asks the “patient” about pain, the instructor provides information in the voice of the patient.  

Students provide care to the simulated patient for approximately 30 minutes. At the completion of the simulated care experience, the instructor leads the students in a structured debriefing session. Each debriefing includes a focused discussion on the safety behaviors that were expected in that case.  Following the group debriefing session, each student writes an individual critique of the simulation reflecting on what went well, what they would like to improve if they were to provide this care in the future, what they learned and how well they worked together as a team.                The student performance, teaching methods and potential for use in other settings will be discussed.