|Teaching Tools: 10-Minute Assessment for Patient Safety
|Lisa Wolf MS, RN, CEN
Elizabeth Fiscella MS, RN, CNS
Helene Cunningham MS, RN
Volume 33 Number 6
Pages 237 - 240
One of the most difficult tasks that a novice student needs to master is the conceptual organization of the patient assessment; many of our clinical students spend a good amount of time standing outside a patient room trying to figure out what to do first. Our 10-minute assessment provides a script, a road map, and a method of student and self-evaluation, which increases student and faculty confidence and encourages patient safety.
Why We Need a Script
Nursing students anticipating their first clinical experiences are inherently stressed. Their exposure to anatomy, physiology, and pathophysiology has been purely academic; the prospect of translating this knowledge into patient care can be exciting, but it can also be intimidating. Students' anxiety may be so acute that it impedes application of clinical skills newly acquired in the nursing laboratory. In our program, we bridge classroom learning and actual patient care with the use of human patient simulators.
Simulation is used to teach and reinforce basic assessment skills, giving students the opportunity to make diagnostic and treatment errors in a safe and controlled setting.1 Simulation is also used to evaluate students using a "standardized" patient, which is nearly impossible in a clinical setting.2 Students report that simulations help codify instructional knowledge and make it applicable to actual patient situations.1,2 Other studies report that simulation allows student-centered, active learning experiences.3 Although practice is a key component of skill acquisition, only a small percentage of students feel really comfortable in head-to-toe assessment even after simulated experiences.4 Henneman and Cunningham 5 suggest that early exposure to simulation is important to increase student comfort.
Because of these issues, we construct simulations, usable early in the program, that address both organizational and critical thinking skills, especially for these novice students. Unlike the actual clinical setting, the clinical simulation laboratory is a controlled environment using SimMan (Laerdal, Wappingers Falls, NY) manikins to provide a predictable, constructive approach to help reduce student anxiety. This uninterrupted, supportive learning environment also promotes the practice of simple to complex problem solving and critical thinking through the use of simulation-mediated case studies. The students can practice their newly acquired skills without fear of making errors that might affect actual patients under their care. The laboratory allows for improvisation, spontaneity, and development of clinical rhythm and style, a beginning socialization into the nursing profession. In addition, this teaching-learning environment promotes one-on-one student-instructor interaction. Nursing faculty can nurture the students' development while facilitating the initial task of just entering the patient room.
The 10-Minute Assessment
Our 10-minute assessment provides a simple framework for conceptualizing that first initial contact with a patient in an acute care setting. It is a step-by-step guide on how to approach the immediate patient care environment. Elements of the assessment are shown in Figure 1. In its initial form for our novice student, the 10-minute assessment requires the student to perform a concise, timely, and realistic head-to-toe assessment. The simulation begins with the student entering the room (sometimes the most difficult of all tasks for a novice); washing his/her hands; introducing himself/herself; and identifying the patient via name band, date of birth, and medical record number. The student then observes the entire patient picture-the breathing pattern, level of consciousness, mental status, pain status, and equipment used and integrates these data with the patient's significant medical history and admitting diagnosis to identify and problem solve any immediate needs of the patient. In the initial simulation for our novice student, the assessment findings are normal as the student assesses the respiratory system, cardiac system, abdomen, extremities, skin, intravenous catheter placement, and running fluids. Novice students have to know what normal is before they can identify abnormal findings.
|Figure 1. Student 10-minute initial and focused problem assessment for a patient.
|Figure 1. continued.
All the students' future clinical courses, including pediatrics, maternity, and advanced medical surgical, have a required 10-minute assessment simulation as a base for more complex simulations. In these more complex laboratory simulations, the patient manikin develops a complaint or abnormal finding that leads the student to a more focused ssessment.
Implementing the 10-Minute Assessment
With the clinical instructor during the first clinical experience, each student is scheduled to perform and obtain a passing grade using the 10-minute assessment tool framework on the patient manikin. This allows the student to have a one-on-one confidential evaluation with his/her clinical faculty member without the distractions and pressure of his/her peers or the added anxiety of an actual patient.
Students have ample opportunity to prepare as they are taking a health assessment course concurrently with their clinical course where they practice on the manikin, taking pulses and blood pressures and assessing heart, lungs, and bowel sounds. Students view a video with a faculty member demonstrating the 10-minute assessment on the manikin. The students are given the 10-minute assessment tool with a short case description of the simulated patient before coming into the laboratory to be tested; they cannot use the tool during the actual simulation but may refer to it at the end of the assessment to make sure they have not missed any important areas.
The clinical faculty member runs the simulation in a control booth and uses a microphone to provide the patient's response; the students speak to the manikin as if it was a real patient. For example, the students are required to identify themselves with their full name and role and give the patient a brief description of what they are about to do ("Good morning, my name is_____. I am a student nurse and I am here to do a brief assessment of your health status today. Is that all right with you?"). At the same time, the faculty also observes the student and uses the tool to record the student's performance. After the simulation, there is time for the students to reflect on their practice (usually what they forgot to do), after which the faculty provides feedback to the student on areas wherein the student did well and areas wherein the student needs to improve. The student and faculty then discuss how the student can improve his/her practice the next time in the clinical setting. If the student does not pass, based on the guidelines listed on the tool, he/she must repeat the simulation experience until he/she is successful. This way faculty can see that the novice student has mastered the objectives and is safe to assess an actual patient.
The 10-minute assessment is designed with a clear focus on process, expectations, and outcomes. It is a framework for teaching, a study guide, and an evaluation tool that addresses student organization, communication, and general assessment skills, as well as patient safety issues. The 10-minute assessment emphasizes the important role of the nurse in the continual assessment of the patient and promotes a comfort level for the student in this new clinical milieu. Assimilating this new information into their general frame of knowledge and through repetition of performing these tasks, students develop a habitual approach to every patient encounter, resulting in safer patient care by and, at the very least, reducing error by patient misidentification.5
This 10-minute assessment is the core around which all subsequent clinical simulations are based. We expect that every nursing student will begin every patient encounter with hand hygiene, self-introduction, proper identification of the patient, allergy identification, and a brief head-to-toe assessment. By practicing this sequence over and over, it becomes second nature; the assessment becomes organic, and the student can more quickly notice abnormalities in the assessment sequence.
As a learning tool, the 10-minute assessment prepares students for clinical practice. Students report feeling more organized and "able to get in, assess, and get out" without getting distracted by visitors, physicians, or nursing assistive personnel. Instructors feel that students are more focused and better able to use the clinical information they obtain. At the end of the simulation experience, students give us feedback, which we use to improve existing simulations and develop new ones. The themes that emerged from recent clinical responses were improved confidence, reduced anxiety, and clarity of process. Students' comments included the following: "Overall, I feel a lot more comfortable practicing a 10-minute assessment on the SimMan than on a 'real' patient!" "Now that I know this 10-minute assessment better, and have been practicing it, I feel a lot more organized." "I feel like I can go into a patient's room with a purpose and a plan" Continuously practicing on the simulation man will reduce identity error and medication error and prevent allergic reactions.
Because the 10-minute assessment is used in the first clinical semester, investigation into how well students perform throughout the program is necessary. Other uses for this tool may include clinical observation and evaluation.
Faculty members are more confident with their students' assessment skills since they can observe and evaluate their students in the clinical simulation laboratory first. They are able to see and, most importantly, the students are able to see gaps in student knowledge, and they can be corrected. This 10-minute assessment is the base upon which all our further simulations and evaluations are built and is a key strategy for our students to be organized, thorough, and safe.
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