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Bedside Clinical Teaching Simulation Role Play

Part I: Description of Bedside Clinical Teaching Part II: Bedside Clinical Teaching Simulation Lesson Plan Part III: Role Play Script
Part I: Description of Bedside Clinical Teaching Description Bedside Clinical Teaching (BCT) is a teaching method for bringing evidence-based knowledge about clinical problems and patient-specific information together in an encounter at the bedside to increase information exchange and skill development between direct caregivers including nurse assistants (NAs), licensed practical nurses, and other RNs providing direct care. This encounter is led by an RN who develops and coordinates the learning experience. BCT facilitates patient-centered care, promotes safety through improved communication and use of evidencebased care practices. BCT can be an effective leadership skill for RN delegation and supervision. Methods In a short encounter of 10-20 minutes, the RN leads a teaching session at the resident‟s bedside that involves identification of a specific clinical topic or skill, and the need for applying or using this skill in the care if that patient. The RN identifies the focus of the session and uses a variety of methods in this experiential learning encounter such as, demonstration/return demonstration, coaching, skill-building. The learning encounter focuses on how the staff would use the new skill in the care of the patient, according to their care needs. The patient‟s care plan is reviewed and goals emphasized. The role and responsibility of each staff member is emphasized and skill building focuses on increasing competency and confidence. Purpose BCT is conducted to build knowledge and skill by strengthening communication and linkage among staff through the exchange of information among paraprofessional and professional nursing staff and the interdisciplinary team in patient care. The BCT session utilizes adult learning principles in dynamic experiential learning sessions that capitalize on existing staff strengths in knowledge and skill, to build a shared fund of knowledge among a functional team (such as on a clinical unit) as well as among staff within the larger organization. Topics for Bedside Clinical Teaching 1. A Resident Care Issue is selected based on identification of a new patient problem that needs assessment, or a chronic problem that requires monitoring. Nursing staff is competent in the relevant assessment or observation skills but need information about the problem and its relevance to the patient‟s current status and care needs, their role, and their responsibilities for assessing, observing, monitoring and/or reporting. 2. A Staff Knowledge or Skill Issue is identified relative to a resident care need that warrants verification of staff competency.

©Bedside Clinical Teaching, D. Lekan, 2008, Duke University School of Nursing

Encourage peer modeling and peer teaching by asking LPNs and CNAs to demonstrate a skill. Outside of the resident‟s room. but optimal size is 6 participants. Provide reassurance about the session. Facilitate opportunities for interdisciplinary co-teaching and for peer learning. Note any significant findings in resident‟s chart and prepare a Nurses Note. skill deficits. Provide praise and recognition to individual staff for performance of skills. care issue or skill to be learned and the relevance to the patient‟s care. Do: Enter the room. Demonstration & Return Demonstration: Demonstrate assessment techniques. Review. Duke University School of Nursing . Review the medical record for recent developments. Coach the LPN or RN in the construction and writing of the note. At the designated time. D. Review the literature and prepare a focused teaching session. or patient care issues. 9. skill. Keep information simple and focus on just a few key points or skills. 7. 5. For the clinical topic. given the type or level of assessment documented. summarize new information and review any medical or nursing care concerns or circumstances. 6. remind staff on the location and time. meet at the nurse‟s station or outside of the patient‟s room. Feedback: Discuss significant clinical findings. Sessions can be delimited to specific units or open to staff. Discuss the clinical topic. explanation. thank the patient for allowing the group to talk with him or her. Select a resident who will be the case exemplar and obtain their consent and willingness to have several staff member conduct an assessment or discuss their care in a short session. date and time. debrief with the staff about the interview and assessment. 4. or specific patient care need. Debrief. Identify how to involve in the learning session. Identify one or two goals for the session. Be sensitive to the patient‟s emotional state and note any anxiety that may arise during this session. 10.Bedside Clinical Teaching Procedure 1. Prepare. discuss key aspects of the clinical topic. Incorporate experiential learning methods. Plan: Determine key people to include as co-teachers. Collaborate: Talk with nursing staff and interdisciplinary team to identify a key clinical problem. Coach RNs and LPNs in specific assessment techniques and coach CNAs in how to become more astute in observing key signs and symptoms. Document. CNAs) as co-teachers and provide brief summaries of information relevant to the instructional topic. Lekan. Recruit and Convene. 8. key skill techniques. Co-sign the note if indicated. or describe their experience in the care of this patient. emphasizing that it is a teaching encounter to help nursing staff better understand their care needs. Elicit their input on their clinical observations. Discuss the key points that will be addressed in the session. a resident care issue or a nursing staff knowledge or skill issue. understanding of the problem. 3. Mentor different nursing staff (RNs. Verify key points of assessment or care plan. or relevant history. ©Bedside Clinical Teaching. On the day of the session. Establish the plan for the teaching session with regard to skill demonstration and return demonstration. if able. Post and disseminate information on the BCT session including topic. 2008. Involve the resident in discussing their care needs. LPNs. Invite questions and discussions. greet the patient and review the purpose of the team visit and ask about their wellbeing. new orders. 2. Encourage questions. Keep the session short and before leaving. patient experiences and case examples. identify the staff‟s current knowledge as well as gaps and provide clarification. and examples. and use principles of adult learning and multiple learning styles to plan the session.

2008. rewards. ©Bedside Clinical Teaching. pre tests and post tests. Lekan. skill checklists. focus groups. Make rounds on a regular basis to approach nursing staff to talk about the new knowledge covered in the BCT session and to get verbal validation of knowledge and to observe their performance. 12. Periodic follow up to for observation and discussion validates continued competence and need for additional education and training. Evaluation: Use different methods to determine the effectiveness of the BCT sessions: participation rates. and to motivate continued competence and a high level of performance. safety data related to proper technique or use of equipment. D. Document program outcomes and evaluation quarterly and in an annual report. Plan additional BCT sessions with groups of staff to improve practice. and commendations for exceptional or exemplary participation. Identify gaps in knowledge and skill and develop individual learning strategies to address these gaps. performance reviews. 13. Evaluation The RN observes staff performance of behaviors and skills and provides constructive and reinforcing feedback. incentives. to foster skill and knowledge acquisition and application. Celebrate success: Provide positive feedback. Publicize individual and group achievements verbally and in writing. staff interview and feedback. Duke University School of Nursing . Give corrective feedback to facilitate deeper understanding. Follow-up.Bedside Clinical Teaching Procedure (continued) 11.

using heart failure (HF) as an exemplar. Specify what data you will collect from the chart. skill and attitudes of additional LPNs and NAs relative to the task at hand procedure scenarios Emphasize importance of knowing individual staff 5. Conducting the Role Play/ Simulation Prebrief: 10 minutes Conduct Debrief: 20 minutes Large Group discussion the Role 1. Explored issues related to RN delegation and supervision with paraprofessional staff in long term care. Give each student a role Highlight issues regarding communication with play: (described below). Explain the scenario Discuss leadership and adult learning teaching per strategies that could be used in the scenario 3.” audience is asked arise e. and how you will conduct the assessment.g. Volunteer students “get that often member‟s strengths and weaknesses and into role. Instruct class to pair up and discuss/record the key aspects of the HF assessment when confronted with the following scenario: You are told by one of the CNAs that Mrs. You decide you need to assess the patient for acute HF. implications for delegation and supervision and to identify one leadership or Staff who BCT as a leadership strategy one adult learning strategy are not they would use in this interested. Objectives At the end of the session the learner will have: 1.Part II: Bedside Clinical Teaching Simulation Lesson Plan Purpose This in-class exercise features an experiential learning exercise using Bedside Clinical Teaching as a leadership skill for RN delegation and supervision of paraprofessional staff in LTC. using heart failure as an exemplar. is coughing up frothy sputum and is confused. D. 2. leadership. scenario too busy ©Bedside Clinical Teaching. Duke University School of Nursing . Heart is having trouble breathing. Lekan. You do not know this patient except that she was admitted yesterday for recovery from flu. Review the Bedside Use of Bedside Clinical Teaching as mechanism play Clinical Teaching for evaluating knowledge. 3. Instructions 1. The learning activity prepares the student for a clinical rotation assignment that highlights strategies for facilitating evidence-based practice in a team context that includes licensed practical nurse and nurse aids and addresses scope of practice implications. 2008. Review key aspects of the session: RN delegation and supervision-understanding roles Generate HF nursing assessment and scope of practice and role 4. skill and attitudes relevant to delegation and supervision. Time 1 hour in-class session. and legal implications of delegation and supervision. paraprofessional staff –the importance of open Print roles on index cards. 10 channels of communication minutes 2. Experienced Bedside Clinical Teaching as a leadership strategy to foster RN appraisal of LPN and CNA knowledge. The role play simulation provides an opportunity for exploration and discussion of the clinical. She has a history of myocardial infarction and heart failure. Solicit volunteers from the class for the role play 2.

Implementing new orders for treatment vi. Immediate reporting of observations to the RN iii. Review key signs and symptoms of acute heart failure and the RN assessment i. Duke University School of Nursing . HF nursing assessment form. lungs. Lekan. vital signs b.Additional Debriefing questions: Large group discussion: questions and feedback from audience a. and NA worksheet d. D. Highlight assessment of heart. How to use of FACES pocket card. Review the purpose of the HF program in the long term care facility: i. RN assessment and determination if MD or nurse practitioner needs to be notified iv. Documentation of the assessment in the Nurses Note v. edema. Student reporting to the Charge Nurse on the HF assessment findings ©Bedside Clinical Teaching. Monitoring patient symptoms each shift c. Early recognition of early changes indicative of evolving heart decompensation ii. 2008.

CNA: JoeCNA 5. Lekan. Patient: Mrs. LPN Charge Nurse: MargaretLPN 7. The director of nursing and medical director support the efforts of the students to teach staff about detection of acute signs and symptoms. RN Staff Development Nurse: RubyRN 4. D. Actors 1. Heart 2. The unit is a 32 bed unit with a high number of heart failure patients who are frequently transferred to the hospital in acute heart failure. RN Day Supervisor: BeckyRNSUP 3. Physical therapist: JackiePT Materials Scripts for each actor printed on an index card Nurse Aid HF Worksheet HF Nursing Assessment Form FACES pocket card ©Bedside Clinical Teaching. 2008.Part III: Heart Failure Role Play Script Background The setting is a 120-bed nursing home. Duke University School of Nursing . RN Charge Nurse: „your name‟ RN 6. Reduction in hospitalizations and better patient outcomes can be achieved by early recognition and reporting of acute heart failure signs and symptoms to the physician or nurse practitioner since in many cases. medical treatment will prevent acute heart failure exacerbations.

However. D. they would not experience the physiologic and emotional stress and trauma of acute heart failure. I‟m not doin‟ it. You think that if patients had better monitoring and early medical treatment. Therefore. You ask him how it is going using the FACES chart and doing the observation. found JoeCNA in the hall. etc.„Your Name’. You went in this morning to see how Mrs. It seems like a routine and you don‟t think that there is enough attention paid to recognizing early the signs and symptoms of acute HF. and ask him about Mrs. This was totally different then his behavior in class. You think that if these S&S were picked up. Heart. He is known as the „class clown‟ and was very interactive and positive about the program. Duke University School of Nursing . I don‟t have time.” You are shocked and surprised. workload. and had attended all the HF classes and unit teaching sessions. RN. You have been teaching the CNAs on your floor how to better observe for early signs of HF by using the FACES chart. You have worked with BeckyRN Staff Development Nurse to implement a Heart Failure Prevention Program. when the acute flare up is mild and not severe. You have noticed that many patients go in to the hospital for heart failure.” You go with JoeCNA to see Mrs. “Let‟s go see Mrs.) You explore the situation and say to JoeCNA. 2008. You minimize the negativity of the interaction (and hold at bay the opinion that CNAs don‟t want to do extra work or resent the management for low pay. Lekan. Let‟s go see her and we can do some observations to see how she is doing. They need to change something here. Some patients never really get back to baseline and progressively lose function little by little. Heart was doing and on the way. they would not go into acute heart failure and need to be hospitalized. and it takes them a long time to recover and get back to their baseline level of function. when you approach him on the unit. assessed by the RN. Charge Nurse This role highlights the role of the student in the clinical setting who is preparing to teach nurse aids and licensed practical nurses about heart failure signs and symptoms. You are a new graduate and have been working at this nursing home for 6 months. you would be able to alert the MD or NP and the patient could be treated in the nursing home. JoeCNA had been initially enthusiastic about the HF program. and reported. You have observed that when patients are hospitalized for HF they come back weaker and more frail. she is in bed resting. Heart. recognizing scope of practice limitations and the importance of open and accurate communication between staff members for patient safety The role play focuses on the application of clinical and leadership strategies to help teach nursing staff new evidence-based information about early recognition of acute heart failure using the FACES pocket card. Heart and I promise you that you already know 80% of this HF worksheet because you KNOW your patient and you are a good observer. he says: “unless they plan to pay us more to do this HF stuff. ©Bedside Clinical Teaching.

You coach him in making observations for each of the FACES symptoms and discuss their significance. but in actuality. It seemed to over-whelming. You learn that he can tell youA LOT about his patient based on his morning care with her. When you complete the assessment you emphasize the importance of reporting these new findings to the Charge Nurse. JoeCNA had avoided using the FACES chart because he did not see the importance in observing for all of the signs and symptoms on the chart. Lekan. Duke University School of Nursing . ©Bedside Clinical Teaching. he was already doing just that. 2008. D. You learn later from the Staff Development Nurse that he has a learning disability and cannot read. You affirm his knowledge of the patient. his keen observation and ability to compare current changes with her usual baseline. He could tell you his observation for each of the FACES indicators.You both stand in the doorway of her room and you ask him to talk to you about her. Nobody really knows this but she and a couple of CNAs who help him do his charting. using the FACES chart to guide the discussion on the main signs and symptoms.

you become more FATIGUED. you did not have a fracture or any other injury but you are bruised and “ache all over”.Patient: Mrs. D. You even have to rest when you are brushing your teeth. You have a “heart condition” that flares up from time to time. your sputum is frothy but not blood tinged. ANXIOUS and SHORT OF BREATH. high cholesterol. osteoporosis. Fortunately. Duke University School of Nursing . You notice that prior to the acute flare up. Here is how you are feeling NOW: F: Fatigue: you feel profoundly tired and have trouble doing your ADLs without taking frequent rest periods. You hope to return to your apartment on the CCRC campus soon. Fast Pulse: you feel your heart racing from time to time A: Activities of Daily Living: you find that you sometimes feel too weak and tired to do your ADLs and the JoeCNA has to help you. You sometimes forget to take your heart medicine on schedule. You are able to walk with assistance. starting last night. You need some help with activities of daily living and transfers but are mostly independent. ©Bedside Clinical Teaching. 2008. mild cataracts Heart Failure History: You have had 3 hospitalizations over the past year for acute heart failure. Heart You are an 84 year old white female. you feel the need to take deep breaths and cough. You have one daughter who looks in on you weekly but she travels periodically out of town with her job. Medical Diagnoses: Heart Failure. you were admitted to the nursing home for a short stay to recover from an upper respiratory infection. Appetite: You notice you just don‟t feel as hungry as usual and you have not eaten well the past couple of days-no appetite. staying about 5 days each time. You need some time to recover because you became very weak and. Today. You live in a one bedroom apartment on the campus of a continuing care retirement center (CCRC). and you are alert and oriented. and had a fall. Two days ago. Cough: you notice a cough. Lekan. This has been going on for 4 days. dehydrated. you experience worsening symptoms for about a week. osteoarthritis. C: Congestion: a few days ago you noticed some growing congestion and sputum. It can take you all morning to do your AM care. Typically. You feel frustrated and discouraged about this. You take the CCRC shuttle to town to shop or meet friends. history of MI 2 years ago.

You lose track of the day time routine and you sometimes have to ask JoeCNA what time it is and what day it is. Duke University School of Nursing . Good thing JoeCNA was there to help you. You don‟t have any chest pain right now. ©Bedside Clinical Teaching. Yesterday. Elimination: you have been up 4 times to urinate the past few nights. You are feeling quite anxious. D. Chest pain: the last time you had acute HF you had mild chest pain.Confusion: you notice you have trouble paying attention and concentrating on what is going on around you. Lekan. You get SOB when you are talking and when eating. S: Shortness of Breath: you are more short of breath than usual and the least little bit of activity makes it worse. E: Edema: you notice that your rings are tight and your shoes don‟t fit. It scared you and you had to take some NTG. 2008. and that was different than before. You have to immediately stop what you are doing. you wore your slippers because your feet were swollen and your legs felt „puffy‟.

Smith. You don‟t feel that you need to assess Mrs. Heart. Day RN Supervisor You have been an RN for 30 years and have worked at this nursing home for 10 years.“standard operating procedure”. Heart you will just call Dr. You notice that she gets really anxious and frightened when she starts getting short of breath. Staff Development Nurse and JackieCNA about the new patient. Heart should be in the hospital and not here. You‟ve seen this before. 2008. to get their medicines „tweaked‟ under medical supervision. Lekan. You know most of the residents very well. it is just a routine event. You happen to be making rounds on the unit when you come upon JoeCNA talking with SheilaRN. This is just a routine occurrence.BeckyRN. You think that Mrs. D. ©Bedside Clinical Teaching. Duke University School of Nursing . who will write orders to have her transferred and admitted to the local hospital. Mrs. You think that patients with heart conditions like hers need to go in to the hospital for „tune ups‟ every so often.

2008. with other RN assessments. you get to know the residents and listen to their stories about what their life was like in younger years. You become alarmed about what JoeCNA tells you about Mrs. he has a learning disability and cannot read. He says that unless “they” pay him for doing this extra work. You tell the RN Charge Nurse confidentially that this may explain why he was resistant to doing the FACES worksheet. Heart‟s symptoms. and needs much more help with her morning care. Mrs. As you question him about her symptoms. Duke University School of Nursing . you learn that he has lots of information about the progression of her heart failure symptoms over the past couple of days. “She is about to jump out of her skin!” and “She is nervous as a cat!” You ask JoeCNA if he used the FACES chart to record his observations. You know Mrs. Lekan. and cares deeply for his patients. Heart does not seem that sick although today she is more SOB and tired and really anxious.RubyRN. You thank him for reporting this information to you at this time. „people here get old and tired.. they indicate signs of a failing heart. It is just a part of the aging process. Staff Development Coordinator You have been an RN for 20 years and worked as a SDC at this nursing home for 6 years. when taken together. You ask him why he did not report these changes sooner and he said that he did not think they were important. You know that he is a good worker who loves his job. You also know that he was abused as a child and suffered mild brain injury. Heart as well. Only you know and a few CNAs who help him do his charting.‟ Besides. You listen to JoeCNA talk about her recent changes in her symptoms. taking a personal interest in them. You love this place. and has not eaten or slept well as she has become more short of breath. and he says no. You praise JoeCNA for his astute observations and tell him that the information he observes is vitally important but in the future he should let you know immediately when he notices these early changes. he is not going to do any extra paperwork. because he could not fill it out and he was put on the spot to do it. As a result. for example. He is very private about this. ©Bedside Clinical Teaching. and they don‟t get better. D.she has become more fatigued.. You reinforce the importance of the symptoms on the FACES chart and say that even though the signs and symptoms might look mild or insignificant.

JoeCNA You are a 30 year old CNA who has worked in the nursing home for 6 years. You have worked other jobs but decided you liked the work of a CNA. you run into the RN Day Supervisor. You tend not to tell the nurse about patient changes because you think that they do their own assessment and don‟t need or value the information you have. You like the nursing home where you work here and take a personal interest in your residents. You bristle and say “Unless they plan to pay us more to do this HF stuff. You are embarrassed and don‟t like to talk about it. Duke University School of Nursing .they will figure it out anyway when they do their assessment. Heart. ©Bedside Clinical Teaching. Only the Staff Development Nurse and a few CNAs know this. You think it will emphasize the importance of the CNA as a source of important information about the patient. Today. You enjoy the emotional connection you make with your patients. you never find out if it made a difference or what happened. and hide this from others. in general you are positive about the program.” You have a learning disability of abuse you experienced as a child. if you do give information to the nurse. As you come out of the room. you are taking care of one of your favorite patients. I‟m not doin‟ it. She puts you on the spot and asks about the Heart Failure Warning Worksheet. You have been avoiding this worksheet because you can‟t read. Sometimes. I don‟t have time. D. Mrs. They need to change something here. You are a high school graduate but did not go to college. Lekan. So you just stopped trying and you just do your job. having attended most of the HF classes. You cannot read but you find ways to cope with everyday life. and have a learning disability. You are known as the „class clown‟ and you were very interactive in the classes. You have been enthusiastic about the HF program. You know a lot of the staff and some are good friends.. You know the patients appreciate your caring attention. and they help you fill out any paperwork or forms. 2008..

“ she‟s doin‟ too much and wearing her heart out..You say. Heart to stay in bed and not overdo it. goes out of town from time to time and Mrs. You don‟t think patients with heart failure should exert themselves and you think that Mrs... You think that this patient is „spoiled‟ and „gets herself admitted to the nursing home‟ because she is lonely. Heart over-extends herself and that is what throws her into her heart failure “spells”.” You encourage Mrs. Her husband died last year and it seems that that is when she started having these heart problems.. Lekan. Duke University School of Nursing . and patients well. staff. Heart gets “goes into a tizzy” when she is gone. 2008.MargaretLPN You have worked in the nursing home for 20 years and know the management.‟ You have limited knowledge about current treatment of heart failure and think that patients just end up going in and out of the hospital to get „tweaked‟ but that the condition is progressive and fatal-no matter what you do they just get sicker and sicker. Her only child. D. a daughter. ©Bedside Clinical Teaching. You think she is over-reacting to her symptoms and is just „nervous.

Lekan.©Bedside Clinical Teaching. Duke University School of Nursing . D. 2008.

and NOT excessive rest. Now. research supports exercise and physical activity in heart failure patients. You see many patients in the facility who are not physically active and have heard some nurses talk about the importance of rest for heart failure patients. 2008. You know that times have changed on this way of thinking about heart patients. D. ©Bedside Clinical Teaching. Lekan.JackiePT You are a physical therapist who has worked at the nursing home for about a year. You have heard them recommend that these patients not exert themselves or even stay out of bed for long. You will plan to talk with the nurses more about this so they can encourage rather than discourage their heart patients from keeping active within their limitations. You have a special interest in cardiac rehabilitation and used to work at the Cardiac Rehab program at the local hospital before taking this position. You know the importance of physical activity and exercise in patients with heart failure. Duke University School of Nursing .