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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 residents 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 patients 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 patients 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

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

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

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

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

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. 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. The role play simulation provides an opportunity for exploration and discussion of the clinical, leadership, and legal implications of delegation and supervision. Objectives At the end of the session the learner will have: 1. Explored issues related to RN delegation and supervision with paraprofessional staff in long term care, using heart failure (HF) as an exemplar. 2. Experienced Bedside Clinical Teaching as a leadership strategy to foster RN appraisal of LPN and CNA knowledge, skill and attitudes relevant to delegation and supervision. Time 1 hour in-class session. Instructions 1. Solicit volunteers from the class for the role play 2. 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. Heart is having trouble breathing, is coughing up frothy sputum and is confused. You do not know this patient except that she was admitted yesterday for recovery from flu. She has a history of myocardial infarction and heart failure. You decide you need to assess the patient for acute HF. 3. Specify what data you will collect from the chart, and how you will conduct the assessment. Conducting the Role Play/ Simulation Prebrief: 10 minutes Conduct Debrief: 20 minutes Large Group discussion the Role 1. Give each student a role Highlight issues regarding communication with play: (described below). paraprofessional staff the importance of open Print roles on index cards. 10 channels of communication minutes 2. Explain the scenario Discuss leadership and adult learning teaching per strategies that could be used in the scenario 3. Review key aspects of the session: RN delegation and supervision-understanding roles Generate HF nursing assessment and scope of practice and role 4. Review the Bedside Use of Bedside Clinical Teaching as mechanism play Clinical Teaching for evaluating knowledge, skill and attitudes of additional LPNs and NAs relative to the task at hand procedure scenarios Emphasize importance of knowing individual staff 5. Volunteer students get that often members strengths and weaknesses and into role; audience is asked arise e.g. 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, scenario too busy
Bedside Clinical Teaching, D. Lekan, 2008, Duke University School of Nursing

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

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

Part III: Heart Failure Role Play Script Background The setting is a 120-bed nursing home. 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. 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. The director of nursing and medical director support the efforts of the students to teach staff about detection of acute signs and symptoms.

Actors 1. Patient: Mrs. Heart 2. RN Day Supervisor: BeckyRNSUP 3. RN Staff Development Nurse: RubyRN 4. CNA: JoeCNA 5. RN Charge Nurse: your name RN 6. LPN Charge Nurse: MargaretLPN 7. 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, D. Lekan, 2008, Duke University School of Nursing


Name, 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, 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. You are a new graduate and have been working at this nursing home for 6 months. You have noticed that many patients go in to the hospital for heart failure. It seems like a routine and you dont think that there is enough attention paid to recognizing early the signs and symptoms of acute HF. You think that if these S&S were picked up, assessed by the RN, and reported, you would be able to alert the MD or NP and the patient could be treated in the nursing home, when the acute flare up is mild and not severe. You have observed that when patients are hospitalized for HF they come back weaker and more frail, and it takes them a long time to recover and get back to their baseline level of function. Some patients never really get back to baseline and progressively lose function little by little. You think that if patients had better monitoring and early medical treatment, they would not go into acute heart failure and need to be hospitalized. Therefore, they would not experience the physiologic and emotional stress and trauma of acute heart failure. You have worked with BeckyRN Staff Development Nurse to implement a Heart Failure Prevention Program. You have been teaching the CNAs on your floor how to better observe for early signs of HF by using the FACES chart. You went in this morning to see how Mrs. Heart was doing and on the way, found JoeCNA in the hall. You ask him how it is going using the FACES chart and doing the observation. JoeCNA had been initially enthusiastic about the HF program, and had attended all the HF classes and unit teaching sessions. He is known as the class clown and was very interactive and positive about the program. However, when you approach him on the unit, and ask him about Mrs. Heart, he says: unless they plan to pay us more to do this HF stuff, Im not doin it. I dont have time. They need to change something here. You are shocked and surprised. This was totally different then his behavior in class. You minimize the negativity of the interaction (and hold at bay the opinion that CNAs dont want to do extra work or resent the management for low pay, workload, etc.) You explore the situation and say to JoeCNA, Lets go see Mrs. 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. Lets go see her and we can do some observations to see how she is doing. You go with JoeCNA to see Mrs. Heart, she is in bed resting.
Bedside Clinical Teaching, D. Lekan, 2008, Duke University School of Nursing

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

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

Patient: Mrs. Heart

You are an 84 year old white female, and you are alert and oriented. You live in a one bedroom apartment on the campus of a continuing care retirement center (CCRC). You have one daughter who looks in on you weekly but she travels periodically out of town with her job. Two days ago, you were admitted to the nursing home for a short stay to recover from an upper respiratory infection. You need some time to recover because you became very weak and, dehydrated, and had a fall. Fortunately, you did not have a fracture or any other injury but you are bruised and ache all over. You have a heart condition that flares up from time to time. You sometimes forget to take your heart medicine on schedule. You hope to return to your apartment on the CCRC campus soon. You are able to walk with assistance. You need some help with activities of daily living and transfers but are mostly independent. You take the CCRC shuttle to town to shop or meet friends. Medical Diagnoses: Heart Failure; osteoarthritis, osteoporosis, history of MI 2 years ago, high cholesterol, mild cataracts Heart Failure History: You have had 3 hospitalizations over the past year for acute heart failure, staying about 5 days each time. You notice that prior to the acute flare up, you experience worsening symptoms for about a week. Typically, you become more FATIGUED, ANXIOUS and SHORT OF BREATH. Here is how you are feeling NOW:


Fatigue: you feel profoundly tired and have trouble doing your ADLs without taking frequent rest periods. You even have to rest when you are brushing your teeth. Fast Pulse: you feel your heart racing from time to time


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. It can take you all morning to do your AM care. You feel frustrated and discouraged about this. This has been going on for 4 days. Appetite: You notice you just dont feel as hungry as usual and you have not eaten well the past couple of days-no appetite.


Congestion: a few days ago you noticed some growing congestion and sputum, you feel the need to take deep breaths and cough. Today, your sputum is frothy but not blood tinged. Cough: you notice a cough, starting last night.

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

Confusion: you notice you have trouble paying attention and concentrating on what is going on around you. You lose track of the day time routine and you sometimes have to ask JoeCNA what time it is and what day it is. You are feeling quite anxious. Chest pain: the last time you had acute HF you had mild chest pain, and that was different than before. It scared you and you had to take some NTG. Good thing JoeCNA was there to help you. You dont have any chest pain right now.


Edema: you notice that your rings are tight and your shoes dont fit. Yesterday, you wore your slippers because your feet were swollen and your legs felt puffy. Elimination: you have been up 4 times to urinate the past few nights.


Shortness of Breath: you are more short of breath than usual and the least little bit of activity makes it worse. You have to immediately stop what you are doing. You get SOB when you are talking and when eating.

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

BeckyRN, Day RN Supervisor

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

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

RubyRN, Staff Development Coordinator

You have been an RN for 20 years and worked as a SDC at this nursing home for 6 years. You love this place, you get to know the residents and listen to their stories about what their life was like in younger years. You know Mrs. Heart as well. You listen to JoeCNA talk about her recent changes in her symptoms. You become alarmed about what JoeCNA tells you about Mrs. Hearts symptoms. As you question him about her symptoms, you learn that he has lots of information about the progression of her heart failure symptoms over the past couple of days...she has become more fatigued, for example, and needs much more help with her morning care, and has not eaten or slept well as she has become more short of breath. You ask him why he did not report these changes sooner and he said that he did not think they were important, people here get old and tired, and they dont get better. It is just a part of the aging process. Besides, Mrs. Heart does not seem that sick although today she is more SOB and tired and really anxious. 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, and he says no. He says that unless they pay him for doing this extra work, he is not going to do any extra paperwork. 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. 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, when taken together, with other RN assessments, they indicate signs of a failing heart. You thank him for reporting this information to you at this time. You know that he is a good worker who loves his job, and cares deeply for his patients, taking a personal interest in them. You also know that he was abused as a child and suffered mild brain injury. As a result, he has a learning disability and cannot read. He is very private about this. Only you know and a few CNAs who help him do his charting. You tell the RN Charge Nurse confidentially that this may explain why he was resistant to doing the FACES worksheet, because he could not fill it out and he was put on the spot to do it.

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

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

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

You have worked in the nursing home for 20 years and know the management, staff, and patients well. You think that this patient is spoiled and gets herself admitted to the nursing home because she is lonely. Her husband died last year and it seems that that is when she started having these heart problems. Her only child, a daughter, goes out of town from time to time and Mrs. Heart gets goes into a tizzy when she is gone. You think she is over-reacting to her symptoms and is just nervous. 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. You dont think patients with heart failure should exert themselves and you think that Mrs. Heart over-extends herself and that is what throws her into her heart failure spells.....You say, shes doin too much and wearing her heart out. You encourage Mrs. Heart to stay in bed and not overdo it.

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

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

You are a physical therapist who has worked at the nursing home for about a year. 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. 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. You have heard them recommend that these patients not exert themselves or even stay out of bed for long. You know that times have changed on this way of thinking about heart patients. Now, research supports exercise and physical activity in heart failure patients, and NOT excessive rest. 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.

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