Sometimes It Really IS That Simple Let me tell you a story. We have Purell anti-bacterial foam dispensers in our Nursing Simulation Complex (NSC). I had them installed outside the door into each of our four simulation rooms. I put them there as props – something to look like what the student nurses will see in a real hospital setting during their clinical practicum. The dispensers are the battery operated kind and they work well, but are rarely used, except by the NSC staff.

Still, they are seen by every student walking into the room. In fact, these dispensers are one of the first things the students see when they nervously enter the simulation complex proper. That and our crash cart!

Inside each room, I had a soap dispenser and automatic paper towel machine installed over the sink. Wave your hand under the dispenser and you get a dab of soap to wash your hands. After washing, another wave of a hand under the towel machine and out comes a length of paper towel so you can dry your hands. Since we have many different hospitals where our students do their clinical rotations and they all have different rules and equipment configurations for hand hygiene, I figured it best to provide multiple options for the students. That’s why I placed a pump bottle filled with anti-bac gel on each sink as well.

Sound good? I thought I had covered all my bases pretty well, but I quickly discovered a problem: Students were coming into the patient’s room, going to the sink and hitting the soap dispenser thinking it was anti-bac foam. They would then walk over to the patient while rubbing their hands and soon discover their hands were a sticky mess; the stuff was not evaporating! This really threw the students off their rhythm and caused simulation sessions to degrade quickly. Here they were, being watched by instructors and peers via a live video feed, and they couldn’t even wash their hands right. Talk about deflating someone’s ego!

After seeing this happen time and time again – even after telling the group ahead of time that the soap dispenser looked like a foam dispenser -- I started thinking I would have to pull the soap containers down and replace them with different ones that didn’t look like Purell dispensers.

Here I am, calculating the impact of this error in my judgment: It would take me weeks to find different dispensers -- ones that looked sufficiently distinct from the foam dispensers -- and get them installed. What do I do with the four soap dispensers I had to pull off the wall, not to mention the four cases of soap bottles, bottles specifically designed for those dispensers? I had limited storage space as it was so I couldn’t just stick them in a corner; I didn’t have an empty corner to stick them in. These dispensers were unique; the University didn’t use battery operated soap dispensers anywhere – only battery operated anti-bac foam and gel dispensers. I couldn’t even give these things away to another department! And I was looking at a total conversion cost of $200-$250 per room from a supplies budget that was already being taxed to the extreme. Plus, I would have to find an interim solution until the new dispensers arrived – assuming I could afford them – and were installed. Considering the pressure I had gotten from the faculty that I have a solid hand hygiene learning module in place for every simulation session, this was looking like a major mess up on my part.

Then, driving in to work one morning it hit me: I only had to change one thing. I arrived at the office, went into the NSC and applied my fix. I had to make it obvious that there was soap in those dispensers!

We have never had another nervous student mistake the soap dispensers for anti-bac foam. Total cost: Basically zero. Total time to implement: Ten minutes, tops.

Why do I tell you this story? Because sometimes the answer you need is not complex. Sometimes we see only the worst possible situation and then set ourselves up for that situation. We actually create our worst case by preparing for it and ignoring easier, more appropriate options that are right in front of us. Sometimes we just need to take a second and think. I was lucky in that I had the time to think while driving; you might not feel you have time in a simulation session so you will have to take the time. Just think about what you are trying to achieve and it often becomes very easy to achieve it. Sometimes it really is that simple.

Almost every student coming into the Nursing Simulation Complex for a simulation session – especially their first session – reports being nervous and afraid of failing while being viewed by their peers. They expect to walk into a crater -- a nightmare situation where they will have to perform super-human nursing feats. They look for the worst case scenario and miss the very basic points of the nursing process.

Here’s what I mean: If you come into the room of a 71 year-old male with a diagnosis of Congestive Heart Failure and edema in his lower extremities, what should you be thinking about? The patient greets you warmly and asks you your name. This tells you immediately the patient is wake, oriented to his surroundings, and able to breathe comfortably. You see TED hose on the foot of the bed and a Kendall compression machine hanging on the footboard but not turned on, what should you be considering as one of your first interventions?

The patient has CHF but is he going to suddenly suffer cardiac arrest? Maybe, but do you have any signs or symptoms indicating that is about to happen? Is an impending crisis the first thing you should worry about? Should you scour their chart for clues as to what disaster might befall you in the next twenty minutes while your colleagues watch you from the observation room down the hall? Or should you check the chart for an order for compression boots? If you don’t see an order, maybe you ought to call check with the charge nurse and see if the order was given but not recorded in the EHR.

But what we often see? Students nervously listening to the heart, over and over, waiting for the tell-tale sign of that impending cardiac arrest. Or they keep assuming that every time the mannequin stops talking the patient has lost consciousness and immediately call for the Rapid Response Team.

Every simulation session is not designed to put you in a position where the life of the human patient simulator is going to come to an abrupt and ignoble end if you don’t spot the first sign of the looming disaster. Odds are, there is no looming disaster Yes, we have some advanced scenarios that involve critical care interventions, but those are for advanced levels of nursing. We are not enamored with crises and running mock codes at the drop of a tongue depressor. At levels I & II we are looking to see you perform the nursing process safely and effectively. We want you to handle a patient encounter, assess your patient and the immediate patient environment. We want to see you make good decisions on how to provide care to your patient. Contrary to everything you may have heard, we are not sadistically planning the nursing school equivalent of the Kobiyashi Maru scenario. There are no no-win scenarios in our simulation learning plan. We are giving you an opportunity to prioritize the tasks at hand and communicate with your patient, their family and your fellow healthcare workers in a safe and supportive environment.

There is an old adage in medicine: When you hear hoof beats, don’t look for zebras.

When you enter into your first simulation session as the primary nurse, don’t expect a burgeoning cardiac code. Be a caregiver. That’s what we are training you to become, right? Is your patient degrading? Are there any indications that you are in immediate need of the Rapid Response Team? If not, proceed with assessing your patient and the environment. Assess the patient, not the possibility of negative events happening. Evaluate the environment and be sure that it is safe for your patient.

In doing your assessments, remember these words in simulation and throughout your nursing career, “If it is in him, on him, or near him, check it!” There may be patient care issues in the simulation session that are wrong – wrong IV hung, wrong O2 rate set, wrong IV site documented -- and you will need to correct those issues as you find them, but there will, in all likelihood, not be a zebra coming into the room.

Look for the small things that you know you need to do in every patient encounter. Always think: In him; on him; near him. In him; on him; near him. IV in him? Check it. Post-surgical dressing on him? Check it. Where is the nurse call button? Is it near him? Can he reach it if he needs it when you are not in the room? Check it! And remember to document what you find. IV in the right hand and not the left as recorded in the EHR? Document the finding.

Speaking of documentation, be sure to use the available information to learn as much as you can about your patient. Use the EHR to pre-lab just like you would in any clinical experience. Then use the EHR and/or the paper chart during the simulation session. Take notes during report. Have all your documentation with you if you have to call for assistance.

And we put details in the chart for a reason. Some are there to give you needed background on the patient. Some are there to indicate points you should evaluate and steps you should take. Some are there to prompt you to critically think about options and prioritize your care. There are rarely going to be zebras in the chart so look for the ponies and decide how you are going to provide care to your patient.

You know what SBAR stands for, right? Situation, Background, Assessment, Recommendation. Make sure you know how to do clear SBAR communication when conveying information and making a request of anyone you call upon for help. SBAR isn’t just for shift change; use it whenever communicating by phone or to any healthcare provider who has just come into the room.

Above all, be a caregiver. Put the various aspects of your previous training together and just be a caregiver. Yes, at some point in your time at the School of Nursing you might be in a simulation session where the nursing care problem we hand you will to be very involved and take every ounce of your strength and know-how to solve, but it won’t be at Level I or Level II. As new nursing students we want you to think about giving care, not about crises. Sometimes, all you will have to do is write SOAP on something to avoid the next person making a mistake and putting your patient at unnecessary risk. Yeah, sometimes it really is that simple.

Ed Rovera

Image Credits

All Photos property of the SFSU School of Nursing except:

Hooves http://www.hoofarmor.com/HoofAr9.jpg

Zebra http://www.greatplay.net/zebra.php

SBAR http://is.gd/hy5ZA

Medical Charting http://harvest-medical.com/images/medical_charting_p5_50.png