Patient deterioration simulation experiences: impact on teaching and learning.

Early recognition and management of patient deterioration are essential nursing skills, and can be improved through education and experience. However, both nursing students and registered nurses may have few opportunities to develop and maintain the emergency management skills necessary to ensure patient safety. Using both theory and empirical evidence, we have developed a simulation-based educational model, 'FIRST2ACT' (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends), to provide nurses with a high-fidelity learning experience. The model has been tested in three different settings: it is highly acceptable to learners, adaptable to different training needs, and shows promise in improving actual clinical performance.

Clinical decision-making: midwifery students' recognition of, and response to, post partum haemorrhage in the simulation environment.

BACKGROUND: This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. METHODS: Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. RESULTS: The students' clinical management of the situation varied considerably. Students struggled to prioritize their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. CONCLUSIONS: The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their interventions to illuminate what else could be done whilst they awaited the emergency team. They did not necessarily serve to prompt the students' or help them plan care prospectively. The limitations of the study are critically explored along with the pedagogic implications for initial training and continuing professional development.

Managing women with acute physiological deterioration: student midwives performance in a simulated setting.

OBJECTIVE: Midwives' ability to manage maternal deterioration and 'failure to rescue' are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives' ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance. METHODS: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data. FINDINGS: The mean total knowledge score was 75% (range 46-91%) with low skill performance, means for both scenarios 54% (range 39-70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario. CONCLUSION: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.

The impact of a musculoskeletal masters course: developing clinical expertise.

A common aim of Masters (MSc) courses in the UK, accredited by the Manipulation Association of Chartered Physiotherapists (MACP), is to promote the clinical expertise of practitioners. Few studies have explored the extent to which this is achieved and understanding is further hampered by the contested nature of expertise. This paper reports on the impact of an MACP approved MSc on practitioners and offers a conceptual model of their development towards clinical expertise. A qualitative theory-seeking case study was used, drawing on the procedures and processes of grounded theory. Twenty-six semi-structured interviews were conducted with eleven alumni from one MACP approved MSc programme. Dimensional analysis and the constant comparative method of data analysis, was used to build the conceptual model. Prior to enrolment, practitioners uncritically accepted knowledge from others and followed habitual routines with their patients. Their diet of informal CPD appeared ineffective in developing these attributes. The impact of the MACP approved MSc involved three developmental aspects of clinical expertise: critical understanding of practice knowledge, patient centred practice and capability to learn in, and from, clinical practice. These inter-related aspects of knowledge, practice and learning offer a conceptual model of the development towards clinical expertise. The most powerful experience to trigger change was direct observation and feedback of their clinical practice by an MACP educator; this highlights the value of clinical mentors facilitating less experienced colleagues. The implementation of such mentorship within departments may offer a cost effective and manageable way to support CPD within the workforce.

FIRST2ACT: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education.

Delayed assessment and mismanagement of patient deterioration is a substantial problem for which educational preparation can have an impact. This paper describes the development of the FIRST(2)ACT simulation model based on well-established theory and contemporary empirical evidence. The model combines evidence-based elements of assessment, simulation, self-review and expert feedback, and has been tested in undergraduate nurses, student midwives and post-registration nurses. Participant evaluations indicated a high degree of satisfaction and substantial self-rated increases in knowledge, confidence and competence. This evidence-based model should be considered for both undergraduate and post-registration education programs.

European and African maize cultivars differ in their physiological and molecular responses to mycorrhizal infection.

Physiological and molecular responses to phosphorus (P) supply and mycorrhizal infection by Glomus intraradices were compared in European (River) and African (H511) maize (Zea mays) cultivars to examine the extent to which these responses differed between plants developed for use in high- and low-nutrient-input agricultural systems. Biomass, photosynthetic rates, nutrient and carbohydrate contents, mycorrhizal colonization and nutrient-responsive phosphate transporter gene expression were measured in nonmycorrhizal and mycorrhizal plants grown at different inorganic phosphorus (P(i)) supply rates. Nonmycorrhizal River plants grew poorly at low P(i) but were highly responsive to mycorrhizal infection; there were large increases in biomass, tissue P content and the rate of photosynthesis and a decline in the expression of phosphate transporter genes. Nonmycorrhizal H511 plants grew better than River plants at low P(i), and had a higher root : shoot ratio. However, the responses of H511 plants to higher P(i) supplies and mycorrhizal infection were much more limited than those of River plants. The adaptations that allowed nonmycorrhizal H511 plants to perform well in low-P soils limited their ability to respond to higher nutrient supply rates and mycorrhizal infection. The European variety had not lost the ability to respond to mycorrhizas and may have traits useful for low-nutrient agriculture where mycorrhizal symbioses are established.

Portfolios and assessment of competence: a review of the literature.

BACKGROUND: The literature review presented here was conducted as part of an English National Board for Nursing, Midwifery and Health Visiting funded project to evaluate the use of portfolios in the assessment of learning and competence. Initial consideration of the topic revealed the need to clarify the terminology and approaches used to assess competence using portfolios, and therefore the literature review was conducted to inform the study. AIMS: To clarify definitions, theoretical bases and approaches to competence and the use of portfolios in the assessment of learning and competence in nursing education. METHODS: A comprehensive literature review was conducted using the CINAHL and MEDLINE databases and the keywords competenc*, portfolios and nursing. Articles published in the period 1989-2001 in English were obtained and their reference lists scrutinized to identify additional references. Twenty articles were found using a combination of the keywords competenc* and portfolios, and 52 using the combination portfolios and nurse education. Articles were included in the review if they focused on the use of portfolios in nursing, and those concerned with professional or transitional portfolios were excluded. This article will analyse definitions of and approaches to competence and its measurement and to portfolios and their use as discussed in the articles identified. RESULTS: Three approaches to competence were identified, each with its appropriate forms of assessment. With regard to portfolios, a number of definitions were again found, but there was a consensus that the theoretical basis of their use is theories of adult learning. A number of reasons for and advantages and disadvantages of their use were found, as well as varying ideas about what a portfolios should consist of and how it should be assessed. CONCLUSION: A holistic approach to competence seems to be compatible with the use of portfolios to assess competence in nursing students, but the concept and its implementation is still evolving. A variety of assessment methods are needed for assessment and portfolios appear to have the potential to integrate these. Reflection is an essential component of a portfolio, as are the student-teacher relationship and explicit guidelines for constructing the portfolio. Issues of rigour in assessment of portfolios need to be addressed, but the assessor's professional judgement will inevitably enter into this assessment.