Major problems with current NRP teaching methods - • A “perfect” score does not help the learner. • We often learn best from our mistakes. • Simulation allows us to push learners to fail in difficult situations and learn from these failures. • Failure should happen during training, NOT patient care
Instructor Requirements • Each instructor watches the NRP Instructor DVD and completes the post-test by January 1, 2012. • Beginning January 1, 2013, every instructor takes the online exam in the 2 years prior to renewal, at no cost. • Teach, or co-teach, 2 courses in 2 years
NRP Course Basics • Lessons 1-4 and 9, minimum • Everyone can practice and perform every skill. • NRP does not certify competence or change legal scope of practice. • Provider status is “renewed” every 2 years
NRP Course Revisions • No separate provider and renewal courses • Minimal lecture and no slides • Students self-study the textbook and/or DVD • Students take the online exam prior to class • No more hard copy tests after Dec 31, 2011 • Instructor:learner ratio = 1:3-4 learners
If your card “expires”??? • The institution decides the employee’s fate
Provider Course Components • Performance Skills Station for practice • Choose all or select skills based on student expertise • Integrated Skills Station for evaluation • Required • Simulation and Debriefing for learning • Required
Structuring of renewals - • The one-person, quick check is an inefficient use of instructor time and interferes with simulation and debriefing.
The “solo” NRP skills check-off • The learner should be aware of his/her expiration date and plan accordingly. • Providing “solo” NRP skills check-offs is NOT the instructor’s responsibility and IS NOT how we will conduct NRP skills check-offs at Cape Fear Valley.
Performance Skills Stations • Reinforces cognitive learning • This is where you may choose to quiz the learner’s knowledge. • The learner practices or reviews hands-on skills with an instructor • When the learner feels confident in his/her skills, the instructor gives a short scenario that begins with the Equipment Checklist. • There is no scoring or grading. • The Performance Checklist is used as a reference.
Simulation & Debriefing • Now a requirement of the Provider Course • Provides a safe setting for integration of cognitive and technical skills, team communication, and patient safety • Confidentiality is essential for participation • No one fails simulation and debriefing, but this is where the learning happens!
What’s wrong with how we have been doing things? • We have fallen into the trap of “feeding” too much information to learners • With the loss of reality, we have a tendency to let learners talk their way through scenarios • Are we doing them a favor by continuing this method? NO
Why simulation???? • The more objective clues that we can provide to learners, the more realistic the practice can be.
Hi-fidelity simulation requires… • $$$ for purchase and maintenance • Space for secure storage • Staff who know how to run and maintain the equipment • Technical knowledge for problem-solving
Low-tech simulation methods…. moulage… • Spray blood – make your own with red fingerpaint, blue dishwashing liquid, baby oil • Meconium – pureed baby food • Vernix – Eucerin with potato flakes • Create the illusion, but don’t overdo it • CLEAN UP!!!
How are WE going to do it??? • Moulage…. • Low-tech • Video
How are WE going to do it??? • Reorganized NRP teaching kits • Moulage…no, but…. • Red cloth = blood • Green cloth = meconium • Spray with water for wetness • If available, we will use a vacant warmer • Simulated equipment panel – Simply NRP
How are WE going to do it??? • Physiologic signs • Breathing, crying • Tone • HR – metronome • O2 saturation
Preparing for effective simulation • Supplies and equipment • Physiologic feedback • Team member orientation and role designation • Confidentiality • Instructions and expectations
Supplies and Equipment • Learners need to find the equipment and handle it • Learners perform the equipment check using the Quick Pre-Resuscitation Checklist • This will cue learners to be sure that they have essential items.
Physiologic Feedback • How will learners know the HR or if the baby is breathing? • We have to familiarize learners with how we will be giving this information • Information is not revealed until the learner performs the appropriate assessment action and/or asks for the information
Team Member Orientation and Role Designation • Let learners get to know each other • Learners should wear visible nametags with their designated role • Important especially if filling a role outside their normal • Remind learners that acting in a role different than their everyday role does not authorize them to perform skills outside their scope of practice in real life
Confidentiality – The Vegas Rule… • Learners have the right to confidentiality and confidence that scenarios will not be held against them in a punitive way • All events are confidential • Protects the learner • Protects the confidentiality of the scenario for use in future classes • The events of simulation and debriefing are NOT part of the learner’s performance evaluation
Confidentiality – The Vegas Rule… • Consent for filming • If the exercise is filmed, the tape is erased at the end of the course, unless the learner has given written permission for its additional use
Instructions and Expectations • Learners need to know the “rules of the game”. • Mistakes are acceptable! • The best learning may come from an error. • The goal of simulation and debriefing is NOT perfection….it is learning. • Laughing and joking are not acceptable during resuscitation…so, they are not acceptable during simulation! • The instructors NEVER trick the learners (ie. sabotaging the scenario)
Instructions and Expectations • Learners need to think out loud. • Helps other team members and instructor know what they are thinking and why • Helps to promote a common “mental model” • Learners need to actually perform the actions, NOT simply say they are doing or would do something • The exception to the rule is administration of fluid and epinephrine. Draw up the med first. Then expel on bed linen and simulate administration.
Instructions and Expectations • Everyone participates during a simulation. • Team members may help each other in any way that is plausible to the scenario. • Communication and teamwork are encouraged and expected! • The instructor, NOT the learner, indicates when the scenario has ended. • “The scenario is over. Let’s debrief.”
What do I do as an instructor? • It is difficult for one instructor to do everything during a scenario. • Instructor #1 – watch the scenario and responses and give the physiologic cues • Instructor #2 – video, take notes about what happens and plan for debriefing • Set video recorder on tri-pod
Conducting a scenario • Learners benefit from participation in more than one scenario. • Once learners know the ground rules, begin with a simple scenario. Then, progress to more complex scenarios that push learners outside their comfort zones.
Conducting a scenario Preparation for the actual scenario • Prepare the manikin with the appropriate visual cues. • Define instructor roles. • Read the scenario. • Allow learners to ask about relevant perinatal history. • Gestational age, fluid color, etc.
Conducting a scenario • Allow learners to – • Designate roles – assign leaders and tasks • Check supplies and equipment • Ask additional questions if needed • Announce when the scenario has begun. • Depending on the complexity of the scenario, other “players” may be used to provide cues and enhance reality.
Conducting a scenario • Once the scenario begins, stay out of the way as much as possible. • For complex scenarios, be prepared to answer questions about information like confirmation of endotracheal tube placement and other resuscitation indicators. • DO NOT give hints or additional information beyond what learners must ask to assess the effects of their actions!
Conducting a scenario • Allow learners to take the scenario down the path they choose without interruption, coaching, or feedback.
Preparing for the debriefing • Use the Scenario Template form to take notes. • Check off the interventions performed as they happen. • Note unexpected occurrences. • Pay attention to which behavioral objectives were met and how that occurred. • Video helps…the camera doesn’t lie! • Note which segments hold key information. • Note the learners who are especially dominant or submissive. • This can effect the debriefing strategies you use.
Managing the unexpected • Unexpected things can happen during a scenario (ie. equipment dropped, med error, mental model not shared). • If this is an event that can happen in real life, learners should solve the problem. • If the scenario continues for a long time and drifts far off-track, the instructor may need to assess the need to end the scenario and debrief without successfully resuscitating the baby.
Managing the unexpected • When a scenario problem or need for redirection occurs, the instructor can send in a “confederate” to play a certain role for a specific purpose. • The “confederate” is not one of the learners participating in the scenario.
Examples of using a “confederate” • A learner cannot stop giggling. So, the instructor sends in the “baby’s grandfather” to remedy the situation by saying – “I’m this baby’s grandfather, and I’d like to know what is so funny. This looks like a pretty serious situation to me.”
Examples of using a “confederate” • Some scenarios can be very complicated and involve may players with a planned script. It is appropriate to have the “confederate” play a set role.
Ending a scenario • End the scenario with an objective statement like – “That ends your scenario. Let’s debrief now.” • The instructor does not end a scenario with a judgmental statement like – • “That was great”. OR • “Well, okay. We have a lot to talk about.”
Ending a scenario • Is it okay for a scenario to end with the baby’s death? • Yes, if that is part of the learning objectives or if there is an egregious error. • NEVER to “punish” the resuscitation team for errors made during the scenario.
Debriefing is the most challenging new skill for NRP instructors • We’ve been taught to lecture and give feedback. • New role is direction of a team-centered discussion by asking open-ended questions. • The learners will discover for themselves what went well, what needs improvement, and how NRP Behavioral Skills impact the outcome. • Give input at the end of the discussion. • Summary of main points, next steps, acknowledgement of good efforts
Ready, Set, Go…. • Review “Ready, Set, Go Instructor Prep Sheet” and “Simulation Preparation, Tips, and Sample Debriefing Questions”
References • Kattwinkel, J., Perlman, J.M., Aziz, K., Colby, C., et. al. (2010). Special Report - Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics, 126(5), e1400-e1413. • Zaichkin, J. (Editor). (2011). Neonatal Resuscitation: Instructor Manual. American Academy of Pediatrics.