A juggling act in the med-surgical unit

Published 7:00 am Sunday, May 7, 2023

Makayla Cole had reported for duty as a charge nurse on a medical-surgical floor when she suddenly found herself in the middle of a human juggling act.

An unconscious woman was suffering from a hemorrhagic stroke. She took short, shallow breaths while awaiting a computerized tomography scan and transport to the intensive care unit. A concerned family member kept hitting the call button, insisting that her loved one wasn’t breathing.

In the next room, a patient was complaining of severe chest pains. In another, someone was in excruciating pain from a right hip fracture. A fourth patient was complaining of neuropathy in her foot.

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One wrong decision and one or more of the patients in Cole’s care could suffer a poor outcome.

That wasn’t all. Elsewhere on the floor, a patient needed swift treatment for a suspected drug overdose; another was in pain from a small bowel obstruction; several required nasogastric tube or Foley catheter placements; the spouse of a potential domestic abuse victim was demanding her release from the hospital; an isolated COVID-19 patient was calling for attention; and a woman ready for discharge was growing impatient while awaiting instructions from a nurse about at-home IV infusions.

“At first, I asked the other nurses if they needed any help, and then things started to get a little crazy,” Cole said. “They started saying, ‘Makayla, I need you to check on Room 2.’ ‘I need you to do this and do that.’ I assisted wherever I could.”

The tension ratcheted up as the Clinton resident’s shift wore on. Thankfully for her and the other nurses on the floor, the diversity and volume of patient complaints that day were uncommon – and orchestrated.

The School of Nursing at Mississippi College conducted the realistic simulation March 31 to help prepare graduating fourth-semester students for actual patient encounters. It was the final sim for the class members, more than half of whom have accepted employment offers and will begin their careers in nursing this summer once they’ve passed the National Council of State Boards of Nursing NCLEX exam.

Kimberly Sharp, dean of the MC School of Nursing, said simulations of varying sizes are embedded throughout the school’s curriculum.

“Simulations help students develop confidence and competence in the skills they need,” Sharp said. “We don’t expect the students to be perfect. We incorporate these scenarios in a place where they can review and practice what they’ve learned in the classroom.

“It is stressful. We want to put the students in a scenario that challenges them and makes them think. It puts them through their paces, and they can reflect on their experience and use the information in a constructive way.”

Jordan Owen, instructor in the School of Nursing, works closely with Amy Sewall, certified technical and simulation support specialist, to design simulation exercises for the school. Each week, students receive up to two hours of sim training related to one or more of their clinical courses. Students participate in teams, record patient reports, prioritize care responsibilities, and manage changes to patients’ status.

“Students should be able to exercise the full variety of what they have been taught up to this point,” Owen said. “This is the first time they’re encountering a sim that has multiple patients at one time. We know that whenever they leave our program, they are going to rapidly pick up patient-to-nurse ratios that are going to be challenging for them. This simulation is the best and safest way to see how they react to given situations.

“If they can practice enough, making the correct care decisions will be second-nature when encountering real hospital patients.”

Tyler Kellum of Raymond cared for three patients with varying illnesses during the sim. His most difficult task was figuring out which patient needed immediate care.

“The most challenging aspect was prioritizing one patient over the other, because you want to give them all equal care,” Kellum said. “Some are sicker than others, so you just can’t do that sometimes. The hardest part was figuring that out and asking some of our classmates for help with the patients’ care.”

Erin Griffin of Hattiesburg said patient prioritization comes down to one element: survival.

“It may be blunt to say, but when you’re dealing with many patients, you have to consider which of them is going to die the quickest,” Griffin said. “One patient had a brain bleed and could die any minute, whereas another had dementia and needed pain medication. That is someone we need to help, but we are going to assess the person with the brain bleed first because it is critical.

“Taking care of several patients at the same time who needed different things was chaotic. You have to stick to your guns, assess which is the most acute, the sickest, and must be taken care of first. The toughest part was making sure that you’ve done everything that you can and not left anything behind.”

Owen said the simulation teaches an essential skill all effective nurses must master: delegation.

“Giving the right task to the right person, depending on their level of practice, is important,” she said. “As a nurse, you want to perform at the full scope of your practice. If you have a pressing task that needs attention, like a patient climbing out of bed or needing to go to the bathroom, you must learn how to delegate those tasks.

“It is difficult for our students, because they don’t want to tell someone else what to do, they don’t want to feel like they’re being bossy, or they don’t want someone to think they’re lazy for giving tasks to other people. But it’s very important to learn, because, as a nurse, sometimes you are the only person who can take care of something for a patient.”

This leads to another valuable skill the simulation emphasizes: communication.

“Learning how to communicate with other people on the team is essential,” Owen said. “Part of the sim involved a Physician Assistant student, which provided an opportunity for the nurses to speak with the PA if they needed orders and learn how to communicate with them. Our department chair, Rick Lewis, served as the doctor, so students could learn how to communicate with him – explain the situation, give the patient’s background and the nurse’s assessment, and offer recommendations for the best care.”

First-semester nursing students served as mock “patients” during the exercise. Owen said they were assigned various illnesses to portray, researched the signs and symptoms of their given conditions, and investigated how they could accurately depict individuals with their respective maladies.

“We like when we can get students from different semesters working together,” she said. “The fourth-semester students are a ‘light at the end of the tunnel’ for the first-semester students, and the fourth semesters can see how far they’ve come since their first semester.”

According to recent research, Owen said some hospital administrators aren’t convinced new nurse graduates are prepared to practice right away. This is due to a number of factors, from the education they receive, the higher patient ratios they encounter, the increasing severity of illnesses reported since the COVID-19 pandemic, or more marked changes in patient status throughout their hospitalizations.

The simulation is an important tool to ensure Mississippi College-trained nurses are prepared for what awaits them in any patient-care setting.

“We’re pushing them and challenging them in ways that are safe here before they get out into the real world,” Owen said. “We want to see how they react. We want them to reflect on their actions and experiences in a way that will be meaningful to them in the future with a real-patient application.”

Cole, who plans to work as a nurse in the Neonatal Intensive Care Unit at the University of Mississippi Medical Center, said the simulation has been a beneficial exercise.

“You can practice all of your skills and your time management and put into practice everything you have learned in a safe environment,” she said. “Professors always tell us, ‘If you make a mistake, you want it to be in a sim when you can talk through it and learn it.’ It’s helpful to put in the practice and essentially trial-and-error everything that we’ve learned.”

Kellum, who plans to serve as an emergency room nurse at Mississippi Baptist Medical Center, said the simulation had provided an opportunity to become familiar with real-life situations.

“They’re real scenarios, but not real people, so if you do make a mistake, you can learn from it and use what you’ve learned in the real world,” he said. “This allows you to properly prepare and understand what you need to improve.”

Griffin said she would rely on her simulation training to help quell any nerves when a patient’s life is in her hands in the Neuroscience Intensive Care Unit at UMMC.

“The MC School of Nursing faculty and staff have done an impeccable job of making sure we have the knowledge needed to practice nursing safely and keep our patients alive,” she said. “Simulation training will help me stay calm in the chaos.

“Whenever I have someone who has symptoms similar to those encountered in the sim, I can remember what I did to take care of them, the protocols that were put in place, to help me have the best outcome for my patient.”