Nurse Educator Vol. 39, No. 6, pp. 263-264 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
Teaching Strategies
Using Courtroom Simulation to Introduce Documenting Quality Wound Care to Beginning Nursing Students Mariann Harding, PhD, RN, CNE Sherri Troyer, MSN, RN Mistey Bailey, BSN, RN
A
ccurate wound assessment and documentation are essential to ensure patient safety and continuity of care. Documentation serves as a communication tool among healthcare team members and must be accurate, with consistent measurements and wound descriptions, if the patient is to receive high-quality, appropriate wound care.1 However, despite the importance placed on wound care and documentation in undergraduate nursing curricula, a number of studies have found that nurses generally poorly document wound assessment and wound care.2-4 The use of a mock trial has been identified as a means to engage nursing staff and students in developing personal accountability and the skills necessary to make decisions about quality of care.5 Faculty generally choose this pedagogy as part of nursing issues and trends courses.6 We chose to use a mock trial as part of clinical simulation in a first medicalsurgical nursing course with the intent that this early exposure will enhance students’ competencies in upholding standards of wound care and documenting accurately. During the first simulation of the semester on wound care, students were individually asked to change a dressing and complete documentation of the wound and care provided. Faculty noted that despite students’ success on performing wound care and objective testing on documentation principles, student performance on the documentation activity was far below desired. After brainstorming how to assist students with understanding the importance of applying principles in practice, faculty decided to stage a courtroom simulation. The simulation was designed as a means for students to understand the importance of precise and accurate documentation and providing quality care based on accepted standards. Author Affiliations: Associate Professor of Nursing (Dr Harding), Assistant Professor of Nursing (Ms Troyer), and Laboratory Coordinator (Ms Bailey), Department of Nursing, Kent State University at Tuscarawas, New Philadelphia, Ohio. The authors declare no conflicts of interest. Correspondence: Dr Harding, Department of Nursing, Kent State University at Tuscarawas, 330 University Cir NE, New Philadelphia, OH 44663 ([email protected]). DOI: 10.1097/NNE.0000000000000078
Nurse Educator
We outlined 3 learning objectives for the simulation: (1) describe defensible documentation, (2) discuss the legal relationship between quality of care and documentation, and (3) identify quality wound care.
Description of Activity The case scenario for the mock trial simulation involved a nurse defending wound documentation when the patient from the prior wound care simulation seeks damages after developing a postoperative methicillin-resistant Staphylococcus aureus wound infection. In the litigation, malpractice was not blatant, and the breach in the standard of care was implied in poor documentation. Because all students participated in the wound care simulation and performed the simulated dressing change correctly, faculty chose this scenario believing the direct association would enhance the student development of a sense of personal accountability and knowledge retention. Using anonymous documentation examples from the wound care simulation, additional materials were added to create a chart for the mock trial. The documentation examples used were chosen from weaknesses faculty identified in multiple students’ work. It was decided that faculty members would fulfill the key roles of prosecuting attorney and judge so they could use a script of key topics to emphasize. Instead of having faculty play all the roles and students observe, we assigned students active roles, including bailiff, patient, family members, the nurse on trial, court reporter, jury, and 2 family members. Because a critical factor in staging a successful simulation is to create an atmosphere of reality, the simulation laboratory classroom was rearranged to mimic a courtroom, and the judge wore a doctoral robe and wielded a gavel. Students were asked to come dressed in business attire but were not given any other prior information. Each 60-minute simulation session had 20 students participating in it. The trial was called to order by the bailiff. The judge introduced the case, and the prosecuting attorney presented an opening argument. The trial proceeded with the nurse testifying on the witness stand. The nurse was asked to recall providing wound care and then asked to compare that description Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
263
to the presented documentation. Photographs of the wound were shown. The prosecutor focused questions on frequently made errors, including misspellings and glaring errors, to help reinforce knowledge to the students (Table 1). Throughout the trial, the prosecuting attorney emphasized quality patient care and the importance of the written note over verbal testimony. At the end of the trial, the judge directed the jury to be fair and impartial and asked the jury if they would find the nurse guilty of the charges based on the documentation and testimony. The verdict in each simulation was overwhelmingly in support of the patient, which was the intended outcome the faculty desired as the purpose of the simulation was to reinforce the importance of proper documentation.
Student Outcomes Debriefing immediately followed the mock trial. Students were encouraged to verbalize their thoughts about the trial and verdict, allowing for self-reflection and faculty evaluation of student satisfaction with trial as pedagogy. Students were enthusiastic about the trial and expressed overwhelming satisfaction with the teaching method, describing it as being engaging, interactive, and an effective learning strategy. The written evaluations were overwhelmingly positive (all 5 on a 5-point Likert scale), and they learned about the significance of documentation in litigation. Comments on the written evaluations included ‘‘documenting needs to be accurate and
Table 1. Sample Trial Questions Student Error
Conclusion This was our first endeavor using a mock trial to emphasize documentation principles. Faculty viewed the experience as a success educationally. While it took time and planning, delivering a mock trial simulation was a simple yet highly effective simulation that can be accomplished with limited resources. In future semesters, we plan to include more students in each simulation, using a larger setting with students as courtroom observers, and evaluate for improvement in documentation in the clinical setting. Nurse educators can use a mock trial simulation as an effective means to assist students early in their education to develop personal accountability. Students who participated in the mock trial learned how critical documentation is as a component of quality patient care. By emphasizing the importance of applying principles learned in classroom to clinical practice, use of a mock trial simulation has the potential to improve students’ documentation and positively influence nursing practice and patient safety.
Question Asked by Prosecutor
Did not sign documentation entries Is this your documentation? How do you know it is yours? Why did you administer ‘‘Viodin,’’ Administered ‘‘Viodin’’ for pain an antiseptic, for pain prior to the prior to dressing change, dressing change? The physician misspelling ‘‘Vicodin’’ ordered Vicodin. You charted the wound length as Inaccurate wound dimensions, 600 cm. Based on this photograph describing wound as of the wound, what does the ‘‘600 10 cm’’ wound actually measure? You state there are no ‘‘S & S of Stated no infection was present infection.’’ Given the previous errors, when obvious redness and why should we believe that? Based on edema were present this photograph, the surrounding tissue is red and edematous.
264
detailed; when it comes to assessment; no detail is too small,’’ and ‘‘I learned the consequences of what happens if I do not do things correctly.’’ We administered pretests and posttests on general and wound documentation based on the students’ most common errors. The average score was the same on both tests (mean, 10.4/12). This reaffirmed our assessment that students understood documentation principles but were having difficulty with applying principles in practice.
Volume 39 & Number 6 & November/December 2014
References 1. Dahlstrom M, Best T, Arora V, et al. Improving identification and documentation of pressure ulcers at an urban academic hospital. Jt Comm J Qual Saf. 2011;37(3):123-130. 2. Gartlan J, Smith A, Robinson A, et al. An audit of the adequacy of acute wound care documentation of surgical inpatients. J Clin Nurs. 2010;19(15-16):2207-2214. 3. Huff J. Adequacy of wound education in undergraduate nursing curriculum. J Wound Ostomy Continence Nurs. 2011;38(2):160-164. 4. Paans W, Sermeus W, Nieweg R, van der Schans C. Prevalence of accurate nursing documentation in patient records. J Adv Nurs. 2010;66(11):2481-2489. 5. March A, Ford C, Adams M, Cheshire M, Collins A. The mock trial: a collaborative interdisciplinary approach to understanding legal and ethical issues. Nurse Educ. 2011;36(2):66-69. 6. Centrella-Nigro A, Flynn D. Teaching evidence-based practice using a mock trial. J Contin Educ Nurs. 2012;43(12):566-570.
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse Educator
Teaching Strategies
Using Courtroom Simulation to Introduce Documenting Quality Wound Care to Beginning Nursing Students Mariann Harding, PhD, RN, CNE Sherri Troyer, MSN, RN Mistey Bailey, BSN, RN
A
ccurate wound assessment and documentation are essential to ensure patient safety and continuity of care. Documentation serves as a communication tool among healthcare team members and must be accurate, with consistent measurements and wound descriptions, if the patient is to receive high-quality, appropriate wound care.1 However, despite the importance placed on wound care and documentation in undergraduate nursing curricula, a number of studies have found that nurses generally poorly document wound assessment and wound care.2-4 The use of a mock trial has been identified as a means to engage nursing staff and students in developing personal accountability and the skills necessary to make decisions about quality of care.5 Faculty generally choose this pedagogy as part of nursing issues and trends courses.6 We chose to use a mock trial as part of clinical simulation in a first medicalsurgical nursing course with the intent that this early exposure will enhance students’ competencies in upholding standards of wound care and documenting accurately. During the first simulation of the semester on wound care, students were individually asked to change a dressing and complete documentation of the wound and care provided. Faculty noted that despite students’ success on performing wound care and objective testing on documentation principles, student performance on the documentation activity was far below desired. After brainstorming how to assist students with understanding the importance of applying principles in practice, faculty decided to stage a courtroom simulation. The simulation was designed as a means for students to understand the importance of precise and accurate documentation and providing quality care based on accepted standards. Author Affiliations: Associate Professor of Nursing (Dr Harding), Assistant Professor of Nursing (Ms Troyer), and Laboratory Coordinator (Ms Bailey), Department of Nursing, Kent State University at Tuscarawas, New Philadelphia, Ohio. The authors declare no conflicts of interest. Correspondence: Dr Harding, Department of Nursing, Kent State University at Tuscarawas, 330 University Cir NE, New Philadelphia, OH 44663 ([email protected]). DOI: 10.1097/NNE.0000000000000078
Nurse Educator
We outlined 3 learning objectives for the simulation: (1) describe defensible documentation, (2) discuss the legal relationship between quality of care and documentation, and (3) identify quality wound care.
Description of Activity The case scenario for the mock trial simulation involved a nurse defending wound documentation when the patient from the prior wound care simulation seeks damages after developing a postoperative methicillin-resistant Staphylococcus aureus wound infection. In the litigation, malpractice was not blatant, and the breach in the standard of care was implied in poor documentation. Because all students participated in the wound care simulation and performed the simulated dressing change correctly, faculty chose this scenario believing the direct association would enhance the student development of a sense of personal accountability and knowledge retention. Using anonymous documentation examples from the wound care simulation, additional materials were added to create a chart for the mock trial. The documentation examples used were chosen from weaknesses faculty identified in multiple students’ work. It was decided that faculty members would fulfill the key roles of prosecuting attorney and judge so they could use a script of key topics to emphasize. Instead of having faculty play all the roles and students observe, we assigned students active roles, including bailiff, patient, family members, the nurse on trial, court reporter, jury, and 2 family members. Because a critical factor in staging a successful simulation is to create an atmosphere of reality, the simulation laboratory classroom was rearranged to mimic a courtroom, and the judge wore a doctoral robe and wielded a gavel. Students were asked to come dressed in business attire but were not given any other prior information. Each 60-minute simulation session had 20 students participating in it. The trial was called to order by the bailiff. The judge introduced the case, and the prosecuting attorney presented an opening argument. The trial proceeded with the nurse testifying on the witness stand. The nurse was asked to recall providing wound care and then asked to compare that description Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
263
to the presented documentation. Photographs of the wound were shown. The prosecutor focused questions on frequently made errors, including misspellings and glaring errors, to help reinforce knowledge to the students (Table 1). Throughout the trial, the prosecuting attorney emphasized quality patient care and the importance of the written note over verbal testimony. At the end of the trial, the judge directed the jury to be fair and impartial and asked the jury if they would find the nurse guilty of the charges based on the documentation and testimony. The verdict in each simulation was overwhelmingly in support of the patient, which was the intended outcome the faculty desired as the purpose of the simulation was to reinforce the importance of proper documentation.
Student Outcomes Debriefing immediately followed the mock trial. Students were encouraged to verbalize their thoughts about the trial and verdict, allowing for self-reflection and faculty evaluation of student satisfaction with trial as pedagogy. Students were enthusiastic about the trial and expressed overwhelming satisfaction with the teaching method, describing it as being engaging, interactive, and an effective learning strategy. The written evaluations were overwhelmingly positive (all 5 on a 5-point Likert scale), and they learned about the significance of documentation in litigation. Comments on the written evaluations included ‘‘documenting needs to be accurate and
Table 1. Sample Trial Questions Student Error
Conclusion This was our first endeavor using a mock trial to emphasize documentation principles. Faculty viewed the experience as a success educationally. While it took time and planning, delivering a mock trial simulation was a simple yet highly effective simulation that can be accomplished with limited resources. In future semesters, we plan to include more students in each simulation, using a larger setting with students as courtroom observers, and evaluate for improvement in documentation in the clinical setting. Nurse educators can use a mock trial simulation as an effective means to assist students early in their education to develop personal accountability. Students who participated in the mock trial learned how critical documentation is as a component of quality patient care. By emphasizing the importance of applying principles learned in classroom to clinical practice, use of a mock trial simulation has the potential to improve students’ documentation and positively influence nursing practice and patient safety.
Question Asked by Prosecutor
Did not sign documentation entries Is this your documentation? How do you know it is yours? Why did you administer ‘‘Viodin,’’ Administered ‘‘Viodin’’ for pain an antiseptic, for pain prior to the prior to dressing change, dressing change? The physician misspelling ‘‘Vicodin’’ ordered Vicodin. You charted the wound length as Inaccurate wound dimensions, 600 cm. Based on this photograph describing wound as of the wound, what does the ‘‘600 10 cm’’ wound actually measure? You state there are no ‘‘S & S of Stated no infection was present infection.’’ Given the previous errors, when obvious redness and why should we believe that? Based on edema were present this photograph, the surrounding tissue is red and edematous.
264
detailed; when it comes to assessment; no detail is too small,’’ and ‘‘I learned the consequences of what happens if I do not do things correctly.’’ We administered pretests and posttests on general and wound documentation based on the students’ most common errors. The average score was the same on both tests (mean, 10.4/12). This reaffirmed our assessment that students understood documentation principles but were having difficulty with applying principles in practice.
Volume 39 & Number 6 & November/December 2014
References 1. Dahlstrom M, Best T, Arora V, et al. Improving identification and documentation of pressure ulcers at an urban academic hospital. Jt Comm J Qual Saf. 2011;37(3):123-130. 2. Gartlan J, Smith A, Robinson A, et al. An audit of the adequacy of acute wound care documentation of surgical inpatients. J Clin Nurs. 2010;19(15-16):2207-2214. 3. Huff J. Adequacy of wound education in undergraduate nursing curriculum. J Wound Ostomy Continence Nurs. 2011;38(2):160-164. 4. Paans W, Sermeus W, Nieweg R, van der Schans C. Prevalence of accurate nursing documentation in patient records. J Adv Nurs. 2010;66(11):2481-2489. 5. March A, Ford C, Adams M, Cheshire M, Collins A. The mock trial: a collaborative interdisciplinary approach to understanding legal and ethical issues. Nurse Educ. 2011;36(2):66-69. 6. Centrella-Nigro A, Flynn D. Teaching evidence-based practice using a mock trial. J Contin Educ Nurs. 2012;43(12):566-570.
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
