LaVelle & Lavelle p.1/4

Creative Teaching Strategies: Applying Cultural Overlays to High-Fidelity Patient Simulations

Beth LaVelle, PhD, RN, CEN and Meghan B. LaVelle, BSN, RN; HealthEast Care Systems, St. Paul, MN

SUMMARY OF KEY POINTS

I. Defining “culture”

Types of cultures

Framework: the Purcell Model for Cultural Competence

  • Person, Family, Community, Society
  • Core values, traditions

Health literacy

  • Impact of culture on patient safety (see Betancourt, 2003)
  • Recognition of symptoms
  • Thresholds for seeking care
  • Ability to communicate symptoms to a provider who understands their meaning
  • Clinical decision-making
  • Ability to understand prescribed management strategy
  • Expectations of care
  • Many more…

II. Simulation

Teaching strategy

Education vs. evaluation vs. remediation

Types of simulation

  • Standardized patients
  • Computer-based tutorials, case studies, interactive media
  • Anatomic models
  • Screen-based partial task trainers
  • Manikin-based (low, moderate, high fidelity)

Emphasis on application and integration of knowledge, skills, & critical thinking

Safety and Simulation

  • Expose to common & uncommon clinical situations
  • Develop skill & practice without risk to patients
  • Allow mistakes  natural consequences
  • Communication… interpersonal relationships…teamwork
  • Mange resources
  • Examine moral, ethical, legal, and cultural aspects
  • Identify & resolve systems-based challenges

III. Culture & Simulation

Differentiating cultural concepts: Awareness, Sensitivity, Competence

Top 10 excuses for why culture isn’t consistently part of simulations

  1. Error of omission
  2. Complicates/muddles the lesson
  3. They’re just learning a psychomotor skill
  4. Most manikins look Caucasian. Its difficult & costly to change skin color/features
  5. No money in budget or time to get appropriate clothing/props
  6. Changing clothing/props between scenarios would take too much time
  7. Faculty knowledge deficit – don’t want to offend participants
  8. Cultures are addressed in other classes
  9. So many cultures – wouldn’t know where to begin
  10. Ostrich syndrome: I’m uncomfortable & I don’t want to look at how my own culture & biases affect the care I give

Using cultural overlays

  • Strategies
  • Primary vs. secondary intent
  • Whose culture are we addressing?
  • Props (wigs, clothing, makeup, artifacts)
  • Mix & match?
  • Examples

Review/Lessons learned:

  • Helpful hints
  • Simple  complex
  • Clear objectives
  • Props set the “stage”
  • Be respectful of all cultures
  • Knowledge doesn’t always = action. Be patient
  • It’s difficult to measure attitudes
  • Don’t underestimate the impact of self-reflection
  • Think outside of the “traditional” cultures
  • What doesn’t work

IV. Questions/Discussion

OUR FAVORITE REFERENCES

Top 5 articles

Beagan, B.L. (2003). Teaching social and cultural awareness to medical students: “It’s all very nice to talk about it in theory, but ultimately it makes no difference.” Academic Medicine, 78(6), 605-614.

Betancourt, J. R. (2003). Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Academic Medicine, 78(6), 560-569.

Eddey, G.E. & Robey, K. L. (2005). Considering the culture of disability in cultural competence education. Academic Medicine, 80(7), 706-712.

Green, A.R., Betancourt, J. R., & Carrillo, J.E (2002). Integrating social factors into cross-cultural medical education. Academic Medicine, 77(3), 193-197

Tervalon, M. (2003). Components of culture in health for medical students’ education. Academic Medicine, 78(6), 570-576.

Top 3 texts

Transcultural Health Care: a culturally competent approach, 2nd ed (2003). Purnell & Paulanka, FA Davis ISBN 0-8036-1057-2

Caring for Women Cross-culturally (2003). St. Hill, Lipson, & Meleis, FA Davis. ISBN 0-8036-1004-1

Culture in Clinical Care (2002). Bonder, Martin, & Miracle. Slack, Inc. ISBN 1-55642-459-0

Top 5 web sites & organizations

Ethnomed

DiversityRx

Cultural Competency in Medicine

Transcultural Nursing Society

AltaVists.com, then Babel Fish

Simulation:

Ideas for Case Studies: Thomson-Delmar series

Clinically focused professional organizations: core curriculum, case studies

Journal articles

Sentinel events, near-misses, QA, initiatives, National Patient Safety Goals

Simulation organizations

  • Society for Simulation in Healthcare (
  • International Nursing Association for Clinical Simulation and Learning (
  • Society in Europe for Simulation Applied to Medicine (

Speaker Contact Information: ;

PREP

L&D Scenario #4: PostPartum Hemorrhage with Infant Abduction

Objectives: At the completion of the simulation, the participant will be able to:

  • Correctly interpret the signs/symptoms of PPH (What are early S&S of PPH? How much blood can a woman lose before exhibiting traditional S&S of hypovolemia?)
  • Identify assessments (amount of bleeding, firmness of uterus) and interventions (notify MD/nurse midwife, large bore IV, massage uterus) needed immediately.
  • Discuss therapeutic interventions for PPH
  • Correctly set-up or administer medications as ordered, verify correct dosages
  • Identify - and demonstrate the management of - patient safety issues related to PPH
  • Maintain security of an infant

Critical Actions:

  • Assesses & appropriately intervenes related to post partum hemorrhage
  • Prevents infant abduction

Potential Overlays:

1)women at higher risk of PPH: Hispanic or Asian, young, prolonged labor, oxytocin use for induction of labor, pre-eclampsia/PIH, anesthesia)

2)minor mother ± husband ± boyfriend ± parents disapprove but support her during pregnancy

3)concerned about finances (no insurance)

4)confusion about last name

Instructor notes: Debriefing guide

Confederates: ± signif other; 2nd nurse, nonstaff female in lab coat (profile if possible: female, lab coat, age=)

Overview of the Plot: While staff are attending mother with postpartum bleeding, an unidentified person in white lab coat, offers to take the baby from the room so that they can concentrate on helping the mother. Only after a nursery staff comes to offer help with the baby, do they realize that an unauthorized person has taken the baby & call for a lock down (code pink, code stork, etc).

Set-up

Manikin / Supplies on / Supplies available
METI HPS / Gown, / Exam supplies, gloves
infant / Post partum belly (boggy uterus)* & breasts / IV start kit/tote, I L LR or NS, phlebotomy supplies
Use CC room / Name band / Meds: pitocin, methergine (see below)
Bassinet/borning table / Blue pad with blood & jelly / Blood bags (correct & incorrect),pump
Medical Record: / Peri-pad with red jelly clots / Infusion pump
  • Admission order sheet
/ Dark wig / PP hemorrhage protocol
  • Standing orders
/ Catholic: cross or saint medallion / OR consent/ OR check list
  • Policy & procedure: Post Partum Hemorrhage, infant abduction
/ *Pink foam with center cut out, insert mushed grapefruit, cover with gel pad / OR scrubs, hat, etc. for spouse
Female abductor: lab coat, name tag
Language board or dictionary

Readings / References: Olds, London, Ladewig, Davidson (2004). Maternal-Newborn Nursing & Women’s Heath Care, 7th Ed.The Postpartal Family at Risk p.1075-81; faculty: Gregory (2006) Clinical Decision Making: Case Studies in Maternity & Women’s Health, p.219-20 & 229-232; www. Ethnomed.org

L&D Scenario #4: Post Partum Hemorrhage with Infant Abduction

Situation: Report from previous shift nurse:

“ (insert name)Lynda Maria LopezdelaRosby is a 16 year old G1P1001. She had a prolonged labor but an uncomplicated delivery of a 9 pound girl at 0400 this morning, VSS. Afebrile. Fundus has been firm at the umbilicus with minimal flow. She had 400 mg of ibuprofen at 0600 & has been sleeping since then. Her boyfriend left to go to work. Infant is at the bedside. She does not speak English very well.

I. Baseline

LOC: alert, oriented; GCS=15

VS: 97/42 -100 -20 – 97.7F(C)

Resp: independentairway, lungs clear

IV: none

Labs: Hgb, Rh ?

Meds/response: slept after ibuprofen (po)

Skin: pale

Patient (in Spanish):“I’m feeling very…. dizzy. I’ve had to change my pad quite a few times ”. “Estoy mareada…” “Tres [3] por la hora pasada.”

Critical Interventions:

How many pads?3 in last hour

Check peri-pad

Lookather: Assess pain, dizziness (tender, cramping off & on, dizzy, wet, thirsty, tired); “El estómago está sensible; esta parte está acalambrada con dolor intermitente; estoy mareada, mojada, tengo sed, estoy cansada.”

Check BP, pulse (may be WNL)

Palpate fundus (boggy)

Massage uterus (was a pain 3/10 but goes up to 7/10 when they massage)

II. Peri-Pad and blue pads are saturated

Patient: “_Estoy mojada, muy mojada. ?Qué pasa? ”

Critical Interventions:

Call for help (and interpreter if not done before, - on the way…)

Notify docs/midwife

Massage uterus “ !Ay ay ay! !No! !Me duele, me duele! Quiero ver a mi familia. ”

Start large bore IV with Lactated Ringers (2nd IV may be necessary)

Preload with 1000ml

Clearly explain the situation to the patient/significant others at the appropriate level “ ?Es necesario? ”

Request that infant be sent back to the nursery

Anticipate medications/check standing orders:

oxytocin (Pitocin) (dosage, route, precautions)

cytotec (dosage, route, precautions)

methylergonovine maleate (Methergine) if not hypertensive (dosage, route, precautions)

or Hemabate if she does not have a history of asthma (dosage, route, precautions)

Set up BP cuff & pulse oximeter

Continue toassess bleeding

Labs: Hgb, type & screen (hold for cross-match) (are patients are typed before admission?)

III. While the staff is occupied with the mother, an unidentified person in a lab coat/scrubs enters the room and wheels the baby out in the basinet.

Critical Interventions:

Prevents removal of infant unless person in labcoat/scrubs is appropriately identified

If they allow the infant to be removed, a few minutes later, a nursery staff member comes to the room to offer help:“I heard you are really busy in here, I can take the baby back to the nursery”.

Critical Interventions:

Recognize that there has been a potential infant abduction

Call an infant abduction code

Staff move to appropriate doorways/lock down.