Tag Archives: Friday Night at the ER

“Friday Night at the ER” is also Simulation and – your school needs it!

It’s been more than a year since I posted in this blog, but the all-time top two entries are still attracting views. the first is “Myths about becoming a nurse practitioner – things to consider about grad school in nursing”  http://wp.me/p1Kwij-au and the second is “part 1: Secrets of a Nurse’s Brain – six steps to success at clinical practice, or anywhere!

I mostly blog about Global Health nursing and Nepal healthcare these days since I no longer live in Hawaii. go to http://www.joeniemczura.wordpress.com

Friday Night at the ER and Scenario-based education strategies

These days one of the trends in nursing education is to adopt scenario-based learning. Most often this turns out to include investing in a skills lab upgrade so as to incorporate much more sophisticated training manikins that require use of a computer as well as a trained operator who can make the manikin breathe, talk or have a cardiac arrest. These are wonders to behold, and supported by marketing from the main company that sells them. Over time, this approach has built an eco-system of professional journals, conferences, web pages and user networks to support dissemination of wisdom about how to provide simulation. Your simulation site can get certified, and there is a book of Standards you can use for ideas.

I’ve been in favor of scenario-based education for a long time, probably ever since I became an EMT in 1975. (was still in nursing school at the time). The American Heart Association uses “megacode” scenarios to advance psychomotor skills and I always enjoyed the game aspect of this approach. In Nepal, I use scenario-based education to promote better critical care response. Minimal lecture, lots and lots of role play.

Scenario-based education is more than just the fancy manikin.

In 2002 I was hired by a school of nursing that suffered a dismal NCLEX first-time takers pass rate and decided to replace some faculty members. Voila, because of my prior management experience I was now teaching the Management and Leadership class with a specific mandate to focus on delegation skills.  I re-wrote the course outline to include activities for this. I was determined to teach it in a manner that reflected the real world.

“Delegation is very boring as a lecture topic, up until that exquisite moment when you realize that you are in legal trouble and could lose your license if you do it improperly, then all of a sudden it is crystal clear and very exciting” I used to say.

Friday Night at the ER is a key vehicle to teach concepts of nursing administration firsthand, that go on all the time, but which nobody ever explains to the new RN. The processes in the game board are extremely well-designed to illustrate the ongoing slog of bed-control and patient flow-through decisions, and players get to apply them. The scoring reflects the financial incentives associated with these processes. Sometimes schools of nursing will assign each senior to shadow a house supervisor for a day to get exposed to these things, but this is a hit-or-miss prospect; Friday Night at the ER guarantees that each participant will get the feel of being a house supervisor.

fner-1

One game board. Best played in a rally format with may game boards. Like Monopoly, there are many twists and turns and the outcome depends on certain skills possessed by the players.

It’s a game board. And each board accommodates four (maybe five) players. Do the math. A cohort of thirty will require six or more game boards. We had a cohort of fiftysix, and divided the experience into two halves, with eight boards each day. To fully implement it at your school requires buying a set of game boards (I took this to another large school of nursing and once they committed they bought eight game boards) and it requires logistical set-up ( lot of small pieces need to be set out on the board, like Monopoly). Also, the way we did it required an all-day scheduling commitment, taking about six hours to include two de-briefings along the way. A strong recommendation? don’t try to squeeze it into just one three-hour class sessions. Do it in lieu of a clinical day.

If you adopt Friday Night at the ER?

Facilitator: Like the manikin-based approach to simulation, the facilitator of Friday Night at the ER does a better job if they also have real-world experience as a mid-level manager, because they have a better idea of the relative value of insights  available during an open-ended event such as Friday Night at the ER.

Debriefing: the academic nursing journals and websites devoted to manikin-based scenario learning are amply stocked with testimonials as to the need for debriefing, as a means to frame the experience. Like using a manikin, it’s possible to do the experience and not actually learn anything or gain insight. De-briefing is absolutely critical. If you adopt Friday Night at the ER,  you need to include ample time for this, and the students need to commit to the idea that they can’t run out of the class as soon as the last score is tallied up.

Integration: Friday Night at the ER is billed as “discovery learning”  and the company that sells it will tell you not to pre-warn the participants in advance as to how to “win” or to share the scoring system, etc.  This presents a challenge, because it’s herder to “sell” people on the merits of playing. In addition to the usual suspension of disbelief required for good simulation, Friday Night at the ER is more fun and experiential when you all learn as a team ( that’s why it is used by non-nursing and non-health care teambuilding consultants – it forces people to communicate and problem-solve.)

Having said that, since the game applies principles of delegation and illustrates they way a health care organization works, you can prepare the students to play it as part of a sequence of learning about delegation, the Nurse Practice Act, etc. I wrote a four-part sequence of blog entries to describe the how I taught delegation, right here on this blog.

Where to get Friday Night at the ER

go to http://blearning.com/

Disclaimer: I am not associated with the company in any way not am I being compensated for this full-throated endorsement in any way. I am merely a satisfied user since 2003. I have led this exercise about forty times I think. (memory is a bit fuzzy). I am very experienced in use of scenario-based education for critical care, especially debriefing.

While we are on it, the company needs to grow their followers on Twitter. go to @FNER_Game and you will find them. pass the word!

My other blog entries on this topic

The first was part 1: Secrets of a Nurse’s Brain – six steps to success at clinical practice, or anywhere! This one addresses personal organization to promote personal accountability, the first step to understand delegation.

The second was part two: checklist culture and your role in quality

The third was How to teach delegation and the Nurse Practice Act, part 1 dec 29 2013 This one explores how delegation is defined in (most) state Nurse Practice Acts.

Another was teaching delegation and the Nurse Practice Act, part 3 Jan 1 2014 This one will show you a free resource from NCSBN that is absolutely critical for every school of nursing to teach, and for every future NCLEX test-takers to read.

And finally, to teach delegation part 4 – getting “street smart” Jan 3 2014 How an organization made up of individually-accountable nurses will support legal practice.

Here is my offer to consult with you on delegation issues in the curriculum

As you can see from the above, I believe strongly that delegation can not be “integrated” into the curriculum as some sort of subliminal brain telepathy. Subtlety does not become it, delegation needs to be laid right out there and preached. And, delegation is not well delivered when presented by a “talking head” as a dry academic experience.   In the paper “Working Well With Others” from the National Council of State Boards of Nursing (NCSBN) a key statement is:

“The strongest set of delegation rules will not work unless the nurse possesses the interpersonal communication skills to enforce them” (paraphrased).

The best way to hone interpersonal skills is to use them and get feedback.

Please note: the Friday Night at the ER site lists experts you can hire. UPDATE: at first glance I thought there weren’t any  nursing educators, but I have been gently reminded (below)  that there are two – Dr Mary Dolansky at Case Western, and Dr Carol Durham at UNC. They come highly recommended.

Dr. Mary Dolansky’s  page is https://nursing.case.edu/about/directories/faculty/dolansky/

and

Dr. Carol Durham’s faculty webpage is http://nursing.unc.edu/people/carol-fowler-durham/

I plan to ask Breakthrough Learning to add me to their list. If your school’s aggregate NCLEX scores show the need to buff up the area of delegation,  I will happily work with you to revise the senior-year curriculum, including coming to your school to help you do it (for a fee). Alas, I do not own any of my own game boards. You would need to buy or rent these on your own.

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to teach delegation part 4 – getting “street smart” Jan 3 2014

note: be sure to click on the hyperlinks, the highlighted text. A prize awaits….

Street Smart is the goal.

My favorite definitions of Street Smart are to be found on Urban Dictionary. warning: adult language and content at times, but funny. Possibility of not politically correct. Street Smart is always contrasted with “Book Smart”

Delegation is key to NCLEX success

To teach delegation is to teach “Street Smart” skills, only they never call it that.  This series is to share with faculty colleagues my views on how to teach delegation skills.  In a final-semester-before-graduation course, sometimes the curriculum will mash together content from “Issues and Trends”  “Career Development” and “Leadership and Management” – this is a widely disparate clump of content. Add this to the idea that the students may be having “senioritis” during the second half of the semester.  Finally, students often need to be convinced that the course is relevant – they want something like ACLS or PALS or more pharmacology.

In one of the earlier blogs in this series I gave the rationale for all this emphasis on delegation, but it bears repeating.

read this carefully:

Every Nurse Practice Act includes rules of delegation which are based on the definition of nursing.

The NCLEX content is not solely determined by NCLEX corporation. it is dictated by NCSBN, which uses a sophisticated process to determine the “test plan”

NCSBN test plan says that 20% or more of the exam will be on – delegation.

NCSBN defines delegation and also publishes their own documents to support their definition. Working with Others is the main one. Every nursing students needs this!

therefore,

it makes sense to devote time in nursing school to the specific materials from NCSBN. This is not rocket science.

If your class work on “legal & ethical issues” focuses only on  such things as how not to get sued, or defining “beneficence” or “utilitarianism” – you are wasting your students’ time.  You need to focus on what the rules say.

As an aside, I think one reason that faculty go astray is that few of the nurses who actually managing a ward want to  become faculty members. they are paid too well doing what they do!

and now for today’s Pearl of Wisdom

first, as the NCSBN monograph says: The key to effective delegation is to have assertive interpersonal skills in conflict resolution. So – don’t just teach this by lecture or directed reading. Find ways to make up exercises for the students to role play.

second, when a student is new, they just focus on their own assignment, and the goal here is to develop the skills to analyze how the assignments of all the nurses mesh with each other. Predicting not just what will happen with your patient, but predicting how many nurses will be needed by the unit overall. Figuring out how to work together as a team, how to help each other.

Too often this is taught by just assigning  the student to multiple patients, and watching them flounder around – “sink or swim.”  I guess some students will only start to pay attention when they see that they are not as good as they think they are – but a better way is to teach all the stuff I am listing here.

Friday Night at the E.R.

all this leads me to the subject of today’s blog. Friday Night at the E.R. is a resource for nursing students, and I think every nursing student should play it, especially if they are thinking of a hospital career. I see that for January 2014 the company that makes and sells it, has upgraded the game board a bit to make it easier to play.

An Excellent Simulation Learning exercise

we tend to define simulation learning narrowly these days, as if it can only be done with a high-fidelity manikin and a room with a two-way mirror. That is an artificial constraint IMHO.

FNER was developed as an interactive game to teach teamwork and decisionmaking, not necessarily limited to nurses. It is used by people interested in Organizational Development. It is a board game with a gazillion small parts. It’s expensive but worth it IMHO. It does have complicated directions and requires a facilitator who knows what it is about. (the company has a policy of only selling it to people or agencies that have a registered facilitator.) if you are going to use it, you need to carefully manage the logistics of it – for example, if you have a class of thirty students you need eight game boards. for a class of sixty you may need to have half the group do it one week, the other half the next. You need to schedule extra time – it can not be done in just three hours – the debriefing is as important as the game itself. Simply critical to debrief.

The most important thing about this simulation game, is that the students learns things about their own problemsolving, which is a reason why the makers of the game are a bit vague about the exact conduct of it. I went to YouTube to see if there was anything there that might entice you to seek further information.  I found a gem in which the professor seems to be trying to teach the students “the right way” to do it prior to playing – the exact opposite of it’s intended lesson. And better yet – it’s in French!

If you buy the game, you do get a DVD that tells a lot more. The idea behind that strategy is to allow the students to discover certain things for themselves and not over-teach.

Achieving Street Smarts?

When I have done the Friday Night at the ER  exercise with students, they come back to class after a week or two and tell me that up until then they did not know what the manager of their unit, or the house supervisor, actually did during a work day. “Didn’t have a clue” they say.

But now their eyes are opened and they see their own role as part of the larger team.  They are more focused on admission/transfer/discharge. They have a better sense of their own “agency” – ability to shape their destiny. They are more able to describe the parameters of problemsolving. all kinds of good stuff like that.

I would love to hear from others who have used this…..

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How to teach delegation and the Nurse Practice Act, part 2 dec 30 2013

today’s blog is not as fancy as yesterday.

The feature of yesterday’s blog was to drive traffic to a YouTube video on delegation I made in 2011 and dug up out of the past. Alas, I don’t have another YouTube to share today.

Executive Summary:

If you teach management and leadership, and you want the students to do well on the section on NCLEX, you need to get this  book by Ruth Hansten et al. If you aren’t covering this content, your students are missing a chance to score better on NCLEX. Is that important to you? then read on!

Course outline

To teach the management skills for surviving as a staff nurse, I deliver a series of lectures and in-class exercises early on the semester. the sequence is:

1) definition of nursing according to Nurse Practice Act ( see my YouTube link above)

2) delegation. MD-to-RN; RN-to-RN; RN-to-UAP.

3) staffing systems (team, primary, functional) (usually this is straight from the textbook, but for some reason students always think this is boooorinnnnggggg – until somebody shows them it is not) and making out the actual assignment.

Note: I am a devotee of Ruth Hansten, RN, PhD of Washington state, who has written a lot of really excellent practical examples of this in her books. While researching this blog, I came across her 2011 book, Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX Examination, 3e. I confess I have not read this specific one, but I highly recommend that you check out the 29 reviews on Amazon. If you are teaching this material at a school of nursing you need to own a copy and consider adopting it. Also a copy  of her book Clinical Delegation Skills on your shelf. (1994, which is “old” but a classic).  It’s the clearest discussion of how the Nurse Practice Act translates in to clinical bedside decisions. Dr Hansten’s consultant work on delegation has informed the national dialog on this subject. Her website is http://www.hansten.com

4) conflict resolution ( as inspired by the NCSBN materials on this subject, more on this in a future blog).

5) bed control and unit-to-unit coordination. ( which uses Friday Night at the ER. I will do a separate blog on this gem of a resource, later).

The overall idea is to give the neophyte nurse an idea as to the context by which care is delivered. if they have this, they think only of their own assignment and they don’t develop the predictive ability they need. If students don’t get these, they are less likely to show initiative in these issues, and the preceptor and staff will notice. workload estimation and priority setting are skills that can be learned, and this is a place where it is taught.here is the problem. Neophyte nurses can become “situationally aware.”

For each of the areas listed above,  I have an in-class hands-on exercise.

Does your school of nursing do this?

If not, they should. hate to be the know-it-all, tell-you-what-to-do-guy, but – that is who I am today.

I know I am old school, because of the fact that I was a nurse-manager for ten years, have  worked on “charge nurse development” when I was a staff development director, and also spent a lot of time dealing with “house supervision” (which I always disliked).

making out the assignment

so, the Pearl of Wisdom for today is an  in-class exercise you can use. it goes like this:

pre-prep required – write a list of  a dozen or so patient summaries such as would be used during a taped shift-to-shift report. the kind that would be done from charge nurse to charge nurse in the report room. bring blank transparencies, marker pens, and templates for writing the report as it is received.

each student gets a paper that has space for them to copy down the report as they go along.

the class begins with a lecture on types of staffing systems (team nursing, functional nursing, primary nursing) and the rationale for each. I like to do the short lecture on this the week before, and assign the reading so the students will be prepared. Also, if they are doing clinical on a ward that does report this way, to find a copy of the assignment sheet and bring it in so we can see an example of how it’s done. if their ward does nurse-to-nurse report, I tell them to ask if they can attend the charge nurse to charge nurse report for a day.

the students would have already had the content on the Nurse Practice Act as well as the content on UAP delegation.

the class is divided into smaller groups of about six. they are told that the outcome of the exercise is to produce an assignment sheet that uses the principles of delegation, the skills level of the staff, and the available personnel. this is the kind that would be posted on the unit. then I draw a diagram of the floor plan of a 12-bed unit, and  tell how much staff they have.

next is for me to give the verbal report while they copy it down. a pitfall at this step is that the reporter ought to go as fast as would be done in real life. it’s not unusual for the students to miss half the data the first time around. this is a learned skill.  It helps to have an assistant here to make sure the students are doing it – I once had a group where one guy didn’t write anything – tried to make a joke out of it. (not an acceptable work behavior).

then the students work as a group to  make out the assignment. I give them about 20 minutes. I bring blank sheets of transparencies to use on the overhead projector, and each group submits theirs.  one by one we go through the critique of how they did.

interactive discussion of the exercise

The success depends partially on how clever the teacher is. leave room for serendipitous learning. One group once made out the assignment but left off a patient – I.e., no nurses assigned to that patient for that shift (gotcha!). You can expect that one group will choose functional (task-oriented) nursing; that is acceptable (it’s not the preferred way, but it is on the palette of choices). They need to decide whether the charge RN takes an assignment or not;  One group demanded to transfer two patients to ICU, call for a float, and send out for pizza.

The critique is just as important as the choices. Invariably the question will arise as to “what is the correct answer?” – and the reply is “there is no single correct way to do this.” which is a good illustration of dealing with the ambiguity of staffing.

If you can do this exercise, it transforms a boring lecture (“here are the alternative staffing systems, here is how you do it”) into a stimulating and fun group exercise that creates a lot of discussion.

let me know how you make out…..

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