Nursing Skills: From Fear to Fun – Student and Faculty Perspective
Jessica Puga, BSN, Michelle Warner, BSN, Angela Koranteng, BSN, Taos McGarraugh, BSN, Lindsey Cardenas, BSN, Nicole Price, RN, MSN, CS/NP
Nursing students‘ education consists of learning theory in the classroom and then learning skills in the nursing skills laboratory and finally, putting skills into practice with real patients in the clinical setting. The clinical setting is quite different from that of the lab. Working with live people instead of mannequins is one of the obvious differences, but one of the not so obvious differences is that you will be expected to perform tasks without receiving a „how to“ demonstration beforehand because you’ve already been checked off on the skill in the lab. Being comfortable with a skill before coming to the clinical setting greatly reduces anxiety. The only way to become comfortable with a skill is to practice. The following is a compilation of instructions on how to perform skills that you should be comfortable with before beginning an advanced Medical-Surgical rotation. We hope that you will practice with this compilation, and that your skills become more precise with it. As your skill level increases, your anxiety level should decrease.
As nursing students from the same program and cohort we all have had the same academic education, but we differ greatly in our technical nursing skills in level and exposure. As a group we wanted to come up with what we thought were some key skills that students going into Advanced Medical-Surgical should be proficient in including central line dressing changes, IV piggyback med administration, and administering enteral feedings via feeding tube. These were all skills we thought Medical-Surgical I students would gain exposure to during their first clinical experience. The brainstorming process allowed us as students to voice where we felt proficient and where we had deficits in our clinical exposure. Collectively we decided that a low stress environment would be where students could gain the most knowledge and exposure in nursing skills. Overall the brainstorming process opened our eyes to the wide range of skill levels acquired by nursing students at the same clinical level.
Recommendations for student learning and satisfaction:
Since nursing students are always pressed to perform for a grade, a different approach to practice skills is to make it less of a bootcamp setting and more of a fun and educational experience. Most people are receptive to learning when they are having fun, and while in nursing school labs, having fun is often replaced by the anxiety to perform well. The following are recommendations (written by students) to make this a positive and less stressful learning experience.
Many nursing students who have had basic Medical-Surgical nursing have had the opportunity to practice few skills on patients. Students may agree that practicing skills on mannequins may not be the most realistic experience, practice does make perfect. Our recommendation is to make it a fun event that everyone will enjoy participating in. Therefore we’ve developed a game to hold before the Advanced Medical-Surgical clinicals begin. We’ve titled the game the „nursing student Olympic“. The idea of this game is to divide the participating students into groups to compete for points. The team that accumulates the most points wins the „Olympic games“ and wins a prize.
How to set up the skills Olympics: 1st divide students into equal groups. Depending on the number of students in the class, 3 or more groups is ideal. Next, decide on the skills the students are to perform. Examples are included in this article. In order to have a true Olympic games, students will compete at the same time to perform the skill. For example, if the skill to compete in is a central line dressing change, all teams will perform the skill at the same time, with one instructor per student. Depending on the skill, there will be vital steps that must be completed (ex. hand washing before you begin). Each step will be awarded a certain number of points. Once the student has completed all of the particular steps, the instructor proctoring the exam will award the point(s). Once the entire skill is complete, the scores are tallied up. The team with the most points overall will win the Olympic games. Ideally, 4 or more skills should be performed. To really get the students in the competitive Olympic spirit, prizes should be awarded to the winning team. Ideas such as penlights, coffee shop gift cards, or school apparel are ideas. Often, students have not had the opportunity to practice many skills that were introduced in fundamentals. Promotional items from local hospitals or drug reps are also good choices. This is a great way to not only refresh students on skills but to show your stuff among your peers.
As nursing students who have recently completed the program, our advice to the students who are coming through is to practice your skills as often and as much as you can. When you are doing your clinical rotations make the best of the experience. We recommend volunteering to practice your skills on patients and asking a lot of questions. Be involved with your nurses and clinical instructors so that they know that you want to perform the skill, either for the first time or routinely for practice. It is important that you jump at the opportunity instead of standing back and letting the other students take it. While performing the skill, the student should verbalize the skill to teach the observing RN or other students. Learn it, do it, teach it!
The following are guides we’ve put together for the following skills:
- Central line dressing change
- Administering IV piggy back medications
- Administering medications/enteral feeding via feeding tube
Administration of IV Piggyback Medication:
The student should collect necessary information for safe administration of the drug, then assess patency of client’s existing IV infusion line by noting infusion rate of main IV line. Assess IV insertion site for signs of infiltration or phlebitis. Make sure the client understands of the purpose of the drug therapy. Next, assemble supplies at client’s bedside. Prepare client by informing him or her that medication will be given through IV equipment. Be sure to identify client by looking at armband and asking client’s name. Explain purpose of medication and side effects to client. Encourage client to report symptoms of discomfort at site. To administer the infusion connect piggyback *(secondary) infusion tubing to medication bag. Allow solution to fill tubing by opening regulator flow clamp, then hang piggyback medication bag above level of primary fluid bag. Connect tubing of piggyback infusion to appropriate connector on primary infusion line:, when using a stopcock wipe off stopcock port with alcohol swab and connect tubing. Turn stopcock to open position. With a needleless system: Wipe off needleless port and insert tip of piggyback infusion tubing. As for a tubing port, connect sterile needle to end of piggyback or tandem infusion tubing, remove cap, cleanse injection port on main IV line, and insert needle through center of port. Then, regulate flow rate of medication solution by adjusting regulator clamp *(on primary tubing). After medication has infused, check flow regulator on primary infusion. Regulate main infusion line to desired rate, if necessary. Leave secondary bag and tubing in place for future drug administration or discard in appropriate containers.
Administering Medications/ Enteral Feedings via Feeding Tube.
Administering medications and feedings through a feeding tube provides an alternative route for administration of medications and nutrition to the patient who cannot take anything by mouth and has a nasogastric, nasoenteric, or gastrostomy tube in place. This part of the article will provide a new Med/Surg nurse with more information on how to succeed in the procedure.
Prior to administering medications or enteral feedings via nasogastric, nasoenteric gastrostomy, or jejunostomy tube bowel sounds will need to be auscultated. For tube feedings the nurse will need to verify expiration date on formula and integrity of container. Tube feedings should be administered at room temperature. The nurse should shake formula container well, and fill container with formula. The stopcock should be opened on the tubing to remove the air and fill tubing with formula. The formula container is then placed on the intravenous pole.
For administering medication via feeding tubes the nurse should check if a medication is available only in tablet form, check with the pharmacist before crushing it. Also ask about compatibility of the medication with the feeding formula. If a tablet can be safely crushed, use a pill crusher to grind it to a fine powder and mix it with 30 to 50 ml of warm water.
The client should then be placed in a high- Fowlers position, or head of bed elevated at least 30 degrees. After applying gloves tube placement should be verified. For a gastrostomy tube a syringe tube is attached and 5-10 ml of gastric secretions will be aspirated; the nurse should observe the appearance and check pH; gastric fluid of a client who has fasted for at least 4 hours usually has a pH of 1-4, especially when client is not receiving a gastric-acid inhibitor.
For a jejunostomy tube intestinal secretions will be aspirated, presence of intestinal fluid indicates that the end of tube is in the small intestine. Generally the intestinal residual is very small (<10ml).
The nurse should also check for gastric residual, which is done by drawing up 30 ml of air with a syringe, connecting it to the tube, and flushing the tube with air. Pull back evenly to aspirate contents and return aspirated contents to stomach unless the volume exceeds 200 ml. Gastric residual volume indicates if gastric emptying is delayed, delayed gastric emptying is a concern if 200 ml or more remains in the clients stomach. The tube then needs to be flushed with 30 ml of water and feeding could be initiated or medications then can be administered. Regardless of which dosage form is used, the feeding tube should be flushed with at least 30 mL of water before and after administration to clear any residual medication.
Central Line Dressing Change
The nurse should gather the necessary supplies to perform a central line dressing change. Some hospitals or facilities may have all the necessary supplies in a kit. If a pre-packaged kit is unavailable, the nurse should gather the following: a mask, sterile gloves, clean gloves, occlusive dressing, ChloraPrep swabs and tape. As with all procedures, it is important to wash your hands and explain the procedure to the client. Open the central line dressing kit and put on your mask then apply your clean gloves. Instruct the patient to turn head away from the insertion site and remove the old dressing in the direction of hair growth. Dispose dressing and clean gloves in biohazard bag. Put on your sterile gloves, activate ChloraPrep and open alcohol swab stick in preparation for site cleaning. With an alcohol swab stick, clean around the insertion site in a circular motion outward and then allow to air dry. Next, cleanse the skin with the ChloraPrep for 30 seconds in a circular motion moving from the catheter insertion site outward. After allowing the solution to dry for one minute, apply an occlusive dressing with a transparent dressing or 4×4 gauze and tape. Use the windowpane method to tape the edges of occlusive dressing. Use tape that is 2 inches wide if using gauze dressing and tape all across to make occlusive. Coil and tape catheter/tubing to the patient’s chest to avoid tension at the exit site. Date, time and initial a dressing change label and apply it to the dressing. Never sign your label on the patient’s chest.
Nursing Skills – Gaining Mastery – An instructor’s perspective
Teaching nursing students in a clinical setting is not for the faint hearted! To quote Forrest Gump „You never know what you are going to get“. Each new clinical group brings their own strengths, weaknesses and potentials. The skill level can vary depending upon how far along the students are in the program and what their clinical background is.
As faculty we all have our preferences when it comes to what we like to teach and how we like to teach. Beginning nursing students are potentially blank slates for us to make our mark. We want to teach the student the correct way to do a certain skill and hopefully set them off on the path to nursing competence. When teaching advanced Medical-Surgical students sometimes we have bad habits to correct and sometimes they are still blank slates. We do our best to teach skills in a nursing lab, but we all know that starting an IV on an „IV arm“ is very different from doing it in real life. The same goes for inserting nasogastric tubes, giving medications through an enteral feeding tube, doing a central line dressing change, or any other skill.
When working with the students in the clinical setting they are often confronted with equipment that is new or different from what they may have seen in the nursing skills lab or from other limited clinical experiences. This can be stressful for students and faculty alike. A chance to practice some skills in the clinical setting using the actual equipment used by the facility is an excellent chance to alleviate student anxiety. A Skills Olympics is a great idea for that first clinical orientation day at the new facility. The instructor should coordinate with the facility, but most units have a clinical nurse educator who can help with equipment and even a place to practice.
The instructor should review the skills verbally with the students describing the steps they would take, the instructor should provide liberal feedback and support during this phase; then the instructor should demonstrate the desired skill before the students try it. Generally allowing two attempts, one scored and one not scored is sufficient. When all of the groups have completed all of the skills, awards are given and feedback is given. In the event 2 or more groups receive the sample score, multiple awards can be given or asking to site evidence based practice can be used as a tie breaker.
There has been a positive response to the Skills Olympics; the students enjoyed it, they developed or refined technical expertise and felt more confident with performing the tasks on their patients. They became more familiar with the evidence-based practice associated with the tasks and their over-all clinical performance improved.
Good luck to all those students reading this article. To the instructors, have fun with your students! J
Phillips, D.Lynn (2005) Manual of I.V. Therapeutics 4th edition. F.A. Davis Company, Philadelphia
Potter, P.A & Perry A.G, (2009) Fundamentals of Nursing 7th edition.Mosby Elsevier, St. Louis
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Source by Nicole Price