Use of Simulation With Pediatric Nurses: Increasing Confidence and Referrals to Social Work of Adolescents Engaging in Risky Behaviors
Doctor of Nursing Practice Scholarly Project Committee Members • Chair – Dr. Jacqueline Saleeby – Dr. Karen Balakas – Dr. Angela Lowery
Background • Throughout the past several decades, the leading cause of death or injury for adolescents has been accidents and often those accidents involve alcohol or drugs • According to the SubstanceAbuse and Mental Health Services Administration (SAMHSA) (2014), approximately 23% of Americans aged 12-20 years reported they drank alcohol in the previous month – 14.2% of respondents reported binge drinking – 3.7% reported heavy drinking
Background – cont.. • The American College of Surgeons (ACS)(2014) recognizes “many injuries have alcohol and drug use as an important contributing factor. Screening and brief intervention for alcohol use are required of all trauma centers ”(p.140) • “S creening for alcohol use must be performed for all injured patients and must be documented. At Level I and II trauma centers, all patients who have screened positive must receive an intervention by appropriately trained staff, and this intervention must be doc umented” (p.141) – Required compliance with this metric is 100%
Significance • In 2014, only 51% of eligible adolescent patients at Saint Louis Children ’ s Hospital (SLCH) with traumatic injuries were screened. • In 2015, in order to increase in compliance with this metric a taskforce was convened – Goals: • The realization that all adolescents ages 12 and over who were admitted should be screened for drug and alcohol abuse – this screening should not be service or injury dependent • The person who spent the most time with the patient would be the best choice for completing the screening • The bedside nurse would do the screening during the initial assessment to the nursing unit
The St. Louis Children ’ s Hospital Study • The 10 th floor was chosen to complete the pilot study as they were the floor where the bulk of trauma patients were admitted • Since the bedside nurses on the 10 th floor lacked experience administering the Cars, Relax, Alone, Family , Friends, & Trouble (CRAFFT) T ool – A simulation experience was developed to • Increase their confidence in using the CRAFFT assessment tool • Complete the requirement of an intervention referral to treatment for all who screen positive
Study Question For nurses working with patients from 12-17 years, does the use of simulation to teach administration and interpretation of the Cars, Relax, Alone, Forget, Friends, and Trouble (CRAFFT) Screening T ool using specific communication skills result in increased identification of appropriate referrals and an increase in nurse confidence in screening for high risk behaviors?
Study Aims • Determine whether administration of the CRAFFT by bedside nurses for all hospitalized adolescents results in improved screening rates among trauma patients. • Determine whether administration of the CRAFFT by bedside nurses for all hospitalized adolescents results in identification of at-risk patients among the general patient population on the • unit. Determine whether appropriate referrals for brief intervention • are completed by the bedside nurse. Determine whether bedside nurses demonstrate improved confidence in their ability to provide screening for high risk behaviors in adolescents
Study Design and Methods • Maryville University Institutional Review Board (IRB) approval received in February 2017 • Instruments: – Demographic Data Form – 15 Question Pre & Post T est on identifying risky behaviors, use of the CRAFFT T ool, and making social work referrals – The Confidence Scale to measure confidence in skill performance • On-site 4 hour training session following consent process: N=44 ▪ Demographic data collected, Pre-test and Confidence Scale administered ▪ Presentation on identification of risky behaviors, how to ask the questions on ool, referral to social work – Round T the CRAFFT T able Discussion ▪ Participation in Simulation Scenarios ▪ Debriefing after each scenario with parents and adolescents present.
Absolutely Certain for only Fairly certain for Certain for Not at all certain certain for all a few steps a # of steps almost all steps steps I am certain that my performance 1 2 3 4 5 is correct Strongly Strongly Agree Unsure Disagree Item Agree Disagree I feel that I perform the skills 5 4 3 2 1 The without hesitation Confidence My performance Scale would convince the observer(s) 5 4 3 2 1 that I am competent I feel sure of myself as I 5 4 3 2 1 perform the skills I feel satisfied with my 5 4 3 2 1 performance of skills
CRAFFT T ool Questions Have you ever ridden in CAR driven by someone (including yourself) who 1. was “h i gh” or had been using alcohol or drugs? 2. Do you ever use alcohol or drugs to RELAX , feel better about yourself, or fit in? 3. Do you ever use alcohol or drugs while you are by yourself, or ALONE ? 4. Do you ever FORGET things you did while using alcohol or drugs? 5. Do your FAMIL Y or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into TROUBLE while you were using alcohol or 6. drugs? • Note: Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children ’ s Hospital Boston
Sample T est Questions • In 1965 what was the average age of initiating drinking for U.S. adolescents? • In 2015 what was the average age of initiating drinking for U.S. adolescents? • The CRAFFT (Car, Relax, Alone, Forget, Friends, & Trouble) T ool is considered positive if: True or False: Patient ’ s answers to the CRAFFT can be shared with • parents/caregivers regardless of the patient situation being life threatening or not, because the patient was admitted to the hospital? What is the leading cause of mortality and morbidity among American • youth?
6 Simulation Scenarios • All Scenarios used the CRAFFT T ool 1. 15 year-old female admitted from the ED for an appendectomy . Parent agrees to leave after explanation of CRAFFT T ool and need to ask questions without parents present Goal: Introducing sensitive questions, asking parents to leave, explaining why 2. 12 year-old male admitted from the ED after a motor vehicle accident (MCV). Parents refuse to leave. Goal: Introducing sensitive questions, asking parents to leave, secondary line of explanation, determination to NOT ask questions in front of parent
6 Simulation Scenarios Cont. 3. 17 year-old admitted for wrist fracture after an all terrain vehicle (ATV) accident. Parents okay with leaving room, but patient refuses to answer, says “I don ’ t want my parents to know. ” A secondary explanation is given to patient, and patients answers questions after the secondary explanation. Goal: Introducing sensitive questions, asking parents to leave, secondary explanation to patient, patient agrees to answer after secondary explanation 4. 14 year-old transferred from the PICU after having a spinal fusion. CRAFFT ool not administered in the PICU due to the patient ’ s sedation status. T Goal: Introduce sensitive questions, nurse understanding how to document for a transfer patient
6 Simulation Scenarios Cont. 5. 13 year-old admitted from PACU following a cholecystectomy , still sedated, nurse is unable to ask questions during admission profile. Goal: Introducing sensitive questions, nurse knowing how to document CRAFFT wasn ’ t done and how to make sure it gets done by subsequent bedside nurse 6. 16 year-old male admitted following a gunshot wound to the leg. Parents refuse to leave and indignant that you would even ask them to leave. Goal: Introduce sensitive questions, asking parent to leave, secondary explanation to parents, politely ending questions and documenting that parents refused to leave.
Video of Simulation Scenario
Post-Session Data Collection • 2 months post-training session n=22 – Post-test and confidence scale placed in CRAFFT T ool 10 th box in the Floor Staff Lounge and nurses asked to complete and place in envelope with personal identifier and seal.
Statistical Analysis • Univariate Summary Statistics for demographic and instrument scores • McNemar T ests to determine changes in binary Knowledge and Confidence instrument item binary variables. • Non-parametric Wilcoxon signed rank sum tests for changes in the confidence scale items • Wilcox-Mann-Whitney tests to compare composite scores
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