Student nurses must recognise the need to accurately complete patient documents and can learn from their mistakes through simulation and formative feedback
Documentation is an essential part of patient care and safety. This article explains how a review of documentation of vital signs completed during simulation sessions revealed that student nurses needed support in this area. Formative feedback after a simulated skills assessment can help students to identify patient safety issues related to their own skills, and the associated documentation.
Citation: Wright W, Everett F (2015) Using simulation to aid students’ documentation. Nursing Times; 111: 8, 18-19.
Authors: Wendy Wright and Fiona Everett are lecturers at the School of Health Studies, University of the West of Scotland.
- This article has been double-blind peer reviewed
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One of the World Health Organization’s 11 patient safety themes concerns learning from errors to prevent harm (WHO, 2011). Studies from across the world have demonstrated that the quality of nursing care has a direct impact on patient outcomes (Clarke and Aitken, 2006). Achieving safe patient care should underpin all clinical nursing education.
The fundamental skills module in part one of the pre-registration nursing degree programme lays the foundation for the subsequent skills modules in parts two and three.
In this module, it is important to introduce skills, through simulation, in a safe learning environment. Using formative assessment in conjunction with simulation to promote patient safety and produce accurate documentation can help students learn from errors and prevent harm. Formative assessment does not necessarily have a grade attached, but it can have an impact on the grade that the student achieves at the summative assessment. It provides a valuable opportunity to offer feedback, which can help students establish how well they are progressing.
Simulation and documentation
The Nursing and Midwifery Council (2010; 2008a) states that nurse education programmes should use evidence-based practice. The essential nursing skills team at Hamilton Campus of the University of the West of Scotland introduced a contemporary, holistic, integrated teaching approach in September 2010 (Everett and Wright, 2011), with which students are immersed in the essential elements of nursing care in a classroom setting. One example is the simulated scenario of assessing, measuring and recording a patient’s temperature, pulse and respiratory rate, which allows students to observe, question, discuss and practise these skills in a safe environment. Box 1 gives examples of other areas covered.
Box 1. Fundamental skills module topics
- Hand hygiene
- Effective communication, including appropriate language and physical contact
- Moving and handling
- Measuring vital signs
- Ensuring patient safety through maintaining accurate, up-to-date documentation
- Appropriate use of equipment
- Infection prevention and control
The NMC code (2008b) is introduced and discussed in relation to duty of care, consent, confidentiality, accountability, communication, feedback and the recording of observations. The concepts of dignity, autonomy and respect are also addressed and demonstrated through the use of language, facilitation of choice, appropriate physical contact and minimal exposure of the patient.
The importance of record keeping (NMC, 2009) is established using local NHS documentation, which helps students become familiar with it and record their findings during simulated scenarios. When students use the modified early warning system (MEWS) chart, they are provided with the opportunity to record vital signs and are introduced to a system for identifying patients who are deteriorating.
According to the National Institute for Health and Care Excellence (2007), these vital signs and associated documentation need to be “carried out well and recorded well”. Absence of findings or errors in the documentation may imply a lack of knowledge or lack of observations, leading to patient safety issues. The documentation should provide an insight into the patient’s condition, at the date and time recorded, to enable the next professional to compare their observations with previous results and provide an accurate record of the patient’s current health status and any changes that have occurred.
Before the skills session, students are given information via the university’s virtual learning environment, Moodle. This takes the form of video and e-learning materials, including quizzes, which allow students to self-evaluate their performance (Everett and Wright, 2012).
Through simulation and formative assessment, students are encouraged to embrace the principle of good record keeping. But after clinical skills laboratories covering the temperature, pulse and respiratory rate, we noticed consistent errors in the completion of MEWS charts. A comprehensive review of completed charts was therefore carried out to check for accuracy.
Students are given formative feedback immediately after the simulated activity. They are provided with verbal comments and a written checklist of individual pass/fail aspects of the assessment, such as correct use of equipment and documentation. As the assessment is not formally graded, students receive guidance in a supportive environment. They can question the lecturer and address any issues.
MEWS charts review
The review of MEWS charts, which took place during one week in February 2014, was carried out by two nurse lecturers who were part of the team conducting the simulated teaching and learning activities.
The sample group consisted of 208 first-year student nurses, who had participated in the simulated activities. Each participant completed a MEWS chart as part of the assessment and all were reviewed.
Documentation was accurate and complete in only 46% of the charts reviewed - meaning the safety of 113 patients would be at risk in a real-life scenario. Fig 1 (attached) gives a breakdown of the types of documentation errors.
Identity information was omitted in 4% of charts, risking serious consequences for patients, as it could mean no recorded data for them is evident or that data is linked to the wrong person. The time and date was not completed in 25% of charts. Other anomalies included:
- Inaccurate plotting of results (46%): this included students verbalising the results during the simulation session, then recording them inaccurately on the documentation;
- Not stating the value within the respiration range (19%): as the MEWS chart has a range for respiratory rate, students are expected to use numbers in this section; they are expected to state the exact value within a range (12 respirations per minute, for example), which would be within range 9-14;
- Using an incorrect process when making an amendment (2%): for example, no line was drawn through the error;
- Charts could not be photocopied or scanned (5%): pencil or an inappropriate pen colour was used.
Discussion and conclusion
As nurse lecturers, we recognise the importance of teaching the assessment, measurement, observation, feedback and recording of vital signs to student nurses. Through simulation and formative feedback, students are now encouraged to embrace and develop the principles of good record keeping. Regular engagement with simulation has the potential to enhance patient safety and reduce errors.
As the fundamental skills module lays the foundation for subsequent skills modules in parts two and three of this pre-registration nursing degree programme, it is important to introduce documentation through simulation, which provides a safe learning environment.
Simulation is an integral element of contemporary nursing education, and its use can enable student nurses to relate more readily to the clinical practice setting, because it reproduces features of a real-life situation.
Future continuous evaluation will include the review of completed MEWS charts for students in parts two and three of the course, following simulated assessments of vital signs to reinforce the principles of good record keeping and its importance in relation to patient safety and clinical outcomes.
- Simulation and formative assessment can enhance the student learning experience
- Accurate documentation is an integral aspect of safe patient care
- Nurse educators have an important role to play in providing formative feedback on documentation
- Simulation sessions are a safe way of helping student nurses develop essential nursing skills
- Student nurses need to recognise their mistakes and learn from them in a supportive environment
Clarke S, Aitken L (2006) More nursing, fewer deaths. BMJ Quality & Safety; 15: 1, 2-3.
Everett F, Wright W (2012) Using multimedia to teach students essential skills. Nursing Times; 108: 30/31, 18-19.
Everett F, Wright W (2011) Measuring vital signs: an integrated teaching approach. Nursing Times; 107: 27, 16-17.
National Institute for Health and Care Excellence (2007) Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital.
Nursing and Midwifery Council (2010) Standards for pre-registration nursing education.
Nursing and Midwifery Council (2009) Record keeping: guidance for nurses and widwives.
Nursing and Midwifery Council (2008a) Standards to support learning and assessment in practice.
Nursing and Midwifery Council (2008b) The code: standards of conduct, performance and ethics for nurses and midwives.
World Health Organization (2011) Patient safety curriculum guide: multi-professional edition.