Journal of Nursing Education

Research Briefs 

Development and Evaluation of an Epidural Analgesia Workshop for Senior Nursing Students

Marian Luctkar-Flude, PhD, RN; Rosemary A. Wilson, PhD, RN(EC); Kim Sears, PhD, RN; Cheryl Pulling, MScN, RN; Diana Hopkins-Rosseel, MSc(RHBS), PT; Melanie Jaeger, MD, FRCP

Abstract

Background:

Most prelicensure nursing students receive little to no training in providing care for patients who receive epidural analgesia, despite exposure in clinical settings and the potential for devastating adverse effects. To develop and pilot an epidural workshop for senior nursing students using standardized patients (SPs), and to evaluate feasibility and learner outcomes.

Method:

A 4-hour epidural workshop consisted of a large group lecture and demonstration, small-group practice scenarios, and individual learner evaluation with SPs. Learning outcomes were evaluated using a performance checklist and critical thinking rubric, and pre- and posttests.

Results:

Participants scored well on the performance-based evaluation (mean score of 86% items performed correctly) and rated the workshop highly. However, learners and instructors made several recommendations for improving the learning module for future sessions.

Conclusion:

This pilot project demonstrated that an epidural analgesia workshop using SPs is feasible and results in positive learning outcomes and high satisfaction with senior nursing students. [J Nurs Educ. 2018;57(6):359–365.]

Abstract

Background:

Most prelicensure nursing students receive little to no training in providing care for patients who receive epidural analgesia, despite exposure in clinical settings and the potential for devastating adverse effects. To develop and pilot an epidural workshop for senior nursing students using standardized patients (SPs), and to evaluate feasibility and learner outcomes.

Method:

A 4-hour epidural workshop consisted of a large group lecture and demonstration, small-group practice scenarios, and individual learner evaluation with SPs. Learning outcomes were evaluated using a performance checklist and critical thinking rubric, and pre- and posttests.

Results:

Participants scored well on the performance-based evaluation (mean score of 86% items performed correctly) and rated the workshop highly. However, learners and instructors made several recommendations for improving the learning module for future sessions.

Conclusion:

This pilot project demonstrated that an epidural analgesia workshop using SPs is feasible and results in positive learning outcomes and high satisfaction with senior nursing students. [J Nurs Educ. 2018;57(6):359–365.]

Epidural analgesia is a commonly used acute pain management strategy for patients following surgery, providing better pain control than systemic opioids (Sawhney, 2012). Although serious complications are rare (Rosero & Joshi, 2016), nurses caring for patients with epidurals must recognize and respond appropriately to “red flags” signalling potentially harmful or life-threatening narcotic-related side effects or catheter-related complications. Medication-related side effects such as a lower limb motor blockade must be differentiated from more serious complications such as epidural hematoma, which present with similar signs and symptoms (Christie & McCabe, 2007). Although the extent that nursing students are allowed to care for patients with epidurals varies by country and region, any nursing student may encounter such a patient when answering a call bell or assisting a nurse with care.

Continuous epidural analgesia provides consistent pain relief and is commonly used to manage pain following major thoracic, abdominal, and orthopedic surgery (Halm, 2015; Kingsley, 2001). Although epidural analgesia has become a standard of practice in perioperative care, prelicensure nursing students often receive little or no training in the care of patients receiving this intervention, despite repeated exposure in the clinical settings. Without entry-level educational groundwork, graduates are dependent on postlicensure education generally occurring during hospital orientations in which multiple advanced skills must be learned. This may result in gaps in knowledge, skills, and behaviors. Education is provided through an authorization process, but nurses are usually tested on knowledge and skill, and not ability to apply knowledge and critical thinking when assessing patients for potential adverse events. For example, locally, graduate nurses receive a learning guide, 1 hour of didactic education, and a preceptor demonstration of psychomotor skills involved in assessment of epidural analgesia.

Epidural-related morbidity is more common among perioperative patients than obstetric and pediatric patients, and knowledge of potential adverse outcomes is essential to effective clinical decision making (Bateman et al., 2013; Bauer, George, Seif, & Farag, 2012). Research has demonstrated nurses' knowledge, confidence, skill performance, and decision making related to epidural analgesia as poor (Bird, Allcock, & Cooper, 2013; Bird & Wallis, 2002; Bird, Wallis, & Chaboyer, 2009). A study of medication administration competence among nursing students found that participants struggled most with epidural analgesia competency (Mettiäinen, Luojus, Salminen, & Koivula, 2014). This suggests a need to enhance nursing education related to epidural analgesia.

Simulation using standardized patients (SPs) is a pedagogical strategy used to promote knowledge, teamwork, communication, and critical thinking skills (Koponen, Pyorola, & Isotalus, 2014; Luctkar-Flude et al., 2014; May, Park, & Lee, 2009). Reviews of studies in health care education have demonstrated that SPs facilitate development of students' clinical competence (Oh, Jeon, & Koh, 2015; Williams & Song, 2016). Findings from a Canadian study suggest that nursing students who practice assessment skills on SPs perform better on Objective Structured Clinical Examinations than students practicing on peers (Bornais, Raiger, Krahn, & El-Masri, 2012); thus, an enhanced curriculum was proposed including SP simulations to expose nursing students to red flag clinical situations and provide them with opportunities to respond appropriately to potential adverse events associated with epidural analgesia. The study objective was to fill a current local gap in nursing education related to assessment and care of patients receiving epidural analgesia. The specific aim of this pilot project was to evaluate feasibility and learner outcomes of a novel epidural analgesia workshop that included interactions with professional SPs.

Method

A pretest and posttest pilot evaluation was conducted with a convenience sample of 48 senior students in a baccalaureate nursing program. Approval was obtained from the university's research ethics board, and informed consent was obtained from study participants. Study tests were administered before and after the workshop. The evaluation included an assessment of outcome measurement tools and feasibility of the approach. The educational intervention consisted of a 4-hour workshop led by a nurse practitioner from the acute pain management service of the local acute care hospital. Learners received a learning guide to review prior to the workshop that included standard content for Advanced Nursing Competency educational delivery at this center. Workshop components included a large-group lecture, demonstration and presimulation briefing, small-group practice, and individual evaluation with SP scenarios (Table 1). Practice and assessment scenarios were developed by study team members experienced in simulation-based education or acute pain management to ensure that commonalities in care of patients receiving epidural analgesia were well represented in the sessions. Educators within the educational center provided SP training following instruction by two study team members. Each SP received a script outlining the past and present medical history, current assessment findings, and a diagram illustrating extent of sensory block. Facilitators were RNs with previous simulation experience who received additional training from the nurse practitioner investigator. Questionnaires included demographic questions, and the following outcome measures were developed or tested in the pilot-study period.

Outline of the Epidural Workshop and Evaluation

Table 1:

Outline of the Epidural Workshop and Evaluation

Pre- and Postknowledge

Pre- and postknowledge were assessed using the Epidural Knowledge Questionnaire (Bird et al., 2009), which consists of 21 multiple choice questions with 4 response options from five key components of epidural analgesia. Content validity was established by an expert panel of professionals from anesthesiology, acute pain management, education, and nursing and midwifery. Pilot testing with a sample of 22 nurses and midwives established face validity, test–retest reliability (r = .98), and internal consistency (Cronbach's α = .76).

Skill Performance

This was evaluated with a performance checklist developed by one of the nurse practitioner investigators who developed workshop content. Content validity was confirmed by two additional pain management educators from the acute care hospital. The checklist, used for authorizing nursing graduates to monitor epidural analgesia in the local acute care hospital, consists of 24 items rated as completed or not completed within seven subscales. The performance checklist has demonstrated good internal consistency (Cronbach's α = .872) and moderate inter-rater reliability (intraclass correlation coefficient = .787).

Critical Thinking

This was evaluated with the Sweeney-Clark's Clinical Simulation Performance Rubric (Hargreaves, Nichols, Shanks, & Halamak, 2010), a modification of Clark's Clinical Simulation Grading Rubric that evaluates cognitive learning on a 5-point scale in six essential areas: (a) assessment, (b) history gathering, (c) critical thinking, (d) communication, (e) patient teaching, and (f) diagnosistic studies (Clark, 2006). Content validity was established by an expert panel and interrater reliability ranged from .64 to .74 (Gantt, 2010). Internal consistency was acceptable (Cronbach's α ⩾ .86) (Kardong-Edgren, Adamson, & Fitzgerald, 2010).

Pre- and Posttest Self-Confidence

Performing assessments and interventions for epidural analgesia was measured with a scale developed based on course objectives. Content validity was established by researchers and instructors expert in the content. Internal consistency of the scale was high (Cronbach's α = .976). Feasibility of the workshop was evaluated through feedback obtained from faculty and facilitators. Satisfaction with the workshop was assessed with a researcher-developed satisfaction scale. Validity was established through peer review by course instructors. Internal consistency was high (Cronbach's α = .83). Qualitative feedback was obtained via open-ended test questions asking about effective aspects of the module and suggestions for improvement.

Data Analysis

Quantitative data were entered into SPSS® software database for analysis. Descriptive data were generated and the primary analysis was to measure change in knowledge and attitudes using paired t tests for continuous data or Mann–Whitney U tests for nominal and ordinal data. Analysis of qualitative data identified emergent patterns concerning participants' perceptions of learning related to epidural analgesia.

Results

Demographics

All nursing student participants in the study were female, with a mean age of 21 years. Most learners had recently completed an acute and specialty care clinical placement and reported learning about epidurals mainly through their undergraduate education (88%) and clinical experience (63%).

Knowledge

The pretest response rate (88%) was high, with a mean grade of 63% (Table 2). The posttest response rate was much lower (31%), with a mean grade of 70%. Due to unequal number of participants on the pre- and posttests, paired t tests were not calculated, and only descriptive results are presented.

Students Answering Knowledge Quiz Items Correctly

Table 2:

Students Answering Knowledge Quiz Items Correctly

Skill

The mean of the total performance scores was 86%. The percentage of learners completing individual items (Table 3) ranged from 21% for “washes hands” to 100% for “uses reference point (face).”

Epidural Assessment Performance Checklist (N = 43)

Table 3:

Epidural Assessment Performance Checklist (N = 43)

Critical Thinking

Learner ratings ranged from novice to competent on the seven items assessed. Students scored lowest on safety, patient teaching, and communication, and highest on clinical judgment, nursing interventions, patient assessment, and history gathering. Most students (58%) were rated as advanced beginners, 40% as competent, and only one student was rated at a novice level of critical thinking ability.

Confidence

The pretest response rate was 71%, whereas the posttest response rate was (42%). Pretests revealed the proportions of nursing students confident with epidural skills were lowest for troubleshooting abnormal findings (32%), reporting abnormal assessment findings (50%), providing patient education (50%), and interpreting sensory assessment findings (53%). Learners were most confident with assessing sensory (62%) and motor blockade (59%), assessing catheter insertion site (59%), interpreting motor assessment findings (56%), and providing patient care (56%). Posttests revealed an increased proportion feeling confident with all skills, ranging from 90% to 100%. Mean confidence scores increased from 29.4 (SD = 9.5) on the pretest to 44.2 (SD = 4.1) on the posttest (p = .001).

Satisfaction With the Learning Module

Ninety-five percent of respondents agreed (somewhat agree, agree, strongly agree) they were able to meet the workshop learning objectives. Most participants (85%) agreed the learning guide (85%) and large-group didactic session (95%) were valuable and contributed to their learning, and all (100%) agreed that large group demonstration, small-group practice scenarios, individual learner evaluation with SPs, and feedback from instructors were valuable and contributed to their learning. In addition, all agreed the session should be offered as an interprofessional education session.

Learner Feedback

Qualitative feedback demonstrated that nursing students perceived the epidural workshop to be an effective strategy, supporting their learning and confidence. One learner commented:

There was an appropriate amount of theory during the large-group lecture and demonstration that gave us the knowledge base to perform and practice assessments with confidence; The workshop was extremely effective…[and] left me feeling confident with the information and assessments after just a few hours.

Learners valued the small group practice sessions:

  • I understood more after the smaller group sessions.
  • The interactive session helped to solidify concepts learned during the presentation.

They also valued the SP encounters:

  • Standardized patients and practicing in small groups is more helpful.
  • The scenarios were a good interactive way to practice.
  • The SPs really enhanced my learning and made the information easier to remember and relatable to practice.

In particular, learners indicated that the workshop contributed to their understanding and critical thinking related to potential adverse effects:

  • [It] provided us with information we need to feel confident in at least knowing the basic assessments, red flags, and basic interventions for epidural patients.
  • I know what I can do independently and when to ask for help in the clinical setting.
  • I learned what serious adverse effects are possible and what to do in the event of abnormal assessment findings.
  • It helped me better understand epidural analgesia and possible adverse effects.

Learners also provided feedback to improve the workshop. The main suggestion related to the timing:

  • It should be provided earlier in the program, such as in third year.
  • It provided valuable information that would have been good to have prior to starting my consolidation placement.
  • Teach it earlier
  • I wish this content was taught to us in second year prior to any clinical.

Some students reported experiencing anxiety related to the testing format of individual SP scenarios:

  • The testing although not being graded makes it stressful.
  • Someone who gets test anxiety and with just learning something and not feeling confident testing is unsettling.
  • Suggest no testing being done.

Instructor Feedback

Informal feedback from instructors provided additional evidence of effectiveness of the epidural module:

  • The progression from theory to practice to testing really supported students in development of knowledge, skill, and critical thinking.
  • Students were engaged in the scenarios and with each other to identify abnormal assessment findings and problem-solve what their next steps should be.

Instructors also suggested changes to improve feasibility of delivering the workshop to larger student groups:

  • The lecture could be videotaped for students to view online before and after the session.
  • Condensing the session time and paying for instructors could address the challenges recruiting nurse evaluators.

In addition, instructors identified frequent learner errors:

  • Confusing intrathecal migration and toxicity.
  • Not palpating the epidural insertion site.
  • Not documenting assessment of epidural site and connections.
  • Assessing sensory block over the patient gown.
  • Being unsure of when to stop the infusion.

Discussion

This initial study provided pilot and feasibility data that supported incorporation of the epidural workshop into the baccalaureate nursing program curriculum. Forty-eight fourth-year nursing students took part in the workshop: 42 completed the pretest, and 15 completed the posttest. Results of the comparison between both testing instances should be interpreted with caution, but, as anticipated, the pretest scores were lower than the posttest scores, showing some improvement among the nursing students' epidural analgesia knowledge. Of note, the proportion of correct answers on eight of the questionnaire items was lower at posttest. These items addressed content from both the written and orally delivered material and reinforced in the interactive simulations. Consistent with these findings, Shin, Park, and Kim (2015) reported a moderate effect size .37, 95% CI: [.04 to .70] for cognitive learning as a result of simulation in nursing education in a meta-analysis of 20 studies. In addition, overall effect sizes were higher in performance-based evaluations than examinations (1.14 versus 0.40). Participants in our study scored well on the performance-based evaluation (mean score of 86% items performed correctly). A disappointing finding of only one-fifth of the sample performing hand washing prior to patient contact highlighted the need to reinforce this basic task in future teaching.

There is little doubt that simulation of any kind is more effective in improving learning outcomes compared with traditional educational methods (e.g., didactic) and is associated with a moderate to large effect size (Shin et al., 2015). Simulation also improves confidence and decreases anxiety (McMullen et al., 2016; Shepherd et al., 2010). Quantitative data and qualitative results suggest that using SPs in an epidural educational module had a positive effect on nursing student learning outcomes and confidence. The novel epidural analgesia educational workshop provided senior nursing students with opportunities to demonstrate knowledge, clinical skills, and critical thinking related to identifying abnormal assessment findings for patients receiving epidural analgesia. Feedback and discussion during debriefing allowed learners to clarify knowledge gaps related to assessment of patients with epidurals and interpreting and acting on findings in a timely fashion. Research suggests debriefing is a critical aspect of simulation during which reflective learning takes place, and students connect theoretical concepts with practice and integrate the experience into their knowledge base (Cantrell, 2008; Shinnick et al., 2011). Responses from the majority of participants suggest both the practice and testing scenarios were effective.

This pilot study demonstrated feasibility of using SP scenarios to foster integration of epidural analgesia principles and practices, and several recommendations were made for improving the learning module for future sessions. The majority of participants indicated that the workshop would have been valuable to have prior to their final integrated practicum, whereas others suggested offering the workshop earlier in the nursing program in the third or even second year. Instructors recommended videotaping the lecture to condense the onsite component of the module, facilitating delivery to larger groups of students. Findings were useful in identifying gaps in learner knowledge, confidence, and skill performance that could be better addressed in both the classroom and future simulation sessions. This pilot project demonstrated feasibility of implementing a multicomponent workshop progressing from theory to practice to SP encounters.

The ultimate goal of this project is to enhance patient care quality. Simulation contributes to patient safety by providing learners with opportunities to practice in an environment in which patients cannot be harmed and, through reflection and constructive feedback, to prevent repetition of mistakes in actual clinical settings (Ziv, Ben-David, & Ziv, 2005). The module allowed learners repeated opportunities to practice skills and critical thinking associated with safe monitoring of and intervention for epidural analgesia.

Limitations

Results of the evaluation of this pilot development and implementation project must be interpreted cautiously in light of several limitations. Low response rates on online posttests limits the ability to attribute positive learning outcomes to the workshop alone; however, qualitative feedback from learners supports that the intended learning took place. In particular, nursing students valued opportunities to apply their learning in the SP sessions. Low response rates may be attributed to the fact that the session was held during the last week of classes and was not mandatory. The posttest was e-mailed to them, but most did not complete it. Posttest responses could have been increased by having students complete hard copies of the test immediately following the session.

Another limitation is that the workshop was implemented at a single university with a small convenience sample; thus results may not generalize to other schools or disciplines. The education was delivered to nursing students only, despite the reality that other health professional students may be involved in care of patients receiving epidural analgesia. Interprofessional education has been shown to contribute to better patient care and, subsequently, improved patient safety (Reeves, Goldman, Sawatzky-Girling, & Burton, 2008); thus, future provision of this education within an interprofessional education module will allow interpersonal interactions between health care disciplines to be explored, and training on communication and team-work provided (Gaba, 2000).

Conclusion

The epidural analgesia workshop using SPs proved to be feasible and satisfactory to a pilot group of senior nursing students, and suggested anticipated learning outcomes were achieved. Further testing with a larger sample of nursing students completing both pre- and posttesting is needed to establish whether the workshop increased knowledge. Further testing is planned to adapt the module for interprofessional education groups to include nursing, physiotherapy, and medical students. It is anticipated that the module will strengthen the curriculum and positively impact patient safety by enhancing health professional students' critical thinking skills related to epidural analgesia with its associated risks.

References

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Outline of the Epidural Workshop and Evaluation

Workshop ComponentDelivery MethodTime Allotted
Presimulation preparation independent studyOnline learning guideAs needed
Epidural knowledge pretest Demographic and experience surveyOnline20 minutes
Review of epidural content Presimulation briefingLarge-group lecture (20 to 25 learners)45 minutes
Demonstration of epidural assessmentLarge group (20 to 25 learners)15 minutes
Practice scenarios with peers:Small groups (5 learners per group)60 minutes
  Sensory block not dense enough
  Tubing undone at filter
  Sensory block too large, potential hematoma
Evaluation scenarios with standardized patients:Individuals (10 minutes per learner)60 minutes
  Sensory block too narrow
  Sensory block too large, potential hematoma
  Potential local anesthetic toxicity
  Sensory block too narrow and not dense enough
Epidural knowledge posttest Confidence and satisfaction surveyOnline20 minutes

Students Answering Knowledge Quiz Items Correctly

Knowledge Quiz Item (Multiple Choice)Presurvey (n = 42)Postsurvey (n = 15)
The epidural space is a potential space located outside the…73%93%
An epidural catheter is inserted at the T5 level. Where would you expect to detect the sensory block?49%60%
What is a dermatome segment?92%80%
Which dermatome segment corresponds to the medial aspect of the lower leg? (see diagram)68%80%
The drug groups commonly used for epidural analgesia are:80%87%
Local anesthetic agents result in blockage of:53%47%
Epidural opioids potentially cause:29%40%
Which epidurally administered drug is most likely to cause respiratory depression?81%80%
When conducting sensory blockade assessment, which of the following areas is used as a control?85%100%
When performing sensory blockade assessment following a left total knee replacement, you would:80%100%
You identified the following sensory blockade in your patient, how would you record your findings?32%20%
Which of the following statements is correct?83%100%
On motor blockade assessment, Mr. C is able to move both his feet, knees, and has full hip flexion. You would document…83%100%
On reassessment Mr. C cannot flex his right knee and hip. You would document…83%100%
The classic signs of epidural hematoma include:39%30%
You suspect an epidural catheter may have migrated. Early signs of intravascular local anesthetic toxicity include:63%100%
Following a bolus dose of local anesthetic, sensory block L1-T2, what is most likely cause of hypotension?64%67%
You have assessed your epidural patient to have a Bromage Score of R = 1; L = 2. Your intervention would be:47%20%
You have assessed your epidural patient to as having an uneven sensory block but no pain. Your intervention would be:93%100%
Your patient's epidural sensory block has extended to T2. You would…78%73%
Before removing your patient's epidural catheter, you would:34%33%
Mean total grade:63%70%

Epidural Assessment Performance Checklist (N = 43)

Assessment DomainPerformance ItemLearners Completing Item
PreparationExplains procedure to patient.98%
Washes hands.21%
Reviews orders and previous assessment documentation.93%
Performs vital signs check.98%
Pain assessmentAssesses pain intensity at rest and with activity.93%
Assesses pain quality and location.63%
Sensory block assessmentUses 1–2 fingers of ice glove.95%
Moves from head to toe, one side at a time.87%
Uses reference point (face).100%
Tests each dermatome in expected zone of analgesia.85%
Motor function assessmentTests hip flexors, knees, ankles, and feet.92%
Tests against gravity.92%
Tests against resistance.95%
Tests both sides.97%
Catheter site assessmentChecks connections.58%
Inspects, palpates, notes markings.93%
Verbal reportIdentifies patient condition correctly.72%
Identifies nursing intervention required.91%
Written documentationDocuments pain assessment on flow sheet and progress note.74%
Documents pain quality, catheter site, and other findings.86%
Documents sensory block correctly.90%
Documents motor assessment using the Bromage scale.100%
Documents pump settings and report.81%
Authors

Dr. Luctkar-Flude is Assistant Professor, Dr. Wilson is Assistant Professor, Dr. Sears is Associate Professor, Ms. Pulling is Associate Professor, School of Nursing, Ms. Hopkins-Rosseel is Professor, School of Rehabilitation Therapy, and Dr. Jaeger is Associate Professor, Department of Anesthesiology & Perioperative Medicine, Queen's University, Kingston, Ontario, Canada.

This research was partially funded by a SIM-one Simulation Research and Innovation Grant.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Marian Luctkar-Flude, PhD, RN, Assistant Professor, School of Nursing, Queen's University, 92 Barrie Street, Kingston, ON, Canada K7L 3N6; e-mail: mfl1@post.queensu.ca.

Received: November 04, 2017
Accepted: January 17, 2018

10.3928/01484834-20180522-07

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