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Instructor’s Guide – Vigilance is Never In Vain
Overview:
This story highlights the importance of Venous Thrombosis Embolism (VTE) prevention protocols. Signs and symptoms of VTE are frequently silent and can lead to fatal pulmonary embolism. All team members are responsible for VTE.
Primary Learning Outcomes
After completing this lesson, the student will be able to:
- Explain the importance of ensuring that patient order sets include a plan for VTE prophylaxis.
- Describe the necessity of re-assessing patients for VTE risk when their conditions or circumstances change (e.g. moving into post-operative phase).
- Develop a plan to communicate patient goals including VTE prophylaxis to all members of the multidisciplinary team.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS Best Practice: Two Challenge Rule
Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals.
Two Challenge Rule
It is important to voice your concern by advocating and asserting your statement at least twice if the initial assertion is ignored (thus the name, “Two-Challenge rule”). These two attempts may come from the same person or two different team members. The first challenge should be in the form of a question. The second challenge should provide some support for your concern. Remember this is about advocating for the patient. The Two-Challenge tactic ensures that an expressed concern has been heard, understood, and acknowledged.
Reflection Questions:
Students will answer reflection questions upon completing the story. These questions are aligned with the QSEN competencies and are designed to help the student reflect on both the content of the story and the QSEN competencies addressed by the story.
*Following each question are some potential answers
- Why is it important to ensure that patient order sets include a plan for VTE prophylaxis?
A: This is one way to ensure the patient does not get a DVT after surgery. The order sets are put into place for a reason and they reflect Evidence Based Practice.
- How could Sally have applied the Two-Challenge Rule when she discovered Dr. Hamdi’s orders?
A: She could have called the doctor right away and asked if he would like to implement the VTE protocol. If the doctor does not agree then the nurse can suggest they implement the VTE protocol.
- What does this story illustrate about the importance of fostering and maintaining open communication, mutual respect, and shared decision-making among the team, regardless of roles or hierarchy?
A: The nurse did not call the doctor because she was nervous about how he would respond. The hospitalist also did not want to contact Dr Hamdi because she did not think he would respond well. Therefore, because the nurse was nervous about speak to the doctor then the patient did not receive the appropriate medication.
Discussion Questions:
Use discussion questions for face to face or online discussion boards to get students to further reflect on the content of the story together.
*Following each question are some potential answers
- What can we learn from this story?
A: The patient needs to be the priority for the nurse and not the concern over what the doctor will say. The patient should have received different medication and the nurse knew that, but she did not feel comfortable calling the doctor.
- What could you do to ensure daily review of VTE risk factors for all patients?
A: All surgical patients should be provided with VTE standards of care. A daily check could be made by the change nurse to ensure this is done.
Suggested Classroom Mastery Activities:
These activities can be tailored for individuals or groups in a face to face or online setting.
- Create a presentation explaining VTE risk, and the precautions that can help prevent fatal errors. Share your work with your classmates.
- Create a VTE prophylaxis protocol/checklist that members of this unit could follow when re-assessing patients.
- Write a dialogue between Sally and Dr. Hamdi where Sally employs the Two-Challenge Rule to advocate for Dina.
Measuring Student Mastery:
| Learning Outcome |
Level 1 |
Level 2 |
Level 3 |
| Explain the importance of ensuring that patient order sets include a plan for VTE prophylaxis. |
Student struggles to explain the importance of ensuring that patient order sets include a plan for VTE prophylaxis. |
Student can explain the importance of ensuring that patient order sets include a plan for VTE prophylaxis, but needs improvement. |
Student can accurately explain the importance of ensuring that patient order sets include a plan for VTE prophylaxis. |
| Describe the necessity of re-assessing patients for VTE risk when their conditions or circumstances change (e.g. moving into post-operative phase). |
Student struggles to describe the necessity of re-assessing patients for VTE risk when their conditions or circumstances change. |
Student can describe the necessity of re-assessing patients for VTE risk when their conditions or circumstances change, but needs improvement. |
Student can accurately describe the necessity of re-assessing patients for VTE risk when their conditions or circumstances change. |
| Develop a plan to communicate patient goals including VTE prophylaxis to all members of the multidisciplinary team. |
Student struggles to develop a plan to communicate patient goals including VTE prophylaxis to all members of the multidisciplinary team. |
Student is able to develop a plan to communicate patient goals including VTE prophylaxis to all members of the multidisciplinary team, but needs improvement. |
Student is able to develop an accurate and complete plan to communicate patient goals including VTE prophylaxis to all members of the multidisciplinary team. |
Additional Story-Specific Resources:
For additional information on improving team communication, please consult the following articles and resources in Further Reading:
Story-Specific Best Practices and Proven Tools:
In addition to the ideas generated by students and mentioned in the activities, there are established best practices that may be appropriate to introduce or reference during this lesson to support communication. Some best practices to consider for improving team communication include:
- Advocacy and Assertion
- Check Backs
- Bedside Handoffs
- Collaboration
- Cross Monitoring
- STEP
- Handoff
- I PASS the BATON
- Two-Challenge Rule
- Debriefs
- SBAR
- AskMe3
- CUS
- Feedback
- Patient Rounding
- Huddles
- Task Assistance
