IMPLEMENTATION STATION

Implementation Station is the third stage within the APIE framework, with a designated time limit of 15 minutes. This station involves interacting with either a real patient or a manikin.

During this phase, participants are tasked with the administration of oral medication, armed with a comprehensive drug chart detailing crucial information such as weight, height, allergies, stat medications, PRN medications, and regular medications. The patient or mannequin assigned here is the same as in the assessment and planning station. In this role-playing scenario, participants are expected to draw upon their skills and knowledge to administer oral medications accurately. Additionally, they must ascertain the patient’s potential allergic reactions to any prescribed medication.

Typically, a prescription chart will contain three or four medicines, among which there might be one the patient is allergic to or one with an incorrect prescription or dose. Participants are required to identify and omit these problematic drugs, administering only those that are due and clearly specified.

Key considerations during the Implementation Station include:

1. Articulating and explaining the prescription aloud while preparing the medicine.

2. Verifying the validity of the prescription and reporting any errors to the prescriber.

3. Confirming the timeliness of medication administration, taking into account the patient’s allergy status. If an allergy is identified, omit the medication with the appropriate code and report the prescription’s illegibility to the prescriber.

4. Checking the prescribed route of administration, and if it is not oral, stating the intention to administer the specific medicine after completing the oral medications.

5. Consulting the British National Formulary (BNF) before administering any drug to obtain essential drug details.

6. Investigating if there are precautions to be observed before administering a specific medicine, with a list of medicines and their required precautions available in the course room.

7. Confirming whether the medicine has been previously administered, particularly for PRN medicines, to avoid potential overdose. Additionally, verifying oxygen and IV therapy by cross-referencing the prescription, dose, and batch number.

Furthermore, participants must ensure adherence to the ten rights of medication administration:

1. Right Patient

2. Right Drug

3. Right Dose

4. Right Route

5. Right Time

6. Right Patient Education

7. Right Documentation

8. Right to Refuse

9. Right Evaluation

10. Right Assessment

PROCEDURE

Begin by entering the patient’s room and assess the scene for safety, ensuring it is safe to approach.

Maintain the patient’s privacy and dignity by closing curtains and the door.

Perform hand washing using the seven steps of WHO hand hygiene.

Introduce yourself, stating, “Hello, I’m [your name], your attending nurse today.”

Request the patient’s name and inquire about their preferred name.

Ask for the patient’s date of birth.

Verify the patient’s details by cross-checking with their ID tag, specifically checking their full name, date of birth, and hospital number.

Inform the patient of your purpose: “I am here to administer your medications due at [specified time].”

Inquire about any medication allergies, and if applicable, ask about the reaction to those medications.

Check if the patient is currently experiencing pain and, if so, inquire about the pain level on a scale of zero to ten.

Determine if the patient requires pain medication and explain that you will check the medication chart for any prescribed prn pain medication.

Ask about any swallowing difficulties and whether the patient has had something to eat.

Inquire if the patient needs to use the toilet and inform them that the procedure will take approximately 15 minutes.

Ensure the patient is in a comfortable position.

Inform the patient that you will check the drug trolley for their medications and invite them to call or use the call bell if needed.

Perform hand hygiene, don PPE and unlock the drug trolley, and inspect the medications.

Read aloud the medication chart, including patient details, admission information, and relevant medical data. Thus; Patient name, DOB, Hospital number, Admission date, Consultant name, prescriber’s bleep number, Height, Weight to help calculate drug dosage eg: weight below 50 kg Tab Paracetamol cannot be administered.

Pay special attention to any allergic medications mentioned in the chart.

If oxygen is prescribed and the patient is using nasal cannula, assess oxygen saturation, and adjust as necessary.

Check the prn medication section for previous administrations; if a pain medication has been given within the past 4 hours, withhold it.

Review regular medications, omitting any wrongly prescribed, illegible, or omitted medications, and document with appropriate codes.

Before administering the first drug, verify the patient’s identity using their ID band, checking their name, date of birth, and hospital number.

Explain the purpose of the medication to the patient and mention any major side effects using BNF.

While handling the tablet, check for expiry both outside and inside the container on the literature, transfer it directly to a cup without touching, and provide it to the patient with water or juice.

Confirm that the patient has swallowed the medication.

Administer medications one by one, signing after each administration.

In the event of an error, verbalize what actions to be taken in real-life scenarios.

When striking off an entry, use a single line, put your signature below, and verbalize the action taken.

Ensure that not administered medications are clearly listed at the back of the medication chart with appropriate reasons, avoiding the use of codes (e.g., patient already received pain medication, incorrect dose, or wrong timing).

After administering all medications, conduct a recheck if time permits, lock the medication trolley, express your intention to clean and prepare it for subsequent use.

Inform the patient that all prescribed medications have been administered.

Hand over the call bell to the patient, emphasizing its use in case of adverse reactions such as breathing difficulties or rashes, reassuring immediate assistance.

Restore the room to its original state by opening the curtains.

Discard PPE and used items. Do hand hygiene using the seven steps of WHO, and exit the room.

NOTE THE FOLLOWING

Prioritize patient identification again before drug administration.

Inquire about any swallowing difficulties and confirm the patient has swallowed the medication.

Remain vigilant for allergies, patient weight, and accuracy of prescriptions.

Adhere to a minimum four-hour gap between successive administrations of similar pain medications, such as Paracetamol.

Be mindful of stat medications already administered.

Seek clarification from the examiner regarding oxygen saturation during oxygen therapy. Verify blood sugar levels before dispensing anti-diabetic medications and assess blood pressure and pulse rate levels before administering anti-hypertensive medications.

If uncertain about any prescribed medication, refrain from administration, verbalize the reason for hesitation, and communicate your intention to consult with the doctor before proceeding.

Evaluation Station

The evaluation process employs the SBAR handover technique, a verbal communication tool designed to enhance the exchange of information among healthcare professionals regarding a patient’s condition. SBAR, which stands for SITUATION, BACKGROUND, ASSESSMENT, and RECOMMENDATION, provides a structured framework to ensure comprehensive details about the patient are effectively communicated to the recipient.

Situation:

In this segment, it is crucial to:

Introduce oneself.

Provide the patient’s name, date of birth, and hospital number and unit/ward.

Specify the reason for admission.

Clearly articulate the purpose of the handover.

Background:

Under this category, the following information should be communicated:

Patient’s admission history e.g. date of admission, diagnosis and treatment.

Allergic status, for instance, any known allergies such as to Penicillin.

Medical history, including conditions like Hypertension since 2010.

Regular medications.

Pertinent details from the social history.

Identify any problems that may impact the patient’s daily activities.

Note the previous assessment findings.

Assessment:

This section involves sharing:

Latest/current observations.

Main nursing needs and interventions taken

Current status of the patient, such as a pain and pain score

Actions taken, like the administration of analgesics.

Any health education provided.

Highlight any areas of concern

Recommendation:

Under this heading, re-lay all information necessary for the recipient to act on, including:

Current scores such as NEWS 2/GCS/MUST/PHQ and the corresponding required interventions.

Anticipated problems and their planned course of action (e.g., if the patient requests pain medication, refer to the prescription; analgesic available as needed).

Suggestions for information, such as the patient will call for assistance when mobilizing.

Specific instructions, such as assessing the wound during subsequent assessment due to the risk of infection.

This structured SBAR handover, incorporating all the information gathered during the evaluation, planning, and implementation stages, is essential for an effective communication exchange. All relevant materials, including scenarios and paperwork used in the previous APIE stations, will be provided for reference during the Evaluation scenario. The allotted time for this station is currently set at 8 minutes, but it is advisable to confirm the latest timings with the coordinator before your OSCE.

NOTE:

It is essential to ensure that:

Your spoken communication is both clear and suitable.

When transferring patient care, a systematic and organized approach is adopted.

Failure in the evaluation stage may occur if:

The candidate neglects to recognize or document the primary care requirements of the patient.

The candidate openly exhibits judgmental behaviour regarding a patient’s personal attributes (e.g., sexuality) or their beliefs, cultural background, or lifestyle preferences.

The candidate does not effectively and accurately communicate with the healthcare professional while handing over patient care.

Planning station is second station in APIE

You are required to complete two critical care plans within a 14-minute timeframe in a quiet writing station. The necessary materials for this task include your NEWS2/GCS/Community Assessment chart, which was utilized during the assessment station of the APIE process.

The primary emphasis of the care plans should be on addressing the marking criteria conditions. To achieve this, carefully review the planning station scenario within the allocated one-minute period before initiating the prioritization of nursing problems. These problems can stem from either the provided scenario or the assessment conducted in the preceding station.

Typical nursing issues that often arise involve pain, confusion, shortness of breath, immobility, activity intolerance, anxiety, weight loss, and more.

In the event of an error, strike through it in a single line and affix your signature below the correction. It is advisable to complete any available spaces before commencing to prevent running out of time, such as filling in candidate and patient details, signature, date, and time.

NURSING PROBLEM

State nursing problem using SMART method ie simple, measurable, achievable, recordable and time bound.

Example, instead of ineffective breathing pattern you can write shortness of breath. In case of pain you can write headache or any other pain per the scenario.

Remember to mention the patient name instead of using ‘patient’ or ‘client’

Mr Amos is experiencing pain at the surgical site as evidenced by pain score of 8/10

Mrs Juna is experiencing shortness of breath as evidenced by respiratory rate of 23 bpm

Always after as evidenced by use data you have got from the assessment station

Patient Name + Problem + Reason

While it’s not obligatory to provide the rationale when formulating a nursing problem, doing so is considered a beneficial practice. This approach ensures that the reader gains a clear understanding of the problem at a glance.

NURSING AIM/GOAL

After writing the nursing problem, you need to specify the aim of our care plan. In other words, aim of care communicate the purpose of the nursing care interventions included in the specific care plan. This should be in future tense but measurable using pain score, observations or objective data

Eg. Mrs. Juna will maintain normal respiratory rate of 18-20 breath per minute

Mr. Amos will verbalize reduced pain 0f 3/10

RE-EVALUATION

We must align the nursing care plan with the established goal, and it’s essential to periodically reassess the care’s effectiveness within a specified timeframe for the patient. This timeframe should be clearly indicated in the ‘re-evaluation date’ section of our care plan.

When determining the re-evaluation date and time, it’s crucial to consider the following points. Keep in mind that the objective is to achieve the care goal, allowing for a re-evaluation and assessment of the care plan whenever feasible. Therefore, when setting the re-evaluation date, use today’s date as a starting point, select the nearest practical time, and remain attentive to any changes in the patient’s clinical condition.

Here you have to write “Today (date), at the end of every shift and as Patient’s clinical condition changes”

But if it’s a;

• Pain, today’s date then 30 minutes after giving pain medication or if clinical condition changes
• Mobility Related, today’s date then when the patient requires assistance or if clinical condition changes
• Community Scenario, re-evaluated in the next visit or if clinical condition changes
• All Other Problems, todays date – with every observations or if clinical condition changes

Eg. 01/01/2020, at the end of every shift and as Juna’s clinical condition changes

NURSING INTERVENTIONS

Now, let’s transition to the central aspect of the care plan, namely, the ‘nursing interventions.’ These interventions form the core of any care plan, outlining the nurse’s strategic approach to accomplishing the care plan’s objectives.

Effectively planning your care becomes more straightforward when initiating interventions using the mnemonic EMATARID – Explain, Monitor, Assess, Teach, Administer, Refer, Instruct, Document. However, the specific words utilized may vary depending on the unique requirements of the care plan. Other terms such as Explain, Monitor, Assess, Teach or Educate, Administer, Provide, Refer, Instruct, Document, etc., may be employed based on the specifics of the care plan.

Now let’s elaborate on the following key elements:

E – Explain

Explain and engage in discussions regarding all aspects of care. Obtain consent for all nursing interventions.

M – Monitor

For patients with breathing problems:

– Monitor and record observations, including respiratory rate and oxygen saturation, every 2 hours. Follow NEWS2 Policy escalation guidelines.

For neurological patients with GCS Score = 15:

– Monitor and record observations every 30 minutes for the first 2 hours, then 1 hourly for the next 4 hours, and subsequently every 2 hours until stability is achieved (GCS maintains 15/15). Escalate as per NEWS2 policy.

– If GCS <15, monitor and record observations every 30 minutes until GCS reaches 15. Escalate according to NEWS2 Policy.

For those at risk for haemorrhage:

– Monitor and record observations every 15 minutes for the first hour, every 30 minutes for the next two hours, and then every two hours for four hours. Escalate as per NEWS2 policy.

A – Assess

Assess for signs of deterioration, pain using a Pain assessment tool and PQRST – stands for Provocation, Quality, Region (or Radiation), Severity (or Scale), and Timing Method, nutritional status using the MUST Score, signs of bleeding, and the mobility status of the patient using the Falls Risk Assessment Tool.

T – Teach

Incorporate health education by:

– Educate on Smoking Cessation program or harmful effects of smoking.

– Educate on the use of assistive devices.

– Educate on Repositioning Techniques and Range of Motion Exercises.

– Educate on PFM (Peak Flow Measurement) for Bronchial Asthma Patients.

– Teach about deep breathing exercises, diversion activities, the importance of exercise, signs of bleeding, signs of respiratory distress, disease condition, and the need for drug compliance.

– Promote knowledge and understanding of the patient’s condition to the patient and immediate relatives.

A – Administer

Administer medications and monitor their effects within this section.

R – Refer

Refer patients to Physiotherapists, Dieticians, Occupational Therapists, Chaplains, Social Services, Smoking Cessation Programs, etc.

I – Instruct

Instruct on using the call bell

Instruct on not moving out of bed without assistance in cases of immobility.

D – Document

Thoroughly document all planned care activities.

Example one

Nursing Problem:

Mr. Amos is currently experiencing pain at the surgical site as evidenced by pain score 7/10

Aim of Care:

Mr. Amos will verbalize reduce pain/will be free from pain

Re-evaluation date:

Today 01/01/2020 12:30 pm or if clinical condition changes

Nursing Interventions:

Explain and discuss all aspects of care to Mr. Amos, obtaining consent for each nursing intervention.

Monitor and document observations of Mr. Amos during off-hours, calculate the NEWS 2 score, and respond in accordance with the NEWS 2 Policy.

Assess Mr. Amos’s level of pain using pain rating scale.

Teach/Educate Mr. Amos on relaxation techniques such as breathing exercises and alternative pain management methods.

Administer prescribed analgesia to Mr. Amos and assess its effectiveness after 30 minutes.

Ensure a comfortable position for Mr. Amos, incorporating additional pillows if needed.

Motivate Mr. Amos to express any concerns and, if necessary, refer to a diversional therapist.

Instruct Mr. Amos on the proper use of the call bell for assistance.

Document all aspects of care provided.

PRINT NAME: Norman

NURSE SIGNATURE: Norman

EXAMPLE TWO

Nursing Problem:

Mr. Razak has risk of infection

Aim/Goal of Care:

Mr. Razak will be free from risk of infection

Re-evaluation date:

Today 01/01/2020 with every observations or if clinical condition changes

NURSING INTERVENTIONS

Explain and thoroughly address all aspects of Mr. Razak’s care, ensuring to obtain consent for each nursing intervention.

Monitor and document vital signs at 15-minute intervals during the initial hour, at 30-minute intervals during the second hour, and 1 hourly for the subsequent four hours, following the NEWS 2 policy thereafter.

Assess for signs of infection, such as redness, exudates, unpleasant odour, compromised wound closure, and pain or tenderness.

Administer antibiotics as prescribed to Mr. Razak.

Employ aseptic non-touch techniques when conducting wound care.

Educate Mr. Razak on proper handwashing techniques and emphasize the significance of maintaining a protein-rich diet.

Encourage open communication for Mr. Razak to express any concerns he may have.

Refer to a tissue viability nurse if necessary.

Instruct Mr. Razak on the use of the call bell for assistance.

Document all aspects of the care provided thoroughly.

PRINT NAME: Norman

NURSE SIGNATURE: Norman

Saline versus Tap water – marking criteria

1. Summarizes the main findings of the article summary and draws conclusions, making recommendations for practice.

• Writes clearly and legibly.

• Informs the patient that trials comparing the occurrences of wound infections when cleaned with sterile saline or tap water have shown no difference between the two.

• Advises the patient that there is a lack of available evidence on the effects of water or saline on wound healing.

• Makes the patient aware that there are no differences in patient satisfaction in either group. However, there was a lack of robust evidence on the instances of pain experienced by patients, or on adverse events.

• Highlights to the patient that there were no standard criteria for assessing wound infection across the trials, which limited the ability to pool the data across studies and limited the results.

• Explains to the patient that tap water has been recommended as a cost-effective option for wound cleaning.

Sample scenario

Situation: At Leeds NHS Hospital, patient Adeola is concerned about her wound and believes it should be cleaned with sterile saline instead of tap water. As the nurse responsible for wound assessment and dressing, how will you address this situation based on the given criteria?

Your answer

I will inform Adeola that studies comparing wound infections when cleaned with sterile saline versus tap water indicate no discernible difference between the two methods.

I will inform Adeola that the existing evidence regarding the impact of water or saline on wound healing is limited.

I will make Adeola aware that there is no difference in patient satisfaction between the two cleaning methods. However, there is a scarcity of strong evidence regarding the occurrence of pain or adverse events.

I will highlight to Adeola that there were no standard criteria for assessing wound infection across the trials, which limited the ability to pool the data across studies and limited the results.

I will clarify to Adeola that tap water is suggested as a cost-effective alternative for wound cleaning.