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Simulation basics: Getting ready for the real thing
By Susan Pauly-O’Neill, DNP, RN, PPCNP-BC and Lisa Sabatini, DNP, RN, CNML
This course is 1 contact hour
Course must be completed by December 15, 2019
Goals and objectives: The goal of this continuing education program is to provide nurses with an overview of simulation as an instructional strategy, not only for nursing education, but also for interprofessional training. After studying the information presented here, you will be able to:
  1. Explain the potential benefits of augmenting healthcare education with simulation
  2. List three professions that have found interprofessional simulation training helpful
  3. Describe the advantages and limitations of this state-of-the-art technology
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
In the same-day-surgery recovery area, Mr. Shapiro awakens from anesthesia after a minor surgical procedure to repair an inguinal hernia and complains of new onset chest pain.
Traditionally, students in healthcare professions have learned by doing: See one, do one. However, concerns about patient safety have given us a push to reassess this largely unstructured apprenticeship approach. An alarming rate of morbidity and mortality among hospitalized patients has intensified the scrutiny placed on healthcare providers, including nurses.2 Quality and safety initiatives in both practice and academia demand top-notch competency and performance from healthcare providers and teams. The pressure is on to find ways to reduce errors and minimize patient risk. This has spilled over from the practice setting into the world of nurse education. How can we educate students with the least risk for patient harm? In addition, there is a severe shortage of faculty, clinical sites, and classroom space for qualified students.3 Student learning is restricted by this limited availability and access to patients coupled with an apprehension about medical errors.4 Placing nursing students into clinical settings in which, by random opportunity, they provide whatever care they can during a shift may no longer suit the needs of healthcare. In addition, the inconsistency in the training that’s available allows some students to fall through the cracks. Many students may complete an entire rotation without participating in activities critical to mastering important competencies. As students are typically assigned to a single stable patient on a med/surg unit, they may not witness significant cardiac dysrhythmias, hemorrhage, shock, or seizures. Here’s where simulation comes in: Students can be exposed to events in which they are expected to be competent yet do not often participate in during a clinical rotation. For example, an employer would expect that a new graduate nurse would be proficient in recognizing and responding to a deteriorating patient condition, such as impending respiratory failure.

If a student completed all clinical rotations without ever having witnessed this event, the student would be unlikely to react effectively when it occurs on the patient care unit. Simulation can fill that gap by offering a realistic recreation of that event, with repetitive practice in how to respond quickly and accurately. Nursing education is retooling to better prepare students for complex care, using simulation as an important component. Rehearsing responses to challenging events is a vital contribution of simulation in the promotion of patient safety, development of decision-making skills, and refinement of interprofessional communication.

Students can use their time in simulation to assess the patient and the environment, isolate the important information that should be communicated to other healthcare providers, and practice that communication.2 Simulation provides an arena comparable to the clinical setting where students can learn to delegate. Simulation allows legitimate practice without patient risk. Students are free to make errors and learn from their mistakes while causing no patient harm. In addition to the safety benefits, the expansion of simulated clinical experiences may reduce the time students need to spend in hospital settings, thus relieving some of the pressure on available clinical sites.3 Nurse educators may substitute a percentage of clinical hours with simulation hours based on the regulations stipulated by the state’s board of nursing. Clinical groups of up to 10 students may split into two groups: one in acute care and the other in the simulation laboratory, rotating back and forth. This allows for smaller groups in the clinical arena at any given time.
It’s easy to imagine why incorporating simulation into nursing education makes sense, from learning basic nursing skills, such as IV fluid management, to perfecting advance practice competencies, such as anesthesia induction and airway management. Simulation is used widely in prelicensure nursing programs across the nation to practice skills and decision making before applying any knowledge to real patients. A mixed educational model that combines classroom lectures, traditional clinical rotations, and simulation is becoming a popular approach to basic nursing education. In fact, a large study by the National Council of State Boards of Nursing of 10 prelicensure nursing programs across the country supported the use of simulation as a substitute for up to 50% of traditional clinical time.5 (Level A) Simulation has also been useful after graduation in nurse refresher courses, advanced cardiac life support training, and critical care reviews, to name a few possibilities. Many healthcare facilities use simulation to validate competencies and help in the transition from student to newly employed nurse during orientation programs. The anesthesia community uses HPSs to teach not only technical skills but also crisis management.6 But what about teamwork? We know that performance is strongly influenced by the interaction between the task, the environment, and the team members’ behavior.7 Everyone has a role to play. In simulated exercises involving teams, members learn how not to step on each other’s toes. In practicing together, they become aware of their synergistic roles.7 Learners from several disciplines can practice relating to one another while providing safe care. A variety of teams use simulation as a training tool. Student teams comprising pharmacy, medical, and physician assistant students found success in a simulated IP rounding experience in which they provided comprehensive medical care for a simulated patient in an inpatient setting.8 (Level B)

IP education has become so important that the University of Washington has established the Institute for Simulation and Interprofessional Studies that uses cutting-edge, simulation educational techniques to improve the quality of healthcare education and, therefore, patient safety and outcomes. This institute is affiliated with more than 30 departments and programs throughout the UW system, including the schools of Medicine, Nursing, Pharmacy, and the Physician Assistant Program.9 Simulation holds promise in professional regulation as well. While variability, validity, cost, and difficulties in standardization may be barriers to using simulation as part of regulatory programs such as licensing and certification, some experts believe that simulation-based assessment may be integral to ensuring that the public is cared for by competent practitioners.10

The Institute of Medicine report “The Future of Nursing: Leading Change, Advancing Health” proposes that simulation scenarios be used for professional assessment.10 In addition, the report suggests that simulation should be considered whenever new procedures and equipment are introduced.
How to earn continuing education
THIS COURSE IS 1 CONTACT HOUR
1.
Read the Continuing education article.
2.
This continuing education course is FREE ONLINE until April 17, 2019, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/simulation-basics. After that date, you can take the course for $12 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse

Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
ONLINE
You can take this test online or select from the list of courses available. Prices subject to change.
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He has a history of hypertension but has not had trouble with angina in the past. He takes a small daily dose of a diuretic and exercises regularly. He is extremely anxious calling for the nurse. The RN notes diaphoresis, cyanosis, and an irregular heart rhythm, and hits the code button. Within minutes, the team arrives: a charge nurse, a resident, and a respiratory therapist. The patient deteriorates quickly into ventricular fibrillation, and the team springs into action.

They begin chest compressions at a ratio of 30:2, but nobody remembers to place a backboard under Mr. Shapiro. The RT effectively opens the patient’s airway, but soon realizes that the oxygen tubing is not attached to the Ambu bag. While the RT tries to secure the tubing, the facemask falls to the floor. The charge nurse begins to draw up epinephrine at the resident’s request, but notices that Mr. Shapiro has a shockable rhythm. Why hadn’t the resident called for the defibrillator? The RN chimes in: “Can we please start over?” Fortunately, this was a simulated, interprofessional exercise in which mistakes cause no harm and practice makes perfect.

When simulated clinical experiences recreate the dynamics of real encounters, learning is sure to take place. This strategy is not new. In fact, in aviation and the military, simulation has been a widely accepted format to train both novice learners and experienced personnel. Simulation is an immersive technique used to replace or amplify experiences found in real life.

In healthcare, it improves patient safety and enhances care, not only by refining individual skill and decision making, but also by honing the performance of clinical teams.1 (Level B) It is a time-efficient, cost-effective method to teach healthcare providers to recognize and avoid errors. Simulation can be used to enhance readiness for practice, teamwork and collaboration, communication, and leadership. It can take a variety of forms, from simple to complex.2
Who uses simulation?
Simulation is not real. The mannequins may resemble humans, but clearly, they are not actual patients. Hence, participants may have trouble suspending disbelief and working through the scenario as though it were an authentic event. The degree of realism, including the capabilities and the limitations of the simulated environment, will impact how well learners can immerse themselves in the activity.20 The team members’ ability and willingness to fully engage affects the communication among participants, which may influence everyone’s learning. While disbelief can be a hurdle, so can anxiety. Some students worry about their ability to work through a critical event and may fall victim to their own fears. This is understandable, as a student would never be expected to take on a real-life crisis, which is routine in the simulation lab. Anxiety may be heightened further when students are evaluated based on their performance. The facilitator’s reassurance is vital to ensure that learners feel confident they will be accepted and respected, no matter what happens in the simulation laboratory.20 Simulation has been found to be most effective when used in small groups or teams. The logistics of rotating all students through the simulation laboratory can be a challenge. Faculty must be present, which may result in the need for additional instructors. Other considerations are faculty training, ongoing technical support, and administrative commitment. Learning to incorporate simulation requires commitment and dedication at a time when faculty already has a heavy workload. Simulation equipment can be expensive, additional laboratory space may not be available, and annual operating costs may be prohibitive. While the HPS simulators can cost up to $75,000 or more, the overall price tag associated with simulation can range widely depending on whether additional space, training, and faculty time are included.21 Thus far, there has not been a complete and realistic accounting of the cost of simulation-based medical education.21
Limitations
Why simulation?
EDITOR’S NOTE: OnCourse Learning guarantees this educational opportunity if free from bias. Susan Pauly-O’Neill, DNP, RN, PPCNP-BC, associate professor at the University of San Francisco School of Nursing and Health Professions, has developed a program of fully integrated clinical rotations using high-fidelity simulation throughout the BSN curriculum and conducted research on using simulation to improve patient safety. Lisa Sabatini, DNP, RN, CNML, assistant professor at the University of San Francisco School of Nursing and Health Professions, is the former director of clinical performance and simulation centers at USF.
Anatomical models, also known as “task trainers,” replicate a portion of the body and can be used to practice skills. For example, an anatomical model of an arm, with realistic-looking veins filled with red liquid, is used to teach IV-line insertion. Another strategy is the use of a standardized patient. These simulated patients are actors playing the role of a patient so a student may perform a physical assessment, take a history, and practice communication techniques. More advanced technology — human patient simulators — are state-of-the-art mannequins equipped with realistic physiological functions that closely resemble humans. Whatever the educator is trying to accomplish determines the equipment to use. Learning to administer an IM injection may require only a task trainer. Improving a nurse’s ability to gather a patient history may require a standardized patient, while teaching a team to resuscitate a patient quickly and effectively may require an HPS. The term “fidelity” is used to illustrate the model’s believability. The higher the fidelity, the more realistic the model. A low-fidelity item, such as a static mannequin with no response capability (similar to a doll), may be used to teach simple psychomotor skills, such as nasogastric tube placement or body positioning. High-fidelity HPSs can simulate breathing, bowel sounds, heart sounds, pupil reaction, and urinary drainage. Because the HPS interfaces with a computer monitor, users can see parameters on a screen, such as cardiac rate and rhythm, continuous blood pressure, oxygen saturation, and even more complex waveforms, including central venous pressure. The values can be changed with a few taps on the computer keyboard, recreating the responses likely to occur when interventions are used. When oxygen is applied, the educator or technician can raise the oxygen saturation reading, for example. Conversely, when the correct action is not taken, vital signs can be quickly turned to life-threatening levels. These top-of-the-line human look-alikes are available from newborn to adult. But the equipment is only part of the technique. Case scenarios are what illustrate the potential course of events, often replicating a high-risk, low-occurrence event, such as postpartum hemorrhage or cardiac arrest. In nursing programs, students may rotate into the simulation laboratory and participate in increasingly more complex cases from a well checkup to septic shock. Some users purchase preprogrammed scenarios; others develop their own. In either case, working in small groups, participants are assigned roles before the simulation begins. Typically, one team member becomes the leader and directs others as the simulated scenario unfolds. During the simulated scenario, the team members collect assessment data, prioritize care, provide treatments, and communicate with one another. The case scenario typically runs for 20 to 30 minutes, depending on the complexity of intervention and teamwork required. After the scenario is completed, the participants spend additional time debriefing, which allows them to talk as a group, reflect on their reactions, share their observations, and discuss their evaluation of personal and team performance. Faculty present during debriefing can help lead the discussion, correct misconceptions, review best practices, and help students work through their emotions.
Is simulation effective?
When the HPS is used to teach basic skills and even crisis management, the benefits have been widely recognized.5 The literature suggests that simulation makes a valuable contribution to healthcare education and training. Among its many positive effects, simulation has been shown to improve nursing students’ critical thinking skills, performance, and knowledge; enhance their ability to care for a deteriorating patient; increase their confidence in personal abilities to perform in each situation; communicate critical information to interdisciplinary team members; and boost medication calculation and administration abilities.11-15 (Level B) Students benefit from observing one another’s successes and errors.2 Nurse educators in academic and practice settings have been using simulation to help improve learning, clinical competency, communication, and confidence.16 Although the deliberate and repetitive practice used during simulation has been shown to improve nursing competence, the positive effects transcend nursing. IP team training using high-fidelity simulation in advanced life support has been shown to improve teamwork attitudes better than clinical experience alone.17 And the use of multidisciplinary teams in hospitals seems to have reduced adverse effects, improved patient outcomes, and enhanced patient and staff satisfaction.18

After IP training with both nursing and medical school students, participants had more knowledge of team skills with a statistically significant improvement in attitudes toward teamwork. As you can imagine, studies demonstrate that simulation training can literally transfer into measurable benefits for patients.10 Improvement in clinical performance because of simulation is beginning to be established in the literature. A recent study involving nursing students revealed that those who participated in simulation had higher performance scores than those who did not participate. The higher performance levels were maintained on the clinical unit where faculty observed that these students acclimated more quickly and achieved performance expectations faster than the control group.19 (Level B) In a study of medical/surgical nurses trained via simulation to react to deteriorating patient conditions, such as cardiac, respiratory, and neurological changes, participants showed an enhanced ability to respond in a systematic way.1 (Level C) The participants were especially pleased with their increased skills in managing breathing difficulties after this training. This was particularly important, as the participants reported using these newly heightened skills between one and five times in the three months after the simulations.1
Let's get real about human patient simulators
Earn 1 credit hour with this free continuing education course
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