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These cases were adapted from preprogrammed HPS scenarios. The HPS is located in a room that is dedicated to its use. The room houses the mannequin on a stretcher, the patient monitor display, a cart with medications and emergency supplies oxygen, IVs, syringes, etc.

There is an adjoining control room that houses the operating tower and computer interface. A one-way mirror enables the computer operator to observe the students and faculty as they participate in the scenario. An infant sound monitor is placed near the head of the mannequin and the receiver is placed in the control room so the operator can hear what is being said in the simulation room. Two nurse educators who act as facilitators and a graduate teaching assistant who operates the computer usually conduct the simulation scenarios.

The nurse educator who is most knowledgeable and experienced with the HPStakes the lead and directs the simulation. Both faculty members assume additional roles as needed, such as a family member and physician or nurse practitioner. The graduate teaching assistant operates the computer from the control room, initiating and managing the physiologic responses of the mannequin in accordance with each particular scenario or simply starting and stopping a preprogrammed scenario.

In an effort to promote realism in the cases, students and faculty dress as they would for the clinical experience in the hospital. In addition, they are asked to wear identification badges and to bring their stethoscopes. It is made clear to students that the HPS simulation is a required experience. Students are expected to come to the HPS simulations with some background knowledge and experience. They may have assigned readings or written assignments to complete prior to the simulation.

A completed written assignment e. All simulation scenarios begin with a presimulation briefing see Simulation Box 1. During this time, students are oriented to the mannequin and the learning environment. A faculty member who will be assisting with the subsequent scenarios conducts this session.

Instructions to the student: Prior to simulation, complete assigned readings, case materials. Each group of students enters the simulation room, accompanied by one of the nursing educators who will facilitate the cases. The first time students encounter the human patient simulator, the technology and equipment involved with the mannequin are explained see Simulation Box 2.

Students are encouraged to uncover and examine and touch the mannequin, listen to the heart and breath sounds, palpate the pulses, and observe pupil response. The voice of the mannequin is demonstrated. It is important to remind students that they are to treat the mannequin as they would a patient in the scenarios.

Students are oriented to the environment, including the computer display and the location of equipment and supplies. After each student has had an opportunity to become acquainted with the mannequin and the environment, the group of four or five is escorted outside the simulation lab where they receive instructions about how the scenarios will proceed.

Each card identifies the responsibilities of that particular role. In subsequent scenarios, role assignments are changed so that no student repeats a role they have already performed.

During the briefing, students are given a concise report on the patient they will meet in the scenario. The setting e. Orientation to the mannequin: Heart and lung sounds- Instruct students to listen to the heart and lungs sounds so that they are be able to differentiate from normal, which is what they are hearing during orientation, and abnormal, which is what they will more The use of index cards to assign specific student roles evolved after conducting a few simulations in which students appeared disorganized and confused about what each one should be doing.

For example, one student would think of something to do and all the students in the group would set about attempting to perform that intervention. There was no evidence of teamwork. Students were hesitant and took too long deciding who would perform each role.

Subsequently, faculty developed index cards to identify each role and the associated responsibilities of that role. During the presimulation briefing, a faculty facilitator shuffles the cards and asks students to draw their roles prior to each scenario.

In addition to saving some time, this technique provides the students with some direction as they begin the scenario. The actual simulation begins as students enter the simulation room. If it is their first encounter with the simulator, they may need some assistance and encouragement in getting started.

The faculty facilitators coach the students as needed. The students acting as primary and secondary nurses are expected to introduce themselves to the patient and family. The primary nurse begins the assessment and directs the secondary nurse to assist or to do other tasks as needed. Based on the assessment findings and any physiologic changes that may occur, the primary nurse determines the interventions that are needed.

He or she may collaborate with the secondary nurse or other team members as necessary. The recorder documents all assessment findings on the whiteboard. At the point it is determined that a call to the health care provider is warranted, the communicator gathers the necessary data and contacts the provider by telephone.

Using the SBAR communication method, pertinent information is relayed to the provider and orders are obtained. The communicator documents the orders. As soon as she or he is finished, the facilitator uncovers a foam board with the orders prewritten large enough that they are visible to the entire team. The orders are implemented at the direction of the primary nurse, who is also involved in carrying out the orders.

The resource nurse looks up any medications that are ordered to identify the type of drug, the actions, dosage, administration, and potential incompatibilities with other medications. This information is communicated to the team prior to administering any medications. The primary nurse can delegate some of the medication administration to the resource nurse.

The faculty facilitators may be involved in numerous aspects of the simulation. One may be assisting with medications, while another may be helping with skills such as applying oxygen or testing blood sugars on the patient. Faculty assist the students as they perform CPR and administer emergency medications.

Debriefing is used to correct any misinformation or improper practice techniques the students may demonstrate. Beaubien and Baker 2 stress the importance of feedback to enhance the ability of students to integrate correct behaviors into their skill set. Through the simulation, gaps in knowledge are identified in individual students that would otherwise go undetected.

Additionally, in the debriefing students are asked to reflect on their own skills and knowledge. They identify what they have done well and areas that warrant improvement.

Because there are multiple activities occurring throughout the simulation and students may be focused only on their specific roles, debriefing can be used to review key points about the simulation. This includes discussion of the events that occurred, psychomotor skills such as setup of a chest tube drainage system, selection of oxygen delivery method and application, rate and technique for IV push medications, etc.

Ask students: What do they think they did well? It is important to provide students with an opportunity to evaluate their experiences and the use of the patient simulator as an instructional strategy. This is done as part of the debriefing, but should also be part of a computerized or written evaluation.

It may be part of a course evaluation or a separate evaluation tool specific to the patient simulation experience. The students who have participated in METI HPS simulations in the baccalaureate of science in nursing and continuing education programs have given overwhelmingly positive evaluations of the simulator as an instructional strategy. This is consistent with other reports of student evaluations in nursing 43—45 , 48 and medical education.

Many students feel that the simulation experience taught them all they know. This concept is evident in the following student evaluative comment:. The simulator was awesome and so realistic. We were required to do rapid assessments of a critically ill patient and to pull it all together to provide care.

Now I better know what I do not know and can work on improving. I learned more in this hour than I have my whole curriculum. Students do not recognize that the simulation provides a synthesis experience in which they draw from previous knowledge and experiences. The didactic and clinical components of their educational experience to date have been instrumental in preparing them to think and act like nurses. Use of the patient simulator as an instructional strategy holds great promise for nursing education.

Simulation can become an integral part of nursing education because of its ability to improve patient care and patient safety. No live patients are placed in jeopardy at the expense of the learner.

Simulation provides standardization of cases, promotes critical thinking, allows mastery of patient care, provides immediate feedback, and helps students integrate knowledge and experience. It is an ideal synthesis learning experience. Because the patient simulator is a relatively new educational tool, nursing educators must become acquainted with the technology, its potential uses, and benefits to learners. Toward that end, it is important that the nursing literature on patient simulation is increased, both in descriptive articles and in research reports.

As faculty become more aware of the advantages of educating students with patient simulation, its utilization in educational programs should increase. Because of the investment of money and faculty time associated with patient simulation, it is imperative that administrators and educators see the value of teaching with simulation.

Administrators need to commit financial resources to procuring patient simulation equipment and training faculty in its use.

Faculty time must be dedicated to the development and implementation of simulation programs. Nursing faculty need to look for new ways to utilize the patient simulation technology with all types of learners.

Schools of nursing can optimize the use of a patient simulator and increase its cost effectiveness by incorporating it into undergraduate, graduate, and continuing education programs.

The paucity of nursing research on the use of patient simulation demonstrates the need for further study. Studies are needed to investigate the best ways to utilize patient simulation in nursing education. Research is also needed to demonstrate that knowledge and skills acquired in a simulated environment are transferable to actual patient care situations. The cost effectiveness of using simulation also needs to be explored.

The use of patient simulators in nursing education is a relatively new instructional methodology. The rationale for using simulation as an educational strategy includes the absence of risk to a live patient; the ability to provide standardization of cases; the promotion of critical-thinking, clinical-decisionmaking, and psychomotor skills; the provision of immediate feedback, and the integration of knowledge and behavior.

Through patient simulation scenarios, essential elements of patient safety can be emphasized, such as prevention of medication errors, promotion of effective communication, and the importance of teamwork.

Learners can be exposed to critical care scenarios and have the opportunity to respond without fear of harming a live patient. By providing students with exposure to a variety of clinical situations through clinical practicum experiences and patient simulations, they can be better equipped to provide safe, effective care and work as contributing members of the health care team.

The challenge is for faculty to embrace patient simulation as an instructional strategy and to seek its effective implementation in nursing education programs. The exciting technology of patient simulation is only as good as the faculty who use it. The potential benefits to learners outweigh the costs of the equipment and faculty training. Acknowledgments to Lindsay Allen, R. To facilitate ease of role identification, when we prepare scripts for the faculty, we color code all the different roles, double space, and highlight key points.

The case is then bound and distributed to all the facilitators. Role context is an RN who has worked the night shift in a busy emergency department ED. Students are told they are coming reporting to work on the day shift in the ED. It is a. Thank goodness you all are here. We have had a terrible night. I need for you to take over care of the patient in room 1.

His name is Alex Jones; he is a year-old Caucasian male, just brought in by his wife. He is complaining of shortness of breath and chest pain. He says he has been up all night, and his wife finally made him come to the ED because it had gotten so bad. His wife has gone to park the car and has all of his meds.

Thanks for taking him over! I have to run back to the code. Escorts students into the simulation room. Direct communicator to area where phone phone is a prop and is not connected is located; direct recorder to white erase board and resource nurse to reference materials. If students are hesitant to begin their assessment, provide encouragement.

Primary and secondary nurses should introduce themselves to Mr. Jones and begin to do the following:. Students need to ask patient appropriate questions. If they seem like they are getting off track, give redirection and guidance to their assessment and history. Computer operator on other side of one-way mirror is the voice of Mr.

Jones, voice is transmitted through microphone. Voice of Mr. One of the faculty facilitators acts as wife of Mr. At some point, preferably when the students are engaged with the patient, a concerned wife runs into the room, anxiously asking about her husband, trying to get to him to hold her hand. What is going on? Is he having another heart attack?

Use therapeutic communication to explain that Mr. Assure her that the team is doing everything they can for him. Attempt to calm the wife down and give her no more than two tasks.

Tell her your name again, and explain that you will be here for the next 12 hours. Thank her for bringing in his meds and reassure her that she did the right thing by bringing him to the ED. When you think that the students are starting to pick up on the diagnosis of congestive heart failure [can be cured by lead faculty], begin coughing as Mr. Pink, frothy sputum can be simulated by mixing a small amount of red powdered Jell-O, ivory dish detergent, and water, shaking it vigorously, pouring off liquid, and putting pink suds in emesis basin.

The students should recognize this as a cardinal sign of pulmonary edema. If they feel that they have enough data, they need to anticipate the following orders:. When the students feel they are ready, the communicator places a call to the health care provider.

A prop telephone is available for the student to use. The student is expected to do the following: If student is having difficulty, they can use the script that follows.

Faculty hands card with script to communicator. Using principles of SBAR situation, background, assessment, recommendation , student accomplishes the following:. The student should write down the orders and read them back to the health care provider. After this is done, the orders are displayed on a prewritten foam board so that they can be seen by all the students simultaneously. The primary nurse delegates tasks to secondary nurse med administration, Foley, etc.

The resource nurse needs to look up the proper rate of administration for Lasix and MSO 4. The primary and secondary nurses administer the Lasix and morphine IV push through the peripheral IV that they placed earlier. The communicator places a call to lab, radiology, and EKG to request stat testing. Students should recognize and state need to call results to the health care provider as soon as possible.

This is one of the most important aspects of simulation. It is imperative that it is done well in order to help students have the best possible synthesis experience. Take the students outside the simulation room. Begin debriefing see Simulation Box 4 while other simulation staff reset the room and mannequin for the next case. Distribute handouts with key points and materials for the student to take with them and review.

Turn recording back on. Help Accessibility Careers. Show details Hughes RG, editor. Search term. E-mail: ude. Background The alarming rise in morbidity and mortality among hospitalized patients throughout the United States heightens concerns about professional competency. Types of Simulation In general terms, simulation is a technique or device that attempts to create characteristics of the real world. Part Task Trainers Part task trainers, also known as low-tech or static task trainers, are designed to replicate only a portion of the body or the environment.

Simulated Patients Simulating patients through role play between learners and educators is commonly used in medical and nursing education. Screen-Based Computer Simulators Screen-based computer simulators are designed to model various aspects of human physiology or specific tasks or environments.

Complex Task Trainers Complex task trainers involve virtual reality and haptic systems, representing the highest level of computer-based technology. Integrated Simulators Integrated simulators combine computer technology and part- or whole-body mannequins to provide a more realistic learning experience. Table 2 Key Terms and Definitions. Human patient simulators Human patient simulators are among the most recent technologic advances in instructional methodologies for medical and nursing education.

Promoting Safety Through Education With the Patient Simulator Patient safety is a multidimensional concept that is central to clinical education. Promoting Effective Communication The overwhelming majority of untoward events occurring in health care settings involve miscommunication. Encouraging Teamwork The IOM report has heightened awareness about the need for system changes to promote patient safety and quality.

Use of Patient Simulation in Nursing Education Programs Patient simulation is an instructional strategy that can be implemented in a variety of settings.

Nursing Education Programs University and community college nursing education programs use patient simulators with a variety of learners. Continuing Education The patient simulator can be incorporated into a variety of continuing education programs, departing from the traditional lecture format to provide a more experiential learning experience for participants. Staff Development Health care institutions can use simulators in staff development programs such as orientation of new graduates and continuing education programs.

Evidence Supporting the Use of Patient Simulation in Nursing Education Search of the literature on patient simulation reveals that the majority of research related to use of the patient simulator has been conducted in medical and anesthesiology settings.

Results were categorized and reported as follows: Curricular use: Greater use of the HPS was reported by community college programs for more hours in all courses with the exception of the maternal newborn course. In university programs, the HPS was most often used in basic skills courses, while community colleges reported the greatest use in advanced medical-surgical nursing courses. Most schools used the HPS as part of required clinical time.

Faculty use: Ninety-three percent of schools indicated that 25 percent or less of their faculty used the simulator; more than half of the sample states that their faculty was generally receptive to HPS use in their courses.

Student views: Twenty-one schools reported collecting information on student perceptions of the HPS. In relation to use of the HPS for competency evaluation of undergraduate students, 42 percent of schools stated that it should be used, 36 percent agreed it should be used in some circumstances, and 22 percent indicated it should not be used.

Six nursing programs and four simulation centers reported use of the HPS in continuing education programs. Advantages of Patient Simulation in Nursing Education The major advantage of using the patient simulator as an instructional strategy in nursing education is that it provides opportunity for active and interactive learning without risk to an actual patient. Knowledge and skills attained from classroom and clinical experiences can be applied in patient care situations Scenarios can be selected or designed to meet specific course objectives and in accordance with learning needs of the students.

After the first day of working with Stan, I went back and read about the specific illnesses that we had encountered in our practice. I found that while we had done many things right, there were many things we had missed.

Stan showed me what happens when these things airway, breathing, circulation are not taken care of and in that order. We had a simulation where a spontaneous pneumothorax which is commonly treated in the ED resulted in Stan crashing, and ultimately we lost him. For example, while my group was working with Stan, I discovered that my ability to apply what I thought I had learned in pharmacology is lacking.

In several cases I had no idea which drug to use or why. If it had not been for the suggestions from the instructors, I would not have been able to figure out which drugs to use. Thus I have identified pharmacology as a topic that I need to study more.

Limitations of Patient Simulators Limitations or disadvantages of the patient simulator are primarily related to its cost, which is prohibitive for many schools. Patient Simulation and Undergraduate Nursing Education The use of human patient simulators for undergraduate nursing education and evaluation offers an excellent means by which to provide learning experiences and to measure competency of knowledge and skills.

Developing and Using Patient Simulation Scenarios Manufacturers of patient simulators provide a variety of predefined scenarios for use in health care education. When adapting an existing simulated program or developing a case scenario, there are important considerations: Q: Are there preprogrammed scenarios that can be used, or is it necessary to develop a scenario? Presimulation Presimulation Faculty Prior to use of the simulator with students, faculty must be fully prepared to facilitate the learning experience.

Presimulation logistics The course coordinator for the senior-level capstone medical surgical nursing course assigns students to groups for the simulation experience. Presimulation student instructions In an effort to promote realism in the cases, students and faculty dress as they would for the clinical experience in the hospital. Presimulation briefing All simulation scenarios begin with a presimulation briefing see Simulation Box 1.

Box Instructions to the student: Prior to simulation, complete assigned readings, case materials. Box Orientation to the mannequin: Heart and lung sounds- Instruct students to listen to the heart and lungs sounds so that they are be able to differentiate from normal, which is what they are hearing during orientation, and abnormal, which is what they will more Intrasimulation The actual simulation begins as students enter the simulation room.

Postsimulation Debriefing is used to correct any misinformation or improper practice techniques the students may demonstrate. Student Evaluations of HPS Scenarios The students who have participated in METI HPS simulations in the baccalaureate of science in nursing and continuing education programs have given overwhelmingly positive evaluations of the simulator as an instructional strategy.

This concept is evident in the following student evaluative comment: The simulator was awesome and so realistic. Practice Implications—The Future of Patient Simulation in Nursing Education Use of the patient simulator as an instructional strategy holds great promise for nursing education.

Research Implications The paucity of nursing research on the use of patient simulation demonstrates the need for further study. Conclusion The use of patient simulators in nursing education is a relatively new instructional methodology.

Acknowledgments Acknowledgments to Lindsay Allen, R. Clinical faculty: facilitator, assume additional roles wife, MD , assist students with psychomotor skills, etc. Note To facilitate ease of role identification, when we prepare scripts for the faculty, we color code all the different roles, double space, and highlight key points.

Facilitator Escorts students into the simulation room. Students Primary and secondary nurses should introduce themselves to Mr. Jones and begin to do the following: Connect patient to the monitor.

Administer O 2 — percent non-rebreather be sure to fill bag with O 2 before putting mask on patient. Facilitator Students need to ask patient appropriate questions. Computer technician Computer operator on other side of one-way mirror is the voice of Mr. The first one was when I was 36 and my last one was 2 years ago. My wife is bringing them in. Faculty facilitator One of the faculty facilitators acts as wife of Mr. Give the paper bag full of his medication bottles from home to one of the students.

List of meds Nitrostat 0. Computer technician When you think that the students are starting to pick up on the diagnosis of congestive heart failure [can be cured by lead faculty], begin coughing as Mr. Facilitator Once Mr. Jones starts coughing, hand the students the emesis basin with pink, frothy sputum. Recipe Pink, frothy sputum can be simulated by mixing a small amount of red powdered Jell-O, ivory dish detergent, and water, shaking it vigorously, pouring off liquid, and putting pink suds in emesis basin.

Students The students should recognize this as a cardinal sign of pulmonary edema. If they feel that they have enough data, they need to anticipate the following orders: Diuretic. The orders are as follows: Lasix 40mg IV stat. Students The primary nurse delegates tasks to secondary nurse med administration, Foley, etc. CXR: Enlarged heart, enlarged hila with indistinct margins perivascular edema , and prominence of veins draining the upper lobes cephalization of flow Show students CXR.

Jones should be transferred? Jones will likely go to an intensive care unit. Remind students they are not to share information with their fellow students because All students should have the same opportunity to learn. It is best for the student to move through the case as they did, experiencing the hot seat as they did.

To discuss the case is similar to sharing answers from a test and would be considered an Honor Code violation. References 1. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care. Gaba DM. The future vision of simulation in health care. Jeffries P. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing.

Nurs Educ Perspect. Low- to high-fidelity simulation: a continuum of medical education? Med Educ. Human patient simulator: Clinical features. Preventing medication errors. Joint Commission on Accreditation of Healthcare Organizations. National patient safety goals. Patient safety and the need for professional and educational change.

Nurs Outlook. Characteristics of medication errors made by students during the administration phase: a descriptive study. J Prof Nurs. The effects of dimensional analysis on the medication dosage calculation abilities of nursing students. Nurse Educ. In reality, these algorithms are unreliable and most recruiters still manually review as many resumes as they can.

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