Updated: Apr 30, 2019
It's very good to see that nursing faculty are going beyond the traditional single-patient, high fidelity human patient simulator experience. But, do these simulations go far enough to achieve the necessary learning outcomes to support nurses working in hospitals? We have a simulation approach modeled after Space Shuttle integrated simulations that does. So how do we do that?
We design our multi-patient simulations to be complex, flexible, and organic (with unanticipated events) utilizing a longer timeline that allows for natural progressions of illness and health events. We create a holistic environment where the whole is greater than the sum of its parts. This focus is necessary to achieve the higher level learning outcomes of critical thinking, priority setting, communication/ teamwork, organizational ability, and caring practices, Most shorter multi-patient sims (and individual sims using high fidelity human patient simulators) can be broken down into their component parts (assessment, priority setting, delegation, medication administration, or other skills, etc.); so, even if not intended, the outcome will primarily be task training.
When a person walks into our 72-hour integrated simulation, it feels like actually being on a hospital patient care unit. It is busy; nursing students have their own multi-patient assignments, providers are present, family members are there, and perhaps the phone is ringing. Students may be delegating to nurse assistants while patients in their assignments are coming back from surgery or procedures; patients are being discharged, or needing pain medication, insulin, or teaching; they may be confused and getting out of bed. And, the hospice nurse, ICU nurse, provider or family member is calling to talk about a patient. We know nurses deal with all of this and more in a normal day in the hospital. In our sim, things happen just as they would in the actual hospital. The true simulated hospital environment is about people and the interaction of events and healthcare concerns affecting the people in the simulation. It's not about the equipment set-up of a lab.
We script each and every detail to focus on the nursing student 24-hours/day for up to 72-hours. We detail the progression of patient care, anticipated responses, all labs, all assessment data (including every single VS), provider orders, etc., and all data in the EHR. Because we generate scripts for each particular simulation, it allows us to adapt to rapidly changing healthcare concerns and new health threats, or design for any hospital area or setting.
A simulation team develops and executes the evidence-based scenario script. Team members are selected with different areas of expertise that contribute to the scenario. A single team member with med-surg expertise, for example, won't design a scenario with the complexity and creativity that team members with different areas of expertise will. A good sim team will design a scenario with more co-morbidities, more issues related to family processes or mental health, with issues such as homelessness addressed, and with interactions among all of these factors, moving the simulation toward toward issues found in a real hospital that nurses must deal with daily. And, they do this within a nursing model of care, notably absent from many nursing programs nowadays.
The longer timeline allows students take report at the beginning of their shift, handoff to another student at the end of their shift, report back the next day, and see the changes in patient condition over that time. It's important to recognize the critical thinking that goes along with handoff, identifying and organizing the information to report, making decisions about what is relevant and what is not relevant, and assuring understanding of key patient care issues. Students can take the debriefing of the handover as well the results of their actions and decisions during the shift to heart and put it into practice during their next shift. Over multiple shifts this facilitates verified improvement of student performance.
Another aspect of our multi-patient 72-hour sim is that we utilize students as the patient actors, not standardized patients. Development of empathy is the key learning outcome of this experience. Putting themselves in the patient's situation and walking in the patient's shoes takes on a whole new meaning. Further, students learn about the disease process, medications, and the care needs of the patients they are portraying (also objectives of the experience). It's a great learning experience.
This simulation approach also provides an awesome opportunity for interprofessional collaboration. Healthcare team members from multiple disciplines can participate on the sim team, and interprofessional student collaboration can be a key learning outcome. For instance, even a script centered around a nursing scenario can easily include other disciplines such as PT, OT, Nutrition, Social Work, and Medicine. This is part of that flexibility that I mentioned. The sky's the limit. The environment is rich for collaboration.
The multi-patient simulations that are being written about in nursing journals today are a good start at introducing students to more realism and to thinking about how to manage a multi-patient assignment. But, because of their short timelines, and often the inclusion of more than one student in one multi-patient assignment, students don't have much opportunity to think on their own, take action, and realize the consequences of their actions. I view these as preparation for a longer sim. It is in the complete environment--the 24 hour/day multi-day simulation that we achieve higher order outcomes.