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Why Night Shift in our Sims?

I get this question pretty frequently. Couldn't you just do your sim during the day and not include night shift? We could. But, you will not get the impact on students (and thus outcomes) that you will with a 24-hour/day continuous 72-hour simulation. The over-the-top value of our approach results from providing a simulated hospital environment as much as possible like the real hospital environment, which, if we are being accurate about it, is a 24-hour/day continuous environment. So, how are the outcomes different?

First, continuity of care is achieved with this approach. It's a holistic environment. Students are handing off to oncoming students from day to night shift, and from night to day shift. They are relaying what happened on their shifts. There is no hypothetical information provided by instructors about what "happened" on a hypothetical night shift as the day shift begins. Students actually provide more detail in handoff than an instructor will about each patient. An instructor may say that an event happened and provide assessment information, etc., but the night shift student lived that experience, and can provide a more vivid description of the event. If, for example, a student had an admission during the night, besides giving information about the patient, the student may need to explain that she/he didn't get something else done for other patients in his or her assignment because of this admission. That becomes real for everyone involved.

From this continuity of care perspective, instructors find that students can begin to understand the full context of patient care that occurs in the hospital. In reality, most clinical experiences nowadays are disjointed in that students see a patient for one day shift and don't participate in the full patient care experience with their patients. The same thing happens with a day long sim. In our sims, students are able to plan and evaluate care across shifts and across multiple days.

Second, students experience the realities of night shift. Staffing may be lower; there may be a different level of activity, and nurses are more on their own--there are fewer people to go to when making clinical decisions. Students learn to make decisions about whether a call to the provider about a patient, and what information to provide when they do call. SBAR is practiced. Further, problems that may be more apparent during night shift come to light, and students make decisions about how to to manage those issues.

Teamwork also becomes a focus. While each student is on his or her own with a multi-patient assignment, they participate together in the care of patients across shifts. In our sim, students collaborate across shifts in planning care for their patients. A student on night shift will have information that is going to impact the plan of care; and, they will continue the discharge planning and teaching that is occurring. Students may realize that they can help out the day shift by completing some non-time sensitive patient care activities. They see the results of teamwork across the shifts.

Okay, this means that faculty are going to have to work the night shift. But, faculty have much to offer students in this much more intimate learning experience than is ever possible in the hospital (or a short sim). We have had faculty who spent much of their career on the night shift bring that experience to the scenario/script and thus the night shift experience. Faculty make it real. We emphasize that this sim should be a capstone, generally a one-time a semester experience. Therefore, it should be planned into the college of nursing's calendar, so that for this one week in the semester, the integrated simulation is what is happening. Therefore, faculty should not have to worry about working a night shift in the sim and having a class or clinical conflict with the next day. Neither should students. This is all planned out ahead of time. With regard to the shortage of clinical placements, more students will participate in a continuous, 72-hour integrated simulation than in a day sim.

As a learning experience, the continuous, 72-hour integrated simulation accomplishes more in our view than is ever possible in single day, or even a multiple day sim. A day-long multi-patient sim, which in itself goes beyond the typical sim, will still primarily accomplish task training (the primary outcome of shorter, simulator based sims). Gains in critical thinking, clinical decision making, clinical judgment, communication, and empathy occur beyond what happens in a typical sim because of the complexity inherent in this holistic continuous environment. Students must prioritize, communicate, and make decisions on their own in this environment. The real world aspect of the 24-hour/day environment, with the night shifts, contributes greatly to what makes this such an amazing learning experience.

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