531CHAPTER 44
Student-Generated Scenarios for Senior Simulation Day
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Implementation of simulation-based pedagogy progressed rapidly at Western Connecticut State University over the initial 5 years of the simulation program. At the time, all simulations were done on static manikins and were primarily skill based. As the lead instructors in the capstone course in the spring semester of 2008, we felt it very important to expose senior students to high-fidelity simulation. High-fidelity simulation allows the student to link theory, use the nursing process, and apply curricular content using a multidisciplinary approach. Additional advantages of high-fidelity simulation include enhancement of psychomotor skills and collaboration with peers and faculty in a nonthreatening environment.
Obtaining our first human patient simulator (HPS) took several tries and much effort over a 2-year period. Once obtained, we made it an immediate priority to introduce high-fidelity simulations at the senior level. This effort turned out to be extremely timely. That year, one of the regional hospitals began competency testing using the HPS. Our graduates, it was reported, were some of the only new graduates who excelled in the testing.
As time went by, simulation was introduced at all levels of the program. By the time the seniors arrive in the capstone course, the students have become accustomed to interacting with the HPS and have developed their own “simulation personalities.” For instance, some came hungry for as much simulation as possible. Others arrived and announced that they had done so much simulation, they were “sick and tired of it!” The year this scenario was introduced, the students arrived and stated they had not done enough simulation and were asking for dedicated time in a nontesting situation to reacquaint themselves with the HPS. As with all capstone courses, our job as faculty is to assess each group’s final learning needs and meet them as the best way we see fit. However, this year it was apparent that the capstone course itself was so anxiety producing that testing on the simulators did not seem feasible. In fact, once the students had completed their intensive capstone course clinical practicum, assessing competencies was not an issue.
Encouraging and supporting critical thinking is, however, a continuous challenge, and simulations serve as a fun yet challenging way to work to synthesize all that has been learned throughout the program as well as within the capstone course. Larew, Lessans, Spunt, Foster, and Covington (2006) suggest that groups of students be asked to develop scenarios as an experiential learning exercise. As a result a “Senior Simulation Day” was created as a substitution for a clinical day to meet the needs of this group of seniors, in which seniors were asked to create student-generated scenarios. Since the introduction of this scenario, other authors have expressed the value of having 532students teach each other during simulations (Dumas, Hollerbach, Stuart, & Duffy, 2015) and encouraging peer-led simulations as a “valuable educational approach” (Valler-Jones, 2014).
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
In 5 years, simulation facilities tripled in the nursing department. In the academic year 2002–2003, when the university held a centennial celebration, nursing graduates from 30 years ago returned and stated that the nursing labs had remained “much the same” as when they were students. Since then, the nursing department has worked tirelessly to upgrade and renovate the original nursing lab and expand the facilities to now include three nursing labs, with a fourth ICU lab. Each of these labs houses an HPS with a designated area and equipment for use with that HPS. In addition, we have found that a student resource center with textbooks, a seminar table, and references are essential for debriefing, processing, and redoing scenario plans. Students have access to online resources and drug references as well as the entire lab. Initially without the space or facilities for using a control room for simulations, the lab was upgraded to remote access for instructors who would like to run the scenarios remotely from the HPS. Often, these scenarios are run by only one instructor, and having a scenario control person is often not possible.
C. SPECIFIC OBJECTIVES OF SIMULATION USE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The objective of this simulation experience is to test senior nursing students’ basic program outcome competencies and knowledge synthesis through creation of one simulated scenario of an advanced medical–surgical disease/condition, integrating the nursing process, communication skills, nursing skills, and critical thinking. Students then try to “stump” their classmates by testing the observing group’s knowledge of the medical–surgical problem.
D. INTRODUCTION OF SCENARIO
Setting the Scene and Technology Used
Students are instructed to “mock up” a high-fidelity HPS to make the scenario as real as possible. They are given full access to the medical–surgical lab and are allowed to use any equipment they need from the lab supplies, including intravenous (IV) machines, IVs, and Foley catheters.
Objectives
Students will be able to identify a common medical–surgical problem from their recent clinical experiences and create a scenario that allows the following:
1. Portrays assessment factors and vital statistics common to that problem
2. Uses a chart and medication record with the appropriate drugs and dosages for that disease
3. Shows common psychosocial issues and concerns through communication with the patients, health care providers, and significant others
4. Requires interventions and evaluations appropriate to the standard of care for the medical–surgical problem being covered, which result, through the playing out of the scenario, in an improvement in the patient’s condition
533The National Council of State Boards of Nursing’s (NCSB) National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan categories and subcategories (NCSBN, 2015) addressed within this scenario include the following:
Safe and effective care environment category: Management of care (collaboration with interdisciplinary team, delegation, establishing priorities, ethical practice, informed consent, legal rights and responsibilities, and resource management), Safety and infection control (standard/transmission-based/other precautions/surgical asepsis and safe use of equipment); Health promotion and maintenance: Techniques of physical assessment; Psychosocial integrity: Coping mechanisms, Therapeutic communication; Physiological integrity: Basic care and comfort (elimination, nonpharmacological comfort interventions, personal hygiene, rest, and sleep), Pharmacological and parenteral therapy (dosage calculation, expected effects/outcomes, medication administration, parenteral/IV therapies, pharmacological agents/actions, pharmacological pain management), Reduction of risk potential (diagnostic tests, laboratory values, potential for complications of diagnostic tests/treatments/procedures, system-specific assessments, therapeutic procedures), Physiological adaptation (hemodynamics, illness management, medical emergencies)
Description of Participants
We encouraged all students in the group who created each scenario to become involved in the scenario. One student is the scenario controller and runs the computer as the scenario progresses. The HPS is the patient, and the other students may become the wife, doctor, nurse, or other participants at the discretion of the student creators.
E. RUNNING OF THE SCENARIO
Students are instructed to access the following simulation assignment from the course website 1 week before the simulation day.
NUR 375 Nursing Practicum
Senior Simulation Day
This day is designed to refamiliarize you with the HPS SimMan. Many hospitals now test basic nursing competencies of new graduates in orientation with the SimMan. Today, we will be creating scenarios from your experience or your imagination. We will split the group in two, and one group will test the other on an advanced medical–surgical scenario.
Objective
To test senior nursing students on one advanced medical–surgical disease/condition, integrating the nursing process, communication skills, nursing skills, and critical thinking.
Instructions
Please access the NURSIM site.
1. Print out the Laerdal Scenario Planning Worksheet (Laerdal Medical, 2008a), first two pages only, and the Scenario Validation Sheet (Laerdal Medical, 2008b) and bring them to clinical on Simulation Day.
2. View the SimMan Introduction PowerPoint presentation about simulation and SimMan.
3. Feel free to browse other documents or links. If you want to know more about the computers hiding in SimMan and the setup, you can look at the SimMan/SimBaby PowerPoint presentation (we do not have SimBaby yet).
534Assignment
• Design a medical–surgical scenario based on a real patient or a simulated patient to run for another group of students as if you are the instructor.
• You will need to mock up SimMan to look as “real” as possible. You can use any equipment in the White Hall Nursing Lab, for example, IVs, the IV machine, medication, carts, Foleys, and so on.
• You may decide to use other students as actors, for example, the distraught wife, the rude doctor, the inattentive nurse.
• Write out how the scenario will progress on the second page of the planning sheet. Include dialog, SimMan settings (respiratory rate [RR], pressure [P], blood pressure [BP], temperature [T], pulse oximeter, etc.), and equipment needed. Include all the knowledge you want to test on the crucial aspects of the disease/condition and medications. List all nursing assessments and interventions needed in order for the patient to improve.
• Just like a play, all scenarios have a beginning, middle, and end, so do not forget to plan for an ending (e.g., the patient with difficulty breathing is breathing better). But scenarios often take on a life of their own, so limit it to 15 minutes.
• Good luck and have fun.
Before arriving for the simulation day, students should download and print the scenario template and evaluation criteria. Students are also instructed to brainstorm on their own about comprehensive scenarios that test in-depth knowledge about common problems they encountered in the capstone clinical. Students are instructed to produce a chart, medication sheet, and history for their simulated patient, keeping in mind that they will need to construct the scenario much like they would write a play. On Senior Simulation Day, faculty introduce each group to the simulation technology from the instructor’s side. Faculty demonstrate simulation technology and the features of the HPS to the student groups. Students are expected to run the scenario in its entirety themselves. Faculty support is available, although independence of the group is encouraged.
F. PRESENTATION OF COMPLETED TEMPLATE
A total of 37 students in five clinical groups were given this assignment. The capstone course coordinator, who is the resident expert on simulation, attended all simulation events along with the clinical instructors. A total of six scenarios were created by the students. Three are presented here. In the end, only four clinical groups participated due to timing issues and scheduling (maternity leave, family emergencies, and illness). Those not participating were given an alternate assignment.
SAMPLE STUDENT-GENERATED SENIOR SCENARIOS 1 TO 3
Scenario 1
Title
Joe Money
Scenario Level
Senior scenario
Focus Area
Nursing 375 nursing practicum
535Scenario Description
Joe Money is a 59-year-old man found on the scene unresponsive with a BP of 180/90 mmHg, weak thready pulses, no reflexes, flaccid extremities, fixed pinpoint pupils, and a history of drug and alcohol (ETOH) abuse. Transported to the emergency room, where his BP is now 230/108 mmHg, with severe respiratory depression progressing to apnea. Patient may also have a head trauma and increased intracranial pressure. When his clothes are removed, $800, a switchblade, and a syringe are found in his jean pockets.
Scenario Objectives
1. Demonstrates proper assessment for drug overdose and trauma with appropriate interventions, including assessment of airway, breathing, and circulation (ABCs).
2. Performs assessment and interventions for increased intracranial pressure.
3. Staff uses proper safety precautions for potential drug-abuse patients.
Setting the Scene
Equipment Needed
HPS, patient monitor, O2 hookup, pulse oximeter, BP cuff, stethoscope, paper chart for documentation, syringe, money, fake switchblade, two large-bore IVs, IV machine, Foley catheter, several vials of mock IV push drugs, and IV access syringes
Resources Needed
Textbooks, drug books, and computer access
Simulator Level
High-fidelity
Participant Roles
Student to run the computer for the HPS.
Scene 1: Student to play a drug user and a student to play Joe Money, two students to play emergency medical technicians (EMTs) who transport the patient.
Scene 2: HPS plays Joe Money and two students play emergency room nurses.
Scenario Implementation
Initial scene takes place in an apartment as Joe Money sells drugs to a customer and then sits down to drink alcohol and smoke crack cocaine. Joe Money passes out, and emergency medical technicians (EMTs) are called.
Scenario resumes in the emergency department (ED), where the patient is now played by the HPS. Two emergency room nurses are assessing the patient and reporting the results to the observing students, who are making suggestions and recommendations for care. Students use the nursing process as a guiding framework for moving through the scenario.
Initial Settings for HPS
BP: 180/90 mmHg at the scene then 230/108 mmHg in the ED. Variable bradycardia with irregular beat, shallow and slow respirations of 5 to 10 progressing to Cheyne–Stokes and then apnea. 536Electrocardiogram (EKG) shows a bundle branch block typical of cocaine abuse. ED nurse (played by student) reports weak thready pulse; toxicology screen positive for cocaine and high blood alcohols levels; blood gasses of PCO2: 32, pH: 7.54, O2: 47, Na: 147, and glucose: 181. Results of CT scan show multiple bilateral deep and superficial cerebral hematomas.
Required Student Assessments and Actions
___Identify symptoms of respiratory depression and cardiac abnormality
___Initiate two large-bore IVs
___Suggest C-spine (cervical spine) x-ray, CT scan, and arterial blood gases (ABGs) based on assessment findings and history
___Raise head of the bed secondary to increasing intracranial pressure
___Assess blood tests, toxicology screen, and urinalysis
___Insert Foley and assess drainage of 3,000 mL over 1 hour as a sign of diabetes insipidus/increasing intracranial pressure
___Obtain EKG and recognize bundle branch block as a sign of cocaine abuse
___Administer medications prescribed. Check dosages and five rights
___Assess results of x-rays and ABGs and recommend actions
___Suggest airlift transport to a level 1 trauma hospital once stabilized
Evaluation Criteria
___Students who have created the scenario use the nursing process to cue the observing students to make recommendations about patient care. Cues are adequate for recognition by the observing students.
___Students observing were able to recognize signs and symptoms as drug and alcohol overdose and proceed with appropriate interventions and safety precautions.
___Students observing were able to recognize the signs and symptoms of possible trauma and follow diagnostic protocol to assess and begin interventions for trauma and increasing intracranial pressure.
___Students observing were able to connect the cardiac arrhythmia with the patient’s drug abuse.
___Students observing were able to accurately assess abnormal blood gases and suggest treatment.
___Students observing were able to suggest correct medication and dosages to treat patient’s condition.
___Patient stabilizes enough for transport, but students watch for signs of impending herniation and possible negative outcome.
Scenario 2
Title
Addison Jane
Scenario Level
Senior scenario
Focus Area
Nursing 375 nursing practicum
Scenario Description
Addison Jane is a 62-year-old White female with a history of hypertension and hyperlipidemia who was found by a bystander in her driveway near gardening tools, clutching her chest and appearing pale. In 537addition, she has blood on her right earlobe. Patient weighs 165 pounds and is allergic to aspirin and penicillin. Her medications are unknown. Pregnant daughter is called and is nearby in the ED.
Scenario Objectives
1. Uses initial assessment/focused history when evaluating patient
2. Prioritizes and initiates emergency patient care with stabilization of the cervical spine
3. Performs automated external defibrillation
4. Understands how to clear patient during the delivery of shocks in defibrillation
5. Demonstrates assessment of patient’s response to resuscitation
6. Properly documents events during the emergency care
Setting the Scene
Equipment Needed
HPS, patient monitor, O2 hookup, bandages, pulse oximeter, BP cuff, stethoscope, and paper chart
Resources Needed
Textbooks and computer access for database search and evidence-based practice
Simulator Level
High-fidelity
Participant Roles
Two nurses, doctor who yells incorrect orders, pregnant family member whose water breaks in the middle of the code, and a student to run the computer for the HPS
Scenario Implementation
Initial settings for the HPS
HR: 62 beats/minute, BP: 106/72 mmHg, RR: 12 breaths/minute, pulse oximeter: 94%
Required Student Assessments and Actions
___Performs initial assessment and cervical spine immobilization
___Performs EKG and recognizes deterioration to ventricular fibrillation with no BP and HR of less than 140 beats/minute
___Correctly performs cardiopulmonary resuscitation (CPR) with the use of a bag-valve mask
___Applies automated electronic defibrillator (AED)
___Administers three shocks at the correct setting, despite physician giving incorrect orders
___Performs CPR
___Establishes IV access
___Gives medications as appropriate: Epinephrine q (every) 3 to 5 minutes; atropine q 3 to 5 minutes
___Patient response to interventions: Return to bradycardic sinus rhythm with vital signs (VS) of BP: 85/52 mmHg, P (pulse): 34 beats/minute, O2 88%, with weak thready pulse and normal heart sounds
___Interventions continue with remedication of atropine and the addition of amiodarone with improvement of VS to BP: 104/68 mmHg, P: 65 beats/minute, and O2: 94%
___Once stabilized, patient is recommended to be sent for head and neck evaluation and MRI
538Evaluation Criteria
___Correct interventions result in the stabilization of the patient.
___Students who have created the scenario use the nursing process to cue the observing students to make recommendations about patient care. Cues are adequate for recognition by the observing students.
___Students observing are able to recognize signs and symptoms of possible trauma and severe hypovolemia.
___Students observing are able to follow proper protocol in directing the sequence of CPR.
___Students take proper safety precautions.
Scenario 3
Title
Dolly
Scenario Level
Senior scenario
Focus Area
Nursing 375 nursing practicum
Scenario Description
Dolly is a 45-year-old woman admitted with a methicillin-resistant Staphylococcus aureus (MRSA) infection of a wound. Her temperature at home was 102°F, with complaints of overall achiness, loss of appetite, and diaphoresis. She has a past medical history of type II diabetes, hypertension, increased cholesterol blood levels, and depression. Wound is currently a stage 3 in the lumbar sacral area. She weighs 325 pounds and is 5 feet, 4 inches tall.
Scenario Objectives
1. Students will be able to state some orders a doctor would write for the signs and symptoms observed.
2. Students will be able to state five continuous orders for a patients with a suspected pulmonary embolism (PE).
3. Students will be able to state five discharge orders for someone recovering from a PE.
Setting the Scene
Equipment Needed
HPS, patient monitor, O2 hookup, bandages, pulse oximeter, BP cuff, stethoscope, paper chart, thermometer, nasal cannula (NC), IV machine, and IV bag with vancomycin and IV bag with heparin and secondary line, primary line
Resources Needed
Textbooks and computer access for database search and evidence-based practice
539Simulator Level
High-fidelity
Participant Roles
Uninterested RN, patient technician, and medical doctor (MD)
Scenario Implementation
Initial settings for HPS BP: 130/70 mmHg, P: 72 beats/minute, RR: 12 breaths/minute, temperature(T): 102°F
Day 1 in the emergency room
Dolly is complaining of decreased appetite and not feeling well. She is found to have a fever of 102°F and a stage 3 lumbar sacral ulcer. After culture, the wound is found to be infected with MRSA. Patient is admitted to the floor with an IV infusion of vancomycin.
Day 3 on the patient floor
8 a.m.: White blood count (WBC) 541 cells/mm3, no complaint of (c/o) of pain, BP: 130/72 mmHg, P: 85 beats/minute, T: 99.2°F, O2: 98% on room air (RA). Patient refuses to get out of bed since admission. Only uses bedpan.
12 p.m.: Patient care technician comes in for VS and reports them to the RN: BP: 130/79 mmHg, RR: 26 breaths/minute, P: 120 beats/minute, T: 100.2°F, O2 94% on RA. Patient states, “My chest hurts, and I can’t breathe.” RN seems uninterested in patient and says she is going on break and will check on patient after her break. Tells patient care technician to keep an eye on the patient.
13 p.m.: RN finally gets around to assessing patient and finds wheezing, 7/10 substernal chest pain on a 0-to-10 scale. Nonproductive cough and increased anxiety. O2 has dropped to 86%, and pulse is 130.
RN puts oxygen on patient 2 L NC, and O2 comes up to 90%.
RN proceeds to call MD, who orders EKG, cardiac enzymes, chest x-ray (CXR), and 1 mg morphine IV.
14 p.m.: Results
EKG: Sinus tachycardia
Cardiac enzymes: Negative
CXR: Infiltrates, elevated diaphragm on right side. Doctor suspects PE and orders baseline coagulation studies: prothrombin time (PT), partial thromboplastin tine (PTT), and international normalized ration (INR); spiral CT to verify PE; heparin bolus 10,000 U and maintenance 1,600 U per hour.
15 p.m.: VS as follows: BP: 120/70 mmHg; RR: 20 breaths/minute, P: 100 beats/minute, T: 99.0°F; O2, 97% on 2 L NC; pain level 5/10 on a 0-to-10 scale and given 1 mg morphine IV
MD continuous orders: High Fowler, incentive spirometer every 2 hours, out of bed as soon as possible with the assistance of physical therapy; Thromboguards, monitor blood values especially PT, INR
Day 7: discharge:
MD discharge instructions: Decrease weight, take Coumadin as prescribed, Thromboembolic-deterrent (TED) stockings, initiate visiting nurses, active range of motion exercise to all extremities, get out of bed as much as tolerated, do not dangle or cross legs
Required Student Assessments and Actions
___Students in scenario assess and intervene in the emergency room based on the recommendations of observing students
___Assess VS, wound, and do a focused assessment/history of patient
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