ADVANCING YOUR PRACTICE

Get a real-world education through simulation
By Charles W. Fort, MSN, RN

Your patient, James, just coded again. You begin CPR while you wait for the code team to arrive. When help arrives, he's promptly and appropriately managed according to advanced cardiac life support (ACLS) guidelines and he's successfully resuscitated.

This is the eighteenth time James has coded today. That's because he's a human patient simulator used to teach healthcare professionals how to recognize and respond to medical emergencies.

Human patient simulators are anatomically accurate manikins that are computer-controlled to provide a realistic, real-time simulation of patient conditions. You'll assess and treat these lifelike simulators using real procedures and equipment, and they respond to treatment the way a real patient might. In this article, I'll review the different types of simulators available and how they can help you improve your nursing practice.

What's simulation?
You had a lot of experience with one type of simulation in nursing school when you discussed case studies and engaged in role playing, using fictional examples based on real patient scenarios to reinforce learning. But case studies and role playing offer few opportunities for hands-on experience.

Basic simulators, also known as partial task trainers, include intubation heads, I.V. insertion arms, and central venous access torsos. You may have used them in school or in ACLS courses to get hands-on experience by practicing a particular skill. But partial task trainers aren't designed to teach complex tasks that incorporate the whole patient with associated environmental factors. That's where human patient simulators come in.

Learning by doing
Human patient simulators help you learn by doing. Confucius said, "I hear and I forget. I see and I remember. I do and I understand." Research has shown that nursing students retain knowledge learned during a simulation longer than when the same skill is taught in a traditional way.1

Patient simulators are often used during orientation to objectively measure competency in certain technical skills.2 A demonstration of a cardiopulmonary arrest scenario can orient new nurses to how codes are run according to facility policy. If a new nurse (or one transferring to a different area of a facility) has trouble adapting to a new department, simulation can help improve critical thinking skills, nursing competencies, and confidence.

Simulation allows clinicians to break down complex tasks into smaller components so they can learn at their own rate. Important skills such as hand hygiene, documentation, and communication can be incorporated into every simulation.

Meet some simulator types
The various types of human patient simulators available are categorized by their capabilities and how they're controlled. Basic models are full- or nearly full-bodied static manikins that have features such as oral and nasal airways that accept intubation, and can generate cardiac dysrhythmias, including ventricular fibrillation that responds to defibrillation. They have no electronic feedback capability.

Intermediate models have some feedback capability and can be programmed via computer to provide specific clinical indicators, such as heart rate, BP, oxygen saturation, and respiratory rate. These can be assessed directly from the manikin or through a patient monitor.

Advanced models react to treatments and interventions such as oxygen administration, medication administration, and needle chest decompression. Scripted computerized scenarios change and adapt according to the clinician's interventions Advanced simulators provide the most clinical feedback because of features like these:

  • carbon dioxide exhalation to assess quantitative end-tidal carbon dioxide
  • air return with needle chest decompression
  • bloody fluid drainage with chest tube insertion
  • urine output with urinary catheter insertion
  • peripheral pulse palpation; pulse intensity varies with BP.

Simulation sites: Setting the stage
Simulation can be performed in the unit or a simulation lab. Both options have pros and cons. In a simulation lab, the human patient simulator and the whole clinical "stage" can remain set up and ready for use, and nurses can work with fewer distractions. On the other hand, if the simulator is brought to the unit, nurses can perform their normal roles where they're most comfortable and use real patient-care equipment. Working in the unit may reveal issues that might not have come to light in the simulation lab. See Simulator shortcomings for a discussion of potential drawbacks to each training option.

A simulation is run by a simulator facilitator or instructor who has the clinical knowledge to guide the simulator through a realistic scenario. Following a simulation, you receive immediate feedback during a debriefing, which may be the single most valuable aspect of simulation learning. At the debriefing, you and the simulator facilitator or instructor can discuss what went well and not so well. The opportunity to detect and correct errors in performance helps you sharpen your clinical skills without patient risk. After the debriefing, you may go through the scenario again to practice the "correct" way.

Pros and cons
Simulation has several advantages over traditional teaching methods, such as lecture:

  • Simulation lets the nurse make mistakes, follow the mistakes to their conclusion, and learn from the consequences without harming the patient.3
  • Simulation can decrease feelings of anxiety and failure that some nurses experience if they haven't yet mastered a skill.4
  • Simulation lets the new nurse develop a process of critical decision making and improve self-confidence in a safe and controlled environment.
  • Simulation lets the nurse practice clinical skills that are high risk but are used infrequently.2

Simulation scenarios with critical situations can help desensitize you to emergencies and keep you from letting your anxiety get the better of you. Even experienced nurses can benefit from practicing how to intervene in rare but potentially lethal complications, such as massive hemorrhage or shoulder dystocia.5

Future simulators
Soon, human patient simulators like James will have new colleagues. Completely wireless models are now available, so you can use them in any setting. For example, you could stage an ED scenario by starting the simulator, throwing it over your shoulder, and carrying it into the ED, saying, "My buddy just got shot."

As computer technology improves, so will the capacity of human patient simulators to act and react more like real human beings—who knows, one day you might find it hard to tell the difference!

Simulator shortcomings
Even though human patient simulators provide opportunities for hands-on learning, they can't replace the experience you get by working with real patients and interacting with colleagues.1 Human patient simulators are expensive, costing from $40,000 to $250,000 each, and they require someone to operate them who has enough knowledge to ensure that the simulated scenario is clinically accurate and meets learning objectives. The simulator facilitator or instructor has to be able to program and control the human patient simulator, which requires training and experience. Simulation can be labor intensive and time consuming. Faculty need to be trained in how to use the simulator, how to let the participant make mistakes, and how to debrief properly, or the educational session isn't as beneficial.

If the simulator is used in a remote lab, it needs to duplicate the clinical environment it represents. A simulation lab requires dedicated facility space, which is often a precious commodity in the hospital. Sometimes the realism of the simulation isn't real enough, and some nurses can't suspend their disbelief enough to take the simulation seriously.

If the human patient simulator is used in an actual clinical space, the simulation has to be scheduled so it doesn't interfere with actual patient care. With no simulation lab, secure storage must be found for the simulator and its related equipment.

References
1. Childs JC, Sepples S. Clinical teaching by simulation: lessons learned from a complex patient care scenario. Nurs Educ Perspect. 2006; 27(3):154-158.
2. Ackerman AD, Kenny G, Walker C. Simulator programs for new nurses orientation. J Nurses Staff Dev. 2007;23(3):136-139.
3. Hravnak M, Tuite P. Expanding acute care nurse practitioner and clinical nurse education: invasive procedure training and human simulation in critical care. AACN Clin Issues. 2005;16:89-104.
4. Winslow S, Dunn P, Rowlands A. Establishment of a hospital-based simulation skills laboratory. J Nurses Staff Dev. 2005;21(2): 62-65.
5. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 2003;102(2):388-392.

Source: Nursing2009. November 2009.


 

 

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