Disaster simulation for nursing students has become fairly common, reflecting the priority that is being placed on national and global health security. Disaster training and emergency preparedness are essential for current nursing education and curricula. Students who learn through participation in disaster simulations are able to increase professional awareness of the issue and develop important and marketable skills (Zapko et al., 2015).
Locally, our college of nursing has been providing disaster preparedness education and practice for undergraduate (UG) nursing students for almost 15 years through live-action, low-fidelity simulation. Until the most recent simulation, however, master's level nurse practitioner (NP) students were not included. Team-based interprofessional collaborative care has been shown to be very effective during disasters and emergency events (Strout et al., 2017), but education of nursing students and NP students in collaborative practice during disaster simulation does not appear to be the norm.
According to numerous authorities in nursing education, disaster preparedness education is an effective method for providing nursing students with the skills to handle real-life disaster and mass casualty patient care. The World Health Organization and the American Association of Colleges of Nursing address the essential need for disaster preparedness in nursing curricula by including it in the Essentials of Baccalaureate Education (Strout et al., 2017; Zapko et al., 2015), along with an emphasis on the importance of collaborative learning and leadership in professional nursing programs (Zapko et al., 2015). Learning by means of disaster simulation helps students develop critical thinking at all knowledge levels and leads toward greater proficiency in nursing care (Berent, 2013).
BACKGROUND
Collaborative and interprofessional education and practice for health care professionals is a topic of great interest in nursing education and has been increasingly studied in recent years. Active collaboration involves the willingness to consider differing opinions and make compromises in order to provide effective care and achieve best outcomes. Because health care professionals encounter a variety of barriers in collaborative care, interprofessional and intraprofessional simulation education provides a critical learning resource for students in all health care professions. Available studies on collaborative care indicate that simulation is a viable and effective means of supporting collaborative learning within the context of an educational program (Bruce et al., 2009; Leonard, Shuhaibar, & Chen, 2010).
Zapko et al. (2015) described a collaborative disaster training event involving nursing and radiology students that offered opportunities for role-play and high- and low-fidelity simulation. Their scenario included all programmatic years of UG nursing students, radiology students, and community disaster management personnel, with students working together to successfully manage simulation patients. Strout et al. (2017) described a simulation that utilized live patient volunteers and local emergency staff to prepare nursing students for dealing with disasters. The training with live "patients" was found to be effective in increasing students' ability to respond in an emergency event. Kaplan, Connor, Ferranti, Holmes, and Spencer (2012) described an emergency preparedness disaster simulation conducted in a nursing school with senior nursing students. The use of low- and high-fidelity simulation helped strengthen students' level of competence and engagement in teamwork. The researchers indicated that graduate nursing students and other health disciplines should be involved in disaster simulation for more interprofessional and collaborative learning.
A study by Bruce et al. (2009) evaluated the effectiveness of collaborative care utilizing a traditional hospital-based nursing scenario with UG and graduate nursing students. Both groups reported increased knowledge, confidence, and satisfaction following the simulation. Examples of various types of interdisciplinary and collaborative disaster simulation training for health care students abound in the literature. All appear to effectively offer students crucial knowledge and increased self-confidence. Unfortunately, there is little in the literature regarding the practices, relationships, and barriers to collaboration between UG and NP nursing students. This is particularly true when considering studies related to effective intraprofessional collaborative care during a disaster simulation.
STUDENT PREPARATION AND ROLES
In preparing UG nursing students for our college's first intraprofessional collaborative disaster simulation, attention was paid to disaster training as well as the placement of students in appropriate care roles. All UG students were trained in the Incident Command System, triage, and disaster nursing concepts through assigned reading, written materials, and classroom instruction based on Federal Emergency Management Agency (FEMA) disaster standards. The NP students were provided minimal preparation for their roles as the primary care providers within the disaster settings; they were encouraged to complete two basic, independent-study (FEMA) courses but were not required to complete them or attend training sessions, other than brief discussions with NP faculty coaches. It was assumed, erroneously, that practicing nurses had been trained in appropriate disaster care by their facilities. The exercise itself simulated care in a college-based mock mass casualty shelter following an F-3 tornado event.
UG students were utilized as command staff and in clinical areas, including triage, medical-surgical nursing, intensive care, obstetrics, pediatrics, and psychiatry. Students applied for staff positions based on their own nursing interests and experience. Other UG students trained for roles as victims. Student victims trained by researching their designated diagnoses and appropriate behaviors. A third, small group of UG students were trained in providing moulage (trauma makeup) for the disaster victims. Graduate students from the final clinical course in the family NP program were volunteers.
IMPLEMENTATION
During the simulation, victims utilized visible injuries, behaviors, and information cards to depict presenting signs/symptoms and diagnoses. Information cards were presented to UG/NP staff only if victims were properly assessed or asked the correct questions. UG/NP staff were tasked to appropriately ascertain what was needed to triage, treat, and discharge/transfer the patients, including patients who were "deceased," either at the start of the simulation or during the simulation if cared for improperly. Volunteer faculty coaches were selected according to their areas of expertise and their ability to mentor students through the disaster process.
During the simulation, both UG and graduate faculty coaches were available to answer student questions and respond to concerns. Faculty coaches were given a briefing prior to the event and were provided with observation checklists to complete during the event. The checklists were used to document student performance based on the training they had, and students at both levels were briefed regarding faculty checklist parameters. The results noted positive performances, with work needed primarily in preparation before the event. The debriefing session after the simulation was attended by faculty, UG, and NP students, with all groups contributing feedback and suggestions.
DISCUSSION
Through a postsimulation five-question narrative survey, students indicated that the collaboration was helpful. The overall student response was positive, with students noting how working together improved patient outcomes. Students focused on recommendations to improve role integration between UG and NP students for future events, including increased preparation for NP students, better NP student awareness of the expertise they bring to the simulation, and increased NP guidance provided to UG students. Students recommended NP-student pairs rather than one NP per unit. Plans were formulated to increase NP student preparation and involvement with UG "staff" training in the future.
CONCLUSION
It is evident that disaster simulation is an important aspect of nursing instruction. This level of education has been recommended by expert consensus, is supported in the literature, and has been demonstrated as valuable and advantageous by students and participants. Inclusion of NP students and use of advanced practice roles enhances collaborative learning and the chance for both student levels to experience the responsibilities of real-life collaboration.
Opportunities for increasing the effectiveness of collaborative intraprofessional disaster simulation in the future must include dual RN/NP student disaster preparedness education and training. Also, because many graduate students have not been adequately educated in disaster provider care prior to entering an NP program, disaster education should be integrated into the graduate curriculum, with efforts made to comply with national initiatives for emergency and disaster preparedness for integrated, multilevel patient care.
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