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Educating Nurses

Simulation provides nurses at All Children's Hospital, St. Petersburg, FL, with realistic scenarios in a safe environment

Research has shown new graduate nurses face a variety of challenges as they transition from the classroom to clinical settings. In addition, there is a need for graduate nurses to develop prioritization skills.

"With the limitation of clinical sites for student nurses, many nurses graduate with limited opportunities to apply clinical judgment in a pediatric setting," said Lisa McGuire, MSN, RN, CPN, advanced clinical education specialist and simulation program coordinator at All Children's Hospital in St. Petersburg, FL. The hospital is a member of Johns Hopkins Medicine.

At All Children's, a team of educators and leadership has built a nurse residency curriculum that integrates simulation throughout the program. Nurse residents practice medication safety, professional interactions, management of the decompensating patient, assessment of the intravascular access device and troubleshooting, and prioritization.

"It is here that nurses gain self-knowledge on their skills, professionalism, ability to delegate, and communication. It is here the educators become aware of gaps in knowledge of the resident and healthcare processes," McGuire said.

Funded through donations raised by Wal-Mart and Sam's Club associates, the state-of-the-art simulation center opened its doors this past January.

Preventing Patient Harm

Simulation is an emerging technology that promotes active and experiential learning, McGuire explained. Dependent on the objectives, however, simulation by itself may not be the most effective approach. Through research, it has been shown adult learners favor varied methods of learning and opportunities for active participation in the learning process.

"We believe, in order for healthcare to become safer, it is vital for simulation to be present in the hospital setting," McGuire said. "We utilize simulation to bridge the gap between didactic learning and clinical application."

McGuire believes multiple disciplines must have the opportunity to practice team communication and handling unexpected situations in a safe, non-judgmental environment that replicates the setting in which they work. Having the opportunity to practice with co-workers provides the realism necessary to effectively improve communication and learn.

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Furthermore, using equipment and supplies found in their own departments improves the ability to use that exact equipment at the bedside accurately. This, in turn, prevents learning how to use the equipment on the patient.

Through simulation, the nurse residents can practice making decisions, speaking up, and later reflecting if that decision might have put themselves and/or their patients in jeopardy.

"Everyone who comes into the simulation knows something difficult and challenging is going to happen and mistakes might occur, but no one is going to die," McGuire remarked. "Through simulation, we can provide training, bridge the gap between lecture halls and the clinical setting, identify our needs, and provide the tools to prevent harm and effectively care for our patients."

The more realistic the environment and scenario, the greater the ability to later apply the gained knowledge.

"We ran a simulation in which a patient had second- and third-degree burns on the chest and required chest compressions. We created the burns. Just prior to placing her hands on the chest for chest compressions, the physician stopped and said, 'Do I need sterile gloves to compress?' Had we asked the team to imagine the burns, the question may never have been raised and compressions potentially delayed in a real setting," she recalled.

Learning Together

The Simulation Center at All Children's offers a variety of scenarios for all staff at different levels, including nurses, physicians, physician residents, respiratory therapists, patient technicians, phlebotomists, security personnel and Health Unit coordinators.

"As healthcare workers, we need to learn from each other," McGuire said. "As healthcare workers, we need to prevent mistakes by practicing in environments we will practice in with people we work with."

Multiple low-fidelity simulators and high-fidelity simulators are used within the Simulation Center. Some are portable and can be taken throughout the hospital if necessary to evaluate flow and current processes for gaps in safety. Simulators cover the lifespan, and All Children's currently has newborn, child, teenager and adult mannequins with multiple capabilities.

Airways can be occluded, lung compliance changed, tongues can swell, adverse lung sounds can be created, a variety of heart rhythms and murmurs created, as well as bowel sounds. The mannequins have pulses and can cry and speak. One even has software that allows for it to correctly respond physiologically to medications given to it, whether right or wrong.

IVs can be inserted, tension pneumothorax can be created and needle decompression with chest tube insertion can be practiced, urinary catheters can be inserted, and mannequins can be intubated and placed on a ventilator.

Realistic Rooms

One of the simulation rooms replicates the med/surg rooms or a room found in the EC/ICUs, dependent on the equipment provided. Another room resembles the NICU. A conference room with a patient head wall and supplies can be converted into a patient room if necessary. Simulation screenings and debriefings are performed in this room. There is also a control room where educators can program the simulators to run and videotape the rooms for debriefing following the simulators.

"This allows the educator to remain unseen and facilitate the realism of the situation," said McGuire. "Before we built the Sim Center, the learner could observe the educator running the mannequin. This defeated the realism and potentially allowed for the learner to gain preempted feedback on their actions."

Research on simulation has demonstrated the value of videotaping and debriefing, said McGuire. Videotaping allows learners to observe themselves in the moment, self-reflect and discover. Learning also takes place during debriefing.

Following debriefing, learners are given the opportunity to practice the scenario again, to reinforce what they attained from the first attempt and practice what they may have not gotten perfect the first time.

Opportunity for All

McGuire noted that everyone comes to the simulation center expecting to practice and learn from each other, whether it is the medical emergency team or one nurse learning from a peer how to better communicate. Everyone must sign a confidentiality agreement so learners feel safe.

"Learners can voice their gaps in knowledge discovered through debriefing or self-reflection without fear of reprisal or fear of their peers thinking less of them. While educators might speak of what was learned from a simulation in a meeting to develop future curriculum, programs and processes, learners are never revealed," she shared.

All Children's has seen a marked reduction in its turnover rates since the curriculum redesign and the addition of simulation into the nurse residency program.

"We want to ensure we provide opportunity for simulation for all healthcare providers in the hospital setting. It is for this reason All Children's Hospital, with the support of the Wal-Mart/Sam's Club associates, is building a second phase of the simulation center," McGuire noted.

Upon completion of phase two in early 2013, the center will have more than 2,600 square feet of usable space. An operating room suite complete with booms, OR lighting and equipment will be in place. The new area will include an additional conference room and two exam bays.

"This will allow the OR staff to evaluate new equipment, train new staff, create new curriculum for residents, practice the 'what ifs' and evaluate processes," she concluded.

Beth Puliti is a frequent contributor to ADVANCE.


Dear sir, December 1st 2012
I observed that nursing Staff are required to handle bundles of paperwork despite their pressure of work to present the case to doctors on rounds.We use case sheets ,files , pads etc even in these days of advancements in information technology.
2) I would suggest that the paperwork can be replaced by flat screen monitors at the bedside of the patients linked to main computers at nurse sataion from where patient data, diagnostic reports , medication etc can be seen by doctors directly, till a patient is discharged.It will help speeding discharge proces.This will avoid human errors.If such a systems exists already please mail me details to my e mail id
C.S.Krishna kumar

KRISHNA KUMAR Independent consultantDecember 01, 2012


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