Four nurses are responding to a patient in trouble at Children's Healthcare of Atlanta. The baby's breathing is abnormal, and his heartbeat is weak. They quickly assess the patient and exchange medical information.

One nurse places a call to the physician. Another monitors vital signs and reports that they are deteriorating rapidly. The patient is going into shock. What should they do?

Photos by LEITA COWART/Special (ENLARGE)

Halli Jones (from left), a coordinator of staff development at Children's Healthcare of Atlanta, observes as student nurses Caroline Darnell and Taylor Flowers check a baby simulator's vital signs. The BabySIM mannequins can be programmed to react realistically to medical treatments and drugs, so nurses can practice their responses to symptoms without risking injury to living patients.

(ENLARGE)

Deborah Thomas (left), president and CEO of SillyMonkey, demonstrates a coaching game to client Karla Brandau of It's Time for Results. 'The power of a good simulation is that it gives people a real dose of reality,' Thomas said.

(ENLARGE)

Deborah Thomas of SillyMonkey creates games that help professionals learn to think on their feet and prepare them for situations they may face in their careers.

Nurses need to know how to handle life-and-death situations quickly and accurately. They can't afford to wing it. Fortunately, with this patient, a BabySIM high-

fidelity simulator made by Medical Educational Technologies Inc., they can practice worst-case scenarios in a safe setting: a training classroom.

"I love these little guys," said Halli Jones, a coordinator of staff development at Children's, referring to the patient simulators that the hospital purchased to help train staff members last year. "They may die, but we can bring them right back to life again."

The hospital purchased two baby (BabySIM) and two child (PediaSIM) full-size mannequins, which can be programmed to cry, wet, blink, sneeze, drool and react in a lifelike way to treatments and drugs.

"The pupils constrict. You can check vital signs at the pulse points. If you program the simulator to have asthma, the breathing sounds like asthma," said Gail Klein, director of clinical staff and position development at Children's. "You can hook up an IV and measure intake and output or defibrillate the heart [to shock it back into normal rhythms]. These highly sophisticated mannequins are great learning tools."

Children's began using the simulators to test competency requirements (such as starting an IV or changing a dressing) that nurses must pass every year. They use a team simulation of a patient going into shock.

"This is much closer to reality than testing skills individually. The nurses must work together and communicate as they would on the floor. At the end, we give them time to reflect and talk about what they did right and what could have been done better," Jones said. "The nurses love it. One told me that it was the best competency exam she'd taken in 25 years."

"The beauty of simulation is that you can practice situations that you may not see all that often on the floor," Klein said. "Later, nurses can respond to an emergency as though it were routine, because they have practiced it multiple times in a safe environment."

Simulation also actively engages its participants.

"You can't be passive in a simulation. You have to do something, so the learning is greater," Klein said.

Using simulation training with new nurses helps accelerate their critical thinking — the ability to put textbook knowledge into nursing practice.

"The closer the simulation is to real-world experience, the better the learning," she said.

Respiratory therapists have used the simulators to test the effectiveness of different equipment before making a purchase, and the trauma team has used them to refine its responses.

The mannequins help student nurses who are working as patient care technicians learn how to do head-to-toe assessments of patients. The instructor has them do assessments repeatedly and changes something each time. The students have to pick up on the changes.

The learning curve with patient simulators was steep for instructors, Jones said.

"We took a lot of training and then we sat with our laptops to learn the ins and outs of programming," she said. "I'm still learning how to make the patient do what I want, but you can create any number of scenarios. The applications for simulation are endless."

She likes that the training is so much more lifelike than PowerPoint presentations or lectures. "It's a different way to educate, and anything we can do to improve the quality of care at the bedside — we're on it."

All work and games

Airline companies, the military and others have used simulations to train people for high-intensity professions for years, but more industries are catching on to the method's effectiveness, said Deborah Thomas, president and CEO of SillyMonkey, a training company in Atlanta.

"We've been building games — instructor-led, Web-based, e-learning — and simulation activities into our training programs for years," said Thomas, who is past president of NASAGA, the North American Simulation and Gaming Association. "Our games always focus on the objectives of the course. They may be used for review, or they may be the course."

Thomas designed a board game for customer service representatives, who roll the dice, pick cards and deal with the situations presented. Other players judge them on their responses.

"Sure, you can give customer service representatives pat answers to memorize, but when faced with an irate customer and an unresponsive computer program they need to use, they'll forget and go with their gut reaction," Thomas said.

Playing the game helps trainees practice better responses and increases their ability to think on their feet.

"When people play the game for the allotted hour and ask to play again, you know you've been effective and they're learning," Thomas said.

An interactive game helps young recruits see if they are really cut out for the Peace Corps.

A simulation puts applicants in a remote area and situation and has them start to write home about it. They get more information — maybe a parent is seriously ill, a boyfriend back home is tired of waiting or a fellow worker dies — that tests their commitment.

"They internalize the information, and it's real to them, so they are better prepared for what might happen if they go," Thomas said. "The power of a good simulation is that it gives people a real dose of reality."

Her company designed a new employee-orientation program for pharmaceutical representatives that gave them marketing training and then simulated the experience of being in hospitals and talking to doctors about their products.

"When people are so enthusiastic after training that they are ready to go — when they are really jazzed about what they'll be doing — that tells you something about simulation," she said. It sure beats "the alternative of people coming out of a week of lectures so overwhelmed that they think they'll never learn it all."

Simulation for training purposes is a growth industry, and there are ways to "make learning very game-intensive and effective on any budget," Thomas said.

A simulation helps people hear, see, respond to and touch the information in various ways. The more hands-on experience they get, the better they'll understand what's being taught and remember it.

Don't just sit there

Welyne Thomas is a business psychologist with Right Management, a subsidiary of The Manpower Co. She uses simulation to help corporate clients select and develop their managers.

"We call it action learning, because the person is actively involved, rather than just sitting and listening," Thomas said. "They have an opportunity to practice their skills."

In an office scenario, executive applicants for a position or managers whom the company would like to develop are given an intense, daylong preview of what they might face on the job.

Placed in a mock office, they receive background material on the company structure, mission, products and competitors. They then must respond to e-mails; interact with people playing the roles of peers, subordinates and the boss; and write a 90-day plan for a major company challenge.

"We can adapt this basic framework for a foreman or a CEO by changing the background information [to fit the culture of the company] and the complexity of the position," Thomas said.

"The challenge is to design the tasks and role-plays so that you can assess the behaviors and skills the company needs to see or develop in that manager," she said. "The company might be looking for conflict management, teamwork, leadership, communication skills and strategic thinking, and you'd set up the simulation to elicit those behaviors and be able to score a candidate against a set of exemplars."

By showing what the job entails, a simulation can help a candidate decide whether he or she is equipped and wants to move up.

"A simulation can give you a portfolio of your skills and insight into your strengths and deficiencies," Thomas said.

For companies making a costly, top-level hire, a simulation exercise can give hiring managers additional criteria.

"If a company decides what is most important and someone scores high on those traits, with no other negatives, then that would be the candidate of choice," she said.

The applications for simulation are growing, and "people are getting more creative in how they use them," Thomas said.