Learning from dummies

How patient simulators are used to train clinical workers

A patient with a cocaine overdose lies in the emergency room. His blood pressure is sky high, his heart racing.

As nurses assess his condition and try to stabilize him, he begins vomiting, which leads to pulmonary aspiration. He develops heart arrhythmia requiring emergency CPR and defibrillation measures. Despite these interventions, the patient dies — until the next time.

Fortunately, this was not a real situation. The patient was a high-fidelity METI-CAE Healthcare patient simulator and the nurses were senior nursing students practicing at “Brenau Hospital,” a simulation center used by the nursing, occupational therapy and psychology departments at Brenau University in Gainesville. Instead of rushing to treat their next patient, the students had a chance to analyze and discuss the experience and their clinical response.

Simulated experiences are part of their nursing education.

“The exercises require some suspension of disbelief, but the results are well worth it,” said Michael McCannon, assistant professor of nursing at Brenau University and former manager of the simulation center.

In the hands of knowledgeable instructors, simulation training can lead to a more complete education, higher competence of working clinicians, better testing of medical devices and even systems innovation.

“Simulation in health care has been steadily evolving. I hear that there’s a mannequin in Japan that can walk around. The use of avatars and virtual environments is coming. It’s a component in nursing education that will be around a long while because it is a powerful tool,” said McCannon, RN, BSN, MSN.

Tools for hands-on learning

During the last four years, McCannon has overseen Brenau’s simulation training as it has gone from one barely-used, high-fidelity mannequin to three mannequins, a simulation center with four fully equipped hospital rooms, a nursing station, a supply area and a waiting room.

“Simulation has been a process that started in one clinical class and has spread through the entire undergraduate and graduate curriculum,” McCannon said.

Divided into small groups, students are assigned nursing roles in patient-care scenarios. Maybe a postoperative patient develops pneumonia or a gunshot victim is treated before surgery and afterward in an intensive care unit.

An operator works on a computer that controls the mannequin’s respiration, pulse, heart sounds, pupil dilation and urinary output. A facilitator stays with the students to observe their actions and interactions.

“Simulation allows us to take didactic content and apply it to create a higher level of learning without endangering patients,” McCannon said. “Students can encounter situations that they might not experience in their clinical training. It also promotes teamwork and the learning of therapeutic communication.”

Janita Mastin, nursing instructor and simulation center manager, wants to take the experiences to an even higher level.

“By using scenario software scripts, we can put instructors with their students so that it is a learning activity for both. It will allow instructors to better assess the strengths and weakness of students and to see gaps in the curricula that need to be addressed,” said Mastin, MSN, BSN.

When nursing students perform required skills — such as inserting a Foley catheter — while role-playing during a simulation scenario, it’s more effective than judging competency in a laboratory setting, she believes. To make the experience even more lifelike, Mastin plans to place a real student acting as a patient with a different condition in the fourth hospital room.

“Hospital nurses usually have more than one patient,” she said.

Mastin’s goal is for students to have simulated experiences before their clinical rotations to build confidence.

Last year, a student faced with a drug overdose patient in her clinical rotation told McCannon that she felt much more confident and prepared because of the simulation she had done beforehand.

The spread of simulation

Like many health care organizations, WellStar Health System has a simulation center that is focused on advanced patient care, clinical skills, teamwork and communication.

“It allows our clinicians to practice and learn new skills in a safe environment,” said Bethany Robertson, executive director of organizational learning at WellStar. “Our research from 2006 to 2007 showed us that simulation does make a difference and improves performance in our staff.”

A second simulation lab at WellStar has a very different purpose, however, and is the result of a three-year collaboration with General Motors Corp.

“We use our simulated work environment (SWE) lab to teach the core principles of Lean Methodology and Six Sigma to our managers and executives,” Robertson said. “It turns out that the core principles of how we manage work are similar across industries. We’ve learned a lot from each other.”

Looking at problems from a different industry perspective is helpful if you want to innovate, Robertson said.

“We’re excited about our collaboration with GM and what we’re learning by looking at things from a process perspective,” she said.

While the assembly of cars and the treatment of patients seem worlds apart, both workplaces involve different departments that contribute to the quality and safety of an end result.

“We use this simulator to teach people different ways of thinking about work, and how the processes of one department affect another,” Robertson said.

Jennifer Strahan, executive director of Lean Six Sigma training, says the SWE is a one-of-a-kind simulation lab that is opening eyes at WellStar.

“Lean methodologies concentrate on eliminating waste in processes to improve efficiency,” said Strahan, MS. “Six Sigma are tools and methods used to eliminate defects to improve quality. When you marry the two together, you get a bigger bang for your buck.”

Small groups of WellStar employees from across the organization go through a daylong SWE simulation to build a 4-by-4 box car, known as a “WellStar Wagon.”

“In the first run, everyone is assigned a role, the process is defined and participants assemble the car using standard operating procedures,” Strahan said.

The group debriefs, learns some new concepts and goes through a second and then a third run to improve operations.

“I love it when the light bulb goes off and they realize that this translates to health care,” Strahan said. “They begin to look at how their job impacts the next person.”

According to Strahan, many employees arrive for the exercise wondering why they have to participate and leave with a greater appreciation for the system and new ideas about how to improve it. Taking employees out of their units and putting them in a different environment often results in the group coming together as a team.

When nurses, doctors and leaders work together in the SWE, it challenges them to think more broadly.
“They can step back and ask, 'Why am I doing this?’ ” Strahan said.

To date, more than 750 WellStar employees have gone through the SWE simulation, and the health system is seeing that incremental changes add up to better efficiency and quality.

“Everything is changing so dynamically, and to provide the best care we all have to look internally to improve our own systems,” Robertson said.

WellStar plans to make the SWE and its curricula available to other community organizations.

Quality care is the mission, but budgets are on every leader’s mind.

“Costs are constantly rising and we estimate that there is an overall 30 percent to 50 percent waste in all health care expenditures,” Strahan said. “When you consider that health care is about 19 percent of GDP (gross domestic product) and up to 50 percent is waste, that impacts everyone. We see a huge opportunity for improvement.”

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