Patients Programmed for Trouble

by Anna Simon

Simulated reality prepares nurses for the toughest of cases.

The pace in the emergency room is frenetic.

A young diabetic in a coma deteriorates rapidly. A doctor barks terse commands at the attending nurse.

An accident victim moans as a nurse injects a painkiller. It doesn’t seem to help. A hovering, hawk-eyed family member unnerves the nurse, who draws a deep breath to regain her composure as she rummages through a cabinet for more medication.

A young woman diagnosed with a sexually transmitted disease has an emotional meltdown. She’s engaged to marry the man who gave her the disease. A prostitute in short skirt, fishnet stockings, and bright lipstick flirts with every passing male until she unexpectedly learns she is pregnant—and HIV positive. Rather than wait for a referral, she stomps out of the emergency room as a bewildered nurse helplessly watches.

It seems like the patients are trying to be difficult. Actually, they are.

Two of the patients are actors. Two are mannequins. They are in a mock emergency room in the School of Nursing’s Clinical Research and Learning Center, a simulation lab on the second floor of Edwards Hall. The nurses are seniors one month away from graduation.

The diabetic and the accident victim are the mannequins, with pulse, heartbeats, and soft skin that can be pierced with needles for injections and intravenous medications. Instructors control the patients’ responses with computers and digital tablets.

Performing-arts students play the roles of the prostitute and the distraught young engaged woman, and have creative license to challenge the nurses’ patience and skills.

Only the diabetic is in imminent danger of death, but all four patients have demanding needs. Prioritizing is one challenge for the nurses. Their medical skills, communication skills, and leadership skills also are put to the test.

“The adrenaline is flowing,” says Jacqueline Dickens, one of the nursing students. “The pressure is high. Everything’s happening at once. You don’t know what’s happening next.

“It’s very realistic,” she continues. “We’ve had sixteen months of experiences from just getting patients out of bed to this.” The simulation lab is part of the curriculum for nursing students in their junior and senior years. This final lab is the “most intense experience so far,” Dickens says.

A crisis well planned

While the nursing students struggle with life-threatening situations and unruly patients in the mock emergency room, a second group of student nurses, in another room, administer CPR and oxygen to an unresponsive patient in a critical care unit. Tubes seem to sprout from every possible place on the mannequin’s body. Lines connect the mannequin’s neck, nose, arms, and bladder to a respirator and other lifesaving equipment. Suddenly, the patient stops breathing. There is no heartbeat. It’s part of a scenario planned by faculty to require nurses to perform CPR and pull out the “crash cart,” packed with emergency drugs and equipment.

The crisis that befalls the patient is planned. The outcome is up to the student nurses. “With the right kind of critical thinking and intervention the patient will improve. If not, the patient will die,” says Tracy Fasolino, an assistant professor of nursing and the driving force behind the simulation lab. On this particular morning, the patient survives.

In a third room, more nursing students care for patients in a surgical unit. Like in the simulated emergency room, nurses are challenged by mannequins and actors portraying various conditions in lifelike scenarios.

Two more rooms in the simulation lab are equipped with big-screen monitors, and other students watch their peers in the simulated hospital settings and discuss what they see.

The scenarios play out, then there’s a debriefing. Faculty, students who took part in the simulation, and peers who watched in the viewing rooms get real about went well, what didn’t, and how the nurses performed under the intentionally extreme pressure.

Students are “under a nurse’s wing” during their clinical experience in actual hospitals and other health-care facilities, but the simulation lab “gives you an idea of how fast things are going to go in the hospital,” says Will Clegg, a nursing student. “In this you’re more on your own. It’s pretty intimidating at first.” Clegg says this after a confrontation with a psychotic patient in the simulated critical care unit.

The simulation lab allows nursing faculty to “reinvent reality in a controlled environment,” Fasolino says.

Critical patients, critical thinking

Each mannequin has a name, an identity, and a diagnosis. As student nurses give injections or put in a catheter or feeding tube, they must also incorporate “the critical thinking element” and make decisions based on the situation with that particular patient, Fasolino says. Some scenarios require the students to take action to prevent further decline. If correct actions aren’t taken, the mannequin may “die.”

This kind of simulation is the core of Fasolino’s research in applying technology to a nursing curriculum. She was one of three principal investigators in a 2012 Medline Discoveries grant titled “Evaluating Nurses Surveillance during Rapid Deterioration Scenarios Using 3-D Virtual Environments.”

In the lab, simulations expose nursing students to uncommon situations that may or may not occur during their clinical experience, Fasolino says. They must be able to think on their feet as they use the skills they’ve learned and make life-and-death decisions. Only in the lab can they experience the conditions of a hospital setting without the risk of harming or killing a real person.

The pressure of performance in the lab adds another dimension to nursing students’ training. The ultimate goal is to improve patient safety and outcomes for the health-care consumer, Fasolino says.

“It’s as close to real life as we can make it,” says nursing instructor Sheri Webster, who dove into an impromptu role as a security officer during the simulation and returned the angry prostitute to the charge nurse in the emergency room.

All of the one hundred to one hundred and fifty students awarded undergraduate nursing degrees at Clemson each year now have this experience. A pilot project will give graduate nursing students simulation lab exposure beginning the spring 2014 semester.

Serving the Navy Reserve

The U.S. Navy Reserve Medical Unit also taps into Clemson’s simulation lab as a training ground. Fasolino is Clemson’s lead facilitator in developing a five-hour scenario to give Navy Reserve corpsmen and women a realistic, hands-on experience that includes a traumatic amputation and a cardiac event.

Use of simulation to highlight ethnic differences and address cultural differences is a critical element of Fasolino’s research. She has created scenarios involving Amish, Hindu, and Mexican-American patients and their families in order to expose students to a diversity of possible experiences and to help them dispel cultural biases or mistaken assumptions.

What goes on in the lab doesn’t stay in the lab. Student performance enables faculty to enhance the curriculum, says John Whitcomb, an assistant professor in Clemson’s School of Nursing and a fellow of critical care nursing. Whitcomb plays the part of the doctor in the mock critical care unit and observes the student nurses’ reactions to the unexpected deterioration of the simulated patient’s condition. Last year students struggled, but this year student performance was “marvelous,” he says, and, “This is the payoff.”

Tracy Fasolino is an assistant professor in the School of Nursing, College of Health, Education, and Human Development. Anna Simon is a freelance writer based near Pendleton, South Carolina.