Microsoft word - final report 2006.doc

Project Number:
Using Human Patient Simulators to Provide Student Project Title:
Nurses with Adjunct Clinical Practice Education Project Leader:
Project Dates:
With the increasing demand from all post-secondary institutions providing health care for student practice placement experiences it has become necessary to seek adjunct methods of preparing nursing students for safe clinical practice. Using interactive human simulator manikins and clinical case scenarios allows students, Project Overview:
individually and in groups, to apply knowledge and skills in safe and realistic situations. The intent of acquiring human simulator models for the Langara College Nursing Education Resource Centre is to support all levels of student nurses in their acquisition and application of knowledge and skills from the beginning to the end of the Table of Contents

Table of Contents. 3
Executive Summary . 3
Introduction . 4
Objectives. 6
Methodology and Outcomes. 7
Conclusions. 8
Recommendations. 8
Future Plans (optional) . 8
Appendixes (optional).11
Executive Summary

With the increasing demand from all post-secondary institutions providing health
care for student practice placement experiences, it has become necessary to seek adjunct methods of preparing nursing students for safe clinical practice. The use of simulation technology permits multiple opportunities for experiential learning that can be adjusted to varying levels of complexity. Using interactive human simulator manikins in clinical case scenarios allows students, individually and in groups, to apply knowledge and skills in safe, supported, and realistic situations. The broad objective of this project was to support the education of the Langara College BSN program students from Term I through Term X. The following objectives related to this project were met. A search of the current literature relating to the use of simulation model in practice nurse education was undertaken. Some simulation scenarios were developed and implemented. Faculty from each term have become involved in ongoing discussion and planning on the use simulation learning within each term. A research project regarding the effectiveness of simulation learning with the Langara College student nurses is in the planning stages. Evaluation on the effectiveness of simulation learning by conducting formative and summative evaluation for both faculty and students engaged in simulation experiences is in progress with all students who have participated in the simulation lab. A pilot study has been conducted with Term I students to explore how working with the simulators influenced their sense of confidence in the application of psychomotor skills. Initial thematic analysis of the information indicates that students find the experience to be confidence building and a valuable learning tool. Recommendations include the development of the modular instructional program for faculty and the further development of a pedagogically sound strategy for integrating appropriate simulation scenarios into the curriculum. Introduction

Langara College Nursing Program
Langara College offers twice-yearly intakes of 70 nursing students, one in September
and the second in January. The program is delivered in consecutive terms over the Fall, Spring and Summer semesters. The curriculum consists of 36 courses (157 credits) offered over ten registration terms. Students who continue in the program without interruption graduate 40 months after their entry into the September or January class. Each term in the program has courses related to the curricular themes of People’s Experiences with Health, Healing, Self & Others and Professional Growth. The focus Health related to Chronic Health Challenges Health and Healing related to Episodic Health Challenges Health and Healing related to Complex Episodic Health Challenges Consolidation and Integration of Learning and Experiences Health Promotion and Community Empowerment Consolidation and Integration of Learning and Experiences Societal Health and Nurses Influencing Change Transition from Student to Professional Nurse Currently, the Langara College Nursing Program has approximately 400 students enrolled. This number will increase to approximately 700 students within the next 18 months as the program expands to offer a complete Bachelor of Science in Nursing. The increasing demand for practice placements from all post-secondary institutions offering health care programs and the increasing number of nursing students requiring practice experiences, coupled with limited experiences in some areas has necessitated the exploration of adjunct methods to prepare students for Practice placements for student nurses have become increasingly difficult to obtain for a variety of reasons. First, there is an increased demand for practice placements from all post-secondary institutions providing health care education. Second, the overall restructuring of the health care system has resulted in limiting access to certain types of clinical areas (Student Practice Placement Summit, 2004). Third, client acuity and technological complexities have both significantly increased. Further, staffing shortages and time pressures frequently create situations not conducive to optimal student learning. Within the context of the current health care arena, therefore, students may not be able to gain the required level of critical thinking, confidence and skill proficiency necessary for competent practice (Atack & Rankin, 2002; Berke & Wiseman, 2004; Feingold, Calaluce, & Kallen, 2004; Rhodes & Curran, 2005). These factors necessitate that educational institutions explore new ways of assisting students to prepare for safe practice. Simulation and the use of simulation models have an extensive history in education. Mechanical simulators have long been used for the acquisition of skills in areas such as aviation and driving. Human model simulators have been used to educate health care professionals in areas such as anesthesia, trauma and emergency medicine (Feingold et al., 2004; Henrichs, Rute, Grady, Ellis, 2002; Nehring & Lashley, 2004). Nurse educators are now using human model simulators to enhance nursing students’ experience and understanding of client care situations. The underlying premise related to the use of the simulation models is that exposure to a constructed realistic situation will result in more successful management of the actual situation (Larew, Lessans, Spunt, Foster & Covington, 2006; Ravert, 2003). Concurrent theory and practice is the hallmark of professional nurse education and students frequently indicate that learning is best accomplished in an experiential situation. Simulation learning affords students the opportunities to apply and consolidate skills in a realistic and safe situation. The advantages of simulation as an educational strategy for student nurses include some of the following: • Simulation of a realistic clinical situation • Errors can be made and corrected without jeopardizing client comfort or • Different outcomes can be undertaken for similar situations • Consistent situations can occur for all students • Procedures and experiences can be repeated • Scenarios can set up for individuals, or groups (group scenarios provide opportunities for practicing team interactions) • Causes to a clinical problem can be controlled • Classroom learning can be immediately applied in simulated clinical settings Simulation as a teaching method has been shown to enhance student learning by providing a safe, unhurried yet realistic learning environment. Using simulation models in a non-threatening environment that does not place clients at risk provides • Strengthen assessment skills • Enhance critical thinking skills • Apply and consolidate psychomotor skills • Refine practice decision making skills • Practice time management • Evaluate performance • Work individually or in groups The Nursing Education Resource Centre (NERC) at Langara College currently houses three laboratory practice areas. Each lab area is enhanced with internet, DVD and video access. The eighteen bed and ten bed lab units are used by students for learning and practicing psychomotor skills. There is a two bed mini-lab available for individual practice. The ten bed lab area was converted into a simulation lab. The Langara College Nursing Department purchased one Laerdal Sim-Man ™ and four Laerdal VitalSim Nurse Annes™ in January 2006 with funds obtained through the Practice Education Initiative Fund. A laptop computer for use with the Sim-Man™ was added in April 2006. A printer for use with all the manikins will be added in December 2006 from Langara College resources. Computer requirements for the Nurse Annes™ have also been met from within Langara College resources. The Laerdal Sim-Man ™ (sim-man) is an example of a mid-fidelity human patient simulator. Sim-man is equipped with a functioning mouth and airway to allow for bag and mask ventilation and a chest wall that imitates the expansion and relaxation of inspiration and expiration. It is possible to program the sim-man with various heart, lung and bowel sounds, and patterns. The accompanying monitor provides a real-time display of various physiological functions. The monitor accompanying this sim-man has been customized to show only those physiological functions appropriate for basic nursing students. There are real-time displays of pulse oximetery, temperature, heart rate and blood pressure. It is possible to insert chest tubes and intravenous lines and bladder catheters on the manikin. The sim-man is also able to speak and can be programmed to say certain phrases at specified times, such as “I am having trouble breathing”. The Nurse Annes™ (Annes) are a lower fidelity simulation model. This model has simulated lungs and stomach to allow for the practice of nasogastric tube insertion and suctioning. Normal and abnormal heart, breath and bowel sounds can be programmed into the model. Blood pressure, including an auscultatory gap, can also be programmed. There is a wet-arm allowing for the insertion of an intravenous line and medication can be administered in all forms including suppositories. These models also have normal breast anatomy that can be used for learning how to do and teach breast exams. Breast abnormalities can also be created so students may learn about lumps, masses and cysts in the breast. Further, these models come with the ability to simulate radical mastectomy for learning about post-surgical care of the mastectomy client. The Annes also have a fundus assessment module with interchangeable contracted and “boggy” uteri. Wound care accessories are available, in particular an infected colostomy, diabetic foot, and a below knee amputation. The two types of simulators provide significant pedagogical scope to the type of learning activities that can be developed. Objectives The aim of this project was to create a simulation lab within the Nursing Education Resource Centre that would be used to support the education of the Langara College BSN program student nurses from Term I through Term X. The following objectives related to this project were developed. Literature search • Relating to the use of simulation model in practice nurse education • Faculty from each term to discuss how best to use simulation learning within • Develop and use simulation learning scenarios where appropriate Evaluate the effectiveness of simulation learning • Conduct formative and summative evaluation for both faculty and students • Begin the process of completing research regarding the effectiveness of simulation learning with the Langara College Student Nurses Methodology and Outcomes

The Langara College Nursing Department purchased one Laerdal Sim-man™ (sim-
man) and four Laerdal VitalSim Anne™ (Annes) manikins in January 2006. Product assembly and orientation of the resource faculty member was completed in March 2006. A laptop computer for use with the sim-man was added in April 2006. The vendor was not always accessible or available to assist with setup of the equipment and faculty orientation. The lack of easily accessible, knowledgeable individuals to assist faculty with orientation and development related to simulation was, and continues to be a challenge to the implementation of simulation within the program. Faculty members wishing to use the manikins were orientated to the human model simulators during March, April and May 2006. Orientation included a review of the simulators demonstrating their varied capabilities. A significant amount of time was spent discussing scenario development and scenario implementation. Students enrolled in the spring (January to April 2006) and summer (May to August 2006) semesters were oriented to the manikins. The students were given the opportunity to touch and operate the manikins and so observe some of their capabilities. The students were orientated to the remote control for the Annes so they could program different blood pressures, lung sounds or bowel sounds independently. In the first term of the program students learn basic assessment skills including how to take vital signs. Both the sim-man and the Annes were utilized in helping Term I students consolidate and apply their theoretical knowledge related to physical assessment and basic vital signs. Scenarios were developed for Term II nursing students including mild asthma, congestive heart failure and medication administration. Both the Annes and sim- man were programmed to provide opportunities for students to listen to normal and adventitious sounds. Appendix I contains information related to this scenario. Students in Term II practice seminars have also used the manikins to assist in their understanding of the older adult client and constipation. The students assessed the client and read the document (nurses’ notes). A component of the assessment was to listen to the client’s bowel sounds. Using their textbooks and teachers as resources they had to devise and propose an intervention. Term IV students used the Annes for chest assessment and to practice the skill of suctioning. Fluid was placed in the simulated lungs of the Annes and students were able to suction. The experience was felt to be “life-like”. Students also used the Annes to practice listening to abnormal chest sounds. A chest tube was inserted into sim-man and students identified and applied decision making skills and nursing strategies related to pneumothorax and chest-tube management. This experience allowed students to visualize the effectiveness of chest tubes as a treatment modality in a planned and structured environment. Appendix II presents a pictorial review through a PowerPoint presentation of some of the activities in the simulation lab. A summative evaluation of the simulation experience has been conducted with all students who participated in the lab. A copy of the evaluation tool is located in appendix III. A summary of the student evaluations is included in appendix IV. A pilot study has been conducted with Term I students to explore how working with the simulators influenced their sense of confidence when applying psychomotor skills. The information is being collected through written reflective journals. Initial thematic analysis of the information indicates that students find the experience to be confidence building and a valuable learning tool, as well as an interesting and enjoyable experience. This initial qualitative data is an important factor in understanding how to design simulation scenarios to maximize student learning. Conclusions

The experience of the faculty and students with the human model simulators has
been overwhelmingly positive. Students have indicated that the experience with the simulators helps them feel more prepared for what may happen with real clients in the practice area. Students have expressed a sense of confidence in their ability to apply their practice skills in the safe and controlled simulation environment. It is also important to consider that there are challenges to the integration of the simulators into the nursing program. As with all new methods and technology, there is a significant learning curve for faculty that is affected by both mechanical and human time. Faculty need to gain knowledge and expertise in simulation pedagogy as this educational approach differs considerably from traditional learning strategies. Significant time is needed to learn about the equipment and how to best use the technology to positively influence students’ learning. There is also a need to have knowledgeable individuals easily accessible for working with the simulators, particularly around scenario development. Recommendations and Future Plans

Recommendations for simulation development in the Langara College Nursing Department include faculty development and curriculum enhancement to ensure that the nursing program fully utilizes the simulation learning models across the curriculum. Based on the experience of the faculty and students with the simulators the following A comprehensive orientation program be developed for faculty consisting of modules • Simulation pedagogy • Simulation technology • Designing and debugging simulation scenarios • Implementing simulation scenarios • Debriefing simulation scenarios • Evaluating simulation outcomes Development of the faculty orientation modules will require a significant amount of time and most of the development work will occur during individual faculty members’ non-instructional terms. Consequently, this work will progress over time. The faculty who develop the simulation strategy modules will be resource people and become a “bank” of individuals knowledgeable in both simulation pedagogy and technology. The Faculty Development Committee and the Nursing Education Resource Centre (NERC) Committee will collaboratively structure a strategic plan for the simulation lab. This will include a plan for how simulation will be integrated throughout the program. For example, as part of the development plan one of the maternal-child health teachers will be developing a scenario to use with students related to the care of a client experiencing childbirth complications. It is planned that this scenario will be ready to run in the summer 2007 term. The projected outcomes of integrating simulation technology as a nursing program component include increased congruency and continuity between the classroom, lab and practice settings. It is anticipated that practice is the simulation lab will increase students’ confidence and competence in the application of psychomotor, critical thinking and decision making skills in the clinical area. Using simulation in nursing education requires that nurse-educators learn a new way of teaching. It is important to recognize that the use of human model simulators in nursing education is still in an early phase of development, but it is anticipated that simulation will be become an increasingly important pedagogical tool in the repertoire of nurse-educators. Appropriate use of simulation and optimal learning will be enhanced through careful planning, implementation and evaluation that thoughtfully consider the goals, features, benefits and challenges of this experiential References

Attack, L., & Rankin, J. (2002). A descriptive study of registered nurses’ experiences
with web-based learning. Journal of Advanced Nursing, 40(4), 457-465. British Columbia Academic Health Council (2004). Student Practice Placement Summit. Vancouver: Author. Feingold, C., Calaluce, M., Kallen, M. (2004). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43(4), 156-163. Henrichs, B., Rute, A., Grady, M., Ellis, W. (2002). Nurse anesthesia students’ perceptions of the anesthesia patient simulator: A qualitative study. AANA Journal, 70(3), 219-225. Larew, C., Lessans, S., Spunt, D., Foster, D & Covington, B. (2006). Application of Benner’s theoryin an interactive patient care simulation. Nursing Education Perspectives, 27(1), 16-21. Nehring, W. & Lashley, F. (2004). Current use and opinions regarding human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25(5), 244-248. Peteanie, L. (2004). Enhancing clinical practice and education with high-fidelity human patient simulators. Nurse Educator, 29(1), 25-30. Ravert, P. (2003). Human simulator use by nursing students: Effects on Critical thinking. Communicating Nursing Research, 36, 352. Rhodes, M., & Curran, C. (2005). Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. CIN: Computers, Informatics, Nursing. 23(5), 256-264. Appendixes
Appendix I
Term II Simulation Scenario
Term II Oxygen Lab Nebulized Medication Sim Man Jane Mighton 200620
Station 1 (in large lab using Sim Man/Q!g,!) Skills: administer Albuterol via nebulizer, respiratory assessment, identify wheezes with a stethoscope, documentation. Case: Olga's surgery is at 0800. The nurse administered her 0700 medications. When the nurse arrived to administer the Lorazepm 30 minutes before surgery, the nurse heard wheezing. Sim Man/Olga provides you with the rest of the scenario. Preparation: Learning activities: Assisting Clients with Oxgen Therapy and Medication Administration. Drug Class card: Asthma and Bronchoconstrictive Disorders Props: oxygen tubing and medication nebulizer, tJow meter, medication cart with Term II Oxygen Lab Nebulized Medication Sim Man Jane Mighton 200620 .Antibiotics 10 days .Narcotics 3 days .Anticoagulants 7 days Date July 10/06 Time 1000 1. Lorazepam 0.5 mg SL 1/2hr pre-op (OR at 0800) 2. Digoxin 0.125 mg po daily 3. Furosemide 20 mg po daily 4. Atroventl Ventolin combo puffer 2 puffs via MDI qid 5. Nitroglycerin patch 0.4 mg/hr po daily 6. Salbutamo12.5 mg via nebulizer pm DrG. Smith (Dr.G. Smith) Term II Oxygen Lab Nebulized Medication Sim Man -Jane Mighton 200620 Olga Chinnikovl September 10 1929 9006064 NERC Medication Record 24 hours from 0800 through 0800 ORDER #5 Nitroglycerin (Transderm -Nitro) 0.4mg/hr (PAT) 0.4 mg/hr daily (apply ORDER #2 Digoxin (Lanoxin) 0.25mg (1:AB) 0.125 mg po daily (record apex) 07jm ORDER #3 Furosemide (Lasix) 40 mg (TAB) 20 mg po daily 07jm ORDER #4 Ipratropium Bromide/Albuterol (Combivent) 18 mcg / puff 103 mcg /puff(MDI) (INH) 36 mcg /206 mcg (2 puffs) via MDI qid Order.#6 salBUTamol (Albute~l)1 mg/1 mL (INH) ORDE~ #1 Lorazepam (Ativan) 0.5 mg (TAB) 0.5 mg sll/2hrpre-op (OR atO800) Allergies: Penicillin Checked by: J. Mighton RN Term II Oxygen Lab Nebulized Medication Sim Man Jane Mighton 200620 Appendix II A powerpoint presentation is attached to this email. Appendix III Student Evaluation of Simulation Scenarios Example of an Evaluation Tool

During your Term IV Lab on patients with oxygen problems, you participated in
simulations using Sim-Man™ and SimAnnie™. You were given a scenario describing a patient and were asked to make decisions and to be competent with a psychomotor skill. The simulation involved Sim-man™ and SimAnnie™ with assessment of oxygen problems involving SpO2, vital signs, auscultation, laboured breathing, coughing and decisions requiring suction through the tracheotomy. Clear, frothy liquid was suctioned as you practiced this skill. Please evaluate this experience for us. Please How well do you feel you used the skill of oxygen assessment in the Lab when How realistic was Sim-man™ and SimAnnie™ during the scenario? How well would you rate your confidence in making a decision (deciding to suction) after you used Sim-man™ and SimAnnie™? How well do you feel your practice on Sim-man™ and SimAnnie™ has prepared you for safety with tracheotomy suctioning? Overall, was the experience in Lab with Sim-man™ and SimAnnie™ an effective teaching resource for your learning? Feingold, C., Calaluce, M. & Kallen, M. (2004, April). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43 (4), 156-163. Jeffries, P. (2005, March/April). Designing, implementing and evaluating simulations used as teaching strategies in nursing. Nursing Education Appendix IV Summary of Student Evaluations of Simulation Scenarios The evaluations were completed anonymously by students in Terms I, II and IV. Each evaluation form addressed relevance of the scenario, transference (safety) of the skills, realism of the simulation and confidence after the experience. The last question asked about overall learning with simulation. The evaluation forms used a five point scale (1=Poor to 5=Very Good) and included space for comments. Terms I, II and IV
Not at all
Very Good


The fatal outcome of an individual with anorexia nervosa and sheehan’s syndrome as a result of an acute enterocolitis – a case report

1 University Hospital Charité Campus Benjamin Franklin, Berlin, Germany2 University College for Psychology, London, United KingdomCorresponding Author: Dr. Werner Köpp, Maassenstr. 8, 10777 Berlin, Germany THE FATAL OUTCOME OF AN INDIVIDUAL WITH ANOREXIA NERVOSA AND SHEEHAN’S SYNDROME AS A RESULT OF ACUTE ENTEROCOLITIS – A CASE REPORT Objectives : To illustrate the close associ

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