Nursing students take charge in Sim Lab

Nursing school combines academics with practical skills. Students hit the books and practice common skills – tracheotomy care, for example – over and over and over again. During their clinical rotations, the students provide care for patients under the direction of the primary registered nurse – but they’re not the ones leading the care.

Sim Lab blends those two experiences, allowing the students to take charge at the bedside and to get a sense of the weight of responsibility that comes with the job – without the possibility of causing harm. After all, the manikins lying in the beds have seen it all through their robotically blinking eyes – so, for that matter, has actor Arthur Nelson, who’s been playing the role of standardized patient for 23 years.

The Sim Lab – more properly called the Health Care Simulation Center – is housed within the College of Nursing at MUSC but is used by students from multiple colleges.

Dawn Terzulli, DNP, R.N., an instructor in the College of Nursing, said the goal for her students is to practice all of the elements of nursing – patient safety, practical skills, communication and clinical judgment – and then to reflect on what went well and where they could improve. Often, what they’re practicing isn’t simply a specific skill, like inserting an IV, but dealing with a complex human situation, like breaking the news that someone has died or interacting with a brusque doctor.

During one recent debriefing, after the students determined they would get a doctor to disclose the news of a death, Terzulli and instructor Heather Neeley, R.N., gently asked the students to think through who they could lean on when talking about death, like the hospital chaplain or social workers, and how there might be times when they can’t hand off the discussion to someone else.

“One time, we were coding a heart patient, and his wife was out of town, so we called her and said, ‘We’re resuscitating him – get here!’” Terzulli told the students. “When she showed up, I was in the doorway, and he had passed. What was I going to say to her? Let me go get the doctor? So sometimes, your hand is forced, and in those instances, it’s good to know that you just need to be present. We didn’t exchange a lot of words, but I did hug her for a very long time. And she was like, ‘Please don’t make me go in there alone.’ So I walked in there with her.”

“You learn words that help people, and you learn words that you don’t want to say to people, but the biggest thing you can do is just be there with them,” Neeley added. “And put your emotions aside. Because your emotions at that time don’t matter. It’s the person you’re telling.”

“And don’t forget about empathy,” chimed in Nelson, the actor playing a patient.

 

The Sim Lab can be set up to run a variety of scenarios, depending on the course. The manikins express complaints and doctors provide orders in prerecorded snippets of conversation. The monitors at the bedsides provide the student nurses with information about the patients’ vital signs. Terzulli and Neeley, sitting behind one-way glass, can observe and hear everything.

Standardized patients, like Nelson, provide an additional level of realism. New simulation vests mean that actors can wear devices that enable students to practice tracheotomy care, chest tube care, inserting an IV or inserting a Foley catheter as if they were performing these tasks on a person. Usually, they practice these skills on a manikin.

But, said Terzulli, “the manikin’s legs don’t move, and the manikin doesn't have an emotional response.”

Nelson has a script that he follows, but that script includes options depending on the choices that the students make – if a student does X, Nelson will respond one way, but if a student does Y, he’ll respond a different way. After so many years of acting in these scenarios, Nelson has picked up quite a bit of knowledge regarding proper protocol, so he immediately recognizes a student’s misstep – for example, mishandling an instrument so it’s no longer sterile.

Fourth-semester student Darby Taylor said the Sim Lab is helpful in that it puts all the skills they’ve learned into a realistic scenario – from deciding which patient needs attention first to coordinating with the other students, who play the roles of patient care tech and charge nurse in rotation. Probably the most nerve-wracking aspect, she said, is the feeling of performing in front of the others and not wanting “to mess up on something I should 100% know by this point.”

Taylor said she prefers working with the standardized patient more than the manikins simply because the standardized patient can respond in real time. Because she’s worked as a patient care tech on the orthopedic floor of University Hospital for three years, she’s comfortable talking with patients.

She left this semester’s simulation feeling more confident than she had in previous semesters – which is appropriate, since she will be graduating in May and taking a nursing job in her current unit.

Terzulli told the students that one of the most important parts of the Sim Lab is practicing the critical thinking that they’ll need to use on the job.

“We just want to make sure you’re thinking and putting some thought into prioritization,” she said. “Part of that, when you’re doing a bedside shift report, is making sure what you’re being told matches the patient. Make sure there’s nothing acute going on. What you’re told may be very different than what’s actually going on. And that can definitely affect the order in which you start your day.

“And then you leave the room, and five minutes later it changes, and you have to reprioritize your day. That's going to be nursing. Constant reprioritization.”