In this continuing series on how nursing professional development (NPD) practitioners can optimize their use of standardized patients (SPs), I interviewed Mary Ellen Elias, MSN, RN, Simulation Coordinator and Co-Director for the Interprofessional Advanced Fellowship in Clinical Simulation for the Pittsburgh, Pennsylvania Veterans Affairs Medical Center, who plans and implements large-scale disaster simulations at her facility. She has been working with trained SPs for the past 5 years through the School of Medicine at the University of Pittsburgh.
MEH: Mary Ellen, please explain how you plan and implement your simulations.
MEE: We have large-scale disaster drills twice a year to engage hospital responders in practicing for a variety of incidents, such as sarin gas exposure, chlorine gas exposure, or other widespread mass casualty events. For all of these scenarios, we use trained SPs to play affected patients and family members. Once we have decided on a specific scenario and overall learning objectives, we determine the basic demographic requirements, such as age ranges, for the SPs that we need.
MEH: It sounds like there is a tremendous amount of planning that needs to occur not only for the events but in SP selection. What characteristics other than demographics do you look for in SPs?
MEE: It is important to understand that using SPs for a disaster drill is quite different than using them for a smaller simulation, such as a physical exam in a controlled simulation room. The SPs have to be willing to undergo possible physical and environmental discomforts. For example, in a sarin gas exposure scenario, we might need an SP to sweat profusely and have a runny nose. We simulate this situation by spraying some glycerine on their skin and putting a small amount of water-based soluble lubricant on their nose. This can get uncomfortable for some SPs, so it is important to ensure that they are able to tolerate it adequately. In addition, we might need an SP to display seizure activity for an extended period of time, which can be challenging for an SP to sustain. If an SP needs to take a break from displaying seizure activity, we have a sign that they can hold that says, "I am still seizing." We find this to be an appropriate compromise without losing too much scenario fidelity.
There are SPs who are not willing or able to participate in these types of simulations due to their own personal situations. Thus, they need to be vetted appropriately during the SP recruitment and selection process to make sure that we are only engaging with SPs who agree to perform for our scenario.
MEH: What kind of preparation do you do for the identified SPs?
MEE: We have a dedicated training session with them before the day of the event where we go over all the specific information on the scenario. We also have a physical walk through of the scenario so that they can see exactly where we will be and internalize what will happen. In the case where they will have to demonstrate seizure activity, we show them a video and discuss how to appropriately act. They typically are very enthusiastic about participating in our drills as they see the importance of making sure that our hospital responders are well prepared for these situations, yet they do raise a variety of questions and concerns. For example, I recently had SPs who would be going through the decontamination process wonder about the temperature of the water and expressed concern about getting too cold. We had to ensure that we used heated water to help alleviate their discomfort. If the water heater did not work, then we would probably have had to cancel the simulation or at least drastically modify it.
MEH: Please explain how you protect the safety of the SPs as the drill progresses.
MEE: One process that has worked well for us is to assign at least one dedicated observer for each SP. The observer needs to ensure that the SP remains safe and that the hospital responders refrain from initiating invasive procedures, such as starting an intravenous line. I have learned that we can never have enough observers for these large-scale events so it is important to recruit them as well.
MEH: That is a very good piece of advice. What else do you do to ensure SP safety?
MEE: We have also learned that even though our observers are diligently watching the SPs, an SP might need to stop the simulation for some reason. We train the SPs to use an agreed upon, nonmedical term to call a time out. The term could be anything, such as "apple," yet it is known by everyone that it actually means "stop."
It is also important to have shared understanding with everyone that there are certain tasks that can be performed on SPs to keep the realism of the scenario, such as placing a nasal cannula, oxygen mask, heart monitor pads, blood pressure cuff, and pulse oximeter. Hospital responders can also auscultate the chest, bandage moulage wounds, take a temperature, and perform other similar tasks. There needs to be an appropriate balance between maintaining the scenario realism as best as possible while keeping everyone involved safe.
MEH: How do you integrate the SPs into the debriefing?
MEE: We encourage the SPs to give feedback on how they felt they were treated and how the team members communicated with them. We elicit from them information on what they think worked well and what could be improved upon. I think it is essential that SPs be treated as part of the team. We emphasize this to the hospital responders so that they also can appreciate the important work that SPs do for us.
MEH: You obviously have a significant amount of experience performing these drills and working with SPs. What lessons have you learned?
MEE: We are always learning how to do things better, and quite frankly, issues come up each simulation that we had not anticipated. For example, I have learned to be very explicit with instructions, particularly when it comes to decontamination simulations, so that there are no surprises for the SPs on the day of the simulation. I explain the details of the process for the SPs and how they will get wet. I provide clothes for them to wear for the simulation and tell them that they need to wear a bathing suit underneath. One thing that I have mistakenly forgotten to emphasize in the past is for them to bring an extra pair of dry shoes so that they are comfortable during the aftermath and debriefing period. I have learned to take nothing for granted and provide as much preparatory information as possible.
It is also important to refrain from making last minute changes to the scenario after the SPs have been trained and know how to proceed. In addition, I have learned that all directions to participating hospital responders need to be very clear, consistent, and concise. We treat these simulations as real and expect that everyone will do the same.
MEH: Mary Ellen, these are excellent points and quite helpful for NPD practitioners to keep in mind when planning to use SPs in this large-scale fashion. I appreciate all of your insight on this topic.
I find several key takeaways from Mary Ellen's experiences that NPD practitioners can use. First, in large-scale simulations happening in uncontrolled environments, recruitment of appropriate SPs is highly important. If an SP is not willing or able to do the necessary tasks, such as go through decontamination, it could cause the simulation to be ineffective or fail. Second, attention to detail when preparing SPs and the hospital responders helps all involved gain a shared mental model of how the simulation will proceed and what the goals are. It is important to be very clear with instructions. Third, as with any simulation involving SPs, it is essential to protect their safety and treat them as a respected member of the team.
We will continue to explore various uses of SPs in future columns and how they add fidelity to educational programs. Do you have a project that involves SPs that you would like to share? Please e-mail me at mailto:[email protected].
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