Running head: SIMULATION EXPERIENCE 1. Improving Care Delivery to Patients Through Multiple-Patient Simulation Experience

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1 Running head: SIMULATION EXPERIENCE 1 Improving Care Delivery to Patients Through Multiple-Patient Simulation Experience Wende Prince MS, APRN, NNP-BC University of Utah In partial fulfillment of the requirements for the Doctorate of Nursing Practice

2 SIMULATION EXPERIENCE 2 Executive Summary Simulation-based learning is part of the standard curriculum in many nursing programs across the nation. However, most simulation experiences focus on single-patient scenarios. This focus does not reflect the reality of professional clinical settings, in which nurses take care of multiple patients simultaneously. Caring for multiple patients can be challenging for even the most experienced registered nurses (RN). Because improving patient safety provided by new RN s is crucial, preparing student nurses for clinical practice by offering them opportunity to provide care to multiple patients concurrently in a safe atmosphere promotes safe and of high quality care and addresses concerns regarding new-nurse inexperience. Growing evidence asserts the benefits of multiple-patient simulation for nursing students. For example, Ironside, Jeffries, and Martin (2009) found nursing students patient safety competencies improved significantly when participating in multiple-patient simulation. In addition, Kaplan and Ura (2010) report that student nurses who experienced multiple-patient simulation were better able to bridge the gap between the role of nursing student and that of practicing nurse. Prior to this project, there has not been a multiple-patient simulation program for College of Nursing (CON) students at Brigham Young University (BYU), which limited learning and applicability to real world experience. The purpose of this project was to improve care delivery to patients through a simulation experience of caring for multiple patients. Objectives of this project were: 1) Develop a multiple-patient simulation scenario for Baccalaureate CON students at BYU, including pre and post-questionnaires; 2) Administer a pilot program of multiple-patient simulation scenarios at BYU, including pre and postquestionnaires; 3) Disseminate findings of the multiple-patient simulation experience to the Baccalaureate faculty at BYU, with recommendations to implement multiple-patient simulation as part of the program curriculum. Multiple-patient simulation scenarios were developed consisting of three patients presenting typical illnesses addressed on a medical-surgical floor. These included a patient with diabetic ketoacidosis (DKA), a postoperative partial gastrectomy patient, and a patient with chronic obstructive pulmonary disease (COPD). Content experts reviewed and approved the scenarios, IRB approval was obtained, and the pilot program was administered to BYU Baccalaureate CON students. The students completed a pre and post-questionnaire regarding their simulation exercise. Results from the pre and post-questionnaires demonstrated that following their participation in the simulation experience, students experienced increased positive attitude, motivation, and knowledge of the content involved in multiple-patient scenarios. Using a 5- point Likert scale, differences between the pre and post-questionnaire were calculated for each statement. Scores for each item improved from the pre to post-questionnaire. Student feedback was overwhelmingly positive and enthusiastic. Students expressed that they found the multiple-patient simulation experience to be beneficial to their learning as it helped with critical thinking and was more representational of clinical settings. They felt like additional multiple-patient simulations would be beneficial to their education. Special thanks and acknowledgement to David Winmill DNP, ANP-BC, CDE, BC- ADM; Gillian Tufts DNP, APRN, CFNP; Barbara Wilson PhD, RNC, Associate Dean, Academic Programs; Debra Wing Major USAFR, NC, MSNEd, RN; Angela Kahoush MSN, RN.

3 SIMULATION EXPERIENCE 3 Table of Contents Executive Summary 2 Acknowledgements 5 Problem Statement 6 Clinical Implications 6 Objectives 8 Literature Search Strategy 9 Literature Review 9 Theoretical Framework 13 Implementation 15 Evaluation 20 Results 22 Recommendations 24 DNP Essentials 25 Conclusions 26 References 28 Appendices 31 Appendix A: Multiple-patient Simulation Scenarios Quick Notes 31 Appendix B: Multiple-patient Simulation Patient Charts 37 Appendix C: Multiple-patient Simulation Drug and Supply List 67 Appendix D: Multiple-patient Simulation Preparation Worksheet/Key 68 Appendix E: Multiple-patient Scenarios Overview for Student Preparation 74 Appendix F: Recruitment Script and Consent 76 Appendix G: Pre and Post Questionnaires 80 Appendix H: Pre and Post Questionnaires Raw Data/Results 83 Appendix I: IRB Approval 87 Appendix J: IRB Letter of Agreement Between U of U and BYU 88 Appendix K: Project Defense Power Point 89 Appendix L: Project Poster 94

4 SIMULATION EXPERIENCE 4 Appendix M: Presentation Utah Valley University Nursing Research Conference 95

5 SIMULATION EXPERIENCE 5 Acknowledgements Special thanks and acknowledgement to David Winmill DNP, ANP-BC, CDE, BC-ADM, Project Chair; Gillian Tufts DNP, APRN, CFNP, Program Director of the MS to DNP Program; Barbara Wilson PhD, RNC, Associate Dean, Academic Programs, Executive Director of the MS and DNP Programs. Additionally, thank you to BYU CON Dean Patricia Ravert PhD, RN, CNE, ANEF, FAAN for her review and suggestions on BYU IRB application. Because of her willingness to give feedback, IRB was expedited making it possible to pilot the program for the students final simulation Fall 2014 semester. Content experts gave support and suggestions for revisions through the entire process of developing the multiple-patient simulation project. They were Debra Wing Major USAFR, NC, MSNEd, RN, Assistant Professor BYU and Assistant Simulation Lab Coordinator at BYU Mary Jane Rawlinson Geertsen Nursing Learning Center; and Angela Kahoush MSN, RN, Simulation Lab Coordinator at Utah Valley Regional Medical Center in Provo, Utah. Thank you to my entire committee for your guidance, suggestions, support, and contributions. I would also like to take this opportunity to express gratitude to my family and friends for their love and support throughout my life. Thank you to my parents, L. Clark and Ida Lee Tolbert, siblings, extended family, in laws, and many friends and colleagues for their words of encouragement. Going back to school with my dear friend, Allison Showalter, was an added blessing. I am especially grateful for my children Leland Travis, Tirzah Wende (her service in the United States Air Force Academy gave me courage), Clara Dawn, Rose Laura, and Melisa Judith Arrieta. I was blessed to accomplish this goal because of the grace of my Heavenly Creator and because of my partner and husband, Leland Frederick Prince, for his unwavering love and support of who I am over the last 31 years, specifically over the last two years.

6 SIMULATION EXPERIENCE 6 Improving Care Delivery to Patients Through Multiple-Patient Simulation Experience Problem Statement Caring for multiple-patients simultaneously can be challenging for even the most experienced registered nurses (RN). Such challenges become even greater for new graduate nurses, who, lacking experience with simultaneous patient care, often do not feel adequately prepared when they enter clinical settings and are required to administer to multiple patients at the same time. In such situations, patient safety becomes an area for particular consideration. Improved patient safety could be better accomplished by providing student nurses with ample opportunity to deliver safe and high quality simultaneous care prior to entering clinical practice. Prior to this project, there has not been a multiple-patient simulation program for College of Nursing (CON) students at Brigham Young University (BYU). Consequently, CON student s simulation programs have had limited real-world application. The purpose of this project was to improve care delivery to patients through creating and implementing a simulation experience for CON students caring multiple patients. Clinical Implications Simulation-based learning is standard curriculum in many nursing programs across the nation. However, most simulation experiences involve single-patient scenarios for practicing student nurses, when in reality, clinical nurses take care of multiple patients simultaneously. Given the discrepancy, there has been some effort to rectify this educational gap. Indeed, there is growing evidence that multiple-patient simulations have been beneficial for nursing student education. Ironside, Jeffries, and Martin (2009) found nursing students patient safety competencies improved significantly when participating in multiple-patient simulation. In addition, Kaplan and Ura (2010) report, students repeatedly expressed insight into the shifts

7 SIMULATION EXPERIENCE 7 in responsibilities experienced when bridging the gap between the nursing student role and the practicing nurse (p. 376). Despite the evidence, many Colleges of Nursing, including BYU, did not provide multiple-patient care scenarios for their student nurses in the nursing lab. Such a program provides a safe environment in which student nurses could gain experience in caring for multiple patients concurrently, before they are faced with this challenge in clinical settings. This multiple-patient simulation experience was developed as a benefit to BYU s CON to bridge the existing educational/real-world gap. The simulation experience aids students through improving clinical reasoning skills, so that student nurses are better prepared to deliver safe and quality care once they enter the work force. The Institute of Medicine s (IOM) reports, To Err is Human (1999) and Crossing the Quality Chasm (2001) go right to the heart of issues concerning patient safety and the quality of health care. These reports form part of the second phase of the IOM s quality initiative, which aims to transform health care practices and patient care. In addition, the third phase of this initiative directly addresses the importance of reforming education in health professions ( Health Professions Education: A Bridge to Quality, 2003). As a result of these reports, all disciplines providing health care have been called to examine, question, and challenge current practices in order to achieve national patient safety and improve quality of care. Along these lines, the National League for Nursing s (NLN) (2003) position statement declares, What is needed now is dramatic reform and innovation in nursing education to create and shape the future of nursing practice. All levels of nursing education are obligated to challenge their long-held traditions and design evidence-based curricula that are flexible, responsive to students needs, collaborative, and integrate current technology (p. 1).

8 SIMULATION EXPERIENCE 8 In order to achieve such reforms as the IOM and NLN have called for, educational gaps between academic practice and real world experience must be bridged. Colleges of Nursing endeavor to cultivate a number of skills in students including ability to prioritize, delegate, implement care, manage time, recognition of a deteriorating situation, teamwork, and collaborative skills. However, student nurses are generally not given the opportunity to care for multiple patients in their clinical sites and therefore struggle to develop many of these skills. As evidenced by such studies as those of Fero, Witsberger, Wesmiller, Zullo and Hoffman (2008) and Bricker and Pardee (2011), new nurse competency is a persistent issue. Consequently, student nurses must be prepared to deliver care that is both safe and of high quality through educational programs accurately mirroring the very real world situations they will face in their clinical careers. Objectives The purpose of this project was to improve the quality of care for patients and the usefulness of simulation-based learning for nurses, through a simulation experience allowing student nurses to care for multiple patients simultaneously. Objectives for this project included: 1) Develop multiple-patient simulation scenarios for Baccalaureate CON students at BYU, including pre and post-questionnaires. 2) Administer a pilot program of multiple-patient simulation scenarios at BYU, including pre and post-questionnaires. 3) Disseminate the findings of the multiple-patient simulation experience to the Baccalaureate faculty at BYU, with recommendations to implement multiple-patient simulation as part of the program curriculum.

9 SIMULATION EXPERIENCE 9 Literature Search Strategy Data bases used for the literature search were PubMed and CINAHL. Search terms included: multiple-patient, multiple-patients, multi-patients, simulation, multiple-patient simulation, students, nursing students, registered nurses, RN, nurses, new nurses, competency, new nurse competency, proficiency, quality of care, and patient safety. No exclusion criteria were used. Literature Review Simulation-based Learning Preparing student nurses to provide safe and quality care in clinical settings is of upmost importance to nursing programs across the nation. One of the key tools used in nursing education to develop the skills necessary for success in the clinical world is simulation. To determine the effectiveness of this technique, studies have been conducted by researchers such as Brewer (2011). Through an integrated review of current literature, Brewer (2011) found simulation to be a successful teaching method. In addition, Bland, Topping, and Wood (2010) have tried to understand and define the concept of simulated learning as a strategy used in the education of undergraduate nursing students (p. 664). Their research has determined that such a definition is a work in progress and further research, development, and understanding [are needed] (Bland, Topping, & Wood, 2010, p. 668). Regardless of definition, systematic reviews conducted by Lapkin, Levett-Jones, Bellchambers, and Fernandez (2010) as well as Yuan, Williams, Fang, and Ye (2012) demonstrate that simulation is effective in teaching clinical reasoning skills and improving knowledge.

10 SIMULATION EXPERIENCE 10 New Nurse Competency Even with the best education, student nurses lack real world experience, making issues of new-nurse competency an on-going concern. In order to identify areas where increased learning was needed, Fero, Witsberger, Wesmiller, Zullo, and Hoffman (2008) conducted a study comparing new graduate nurses with experienced nurses. The study was carried out in a southwest Pennsylvanian university-affiliated healthcare system, which included 19 hospitals. The study spanned the years 2004 to 2006, and included 2,144 consecutive newly hired nurses. In the study, nurses were required to view and respond in written form to 10 videotaped vignettes displaying common problems arising in clinical practice. Learning needs were categorized into six areas and were determined through analyzing rates of met and unmet expectations displayed in the written reviews. Findings showed that years of experience differed in those meeting or failing to meet expectations (p<0.0004), those with the least experience had the highest rate of not meeting expectations, while those with the most experience had the lowest rate (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2008, p. 144). These findings indicate a need for educational techniques that better prepare student nurses for clinical practice, where specific skill sets requiring critical thinking and reasoning can be developed in safe settings. Simulation and New-nurse Competence In order to address issues of education and new-nurse competence, some training initiatives have specifically focused on simulation. In an attempt to help new graduates transition competently to the work place, Bricker and Pardee (2011) developed and implemented a high-fidelity simulation program. The program was designed by expert nurses specifically in order to address concerns regarding patient safety, and focused on possible complications arising in response to a rare form of spinal cord surgery. Bricker and Pardee (2011) report, new

11 SIMULATION EXPERIENCE 11 graduate nurses were overwhelmingly positive in the post-simulation debriefing, reporting increased confidence and knowledge necessary to care for these patients (p. 34). Also assessing the effectiveness of simulation in nursing education, Hayden, Smiley, Alexander, Kardong-Edgren, and Jeffries (2014) examined findings from the The National Council of State Board of Nursing (NCSBN) National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. The NCSBN study is the largest and most comprehensive examination of simulation-based learning for nursing students. It included 666 incoming nursing students, from ten prelicensure programs. The study followed these nurses from fall semester 2011, beginning with their first clinical nursing course, through their graduation in May The students were randomized into three study groups including a control group where students completed traditional clinical work, in which up to 10% of clinical time was allowed in simulation, students who completed 25% simulation in place of traditional clinical hours, and students who completed 50% simulation in place of traditional clinical hours. The students were assessed on their clinical competencies and nursing knowledge. Hayden, Smiley, Alexander, Kardong- Edgren, and Jeffries (2014) concluded that substituting up to 50% of traditional clinical hours for high quality healthcare simulation was acceptable in all core courses and did not affect National Council Licensure Examination (NCLEX) pass rates. Student s clinical practice was assessed at six weeks, three months, and six months with no differences found between groups critical thinking, clinical competency, and overall readiness for practice (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014).

12 SIMULATION EXPERIENCE 12 Multiple-Patient Simulation for Student Nurses While traditional simulation-based education focuses on single-patient scenarios, some nursing programs have begun experimenting with multiple-patient simulation. In their 2009 study, Ironside, Jeffries, and Martin looked specifically at the relationship between nursing students patient safety competencies and participation in multiple-patient simulation exercises. In this multi-site study, students were required to care for four patients in similarly complex health conditions. This multiple-patient exercise was conducted between the third and fourth weeks and again between the ninth and tenth weeks of the final semester of school. In this study, Ironside, Jeffries, and Martin (2009) found significant differences in the implementation of the patient safety competencies from week three to week 10, p < (p. 336), indicating that students who experience simulations of multiple-patient assignments are more likely to have better patient safety competencies. In addition, findings concerning several multiple-patient simulation projects have been published which examine the relationship between participation in such simulations and student nurses ability to safely and effectively prioritize, delegate, implement care, and transition to clinical practice. Specifically, Kaplan and Ura (2010) developed a simulation-based learning experience using three patient simulators for a multiple-patient simulation scenario. Participants included 97 senior nursing students in their final semester of a university-affiliated nursing school. The goal for the development of this simulation-based learning experience was to help transition students to being novice staff nurses. Kaplan and Ura (2010) asserted that the multiple-patient simulation experience was successful because self-reported confidence in both prioritizing and working in teams was increased, as well as understanding about how to prioritize and delegate care (p. 375).

13 SIMULATION EXPERIENCE 13 In a similar attempt to help students transition to clinical practice, Chunta and Edwards (2013) developed a multiple-patient scenario involving three realistic simulators for 10 senior nursing students. Chunta and Edwards (2013) explain the logic driving their project, asserting that the use of a multiple-patient simulation assignment provided a realistic experience that mimicked expectations and responsibilities of new graduates, thus bridging the gap as students transition into practice (p. e496). The research of Josephsen and Butt (2014) corroborate the findings of both Chunta and Edwards (2013) and Kaplan and Ura (2010) with their virtual multipatient simulation project. The aim of their project was to aid nursing students to develop skills allowing them to integrate, prioritize, delegate, and collaborate (Josephsen & Butt, 2014). In the project, students reviewed three author created electronic health records and viewed and debriefed a video of a multi-patient simulation. The students were then asked to identify from the video what the RN did well, what they would change and why, and how they would make that change. The researchers were concerned with whether students could distinguish Quality and Safety Education for Nurses (QSEN); competencies related to patient-centered care. They were also trying to identify patient safety, teamwork, and collaboration through observation of the video. Results of the project indicated that student nurses responded positively to participation in multiple-patient simulation (Josephsen & Butt, 2014). Although findings concerning multiple-patient simulation for student nurses are relatively limited, existing evidence establishes this as a beneficial practice, with potential positive affects for the safety and quality of care and the confidence and skills of new nurses. Theoretical Framework Benner s (1982), From Novice to Expert theory provided the framework for this project. In the article, From Novice to Expert first published in the American Journal of

14 SIMULATION EXPERIENCE 14 Nursing in 1982, Benner introduces her model, derived from the Dreyfus Model of Skill Acquisition. In the article, Benner (1982) explains how nurses move through five stages of development: novice, advanced beginner, competent, proficient, and expert. According to Benner (1982), novice nurses have no experience with the situations in which they are expected to perform tasks. In order to give them entry to these situations, they are taught about them in terms of objective attributes. These attributes are features of the task that can be recognized without situational experience (Benner, 1982, p. 403). On the other hand, the advanced beginner is able to show acceptable performance because of previous experiences needed for recognition (Benner, 1982). Nurses then become competent after working for two to three years (Benner, 1982). At this time, they have mastered certain skills and have the ability to manage situations in a clinical setting (Benner, 1982). In the proficient stage, nurses can see clinical conditions as a whole and as a result of previous experience, know what to expect in a variety of situations (Benner, 1982). In addition, nurses at this stage develop flexibility, and an ability to respond when things do not go according to plan, thus strengthening their decision making skills (Benner, 1982). Finally, Benner (1982) describes the expert nurse as one who because of, her/his enormous background of experience, has the intuitive grasp of the situation and zeros in on the accurate region of the problem without wasteful consideration of a larger range of unfruitful possible problem situations (p. 405). Benner s From Novice to Expert theory was appropriate for this project because nursing students are novice, having no experience with the situations in which they are expected to perform tasks (Benner, 1982, p.403), in this case, no experience of caring for multiple patients concurrently before beginning as clinical nurses. Offering students a multiplepatient simulation experience to learn from in a safe simulation lab may help them show

15 SIMULATION EXPERIENCE 15 acceptable performance because of previous experiences needed for recognition (Benner, 1982). In other words, help them move through Benner s five stages, from novice to advanced beginner, thus ensuring the safety and quality of health care for their patients once they enter the professional arena. Implementation Objective 1 Multiple-patient simulation scenarios were developed involving three patients with illnesses typically cared for on a medical-surgical floor. These included a patient with diabetic ketoacidosis (DKA), a postoperative partial gastrectomy patient, and a patient with chronic obstructive pulmonary disease (COPD). For reference and to help ensure that the objectives for each scenario were met, an overview was written about each patient. The overview included the patients name, diagnosis, age, gender, background, and simulation focus. Each scenario had two parts, or states. The states defined how the patient was responding, vital signs, lab work, what the students should be focused on, and the physician orders (Appendix A). Patient charts were developed for each patient (Appendix B), laminated, and placed in binders with tabbed dividers. BYU s simulation lab computerized medication cart was programed for the medications that were given during the simulation experience. A drug and supply list was compiled for BYU s simulation lab (Appendix C). Prior to participation in the multiple-patient simulation experience, students were required to complete an assignment on DKA, postoperative partial gastrectomy, and COPD. This assignment, key, and breakdown of points was designed and given to the simulation instructor (Appendix D). Additionally, to help the students be prepared for the multiple-patient simulation experience, days prior to participation, they received an overview of the scenarios

16 SIMULATION EXPERIENCE 16 (Appendix E). The recruitment script was read to the students in their medical-surgical class on November 11, 2014 and each student was given a copy of the consent form, including the principal investigators contact information for any questions or concerns (Appendix F). The pre and post-questionnaires were written to determine the students perceptions of their cognitive and affective skills before and after the multiple-patient simulation experience. These were administered in order to determine the learning experienced as a result of the multiple-patient simulation (Appendix G). Institutional Review Board (IRB) applications were submitted to both the University of Utah (U of U) and to BYU in order to obtain approval for the pre and post-questionnaires which students completed before and after participation in the pilot program of the multiple-patient simulation experience. U of U and BYU signed a letter of agreement determining that BYU would assume responsibility for the IRB review (Appendix J). IRB exempt approval was obtained from BYU (Appendix I). Objective 2 Upon BYU s IRB approval, the multiple-patient simulation pilot program was administered to BYU Baccalaureate CON students in their recent remodeled and expanded Mary Jane Rawlinson Geertsen Nursing Learning Center simulation lab. Participants of the multiplepatient simulation pilot were third year nursing students. The pilot was the fifth and final simulation of their medical-surgical rotation and was the only multiple-patient simulation administered. All 52 students in the medical-surgical rotation were required to participate in the multiple-patient simulation experience. However, it was explained in the recruitment script that participation in the pre and post-questionnaires was voluntary. The questionnaires consisted of 12 questions using a Likert scale, three affective questions and nine questions focused on the

17 SIMULATION EXPERIENCE 17 cognitive objectives of the scenarios, three objectives for each scenario. The post-questionnaire had an additional open-ended question asking for suggestions on improving the multiple-patient simulation experience. The questionnaires were completed anonymously. The pilot program was administered on November 21 st, November 25 th, and December 4 th, All 52 students signed the consent form and completed the pre-questionnaire at the beginning of the pre-briefing session. The students were divided into seven groups and then divided again over three designated days; eight students per group, with two groups having six students. Within each group, two students acted as assessment nurses, two students acted as medication nurses, one student acted as the recorder and three students observed video/audio in a separate room. These observing students were responsible for filling out observer forms focusing on prioritization, delegation, teamwork, and communication, in order to fulfill the objectives of the multiple-patient simulation. Halfway through the simulation, the assessment nurses, medication nurses, and recording nurse gave a five minute handoff report to the three observers and switched roles. Each multiple-patient simulation experience took two hours to complete. The time was broken down as follows: 15 minutes for an introduction to the multiple-patient simulation experience, signing the consent, and completing the pre-questionnaire; 15 minutes for a DKA lecture (the students had previous simulation scenarios of a patient with pneumonia, a patient who was post-op with a colostomy, and a patient who had psychosocial issues); five minutes for a bedside report of all three patients; 25 minutes for the first group to complete state one; five minutes for the first group to give a handoff report to the second group; 25 minutes for the second group to complete state two; then 30 minutes for debriefing and completion of the postquestionnaire. The purpose of the debriefing exercise was to give the students input on their

18 SIMULATION EXPERIENCE 18 performance, which included pointing out what went well and what could have been improved on or done differently. Objective 3 Information from the questionnaires was carefully reviewed, analyzed, and compiled. Once this information was organized, the findings were disseminated to the Baccalaureate faculty at BYU on January 12, Information disseminated covered development of the multiple-patient simulation scenario, the simulation experience, the debriefing experience, and analysis of pre and post-questionnaires. Recommendations to implement multiple-patient simulations into their future curriculum were made. It was recommended that implementation apply to not only their medical-surgical student rotations, but also all rotations that include simulation. Recommendations also included building upon single patient simulation, by increasing to two patient simulation and then multiple-patient simulations of three or four patients. BYU has indicated they are implementing multiple-patient simulation into their curriculum and are running the program again early April The scholarly project, Improving Care Delivery to Patients Through Multiple-Patient Simulation Experience, was presented on March 11, 2015 at Utah Valley Universities 5 th annual Nursing Research conference (Appendix M). The 45-minute presentation consisted of an overview of simulation in nursing education, development of the multiple-patient simulation project including the three medical-surgical patients, administration of the pilot program, pre and post-questionnaire findings, and recommendation to implement multiple-patient simulations into Colleges of Nursing curricula. Additionally, manuscript submission for publication in the research brief section of NLN s research journal, Nursing Education Perspectives, special issue

19 SIMULATION EXPERIENCE 19 on the use of simulation in nursing education for September-October 2015, was made on April 1, Table 1 Implementation and Evaluation Summary Objective Implementation Evaluation Developed Multiple-patient Simulation Scenarios (MPSS) Developed outline of MPSS 3 medical/surgical patients 10/08/14 IRB Application submitted to U of U & BYU 10/10/2014 Completed development of the MPSS, including pre & post-questionnaires 11/14/2014 Outline of MPSS approved by content experts IRB approved MPSS approved by content experts Administered MPSS to BYU Baccalaureate nursing students, included pre & post-questionnaires Administered Pilot MPSS at BYU 12/04/14 Participants completed pre & post-questionnaires 12/04/14 MPSS included debriefing, for students to receive feedback 12/04/14 MPSS pilot administered Pre & post-questionnaire completed Students debriefed Disseminated findings of MPSS experience to BYU faculty & offered recommendations for future curriculum Disseminated findings of MPSS experience to BYU faculty 01/12/15 Offered recommendations regarding incorporation into curriculum 01/12/15 Findings presented to BYU faculty Recommendations offered for incorporation to curriculum

20 SIMULATION EXPERIENCE 20 Evaluation Objective 1 After the multiple-patient simulation scenarios were developed, content experts reviewed the scenarios, giving input and suggestions for revision. Corrections and revisions were made to the scenarios, resubmitted to content experts, and then approved by content experts. Content experts also reviewed and approved the multiple-patient simulation scenarios quick notes, patient charts, student preparation worksheet/key, and overview of scenarios for students preparation. At the beginning of developing the multiple-patient simulation scenarios, the content experts gave recommendations on the three objectives for each scenario. They also reviewed and approved the pre and post-questionnaires before they were included in the IRB application. IRB exempt approval was obtained by BYU after applications were submitted to both U of U and to BYU. The two institutions then signed a letter of agreement determining that BYU would assume responsibility for the IRB review. Receiving IRB approval was a roadblock because of the requirement to apply to both IRB s. This requirement demanded extra coordination and communication between the two facilities. The time constraint was a potential dilemma as IRB approval was required in order to pilot the simulation that was scheduled to run from the end of November through the first part of December. The content expert from BYU wanted this multiple-patient simulation to be the final simulation of the semester. Fortunately, IRB approval was obtained in time to pilot the simulation as planned. Objective 2

21 SIMULATION EXPERIENCE 21 One of the content experts observed the first group of students to pilot the multiplepatient simulation program and made suggestions. Adjustments were made as indicated by the content expert and applied to all groups thereafter. The postoperative partial gastrectomy scenario was initially written so that during state one, student nurses delegated a social worker to consult with the patient and during state two, a decision of which PRN pain medication to give was identified and administered. However, after the first group completed the simulation, it was apparent that all medications were given during state two of the simulation, making the tasks disproportionate between students. The sequence of events was consequently adjusted requiring a pain medication be given during state one and social worker consultation occurring during state two for the postoperative partial gastrectomy patient. This change made the simulation run more smoothly and more evenly distributed the tasks between the two groups in each simulation. In addition, the audio equipment did not work as well during one of the simulations, so the simulation technicians could not hear the students. However, the issue was quickly identified and corrected. Objective 3 Presentation for disseminating the findings of the multiple-patient simulation experience to the Baccalaureate faculty at BYU was scheduled for January 12, This included information on development of the multiple-patient simulation scenario, the simulation experience, the debriefing experience, and the analysis of the pre and post-questionnaires. Recommendations to implement multiple-patient simulations into their future curriculum were made, not only as applicable to medical-surgical student rotations, but to all CON student simulation exercises. Recommendations also included building upon single patient simulation,

22 SIMULATION EXPERIENCE 22 by increasing to two patient simulation and then multiple-patient simulation of three or four patients. Results Results from the pre and post-questionnaires demonstrated that following their participation in the simulation experience, students experienced increased motivation, feelings of positivity and knowledge of content. Using a 5-point Likert scale, differences between the means for the pre and post-questionnaire answers were calculated for each statement. Scores for each category improved from the pre to the post-questionnaire. Table 2 Pre and Post Module Questionnaire Likert Scale Items 5-Point Scale Legend: 1=Strongly Disagree 2=Disagree 3=Neither Disagree/Nor Agree 4=Agree 5=Strongly Agree Attitudes and Motivation Pre-questionnaire N=52 Post-questionnaire N=52 Difference I am interested in the content of this multiple-patient simulation experience. I think the material in this multiple-patient simulation experience is useful for me to learn. I will be able to use what I learn in this multiple-patient simulation experience in clinical practice. Knowledge of Content Areas I am able to recognize the symptoms of diabetic ketoacidosis (DKA). I am able to design a plan of care for the nursing management of a patient in DKA. I am able to modify nursing care as appropriate for a patient in DKA. I am able to identify abnormal assessment findings in a postoperative gastrectomy

23 SIMULATION EXPERIENCE 23 patient. I am able to discuss the significance of abnormal assessment findings in a postoperative gastrectomy patient. I am able to identify nursing strategies to enhance patient coping in a postoperative gastrectomy patient. I am able to recognize signs of deterioration in respiratory status in a patient with chronic obstructive pulmonary disease (COPD). I am able to demonstrate the ability to provide respiratory support in a patient with COPD. I am able to recognize the need for further intervention in a patient with COPD The post-questionnaire open-ended question was completed by 47 of 52 students (Appendix H). Consequent suggestions and comments were placed into six categories according to the frequency with which a given response appeared. Overwhelmingly, the most frequent response was students wanted to have the opportunity to do more multiple-patient simulations, accompanied by assertions that it was a positive learning experience. Typical comments were: Loved it! ; Closer to real life ; More realistic to hospital setting ; Helps me critically think and practice prioritizing ; Want to have this experience as an individual ; Do more frequently ; Great idea ; Great learning experience ; Enjoyed it ; Fun ; Awesome! ; Learned so much ; I vote multi-patient simulation every week ; and Thank you!. The second most frequently appearing comment was that students preferred working in smaller groups or individually in order to allow each individual more responsibility, experience, and accountability. Third, students desired more time to go through the multiple-patient simulation. Fourth, students stated that during the pre-briefing cleared expectations were needed. Fifth, students suggested that clocks should be placed in patient rooms. Sixth, suggestions were made

24 SIMULATION EXPERIENCE 24 concerning logistics of the multiple-patient simulation, such as placing patients in separate rooms rather than in one room. However, it should be noted that the simulation was originally set up with patients sharing rooms in order to allow for restraints of the audio video equipment. Recommendations Following are recommendations for future development of multiple-patient simulations, addressing both future DNP students who may wish to build on this project and CON that decide to implement or continue with multiple-patient simulations. Data drawn from the postquestionnaire should be strongly considered, with particular attention paid to student s overwhelming request for more multiple-patient simulations. This could be implemented by degrees that accurately reflect where students are in their knowledge and training so that every semester students are required to participate in simulations, there would be a concurrently progressive development of knowledge and skills. For example, at the beginning of a semester, simulations could involve one patient, as the students are learning new material in new clinical settings. The simulations could then build on each other by increasing from a one patient scenario, to a two patient scenario, and then to a three patient scenario for the semester s final simulation. Another consideration would be decreasing the number of students who are going through the multiple-patient simulation at a time. Logistically, it may not be possible for each student to individually participate in a multiple-patient simulation because of time constraints, space constraints, and faculty availability. However, it would be advantageous to pair students with as few fellow students as possible, in order for them to have a more realistic clinical experience and feel more responsibility and accountability when caring for multiple patients at a

25 SIMULATION EXPERIENCE 25 time. Thus, the simulation experience would more accurately depict the clinical settings students would encounter as a new graduate. Another aspect of the multiple-patient simulation would be to develop a rubric for the simulation experience. All students who were enrolled in the simulation course were required to participate in the simulation and received a pass grade for the multiple-patient simulation. However, for future development of multiple-patient simulations, a standardized grading tool would help increase student accountability for learning the content of the simulation. An example of a grading scale could include student recognition of specific findings identified in the objectives, which if not recognized would result in a score of zero. On the other hand, if objectives were met, students would receive one point for each objective. Furthermore, if they were able to acknowledge the meaning of a specific finding identified in the objective, they would receive two points. The rubric could include a grading scale for all identified objectives. In this project, the multiple-patient simulation identified three knowledge of content objectives for each scenario of student learning, totaling nine objectives. Limitations Following completion, pre-questionnaires were gathered and placed in an envelope. The same procedure was followed for post-questionnaires. If the pre and post-questionnaires had been connected to each other, or in other words paired in such a way as to still assure student confidentiality, results could have been analyzed to more easily determine statistical significance. DNP Essentials Having the BYU CON organization of faculty and students involved in the pilot offered insights into competencies essential for today s healthcare professionals. Providing

26 SIMULATION EXPERIENCE 26 opportunities for student nurses that are more realistic to clinical setting helps them prepare for entering the workforce where they will care for multiple-patients at a time. The multiple-patient simulation project met these topics, which are crucial components of the American Association of Colleges of Nursing (AACN) (2006), Essentials of Doctorial Education for Advanced Nursing Practice. In addition, ensuring accountability for improving care delivery, promoting patient safety, and excellence in practice are all included in DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking (AACN, 2006). The focus of this project was to improve care delivery by offering students an experience that is closely related to the clinical settings they will practice in. Providing future professionals with opportunities to collaborate and work together establishes high functioning teams. This relates to DNP Essentials VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes (AACN, 2006). Through the multiple-patient simulation experience students were given an opportunity to work in teams, which helped them to have a successful experience. Conclusions Results from the multiple-patient simulation pilot confirmed it to be an effective learning experience, exemplified by the higher group means in all areas of knowledge as reported on postquestionnaires. Improved scores were underlined by a reported increase in positive attitudes and motivation. In addition, student feedback was overwhelmingly positive and enthusiastic, including their responses during the debriefing exercise following each simulation and their written responses to the open-ended question. Specifically, students expressed that they thought the multiple-patient simulation experience to be beneficial to their learning, helping them to critically think and was a more realistic representation of clinical setting.

27 SIMULATION EXPERIENCE 27 The positive effects of the simulation project and the results of the post-questionnaire bare out and substantiate the findings of the NCSBN s National Simulation Study (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014), asserting the positive effects on nursing education with substitution of up to 50% of traditional clinical hours for high quality simulation. Furthermore, inclusion of multiple-patient simulation in nursing curricula address concerns asserted by the IOM regarding national health care quality and safety. Indeed, the IOM (1999, 2001, and 2003) and the National League of Nursing (2003) have indicated that all disciplines involved in health care need to take an active role in improving care delivery and guaranteeing patient safety; including educators of future health care workers. While, lessening availability of clinical sites for educating future health care workers is of growing concern and may affect the ability to implement more simulation time into existing nursing education curricula, the benefits of increased simulation time, specifically multiple-patient simulation exercises, make any increased demands to the education system warranted and worthwhile. Overall, the students perceived the multiple-patient simulation experience to be a benefit to their education. This type of simulation experience may help to meet the concerns of the IOM and NLN to promote practices focused on patient safety and excellence. Developing, offering, and teaching methods that are more realistic to the clinical setting may result in an increase of effective student learning. Consequently, integrating such simulation experiences into curricula may improve care delivery and ensure patient safety once students enter the workforce.

28 SIMULATION EXPERIENCE 28 References American Association of Colleges of Nursing (AACN). (2006). The Essentials of Doctoral Education for Advance Nursing Practice. Retrieved from Benner, P. (1982). From novice to expert. American Journal of Nursing, Mar., Bland, A. J., Topping, A., Wood, B. (2011). A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Education Today, 31, doi: /j.nedt Brewer, E. P. (2011). Successful techniques for using human patient simulation in nursing education. Journal of Nursing Scholarship, 43(3), Bricker, D. J., & Pardee, C. J. (2011). Nurse experts jump-start clinical simulation in rehabilitation nursing: Supporting new graduate transition to competence. Nursing Education Perspective, 32(1), Chunta, K., & Edwards, T. (2013). Multiple-patient simulation to transition students to clinical practice. Clinical Simulation in Nursing, 9(11), e491-e496. doi.org/ /j.ecns Fero, L. J., Witsberger, C. M., Wesmiller, S. W., Zullo, T. G., & Hoffman, L. A. (2008). Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nurses, 65(1), doi: /j x Kaminski, June. (2014). Nursing-informatics.com a professional development initiative. Retrieved October 3, 2014, from Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., Jeffries, P. R. (2014). The

29 SIMULATION EXPERIENCE 29 NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), Institute of Medicine (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press Institute of Medicine (2001). Report brief: Crossing the quality chasm: The new health system for the 21st century. Retrieved from Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx. Institute of Medicine (1999). Report brief: To err is human: Building a safer health system. Retrieved from Health-System.aspx Ironside, P. M., Jeffries, P. R., & Martin, A. (2009). Fostering patient safety competencies using multiple-patient simulation experiences. Nurs Outlook, 57(6), doi: /j.outlook Josephsen, J., & Butt, A. (2014). Virtual multipatient simulation: a case study. Clinical Simulation in Nursing, 10(5), e235-e240. doi.org/ /j.ecns Kaplan, B., & Ura, D. (2010). Use of multiple patient simulators to enhance prioritizing and delegating skills for senior nursing students. J Nurs Educ, 49(7), doi: / Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207-e222. doi: /j.ecns

30 SIMULATION EXPERIENCE 30 National League for Nursing. (2003). Innovation in nursing education: A call to reform. Position Statement Yuan, H. B., Williams, B. A., Fang, J. B., & Ye, Q. H. (2012). A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation. Nurse Education Today 32, doi: /j.nedt

31 SIMULATION EXPERIENCE 31 Appendix A Multiple-patient Simulation Scenarios Quick Notes Keegan Sugamoto DKA, 40 y.o. Male. DOB: 5/14/ 19xx, Married, Wt 75 kg Date: 11/ Background: This patient is a 40-year-old male in DKA secondary to an infectious process. The patient is a type 1 diabetic, who due to prolonged vomiting and anorexia stopped his insulin administration two days ago. He is tachycardic and hypotensive. Diagnosed 1 year ago. Direct admit to the Medical-Surgical Unit. Simulation Focus: Lab interpretation--fluid and electrolyte imbalance K+ Insulin administration State Use DKA from Med- Surg State #1 Admission to 0700 hours Patient is confused and agitated. Answering questions improperly *make sure there are stickers for urine output and skin *change urine output sticker to 40mL/hr dark yellow and hazy after student leave room Event HR=130 BP 82/46 RR=32 SpO2=92% on 2L/NC Temp=38.5C Weight=75 kg Tachycardia Urine 30mL/hr dark yellow, hazy Acetone Breath Skin Flush and Dry Lab results: CBC: WBC 14.2, Hgb 18 Hct 55%, platelets 250 Chemistry: Na 129, K 3.2, Cl 93, CO2 11, capillary glucose 462, Creatinine 1.8, BUN 66, Ca 8.3, PO4 3.2 Mg 1.5, Anion Gap 25 ABG: ph 7.20, PaCO2 25, Pa02 94, HC03 11, SpO2 94% UA: ph 5.0, specific gravity 1.030, Protein 4, Glucose 4+, Ketones Large, Blood Neg, WBC 6-10 Chest x-ray: Negative ECG: Sinus Tachycardia Student Behavior Reviews MD orders Completes focused assessment (no more than 5 minutes) Review labs, and x- ray results Notifies MD of initial labs and x-rays and requests potassium and insulin Hangs IV #2 at 500 ml/hr

32 SIMULATION EXPERIENCE 32 Healthcare Provider s Orders: IV #2: Change IV to NS with 20 meq KCL at rate of 500 ml/hr Order serum glucose Stat and call with results for insulin order Repeat Chem panel in 2 hours. State #2 Change Patient is still confused but less agitated. Lab personnel calls with glucose results 540 After students initiate insulin change simulator to state 3 HR=128 BP=90/50 RR=30 SpO2=95% Temp: 38.4C Tachycardia Urine Output=40 ml/hr dark yellow, hazy Quick focused assessment Notifies MD of Serum Glucose Administers bolus of Humulin Regular insulin at 0.15 units/kg IV (0.15 X 75 =11 units) in port closest to patient retrieves second pump and begins continuous Humulin regular insulin infusion at 0.1 units/kg/hour IV (7.5 ml/hr). Healthcare Provider s Orders: IV bolus of regular insulin at 0.15 units/kg stat Start a continuous regular insulin infusion of 250 units of humulin regular insulin in 250 ml 0.9% NS at 0.1 units/kg/hour IV Repeat a CBC and Chem panel at Call with results Hand-Off Report Keegan Sugamoto is a 40-year-old male directly admitted to the Medical-Surgical Unit after his wife found him confused and agitated in their apartment. According to his wife, he has had the flu for 5 days, with nausea, vomiting, and anorexia. He stopped taking his insulin 2 days ago when he was unable to eat. Prior to being admitted, he was seen in his healthcare provider s office where he was hypotensive, tachycardic and confused. The provider sent the patient and his wife to the hospital where he was admitted directly to the Medical-Surgical Unit with a diagnosis of diabetic ketoacidosis. A peripheral IV was inserted into his right arm and an IV of 0.9% NS was initiated at 1,000 ml/hr. Has Saline Lock in left arm. A urinary catheter was inserted. Current output is 30 ml dark cloudy urine. Stat labs have been drawn with results pending. A capillary glucose showed blood sugar at 462. A portable chest x-ray was negative and ECG results show sinus tachycardia. VS: HR-130, BP-82/46, RR-32, Kussmauls respiratory pattern is present, NC at 2 LPM, SpO2-92%, breath sounds clear, BS active. Skin is warm and dry. Patient is confused and agitated. Wife has left to take children to school.

33 SIMULATION EXPERIENCE 33 Russell Husk COPD Exacerbation 67 y.o. Male. DOB: 1/19/1947 Date: 11/ Background: This patient is a 67 year old 2 pack/day smoker with a hx of COPD who states that he started feeling short of breath yesterday when the air conditioning at his house broke down. He continued to experience shortness of breath all night and was unable to sleep because of the difficulty breathing and began gasping for air. His chest feels tight like his previous COPD exacerbation but denies chest pain. No fever, but increased cough since the event started without production. Russell called 911 and was transported to the hospital via ambulance. He received one Albuterol treatment en route to the hospital. Admitted to the Medical-Surgical unit through the ED Simulation Focus: Assess patient s home oxygen use Apply oxygen via N/C Recognize deteriorating respiratory status Arrange for Nebulizer tx State Event Student Behavior State #1 Patient Stable HR=107 BP=175/92 Reviews MD orders Completes focused RR= 40 and labored assessment (no more SpO2 86% RA than 5 minutes) Temp=37.3C Recognizes need to Weight=79 kg place NC. Breath Sounds=bilateral wheezes, poor Assess patient 02 air movement bilaterally Patient states he is on 2L/NC of 02 at home. His air conditioning broke down and he has to wait for his retirement check before he can get it fixed. He started having problems breathing yesterday so he called the ambulance. The breathing treatment in the ambulance helped a lot. He knocked his NC off and can t find it. His normal sats at home are 94% on 2L Is it OK to smoke? Lab results: CBC: WBC 15.3, Hgb 12.1, Hct 43.7, platelets 267 Chemistry: Na 142, K 3.6, Cl 110, Glucose 110, BUN 20 ABG:pH 7.3, PaCO2 50, Pao2 58, HCO3 21, SpO2 86% RA Chest X-ray: Chronic lung changes. No evidence of infiltrations needs at home Initiates 2L/NC After students initiate oxygenation, change the 02 sats to 91% and RR to 32 State #2 Change Patient Changes RR=44 labored and pt is coughing Sp02= 88% on 2L/NC Breath Sounds=bilateral wheezes Students recognize patient changes Reviews MD orders

34 SIMULATION EXPERIENCE 34 *manually change the RR to 44 and decrease 02 to 88% Patient is wheezing and coughing and asks for another treatment for Nebulizer TX Calls RT for breathing tx Follows up with patient After RT arrives, change the O2 sats to 90% and decrease RR to 32 Hand-Off Report Russell Husk is a 67 year old man who states that he started feeling short of breath yesterday when the air conditioning at his house broke down. He continued to experience shortness of breath all night and was unable to sleep because of the difficulty breathing and began gasping for air. His chest feels tight like his previous COPD exacerbation but denies chest pain. No fever, but increased cough since the event started without production. Russell called 911 and was transported to the hospital via ambulance. He received one Albuterol treatment en route to the hospital that he reported made him feel a little better. He was admitted to the Medical- Surgical Unit for observation. Mr. Husk is a 2 pack/day smoker x 45 years and drinks 2-4 beers daily. A SL was inserted into his R arm. Labs have been drawn and a chest x-ray has been taken. Results are in his chart. VS: HR-107, BP 175/92, RR-40 and labored, SpO2 86% on RA, Temp 37.3C, breath sounds, bilateral wheezes with poor air exchange.

35 SIMULATION EXPERIENCE 35 Ann Cunningham Post-Gastrectomy day 2 76 y.o. Female. DOB: 7/13/1938 Date: 11/ Background: The patient is a 76 year-old female who is two days postoperative partial gastrectomy. Her diagnosis has been confirmed as gastric cancer. Her recovery has been unremarkable. She is exhibiting signs of depression because of her recent diagnosis. Simulation Focus: Recognize Patient depression Enlist help from the hospital social worker Evaluate pain scale State: Use post-op Gastrectomy from Assessment State 2 Patient is in 0800 Complaining of pain 6/10 Event HR=87 and irregular BP=145/85 RR=20 SpO2=94% on RA Temp=37.5C Cardiac=atrial fibrillation Breath Sounds=clear to bases Bowel Sound=absent Urine Output=70 ml/hr Lab Results: CBC: WBC 6.7, RBC 5.8, Hgb 12.8, Hct 41% Chemistry: Na 144, K 3.6, Cl, 107, Ca 10.2, Glucose 102, BUN 15 Student Behavior Completes focused assessment (no more than 5 minutes) Recognizes patient is in pain and assesses location, type, pain scale Determines which pain medication to give Administers medication using 5 rights. State 1 Patient stable and emotional Patient is tearful and agitated. States she wishes she could have died on the operating room table so that she didn t have to suffer and die. Afraid to go home and be all-alone. How is she going to get around? Who will take care of her? No changes in events Recognize patient psychosocial needs Recognize need delegate to social worker

36 SIMULATION EXPERIENCE 36 Hand-Off Communication Ann Cunningham is a 76 year-old female who is two days postoperative partial gastrectomy. Her diagnosis has been confirmed as gastric cancer. Her recovery has been unremarkable. Vital signs have been stable with HR in the 70s-110s, BP in the 100s to 140s-60s to 90s, RR in the mid-20s, SpO2 in the mid-90s and tem or 37.5C. Cardiac rhythm is atrial fibrillation and breath sounds are clear to the bases. Bowel sounds remain absent. There is an abdominal dressing with minimal serous sanguineous drainage. There is minimal dependent edema is present bilaterally in her lower legs. There is a Saline Lock in her right hand and she has bathroom privileges with assist. She has been concerned about her diagnosis and not having anyone at home to help take care of her.

37 SIMULATION EXPERIENCE 37 Appendix B Multiple-patient Simulation Patient Charts Last name Sugamoto First name Keegan Age 40 Gender Male Date of Birth5/14/XXXX Medical Record # Physician: Brent Olsen Allergies: Isolation: Ht: BSA: NKDA Admission Wt: 75 kg Service: Current Wt: 75 kg BMI: Admission Dx: Diabetic Ketoacidosis Principal Problem: Type I Diabetes Mellitus PATIENT PROFILE SUMMARY Patient Profile Summary Code Status Information Code Status X Full Limited None Treatment Team PROVIDER ROLE FROM TO Dr. Brent Olsen Admitting Provider Admit Discharge 11/21 Dr. Consulting Provider Hospitalization Problems Hypotension Vomiting Anorexia High capillary glucose Chronic Problem List Type I Diabetes Mellitus

38 SIMULATION EXPERIENCE 38 ACTIVE ORDERS Active Orders Orders to be Acknowledged for Sugamoto, Keegan New orders: Ordered at [Order 11/ ] Acknowledge all: Date/Time Description Ordering Provider 11/ Admit to Medical-Surgical unit Brent Olsen MD Continuous pulse oximetry Cardiac monitor Vital signs every hour for 6 hours, then vital signs every 2 hours Notify health care provider of any acute changes Activity: up as tolerated with assistance Oxygen via nasal cannula at 2L/min Maintain SpO2 >92% IV fluids: Normal saline 1 liter over 1 hour, then call healthcare provider for additional IV fluid orders Intake and Output every shift Insert and maintain urinary catheter Medications Order Description Dose Route Rate Freq Start Stop Dt/Tm 11/ Normal Saline STAT 1 L IV 1 hour Call after admin for additional orders Diet Orders 11/ calorie ADA Lab Orders 11/ STAT LABS: CBC, BMP, Phosphate, Magnesium, ABG, UA, urine culture and sensitivity, blood cultures X2 HOURLY LABS BMP every hour for 6 hours Imaging Orders 11/ Chest x-ray STAT 12-lead electrocardiogram STAT Other Orders 11/ Capillary blood sugar STAT Dipstick urine now and every shift

39 SIMULATION EXPERIENCE 39 MEDICATION ADMINISTRATION RECORD Medication Administration Record (Page 1 of1) Medications Date 11/21 Date 11/22 DRUG NS TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 1 L ROUTE IV FREQ once DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ

40 SIMULATION EXPERIENCE 40 DIABETIC SLIDING SCALE RECORD DO NOT USE SLIDING SCALE UNTIL ORDERED DATE/TI ME BLOOD SUGAR DIABETIC SLIDING SCALE RECORD INSULIN INJECTIO SLIDING N COVERAGE HOUR TYPE DOSE SITE NEEDED CARB GRAMS EATEN RN INIITIAL N N N N N N N N Y Y Y Y Y Y Y Y Y N SLIDING SCALE Insulin Sliding Scale Regular Insulin Aspart (Novolog) Blood Glucose (except Hs) Mild (Thin, NPO, or elderly) Moderate (avg. weight &eating) Aggressive (on steroids or infected) unit 3 units 4 units units 5 units 6 units units 7 units 10 units units 9 units 12 units units 11 units 15 units units 13 units 18 units > 400 Call MD Call MD Call MD

41 SIMULATION EXPERIENCE 41 Night Insulin Sliding Scale Regular Insulin Aspart (Novolog) Night (HS) Blood Glucose Night (HS) (do not use if on TPN/TF) NONE units units units units units > 400 Call MD

42 SIMULATION EXPERIENCE 42 VS/I & O DAY SHIFT Date: VS BP Pulse Resp Temp SaO2 Pain VS / I&O SUMMARY Time Intake PO IV Blood Other IVPB Tube Fdg TPN Lipids Breast Feed Total In Output Urine Emesis Drains Other Stool Ostomy Unmeasured Incontinent Blood CRRT Total Out

43 SIMULATION EXPERIENCE 43 HEMATOLOGY - LAB REPORT HEMATOLOGY DATE 11/21 DATE DATE RANGE TIME 0730 TIME TIME CBC RBC MCV MCH MCHC RDW HEMOGLOBIN g/dl HEMATOCRIT 55% % RETICULOCYTES WBC ,500 10,000 DIFFERENTIAL % NEUTROPHILS SEGS BANDS 0-5 EOSINOPHILS 0-3 BASOPHILS 1-3 LYMPHOCYTES MONOCYTES 2-6 PLATELETS , , 000 PT aptt INR 1.0 D-DIMER NEGATIVE

44 SIMULATION EXPERIENCE 44 CHEMISTRY - LAB REPORT CHEMISTRY DATE 11/21 DATE DATE RANGE TIME 0730 TIME TIME ALBUMIN g/dl ALT ALP AMMONIA µg/dl AMYLASE ANION GAP mEq/L AST 0-35 ANH BNH BUN BUN/CREATININE 10:1 20:1 RATIO CALCIUM mg/dl CHLORIDE meq/l CO² meq/l HDL >45 LDL <130 CPK 5-35 GLUCOSE GGT 3 23 IU/L IRON IRON-BINDING CAPACITY (TIBC) LACTIC ACID (venous) mmol/l LDH IU LIPASE IU/L MAGNESIUM meq/l OSMOLALITY PHOSPHATE mg/dl POTASSIUM meq/l PROTEIN 6 8 g/dl SODIUM meq/l TRIGLYCERIDES mg/dl URINE CREATININE ml/min CLEARANCE CREATININE g/day PROTEIN <150 mg/day

45 SIMULATION EXPERIENCE 45 SODIUM mea/day MICROBIOLOGY - LAB REPORT MICROBIOLOGY ANTIBIOTIC SUSCEPTIBILITY SENSITIVE INTERMEDIATE RESISTANT CULTURES BLOOD SPUTUM STOOL THROAT WOUND URINE OTHER : STOOL OCCULT BLOOD O & P DATE 11/21 DATE DATE RANGE TIME 0730 TIME TIME NO PATHOGEN NEGATIVE NEGATIVE URINALYSIS ph SG PROTEIN 4 NEGATIVE GLUCOSE 4+ NEGATIVE KETONES Large NEGATIVE OSMOLALITY RBC Negative 1-2 WBC

46 SIMULATION EXPERIENCE 46 ARTERIAL BLOOD GAS - LAB REPORT ARTERIAL BLOOD GAS DATE 11/21 DATE DATE TIME 0730 TIME TIME RANGE ABGs ph PaCO mm Hg Pao mm Hg HCO meq/l BE +2 to -2 meq/l Oxygen Saturation 94% RA 95-99

47 SIMULATION EXPERIENCE 47 IMAGING REPORT CHEST X-RAY Date/Time 11/ Findings Negative ELECTROCARDIOGRAPH Findings Sinus Tachycardia

48 SIMULATION EXPERIENCE 48 HISTORY & PHYSICAL DATE/TIME 11/ History & Physical Past Medical History: The patient was diagnosed with type 1 diabetes mellitus 12 months ago and suffered a broken collarbone at age 17 due to a sportsrelated accident Allergies: No known drug allergies Medications: NPH insulin 20 units plus regular insulin 12 units SUBCUT every morning before breakfast. Regular insulin 8 units SUBCUT every evening before dinner. NPH insulin 8 units subcutaneous every night at bedtime Code Status: Full code Social/Family History: He is a lawyer with a private law firm and is married with 2 school-age children. He denies tobacco or drug use and reports drinking 1 to 2 drinks a week Assessment: Vital signs: HR 133, BP 80/50, RR 26 and deep, SpO2 93% on room air, Temperature 38.5C General Appearance: Agitated. Appears stated age Cardiovascular: Sinus tachycardia Respiratory: Respirations deep. Breath sounds clear bilaterally GI: Abdomen soft. Bowel sounds normal GU: Incontinent of strong-smelling urine Extremities: Moves all extremities with generalized weakness Skin: Flushed and dry Neurological: Confused and restless. Oriented to person. Pupils equal, round, reactive to light and accommodation IVs: 20-gauge saline lock in the right arm, patent and non-reddened Labs: STAT labs (complete blood count, basic metabolic panel, phosphate, magnesium, arterial blood gases, urinalysis, urine culture and sensitivity, blood cultures X 2), chest x-ray and ECG were completed in the lab before arrival to the unit. Results should be available now. Fall Risk: High-risk Pain: Denies being in pain Recommendations: Admit to Medical-Surgical Unit. Perform a complete assessment and initiate fluid resuscitation upon admission.

49 SIMULATION EXPERIENCE 49 Last name Husk First name Russell Physician: Dr. Laura Rose Allergies: Isolation: NKDA Age 67 Ht: 5 ft 9 inches Gender Male Date of Birth 1/19/47 BSA: Medical Record # Admission Dx: COPD Service: Admission Wt: 68 KG Current Wt: 68 KG BMI: Principal Problem: COPD Hypertension PATIENT PROFILE SUMMARY Patient Profile Summary Code Status Information Code Status x Full Limited None Treatment Team PROVIDER ROLE FROM TO Dr. Laura Rose Admitting Provider Admit Discharge 11/21 Dr. Consulting Provider Hospitalization Problems COPD Exasperation Chronic Problem List COPD Hypertension

50 SIMULATION EXPERIENCE 50 ACTIVE ORDERS Active Orders Orders to be Acknowledged for (Husk, Russell) New orders: Ordered at [Order Dt/Tm] Acknowledge all: Date/Time Description Ordering Provider 11/ Admit to Medical-Surgical unit Laura Rose MD Continuous pulse oximetry Cardiac monitor Vital signs every hour for 6 hours, then vital signs every 2 hours Notify health care provider of any acute changes Activity: up as tolerated with assistance Oxygen via nasal cannula at 2L/min Maintain SpO2 >90% Intake and Output every shift Medications Order Description Dose Route Rate Freq Start Stop Dt/Tm 11/ Albuterol 3 mg Nebulizer Every 4 hrs 11/ Albuterol 3 mg Nebulizer Every 2 hrs PRN 11/ Atrovent 0.5 mg Nebulizer Every 4 hrs 11/ Norvasc 5 mg PO Every 24 hrs Diet Orders 2/ calorie ADA Lab Orders 11/ ABG Stat 11/ CBC 11/ BMP Imaging Orders 11/ CXR Respiratory Orders 11/ NC 2 LPM

51 SIMULATION EXPERIENCE 51 MEDICATION ADMINISTRATION RECORD Medication Administration Record (Page of ) Medications Date Date DRUG Albuterol TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 3 mg ROUTE Nebulizer FREQ once DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ DRUG TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT ROUTE FREQ

52 SIMULATION EXPERIENCE 52 VS/I & O DAY SHIFT Date: VS BP Pulse Resp Temp SaO2 Pain VS / I&O SUMMARY Time Intake PO IV Blood Other IVPB Tube Fdg TPN Lipids Breast Feed Total In Output Urine Emesis Drains Other Stool Ostomy Unmeasured Incontinent Blood CRRT Total Out

53 SIMULATION EXPERIENCE 53 HEMATOLOGY - LAB REPORT HEMATOLOGY DATE 11/21 DATE DATE RANGE TIME 0715 TIME TIME CBC RBC 4-6 MCV MCH MCHC RDW HEMOGLOBIN g/dl HEMATOCRIT % RETICULOCYTES WBC ,500 10,000 DIFFERENTIAL % NEUTROPHILS SEGS BANDS 0-5 EOSINOPHILS 0-3 BASOPHILS 1-3 LYMPHOCYTES MONOCYTES 2-6 PLATELETS , , 000 PT aptt INR 1.0 D-DIMER NEGATIVE

54 SIMULATION EXPERIENCE 54 CHEMISTRY - LAB REPORT CHEMISTRY DATE DATE DATE RANGE TIME TIME TIME ALBUMIN g/dl ALT ALP AMMONIA µg/dl AMYLASE AST 0-35 ANH BNH BILIRUBIN INDIRECT DIRECT TOTAL BUN BUN/CREATININE 10:1 20:1 RATIO CALCIUM 9 11 mg/dl CHLORIDE meq/l CHOLESTEROL <200 HDL >45 LDL <130 CPK 5-35 GLUCOSE GGT 3 23 IU/L IRON IRON-BINDING CAPACITY (TIBC) LACTIC ACID (venous) mmol/l LDH IU LIPASE IU/L MAGNESIUM meq/l OSMOLALITY POTASSIUM meq/l PROTEIN 6 8 g/dl SODIUM meq/l TRIGLYCERIDES mg/dl URINE CREATININE CLEARANCE ml/min

55 SIMULATION EXPERIENCE 55 CREATININE PROTEIN SODIUM DRUG MONITORING LEVELS THERAPEUTIC TOXIC g/day <150 mg/day mea/day MICROBIOLOGY - LAB REPORT MICROBIOLOGY ANTIBIOTIC SUSCEPTIBILITY SENSITIVE INTERMEDIATE RESISTANT CULTURES BLOOD SPUTUM STOOL THROAT WOUND URINE OTHER : STOOL OCCULT BLOOD O & P DATE DATE DATE RANGE TIME TIME TIME NO PATHOGEN NEGATIVE NEGATIVE URINALYSIS ph SG PROTEIN NEGATIVE GLUCOSE NEGATIVE KETONES NEGATIVE OSMOLALITY RBC 1-2 WBC 3-4

56 SIMULATION EXPERIENCE 56 ARTERIAL BLOOD GAS - LAB REPORT ARTERIAL BLOOD GAS DATE 11/21 DATE DATE TIME 0715 TIME TIME RANGE ABGs ph PaCO mm Hg Pao mm Hg HCO meq/l BE to -2 meq/l Oxygen Saturation

57 SIMULATION EXPERIENCE 57 IMAGING REPORT CHEST X-RAY Date/Time 11/ Findings Chronic lung changes. No evidence of infiltrations concerning for 11pneumonia.

58 SIMULATION EXPERIENCE 58 HISTORY & PHYSICAL DATE/TIME 11/21 07 History & Physical Past Medial History: Russell Husk is a 67 year old who has had COPD for the last years. He also has hypertension and is on medication for that. Allergies: No known drug allergies Medications: Norvasc 5 mg po every am Code Status: Full code Social History: Retired mechanic who lives alone. Smokes 2 PPD cigarettes and drinks 2-4 beers a day. Assessment: Vital Signs: T 37.3 HR 107 RR 40 BP 175/92 SpO2 86% on RA General Appearance - Anxious appearing, severely dyspneic, diaphoretic HEENT normocephalic and atraumatic, mouth open, head bobbing NECK - supple, +Jugular veins distended CHEST - wheezes bilaterally with poor air movement bilaterally CARDIAC - slightly tachycardic, no murmurs, rubs or gallops ABDOMEN - soft, non-tender, non-distended, + bowel sounds EXT - mild digital clubbing, good distal pulses NEURO - anxious but nonfocal IVs: 20-gauge saline lock in the right arm, patent and non-reddened Labs: complete blood count, basic metabolic panel, arterial blood gases, chest x- ray were completed in the lab before arrival to the unit. Results should be available now. Fall Risk: Low-risk Pain: Denies being in pain Recommendations: Admit to Medical-Surgical Unit. Perform a complete assessment and initiate O2 therapy and nebulizer treatments upon admission.

59 SIMULATION EXPERIENCE 59 Last name Cunningham First name Ann Age 76 Gender Female Date of Birth 7/13/1938 Physician: Dr. Dawn Claire Allergies: Isolation: Ht: BSA: NKDA Medical Record # Admission Dx: Suspected gastric Cancer Service: Admission Wt: 55 KG Current Wt: 51 KG BMI: Principal Problem: Dyspepsia and epigastric pain Weight loss fatigue PATIENT PROFILE SUMMARY Patient Profile Summary Code Status Information Code Status X Full Limited None Treatment Team PROVIDER ROLE FROM TO Dr. Dawn Claire Admitting Provider Admit Discharge 11/19 Dr. Consulting Provider Hospitalization Problems Cancerous lesion Weight loss Epigastric pain Chronic Problem List Chronic gastritis

60 SIMULATION EXPERIENCE 60 ACTIVE ORDERS Active Orders Orders to be Acknowledged for (Cunningham, Ann) New orders: Ordered at [Order 11/ ] Acknowledge all: Date/Time Description Ordering Provider 11/ Admit to Medical-Surgical unit Dawn Claire MD Status post partial gastrectomy Continuous pulse oximetry Cardiac monitor Vital signs every 4 hours Notify health care provider of any acute changes Activity: up as tolerated with assistance Oxygen via nasal cannula at 2L/min Maintain SpO2 >92% Intake and Output every shift Insert and maintain urinary catheter Saline lock Physical therapy for strengthening Incentive spirometer every hour while awake Medications Order dt/tm Description Dose Route Rate Freq Start Stop 11/ Heparin 5,000 units Subcut 1300 q day 11/ OxyCODONE 5 mg PO Q 4 hrs prn Pain 11/ Acetaminophen 325 mg PO Q 4 hrs prn Pain 11/ Morphine 2 mg IV Q 4 hrs prn severe pain 11/ Ondansetron 4 mg IV Q 8 hrs prn nausea Diet Orders 11/ Clear liquid 11/ Advance to full liquid as tolerated Lab Orders 11/ Ptt daily and notify MD of results Respiratory Orders 11/ NC 2 LPM Other Orders [Order [Enter order here] Dt/Tm]

61 SIMULATION EXPERIENCE 61 MEDICATION ADMINISTRATION RECORD Medication Administration Record (Page 1 of1) Medications Date 11/20 Date 11/21 DRUG Heparin TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 5,000 units 1300 lp ROUTE Subcut FREQ Q 24 hrs DRUG OxyCODONE TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 5 mg 1000 lp 0645 fr ROUTE PO 1630 lp FREQ Q 4 hrs prn Pain 2345 km DRUG Acetaminophen TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 325 mg ROUTE PO FREQ Q 4 hrs prn Pain DRUG Morphine TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 2 mg 1250 lp 0250 fr ROUTE IV FREQ Q 4 hrs prn severe pain DRUG Ondansetron TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL AMOUNT 4 mg 1730 lp ROUTE FREQ DRUG AMOUNT ROUTE FREQ DRUG AMOUNT ROUTE FREQ DRUG AMOUNT ROUTE FREQ IV Q 8 hrs prn nausea TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL

62 SIMULATION EXPERIENCE 62 VS/I & O DAY SHIFT Date: VS BP Pulse Resp Temp SaO2 Pain VS / I&O SUMMARY Time Intake PO IV Blood Other IVPB Tube Fdg TPN Lipids Breast Feed Total In Output Urine Emesis Drains Other Stool Ostomy Unmeasured Incontinent Blood CRRT Total Out

63 SIMULATION EXPERIENCE 63 HEMATOLOGY - LAB REPORT HEMATOLOGY DATE 11/20 TIME 6300 DATE DATE 11/21 TIME 0650 TIME RANGE CBC RBC MCV MCH MCHC RDW HEMOGLOBIN g/dl HEMATOCRIT % RETICULOCYTES WBC 6,700 4,500 10,000 DIFFERENTIAL % NEUTROPHILS SEGS BANDS 0-5 EOSINOPHILS 0-3 BASOPHILS 1-3 LYMPHOCYTES MONOCYTES 2-6 PLATELETS , , 000 PT aptt INR 1.0 D-DIMER NEGATIVE

64 SIMULATION EXPERIENCE 64 CHEMISTRY - LAB REPORT CHEMISTRY DATE DATE DATE RANGE TIME TIME TIME ALBUMIN g/dl ALT ALP AMMONIA µg/dl AMYLASE AST 0-35 ANH BNH BILIRUBIN INDIRECT DIRECT TOTAL BUN BUN/CREATININE 10:1 20:1 RATIO CALCIUM mg/dl CHLORIDE meq/l CHOLESTEROL <200 HDL >45 LDL <130 CPK 5-35 GLUCOSE GGT 3 23 IU/L IRON IRON-BINDING CAPACITY (TIBC) LACTIC ACID (venous) mmol/l LDH IU LIPASE IU/L MAGNESIUM meq/l OSMOLALITY POTASSIUM meq/l PROTEIN 6 8 g/dl SODIUM meq/l TRIGLYCERIDES mg/dl URINE CREATININE CLEARANCE ml/min

65 SIMULATION EXPERIENCE 65 CREATININE PROTEIN SODIUM DRUG MONITORING LEVELS THERAPEUTIC TOXIC g/day <150 mg/day mea/day MICROBIOLOGY - LAB REPORT MICROBIOLOGY ANTIBIOTIC SUSCEPTIBILITY SENSITIVE INTERMEDIATE RESISTANT CULTURES BLOOD SPUTUM STOOL THROAT WOUND URINE OTHER : STOOL OCCULT BLOOD O & P DATE DATE DATE RANGE TIME TIME TIME NO PATHOGEN NEGATIVE NEGATIVE URINALYSIS ph SG PROTEIN NEGATIVE GLUCOSE NEGATIVE KETONES NEGATIVE OSMOLALITY RBC 1-2 WBC 3-4

66 SIMULATION EXPERIENCE 66 HISTORY & PHYSICAL DATE/TIME 11/ History & Physical Past Medical history: Her diagnosis has been confirmed as gastric cancer. She has a history of chronic gastritis. She is exhibiting signs of depression because of her recent diagnosis. Allergies: No known drug allergies Code Status: Full code Social/Family History: Husband died several years ago. One child visits. Assessment: Vital Signs: HR 87 regular, BP 145/85, RR 20, SpO2 94%, Temperature 37.5C General Appearance: Teary and withdrawn. Appears stated age Cardiovascular: HR is regular. Respiratory: Breath sounds are clear GI: Bowel sounds absent GU: Voiding without difficulty Extremities: Bilateral dependent edema in lower legs. Movement is weak in all four extremities (3+) Skin: Warm, dry and pale. Abdominal dressing with moderate amount drainage Neurological: Alert and oriented to person, place and time. Pupils are equal, round and reactive to light and accommodation. No neurological deficits IVs: 20-gauge IV to saline lock in the right forearm, patent and non-reddened Fall Risk: High-risk Pain: 7 out of 10 Recommendations: Continue to monitor postoperative course and provide emotional support. Monitor Incision and dressing closely.

67 SIMULATION EXPERIENCE 67 COPD Medications: Appendix C Multiple-patient Simulation Drug and Supply List Albuterol 3 mg Nebulizer Every 4 hrs Albuterol 3 mg Nebulizer Every 2 hrs PRN Atrovent 0.5 mg Nebulizer Every 4 hrs Norvasc (Amlodipine) tablet 5 mg PO Every 24 hrs Solumedrol (Methylprednisolone) 40 mg IVP x 1 COPD Supplies: NC set up DKA Medications: Normal Saline STAT 1 L IV 1 hour Call after admin for additional orders Regular Humulin Insulin bolus 0.15 units/kg IV STAT Regular Humulin Insulin drip: 250 units per 250 ml of NS rate of 0.1 units/kg/hr IV K+ rider: Change IV to NS with 20 meq KCL rate 500 ml/hr DKA Supplies: NC set up Postop Gastrectomy Medications: Heparin 5,000 units Subcut 1300 q day Oxycodone capsule 5 mg PO Q 4 hrs prn Pain Acetaminophen tablet 325 mg PO Q 4 hrs prn Pain Morphine carpujet 2 mg IV Q 4 hrs prn severe pain Ondansetron 4 mg IV Q 8 hrs prn nausea Postop Gastrectomy Supplies: Soiled dressing Dressing Change Kit NC set up

68 SIMULATION EXPERIENCE 68 Appendix D Multiple-patient Simulation Preparation Worksheet/Key Diabetic Ketoacidosis (DKA): 1. Describe the pathophysiologic changes in DKA. Total 2 points a. Why do blood glucose levels increase? (must have 2) Absolute lack of insulin in the body Triggers liver to produce and release glucose Glucose continues to be released due to lack of insulin b. What fluid and electrolyte disturbances commonly occur? (must have 3) Hypovolemia Hyper>Hypokalemia Hypernatremia Hypochloremia c. What causes the fluid and electrolyte disturbances? (must have 3) K+ loss is caused by a shift of K+ from the intracellular to the extracellular space in exchange with hydrogen ions leading to acidosis In an attempt to stabilize the blood, kidneys attempt to rid the body of excess glucose Kidneys excrete glucose along with the water and electrolytes Electrolyte depletion occurs 2. Describe the medical management of a patient in DKA. Total 2 points a. How is fluid status monitored in the acute stage of DKA? (must have 3) VS I & O Lung sounds Skin Turger Hyperventilation b. How is hypovolemia corrected? (must have 2) Initial rehydration 0.9% NS 0.45% NS (usually with K+) Repeat IVF s to correct ketosis and acidosis and electrolyte shifts as well as dehydration 5% dextrose as BS reaches between 200 and 300 c. How are elevated blood glucose levels corrected? (must have both) Insulin Hydration

69 SIMULATION EXPERIENCE 69 d. How quickly is blood glucose corrected? Why? (must have both) Slowly over hours Care must be taken to avoid rebound, further electrolyte imbalances, cerebral edema or hypoglycemia 3. Describe the nursing management of a patient in DKA. Keep in mind the following: Total 1 point a. Fluid status (must have 2) Hydration Measure I & O VS, orthostatics, HR b. Blood glucose levels (must have 1) Monitor levels hourly Avoid rapid drop c. Electrolyte disturbances (must have 3) Monitor lab values Corrections of fluids based on lab values Frequent ECG monitoring Monitor LOC, edema, cardiac status Check dehydration 4. Regular Humulin Insulin: Total 2 points a. How is this drug administered? (must have both) May be administered SQ, bolus or IV drip. When IV drip, contents must be on a pump **with ml waste b. Describe how to set up an insulin drip, including priming the tubing. (must have all) Flush the insulin solution through the entire IV infusion set and discard the first ml of fluid c. Why is this drug being given to this patient? (must have explanation) Due to PT illness and lack of insulin injections. Pt has high blood glucose resulting in ketosis and acidosis. Insulin is needed to decrease high glucose levels and help adjust accompanying metabolic acidosis

70 SIMULATION EXPERIENCE 70 d. What are the possible side effects for this patient? (must have 2) Insulin allergy rebound hyper/hypoglycemia fluid related cerebral edema e. What should you assess about this patient after administration? (must have 3) Glucose levels every hour HgA1c UA s/s of hypo/hyperglycemia level of consciousness Chronic Obstructive Pulmonary Disease (COPD): 5. What are 2 main characteristics of COPD? Total 0.5 point (must have both) Bronchospasm Dyspnea 6. Describe the pathophysiology of COPD. Total 0.5 point (must have a description) COPD include emphysema and chronic bronchitis. The two major changes that occur with emphysema are loss of lung elasticity and hyperinflation of the lung. These changes result in dyspnea and the need for an increased respiratory rate. The hyperinflated lung flattens the diaphragm weakening the effect of this muscle. Bronchitis is an inflammation of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke. The irritant triggers inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. Chronic inflammation increases the number and size of mucous glands, which produce large amounts of thick mucous. 7. What is the greatest risk factor for developing COPD? Total 0.5 point (Must have smoking as answer) Smoking 8. Describe 4 complications of COPD. Total 0.5 point (must have all 4) Hypoxemia Acidosis Respiratory infection Cardiac failure 9. Name and describe 2 breathing techniques that are important to teach patients and their families to help manage dyspneic episodes. Total 1 point (must have both listed with some description for each)

71 SIMULATION EXPERIENCE 71 Diaphragmatic or Abdominal Breathing o If you can do so comfortably, lie on your back with your knees bent. If you cannot lie comfortably, perform this exercise while sitting in a chair. o Place your hands or a book on your abdomen to create resistance. o Begin breathing from your abdomen while keeping your chest still. You can tell if you are breathing correctly if our hands or the book rises and falls accordingly. Pursed-Lip Breathing o Close your mouth, and breathe in through your nose. o Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in. o Use your abdominal muscles to squeeze out every bit of air you can. o Remember to use pursed-lip breathing during any physical activity. Always inhale before beginning the activity and exhale while performing the activity. Never hold your breath. 10. Describe the purpose/action of the following medications for COPD: Total 1 point (must have description for each) Albuterol: Bronchodilator, Short-Acting Beta2 Agonist (ASBA) - Causes bronchodilation by relaxing bronchiolar smooth muscle through binding to and activating pulmonary beta2 receptors. Atrovent: Cholinergic Antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system, allowing the sympathetic system to dominate, releasing norepinephrine that activates beta2 receptors. Solumedrol: Corticosteroid Disrupts all known production pathways of inflammatory mediators. Postoperative Partial Gastrectomy: 11. What would the focused assessment of a postoperative partial gastrectomy patient include? Total 1 point (must have 4) o Patient tolerance of oral intake o Return of appetite o Assess for the presence of nausea or vomiting, flatus, abdominal distention (bloating, cramps) and abdominal firmness or tenderness upon palpation o Intake and output o First bowel movement o Pain 12. What are possible abnormal assessment findings for a postoperative gastrectomy patient? Total 0.5 point (must have 3) o Increased heart rate o Increased blood pressure o Absent bowel sounds

72 SIMULATION EXPERIENCE 72 o Atrial fibrillation o Lower leg pulses diminished o Emotional state 13. What should the nurse do if an abnormal finding has been assessed? Total 0.5 point (must have 2) o Document on the medical record o Notify the healthcare provider o Encourage incentive spirometer o Encourage verbalization of feelings 14. Describe the differences in drainage: Total 0.5 points (must have all) serous thin, yellowish serosanguinous thin, pink sanguinous thicker, red 15. What strategies could a nurse use to assist the patient to cope with a new diagnosis? Total 0.5 point (must have 2) o Empathetic active listening o Allow patient to talk and express feelings o Engage patient in exercise or activity o Referral to supportive services 16. Describe the stages of grief: Total 1 point (must have all 5 stages and one description of each stage) o Denial o Involves patient and/or family members o Shock o Unable to handle reality o Helps person survive loss o Protects from being overwhelmed o Anger o May occur once patient faces reality o Questions- Why? How? Now? o It is not fair! o Anger towards deceased, healthcare workers, oneself o Allow patient to talk and express feelings o Engage patient in exercise or activity o Don t keep it in o It won t last forever o Bargaining o The what if stage o Provides temporary escape and hope o Allows time to adjust to reality o Depression o Occurs when reality sinks in o Sadness, decreased sleep and decreased appetite are common

73 SIMULATION EXPERIENCE 73 o No sustained functional impairment o Rare to have suicidal thoughts o Normal after loss o Give patient time they need in this stage o Group discussion many help express their feelings o Acceptance o Accepting reality and the fact that nothing can change the reality o Does NOT mean patient is okay with the loss o Learning to move on o Final stage of healing

74 SIMULATION EXPERIENCE 74 Keegan Sugamoto Age: 40 Weight: 75 kg Location: Medical-Surgical Unit Appendix E Multiple-patient Scenarios Overview for Student Preparation Past Medical History: The patient was diagnosed with type 1 diabetes mellitus 12 months ago and suffered a broken collarbone at age 17 due to a sports-related accident Allergies: No known drug allergies Medications: NPH insulin 20 units plus regular insulin 12 units SUBCUT every morning before breakfast. Regular insulin 8 units SUBCUT every evening before dinner. NPH insulin 8 units subcutaneous every night at bedtime Code Status: Full code Social/Family History: He is a lawyer with a private law firm and is married with 2 schoolage children. He denies tobacco or drug use and reports drinking 1 to 2 drinks a week Handoff Report Situation: The patient is a 40-year-old male directly admitted to the Medical-Surgical Unit after his wife found him confused and agitated in their apartment. Prior to being admitted, he was seen in the healthcare provider s office where he was hypotensive and tachycardic. An intermittent peripheral lock was inserted in the right arm. A 250 ml bolus of normal saline was administered. Capillary glucose testing indicated results greater than 450 mg/dl. Orders were written to admit the patient directly to the Medical-Surgical Unit with an admitting diagnosis of diabetic ketoacidosis. According to his wife, he has had the flu for 5 days, with nausea, vomiting, and anorexia. He stopped taking his insulin 2 days ago when he was unable to eat. Russell Husk Age: 67 Weight: 79 kg Location: Medical-Surgical Unit Past Medical History: COPD, 3 previous intubations, Hypertension Allergies: No known allergies Medications: Albuterol, Atrovent, Norvasc Code Status: Full code Social/Family History: Smokes 2 PPD cigarettes and drinks 2-4 beers a day Handoff Report Situation: Russell Husk is a 67 year old man who states that he started feeling short of breath yesterday when the air conditioning at his house broke down. He continued to experience shortness of

75 SIMULATION EXPERIENCE 75 breath all night and was unable to sleep because of the difficulty breathing and began gasping for air. His chest feels tight like his previous COPD exacerbation but denies chest pain. No fever, but increased cough since the event started without production. Russell called 911 and was transported to the hospital via ambulance. He received one Albuterol treatment en route to the hospital. His chief complaint is that he cannot breath. Ann Cunningham Age: 76 Weight: 55 kg Location: Medical-Surgical Unit Past Medical History: Chronic gastritis Allergies: No known allergies Medications: Antacids Code Status: Full code Social/Family History: Husband died several years ago. Ann s one living daughter has been staying round the clock with her. Handoff Report Situation: The patient is a 76 year-old female who is two days postoperative partial gastrectomy. Her diagnosis has been confirmed as gastric cancer. She is exhibiting signs of depression because of her recent diagnosis.

76 SIMULATION EXPERIENCE 76 Appendix F Recruitment Script and Consent

77 SIMULATION EXPERIENCE 77

78 SIMULATION EXPERIENCE 78

79 SIMULATION EXPERIENCE 79

80 SIMULATION EXPERIENCE 80 Appendix G Pre and Post Questionnaires Pre Multiple-Patient Simulation Questionnaire We are interested in your view about multiple-patient simulation experience. There is no right or wrong answer. Please answer as accurately as you can. KEY: SD= Strongly Disagree D= Disagree NA/ND=Neither Disagree nor Agree A=Agree SA=Strongly Agree Pre Sim Lab Question/Statement Attitudes and Motivation 1 I am interested in the content of this multiple-patient simulation experience. 2 I think the material in this multiple-patient simulation experience is useful for me to learn. 3 I will be able to use what I learn in this multiple-patient simulation experience in clinical practice. Knowledge of Content Areas 4 I am able to recognize the symptoms of diabetic ketoacidosis (DKA). 5 I am able to design a plan of care for the nursing management of a patient in DKA. 6 I am able to modify nursing care as appropriate for a patient in DKA. 7 I am able to identify abnormal assessment findings in a postoperative gastrectomy patient. 8 I am able to discuss the significance of abnormal assessment findings in a postoperative gastrectomy patient. 9 I am able to identify nursing strategies to enhance patient coping in a postoperative gastrectomy patient. 10 I am able to recognize signs of deterioration in respiratory status in a patient with chronic obstructive pulmonary disease (COPD). 11 I am able to demonstrate the ability to provide respiratory support in a patient with chronic obstructive pulmonary disease (COPD). 12 I am able to recognize the need for further intervention in a patient with chronic obstructive pulmonary disease (COPD). Answer Type/Choices Circle Your Choice SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA

81 SIMULATION EXPERIENCE 81 Post Multiple-Patient Simulation Questionnaire We are interested in your view about multiple-patient simulation experience. There is no right or wrong answer. Please answer as accurately as you can. KEY: SD= Strongly Disagree D= Disagree NA/ND=Neither Disagree nor Agree A=Agree SA=Strongly Agree Post Sim Lab Question/Statement Attitudes and Motivation 1 As a result of completing this multiple-patient simulation experience, I have increased interest in learning more about multiple-patient simulation. 2 I think the material in this multiple-patient simulation experience is useful for me to learn. 3 As a result of completing this multiple-patient simulation experience, I will be able to use what I learn in this multiple-patient simulation experience in clinical practice. Knowledge and Content Areas 4 As a result of completing this multiple-patient simulation experience, I am able to recognize the symptoms of diabetic ketoacidosis (DKA). 5 As a result of completing this multiple-patient simulation experience, I am able to design a plan of care for the nursing management of a patient in DKA. 6 As a result of completing this multiple-patient simulation experience, I am able to modify nursing care as appropriate for a patient in DKA. 7 As a result of completing this multiple-patient simulation experience, I am able to identify abnormal assessment findings in a postoperative gastrectomy patient. 8 As a result of completing this multiple-patient simulation experience, I am able to discuss the significance of abnormal assessment findings in a postoperative gastrectomy patient. 9 As a result of completing this multiple-patient simulation experience, I am able to identify nursing strategies to enhance patient coping in a postoperative gastrectomy patient. 10 As a result of completing this multiple-patient simulation experience, I am able to recognize signs of deterioration in respiratory status in a patient with chronic obstructive pulmonary disease (COPD). 11 As a result of completing this multiple-patient simulation experience, I am able to demonstrate the ability to provide respiratory support in a patient with chronic obstructive pulmonary disease (COPD). Answer Type/Choices Circle Your Choice SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA SD D ND/NA A SA

82 SIMULATION EXPERIENCE As a result of completing this multiple-patient simulation experience, I am able to recognize the need for further intervention in a patient with chronic obstructive pulmonary disease (COPD). 13 What suggestions do you have on improving this multiplepatient simulation experience? SD D ND/NA A SA Fill in the Blank

83 SIMULATION EXPERIENCE 83 Appendix H Pre and Post Questionnaires Raw Data/Results Weighted Likert Scale Legend: 1=Strongly Disagree 2=Disagree 3=Neither Disagree/Nor Agree 4=Agree 5=Strongly Agree Question/Statement Attitudes and Motivation I am interested in the content of this multiple-patient simulation experience. I think the material in this multiple-patient simulation experience is useful for me to learn. I will be able to use what I learn in this multiple-patient simulation experience in clinical practice. Knowledge of Content Areas I am able to recognize the symptoms of diabetic ketoacidosis (DKA). I am able to design a plan of care for the nursing management of a patient in DKA. I am able to modify nursing care as appropriate for a patient in DKA. I am able to identify abnormal assessment findings in a postoperative gastrectomy patient. SD (1) 0 0 Pre-Questionnaire N = 52 D ND/ A (2) NA (4) (3) 3 (9) (2) 1 (2) 1 (2) *1 = blan k 11 (33) 21 (63) 24 (72) 6 (18) 38 (152) 25 (100) 24 (96) 35 (140) 28 (112) 26 (104) 43 (172) SA (5) 11 (55) 27 (135) 27 (135) 5 (25) 2 (10) 1 (5) 3 (15) Item Ave. SD (1) Post-Questionnaire N = 52 D ND/ A (2) NA (4) (3) 5 (15) 2 (6) 1 (3) (6) 5 (15) 4 (12) 10 (30) 18 (72) 16 (64) 19 (76) 31 (124) 27 (108) 35 (140) 23 (92) SA (5) 29 (145) 34 (170) 32 (160) 21 (105) 20 (100) 13 (65) 16 (80) Item Ave

84 SIMULATION EXPERIENCE 84 I am able to discuss the significance of abnormal assessment findings in a postoperative gastrectomy patient. I am able to identify nursing strategies to enhance patient coping in a postoperative gastrectomy patient. I am able to recognize signs of deterioration in respiratory status in a patient with chronic obstructive pulmonary disease (COPD). I am able to demonstrate the ability to provide respiratory support in a patient with COPD. I am able to recognize the need for further intervention in a patient with COPD (39) *1 = blan k 10 (30) 1 (3) *1 = blan k 7 (21) 13 (39) 36 (144) 41 (164) 40 (160) 40 (160) 35 (140) 2 (10) 1 (5) 10 (50) 5 (25) 4 (20) (4) (30) 4 (12) 4 (12) 1 (3) 1 (3) 26 (104) 32 (128) 24 (96) 28 (112) 28 (112) 14 (70) 16 (80) 24 (120) 23 (115) 23 (115) Additional Question from Post Multiple-Patient Simulation Questionnaire What suggestions do you have on improving this multiple-patient simulation experience? Do more of them! I liked them and it would be very helpful. I really liked being able to practice giving report. I really thought it went well and it was a great learning experience. More time would be great. I loved it. I think something that would help is the ability to sit outside and chart instead of standing around and not knowing what to do. Great idea! Loved it. Great experience. I liked the idea of multiple patients. But I feel like we needed more time (first group only got to assess each patient once). It was difficult to stay together as assessment/med nurses (as one nurse ) This experience was very beneficial. I liked having multiple patients and being able to delegate and prioritize. I think that I ve grown a lot since the first experience with simulation and I think this lab helped me learn about real-life nursing experiences. Maybe have more opportunities to do a multi sim lab. Good practice Overall, I enjoyed it! I vote multi-patient every week! 1 assessment nurse that gets to do multi-

85 SIMULATION EXPERIENCE 85 patient on his or her own. It was better than 1 patient, but it still felt unlike a hospital setting. I thought it was great. Maybe make it so 2 patients can speak at the same time. That way we could delegate care more and divide and conquer faster. Unless you want us to all stay together, then I d understand why only one can be done at a time. Do it individually. Do it frequently. Not many. I really liked this. It was even closer to real life than just simulation. I liked learning about all the patients and trying to prioritize. Also, I like all of the little things that were added to help us learn everything. I really enjoyed this simulation. I wished we had more time to do meds and also we were a little lost and we were trying to get everything done. It was a good learning experience. I think there is nothing to change. I like how we can call on the phone to ask for help. Working together with all the students helps me learn the best. I would have enjoyed doing more multiple patient simulations throughout the semester because it is much more realistic to the hospital setting and helps me critically think and practice prioritizing better! In addition, I feel like it would have been more beneficial to run through the full simulation or a longer simulation and have one assessment and one med nurse. Thank you! If there was a way to lessen the amount of students to 1 assessment nurse and 1 med nurse would be better, but maybe not possible. Fewer nurses! Maybe separate roles? More different roles just not 2 assessment. Let the assessment nurse record themselves/write the report. Helps to reinforce all the little details. I think its reassuring to have multiple nurses help you, but it might be cool to really be the single nurse doing meds, assessment, recording, etc Teach nurses about resources they have before simulation. I really think sim lab is awesome!! I learn so much about what I need to improve on. As med nurse you miss some of the teaching assessments and implementation practices when you re preparing the meds. It would have been nice to be apart of all of it. FUN SIM LAB! More time would be nice. Maybe curtain off the rooms so it feels more like individual rooms. It was kind of hard to have 2 assessment nurses and only be able to work with one patient. Maybe spread out the roles. Maybe one assessment nurse per patient? So if I m assessment nurse for patient 1, I would be medication nurse for patient 2 and recording nurse for patient 3. Everyone gets a chance but still get the effect of multi-patient simulation. Let the assessment nurses split up. In a real healthcare setting, you work as a team (charge nurse, tech, nurse). Overall though, good experience. I actually felt like as the medication nurse there wasn t enough to do. In the hospital nurses are always giving tons of medications so I think it would have been a good learning experience to give more meds. Either this needs to have two different labs or split everything more evenly. I think it would be more beneficial to have just one role per group (ie. just one assessment nurse, one medication nurse). I thought the scenarios were well planned and realistic. Mainly less people and more time - allows each individual more responsibility and accountability about decisions. It would ve been nice to have a little more time. Also, as the med nurse I feel like I didn t get a whole lot of opportunities to do much. Give us more time. Don t hover and tell us what to do. This was frustrating and was not similar to anything I ve seen or done in the hospital up to this point. I did not like this experience. Time (knowing what time). More time to assess patient. More time to prioritize. Informing us over and over that we will mess up and that s okay.

86 SIMULATION EXPERIENCE 86 Tell us how much time we ll have beforehand. I feel like we didn t have enough time. We re used to having no help no one standing in the door telling us what to do. It threw me off. We had very different roles than usual. I didn t know if I was supposed to divide and conquer or everyone stay together the whole time. More opportunity to prioritize care and discuss as a group. More time to debrief. More time. Separate out the groups. I also felt like we were being prompted to just get back to the high priority patient by the observer. I feel that if we had more time to do certain things outside of the patients room, like we would in the hospital, we would get a better feel of exactly how it works. I liked having two groups, but at the same time I would have liked more time/experience taking care of three patients at a time. I feel like more time is always beneficial. I also think that if we had one nurse that is supposed to be the nurse and then delegate to the others it would be more realistic. More time! I wish we didn t have to split and rotate halfway through. First people just assessed didn t really do much care for patient. Second group had a good idea of what to do after watching. I was in the first group and I felt like we had a lot less things to do than the second group. The first group didn t really get to do a lot, so maybe equal balance. Have the first group be able to do more interventions. Maybe divide the rooms a bit more so it s more realistic and easier to remember hand hygiene. I feel like in the hospital setting, we hardly ever have to call because the physician has everything ordered. I feel like all we do is call the doctor and ask what to do instead of looking at the chart and deciding what we should do. Set timetable. Make clearer how much time has passed by. I was a little confused about the medication time. I wasn t sure what time was when we started the simulation. Clocks for time change. Maybe have different people for each speaker (just for med admin). I would have appreciated more structure/explanation of what was expected in our teams. The roles and responsibilities weren t very clear. Very good to have to prioritize and think. It would be nice to know more about our limitations in working apart and together. Split up medications equally for all students. I felt a little confused for most of the first part of the simulation, so maybe more clarity on what we re supposed to do. More knowledge on resources and how to access those prior to simulation. More family interaction. Other roles involved. I really enjoyed the simulation. I think that maybe providing a list of Drs. orders to each lab participant and originally going over patient labs and charts during the pre lab patient info that the instructor gives. I think that this will allow everyone to fully understand the patient and be on the same page for the care needed. Open lab. LOVED IT!

87 SIMULATION EXPERIENCE 87 Appendix I IRB Approval

88 SIMULATION EXPERIENCE 88 Appendix J IRB Letter of Agreement Between U of U and BYU

89 SIMULATION EXPERIENCE 89 Appendix K Project Defense Power Point

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94 SIMULATION EXPERIENCE 94 Appendix L Project Poster Improving Care Delivery to Patients Through Multiple-Patient Simulation Experience PURPOSE The purpose of this project was to improve delivery of care by providing nursing students a multiple patient simulation experience. Objectives included: Development of multiple-patient simulation scenarios for College of Nursing (CON) students at Brigham Young University (BYU) Administration of a pilot program of multiple-patient simulation scenarios at BYU, including pre and post questionnaires Dissemination of findings of the multiple-patient simulation experience to the faculty at BYU with recommendations for curriculum development BACKGROUND The Institute of Medicine and the National League for Nursing s have led initiatives to make necessary changes in practice to provide quality of care. All disciplines providing health care, including educators, have been called to examine, question, and challenge all areas in order to achieve national patient safety and improve quality of care. Caring for multiple patients can be challenging for even the most experienced registered nurses (RN). New graduate nurses often do not feel adequately prepared when they enter the clinical setting and are required to provide care to multiple patients simultaneously. Improving patient safety provided by new RN s is crucial. This can be better accomplished by preparing student nurses for clinical practice where they will be expected to provide care to multiple patients that is both safe and of high quality. Method Three Medical-Surgical Scenarios were developed and related patient charts created Diabetic Ketoacidosis (DKA) Postoperative Partial Gastrectomy Chronic Obstructive Pulmonary Disease (COPD) Pre and post Questionnaires were developed and Institutional Review Board approval sought 12 item pre and post questionnaire to assess student attitude, motivation, and knowledge of content areas of 3 scenarios Post Questionnaire also elicited suggestions for improving experience Participants were recruited from BYU CON students in the Medical Surgical rotation after IRB approval was obtained Program was piloted among nursing students in Fall 2014 Wende Prince MS, NNP-BC, DNP student University of Utah College of Nursing I am able to identify abnormal assessment findings in a postoperative gastrectomy patient. I am able to discuss the significance of abnormal assessment findings in a postoperative gastrectomy patient. I am able to identify nursing strategies to enhance patient coping in a postoperative gastrectomy patient. I am able to recognize signs of deterioration in respiratory status in a patient with chronic obstructive pulmonary disease (COPD). I am able to demonstrate the ability to provide respiratory support in a patient with COPD. I am able to recognize the need for further intervention in a patient with COPD.! Results Table 1 Pre and Post Module Questionnaire Likert Scale Items Weighted 5 Point Scale Likert Scale Legend: 1=Strongly Disagree 2=Disagree 3=Neither Disagree/Nor Agree 4=Agree 5=Strongly Agree Attitudes and Motivation I am interested in the content of this multiplepatient simulation experience. I think the material in this multiple-patient simulation experience is useful for me to learn. I will be able to use what I learn in this multiple-patient simulation experience in clinical practice. Knowledge of Content Areas I am able to recognize the symptoms of diabetic ketoacidosis (DKA). I am able to design a plan of care for the nursing management of a patient in DKA. I am able to modify nursing care as appropriate for a patient in DKA. Pre Questionnaire N=52 Post Questionnaire N=52 Difference Acknowledgements DNP Committee Chair: David Winmill DNP, ANP-BC, CDE, BC-ADM; Content Experts: Debra Wing Major USAFR, NC, MSNEd, RN; Angela Kahoush MSN, RN METHODS DISCUSSION All 52 students participated in the pilot and all participants voluntarily completed the questionnaires. Participant attitude, motivation, and knowledge of content areas improved after experiencing the multiple-patient simulation. Participant suggestions/comments for improving multiple-patient simulation were overwhelmingly enthusiastic and positive: Loved it!, Closer to real life, More realistic to hospital setting, Helps me critically think and practice prioritizing, Want to have this experience as an individual, Do more frequently, Great idea, Great learning experience, Enjoyed it, Fun, Awesome!, Learned so much, I vote multi-patient every week, Thank you! Recommendations for Improvement: Decrease number of students per lab allowing more individual responsibility, experience, & accountability Allow More Time for Simulation Clearer Communication of Expectations CONCLUSION Students found the multiple-patient simulation experience to be beneficial to their learning as it was more realistic to the clinical setting and helped with critical thinking. All involved with health care have a responsibility to promote practices focused on patient safety and excellence in practice. This will increase accountability for quality health care and will improve patient outcomes. Developing, offering, and teaching methods that are more realistic to the clinical setting will result in effective student learning. The goal is to integrate curriculum that will improve care delivery and ensure patient safety once students enter the workforce.