YSN's Simulation Learning Lab prepares nursing students for the real world

This article originally appeared in Yale Nursing Matters magazine. 

Two Yale School of Nursing (YSN) students stood beside Sophia’s hospital bed as they introduced themselves to the 81-year-old patient. She had fallen the day before at her son’s home, hurting her hip.

“I think I’m OK, but my leg just started hurting a lot more,” Sophia said sounding distressed.

“Where is your pain and what does it feel like?” asked one student. Sophia said she thought it was to her left leg. Lifting the sheets, the students took turns tentatively poking at their patient’s purple hip.

 “We can give you some morphine,” said one of the students after checking the medical records.

“But I can ONLY take Tylenol!” said Sophia with surprising authority.

Observing these interactions, via video from an adjacent room, was a group of five nursing students. With the help of a checklist, their job was to make observations about what they did or didn’t see happening as their classmates interacted with Sophia.

“OK, this simulation is done,” said a voice over a loudspeaker. “We'll get everyone together and debrief in five minutes.”

The two students caring for Sophia looked relieved. They patted her head, slightly dislodging her wig, and walked into the hallway of YSN’s simulation space, the location of the staged hospital room and the permanent home of “Sophia”—one of several hi-fidelity manikins used in clinical simulations. The Sim Lab encompasses 5,300 square feet of innovative learning space on the school's garden level. Here, simulations are taught using interactive, practice-based instruction with the goal of preparing students to transfer classroom learning to the realities of clinical practice.

In nursing education, simulation covers a range of modalities. Examples include low-fidelity simulators such as a simulated wound site or computer programs with avatars; immersive simulations using hi-fidelity computerized manikins that can breathe, sweat, bleed and give birth; and even hybrid simulations that pair technology with specially trained actors known as “standardized patients.”

In 2014, Virginia “Ginger” Sherrick, MSN, APRN, FNP-BC, RN-BC, CHSE was appointed the director of the Simulation Learning Lab. Under her energetic leadership, the use of simulation has grown significantly, especially in the Graduate Entry Prespecialty in Nursing (GEPN) program where students participate in thirteen simulations throughout the year. They begin with simple skills, such as talking to patients, and progress to include more complex content—from assessing patients in a home-based setting to triaging in a community disaster. Because they are carried out in a controlled setting with supervision and feedback from course faculty, simulations offer a safe environment where students can master clinical techniques and develop communication and critical thinking skills.

Cate Cherry, in her first year in the Nurse-Midwifery/Women's Health Nurse Practitioner Specialty, entered YSN in the GEPN program. “In GEPN we spent a lot of time in the hi-fidelity simulation rooms. We did pharmaceutical, hospital, pediatric and post-partum simulations, as well as other simulations for every section of nursing,” she explained. “The 'pharm' simulation, where a someone has a drug reaction, was very stressful. It was good to see a panic situation in a hospital setting. I realized that I’m not great at pharm under pressure, which helped me to know what I can do better.”

Cherry said that simulations also contribute to reducing anxiety. “A simulation allows you to see something for the first time. You don't know what you might be nervous about or that it might be harder than you expected,” she said. “For instance, I thought I was going to be really nervous about doing a pelvic exam on someone. But when I did it, it wasn't so bad. I'm so glad I did it before I went into clinical.”

Sherrick is a staunch advocate of simulation. “Simulation lets us level the playing field, ensuring that all YSN students are getting fundamental information by having access to the same experiences,” she said. “If a faculty member, in any specialty or discipline, identifies a key situation or skill, we can create a simulation to ensure that every YSN graduate knows how to manage it.”

Assisted by Shannon Pranger, MSN, RN-BC, CEN, Sherrick oversees every aspect of the center from creating and running simulations (while ensuring they meet national standards), to training faculty in simulation technology. She often participates in sessions either as a live actor or by controlling a hi-fidelity manikin. “We're blowing the lid off,” she said about the many YSN courses requesting simulations. “The need for simulation-based learning is increasing exponentially.”

As pedagogy, simulation has been studied more thoroughly at the undergraduate nursing level than at the graduate level. But the use of simulation in YSN graduate programs is expanding. At this level, simulation gives students an opportunity to practice everything from cognitive and critical skills sessions to hands-on psychomotor skills and effective communication. Simulation has been found in meta-analyses to have positive effects on nursing and other clinical student learning and behaviors (Kim etc al 2016; Cook et al 2011)

According to Sherrick, medical simulation, using actors in an immersive experience, started in the mid-1960s at the University of Southern California in a medical program. Medical schools have used simulation as part of the practical exam for boards for some time. “Nursing schools have typically relied on the skills lab with partial trainers, body trainers, and full manikins, but not necessarily on scenarios where a student may walk into a simulated hospital room to care for a patient,” she said.  “In the 1990s [simulation] became more prevalent. And in the 2000s there was a dynamic shift, which embraced it as an actual methodology or pedagogy.”

As the field grew, two national societies emerged that set standards for simulation-based learning. The International Nursing Association for Clinical Simulation and Learning (INACSL) develops standards for best practice. And the Society for Simulation in HealthCare (SSH), offers certification as a simulation in healthcare educator.  Sherrick is one of about a thousand certified simulation healthcare educators in the world, and is one of only one hundred INACSL fellows.

Creating a simulation is a highly detailed and thorough process. If a faculty member wants to create a simulation, they first meet with Sherrick to discuss the goals, which are based on course objectives. “We need to know what students should get out of the experience. Do you want them to perform a particular skill? Do you want to see critical thinking applied to a situation? Or evaluate how they are interacting with their patients?” Sherrick explained. “Each of these outcomes is designed differently in a simulation, and the equipment chosen to add realism is very different for each of those outcomes.”

The next step is checking to see if an existing simulation can be used or tweaked. If not, then a new one must be written. “Every simulation, if written appropriately, is typically the size of a course syllabus,” said Sherrick.  A case is developed including criteria such as the person's demographics, family, social, and medical history. Next, the onset, location, duration, and characteristics of the medical issue are defined, and medical records, scans, and labs are created, so they can be available to students during the simulation.  

Standardized patients, whether portrayed by a live actor or as one of the hi-fidelity manikins, must be prepared to answer possible questions. A pilot is then run to ensure that everything runs smoothly. “The final project is often very different from the glitz and glamor that someone initially envisioned,” Sherrick said. Once the validity and reliability of a simulation are established, it can be used over and over again. 

Ami Marshall, MSN, APRN, ANP, lecturer and faculty clinical coordinator at YSN, has developed several simulations with Sherrick, and she participates in the Simulation Committee, which is made up of representatives from all of the different programs in the school.

Together Marshall and Sherrick introduced a computer-based simulation that uses patient avatars, called Shadow Health, into one of Marshall's health assessment courses. They also created a hi-fidelity simulation that helps students practice evaluating male genitourinary complaints. “We didn't have a consistent way to ensure students were getting this experience in clinical settings,” Marshall said. “So, we decided to make a simulation about it, ensuring that our students can work up this complaint.” They also developed a case with a complex diagnosis, and they will soon launch a new simulation about orthopedic pain management. 

On average immersive simulations run about twenty to thirty minutes with three to five students participating in the simulation. The other students in the class observe, using a checklist, from a different room or via live streaming into a classroom.

Andrée de Lisser, DNP, APRN, PMHCNS-BC, teaches in the Psychiatric Mental Health Nurse Practitioner specialty.  Her “Group Psychotherapy Seminar” is a third-year course that uses the lab for a group therapy simulation. The class is divided into two: one group observes from the control room using a two-way mirror and cameras that can focus on individuals or give a panoramic view of the group, while the group on the other side of the mirror is led by two students. This setting helps the observers detect non-verbal cues and makes observing less intrusive.

“The intent of this simulation is not group therapy. Rather, it is an opportunity to learn about group leadership and group dynamics,” de Lisser explained. “It’s also very important for students to have some sense of what it’s like to be a patient. They can see some of the things that I’ve lectured about actually happening in the group.” After the hour-long session, observers and participants meet together to debrief and share their observations and experiences.

“It’s really powerful,” de Lisser said. “The simulation isn't graded, but students often feel a lot of dread going into it. They usually end up finding it very helpful. Just yesterday, one of the students said to me, ‘I just can’t believe how much I am learning from this class!’”

The simulation is run ten times so that everyone has at least one opportunity to lead and the groups switch roles for subsequent simulations. “This is the fourth year I've done it, and it feels like such a great experience for them,” de Lisser said. “I feel like the theory comes alive. The students are experiencing it themselves, and because it integrates a lot of therapy principles, they can see some of them in action.”

One of the most significant benefits of simulation is the regular feedback it affords students. “Debriefing allows students to verbalize and reflect on the choices they made and allows the facilitator to guide them to the appropriate differential diagnoses and decision-making,” Sherrick said.

The debriefing format is based on the objectives of the simulation. Sherrick and Marshall both said that debriefing is often where the real learning takes place. In fact, according to Sherrick, studies indicate that the observers often learn more than the participants. During the debriefing session participants and observers meet together with a facilitator to review what was done correctly and incorrectly and to exchange feedback and insights that can help develop critical thinking skills.

Currently, the Center is a combination of primary care and acute care space that includes a task trainer room, a large assessment lab, two fully equipped examination rooms, and four immersive simulation rooms served by a shared AV/computer room.

The task trainer room has a central teaching space surrounded by learning stations where students can practice and review technical skills related to physical exams and procedures. A dozen semi-private curtained areas, equipped with exam tables and key clinical instruments surround the assessment lab’s large teaching space.

The two clinical exam rooms are set up like those in a doctor's office and used for health assessments or physical examinations. Three of the four immersive simulation rooms are set up and equipped like a hospital room, and the fourth is swing space that is used for simulations that might not require a hospital setting, such as a mock group therapy session.

The benefits of the Center are not limited to just YSN. The Interdisciplinary Longitudinal Clinical Experience (ILCE) is a course with students from the Nurse Practitioner Specialty Program, the Yale School of Medicine, and the Physician Associate Program. ILCE simulations have included approximately 120 students in previous years, but this fall, that number has increased to 250 students, who will participate in three simulations focused on communication and teamwork.

Over the past two summers, YSN hosted a nursing camp through a partnership with the National Student Leadership Conference (NSLC), which offers pre-college summer programs for high school students to “prepare them for the most sought-after professions.” Students are introduced to nursing beginning with the history of nursing and the types of nursing practice. They are then immersed in nursing school where they learn about everything from personal protective equipment to anatomy and physiology skills.

“They also learn how to start IVs, do a head to toe physical assessment and on day three, we put them through simulations where they have to apply everything they have learned,” Sherrick said. “They do a mock code, and disaster and birthing simulations.” This unique program may help attract a new generation of students to nursing and perhaps one day, to YSN.

Carmen Portillo, Executive Deputy Dean for YSN believes, “The world needs YSN nurses and midwives now more than ever. The programs that YSN’s Sim Lab provides are critical to preparing our students to take on real-life situations and to ensuring that YSN remains at the forefront of nursing science and research.”

Expansion of the Simulation Lab

An expansion of YSN’s Simulation Lab is scheduled to begin in late 2017, nearly doubling the size of the space it currently occupies on the first floor. The new plans include a large assessment lab, six primary care simulation rooms, a standardized patient green room for actors, and two debriefing rooms. When complete the first-floor rooms will become primary care space and the garden-level (the lower level) space will be dedicated to acute care. This substantial expansion will increase YSN's capacity to enroll a larger master's student class without having to increase the number of clinical sites.

“By investing in the expansion of the simulation lab, Yale School of Nursing is committed to ensuring that the next generation of nurse leaders, scholars, and practitioners are fully prepared for the future challenges in national and global healthcare. This exciting venture will help us maintain our status as one of the top graduate nursing programs in the world”, commented Dean Ann Kurth.

The Sim Lab expansion will be a major fundraising focus for the school. If you’re interested in a partnership or want to learn more, please email Niamh Emerson, Associate Director for Development, at niamh.emerson@yale.edu, or call her at: 203-737-2521.