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School of Nursing

arly in spring semester, when the air is still nippy and the dogwoods have yet to bloom, Noelle delivers her babies with ease, her feet in stirrups, her abdomen growing rigid with each contraction, her cervix opening around the crown of the baby’s head. The deliveries are textbook, and the babies perfectly healthy. The junior nursing students who receive each baby under the guidance of the faculty nurse-midwife carry the newborn to the nearby warming bed with hidden sighs of relief and visible grins of delight.
     But as in real life, things are not always so easy for the stoic mannequin. By the end of the semester, her deliveries become longer and more difficult. The baby fails to shift to the right birth position, and the umbilical cord becomes wrapped around its neck. Noelle’s late spring babies arrive with serious problems. Deprived of oxygen, their lips and fingers slowly become cyanotic, setting off the code alert that brings the now more advanced students racing to the bedside.
     Noelle can deliver a baby every five minutes if and when the nursing faculty need her to. But she is only one of the life-size mannequins—officially known as high-fidelity human patient simulators—helping revolutionize clinical education in the Nell Hodgson Woodruff School of Nursing. Her older and even more sophisticated brother, SimMan, has realistic heart and chest sounds. His chest rises and falls with each breath, his pulses are palpable, and he groans with pain, answers questions, and asks for help. He—or she, with the quick addition of a wig, female anatomy, and softer voice—is dependably unhealthy, suffering whatever ailment and requiring whatever diagnosis and treatment that undergraduate or graduate students need to learn.
     When students meet SimMan shortly after they enter nursing school, he usually has chest pain and difficulty breathing. They painstakingly take his vital signs and history, which he provides between wheezes, and study the monitor over his head. By the time they are seniors, his problems have become more critical—an undiagnosed pulmonary embolus, for example—and so have the decisions they need to make. Wrong ones, or ones made too slowly, and his respiration slows and eventually stops. “What could we have done differently?” asks the supervising faculty member. For the rest of their professional lives, faced with flesh-and-blood patients with similar problems, the shocked students will remember those answers.
     “These simulations become very real to our students,” says Barbara Kaplan, coordinator of the Charles F. and Peggy Evans Center for Caring Skills. No one would mistake expressionless Noelle, her little baby with its protruding umbilical cord, or SimMan with his injectable rubber arm patches, for living, breathing humans. What quickens the students’ heartbeats, what makes them impulsively reach out to stroke the mannequin’s arm in comfort, are the patient care scenarios carefully planned and programmed by nursing faculty like Corrine Abraham (for undergraduates), Julie Davey (for graduate students) and Bethany Robertson (who developed the Noelle program) in collaboration with Kaplan.
From Learning to Doing

imulation is the single most important trend in nursing education today, the way to move from learning to doing,” says Darla Ura, clinical associate professor of adult and elder health and director of the Evans Center. Its use, she adds, is non-negotiable in today’s health care environment. High patient acuity (seriousness of disease on admittance) and compressed length of stay leave little time for clinical education. A cholecystectomy patient who might have spent a week or 10 days in the hospital when Ura entered practice now has the operation on an outpatient basis or a 24-hour short stay (most likely a laparoscopic procedure the surgeon first learned using a virtual reality simulator). At the same time, nurses on the medical-surgical unit or in the ICU are increasingly responsible for more tasks and sicker patients. Although senior nursing students still have rotations through Emory and other area hospitals, much of the hands-on learning most practicing nurses acquired in clinical settings now must be taught in simulation laboratories.
     Changing the traditional “see one, do one” method of teaching from human patients to simulated ones gained further support after a hard-hitting Institute of Medicine report focused on medical errors and how to reduce them (“To Err Is Human: Building a Safer Health System,” 1999).
     Whatever the reasons behind it, this shift to simulation suits the nursing students just fine. Because the patients aren’t real, even students early in their training are allowed to become more involved in hands-on care, critical decision-making, and teamwork. Like airline pilots crashing and burning repeatedly as they “fly” in simulated cockpits, nursing students can make mistakes without causing disasters. No one gets hurt from errors in simulation, and students learn lessons that will benefit them and their patients for the rest of their careers.

A (simulated) hospital of its own

lmost overnight, the Evans Center enabled the nursing school to become the Woodruff Health Sciences Center’s biggest user of high-fidelity mannequins.
     The use of such technology had not been an option in the nursing school’s former building (located on Asbury Circle behind Emory University Hospital), which wasn’t wired adequately for students even to operate an electric hospital bed and where the only life-size “care dolls” (less realistic models used for changing dressings, setting casts, and other tasks) had no flexible joints, much less pulses and voices. In the late 1990s, a grant from the Helene Fuld Health Trust made possible the purchase of more realistic mannequins, ones with veins in which an IV could be started, patches for injections (saving hundreds of oranges used for practice each year), and programmable heart and breath sounds. Ura and other faculty began visiting sister nursing schools where simulation was already taking off and compiled the school’s “must have” shopping list in hopes that if they planned well, the money would come.
     Miraculously, it did. As the nursing school prepared to move into its new building on Clifton Road in December 2000, the school learned that the late Charles and Peggy Evans, who built an automobile sales enterprise in the Atlanta area, had bequeathed Emory a multimillion dollar gift in appreciation for the medical and nursing care they received before their deaths. What better way to honor their generosity and memory than to build a center where such caring skills could be taught? (A large portion of their gift also is being used by the medical school for a new education building and programs.)
     Already twice renovated to expand size and technology, the Evans Center includes a small hospital ward, with eight beds separated by privacy curtains. Until recently, ever-pregnant Noelle stayed in another spacious room near the ward with her newborn. Two SimMan mannequins kept her company, along with other life-size children and adult mannequins, care dolls, and numerous simulated body parts, such as the shoe box-size pelvis on which students learn catheterization. Computers spit out realistic laboratory results and X-rays.
     In May, the first Emory BSN students with two years of simulation training graduated, entering nursing practice with unprecedented experience and greater confidence in a wide range of clinical situations. This summer, the Evans Center added an observation and control room (where Noelle and SimMan now reside) with one-way mirrors, video cameras, and enhanced technology. In September, an ongoing teaching partnership between nursing and medicine was expanded as fourth-year medical students and nursing seniors began working together in the Evans Center to learn how to respond as a team in a medical emergency.

Playing well with others

he School of Nursing is well on its way to becoming a national leader in simulation training, according to Dr. Carol Fowler Durham, a simulation expert at the University of North Carolina School of Nursing. When Durham came to Emory to give the 2004 David Jowers Lecture and conduct a simulation workshop for nursing faculty, she was impressed by the high-tech Evans Center and the faculty’s enthusiasm and eagerness to use simulation. In many ways, especially in terms of teamwork between the medical and nursing schools, the school is “way ahead of the game,” she says.
     Last year, the School of Nursing and the School of Medicine jointly recruited Dr. Martin Reznek, a highly experienced expert in simulation training for medicine and nursing, to expand simulation training opportunities for students in both fields.
     “Emergency medicine is a great field for this kind of collaborative training,” says Reznek, an assistant professor in the School of Medicine. “When a patient arrives in the ER, there are always more tasks than one person can do, forcing quick decisions and delegation of responsibilities. Nurses and physicians interact in crisis situations all day long, and the physician/nurse hierarchy is not as firmly established as in some fields.”
     Reznek’s tasks include expanding simulation programs for nursing and medical students and bringing in grants to the nursing school. The new class that began in September—“Learning in Interdisciplinary Teams Makes Us Safer” (LITMUS)—does both, having won an educational grant from the university.
     In LITMUS, groups of two medical students and two nursing students listen to lectures about the different tasks that need to be done in specific medical crises and how physicians and nurses work together to get those tasks done quickly and correctly.
     The simulation begins when a code sounds, and the four students crowd around a bed where SimMan is in programmed peril. As in the real ER, they don’t know what to expect. The case may be a cardiac arrhythmia that has turned into cardiac arrest. Or it may involve the altered mental status of head trauma. “Part of the art form of developing simulations,” says Reznek, “is to match what students know intellectually and what they need to know operationally.”
     Whatever the case, learning to respond as a team is the primary imperative. That’s not easy to learn in the simulation’s crisis atmosphere and with two different professional cultures and four personalities around the bedside. But it is a lot easier—and a lot safer, as the course title implies—than trying to learn it for the first time around the bedside of a barely living patient. And it will give students an early chance to discover the strengths of each other’s profession.
     After the simulation ends, the faculty undertake the most important step—debriefing. Students watch their simulation on videotape made in the Evans Center’s new control room and answer two questions that open each session: What did you do well? What could you have done better?
     More steps are in store for faculty, says Reznek. Using the videotapes, they can hone the scenarios and curriculum to improve team interaction and conduct research on the effectiveness of simulation and its impact on patient safety. Other research may focus on whether doctors and nurses have different perceptions of what is important for patient care that may affect how well they work as a team.
Simulation, synthesis, and the making of a nurse

xuberant students often claim they learned more in an hour in the simulation laboratory than they learned all semester. Their instructors just smile. They know the real strength of simulation is to show students the effects of the pathophysiology they have been studying and to synthesize theory into practice. They also know that moment of synthesis is both an emotionally and intellectually powerful experience that helps students become better nurses more quickly.
     Kaplan tells of a senior nursing student who was crestfallen after her first simulation with a code, the alarm that sounds when a patient turns critical. “I was awful,” she said, near tears. “How will I ever learn enough?”
     The next week, during her hospital rotation, the patient with whom she was talking suddenly lost consciousness. The student called the code, grabbed the crash cart, placed a board under the patient in preparation for defibrillation/compression, and began CPR. “I knew what to do,” she later told Kaplan gleefully.
     SimMan (and the nursing faculty) had done it once again.

Sylvia Wrobel is the former associate vice president for health sciences communications and a frequent contributor to Emory’s health sciences publications.
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