Teamwork is key goal of medical simulation

By Sandra Snyder / For The Scranton Journal

You can lead a patient to a medical examination table, but you can’t make him wheeze. Nor can you force his blood pressure to drop or his pulse to slow.

That’s the beauty of SimMan, an advanced patient simulator that recently gave nursing students at the University of Scranton, social-work students at Marywood University and future doctors at The Commonwealth Medical College not only some real-life lessons in handling rapidly declining patients but taught the value of interdisciplinary teamwork.

Unlike real human beings, actors often employed to train health-care workers in various specialized disciplines, SimMan can decline on command, not necessarily the command of students, who hope and labor for better outcomes, but of their teachers, who can program the lifelike mannequin not only to wheeze but to have a specified heart rate, blood pressure or breathing level at any given time.

SimMan, in this case, was a 16-year-old boy suffering from an advanced case of asthma exacerbated by family challenges such as lack of health insurance. His parents were immigrants of several years ago, explained Deborah Zielinski, R.N., M.S., director of the nursing laboratory and clinical coordinator at the University.

The two standardized actors who played mom and dad outlined the financial and other serial problems that prevented them from staying on top of their son’s treatment. The lack of insurance, for example, meant he had not been using his nebulizer because they were unable to pay for it. They also had another child at home with special needs.

Those issues were first explained to the six Marywood social-work students involved in the simulation, who passed along the critical information to the nursing students to aid their initial assessments.

The backstory helped student nurses better understand the rapid deterioration of their patient, said Colleen Oggeri, a 21-year-old senior from Long Island, N.Y., who was the only nursing student to enter her simulation without a nursing partner.

The numbers worked out so that one nursing student had to fly solo, Oggeri explained, adding she did not mind and simply chose to rely on the medical students more than she otherwise might have.

But the medical students also relied on her, she said. They had been accustomed to providing a first assessment in these scenarios, but she suggested a reversal of order.

“In reality the nurses are going to you and telling you what they have found,” she said she told the medical students. “The nurses are often the ones recommending and prescribing, and it really falls on the nurses to give the initial assessment.”

That’s not to say her key role was not deferential.

Oggeri, who hopes to secure a cardiac-nursing position at Long Island Jewish Medical Center in New Hyde Park, N.Y., after she graduates this spring, said she enjoyed getting the medical students’ feelings on various asthma treatments, such as steroids, inhalers and nebulizers.

 “It was great. I absolutely loved it,” she said, chuckling as she remembered realizing “how smart” the future doctors are.

Oggeri also said going last as well as alone prepared her for the worst, which was bound to happen. Knowing ahead of time that her patient was going to enter a rapid-response state, the cutoff point for the simulation, she said, she knew to “get the doctor pretty quickly.”

This was a high-fidelity simulation, which permits a changing and escalating situation, explained Margarete Zalon, Ph.D., R.N., who organized the challenging effort, which involved about 150 students across the three campuses.

“The mannequins respond physiologically to student interventions such as administration of oxygen,” she said.

In this case, though, the students actually were doomed to fail but for a higher purpose: developing critical collaboration skills. In other words, forget doctors giving all the orders and involve professionals across the spectrum talking to one another about their patients.

Zielinski put that purpose into perspective

“The scenario was set up so the patient wasn’t going to get better no matter what they did,” she said. “The whole goal was we wanted them to work as a team.”

Many times, she said, medical errors are related to poor communication.

Giving the students the opportunity to think critically while working together is crucial, Zalon said, citing research data that show collaboration produces better outcomes.

“Many times students don’t see an emergent situation in their learning,” she said, and are therefore not highly exposed to consequence. “Here you can do things (such as control heart rate) that allow the students to have that realistic experience.”

In these simulations – of which there were 18 over two days for a total of 36 – students were presented with the situation and given a few minutes to talk to one another about their roles before working together to manage the care of the declining patient.

Some were done at the University and some at The Commonwealth Medical College. Both schools have hi-fi simulators, Zalon said.

The planning for the simulations also was collaborative, she added, noting it began as a result of a pilot study 20 months ago and was “quite a feat to pull off.”

That pilot study, performed at TCMC by a much smaller group but deemed successful, had to be transformed so it could be replicated 36 times, Zalon said. The transformation focused on critical elements and employed key principles of a Team Steps program hospitals use to help people work together.

An interdisciplinary simulation on such a large scale is new territory for Northeastern Pennsylvania, Zalon said.

After each simulation came the equally important debriefings, in which faculty members spent time with the nursing and medical students focusing largely on how the teamwork went, she said.

That focus goes back at least 10 years, Zalon said, to when The Institute of Medicine, an independent advisory organization that is the health arm of the National Academy of Sciences, issued a report about areas on which health-care professionals need to work. Collaboration and teamwork were high on that list.

The collaboration, which Zielinski said various accrediting agencies expect and look for, impacted not only the students but the faculty as well.

“It was just exciting to do something that was so different,” she said, noting she appreciated the opportunity to work so closely with the other institutions and “just see what’s going on.”

“It was a learning experience for us, too,” Zielinski said.