Simulation lab brings a dose of reality to nursing education


“I don’t like needles,” the patient blurts, as the nursing student prepares to draw blood. Jeff Louritt has prepped the injection site. The needle enters the patient’s arm smoothly, and red liquid flows into the test tube, as monitors record the patient’s vital signs. The patient appears stable.

But anything can happen in a medical setting, and nurses and other personnel must quickly respond with appropriate measures. For example, another nursing student recently became nervous about administering medication and stepped away from her patient momentarily. That delay resulted in the patient beginning to vomit; he then aspirated the vomit. His respiratory rate decreased quickly, his heart rate increased, and the patient was in distress. The nursing students had a “code” on their hands - respiratory arrest.

A crisis? Not in the new nursing simulation lab at Adams State, where students can perfect procedures and learn from their mistakes. Because the patient in these cases -- although he can speak, cry, bleed, vomit, and sweat -- is actually a $65,000 computerized mannequin: SimMan 3G.

Working together to improve health care

ASC’s nursing program arose from a collaboration among Adams State, the San Luis Valley Nurses' Forum, Trinidad State Junior College, the San Luis Valley Regional Medical Center, and Valley-Wide Health Systems. The goal of the SLV Center for Clinical Excellence is to better prepare nurses and clinical staff in rural Colorado.

“There has been such strong community support for our program from all the health care facilities in the valley. Most are represented on our advisory committee, which is fabulous,” said Dr. Amanda Jojola, director and assistant professor of nursing.

In 2005, Adams State launched its RN-to-BSN completion program, designed for nurses in the field desiring to advance their education without relocating. A full four-year Bachelor of Science in Nursing program began last spring. Jojola noted there is a national trend to require a BSN for entry-level nurses, because research shows that BSN-prepared nurses result in better patient outcomes. “As a medically underserved, rural area, our community also has a huge need for associate-degree nurses,” she added.

The bachelor’s degree gives nurses expanded opportunities in nursing management, pediatrics, and public health. Another important option is graduate education, which has attracted a large percentage of ASC’s nursing graduates.

Adams State now has 153 students majoring in nursing or pre-nursing, Jojola said. To date, 18 nurses have finished the RN-to-BSN program; 20 students -- the first cohort of the four-year BSN program -- will graduate in May 2012. Within a year, Jojola plans to have the RN-to-BSN completion program available online, with the exception of labs and clinical rotations.

“This will increase our enrollment and give more flexibility for students who work.”

After three semesters in the pre-nursing program, students with a minimum GPA of 3.0 may begin the BSN program in spring of their sophomore year. Upper-level courses are offered in the “block” format. Students take only one course at a time over the course of two to four weeks, for a total of 15 credits in a semester. “This allows students to concentrate on only one course at a time, while still building upon and integrating information from previous courses,” Jojola explained.

In their junior and senior years, students complete 750 hours of clinical rotations in local and regional hospitals. Their final immersion experience is 150-hour internship with specialization in an area of the student’s choosing. Students also devise projects to benefit underserved communities, through the service learning requirement. One student established a mentoring program for nursing students, while others have gone on mission trips to Haiti and Honduras.

National need for nurses

Once they start job hunting, ASC’s nursing students will find their rigorous college training pays off. Sixty-five percent of BSN recipients have job offers at graduation, compared to an average of 24.4 percent of all new college graduates, according to American Association of Colleges of Nursing (AACN). In the western United States, that figure is 54 percent for BSNs; 78 percent become employed within 4-6 months of graduation.

The current shortage of health care professionals, nurses in particular, is only going to increase. It is estimated that vacancies outnumber healthcare job seekers by more than 2 to 1 nationwide. By 2020, the U.S. is expected to be short about 1 million nurses, according to the Health Resources and Services Administration. The Institute of Medicine has called for an increase in the number of BSN-degreed nurses from 50 to 80 percent by 2020 to meet the national need.

In Colorado, 2,000 nurses are expected to retire annually over the next ten years. The Colorado Center for Nursing Excellence estimates the state’s nursing shortfall at 31 percent by 2020. These shortages hit rural areas even more acutely, due to limited resources and lower pay scales. Most counties in Colorado, including the entire the San Luis Valley, are considered medically underserved, due to poverty levels or geographic access issues.

Assuring quality nurse education

Jojola and her faculty are awaiting final word on a reaccreditation site visit conducted in January by the Commission on Collegiate Nursing Education (CCNE) with the AACN. Both the four-year BSN and RN-to-BSN programs were evaluated.

“Our accreditors were extremely impressed with our lab -- and they’ve been to many larger universities who would die to have such a facility,” Jojola said.

The simulation lab was just one aspect of ASC’s nursing program that made a positive impression. Another program advantage is the ASC Nielsen Library’s nursing liaison librarian, Mary Walsh, who specializes in health care. Jojola said the group also complimented the clinical scholar program, the college’s Student Support Services, and support from both the community and ASC administration.

CCNE assesses program quality on four standards:

  1. Mission and governance
  2. Institutional commitment and resources
  3. Curriculum and teaching/learning practices
  4. Program effectiveness

Effectiveness is measured by reviewing student and faculty outcomes, use of best practices to enhance the learning environment, and professional service to the community. The faculty are expected to maintain their clinical expertise and serve as professional role models, Jojola said. She recently earned her Doctorate of Nursing Practice at Colorado University-Denver College of Nursing. Nursing instructor Shawn Elliott is also completing the program, a terminal degree in nursing with a focus on clinical expertise.

Simulation makes perfect

Simulation labs were first developed about ten years ago for training in anesthesiology, and their use is growing rapidly.

“Now it’s a must-have,” said Allison Bennett, the nursing simulation lab coordinator. “We are ahead of most nursing programs, particularly those in rural areas. Ours is among the top labs in the nation.” The SLV Center for Clinical Excellence is equipped with state-of the art medical equipment, as well as sophisticated simulation technology.

“Wherever our students go, they will have experience with equipment that is in use now,” Bennett said. Just like a real hospital, the lab employs an operating room light, ICU bed, EKG monitor, crash cart, birthing bed, infant warmer, incubator, ventilator, IV pump, and a PCA pump (patient controlled analgesia.)

“We are the only simulation lab in a three-state area that has an actual Pyxis Medication Station,” she added. Fingerprint identification allows nurses to access the device, which dispenses the requested drug and records the transaction.

Bennett joined ASC’s nursing faculty last spring and began researching simulation labs to determine the best components for ASC’s facility. She and her technical assistant, senior Alfonso “Fonz” Velasquez, also underwent extensive training to operate the simulation equipment and software. Bennett is working on a graduate certificate in simulation education with Bryan LGH College of Health Sciences to gain further education to support the collaboration. She works with the nursing faculty to devise relevant “scenarios” to prepare students for virtually any medical situation they might encounter.

“I try my best to simulate actual scenarios. I’m constantly thinking ‘in real life.’ We try to be as realistic as possible,” Bennett added. In clinical rotations, nursing students are exposed to whatever conditions actual patients present, but in the simulation lab, instructors can be sure to cover the gamut of disease processes, medical-surgical events, mental health issues, and obstetric and pediatric situations. While instructors coach students through a scenario, she and Velasquez work behind the scenes in the lab’s control room, which uses 8 monitors and 8 computers to operate the mannequins. “Every simulation is different; we react to what the students are doing.” Hence, the aforementioned respiratory arrest that followed a medication delay.

The lab’s mannequins can emit heart and breath sounds, exhibit blood pressure and other vital signs, and produce bodily fluids. Simulated blood, urine, vomit, and other substances are created with moulage kits. Wound modules can be applied for practice with dressing changes and wound care. SimMan 3G can be modified to represent a female patient, to practice Foley catheterizations. Students can practice inserting IV’s and naso-gastric tubes and perform intubations, as well as subcutaneous, intramuscular, and intraosseous injections (infants and children require some injections into the bone, because of limited vein access). A special RFID (radio-frequency identification) arm works with electronic “tags” on simulated medications, so instructors can monitor whether medication was accurately administered.

Jojola said nursing students love the lab, because it lets them perfect techniques. The most important component of a simulation, according to Bennett, is the debriefing. Audio/visual technology records the scenarios, and the B-line simulation software integrates all the recorded information to allow for debriefing. The video can be streamed live into a classroom. Students review the simulation afterward with their professor and classmates, noting what they did well and what could be done differently.

“We encourage students to talk as they participate in a simulation, so we can understand their thought process,” Bennett explained. “This reflective learning supports critical thinking, so they can complete the procedure in a clinical setting and make critical decisions quickly.” The lab is also used by the TSJC nursing program, and is available for staff development by area health care organizations.

Angie Medina ‘08 earned her BSN at Adams State, having worked as an intensive care and critical care nurse, as well as a flight nurse. Her BSN qualified her for a faculty opening in the TSJC Valley Campus nursing program, and she is now the school’s simulation lab coordinator. She and fellow TSJC faculty Jodi Garcia and Martin Dineen oversee scenarios in ASC’s simulation lab for their students. She’s also mid-way through a Master of Science in Nursing offered online through Nebraska Methodist College.

“I jumped right on the opportunity to serve on the committee formed to get the lab going. I love simulation -- it’s so exciting. There’s so much more to learn, and new research is showing how important it is for students,” she said. “Medical errors happen, but that’s where you want them, in the lab. You can be sure the student who delayed medication will never do that again.”

She said her students recently dealt with simulations on end-stage liver disease and code blue (cardiac arrest). In the next course, they’ll work on childbirth and infant care.

“It takes nurse training to another level. The hands-on experience, seeing the lab work and caring for the patient, really helps students tie things together with the theory,” Medina said.

By Julie Waechter