Journal of Neuroscience Nursing:
Clinical Nursing Focus
Use of Simulation in Stroke Unit Education
Aebersold, Michelle; Kocan, Mary Jo; Tschannen, Dana; Michaels, Janet
Questions or comments about this article may be directed to Michelle Aebersold, PhD RN, at firstname.lastname@example.org. She is a clinical assistant professor at the School of Nursing, University of Michigan, Ann Arbor, MI.
Mary Jo Kocan, MSN RN CNRN, is a clinical nurse specialist at the University of Michigan Health System, Ann Arbor, MI.
Dana Tschannen, PhD RN, is a clinical assistant professor at the University of Michigan School of Nursing, Ann Arbor, MI.
Janet Michaels, RN, is an educational nurse coordinator at the University of Michigan Health System, Ann Arbor, MI.
The authors declare no conflict of interest.
Approximately 795,000 people in the United States experience a stroke each year; 610,000 of these are new and 185,000 are recurrent attacks (American Heart Association, 2010). Stroke is the third leading cause of death and the leading cause of long-term disability in this country and will cost an estimated $73.7 billion in direct and indirect costs this year (American Heart Association, 2010). A review of the literature on stroke treatment reveals improved functional ability, decreased length of stay, and decreased mortality for patients receiving care in an acute stroke unit as compared with routine care units (Krespi, Gurol, Coban, Tuncay, & Bahar, 2003; Govan, Langhorne, & Weir, 2007; Roquer et al., 2008; Saposnik et al., 2009; Stroke Unit Trialists’ Collaboration, 2007; Sulter, Elting, Langedijk, Maurits, & De Keyser, 2003; Terent et al., 2009). Continuous monitoring of physiologic variables, coupled with early intervention by nursing staff with specialized training in stroke care, has been postulated as the reason for this difference in outcome (Cavallini, Micieli, Marcheselli, & Quaglini, 2003; Sulter et al., 2003). Maintaining adequate oxygenation and arterial perfusion to brain tissue is essential to minimizing neuronal damage after stroke, especially in the area of the penumbra. Early detection and intervention when desaturation, hypotension, or hemodynamically significant arrhythmias occur are key to minimizing damage and maintaining function (Cavallini et al., 2003; Roquer et al., 2008). Stroke units have been opened in many health systems across the country in both the academic settings and community hospitals. Providing highly specialized training to the nursing staff is challenging when, often, the training and the opening of the unit occur simultaneously. The purpose of this article is to describe an innovative education plan implemented to train stroke unit nurses for the opening of a new stroke unit at a large academic medical center in the Midwest. The training was so successful that it has become part of the ongoing training for all new nurses to the stroke unit.
In December 2005, a six-bed acute stroke unit within the acute care neuroscience unit was opened. Beds were equipped with the same physiologic monitors used in the emergency department and critical care units to allow for seamless capture of physiologic data. Standard patient monitoring consisted of continuous electrocardiogram (EKG), pulse oximetry, and noninvasive blood pressure monitoring at the frequency ordered by the physician. Continuous invasive blood pressure and central venous pressure monitoring were also available based on patient status and physician discretion. Patients who required invasive ventilatory support and invasive intracranial pressure monitoring continued to be managed in the neuro intensive care unit (NICU).
In preparation for the opening of the stroke unit, 26 nurses were in the initial orientation groups, representing 49% of the staff. Additional groups were scheduled in the spring, with the goal of having the entire staff oriented in 6–9 months. Staff were then scheduled to work in the stroke unit or the acute care side of the unit on a shift-by-shift basis. Classroom training consisted of the following:
1. 16 hours of EKG interpretation (same class given for critical care and telemetry units);
2. 8 hours of hemodynamics, including pathophysiology, waveform analysis, troubleshooting and hands-on practice with line setup and monitoring equipment, vasoactive medications chosen as drugs of choice for the stroke unit (vasopressor, antihypertensive, and antiarrhythmic agents); and
3. 8 hours of education on rationale for the stroke unit model, identification and management of acute stroke, incorporating rehabilitation principles into acute care, medical complications, EKG changes seen in acute stroke, risk factor modification, secondary prevention, discharge education, and stroke research.
In addition, nurses completed an online certification for using the NIH Stroke Scale available through the American Heart Association. To ensure that skill building occurred prior to caring for stroke patients in the new unit, nurses had 8 hours of structured clinical time in the NICU. During this time, nurses were required to complete a checklist of required experiences, including setup, changing and assisting with inserting invasive hemodynamic lines, blood drawing, central venous pressure, troubleshooting and discontinuing invasive lines, titrating vasoactive infusions, and accompanying patients on transport for off-unit diagnostic procedures. If these experiences were not available during the scheduled time in the unit, the intensive care unit preceptor provided theory and process information about the skill.
After opening of the unit, an evaluation of the effectiveness of the orientation program was conducted. Feedback from staff indicated discomfort and lack of confidence in their ability to complete necessary tasks and assessments, including interpretation of EKG rhythms and identification of significant arrhythmias and titration of vasoactive and antiarrhythmic infusions, and in their ability to intervene in situations of acute physiologic instability. Within the unit, invasive lines were rarely inserted, and the two to three patients who had the lines had these for only the first day or two of admission. Staff also found that rotating between the general neuro beds and the stroke unit beds made it difficult for them to develop their skills in EKG interpretation. As a result of this feedback and a desire to improve the comfort level for future stroke unit orientees, an educational strategy using simulation was developed.
The use of simulation to provide education to nursing students and medical personnel has become more widespread. Simulation training has been extensively used in the aviation industry and for anesthesia training. The techniques used in simulation are well established in several disciplines and are used for pilots, astronauts, war games and training exercises for military personnel, management games for business executives, and technical operations for nuclear power personnel (Salas & Cannon-Bowers, 2001).
Simulation is a “technique” and not a “technology.” Simulation refers to the artificial replication of sufficient elements of a real-world domain to achieve a stated goal-and typically includes training of individuals and teams to deal with the domain, or testing the capacity of personnel to work in the domain. (Gaba, 2004, p. 7)
The benefits to physician education are well established in the literature (Eriksen & Grantcharov, 2005; Maithel et al., 2006; Rosenthal et al., 2006; Van Sickle, McClusky, Gallagher, & Smith, 2005). Simulation in nursing education is varied, but one of the primary benefits of simulation is the ability to mimic real-life situations without putting patients at risk (Morgan, Cleave-Hogg, McIlroy, & Devitt, 2002; Nehring & Lashley, 2004). Simulation can also provide opportunities to encourage and support use of evidence-based practice guidelines (Aebersold, 2010). Skill transfer is another area where simulation is effective. In a study on advanced cardiac life support (ACLS) training, findings demonstrated that simulation-based ACLS training significantly improved quality of care provided by resident physicians during actual ACLS events (Wayne et al., 2008).
In addition to delivering learning experiences to the student, prompt feedback in the form of debriefing is given. Feedback during simulation has been shown to significantly improve performance over feedback given in the actual clinical site (Day, Iles, & Griffiths, 2009). Simulation can be used as part of an overall curriculum to prepare nursing students, particularly with a shortage of educators and clinical practice sites. Simulation effectiveness has been studied as pedagogy for nursing education (Jeffries, 2005). Simulation can also be used for summative evaluations to assess student performance (Jeffries, 2007).
For the stroke unit, the goal of the simulations was to address the educational needs of the nursing staff that the classroom and precepted clinical experiences did not meet, in particular around those areas involving high-risk, low-volume patient situations that the staff identified as needing more practice. The event-based approach was used to develop the simulation scenarios to support the stroke unit education. In this approach, the simulations are structured and guided to address the knowledge, skills, and attitudes essential to improve the performance of the staff and are developed using critical events that drive learner behavior so their actions can be observed and evaluated (Rosen et al., 2008).
For the stroke unit, the simulations were targeted toward management of vasoactive or antiarrhythmic continuous intravenous medications, use of arterial lines, responding to critical events, and interprofessional communication. Three scenarios were developed, incorporating these activities. The first involved a patient with a baseline rhythm of atrial fibrillation who develops a symptomatic increase in heart rate due to rapid ventricular response. This patient required treatment due to risk for further complications from his recent stroke. The simulation included the roles of bedside nurse and a charge nurse who could be called upon for backup. The nurse needed to identify the problem, contact a physician, and after obtaining an order for diltiazem hydrochloride, calculate the bolus and continuous drip rate and start the infusion using the current intravenous pumps. During the scenario, the patient continued to experience symptoms and the heart rate continued to increase, adding “pressure” to the situation.
The second scenario involved a patient who was post intra-arterial thrombolysis, who had some oozing from his femoral puncture site. When the resident put pressure on the groin site to stop the bleeding, the patient became significantly bradycardic and eventually unresponsive. Again, two nurse roles were used (bedside nurse and charge nurse) in addition to a resident who was holding pressure on the site. The correct actions were to recognize the “vagal” response, ease pressure, and treat with atropine. This scenario was based on a real situation that had occurred in the unit.
The third scenario was a repeat of the first scenario, but in this one, the physician was unwilling to give an order for an antiarrhythmic, preferring to “just wait and see.” The patient becomes increasingly tachycardic and symptomatic. The nurse in this situation needed to use the chain of command to contact a physician who would initiate the appropriate therapy.
Each scenario ran for about 15–20 minutes and was debriefed immediately afterward. Debriefing was conducted using the debriefing with good judgment approach (Rudolf, Simon, Dufresne, & Raemer, 2006). This approach values both the expert opinion of the instructors and the perspective of the learners. It creates transparency in the communication and focuses on creating a context that will help learners move forward to achieve key objectives. It involves both advocacy and inquiry as means of helping the learners reflect back on their performance during the simulation so they can both understand their actions and hear the feedback from the instructor. The nurses rotated roles so each had an opportunity to play the role of the bedside nurse in one scenario. The simulations were not scored in any way, but it was noted that they needed practice in identifying correct drip calculations and in programming the infusion pumps. Most of the nurses did not recognize the cause of the bradycardia in scenario 2 and were delayed in treatment with atropine until the patient became unresponsive and the heart rate was below 30. The third scenario saw the most variation in how nurses responded to the difficult physician; some were quick to up the chain of command, whereas others were uncomfortable waiting but unsure what to do. To date, four groups have gone through the simulation training.
A formal evaluation of the stroke training class was conducted in all of the groups. Respondents rated each learning modality (i.e., speakers, shadowing experience, and simulation) for knowledge on the topic and effectiveness of the presentation using a 3-point Likert scale: excellent, acceptable, and unsatisfactorily. Respondents were also asked to identify “how they would change their practice as a result of participating in the educational activity” and if they had any suggestions for improvement in the training.
A total of 35 nurses participated in the stroke training classes between April 2008 and December 2009. Table 1 provides an overview of the respondents’ perceptions of knowledge and effectiveness for the speakers, shadowing experience, and simulation. As noted in Table 1, 98.2% of the nurses rated the speakers as having excellent knowledge of the topics, with the remaining 1.8% rating the speakers as having adequate knowledge. In terms of effectiveness of the speakers, 95.5% of the nurses rated the effectiveness of the presentation as excellent; 3.2%, as adequate; and 1.3%, as unsatisfactory. The NICU shadowing experience was rated as excellent by all respondents for both knowledge of the topic and effectiveness of presentation (100%). In contrast, the stroke unit shadow was rated as excellent by only 80% of the respondents in relation to knowledge and 20% of the nurses reported the experience as adequate. In terms of effectiveness of the stroke unit shadow experience, only 55.6% of nurses reported the experience as excellent; 38.9%, as adequate; and 5.6%, as unsatisfactory.
Nurses identified several ways in which their practice would change as a result of participating in the training session. Many comments identified the session as providing them with a better understanding of practice, as noted by the following comment, “This classroom presentation provided a theoretical approach to the practice of acute stroke management by nursing…much more aware of treatment process for CVA patients…” Nurses also highlighted the importance of having hands-on experiences through the simulation: “Thanks for the hands-on with the monitors! The SimLab was really interesting, especially to recreate scenarios that have happened.” Other comments relayed a feeling of confidence in caring for this population of patients after participation in the stroke training, “I can now take stroke patients (in the stroke unit) and feel at least capable of going into the room…it gave me a chance to see stroke patients in a different more critical aspect.”
Suggestions for improvement related to speaker content redundancy, hands-on experiences, and increased shadowing opportunities. Although the nurses believed the speakers to be very knowledgeable about the topics and the presentations to be effective, they believed that the amount of material was hard to comprehend in the short time frame of the training session. In addition, some of the material was covered in more than one speaker session. The nurses also highlighted the importance of the hands-on experiences (i.e., set up arterial line, monitor troubleshooting) received in the simulation, and several commented on the desire to have more of these types of experiences. Similarly, nurses requested more time shadowing in the NICU but wanted less time shadowing in the stroke unit.
It is difficult to train acute care nurses to be able to perform proficiently in a higher acuity environment such as a stroke unit when limited opportunities are present for them to gain the experience needed. With the use of simulation, nurses can gain experiential knowledge and practice with high-risk, low-volume clinical situations so that the first time they encounter those situations with a live patient, they have some background to draw upon. Simulation has been very effective in both skills training and knowledge transfer and will continue to be an asset to support any nursing training program.
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