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The incorporation of high fidelity simulation training into hemodialysis nursing education: an Australian unit's experience.

Nurses working in hemodialysis (HD) units are surrounded by rapidly advancing technology and increasing patient acuity.

Within this environment, nurse educators are striving to meet competing demands while delivering training programs that prepare nurses to safely care for people undergoing HD (Sinclair & Levett-Jones, 2011). Nurse educators face numerous challenges as they prepare nurses to perform HD, not the least of which is main-mining patient safety while exposing new nurses to the myriad of potential complications they must learn to manage competently. To meet the complex needs of an evolving workforce, it is vital that educators, managers, and staff nurses all embrace

Copyright 2011 American Nephrology Nurses' Association

Dunbar-Reid, K., Sinclair, P.M., & Hudson, D. (2011). The incorporation of high fidelity simulation training into hemodialysis nursing education: An Australian unit's experience. Nephrology NursingJournal, 38(6), 463-472.

A high-fidelity hemodialysis simulation program has been introduced and evaluated in a Far North Queensland dialysis unit. This program engages and challenges hemodialysis staff across the learning continuum. It provides a realistic, safe, and controlled learning environment for nurses to develop essential hemodialysis competencies while posing no threat to patient safety. This teaching method combined with clinical experience is a positive step forward in meeting future educational needs of the renal workforce.

Key Words: Simulation, kidney, hemodialysis, education, nursing.


To provide an overview of a hemodialysis simulation program.


1 Define healthcare simulation training.

2. Explain the initiation of the HD-specific patient simulation program and the renal simulation experience at one facility in Queensland, Australia.

3. Discuss the importance of simulation education for nurses new to the nephrology specialty.

available technology to improve nephrology nurse education delivery and patient care. One training method widely used to prepare undergraduate nurses for practice is clinical simulation, which is in its infancy in HD.

This article describes the genesis of a high-fidelity HD simulation program in Cairns, Far North Queensland, Australia, and reports the evaluation of this training method in a cohort of 78 bachelor-prepared nurses.


Simulation was first seen in aviation training in 1922 with the introduction of the Link Trainer (Grenvik & Schaefer, 2004). Its emergence in the healthcare field occurred in the 1970s in anesthesiology training (Nehring & Lashley, 2010); the first documented evidence of its use in nursing appears in the late 1990s (Roche, 2010). In nursing, the major focus in the simulation literature has been in undergraduate or pre-license programs.

Gaba (2004), a pioneer of simulation in health care, defined simulation as "a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion" (p. 2). Simulation training bridges the theory-practice gap in nursing. It aligns with patient safety imperatives by allowing staff to practice and make mistakes to improve their patient care and clinical competence within a safe learning environment (Shepherd, 2009). The principles of simulation-based learning are student-centered and work positively within different learning and generational styles (Arthurs, 2007;Jeffries, 2007).

As an education technique, simulation utilizes human patient simulators (sometimes referred to as mannequins) that are classified as low, medium, or high fidelity. The fidelity of the simulation relates to the degree of reality projected by the simulation (Jeffries, 2007) and includes equipment fidelity (how closely the simulator resembles the human body), environmental fidelity (how closely the location of the simulation mimics the real care setting), and psychological fidelity (how closely the learner perceives that the simulation approximates the reality of practice) (Doyle, 2011). Low-fidelity patient simulators and partial task trainers (such as resuscitation torso and cannulation arms) provide only anatomical representation (Grady et al., 2008) and have long been used to support didactic learning for skills, such as cardiopulmonary resuscitation, venipuncture, and cannulation. High-fidelity patient simulators have the anatomical representation but also use embedded software that is able to be pre-programmed. This allows real-time learning opportunities and affords educators the opportunity to respond to participants' interventions through changing physiological parameters, such as heart rates, cardiac rhythms, respiratory rates, and lung sounds (Decker, Sportsman, Puetz, & Billings, 2008; Grady et al., 2008). Vocal responses can also be utilized via a microphone link in a control room to add to the reality of the scenario.

Technology has now evolved to the point where high-fidelity patient simulators can be operated remotely. Wireless technology affords the creation of an immersive learning environment in which educators can create realistic scenarios for practitioners to learn where errors can be made with no risk to patients. Active involvement in simulation affords participants the opportunity to develop experience and increase confidence in clinical decision-making, particularly in scenarios that are time-critical (Nehring & Lashley, 2010).

Universities in Australia utilize clinical skills laboratories to support nursing students to develop the necessary clinical reasoning and psychomotor skills associated with their profession. While variations exist in the availability of simulation technology (Arthur, Kable, & Levett-Jones, 2010), graduating nurses transition from an environment that provides access to high-level simulated learning opportunities to hospitals that may or may not utilize simulation as part of ongoing professional development. The use of high-fidelity clinical simulation is a rarer component of nurse education in the hospital setting in Australia.

Simulation also provides the opportunity for interdisciplinary education. The synergistic effects of interdisciplinary training enhances professional communication, teamwork, and work effectiveness, resulting in the increased delivery of safe, quality care (Jeffries & McNelis, 2008). Interdisciplinary simulation also promotes interprofessional education to break down the historical "silo" style of health training (Barnsteiner, Disch, Hall, Mayer, & Moore, 2007). Scenarios that involve the multidisciplinary team expose the knowledge, skills, and critical thinking of the participating disciplines, which augments the learning process. Additionally, participants develop a shared fostering of trust, respect, and mutual appreciation and understanding of each other's roles in patient care, which is central to patient safety and assists in the reduction of patient care errors (Barnsteiner et al., 2007; Jeffries & McNelis, 2008).

Simulation in Nephrology Education: A Journey to Discovery

There is a paucity of literature describing the use of simulation in nephrology education. A review of CINAHL and PubMed databases using the keywords "kidney" and "simulation" revealed one small (N= 18), prospective, observational study that reported how a simulation-based curriculum increased nephrology fellow skills in temporary HD catheter insertion (Barsuk, Ahya, Cohen, McGaghie, & Wayne, 2009).

Anecdotal information suggests that in Australia, nurses new to HD undertake an orientation and training program during a supernumerary period between two and six weeks, depending on unit training policy and conditions. While there is regional variation in both the duration and requirements of the training program, new nurses must achieve core competencies relating to the basic principles of HD, fistula cannulation, and care of individuals on HD. Theoretical components of the care for patients on dialysis are easily taught using traditional education delivery methods. However, learners who are visual and kinesthetic by nature require numerous "practices" and repetitions of a skill set before displaying confidence in time-critical patient interventions. Historically, training for specific nephrology clinical scenarios could only be taught via tutorial format, recreating the scenario with a lined dialysis machine in recirculation or through opportunistic learning where clinicians hone their skills while "learning on the job" (Bruppacher et al., 2010).

The issue of time-critical, renal-specific scenarios, such as cardiac arrest during dialysis or management of hemolysis, need to be included into staff training. Common intradialytic complications, such as hypotension or cramping, are generally witnessed during new staff members' supernumerary time. However, complications, such as chest pain, cardiac arrest during dialysis, or anaphylaxis during iron transfusion, are not routinely seen during the supernumerary training period. Some patient scenarios, such as air embolus and water contamination, may not have been experienced by some renal nurses in their whole career, yet renal nurses need to be able to confidently and safely manage such patient complications.

Simulation provides an alternative solution to teaching skills traditionally taught at the point of care. Within the context of HD, simulation affords the opportunity to rehearse a range of clinical scenarios that occur in HD units, while less expensive, low-fidelity simulators and partial task trainers are adequate for teaching and practicing skills, such as cannulation and basic life support (BLS). However, they lack the functionality to support higher-level training for complex scenarios, such as managing hypovolemia or cardiac arrest while on HD, or rarer emergency scenarios, such as air embolus or dialyzer hypersensitivity. High-fidelity patient simulators, on the other hand, afford the opportunity to provide realtime physiological changes and voice appropriate responses according to whichever scenario is being simulated. Through incorporating renal scenarios with specific learning objectives, renal healthcare professionals can practice and master a range of clinical skills to prepare for clinical situations that occur frequently and those that do not.


The Cairns Simulation Experience

After a period of research, consultation, and experimentation, the Cairns dialysis unit, in conjunction with the Cairns Skills Centre, developed a renal and HD-specific patient simulation program to augment traditional educational resources (see Table 1). The realism of the simulation experience is constructed by con figuring the Cairns Skills Centre scenario room to replicate a dialysis bay, including a fully operational HD machine and a high-fidelity mannequin, affectionately known as Marvin (see Figure 1). A dialysis chair is bought to the scenario room to enhance the realism of a standard dialysis bay. Fully operational oxygen and suction equipment, as well as an arrest cart with an operational automated external defibrillator, are also available. There is also a range of commonly used medications, monitoring equipment, documentation, and blood tubes readily available for participants. To further complement the scenarios, there are a variety of pathology results and electrocardiograms to use for specific scenarios.


To provide high-fidelity renal simulation training in a realistic renal environment, Marvin is seated in a dialysis chair and has an attached specifically adjusted "renal" arm (see Figure 2). He is then connected to a pre-adjusted dialysis machine and portable reverse osmosis (RO) unit. A standard HD machine contains sensory mechanisms to sense patient blood and indicate dialysis can be initiated. Because this function is void of an inert dialysis machine, subtle alterations to the dialysis machine were required to mimic circulation fluid, and thus, enable the operator to initiate dialysis on the simulation mannequin. Because the human patient simulator is located in a skills center, rather than in a dialysis unit, specific tap connections were required to direct feed water into the portable RO unit. The RO reject line also required connections to allow the free flow of reject water.

To enhance the fidelity of the scenario, medical dye and food coloring were used to mimic blood, but it dialyzed off. Intravenous vitamin B did not dialyze off, but due to cost and its imperfect representation to blood, it was not a feasible option. Therefore, the lack of color to the "patient's" blood is one limitation of realism that is explained to staff.

To successfully "dialyze" Marvin, a circuit of fluid is hidden at the back of the dialysis machine and is attached to a connection of the revascularized cannulation arm. This allows staff to ultrafilter, dialyze, and fluid resuscitate their patient completely as any nurse working in an actual renal unit would. The reality of the scenario is further enhanced through the use of props, including wigs, clothes, and mimic dialysis folders for various patients on dialysis.

To sustain realistic dialysis blood pump speeds with the absence of any fluid leakages, a standard cannulation training arm was "re-vascularized." This involved stripping the veins of the cannulation arm and replacing them with a looped vein made of silicone tubing. After numerous wet floors, the appropriate bungs and IV attachments were finally attached and successfully trialled. Adapting a simulator arm with vascular access options will be described in a future article.

The Renal Simulation Curriculum

The design of simulation scenarios must be based on sound pedagogical principles to provide valuable teaching and learning outcomes (Arthur et al., 2010). The curriculum for the simulation program is described in the following section.

The session objectives were to:

* Provide immersive clinical simulation of patients undergoing HD.

* Practice and manage emergency measures in this setting.

* Utilize structured debriefing sessions to provide constructive critique and an opportunity for reflection. This involves video recording of performance and provision of feedback to the participants post-scenario.

Renal Simulation Programs

To date, five renal simulation programs have been developed: three-hour renal simulation workshops, HD skills stations, international preconference workshop, BLS and use of automated electrical defibrillator (AED) training, and interdisciplinary simulation training.

Three-hour renal simulation workshops. Learning objectives are written for renal staff, including acute dialysis unit, home-training staff, and satellite unit staff. There is a formal introduction to the concept of simulation and an orientation to the "dialysis bay" and high-fidelity patient simulator. Individual renal scenarios are conducted. Each scenario is 5 to 15 minutes in length, depending on complexity. Each scenario is then followed by a structured debriefing process.

HD skills stations. Two-hour HD skills stations are repeated over a full day. With the introduction of a newer dialysis machine model, several basic skills were listed, and a full skills station day was conducted. With nursing staff in pairs and allocated a two-hour timeslot, staff rotated through and performed the following renal specific clinical skills:

* Setting up the dialysis machine, including lining machine with online modality.

* Performing recirculation and recommencement (patient requesting to go to the toilet during dialysis).

* Performing isolated ultrafiltration.

* Performing fluid bolus using online mode.

* Management of air in line alarm.

* Management of a cardiac arrest during dialysis on the new model.

* Performing line changes for heparin-free dialysis.

* Completing dialysis before the recommended time.

International pre-conference workshop. The workshop included lectures on the concept of simulation, how to incorporate renal education into simulation, and specifics of how to conduct renal simulation. After orientation to high-fidelity simulation, participants were rotated through renal scenarios, as well as the debriefing process and viewing the technical aspects in the control room. Each participant was given a disc with the lectures, scenario examples and template, a list of required equipment, and a "how to" manual with step-by-step approaches to prepare and conduct renal simulation.

BLS and use of automated electrical defibrillator (AED) training. A two-hour time slot was incorporated in the unit's mandatory competency day. Staff had the opportunity to incorporate renal scenario practice with mastery of BLS and the use of an AED.

Interdisciplinary simulation training. Nursing and medical staff participated together in renal simulation scenarios as an effective interdisciplinary educational and team-building opportunity.

Scenario Development

Each renal scenario (see Table 2) has written clinical and leadership objectives for the participant to achieve. Scenario templates provide the cornerstone to the renal simulation curriculum. A full example is provided in Table 3. The scenarios are flexible enough to incorporate "on the fly" training. This affords the opportunity to adapt the learning experience depending on the level and experience of participants. For example, Marvin will deteriorate slower for a novice nurse as opposed to more rapidly for an expert nurse.

Within these scenarios, many "real" patient characteristics are also built into the experience (for example, having an anxious or aggressive patient or caring for a patient who is a poor historian). This adds to the reality of the scenario while developing non-clinical skills, including communication and conflict resolution.

Simulation Debriefing Process

The simulation learning experience is augmented by a post-scenario debriefing process. This enables participants to deconstruct the scenario with a facilitator and reflect on areas of practice that require improvement or attention. There is a process of obtaining consent from participants, and participant confidentiality is discussed prior to each simulation session.

Seropian (2003) has described debriefing as an art, with the core element being the facilitation of learning and discussion in a non-threatening and organized manner. The time spent during the debriefing process is as equally important to learning outcomes as the time spent in the simulation scenario itself. Debriefing promotes discussion and learning in relation to therapeutic communication skills, leadership, procedural clarification, and subsequent changes in practice, all of which influence patient safety (Cantrell, 2008; Clancy, 2008).

Simulation can be digitally recorded to supplement the debriefing process. The debriefing process itself is a teaching and learning strategy (Cantrell, 2008), and affords the opportunity for healthcare professionals to reflect and learn from their errors in a safe and non-threatening environment to improve their clinical decision-making skills. Participants also learn from watching their peers in addition to their own performance from playback of recorded scenarios (Seropian, Brown, Gavilanes, & Driggers, 2004). Debriefing also provides the opportunity to address and affirm learners' emotions, as well as provide dedicated time for reflection and the opportunity for unbiased nurturing and critique (Cantrell, 2008). The questioning style utilized in debriefing explores the experience of participants and provokes reflective practice to identify areas of learning, clinical strengths, and areas requiring remediation. Additionally, it allows the teaching content to be adapted to meet each individual's performance, an opportunity that cannot be offered with conventional education (Bruppacher et al., 2010).

Evaluation of the Cairns' Simulation Experience

To date, 11 HD simulation workshops have been conducted, with a total of 78 participants. At the end of each workshop, participants completed a 4-item evaluation survey. A Likert-type scale was used ranging from poor (1) to excellent (5). Mean scores ranged from 4.80 to 4.87 (see Table 4). Free-text comments were highly positive and are provided in Table 5.


The findings from these evaluations suggest high participant satisfaction with high fidelity simulation in the HD context. These findings are consistent with studies that have measured participant experience and satisfaction using simulation training (Kuznar, 2007; Laschinger et al., 2008; Smith & Roehrs, 2009).

Seropian et al. (2004) have suggested that the inherent unpredictability of participants' actions and reactions during simulation can lead to many unanticipated educational benefits. During the course of the simulation experience discussed in this article, the unintentional training (such as correction of BLS techniques and protocol updates) enriched the overall learning experience. The debriefing process afforded all participants the opportunity to share their learning experience in a relaxed and non-judgmental environment. In particular, the discussions around communication techniques and crisis management principles assisted participants to transfer best practice principles into real-world practice. It also provided an opportunity to actively discuss how to improve clinical decision-making processes within the clinical context.

While experienced staff enjoyed being challenged clinically, those less experienced were encouraged to take on leadership roles during simulation scenarios. Experienced nurses can be utilized as actors and introduced to other participants as new graduate nurses. Although participants are often nervous, the safety of this learning environment and the support of an educator who can "appear" during the simulation at any time assist in the participants' professional growth and confidence. Because the safety and integrity of participants is critical, the reflection and group discussion are facilitated by a person skilled in conducting a debriefing process.

The "success" of simulation is not only measured by evaluating participants' confidence or satisfaction levels (as discussed here), but more importantly, by the potential to improve patient outcomes in health care (Goodman & Lamers, 2010). Strengths of simulation are practicing, mastering, and ensuring safe patient care. Future research priorities in renal simulation need to move beyond evaluating participant experience and measure patient outcomes associated with this education technique. The role of simulation in renal education needs to be validated in terms of cost-effectiveness compared to traditional educational methods. Studies are also required to investigate the efficacy of simulation training compared to "on the job" training or a blended approach incorporating simulation into existing training methods. This will guide educators in the development of future clinically based education curriculum.


This article has described the development and preliminary evaluation of a hospital-based, high-fidelity clinical simulation program for staff who perform HD. Nephrology nurses can learn, practice, and improve skill routine and emergency HD patient care in a safe and supportive learning environment. The education program combines all the benefits of using simulation and HD technology to create realistic scenarios about patients on dialysis. Evaluation of this program revealed it was positively received and contributed to improving participants' confidence to manage a range of clinical situations. Participants highlighted the benefits of learning in a non-threatening but realistic clinical environment and reported that the debriefing process afforded the opportunity to critically reflect upon their own clinical practice.

Renal simulation training allows participants to be fully "present" and immersed in the scenarios. This uninterrupted and dedicated time can be used to discuss important features of renal nursing and patient care, an opportunity that is often lacking in the clinical setting. Additionally, multidisciplinary renal simulation training provides a perfect opportunity for inter-professional teamwork, education, and proactive patient management discussions and practice changes.

While HD simulation is in its infancy, the potential exists to incorporate this education into new staff training, current staff re-skilling and skills advancement, and staff remediation, as well as for staff returning after extended leave periods. This modality could also be incorporated into training for patients on home HD, and would afford patients and careers the opportunity to practice clinical skills prior to being discharged to their home environment. Simulation provides a positive solution to the challenges faced in HD education, particularly in teaching rare time critical scenarios. Simulation in the nephrology context affords interactive and immersive learning opportunities by recreating clinical experiences with no patient exposure, which allows for experiential staff learning in a risk-free environment.



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Nephrology Nursing Jouma/Editorial Board Statements of Disclosure

In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below

Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant and research coordinator, is on the speaker's bureau, and has sat on the advisory board for Genentech.

Patdcia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen, Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the recipient of unrestricted educational grants from OrthoBiotech and Roche

Kylie Dunbar-Reid, MNS, is a Nurse Educator (Renal Portfolio), the Cairns and Hinterland Health Service District, Cairns, Queensland, Australia. She may be contacted via e-mail at Kylie_

Peter M. Sinclair, MPhil(c), is a Lecturer, the University of Newcastle, Newcastle, New South Wales, Australia, and the Inaugural Chair of the Nephrology Educator's Network, the Education Subgroup of the Renal Society of Australasia.

Denis Hudson, RN, is the Simulation Educator, the Cairns Skills Centre, Cairns, Queensland, Australia, and is affiliated with the Australian Society for Simulation in Healthcare, Queensland, Australia.

Acknowledgements: Kylie Dunbar-Reid acknowledges the Cairns Skills Centre staff: Emy Dezen and Deidre White, Dr. Jenny Sando, ADON Nurse Education and Research Unit Cairns, and the Cairns Renal Unit Nursing, Medical, Administration, and Technical staff for their support.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This offering for 1.4 contact hours and 84 pharmacology minutes is provided by the American Nephrology Nurses' Association (ANNA).

ANNA is accredited as a provider of continuing nursing education (CNE) by the American Nurses Credentialing Center's Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.

Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.

This CNE article meets the Nephrology Nursing Certification Commission's (NNCC's) continuing nursing education requirements for certification and recertification.
Table 1

A Step-By-Step Guide to Setting Up Hemodialysis Simulation
in Your Nephrology Department

1. Liaise with local skills center/university regarding use of
   simulation mannequin.

2. Engage nursing management support.

3. Evaluate safety measures; consult with plumber and dialysis

4. Revascularize a cannulation-training arm.

5. Write objectives and simulation scenarios.

6. Collate educational equipment.

7. Book simulation room for practice ....

8. Book simulation room for renal simulation scenarios.

9. Notify nursing management and roster staff of educational
   dates for rostering purposes.

10. Engage nursing staff via ward meetings, promotional flyers.

11. Conduct renal simulation scenarios.

12. Collate evaluations, review, and modify as required.

Table 2

Current Renal Simulation Scenarios Offered

* Management of a fluid-overloaded patient on dialysis.

* Management of hyperkalemia while waiting for dialysis availability.

* Management of hypotension on dialysis.

* Commencement of first-dose iron during dialysis.

* Management of anaphylaxis (iron) on dialysis.

* Management of chest pain on dialysis.

* Management of cardiac arrest during dialysis.

* Setting up and initiation of single-needle dialysis.

* Setting up and initiation of therapeutic plasma exchange.

Table 3

Example of a Renal Simulation Scenario ('Marvin'): Chest Pain on
Dialysis/Anterior AMI/VT/VF

Theory Objectives                    Procedures

1. Recognition and management of     1. Terminating dialysis
ischemic chest pain on dialysis
                                     2. Airway maintenance
2. Initial management of
myocardial infarction on dialysis    3. CPR in a dialysis chair/unit

3. Management of pulseless VT/VF,    4. Defibrillation
BLS algorithms

Crisis Management Behaviors

1. Anticipation and planning

2. Leadership/teamwork/communication/use of resources during CPR

  a. Prioritization of tasks and updating team goals

Participant Group:

Setting: Patient having routine 5/hour dialysis. FX80, Clexane 60 mg,
K2. During treatment, patient complains of dull central chest pain; 3
nurses, 1 doctor (or another nurse), +/- arrest team.

Patient: Marvin, 57 years old, Diabetic nephropathy, been on dialysis
2 years.

Background: Diabetic, ESKD, dialysis for 2 years. No allergies.
History of myocardial infarction 2 years ago. Attends dialysis
regularly. Smokes 20 cigarettes daily.

Roles: Nurse 1 receives patient complaint. Nurse 2 working in another
area close by. Doctor is in clinics. Nurse 2 comes when called by
Nurse 1. Doctor (or nurse) comes in when called by nurse. Arrest team
arrival at end of BLS.

Standard Props: High fidelity mannequin, arrest trolley, IV trolley,
monitor (including ECG, SP02 monitor), BP cuff.

Extra Props: Tap fitting, dialysis arm, dialysis machine, portable RO,
RO tap fittings, dialysis chart/paperwork, previous ECG #11 and #12,
dialysis chair, PPT of ECGs, troponin level, dialysis trolley, blood
tubes, paper cup, aspirin, clopidigrel, morphine.

Commencement of Scenario Observations:

* BP: 156/80 mmHg

* P: Regular 76

* Temp: 36.5[degrees] C

* RR: 22 regular

* [O.sub.2] sat: 98% room air

Patient sitting in dialysis chair, patient chart completed,
on dialysis

Approximate                                           Expected
Time              States            Details           Actions

00:00             A: Patient on     "Nurse, my        * OF off
                  dialysis (obs     chest doesn't
                  stable). Patent   feel right.       * Oxygen
                  calls nurse,      I've got pain
                  complaining of    in my chest."     * Monitoring
                  dull chest
                  pain.             Nurse to          * BP/PR/Sats
                  B: RR 20 in                         * Lie patient
                  setting g of      Able to give      semi-reclined
                  pain. pain.       history of
                                    ischemic          * Call for
                  C: Pale,          sounding chest    nurse
                  clammy. PR 80     pain. Never had   assistance to
                  irregular, BP     before. No        collect ECG
                  150/80.           other medical     machine
                  D: Alert,         Medications       * Administer
                  oriented, able    include ESA,      anginine if
                  to give           calcitriol,       prescribed
                  history--pain     metoprolol. No
                  radiating to      allergies.        * Call medical
                  left shoulder,                      assistance
                  been present
                  for about 30                        * ECG
                                                      * Locate
                                                      previous ECG
                                                      for comparison

                                                      * Place on ECG/

00:05             Patient           When asked:       Medical staff
                  complains pain    "It's in the      to review ECG
                  becoming severe   middle of my
                  with radiation    chest."           * Note
                  to left                             importance of
                  shoulder          When asked is     CCU admission
                  continuing        it any where      for
                                    else: "It's in    thrombolysis
                  Patient pale      my left           option
                  and clammy        shoulder."
                                                      * Administer a
                  BP-105/58 P 136   When asked        saline bolus
                  irregular         other symptoms:
                                    "I'm feeling


0:08              Patient becomes   (ECG shows        * Initiate BLS
                  unresponsive.     anterior MI)
                                                      * Call arrest
                  Patient in                          team
                  cardiac arrest
                  with pulseless                      * Cease
                  VT and then VF                      dialysis,
                  A: Able to be                       patient's blood
                  ventilated with                     with saline
                  bag valve mask.
                  Standard airway                     * Obtain
                  difficulty.                         pathology as
                                                      per medical
                  B: No                               team
                  breathing. No
                  sats trace.                         * Leave in
                  Output, very                        venous line,
                  damped trace                        flush with
                  with CPR.                           saline until

                                                      * Complete

                                                      * Airway
                                                      protection with
                                                      rolling and
                                                      suctioning of

                                                      * Recognition
                                                      of VT pulse

                                                      * Preparation

                                                      * Initiation of

                                                      * Adrenaline

00:12                               NB: Give          BLS protocol
                                    prompts of        execution
                                    "patient is
                                    unresponsive"     * Repeated
                                    if participants   defibrillation
                                    are not in
                                    position to       * CPR with
                                    notice this       minimal
                                    when the          interruption to
                                    patient becomes   chest
                                    pulseless.        compressions

                                    Two cycles of     * Appropriate
                                    pulseless VTNF    attention to
                                    algorithm.        airway--should
                                    After second      initially be
                                    defibrillation,   bag valve mask
                                    rhythm will
                                    become SR and     * teamwork/
                                    gradually         leadership

00:15 to 00:20    Will soon begin   Patient moans.    * Possible
                  to breathe.       Return to SR      lysis/
                  Sats 99%. SR      with good         angioplasty
                  with output       output. Patient
                                    will begin to     * Heparin
                  BP--140/60 PR     cough/move over
                  120               next 1 to 2       * Possible
                                    minutes.          amiodarone
                  Minimal verbal                      infustion
                  response          Patient remains
                                    stable with       * Sedation
                                    obs.              * CCU/ICU
                                    "Cough cough,
                                    moan" Arrest      * Regrouping/
                                    team arrival.     summarizing

Discussion/Debriefing Points

* Anticipation and planning with patient deterioration
* Role clarity, participants' responsibilities
* Leadership/Teamwork/Communication (closed/loop techniques)/Use of
resources during CPR
* Prioritization of tasks and updating team goals
* Revision of management of AMI + BLS protocol in dialysis
* Situational awareness--AED
* CPR-correct ratio, oxygen delivery, airway maintenance
* Satellite unit variations
* PQRSTH for chest pain (pain, quality, radiation, severity/symptoms,
time, history)
* Troponin levels, ECG review

Table 4
Results from Post-Workshop Evaluations

Item                             Mean Score (n = 78)

Overall simulation experience            4.87
The education component                  4.85
The simulation                           4.84
The debriefing sessions                  4.80

Table 5

Summary of Responses to Open-Ended Questions about Experience with
Simulation Workshop

What did you like about the simulation sessions?

"Enlightening and exciting, learning revelations, amazing-skills,
communication, leadership, and teamwork."

"Practical and real; a very life-like experience; you can see where
you went well and where you could improve."

"Very real, forgot about the camera."

"Felt so very real."

"Non-threatening environment."

"Could not hurt anyone."

"Be educated without harm to patients. Takes the stress out of

"Debriefing with co-workers."

"Revisits skills, updates skills, and also helps confidence."

"Challenging and informative."

"It made me think about what action I needed to take and why I was
taking that action."

"To actually re-enact the situation and then watch the performance
on screen to see your own actions and teamwork"

Do you feel that your experience in these simulations will improve
or change your clinical practice?

"Gets people discussing pros and cons of actions and alternative
ways to do things."

"Yes, make me more aware of everyone else's roles in different

"Promotes self-evaluation"

"Improve practice on reflection of actions and knowledge."

"Improve clinical practice, improve education."

"Definitely improve - would like a lot more."
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Article Details
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Author:Dunbar-Reid, Kylie; Sinclair, Peter M.; Hudson, Denis
Publication:Nephrology Nursing Journal
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2011
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