Innovating Education for 21st-Century Care

The train-wreck survivors are bloodied and bruised. A man with a broken nose begs for morphine, as does a woman whose gashed ankle reveals a protruding bone. Another woman, her wrist swollen and blue, pleads for someone to call her child’s nursery school. Nearly 100 onlookers from New York City health care institutions observe students taking turns assessing wounds. A film crew captures the disaster as patients moan in fear and pain.

The emergency is staged, the injured are actors. But the students are not pretending. They are applying classroom learning to a real-world setting during an open house in Columbia University School of Nursing’s Helene Fuld Health Trust Simulation Center, where the school showcased how new technology is transforming education, and shared best practices with experts and educators in the field.

Transforming Simulation Technology in Nursing Education

Simulation is not new to nursing education or to Columbia Nursing. Students have traditionally used manikins to practice listening to heart and lung sounds, dressing wounds, and inserting catheters. But with the opening last fall of the Helene Fuld Health Trust Simulation Center, which features a high-tech manikin that responds to the administration of anesthesia by nurse anesthetist students, another manikin that delivers a baby with the help of midwifery students, and other scenarios made possible by state-of-the-art simulation technology, the school has raised simulation education to a higher level. The technology is being used not only for task training but also to create lifelike situations in which students must think critically, respond quickly, and make informed decisions.

“The school is enhancing the science of simulation and how it is being used to prepare students,” says Stephen Ferrara, DNP, assistant professor and associate dean of clinical affairs. “Our simulation center is a learning environment, as well as a platform for advancing the field by increasing the quality and safety of care, and exchanging ideas with other educators and health care systems.”

In this 16,000 square-foot, ultramodern learning laboratory, MDE (master’s direct entry) and advanced practice registered nursing students encounter the myriad tasks and scenarios that mirror what they will face in real-life clinical settings. The simulation center features authentically appointed patient examination rooms, two inpatient hospital rooms, a labor and delivery suite, and an operating room. Every room has been furnished with the equipment one would find in a clinical setting––blood pressure cuffs, thermometers, otoscopes, ophthalmoscopes, oxygen supplies, nitrile gloves, and monitors––for assessing and tracking patients’ health status. All have a sink for handwashing, and a laptop computer for maintaining electronic medical records (EMRs). And each room has the latest audiovisual technology for recording students in action, providing a source of instructor feedback. “This gives students the opportunity to work on a scenario and hone their skills for real-world situations,” Ferrara says.

Research shows that simulation education increases student confidence and improves patient safety. Instead of performing a procedure for the first time on a patient, students first practice on manikins, says Kellie Bryant, DNP, assistant professor and the center’s executive director. “The more they practice and build their skills, the more confidence they acquire, and the better they will perform in a real clinical setting,” Bryant adds.

Kamal Nguyen, an MDE student who hopes to pursue a degree as an adult gerontology acute-care nurse practitioner, says that learning in the simulation center has boosted his self-assurance. “It ensures that I will provide safer care to my patients, and enhance patient outcomes, which is the main goal.”

Learning to Think Critically in Real Time

The simulation center features an array of task trainers and manikins––from low fidelity to high fidelity. A technician operates the computer that makes the high-fidelity manikins breathe, gasp for air, speak, blink, and respond to medication.

Caring for these computerized “patients” familiarizes students with the protocols of patient care: hand-washing, donning nitrile gloves, scanning bar-coded wristbands, performing an assessment, and recording patient information in an EMR. They also learn to track clinical treatment orders, insert intravenous lines, administer medications, and continually assess patients. The advanced practice registered nurse students perform sophisticated procedures: diagnosing and treating acute and chronic illnesses; attending simple or complex deliveries; evaluating a newborn’s Apgar scores; or intubating a patient awaiting anesthesia.

Repeating these tasks helps students perfect their clinical skills. Yet it’s confronting the unexpected that teaches what classroom lectures cannot: how to get students to think step by step, and on their feet, says Eileen Thomas, EdD, assistant professor and simulation educator. For example, an instructor can program a manikin to develop fluid in its lungs, or have signs and symptoms of a heart attack. “Simulation encompasses diverse ways of learning, but usually when we speak about simulation education, we are speaking about running an unfolding case study,” Thomas says. “It is here that students’ critical-thinking skills are developed.”

Critical thinking is essential to good decision making, Ferrara adds. “It’s not just about being able to administer a treatment or medication but also asking, ‘Is this the appropriate treatment for this patient’s diagnosis?’”

Seeing Patients as People

Columbia Nursing students have always received clinical preparation by rotating through a number of clinical sites, including Columbia Nursing’s faculty practice. Simulation education doesn’t replace these experiences; rather, it augments students’ skills, says Karen Desjardins, DNP, assistant professor and assistant dean for academic affairs. “We’re trying to help students increase their confidence and rehearse their critical-thinking process in a safe and efficient environment so they develop clinical competence.”

Nguyen says that working with a manikin that simulates a birth was the best preparation he could have had for his obstetrics-gynecology rotation at Mount Sinai Hospital. “Caring for a patient during a vaginal birth was unlike anything I’d ever experienced,” he says. “I was able to look back and remember the step-by-step nursing interventions when I got into the hospital setting.”

But task training is only one part of simulation education, Ferrara notes. Indeed, the scenarios that students experience in the simulation center challenge them to see beyond tasks and into patients’ lives. “They learn how to manage complex issues, such as helping individuals with adherence to treatment, and patient and family interactions,” Ferrara says.

Scenarios frequently involve role-playing. Students take turns pretending to be patients or family members; some role-play with professional actors––known as standardized patients––who portray patients with any number of conditions such as a cough, congestion, or gastrointestinal discomfort, symptoms that require investigation. “We use actors more for advanced practice students who are going into primary care,” Ferrara explains. “We may create a scenario where a patient has been experiencing increased thirst, urination, and weight loss over a couple of months, signs and symptoms suggestive of early-onset diabetes. Students are responsible for taking a history, performing the appropriate exam,  ordering the appropriate lab or radiology tests, and doing it in an economical and comprehensive way,” he says. Some scenarios also require students to have conversations with patients who are facing a difficult diagnosis or treatment.

“The scenarios challenge us to look at a patient holistically, to think about their living situation, their cultural background, whether they’re getting family support, and the effects on their health,” Nguyen says. “They force us to think critically.”

Modeling Nursing Education and Patient Care

In addition to facilitating real-world clinical preparation, Columbia Nursing’s simulation education is inspiring new models for teaching and patient care through partnerships with other health care organizations. For example, a local health system has solicited the school’s expertise in helping prepare NPs to recognize and address the multiple challenges of caring for orthopedic surgery patients who present with common comorbidities such as cardiovascular complications, obesity, sleep apnea, and diabetes; opioid and alcohol use; and the lack of family or social support.

With these considerations in mind, Columbia Nursing has developed a customized symposium for the Hospital for Special Surgery (HSS), featuring scenarios in which manikins or actors develop potentially grave postoperative complications, according to Patricia Quinlan ’09, PhD, the hospital’s assistant vice president of nursing excellence. “I want our nurses to have the simulated experiences of managing cases that would be similar to those found at HSS,” Quinlan says, adding that the symposium will also cover pain management, transitioning patients from hospital to home, care coordination, leadership, and patient advocacy. “They need to know how to think on their feet as problems escalate.”

Being able to respond quickly improves outcomes and increases patient safety, says Desjardins, who designed the HSS symposium. “When emergencies happen in the hospital, you don’t have much time. You have to learn critical thinking beforehand, and practice the decision-making process in your mind so that when something happens in real time you know what to do.”

Helping to Stem Opioid Overdoses

Columbia Nursing’s use of sophisticated technology to replicate real-life emergencies for education is one of the reasons why the New York State Department of Health (DOH) has registered it as a site for training in opioid overdose recognition, treatment, and prevention. “Overdose from opioids is the number-one killer of people under 50 in the United States,” Bryant says. “Our collaboration with DOH allows the school to play a critical role in helping to stem the opioid epidemic.”

As executive director of the simulation center, Bryant provides the hands-on education, which entails distributing kits provided by the DOH containing the overdose reversing agent naloxone and teaching participants to use them. Bryant will prepare all Columbia Nursing students, Columbia University Irving Medical Center practitioners, and anyone in the community who is interested, which will have profound lifesaving potential.

One of the first to receive the training at Columbia Nursing was New York State Lieutenant Governor Kathy Hochul, who received her naloxone education and training from Bryant and Thomas and has prioritized fighting the state’s opioid epidemic. “New York is investing heavily in higher education to train our students of today for the careers of tomorrow, especially careers in STEM-related fields,” she says. “Columbia University School of Nursing is at the cutting edge of clinical simulation, providing students with a realistic setting to hone their skills before entering the field and caring for real patients. By investing in the future of our students, we are investing in the economic future of New York State.”

Transforming Models Beyond Simulation

Simulation technology and Columbia Nursing’s ongoing collaboration are just some of the ways in which the school is using new and replicable teaching models to transform education. Its partnership with the Boomer Esiason Foundation and the Johnson & Johnson TRUE Heroes Program to create the October 2017 conference, The Path Forward in Cystic Fibrosis: Advanced Education for Nurses, is another.

The school developed the national, multidisciplinary conference to educate registered and advanced practice nurses about breakthroughs and challenges in cystic fibrosis (CF) treatment and care. In addition to presenting the most current in CF science, the conference connected nursing leaders from all over the country who came seeking new knowledge, skills, and professional support, says Lisa Iannacci-Manasia, PNP, clinical instructor and conference program director. “Not many nursing programs, even in advanced education
tracks, can address the breadth of knowledge that is needed to care for individuals living with CF,” Iannacci-Manasia says. “This program bridges that gap.”

The inaugural program also provided a model for the four collaborating cystic fibrosis centers at the University of Pennsylvania (PennMed), Boston Children’s Hospital, Cincinnati Children’s Hospital, and the Baylor College of Medicine that will sponsor similar conferences during the next year, under Columbia Nursing’s guidance. “These centers will be building upon the Columbia Nursing CF curriculum and, accordingly, they will be educating hundreds more nurses in CF treatment and care,” Iannacci-Manasia says.

Continuing a Tradition of Innovation

The imperative to advance nursing research and clinical practice has driven innovation at Columbia Nursing for more than a century. Innovation thrives on the exchange of ideas and best practices, which has inspired the school to partner with other organizations and to host events, like the upcoming Helene Fuld Institute for Excellence in Simulation Summit this fall, at which national and international experts will convene to discuss the future of simulation education, its impact on patient safety and outcomes, future research, and accreditation.

Bryant calls the summit, the first that will occur at the school annually for the next five years, a “simulation education think tank” for nurses and other health care leaders seeking an opportunity to network and collaborate. “We know that simulation education has a major impact on nurses’ professional development, confidence, and on patient safety,” she says. “Now we need to come together and focus on what research needs to be done to advance the field.”

And what better place than Columbia Nursing, which has a 125-year tradition of transforming nursing education? “Our goal is to be a center of excellence, to make this the place people will come to when they want the latest in simulation-based education,” Bryant says. “We want to continue to be the innovator and leader people look to.”