When people in healthcare hear the word simulation, they generally think of a computerized mannequin that talks, breathes, and has other human physiological characteristics. Though the development of this human patient simulator, or HPS, has been able to serve as a breakthrough in the teaching/learning environment, there is more than meets the eye with the whole field of simulation.
Human patient simulation
HPS technology has been in use for about the last 10 years in some fashion. Implementation of HPS technology originally gained the most attention in nursing and medical schools, where its use continues to proliferate as new users encounter this technology for the first time.
More recently, such technology has made its way to the clinical practice arena and is used for orientation of new graduate nurses, ongoing staff development, staff competency assessments, required courses such as ACLS and PALS, and team training exercises for interprofessional education.
HPS technology is considered high fidelity, meaning that it is more lifelike than the older mannequins that did not respond via voice or change in physiological parameters when an intervention occurs. For example, high fidelity HPS technology can make a palpable pulse go away when there is ventricular fibrillation or asystole on the cardiac monitor, raise and lower the blood pressure in response to a drug being given, etc.
Standardized patients
There are other simulation teaching/learning modalities that can be used in concert with HPS technology or by themselves. Standardized patients, or trained medical actors, have been used in medical schools for the past 40 years to help medical students interact with real human beings. The use of SPs, as they are referred to, is gradually started to grow in nursing schools. SPs can act not only as a patient but as a family member or a disruptive colleague. This is particularly important, say, when staff development educators are trying to teach clinicians about teamwork and how to assertively speak up if they see something wrong.
For example, a "confederate," (also referred to as a disrupter), SP can act as an overbearing physician who adamantly insists that a nurse give a drug, even though it is not appropriate in that particular clinical situation and giving that drug could cause extreme harm or death to the patient. During the simulation activity, the nurse can learn how to effectively confront this confederate with good communication skills, which are an essential part of teamwork and patient safety.
Serious games and computer interactive devices
Other simulation modalities include serious games, which are essentially video games that are designed to teach concepts in an immersive computerized environment. The same game development technology that is used to build entertainment-focused virtual game worlds where "players" interact online using avatars (onscreen representatives of themselves), can be used to build learning games. Since the average age of video game players is now almost 40 years old, many in the workforce are very comfortable with this technology and would naturally be adept at learning this way.
Medical and surgical simulators, including devices that teach bronchoscopies, endoscopies, surgical procedures, coronary angiography, and many other skills, are proliferating in use. Computer interactive devices that teach IV insertion and IV therapy skills can be used for many different levels of providers, including paramedics, nurses, physicians, physician assistants, etc. Investment in these simulator devices, particularly for high-risk skills, can truly pay off in the long run.
Teaching teamwork
With patient safety being paramount, many institutions are using simulation modalities to teach and enhance interprofessional team training. One model that is commonly used is the Agency for Healthcare Research and Quality and the Department of Defense's TeamSTEPPS system, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety. Since healthcare teams are often contingency teams where the individuals do not necessarily work together on a regular basis (unlike a football team), there is even more need to make sure that all staff are trained in good teamwork and communication skills as they are not likely to know each other's capabilities and weaknesses.
Using simulation techniques can provide a safe and effective environment for all levels of staff to learn and interact with others on the healthcare team. More information on TeamSTEPPS can be found at http://teamstepps.ahrq.gov.
Competitive advantage of simulation
One of the major challenges that permeates simulation methodologies is cost. HPS can run tens of thousands of dollars for the initial investment alone. SPs are generally paid hourly not only for their simulation time, but for their rehearsal and training time for each character that they portray.
Serious games can be expensive for an initial startup, but once built, that technological platform can be used to produce different immersive learning scenarios very efficiently and effectively. Medical and surgical simulators, though costly, can be used extensively and with many learners over a long period of time. Even with the cost issue, these methodologies are extremely important to implement if institutions wish to remain competitive.
For example, students who are graduating from nursing and medical school have now been generally exposed to some type of simulation teaching/learning during their educational program. They naturally expect the institutions at which they will work will also have the same technology and employ the same teaching/learning strategies. Having a solid simulation program at an institution where the equipment and infrastructure are in place, along with well-trained and enthusiastic staff development personnel, can only be a plus for recruitment and retention of staff. In addition, simulation has been shown to increase learner retention and engagement. As noted previously, it provides a safe alternative to learning and practicing difficult skills since no real patients are involved.
One way to control costs is to partner with the healthcare professional schools in the local region. Regional simulation centers are growing around the country, and sharing of resources can help control costs for all involved. In addition, it can have the added benefit of bringing together diverse learners who might not otherwise interact. Multi-environment simulations can also be done in these centers, such as an EMS transport to the emergency department, then a transfer to the ICU, and then a transfer to the operating room.
The technology for simulation modalities is continually improving as companies respond to user requests for more and more capability. Institutions need to jump on the bandwagon or will eventually get left behind as this progression occurs.
For more information on the many uses of simulation, go to the Society for Simulation in Healthcare Web site at www.ssih.org.
Mary Holtschneider, RN, BSN, BC, MPA, NREMT-P, is the director of nursing practice and education for the North Carolina Nurses Association in Raleigh.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Working with nurses over the years, I've heard many stories about disruptive physician behavior and its effect on nurses and patient care. Here's one I heard just last week: A neurosurgeon walks on to the floor and starts screaming at a nurse because of something the surgeon didn't like about a patient's chart. After the surgeon leaves, the nurse looks at the other physician in the room and says, "I can't even breathe when he's in the room. Let alone talk to him."
The story was related as an example of the challenge hospitals face with improving patient safety. After receiving a public berating like that, how likely is the nurse to question the surgeon when he gives an order that might not be clear or that is not understood?
There's been a lot of discussion about the importance of interdisciplinary collaboration in recent years and a lot of work done to improve it, but a new survey conducted by the American College of Physician Executives demonstrates that disruptive physician behavior—and disruptive nurse behavior—is still alive and well.
More than 2,100 physician and nurse executives took part in the survey. Nearly 98% reported witnessing behavioral problems between nurses and physicians within the last year. Apparently, the behavior is not infrequent. Thirty percent reported witnessing bad behavior between physicians and nurses weekly, 25% said it happened several times a month, 30% said only a few times a year, and a shocking 10% said they witnessed it every day.
Sixty-seven percent of respondents were nurses and 33% physicians. Interestingly, while there were complaints about nurse behavior, both physicians and nurses reported that physicians were a large cause of disruptive behavior.
The most common complaint was about degrading comments or insults—reported by 85% of respondents—while 73% cited yelling. Other problems included cursing, inappropriate joking, and refusal to work with each other. Complaints about nurses covered issues such as backbiting, gossiping, or attempting to blackball physicians.
None of these stories are new to Kathleen Bartholomew, who has been speaking about improving relationships in healthcare since 2005 and published a book on the topic, Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication.
Bartholomew explains that problems persist because of the deeply-engrained healthcare culture. "Culture is so powerful that it even trumps best practice and education."
And she says that leadership has to take the lead in changing culture at organizations so that disruptive behavior is eliminated and relationships can improve.
There are three things organizations can do to reduce the effect of disruptive relationships, according to Bartholomew:
1. Survey your staff: Leaders need to have an understanding of the extent of disruptive behavior and how that behavior affects the institution, and the only way to do that is to ask.
2. Educate: The organization's zero tolerance policy has to cover everyone—without exception. The policy must be clear and direct: Describe what behavior is acceptable and desirable and which types of behavior will not be tolerated. Then, educate everyone about the zero tolerance expectations and continue with frequent reminders.
3. Follow up: There's no point having a policy if transgressions are ignored or swept under the carpet. For example, at one hospital, when a nurse makes a complaint about a physician, the situation is handled, and then someone comes back to the nurse and tells him or her, in confidence, what is being done about it.
At many organizations, complaints against physicians by nurses are dealt with by a committee staffed by physicians, which Bartholomew says can be a problem.
She suggests organizing an interdisciplinary committee to deal with formal complaints. Whenever an incident happens, no matter with whom, it then comes before a group of three or four people, including a physician, a nurse, and maybe some people from HR. That group examines the behavior and decides what actions should be taken. The multidisciplinary committee ensures actions are based on behavior, rather than who the complaint is about.
Bartholomew is a proponent of working on relationships on a personal level to help overcome the strong culture of hierarchy and power that plagues physician-nurse relationships. She recommends physicians go up to a charge nurse with whom they work frequently and ask, "What do you like that I do that improves patient care? What do you want to see more of?" And nurses should have similar conversations with the physicians.
Another strategy involves staging a physician and nursing summit. As a group, the nurses discuss and come up with a list of the five things physicians do that really bother them regarding patient care. And the physicians do the same thing about the nursing staff. Then they get together over dinner and discuss the results. For it to work, the focus has to be on patient care, rather than simply the relationships. The groups have to look at what they can do as a team to improve patient care.
Removing barriers that inhibit communication is ultimately one of the best ways to improve relationships and patient safety.
"We don't even have holiday parties together," says Bartholomew. "Doctors have them at a doctor's house and the nurses have them at a nurses' house. Until we can get rid of this segregation, we'll never have safe patient care."
Ultimately, no matter how good you think the relationships at your organization are, they can always be better. And if they are, then patients will be safer.
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A new survey conducted by Misericordia University and Braun Research found that two in five Americans plan to spend less this holiday season as a result of rising health costs, and three in 10 said healthcare costs have led to arguments and tension with friends and family members.
The Health Care in America survey also concluded that the healthcare reform debate is a cause of stress and annoyance among the majority of Americans. Those surveyed reported that their top concerns with healthcare reform include the cost to future generations and its impact on the federal deficit, the cost of out-of-pocket expenses, and the accessibility of quality coverage.
"As we move closer and closer to healthcare reform legislation in this country, it is paramount that we keep in mind the impact that this process is having on individual Americans," said Misericordia University Michael MacDowell, EdD, in a statement.
The survey of 1,000 U.S. residents was conducted via telephone between Nov. 6 and Nov. 16. Other key findings of the report include:
Nearly a quarter of Americans admit that they would consider withholding information from an insurance provider if it might limit their ability to access healthcare.
At the same time, nearly 80% of those surveyed said they have not withheld information or "bent the truth" regarding compliance with a healthcare provider's instructions, lifestyle issues surrounding areas, such as exercise or smoking, and medical history.
Families and doctors are the most trusted sources of information for healthcare reform. Younger people (ages 18-34) trust President Obama on the issue, but the survey found politicians garner very little trust from Americans. In addition, though those surveyed said they put less trust in news programs, newspapers, and Web sites, they continue to turn to them for information on health reform.
The recession has pressured Americans to prioritize healthcare alongside other expenses, and many have changed their behavior, including dealing with illness without treatment and visiting the doctor less.
Nearly half of those surveyed tried to "get over" being sick without treatment and 98% are trying to visit the doctor less frequently. In addition, 11% of those surveyed were forced to drop healthcare coverage because of the recession, and 33% were concerned about losing their health insurance.
While more than 90% of Americans are satisfied with their insurance coverage, about 33% of Americans do not take advantage of preventive health testing/screenings even when it is available.
A quarter of those surveyed said the current discussion about health reform has impacted their use of their healthcare. Of those that said healthcare reform has impacted their decisions, 55% said they will only do what is absolutely necessary, and 28% said they will take advantage of everything covered by their insurance.
The majority of Americans feel either annoyed or frustrated by the current healthcare debate. Older Americans nearing retirement are following the debate more closely and tend to feel more anger, tension and helplessness.
Fifty-three percent of those surveyed said healthcare causes stress. Those with an annual household income of $30,000 or less were more likely (67%) to say that healthcare costs cause stress, while those with an income of $100,000 or more were much less likely to say health costs caused stress (28%).
Holiday spending will be lower this year for 40% of those surveyed because of rising healthcare costs. Those without health insurance are more likely than others to spend less, and the likelihood of spending less decreased as the household income of the respondent increased.
After months of negotiations, representatives from the nation's three largest registered nurses unions voted unanimously Monday to merge and create a 150,000-member, coast-to-coast "super union" with a mission to organize every bedside RN in the nation.
The new union, National Nurses United, which organizers say is the largest union and professional organization of registered nurses in U.S. history, will represent RNs who up to now had been served by the California Nurses Association/National Nurses Organizing Committee, United American Nurses, and the Massachusetts Nurses Association.
"We are going to make sure we organize every single direct-care RN in this country. RNs and our patients deserve to have a national nurses movement that can advocate for them," said Deborah Burger, RN of CNA/NNOC, who was elected Monday as one of three charter co-president of NNU, in a media release.
The other two NNU co-presidents are Karen Higgins, an RN from Massachusetts, and Jean Ross, the secretary-treasurer of the UAN.
Monday's vote at a ratifying convention in Phoenix, AZ, was the culmination of months of planning that began in February when the three unions announced the proposed merger. Each union conducted separate ratifying votes among its members this fall, and Monday's overwhelming vote of approval was not a surprise.
In adopting a constitution and electing national officers, the NNU said it will campaign to:
Advance the interests of direct-care nurses and patients across the U.S.
Organize all direct-care RNs "into a single organization capable of exercising influence over the healthcare industry, governments, and employers."
Promote effective collective bargaining representation to all NNU affiliates to promote the economic and professional interests of all direct-care RNs.
Expand the voice of direct-care RNs and patients in public policy, including the enactment of safe nurse-to-patient ratios and patient advocacy rights in Congress and every state.
Win "healthcare justice, accessible, quality healthcare for all, as a human right."
"This means we finally have [an organization and constitution] that directly challenges the role of corporations in healthcare delivery, instead of accommodating and enabling their control," said Minnesota Nurses Association President Linda Hamilton, RN.
NNU is affiliated with the AFL-CIO. Stewart Acuff, personal assistant to AFL-CIO President Richard Trumka, attended the ratifying vote and called the formation of the NNU a major step in the fight to achieve "healthcare for every American regardless of ability to pay, socio-economic status, or accident of birth."
He then urged the NNU delegates to work toward passage of the Employee Free Choice Act.
Steris Corp. has reacted strongly to a Food and Drug Administration (FDA) recommendation that hospitals consider alternatives to a popular Steris sterilizing product.
In a safety notice published last week, the FDA said Steris modified its Steris System 1 (SS1) processor and that the agency hasn't approved the modifications yet. The SS1 is used in surgical and endoscopy suites for sterilizing or disinfecting medical devices.
The agency also said that despite discussions with Steris since 2008, the FDA is not satisfied with the company's response to concerns about providing hospitals with adequate replacements to the SS1.
Steris, based in Mentor, OH, issued a statement late Friday criticizing the FDA's alert.
"We disagree with the FDA's recent notice and are working to engage in further dialogue with the agency about this matter," said Walt Rosebrough, Steris' president and CEO.
About 23,000 SS1s have been used in more than 5,000 hospitals and clinics in the country, according to Steris.
"There has not been a documented case of infection directly caused by a System 1 Sterile Processing System when proper guidelines and instructions are followed by certified health professionals," the company said in correspondence with customers also published Friday.
The FDA countered that it has received some reports of SS1 malfunctions that had the potential to cause infections. "Infections that occur after a procedure using a medical device reprocessed in the SS1 may be difficult to attribute to the SS1 and may go unreported," the notice said.
The FDA notice made the following recommendations:
If hospitals have an acceptable alternative to the SS1 to meet sterilization and disinfection needs, facilities should transition to that alternative as soon as possible to ensure patient safety
If hospitals don't have an acceptable alternative, facilities should promptly assess patient care needs and sterilization and disinfection requirements, and take steps to obtain legally marketed substitutes for the SS1
Based on earlier unease from the FDA, Steris sent customers correspondence about its submittal of a new premarket notification for the updated SS1 in January. The SS1 revisions in question include mechanical and software changes to the processor, according to Steris.
Steris has established a dedicated hotline for more information about the SS1 at 440-392-7223.
If proposed healthcare reforms, including a public insurance option, are good enough for the country, Senators Tom Coburn (R-OK), Charles Grassley (R-IA), Richard Burr (R-NC), and David Vitter (R-LA) said they should be good enough for the White House and Congress. On Tuesday, they proposed just that in an amendment to the Senate healthcare reform bill.
The amendment is not exactly new. This past summer, Coburn (a public option foe) had introduced an amendment that stated that if the public option passed, members of the White House and Congress should enroll in those plans in their jurisdictions. Coburn's amendment passed this summer in the Senate's Health, Education, Labor and Pensions Committee reform bill. "I can think of no better way to ensure that the public option is responsive to our citizens than by having the politicians in charge of the system enrolled in the same program," he said.
Similarly, Grassley, ranking minority member of the Senate Finance Committee, had proposed his public option enrollment amendment during the committee's deliberation this past fall—which received unanimous support from both sides of the aisle. However, the amendments disappeared during the reconciliation process for the final Senate bill.
Grassley said he learned last week that the staff members of Senate leadership offices and committees would be exempted from the requirement that members of Congress and congressional staff get their employer—based health insurance through the same system that would apply to the rest of the country. Grassley said the carve—out came to light after he asked the Congressional Research Service to analyze the bill—and they confirmed the carve—out.
The amendment filed Monday combines the Coburn and Grassley amendments, and calls for putting all members of the House and Senate and their staffs in the public option in states that have one and in the exchanges in states that opt out of the public option. The amendment also calls for enrolling the president, the vice president, White House staff, and all administration political staff in the public option or exchange (depending on their state).
"The White House and cabinet secretaries are working very hard for this massive overhaul of America's healthcare system," Grassley said in a statement. "It's only fair that if this bill becomes law, these individuals should themselves be subject to the reforms. The same is true for congressional staff. Quietly carving out leadership staff and committee staff behind closed doors is unacceptable. If the reforms are as good as their supporters say, the reforms should be good."
In other Senate healthcare reform action:
The Senate approved an amendment proposed by Sen. Mark Pryor (D-AR) in which an enrollee satisfaction survey system would be used to evaluate the level of enrollee satisfaction with qualified health plans offered through the states' new insurance exchanges.
An amendment by Sen. Judd Gregg (R-NH) to "prevent Medicare from being raided for new entitlements and to use Medicare savings to save Medicare" was defeated.
Debate and a possible vote are expected today on the abortion amendment introduced by Sen. Ben Nelson (D-NE) and Sen. Orrin Hatch (R-UT) on Monday that would ban abortions in public and private health insurance plans that receive federal subsidies.
Seeking to resolve two contentious issues blocking healthcare reform in the Senate, lawmakers began consideration of an amendment to restrict abortion coverage, while Democrats closed in on alternatives to the public-insurance option, the Washington Post reports. The abortion provision would bar individuals who receive federal insurance subsidies from purchasing private policies that cover elective abortions. A group of 10 liberal and moderate Democrats said they were considering alternatives to a federally sponsored health insurance plan that could expand Medicaid and Medicare and create new national private plans overseen by the government.
In return for concessions on their proposal for a new government-run health insurance plan, liberal Democratic senators pushed for expansion of Medicare and Medicaid and more stringent federal regulation of the insurance industry. Liberal and centrist Democrats are trying to work out a deal on the proposal for a public option. Under a possible compromise, the federal Office of Personnel Management would negotiate with insurance companies to offer national health plans to individuals, families, and small businesses, the New York Times reports.
Senate Democrats are considering a significant expansion of Medicare and Medicaid as part of a package of potential changes to health-overhaul legislation that would also sharply scale back a proposed new government-run insurance plan, the Wall Street Journal reports. The proposals have emerged in closed-door negotiations among 10 Democratic senators assigned by party leaders to break the political deadlock that has slowed Senate action on the health bill. Negotiators were considering a proposal that would open Medicare to people ages 55 to 64 if they couldn't find coverage elsewhere. The proposal would allow them to buy insurance coverage at subsidized rates under Medicare, though the subsidies wouldn't be as great as those for people 65 and over, reports the Journal.
Nurses from three unions have founded a new national union to influence national healthcare policies and try to extend California's patient ratio law into other states. Organizers said the 150,000-member National Nurses United, the largest professional union for registered nurses in the country, will also push for a stronger voice in the healthcare overhaul process going on in Congress and the expansion of representation for nonunion nurses. The merger, approved at a convention in Phoenix, combines the California union with the Massachusetts Nurses Union and members from the United American Nurses, who work primarily in the Midwest. The unions will continue to operate separately, but will be aligned under the larger umbrella of National Nurses United, the San Francisco Chronicle reports.
