This piece is part of the DrexelNow series showcasing "A Day in the Class" for some of Drexel University's most interesting and impactful courses.
In the control room before the quarterly Disaster Simulation run by Drexel University’s College of Nursing and Health Professions, several of the more than 35 people it takes to make the simulation a success perform preparatory duties.
Nursing faculty discuss their strategy for the various scenarios they’re about to run for students and debrief them on afterwards. Local actors who become simulated patients during the lab mill about, applying make-up and pieces of costume.
“Do you know how to turn on SimMan?” asks one, who will later voice this mannequin he’s asking about, as it will become a coding patient in need of revival. “I’m having a rough dayyyy,” he continues, singing this last part rather than saying it.
It is, in fact, about to be a rough day, and unfortunately, that’s the point.
The simulation lab is a required rite of passage for all of Drexel’s Bachelor of Science in Nursing (BSN) students, and is a key component of the class titled “Population Health Concepts.” It simulates the worst-case, yet realistic scenarios that nurses might come across in their career, from pandemics to disasters to mass-casualty situations — and the chance to practice before they treat out in the field.
These are conducted in the College’s simulation labs run through the Center for Interprofessional Clinical Simulation and Practice, whose purview encompasses more than 22,000 square feet of lab space and state-of-the-art simulation technology.
As the faculty and simulated patients continue to prepare, the students participating in today’s lab gather in the hallway outside, speaking quietly amongst themselves.
“I’m feeling a little nervous,” said Audrey Tibay, a fifth-year nursing student, adding that they only do simulations like this twice a year as part of the program. “It’s always a little nerve-wracking going in, but I’m excited to learn something and get something out of it.”
“I’m more excited,” Melissa Radcliff, also a fifth-year nursing major, chimed in. “I like learning about disasters and I think it’s interesting. It’s not the stuff that we would do every day — it’s more worst-case scenario, so I think it will be a fun time.”
Luan Ta, also a fifth-year nursing major, was feeling a mixture of both emotions relayed by his classmates, but knew that this simulation would be a good experience.
“I’m as prepared as I can ever be because I don’t think anybody is ever 100 percent prepared for a disaster,” he said.
Whatever the primary emotion they’re feeling, it’s likely mixed with adrenaline as the students file into one of the two rooms that adjoin the control room in the Human Patient Simulation Lab for a preliminary briefing. They put their belongings down in a cluster on the floor and pull their stethoscopes out of their bags, then join their classmates standing in a horseshoe around Helen Teng, PhD, assistant clinical professor and the course chair.
Teng asks how the students are doing and takes roll while also announcing their groups for the day. She then sets up important framework points for lab: that there will be four scenarios, and a small break in between each one; that they can ask questions before and after, but “once the simulation starts, the faculty are just flies on the wall”; that some actors will play multiple roles within a scenario; that this simulation will not be graded.
“This is purely a learning experience for you, so engage, enjoy and have fun,” Teng said after summing everything up.
The groups break and prepare for disaster.
“Did it make you think?”
Tibay, Radcliff and Ta, along with their two classmates, form a group and file into their first scenario. Here, adjunct CNHP faculty member Kayann Laughlin talks the students through a tabletop exercise where they must determine the steps of managing a pandemic from a public health perspective. Laughlin primed the students by saying this exercise would be different than the others in that it was more theoretical rather than active.
According to Teng, some nursing schools only do these theoretical tabletop simulations if they do simulations at all, and while it’s also effective, it’s also obviously very different from the simulated patient scenarios this group of students will experience later on.
“I think in terms of the quality and the effort and the financial investment we put in ours, [Drexel’s simulations are] probably on the higher end,” Teng said.
This elevated status of Drexel’s simulation program is also not in small part due to the effort that goes into the simulation before the lab day even comes. The students study and are quizzed on online modules meant to prepare them with the nursing and procedural knowledge needed to navigate each scenario. They are also provided a lecture the week before lab day to refresh them on what they learned from the online modules, with “clues” inserted on what areas they should focus on reviewing before the day comes.
Teng preps the faculty and staff involved with each Disaster Simulation scenario, reviewing previous student feedback and making sure they’re in roles and facilitating scenarios they feel most comfortable with. She also speaks with each of the actors one-on-one to make sure they understand the scenarios, the roles they’re portraying and what the appropriate responses should be to students’ actions.
Each scenario is something these students could possibly come across in the workplace, Teng said, making these safe, experiential learning environments for them to practice their skills and responses very important.
“It is good to expose our students to these ways of thinking and encourage them and engage in their psycho-motor domain of learning by doing,” she said.
“We value experience and we value not just didactic teaching but pairing it with simulation in order to give learners an opportunity to practice and get feedback and reflect on the decisions and their thinking in order to be safer practitioners in the future,” added Kate Morse, PhD, assistant dean for Experiential Learning and Innovation for the College of Nursing and Health Professions.
As the first scenario wraps up, Laughlin asks, “Did it make you think?” and the students all nod their heads in agreement. She adds that the goal of the exercise is to help them look at the problem through the lens of the core tenets of public health: policy, risk assessment and assurance.
“It made me think outside the nursing world,” Ta added.
“Take a deep breath.”
Next, the students file into a classroom with chairs and tables strewn across the floor in disarray. Assistant Clinical Professor Mary Green and Adjunct Faculty Omolabake Fadeyibi explain that the students have five minutes to set up the room to effectively run patients through stations for mass-outbreak vaccination clinic. Right as they’ve determined and set up necessary stations, there are already five simulated patient actors waiting to get in. Soon, that number doubles, and the five nurses are handling multiple disruptive and disgruntled patients answering an onslaught of questions that might all come up if this was the real thing.
Suddenly, a couple starts a disturbance at the registration table. Radcliff quickly jumps in to take control of the situation and tells one of the actors to calm down.
“Take a deep breath,” she says, but the actor tries to leave. Radcliff blocks her way.
“I think it will be better if you stay,” she urges.
Radcliff said she learned how to handle tough situations like this through co-ops, and that full-time exposure to the profession.
“I get attacked all the time. I’ve been punched, choked. I was pinned up against the wall…” she said matter-of-factly. “But you do get used to it.”
“Not saying you get comfortable with it, but you get desensitized to it,” added Ta.
“You develop some thick skin,” said Tibay.
Morse agrees that co-op experiences help these students accelerate their coping skills more quickly, and lend them the ability to transition to a real practice much faster when they graduate. This is also a goal of the Disaster Simulation, but some students don’t necessarily expect this level of chaos, even after experiencing co-op, added Teng.
“I think it is important for our students to have the experience to kind of be put on the spot, where the resources are a little bit stretched, there’s little man power, to get a sense of the urgency of this organized chaos that needs to take place in these situations,” she said.
And the students certainly felt the chaos embedded in this simulation. After the bickering couple, they also navigated working with inebriated and distracting simulation patients, as well as others with virtually unanswerable questions.
“How did it go?” Green asks the students after the simulations ends, to which they respond with “Bad” and “Terrible.”
Though Radcliff was praised for stepping in and taking charge, she later said that this was the most stressful scenario for her even despite what was to come.
“They just try to encourage us to take the theory we learned from lecture and put it into practice,” Tibay said.
“But nursing is not by the book,” Ta replied.
“We’re dying here!”
Their third scenario requires the group of students to don full-body personal protective equipment (PPE), which may make them feel hot and claustrophobic on top of the stress of the task at hand — a mass-casualty site requiring triage, where the nursing students have become first responders. The scene encompasses simulated patients and mannequins in all variations of distress. And those simulated patients are by no means quiet. Actors in the adjoining control room voice the mannequins who represent live patients while others in the simulation room congregate on the sidelines awaiting care, and growing impatient.
“Why don’t you people do something!” wails one particularly loud actor. “You’re standing around. We’re dying here!”
The students later reflected on how emotionally charged this simulation made them feel due to the reactions from the simulated patients.
“They kind of go ham, and try to make it so intense, which is realistic but also not,” Radcliff said.
“They didn’t let us focus on what we were really there for, which we should really practice,” added Tibay.
“It was constant distractions,” finalized Ta.
Kris Eden, simulation lab specialist for the College, said that different simulations afford different latitudes to the actors in terms of their performance, with Disaster Simulation offering one of the wider latitudes.
“That is what they go over in training — kind of how hammy and how big they can be with the character that they’re embodying,” he said.
Eden described his role in the simulations like that of a stage manager for the theater. He manages the hiring and day-of coordination of the simulated patients as well as providing technical support from the control room and many other reactionary responsibilities.
“I am there to kind of catch the pieces as they fall and rearrange them,” he added with a laugh.
It is this close orchestration of the patient actors that really set the College’s simulations apart from other schools, said Morse, and that provide the right amount of emotional activation without overwhelming the students.
“I don’t think it detracted from their learning because being able to adjust and respond and manage those kinds of situations is a critical skill for a nurse in a disaster and everyday nursing life,” Morse said.
After the simulation ended, faculty debriefing the students agreed that this was the loudest the actors had been all day.
“Unfortunately it could be like this, or even worse, in a mass casualty scenario,” said adjunct faculty Eileen Kelly.
“You’ve had a really bad day…”
The scenarios have gotten steadily more stressful as the day has gone on for these students. It’s been three hours of non-stop simulation with one more to go. The students are told that they will now be helping out in a fictional ER with multiple victims arriving following a mass casualty event. Expected chaos ensues as the students work to corral the confused, each new walk -in vying for their attention. And not all the patients are walking. Radcliff and her fellow student treat a SimMan mannequin through multiple phases of cardiac distress.
The SimMan can mimic a variety of ailments that come up regularly on the job, from a closed airway to abnormal breath sounds to pulse palpations. Eden said mannequins like this are important to incorporate into the Disaster Simulation because there are limits to what you can ask an actor to do.
“We’re able to put our mannequins through a lot more, things that people can’t really control like their pulse and their blood pressure,” he said. “Those aren’t things you can just tell somebody to change on a whim. … Sometimes we need someone to go through a heart attack scenario and that’s not something you can ask a person to do.”
While Radcliffe and her partner are busy working on their patient, they don’t see that their three other group members are floundering with the simulated patient actors coming into the ER. It’s chaos up until the very end when a call that “The scenario is now over” echoes across the room.
Morse helps debrief the students this time. She asks if, in the chaos, they thought to try to connect quickly as a team.
“Even when it gets chaotic like that, taking 10 seconds will bring you 10 minutes of calmness,” she said.
Morse describes what happened with the students as situational awareness, where nurses can get so focused on the patient they’re helping at the time that they are unaware of each other and the situation as a whole. But she also doesn’t discredit the fatigue these students might be feeling after the day they’ve had.
“You’ve had cognitive overload today. You’ve had a lot of disasters,” she said as the debrief came to an end. “You’ve had a really bad day. But that is the reality of the profession.”
After this “really bad day,” Teng and Morse hope students come away with some important skills, like this increased situational awareness and how to communicate effectively through the chaos. Additionally, they believe it bolsters students’ confidence in their nursing assessment and leadership abilities. And, for obvious reasons, it’s better to hone these skills in the lab rather than on the job.
“[This is a] psychologically safe space for the learners, meaning they feel comfortable sharing what they don’t know, mistakes, sharing their thinking when they think it might be different from somebody else’s,” Morse said. “And they’re adult learners, so they’re going to continue to reflect after they leave the session.”
This was certainly the case for Radcliff, Tibay and Ta, who, even days after the lab, readily agreed that simulations are very beneficial, and provide experiences they will draw on in their future careers.
“I feel like the feedback always helps every time we do Sim,” Tibay said. “I always take whatever feedback the [simulated patients] or the professors who are watching give me and keep that in mind for next time or even when I work.”
And there was one more thing they all agreed on.
“I would have failed if it was graded,” said Ta as Radcliffe and Tibay nodded.
“I would have been so much more nervous,” Radcliff added.