Author: Naomi Cazeau, MSN, ANP-BC, AOCNP
Title: Adult Stem Cell Transplant Nurse Practitioner & Ed.D student
Institution: Memorial Sloan Kettering Cancer Center/ Teachers College, Columbia University
Skills or Simulation Laboratories
1. Enhance learner knowledge and confidence with the stem cell infusion process (knowledge, attitudes)
2. Orient learner to key elements of the interdisciplinary management of the critically ill BMT patient (knowledge, attitudes)
3. Review basic components of stem cell infusion process (knowledge, skills, attitudes)
4. Demonstrate patient and room set up for a stem cell infusion (skills)
5. Identify primary components of emergency code cart (knowledge, skills, attitudes)
6. Apply evidence-based communication techniques (i.e., SBAR, closed loop) to a resuscitation event (skills, attitudes)
7. Simulate the interdisciplinary management of a BMT patient emergency (knowledge, skills, attitudes)
According to Stephenson (2015), simulation can be used to ensure competency and evaluate nursing performance with high risk/low frequency procedures and processes. Stem cell transplantation and codes are both such events in healthcare. This strategy submission details the design of a stem cell infusion/mock code simulation learning activity for the professional development setting. The simulation is based on a stem cell infusion evolving case study, wherein the patient rapidly declines and requires a medical code. The program was designed and implemented within an inpatient stem cell transplant unit orientation for new graduate nurses. The topic was selected based on a needs assessment from the unit clinical nurse specialist and one of the senior staff nurses. The simulation program aims to enhance learner knowledge and confidence with the stem cell infusion process and orient the learner to the key elements of the interdisciplinary management of a critically ill stem cell transplant patient. The program also aims to foster clinical reasoning, clinical judgement, and improved communication skills within the new graduate nurse.
Institutions vary in the prescribed clinical practice guidelines and role for the bedside nurse managing patients with stem cell infusions. Hematopoietic stem cell transplantation: A manual for nursing practice (Ezzone, 2013), published by the Oncology Nursing Society, guided the stem cell infusion aspect of this activity. For the mock code, Kaye’s (1981) landmark article on mega-code for advanced cardiac life support provided an evidence-base. More recent literature was also used to guide the design of the mock code (Adams, Dobbs, Greene, MacGillis, & Stockhausen, 2002; Spunt, Foster, & Adams, 2004).
According to the International Nursing Association for Clinical Simulation and Learning (INACSL, 2016) a theoretical or conceptual framework is a required element of simulation design. Frameworks help structure learning activities and provide guidance in how learners connect clinical learning to theoretical knowledge. Simulation frameworks should align with overall program curricula objectives, simulation objectives, and the knowledge and skill level of anticipated learners (INACSL, 2016; Nehring & Lashley, 2010). The Outcome-Present State-Test (OPT) Model (Persut & Herman, 1998), The Nursing Process (Yura & Walsh, 1988), and PEARLS Debriefing Model were the conceptual frameworks used in this simulation scenario.
The OPT model is an outcomes-focused approach to the nursing process (Persut & Herman, 1998). According to Persut & Herman (1998), “This process results in framing the context and content of clinical reasoning for the purpose of testing outcome achievement. Outcome achievement is determined by juxtaposing outcome-state criteria with present-state client data” (pg. 29). The OPT model has encouraged clinical reasoning within high-fidelity simulation in nursing education (Kuiper, Heinrich, Matthias, Graham, & Bell-Kotwall, 2008). Because clinical reasoning is a learning outcome of interest, this model was chosen as the framework for the pre-briefing portion of the activity.
Promoting Excellence and Reflective Learning in Simulation (PEARLS; Eppich & Cheng, 2015) is a blended scripted debriefing framework, which consists of four phases (reaction, description, analysis, and summary). This scripted model facilitates debriefing for the novice simulation educator. A pediatric study using the EXPESS scripted debriefing model also showed the effectiveness of a similar model in improving knowledge acquisition among learners in a simulated cardiopulmonary arrest (Cheng et.al., 2013). For these reasons, PEARLS scripted debriefing model was chosen for the debrief of this simulation.
The nursing process (Yura & Walsh, 1988) was the conceptual framework used to structure the simulation scenario. Based on the patient’s background and clinical data, learners will be expected to make specific nursing assessments and interventions.
This activity was designed for a group of 8 new graduate nurses, as part of orientation to an inpatient stem cell transplant unit.
The simulation lab at the hospital where this activity took place consisted of a mock hospital room (including vital signs control monitor, bed, wall oxygen, suction and air, infusion pump, primary and secondary infusion bags and tubing, bedside table, dining tray, code cart, supply cart [including infusion bags, IV tubing, peripheral IV insertion kits, central line dressing kits, gauze, medical tape, urinals, indwelling catheter insertion kits, and toiletries], and a desktop computer). The Laerdal SimMan is located in this room, on the hospital bed. The manikin is a Caucasian adult male, dressed in a hospital gown. Wigs are available, if required for a female scenario. The lab does not have a control room or audiovisual recording capability. There is not a separate room available for pre-briefing and debriefing. There is a conference table (~120W x 48D) with 10 office chairs, a projector screen (with connectivity to the labs desktop computer), and projector available in the simulation lab.
The Nursing Education department allotted 4 hours of simulation lab time for this activity. The plan was to allot 30 minutes in orientation; 30 minutes in pre-briefing; 1 hour in the scenario (30 minutes each for two 4-learner groups); and 2 hours in debriefing and evaluation. The simulation takes place in 2 phases; phase 1 includes the stem cell infusion and phase 2 includes the mock code. The first 4-learner group will perform phase 1 of the simulation and hand-off the patient to the following group, who will perform phase 2.
Prebriefing is the phase of simulation in which the learners are generally oriented to the simulation activity. Facilitators can use this period to introduce the learning objectives, scenario, roles, program schedule, and confidentiality agreement (Page-Cutrara, 2014). Theoretical content can also be reviewed in this phase to ensure learners all have the knowledge basis needed to proceed with simulation activity.
The prebriefing for the stem cell infusion/mock code simulation begins with a welcome, wherein the instructor and learners each introduce themselves. The instructor describes their role as facilitator and informs participants that the goal is for them to actively learn from one another. The instructor also establishes a non-judgmental safe environment where mistakes are anticipated and will be used as a means of learning. The objectives and schedule outline are reviewed, followed by a review and signing of the confidentiality agreement.
Pesut & Herman (1998) explain that knowledge work (reading, memorizing, writing, practicing) is essential to clinical reasoning. In preparation for simulation, learners would be provided with required reading 1-week prior to the activity (readings detailed below, in simulation outline). In prebrief, the instructor would guide learners through the development of a concept map for their patient. Using the OPT model, learners would analyze the patient case, including their history, present illness, and clinical scenario (client-in-context). From there, learners would identify potential areas of concern (keystone issues) that would frame the context of care. Lastly, learners would compare the present clinical state of their patient to standard outcomes and make judgments about areas requiring nursing intervention to transition from a suboptimal present state to the standard outcome state (Pesut & Herman, 1998). The simulation scenario is based on a patient with cardiac amyloidosis receiving an autologous stem cell transplant. Common issues in these patients, which the facilitator would plan to identify with learners, include heart failure, constipation, musculoskeletal pain, neuropathy, and (for those receiving stem cell transplantation) anxiety. The instructor would also review the key components of inpatient code management and briefly review the components of the code cart. Lastly, the instructor would challenge the learners to identify ways in which a cardiopulmonary arrest would alter their concept map for the patient.
Orientation to Simulation Lab
Following the prebrief, learners would be oriented to the simulation lab. Beginning with the room, learners would be guided through the layout of the vital signs monitor; the location of the wall oxygen, suction and air, as well as how to control each; supplies available in the supply cart; and the computer (including how to log-in to SimChart, where their patient’s orders, labs, notes, and flowsheets will be). Orientation to the SimMan would include its basic functions (i.e., blinking, pupil response, spontaneous breathing, normal and abnormal breath sounds, detectable peripheral oxygen saturation, peripheral pulses, IV access (right arm only), and CPR capability (Laerdal, 2018). Manikin precautions would also be provided, such as avoiding exposure to ink and no actual administration of oral or iv medications. For this scenario, the SimMan will have additional attachments for the learner to be aware of, including a right chest wall central venous catheter and Foley catheter. The central line will be connected to a primary IV line that is regulated by an Alaris pump. However, the pump will be powered off so as to avoid actual infusion into the manikin. Learners would be notified of areas lacking fidelity (i.e., fluid output [urine, emesis, stool] & blood return), where the instructor will verbalize details if necessary. Learners would also be instructed to verbalize or simulate medication administration.
Using the National League for Nursing (NLN, 2015) Simulation Design Template, an outline of the simulation scenario is attachment file below.
Adams, D.A., Dobbs, J., Greene, M., MacGillis, P.A., Stockhausen, P.A. (2002). A model to enhance
staff response in cardiopulmonary arrest. Journal of Nursing Care Quality, 17, 47-54.
Blom, L., Petersson, P., Hagell, P., and Westergren, A. (2015). The Situation, background, assessment
and recommendation (SBAR) model for communication between health care Professionals: A
clinical intervention pilot study. International Journal of Caring Sciences, 8, 530-535.
Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy
MA, Thompson TM, Zimmerman JL. Part 8: post–cardiac arrest care: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2015;132(suppl 2): S465–S482.
Cheng, A., Hunt, E.A., Donoghue. A., Nelson-McMillan, K., Nishisaki, A., LeFlore, J.,…Nadkarni, V.M.
(2013). Examining pediatric resuscitation education using simulation and scripted debriefing: A multicenter randomized trial. JAMA Pediatrics, 167, 528-536.
Eppich, W., Cheng, A. (2015). Promoting excellence and reflective learning in simulation (PEARLS):
Development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare, 10, 106-115.
Ezzone, S.A. (2013). Hematopoietic stem cell transplantation: A manual for nursing practice 2nd Ed
Pittsburgh, PA: Oncology Nursing Society.
INACSL Standards Committee (2016, December). INACSL Standards of Best Practice: SimulationSM
Outcomes and objectives. Clinical Simulation in Nursing, 12, S13-S15. http://dx.doi.org/10.1016/j.ecns.2016.09.006.
Jeffries, P. (2012). Simulation in Nursing Education: From Conceptualization to Evaluation 2nd New
York, NY: National League for Nursing.
Kaye, W. (1981). The mega-code for training the advanced cardiac life support team. Heart and Lung, 10,
Kuiper, R.A., Heinrich, C., Matthias, A., Graham, M.J., Bell-Kotwall, L. (2008). Debriefing with the OPT
model of clinical reasoning during high fidelity patient simulation. International Journal of Nursing Education Scholarship, 5, 1-14.
Laerdal. (2018). SimMan 3G. Retrieved from https://www.laerdal.com/us/products/simulation-training/emergency-care-trauma/simman-3g/.
Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ,
Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced
cardiovascular life support: 2015 American Heart Association Guidelines Update for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;
132(suppl 2): S444–S464.
Miceli, T., Lilleby, K., Noonan, K., Kurtin, S., Faiman, B., Magnan, P.A. (2013). Autologous
hematopoietic stem cell transplantation for patients with multiple myeloma: An overview for
nurses in community practice. Clinical Journal of Oncology Nursing, 17, 13-24.
National League for Nursing. (2015). Simulation Design Template. Retrieved from
Nehring, W. M. & Lashley, F. R. (2010). High-Fidelity Patient Simulation in Nursing Education.
Boston, MA: Jones & Bartlett. ISBN 978-0763756512
Page-Cutrara, K. (2014). Use of prebriefing in nursing simulation: A literature review. Journal of Nursing
Education, 53, 136-141.
Pesut, D.J., Herman, J. (1998). OPT: Transformation of nursing process for contemporary practice.
Nursing Outlook, 46, 29-36.
Spunt, D., Foster, D., Adams, K. (2004). A mock code: A clinical simulation module. Nurse Educator,
Stephenson, E. (2015). Tips for the use of simulation to maintain competency in performing high-
risk/low-frequency procedures. The Journal of Continuing Education in Nursing, 46, 157-159.
Wechalekar, A.D., Gillmore, J.D., Hawkins, P.N. (2016). Systemic amyloidosis. Lancet, 387, 2641-54.
Weil, M.H., Fries, M. (2005). In-hospital cardiac arrest. Critical Care Medicine, 33, 2825-2830.
Yura, H., Walsh, M.B. (1988). The nursing process: assessment, planning, implementation, and
evaluation. 5th ed. Norwalk, CT: Appleton and Lange.
The instructor would note overall strengths and challenges of each learner during the simulation and share formative feedback during the debrief. Learners would also be specifically evaluated on the stem cell infusion process and SBAR technique, using the Stem Cell Infusion and SBAR Communication checklists (Appendix B and C).