Digital Repository Masters Projects Spring 2025 Using Simulation to Enhance Speaking-Up Behaviors in Nursing Students Sharon Mann Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Mann, S. 2025. Using Simulation to Enhance Speaking-Up Behaviors in Nursing Students. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Using Simulation to Enhance Speaking-Up Behaviors in Nursing Students Project Title by Sharon Mann Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY 4/25/25 Ogden, UT Date Sharon Mann, BSN, RN, MSN Student 4/25/25 Student Name, Credentials (electronic signature) Date Anne Kendrick, DNP, RN, CNE 4/25/25 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. 4/25/25 Date 1 Using Simulation to Enhance Speaking-Up Behaviors in Nursing Students Sharon Mann, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purpose/Aims: Adverse patient events can often be prevented when nurses speak up to advocate for patients. This project uses simulation to educate student nurses on the importance of speaking up for patient safety and to increase their confidence in speaking up in healthcare settings. Rationale/Background: Although patient advocacy is recognized as a fundamental responsibility of nurses, nurses often hesitate to speak up for patient safety. Barriers such as fears of conflict, retaliation, harming relationships, or questioning those in authority often prevent nurses from raising concerns. However, this can result in negative consequences for patients. Empowering student nurses to speak up for patient safety is critical. Incorporating simulations with debriefing sessions can enhance student confidence in advocating for patient safety and increase the frequency of speaking-up behaviors. Methods: Four 15-minute simulations were developed, each requiring students to advocate for patient safety. Once the students have completed the simulations, facilitators will conduct debriefing sessions to emphasize the importance of speaking up and discuss strategies for overcoming barriers. Pre- and post-simulation surveys will evaluate the impact of the experience on increasing student confidence in speaking up. Results: Compared to pre-simulation surveys, post-simulation surveys are expected to reflect greater confidence and an enhanced sense of responsibility in advocating for patient safety. Conclusions: Simulations show potential in reducing adverse patient events by encouraging students to advocate for their patients and enhancing their confidence in speaking up for patient safety. Keywords: simulation, nursing students, speaking up, assertive communication, patient advocacy, patient safety, education, debriefing, and evidence-based practice 3 Using Simulation to Enhance Speaking-Up Behaviors in Nursing Students Nurses must speak up when concerned about patient safety because they are often the last line of defense in identifying clinical errors (Kuo et al., 2020). Studies have shown that 60-70% of medical errors are due to failures in communication, and 23% of those could have been prevented if someone had spoken up (Peadon et al., 2020). Therefore, fostering a culture of safety that empowers nurses to communicate their concerns is vital. The Quality and Safety Education for Nurses (QSEN) initiative encouraged a greater emphasis on safety in nursing curricula (Bedgood & Mellott, 2021). If nursing students are taught a culture of safety while still in school, they will carry that culture into their professional practice. This MSN project aims to enhance the safety culture for nursing students through simulation by increasing student confidence, addressing barriers to assertive communication, and encouraging speaking-up behaviors during these experiences. Statement of Problem Nurses often hesitate to speak up due to fears of retaliation, conflict, damaging relationships, or the hierarchical nature of healthcare (Hemon et al., 2020). A 2018 report from the Agency for Healthcare Research and Quality (AHRQ) showed that, on average, only 79% of nurses felt comfortable speaking up when something did not seem right (Shanks et al., 2020). That number dropped to 50% when it involved speaking up to someone with more authority. Nursing students were found to have an even greater risk of failing to speak up due to their inexperience (Kuo et al., 2020). Bedgood and Mellott (2021) found that only 37% to 43% of nursing students felt comfortable speaking up to someone practicing unsafe behavior. Studies indicate that students often lack understanding of their role in patient safety, feel intimidated about speaking up, lack confidence in their knowledge of how to do so, and feel unsupported in 4 their efforts (Bedgood & Mellott, 2021). However, failing to speak up risks patients' safety (Peadon et al., 2020). Therefore, nursing students must learn how to advocate for patient safety prior to beginning their clinical practice. In 2023, AHRQ released an updated Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) Pocket Guide, which offers strategies for enhancing communication in healthcare. TeamSTEPPS strategies have effectively increased assertive communication (Lee et al., 2023). This MSN project will educate nursing students on the importance of speaking up using TeamSTEPPS and will provide opportunities for practice through simulations and debriefings centered on patient safety events. By participating in these activities, students will explore barriers and advocacy strategies, helping them gain confidence in their ability to advocate for patient safety. Significance of the Project Insufficient education for nursing students regarding their role and methods for advocating for patient safety is the first gap this project seeks to fill. AHRQ (2023) encourages all team members to assertively and respectfully advocate for corrective actions. To support this, AHRQ’s (2023) TeamSTEPPS Pocket Guide will be used to teach students their role in promoting patient safety and effective strategies for communicating their concerns. Research has shown that the strategies outlined in TeamSTEPPS can improve communication and reduce medical errors (Parker et al., 2019). Another key objective of this project is to empower student nurses and build their confidence in speaking up for patient safety. Simulation will be utilized, as research indicates that this teaching method significantly enhances student confidence (Moreno-Camara et al., 2024). More specifically, studies have shown that simulation is an effective tool for promoting confidence in speaking up (Chen et al., 2023; Hall et al., 2022; Hamilton, 2020; Kuo et al., 2020; 5 O’Donovan & McAuliffe, 2020; Shanks et al., 2020). By providing opportunities to practice assertive communication in a realistic environment, students can begin to understand the importance of speaking up for patient safety. This experience can help them recognize their ability to communicate safety issues effectively, empowering them to do so in the future. This project also aims to address gaps in safe patient care and improve patient outcomes. Bedgood and Mellott (2021) explain how creating a culture of safety improves patient outcomes, and promoting this culture should begin in nursing programs. A safety culture encourages questioning and speaking up while reducing fears associated with hierarchy and incivility. Research shows that simulation significantly increases the frequency of speaking up (Chen et al., 2023; Kuo et al., 2020; Lee et al., 2022). Therefore, this project aims to foster a safety culture among students, which they can carry into their professional careers to reduce medical errors and improve patient care. A current literature review will further explore the effects of simulation on student nurses’ speaking-up behaviors. Review of the Literature A literature review examined current research on how simulation promotes speaking-up behaviors. The PICOT question guiding this project's literature review was: For nursing students, would participation in one simulation experience about patient safety, compared to no simulation experience, increase student confidence in speaking up after a two-hour simulation experience? Various sources were used to identify relevant evidence and find the most effective evidencebased framework for this project. The Johns Hopkins Evidence-Based Practice model was used as the framework for this project (Gawlinski & Rutledge, 2008). Framework 6 This project will utilize the Johns Hopkins Evidence-Based Practice (EBP) model to facilitate the translation of evidence into practice. The Johns Hopkins EBP model emphasizes three guidelines termed the “PET” process, which stands for “practice question, evidence, and translation” (Gawlinski & Rutledge, 2008, p. 298). Using the PET process, a practice question is developed, evidence is gathered through a literature review to address the question, and the findings are translated into practice. The first step is to develop a practice question. The Johns Hopkins Health System/Johns Hopkins School of Nursing (2022) developed a “Question Development Tool,” which guides users in creating a PICOT question (see Appendix A). This question specifies the population, intervention, comparison, outcomes, and timeframe being addressed. With permission from the authors, the Question Development Tool was used for this project to facilitate the development of the PICOT question. Next, the Johns Hopkins EBP model recommends gathering evidence through a literature review, synthesizing evidence, and appraising current literature (Friesen et al., 2017). The Johns Hopkins Health System/Johns Hopkins School of Nursing (2022) created several tools to assist in organizing findings and appraising research (see Appendix B) and nonresearch (see Appendix C) literature. With permission from the authors, these tools were referenced in appraising relevant articles from the last five years. High-quality articles were synthesized into a literature review for this project. The final step of the Johns Hopkins EBP model is translating findings into practice by developing a plan to integrate evidence, implementing that plan, evaluating the results, and communicating the findings with others (Gawlinski & Rutledge, 2008). For this project, a plan was developed to obtain permission from stakeholders, create a knowledgeable team, develop 7 simulations designed to encourage speaking-up behaviors, and create pre- and post-simulation surveys to evaluate the project’s effectiveness. Implementation will include training simulation facilitators and technicians on this simulation experience, distributing pre-simulation surveys, assisting with the simulation and debriefing sessions, and administering post-simulation surveys. The evaluation will analyze the survey data, and the results will be communicated to the simulation director and presented in an oral online poster presentation at Weber State University. Strengths and Limitations The Johns Hopkins EBP model was selected due to its notable strengths. One strength of the model is the simplicity of condensing EBP into just three steps of the PET process. Friesen et al. (2017) found that the simplicity of the Johns Hopkins EBP model was key to its success. This study also reported that using the Johns Hopkins model increased the frequency of EBP implementation. Given that this project aims to translate evidence regarding simulation into practice, this model was chosen to enhance its likelihood of success. Another study noted that nurses preferred using the Johns Hopkins EBP model because it includes helpful tools to assist in the process (Speroni et al., 2020). These tools strengthened this project by guiding it through the steps of the EBP process. Limitations to the Johns Hopkins EBP model include the time and training needed to participate effectively in EBP. Friesen et al. (2017) found that many nurses hesitated to participate in the process because of the time investment involved. Furthermore, education and mentors were needed to support the implementation and sustainability of EBP using the Johns Hopkins model. However, it was noted that the value of EBP in enhancing the safety and quality of health care was worth the investment required for successful implementation. To address these 8 limitations, faculty mentors will be assigned to support the project, and sufficient time will be allocated for implementation. Analysis of Literature Given the critical need to teach nursing students to speak up for patient safety, a literature review was conducted to evaluate the PICOT question. The review revealed several common themes. This section will discuss the search strategies used, the themes identified, and a summary of the findings. Search Strategies To identify current evidence, a literature search was performed using the CINAHL, Ovid, PubMed, and Google Scholar databases. Only articles published from 2018 to 2024 were included in this review to ensure current literature. The search included keywords such as “simulation” AND “nursing students” AND “speaking up” OR “assertive communication.” Alternate words used were “patient safety,” “education,” “debriefing,” “quality improvement,” and “evidence-based practice.” Various Boolean combinations of the keywords were created to conduct a comprehensive search. Search results were narrowed to include only those that addressed simulation, speaking up or assertive language, and nursing students. However, due to limited results, the search was broadened to include literature regarding nurses, nursing students, and medical students. Synthesis of the Literature The literature review found four significant themes regarding the impact of simulation on nursing students’ confidence in advocating for patient safety. First, simulations helped students identify and overcome barriers to speaking up (Bedgood & Mellott, 2021; Chen et al., 2023; Hemon et al., 2020; Kuo et al., 2020; Shanks et al., 2020). Second, simulations effectively 9 boosted students’ confidence in assertive communication to speak up for patient safety (Hall et al., 2022; Hamilton, 2020; Lee et al., 2023; Shanks et al., 2020). Third, simulations increased the frequency of speaking up (Chen et al., 2023; Kuo et al., 2020; Lee et al., 2022; Oner et al., 2018). Finally, the debriefing portion of the simulation experience was instrumental in promoting speaking-up behaviors (Hall et al., 2022; Hemon et al., 2020; Kuo et al., 2020; O’Donovan & McAuliffe, 2020). These themes support integrating simulations focused on speaking up into nursing education. Identify and Address Barriers to Speaking up During simulations, nursing students often recognize that they hesitate to speak up for patient safety (Bedgood & Mellott, 2021; Chen et al., 2023; Hemon et al., 2020; Kim et al., 2020; Kuo et al., 2020; Shanks et al., 2020). An integrative literature review found that nursing students did not feel comfortable speaking up to someone about unsafe behavior due to a perceived lack of knowledge or insufficient support for speaking up (Bedgood & Mellott, 2021). Likewise, in a qualitative study evaluating speaking up in a simulation setting (n = 98), very few students spoke up for patient safety (Hemon et al., 2020). Not a single student spoke up when hand hygiene was not performed; only two students spoke up about a senior nurse breaking a sterile field, and only three nurses spoke up about disrespectful behavior toward the patient. Afterward, during the debriefing session, students discussed why they had stayed silent. Out of 16 groups, all mentioned that, as a student, they did not feel it was their place to comment on the care a registered nurse gave. Furthermore, 14 groups did not feel it appropriate to correct a nurse in front of a patient; 14 groups were afraid of reprisal; 13 groups feared damaging relationships; and 13 groups stated they did not know the nurse well enough to speak up (Hemon et al., 2020). 10 The consistency of findings in these studies acknowledging barriers to speaking up exemplifies the need to educate students on effectively overcoming these barriers. Kim et al. (2020) suggest that educators can address barriers by teaching effective speaking-up phrases and helping others transform their negative emotions about speaking up into learning experiences. As students recognize the negative consequences of staying silent, they are more likely to overcome their negative emotions regarding speaking up and saying something to advocate for their patients. Chen et al. (2023) found that teaching assertive communication strategies in AHRQ’s TeamSTEPPS Pocket Guide empowered nurses and students to overcome barriers to speaking up. The TeamSTEPPS Pocket Guide states that team members should stop and address an issue if anyone speaks up with a concern (AHRQ, 2023). This emphasizes to students that their voices are valuable and can be effective. Through simulation training, student nurses can recognize their responsibility in promoting patient safety and practice overcoming barriers to speaking up. Enhancing Nurses’ Confidence in Speaking up Several studies found that simulations increase confidence in speaking up (Hall et al., 2022; Hamilton, 2020; Lee et al., 2023; Shanks et al., 2020). Simulation is an effective and adaptable tool for increasing student confidence in various skills and behaviors (Moreno-Camara et al., 2024). By bridging theory with practice, simulation enables students to become more confident in acting on their knowledge. A quality-improvement project using simulation to enhance the speaking-up behavior of six newly graduated nurses showed a 24% increase in confidence scores (p = 0.01) and a 27.6% increase in communication scores (p = 0.05) on Clinical Confidence Communication Composite Surveys (Hamilton, 2020). An additional quality improvement project found that 94% of students agreed that simulations were good practice for 11 developing assertiveness and advocacy skills, and 97% felt the simulation experience should continue to be offered to students (Hall et al., 2022). This provides evidence that simulation could improve student confidence in speaking up for patient safety. Although many studies showed positive improvements in nurses’ confidence after participating in simulations to improve speaking-up behavior, not all studies found statistically significant results. One such quantitative quasi-experimental study (n = 62) by Shanks et al. (2020) found that simulations encouraging TeamSTEPPS strategies, such as the two-challenge rule or CUS (I am concerned, I am uncomfortable, this is a safety issue), did increase confidence scores using the Health Professional Education in Patient Safety Survey, but results were not significant (H-PEPSS; pre-intervention 151.0 to post-intervention 160.5, p = 0.076). Likewise, a systematic review by Lee et al. (2023) on educational tools to improve assertive communication found that only two out of five studies utilizing simulation reported statistically significant improvements in student confidence in speaking up. Both Lee et al. (2023) and Shanks et al. (2020) suggested that small sample sizes and convenience sampling may have contributed to the lack of significant results. Despite these variations, Lee et al. (2023) and Hamilton (2020) argue that simulations provide a low-risk environment for practicing speaking-up behaviors, making them a valuable educational tool. This evidence supports nursing schools incorporating simulation into curricula to enhance speaking-up behaviors. Increasing the Frequency of Speaking-Up Behaviors Many studies have found that simulation can increase the frequency of speaking-up behaviors (Chen et al., 2023; Kuo et al., 2020; Lee et al., 2022; Oner, 2018). Kuo et al. (2020) used a quantitative study with a quasi-experimental design (n = 93) to find that a two-hour simulation featuring eight medication errors led to significantly more speaking up in a post- 12 intervention test (t = 5.99, p < 0.001). Similarly, Chen et al. (2023) conducted a meta-analysis combining data from eleven studies, showing that assertive communication training significantly increased the frequency nurses and student nurses spoke up. Results showed an increase in nurses speaking up about medical errors, from 38% of cases in the pretest (95% CI, 0.14-0.68) to 78% of cases in the post-test (95% CI, 0.70-0.85). Finally, a scoping review of 21 articles concluded that assertive communication training programs increase speaking-up behavior, but they also increase job stress and communication conflicts in the workplace (Lee et al., 2022). Therefore, encouraging students with simulation to help create a culture that promotes speaking up for patient safety rather than fostering conflict is crucial for students' success in speaking up. Although the results from the studies mentioned are encouraging, it is important to acknowledge that students may only focus on speaking up shortly after a simulation experience. The long-term effects of simulation are still unknown. Lee et al. (2023) found that few studies have evaluated the long-term impact of simulation in nursing programs on speaking-up behavior later in a clinical setting. Another limitation of these studies is that students may feel more comfortable speaking up in a simulated environment than in actual clinical situations, potentially affecting the results (Kuo et al., 2020). One randomized control trial evaluated nurses' frequency of speaking up in real clinical settings before and after a simulation (Oner et al., 2018). Although this study involved licensed nurses rather than nursing students, its findings provide valuable insight into whether simulations can influence behaviors in real-life clinical situations. This study found statistically significant increases in the frequency of speaking up in a postpartum unit following the simulation. However, while there was also an improvement in speaking up frequency in the labor and delivery unit, the results were not statistically significant. The researchers speculated that a preexisting culture of speaking up for patient safety in the labor and 13 delivery unit could have diminished their findings. Regardless, Oner et al. (2018) still supported using simulation to encourage speaking-up behaviors. The ultimate goal of these simulations is for students to translate what they learn into clinical practice so that they speak up for patient safety. Future research needs to evaluate the long-term effectiveness of undergraduate simulations in improving speaking-up behaviors. Debriefing Promotes Speaking-Up Behavior After a simulation, a debriefing session helps students learn and self-reflect on their assertive communication skills (Hall et al., 2022; Hemon et al., 2020; Kuo et al., 2020; O’Donovan & McAuliffe, 2020). A qualitative study found that debriefing sessions transform students' superficial knowledge into deeper reflection (Lim & Bae, 2024). Deep reflection enables students to think critically and apply their enhanced knowledge in future situations. Kuo et al. (2020) suggest that significant improvements in students’ confidence in speaking up after simulations were likely due to effective debriefing sessions. These debriefing sessions may be more effective than classroom discussions because they are tailored to students’ performances. Debriefings can review how mistakes made in the simulation can help students understand their weaknesses and enhance their skills for real-life events. A quality improvement project surveyed students to identify the most beneficial aspects of the simulation scenarios. One of the most frequent responses was that the debriefing session was helpful because it provided constructive feedback and introduced new strategies for speaking up (Hall et al., 2022). Hemon et al. (2020) further explained that their qualitative study found that debriefing was important for students to reflect on what personal emotions or barriers kept them from speaking up. This allowed educators to help students find ways to overcome recognized obstacles. Finally, O’Donovan and McAuliffe (2020) discovered in their systematic review of simulations and 14 debriefings that debriefing sessions offer educators the chance to exemplify how to address concerns in a psychologically safe manner. As critiquing students’ performances involves speaking up about the students’ actions, debriefing offers an ideal opportunity for educators to model how to discuss the actions of others in a psychologically safe way. While all four studies found different benefits to debriefing students on their simulation experiences, they all agreed that debriefing is a key tool for promoting speaking-up behaviors. Summary of Literature Review Findings and Application to the Project There is consensus in the literature that simulation is an effective tool for enhancing speaking-up behaviors in nursing students. Simulation experiences address barriers that nursing students face in speaking up, provide opportunities for practice to build confidence, can increase the frequency of speaking up, and facilitate discussions during debriefing sessions to enhance assertive communication skills. Although there are a few conflicting results regarding the significance of findings to support the use of simulation, it remains a low-risk, widely supported method for students to learn and practice speaking-up behaviors (Hamilton, 2020). Therefore, this project aims to implement the findings of this literature review by creating a simulation experience for nursing students to promote speaking up for patient safety. Project Plan and Implementation This project seeks to implement a simulation experience to encourage nursing students to speak up for patient safety based on the evidence found in the literature review. Students will be assigned to review AHRQ’s (2023) TeamSTEPPS Pocket Guide to learn strategies for improving communication skills and advocacy techniques. Then, a pre-brief will be held, and students will be given a pre-simulation survey assessing their confidence and sense of responsibility regarding communication and patient safety advocacy (see Appendix D). Afterward, each student will 15 participate in a simulation experience designed to allow them to speak up for patient safety. A debriefing session will allow students to reflect on their experiences, discuss emotions, identify obstacles to speaking up, and explore techniques that can be used for patient advocacy in the future. A post-simulation survey will also be administered to evaluate the effectiveness of the simulations and gather feedback on what can be improved (see Appendix E). This section further discusses the plan and implementation process, including a description of the interdisciplinary team, project deliverables, and timeline for implementation. Plan and Implementation Process For this project, four fifteen-minute simulation scenarios were created for undergraduate students in their final semester of a nursing program at a university in central Utah (see Appendices F, G, H, and I). Each scenario addresses a situation where a nurse should speak up for patient safety, with students taking on the role of newly graduated nurses. In the first scenario, a student nurse will witness a more experienced nurse contaminating a sterile field while placing an indwelling urinary catheter (see Appendix F). The second scenario involves a student nurse being assigned a full load of medical/surgical patients in addition to a suicidal patient without one-to-one supervision, which is against hospital policy (see Appendix G). In the third scenario, a student nurse is assigned an inappropriate patient load in the intensive care unit (see Appendix H). This includes three critically ill patients who require close observation. Meanwhile, more experienced nurses on the unit are given the standard load of two patients, all less acute than the student nurse's patients. The final scenario involves a student witnessing an experienced nurse treat another new nurse with incivility when asked a patient-care-related question (see Appendix I). All four scenarios will be reviewed and approved for use by the simulation director of the nursing program. 16 Additionally, electronic surveys using Qualtrics were developed to evaluate nursing students’ confidence levels and sense of responsibility in communicating and advocating for patients before (see Appendix D) and after (see Appendix E) the simulations. Since this project involves research with human subjects, approval must be obtained from the participating university's Institutional Review Board (IRB). The written plan, pre-simulation and postsimulation surveys, and simulation scenarios will all be submitted for IRB approval. Once IRB approval has been obtained, simulation facilitators, technicians, and standardized patients will be trained to run the simulations. A test run will be conducted with volunteer students to gain feedback and identify potential concerns with the process. Finally, student consent will be obtained to participate in the simulation project. In preparation for the simulation experience, students will be assigned to read AHRQ’s (2023) TeamSTEPPS Pocket Guide. This guide reviews multiple communication techniques, including SBAR (Situation, Background, Assessment, and Recommendation or Request), closedloop communication, STAR (Stop, Think, Act, and Review), formative feedback, the twochallenge rule, CUS (I am Concerned; I am Uncomfortable; This is a Safety issue), DESC (Describe, Express, Suggest, Consequences), and more. These techniques help students communicate concerns professionally to advocate for patient safety. The students will have a pre-brief on the simulation day to review the expectations for maintaining the simulation lab as a positive and safe learning environment. They can also ask questions regarding AHRQ’s (2023) TeamSTEPPS Pocket Guide. A pre-simulation survey will be administered to evaluate the students’ confidence and sense of responsibility in communicating effectively in the clinical setting. While the students will likely expect the need 17 to communicate in some manner during the simulation, they will not know that the simulations are specifically designed for them to speak up for patient safety. With the help of multiple simulation facilitators, technicians, and simulated patients, all four simulations will be run simultaneously in separate rooms so that each student can recognize how they react to unexpected circumstances requiring them to speak up. However, each simulation will be recorded and viewed during the debriefing session so that the students can learn from the experiences of the other students. After viewing each simulation during the debrief, students can discuss the scenario, share the emotions they experienced, reflect on what went well, identify any barriers they encountered, and consider how they would change their approach in the future. Finally, students will be given a post-simulation survey with the same questions as the pre-simulation survey for comparison. In addition, two additional questions will allow students to provide feedback on whether the simulation helped prepare them to speak up in clinical situations. Interdisciplinary Team This project will require contributions from the simulation director, facilitators, technicians, standardized patients, and nursing students. The simulation director will manage the scheduling of staff and students to participate in the project. Simulation facilitators will conduct the pre-brief, be a resource during the simulations, and lead the debrief discussion to encourage speaking up. Simulation technicians will be needed to set up the rooms and manikins in preparation for the simulation, provide voiceovers for the manikins, and control the vital signs on the patient monitors during the simulation. Simulated patients will act as patients, experienced nurses, charge nurses, house supervisors, or physicians in the scenarios. Nursing students will participate in the simulations and discussions, and they can provide feedback on the experience. 18 Each team member's expertise will be necessary for this project to help create a culture of advocacy among nursing students. Additionally, while the simulation scenarios written for this project mainly involve nurses, the simulation facilitator will discuss with students the importance of advocacy amongst all members of a patient’s interdisciplinary team. The project aims to empower nursing students to speak up to administrators, doctors, respiratory therapists, pharmacists, laboratory technicians, family members, and others to keep their patients safe. Description and Development of Project Deliverables This project required developing two surveys and four written simulation scenarios. The surveys will evaluate the project's effectiveness by gathering student feedback, and the written simulation scenarios will guide the simulation facilitators, technicians, and standardized patients to ensure consistency in the implementation of the simulations. Surveys. A pre-simulation (see Appendix D) and post-simulation (see Appendix E) survey were created in Qualtrics using five identical questions, with two additional questions included in the post-simulation survey to gather supplemental feedback. The five identical questions will allow for a comparison to assess the impact the speaking-up simulations had on the students’ beliefs and confidence in speaking up for patient safety. Prior to the simulation experience, students will only know that the objective is to use good communication skills as learned in AHRQ’s (2023) TeamSTEPPS Pocket Guide. They will not be told that the specific goal of the simulation is to speak up for patient safety, allowing for a more natural response during the simulations. Therefore, the survey was designed to address various aspects of communication without directly disclosing the simulations’ purpose. The surveys include questions asking the students to use a 5-point Likert scale to rank their confidence in giving a report using the SBAR format, using closed-loop communication, and speaking up in clinical 19 situations. Then, on a separate 5-point Likert scale, they will determine how much responsibility they believe student nurses have in communicating effectively with other healthcare professionals and speaking up about safety concerns. The post-simulation survey also contains questions asking how the simulation prepared students to speak up in clinical settings and whether they believe any factors will continue to prevent them from speaking up. Answers to these questions will provide qualitative data for evaluating the students’ experiences with the simulations. Furthermore, these questions will help identify areas for improvement and guide modifications to improve these simulations for future use. Written Simulations. Four simulation scenarios were created for this project, each providing an opportunity for a student to speak up for patient safety (see Appendices F, G, H, and I). These simulations were designed due to optimistic findings in the literature review that supported the use of simulations to encourage speaking-up behavior (Bedgood & Mellott, 2021; Chen et al., 2023; Hall et al., 2022; Hamilton, 2020; Hemon et al., 2020; Kuo et al., 2020; Lee et al., 2023; Oner et al., 2018; O’Donovan & McAuliffe, 2020; Shanks et al., 2020). In addition to an outline of the scenario's events, the written simulations contain key information and directions for the simulation facilitators, technicians, and standardized patients to implement the simulations successfully. Each written simulation begins with an overview for the students, which will be displayed on the door of their simulation room. These overviews provide a brief description of the student’s role in the upcoming simulation. For example, one student will be instructed to enter a patient’s room to assist an experienced nurse with placing an indwelling catheter. Another student will be told that they will receive a bedside report for one of their assigned 20 patients. A third student will be notified that they are floating to a new unit, where they will receive a report from a charge nurse. The final student will be advised to prepare for a new patient admission by reviewing the patient’s chart at a simulated nurses’ station. These overviews help ensure that each student is prepared for their specific responsibilities in the simulation. Next, the written simulations clearly state the scenario objectives. This ensures that all staff working with the simulations are focused on the same goals. Some written simulations also include facilitator reminders, highlighting important details to maintain a safe and smooth simulation environment. Following the objectives, patient information is presented, including the simulated patient’s history, diagnosis, assessment findings, and provider orders. This information will be included in the simulated electronic chart, which students can review. Additionally, patient information provides important background information and context for the nurse facilitator, standardized patients, and simulation technicians. In two of the scenarios, a standardized patient, acting as a nurse, uses this information to give a hand-off report to the student. The overview of the scenario is then presented. This section includes a description of events, the progression of vital signs for the technician to adjust on the patient monitor, a list of student expectations, and scripts for the simulated patients and technicians voicing the manikins in the scenario. Finally, there are set-up instructions for the technicians. This section details how to set up the manikin, what medications and equipment should be accessible, and how to stage the patient room. To ensure the smooth implementation of the scenarios, all staff participating should be familiar with these written simulations. Timeline 21 Once the literature review and deliverables were completed, a timeline for implementation was created (see Appendix J). First, the simulation director will review the project plan and deliverables. Any necessary changes based on feedback will be made within one week. Next, IRB approval will need to be obtained. IRB approval could take up to four to eight weeks, so sufficient time will be allotted for this process. Once IRB approval has been obtained, simulation staff will be trained prior to the start of the semester when implementation is scheduled. The written simulations will be distributed and reviewed with any facilitators, technicians, and standardized patients involved in the simulations. At the start of the semester, participating students will be assigned specific dates for their simulations. Twelve different sessions will be available over three days near the end of the semester. A Canvas module for this simulation will also be accessible at the beginning of the semester, including a consent form and an assignment to read AHRQ’s (2023) TeamSTEPPS Pocket Guide. The consent form will need to be signed prior to participation in the simulation experience. Then, two weeks prior to the first simulation session, a trial run of the simulations will be conducted. On simulation day, the presimulation survey will be administered during the pre-brief. The post-simulation survey will be distributed during the debrief, and data evaluation will begin after the final simulation session. The detailed implementation plans for this project were carefully designed to create a valuable experience for nursing students. Obtaining IRB approval, training an interdisciplinary team, and conducting a trial simulation will help ensure the smooth execution of the simulations. Simulation scenarios were written to encourage a culture of safety, and discussions during the pre-brief and debrief will hopefully empower students to speak up for patient safety. Valuable feedback to assess the effectiveness of these simulations will be obtained by comparing the presimulation and post-simulation data. 22 Project Evaluation This project seeks to determine if implementing a simulation promoting speaking-up behaviors will improve student confidence and willingness to advocate for patient safety. The effectiveness of this project will be evaluated using a pre-simulation (see Appendix D) and postsimulation Qualtrics survey (see Appendix E) containing five identical questions asking students to rate their confidence level or sense of responsibility regarding communication and patient safety advocacy on a 5-point Likert scale. The data will be analyzed using IBM SPSS Statistics (Version 29) to perform a Wilcoxon signed-rank test, which will determine the extent of the differences between the pre-simulation and post-simulation surveys (IBM, 2021). The results will provide quantitative evidence of whether the simulation intervention significantly affects the development of speaking-up behavior among nursing students. The post-simulation survey will also ask whether students felt the simulation experience helped them feel more prepared to speak up in clinical settings. To justify the continued use of the simulations, the goal is for 75% of students to answer “Yes” to this question. This percentage was chosen because it represents most of the study body, indicating a strong positive response to the simulation experience. Additionally, the post-simulation survey will ask students to describe how the simulations prepared them to speak up in clinical situations and any factors that continue to make them feel unprepared to do so. Common themes from these responses will guide changes to improve the effectiveness of the simulations. Qualitative data will also be obtained throughout the project, including feedback from facilitators, technicians, standardized patients, and students to enhance the design and implementation of the simulations. Ethical Considerations 23 This project encourages social responsibility by creating a culture of safety in which nursing students are encouraged to speak up for patient safety. Increasing student confidence and addressing barriers to assertive communication can prevent errors and result in better patient outcomes. IRB approval will be obtained to ensure all ethical concerns are addressed before implementing this project. The project seeks to eliminate discrimination and embrace diversity. Every capstone student enrolled in the nursing program of the participating university will be invited to participate in the simulation experience. Facilitators will encourage all students to express their thoughts during the pre-briefing and debriefing discussions so that multiple perspectives are heard. Any student who chooses not to participate in the study will not be given the surveys and will have access to alternative learning opportunities without negative consequences. Additionally, the simulation aims to create an inclusive environment where every voice is valued in the clinical environment. A safe learning environment will be promoted by discouraging judgment and prohibiting the disclosure of any aspects of the discussion or simulation experience outside of the debriefing discussions. While complete privacy cannot be guaranteed due to the group setting, the facilitator will emphasize the importance of privacy and respect during the pre-briefing. Likewise, surveys will remain anonymous to protect student privacy and promote honest answers, thereby decreasing bias in the data results. Finally, participants will be asked to sign a consent form acknowledging that the simulations will be recorded for group review of the scenarios during the debriefing session. The videos will be used solely for this purpose and deleted once the debriefing session concludes. If participants choose not to consent to be recorded, they will be given an alternative assignment with a similar objective but will not participate in the simulations 24 and surveys. These measures protect privacy while encouraging open and honest reflection about the simulations during the debrief and surveys. Discussion Nurses are responsible for preventing harm by speaking up when they see any threats to patient safety (Kuo et al., 2020; Lee et al., 2022; Lee et al., 2023). The World Health Organization (2024) reports that approximately ten percent of patients are harmed, and over three million people die annually worldwide due to unsafe care, with more than half of these incidents being preventable. Many preventable errors could be avoided if nurses actively raised concerns when necessary (Peadon et al., 2020). This MSN project aims to address this issue by using simulation to empower students to advocate for their patients and raise awareness of the critical role all nurses, regardless of experience level, play in speaking up for patient safety. The following sections will discuss evidence-based solutions for dissemination, the significance of this project to nursing practice, the implications of the project, and recommendations for future research. Evidence-based Solutions for Dissemination Once the project is completed, the data gathered from the pre- and post-simulation surveys will be presented to the simulation director and facilitators for review. Based on the objective data and feedback obtained, a decision will be made on whether to include the simulations in the regular curriculum. If the simulations are integrated into the curriculum, potential improvements will also be discussed to enhance the students' experience. Further dissemination will be pursued through presentations or publications. The results of this project will be shared through a poster presentation for peers and faculty at Weber State University. If the findings are significant, additional opportunities to present the findings will be 25 pursued, such as at the International Nursing Association for Clinical Simulation and Learning annual conference or through publication. These efforts will promote the implementation of similar simulation scenarios in other academic and clinical training programs. Significance to Advance Nursing Practice This project seeks to create a nursing culture that prioritizes safe patient care. Historically, nurses have hesitated to speak up in practice. In 2005, a landmark study called “Silence Kills” showed that less than ten percent of healthcare workers who had witnessed safety concerns in the workplace discussed their concerns with the coworker directly involved, and many did not even think it was their responsibility to do so (Maxfield et al., 2005). Studies have shown that this lack of communication has resulted in preventable medical errors (Maxfield et al., 2005; Peadon et al., 2020). In contrast, when nurses speak up about potential safety concerns, corrective actions can be taken to prevent harm and reduce medical errors. However, recent studies confirm that nurses continue to stay silent rather than speak up for patient safety (Bedgood & Mellott, 2021; Chen et al., 2023; Hemon et al., 2020; Kim et al., 2020; Kuo et al., 2020; Peadon et al., 2020; Shanks et al., 2020). Therefore, this project seeks to advance nursing practice by empowering student nurses to speak up for patient safety. Existing research supports the use of simulation in increasing the frequency of speaking up (Chen et al., 2023; Kuo et al., 2020; Lee et al., 2022). By providing a platform for nursing students to practice assertive communication, addressing barriers to speaking up, and encouraging patient advocacy, medical errors may be reduced and patient outcomes improved. Implications This project has several strengths. The Johns Hopkins EBP model helped guide the project in finding, appraising, and integrating research regarding simulations about speaking up 26 into practice. The tools provided by the Johns Hopkins Health System/Johns Hopkins School of Nursing (2022) strengthened this project by helping to identify relevant, high-quality research that supports the implementation of the project. Additionally, the model encourages a continuous cycle of examining evidence, reflecting on its application, implementing findings, and evaluating the outcomes to inform future practice (Gawlinski & Rutledge, 2008). This will allow for improvements to be made even after the initial implementation has been completed, supporting the search for the best practices. The simulations will be evaluated by assessing pre- and postsimulation surveys. These surveys will include questions using either a 5-point Likert scale or free-text format, providing valuable quantitative and qualitative data regarding the effectiveness of the simulations. Finally, the written simulations provide clear instructions for all simulation staff to support consistency in their implementation. This project is limited due to the use of a small convenience sample. The sample will include sixty-five capstone students from one university, which limits the generalizability of results to other universities. However, all students enrolled in their capstone semester at the participating university will be used to decrease the potential for bias. Furthermore, the study does not evaluate the effect of simulation on the frequency with which these students speak up in actual clinical practice. Instead, it evaluates any changes in the students’ perceptions of their confidence and sense of responsibility in speaking up for patient safety. Therefore, it is unknown if the lessons learned in simulation will translate into clinical practice. If positive feedback is obtained from the project's initial implementation, future studies or feedback could evaluate clinical behavior changes after participating in the speaking-up simulations. Furthermore, this project is limited to discovering the short-term effects of using simulation to increase speaking- 27 up behavior. Follow-up surveys may be considered to determine if students continue to remain confident in speaking up after graduation. The findings from this project will provide evidence on whether simulations can improve student confidence in speaking up for patient safety. This will help guide future curriculum development aimed at enhancing patient safety. It is hoped that enhancing student confidence and raising awareness of the need to speak up in practice will reduce medical errors. Recommendations Future research on using simulations to encourage speaking-up behavior could track the frequency of such behavior and any reductions in medical errors following simulation implementation. One recommendation is to gather feedback from the students’ capstone clinical preceptors on the occurrence of students speaking up for patient safety in practice. This information would be valuable in determining whether the confidence gained in the simulations translates into real-world behavior in clinical environments. Additional studies could assess for a decrease in preventable medical errors due to nurses speaking up in the months and years following the implementation of speak-up simulations. Follow-up anonymous surveys could ask former students whether they have observed a medical error without intervening, spoken up in nursing practice, or continued to feel confident in speaking up during the months after graduation. Expanding this project to include other nursing programs and healthcare institutions could strengthen the impact of the simulations on changing the safety culture within nursing. Future studies should explore whether simulation training can be implemented at clinical sites to encourage speaking-up behavior among already licensed nurses. By fostering speaking-up 28 behaviors in both students and practicing nurses, advocating for patient safety can become a central priority in healthcare settings. Conclusions Simulations have effectively enhanced students’ confidence in speaking up for patient safety (Hall et al., 2023; Hamilton, 2020; Lee et al., 2023; Shanks et al., 2020). This is crucial because studies have shown that many patient safety events could have been prevented if someone had spoken up (Peadon et al., 2020). Nurse educators have been encouraged to emphasize patient safety and teach students their responsibility for speaking up for patient safety (Bedgood & Mellott, 2021). Therefore, this project encourages simulation to raise awareness among students about their roles in ensuring patient safety and empowers them to advocate for their patients. The simulation experience will allow students to practice using assertive communication and discuss ways to overcome common barriers to speaking up for patient safety. Previous studies have shown that these methods increase the frequency of speaking-up behaviors (Chen et al., 2023; Kuo et al., 2020; Lee et al., 2022; Oner et al., 2018). While this project focuses on increasing student confidence and awareness, future research will be necessary to assess whether the simulations created for this project translate into real-world clinical practice and lead to measurable reductions in medical errors. Further research can also determine if similar simulation scenarios could be used in clinical training to encourage speaking-up behaviors in licensed nurses. Ultimately, the goal is to promote a safety culture where students and nurses prioritize safety, speak up for patients, and improve patient outcomes. 29 References Agency for Healthcare Research and Quality. (2023). TeamSTEPPS 3.0 pocket guide: Team strategies & tools to enhance performance and patient safety. https://www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamsteppspocket-guide.pdf Bedgood, A. L., & Mellott, S. (2021). The role of education in developing a culture of safety through the perceptions of undergraduate nursing students: An integrative literature review. Journal of Patient Safety, 17(8), 1530-1536. https://doi.org/10.1097/PTS.0000000000000548 Chen, H., Wu, J., Kang, Y., Chiu, Y., & Hu, S. H. (2023). Assertive communication training for nurses to speak up in cases of medical errors: A systematic review and meta-analysis. Nurse Education Today, 126. https://doi.org/10.1016/j.nedt.2023.105831 Friesen, M. A., Brady, J. M., Milligan, R., & Christensen, P. (2017). Findings from a pilot study: Bringing evidence-based practice to the bedside. Worldviews on Evidence-Based Nursing, 14(1), 22-34. https://doi.org/10.1111/wvn.12195 Gawlinski, A., & Rutledge, D. (2008). Selecting a model for evidence-based practice changes. AACN Advanced Critical Care, 19(3), 291-300. https://www.doi.org/10.1097/01.aacn.0000330380.41766.63 Hall, N., Seldomridge, L., & Allen, K. (2022). Using toolkits to improve students’ skills in advocacy. Journal of Nursing Education, 61(10), 599-602. https://doi.org/10.3928/01484834-20220417-05 30 Hamilton, H. (2020). Simulation to improve confidence among newly licensed nurses in the pediatric intensive care setting [DNP Project, University of Maryland Baltimore]. http://hdl.handle.net/10713/13024 Hemon, B., Michinov, E., Guy, D., Mancheron, P., & Scipion, A. (2020). Speaking up about errors in routine clinical practice: A simulation-based intervention with nursing students. Clinical Simulation in Nursing, 45(1), 32-41. https://doi.org/10.1016/j.ecns.2020.03.003 IBM. (2021). Wilcoxon signed-rank test. https://www.ibm.com/docs/en/spssstatistics/beta?topic=tests-wilcoxon-signed-rank-test Johns Hopkins Health System/Johns Hopkins School of Nursing. (2022). Johns Hopkins Evidence-Based Practice Model. https://www.hopkinsmedicine.org/evidence-basedpractice/model-tools Kim, S., Applebaum, N. P., Baker, N., Bajwa, N. M., Chu, F., Pal, J. D., Cochran, N. E., & Bochatay, N. (2020). Patient safety over power hierarchy: A scoping review of healthcare professionals’ speaking-up skills training. Journal for Healthcare Quality, 42(5), 249263. https://doi.org/10.1097/JHQ.0000000000000257 Kuo, S. Y., Wu, J. C., Chen, H. W., Chen, C. J., & Hu, S. H. (2020). Comparison of the effects of simulation training and problem-based scenarios on the improvement of graduating nursing students to speak up about medication errors: A quasi-experimental study. Nurse Education Today, 87(1). https://doi.org/10.1016/j.nedt.2020.104359 Lee, E., De Gagne, J. C., Randall, P. S., Kim, H., & Tuttle, B. (2022). Effectiveness of speak-up training programs for clinical nurses: A scoping review. International Journal of Nursing Studies, 136. https://www.doi.org/10.1016/j.ijnurstu.2022.104375 31 Lee, S. E., Kim, E., Lee, J. Y., & Morse, B. L. (2023). Assertiveness educational interventions for nursing students and nurses: A systematic review. Nurse Education Today, 120(1). https://doi.org/10.1016/j.nedt.2022.105655 Lim, S., & Bae, M. (2024). Comparative analysis of nursing students’ reflection levels before and after debriefing in simulation training in South Korea: Qualitative analysis design. Child Health Nursing Research, 30(3), 167-175. https://doi.org/10.4094/chnr.2024.015 Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence kills: The seven crucial conversations for healthcare. VitalSmarts. https://www.aacn.org/nursingexcellence/healthy-work-environments/~/media/aacn-website/nursingexcellence/healthy-work-environment/silencekills.pdf?la=en Moreno-Camara, S., da-Silva-Domingues, H., Parra-Anguita, L., & Gutierrez-Sanchez, B. (2024). Evaluating satisfaction and self-confidence among nursing students in clinical simulation learning. Nursing Reports, 14(2), 1037-1048. https://doi.org/10.3390/nursrep14020078 O’Donovan, R., & McAuliffe, E. (2020). A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour. BMC Health Services Research, 20(101). https://doi.org/10.1186/s12913-0204931-2 Oner, C., Fisher, N., Atallah, R., Son, M. A., Homel, P., Mykhalchenko, K., & Minkoff, H. (2018). Simulation-based education to train learners to “speak up” in the clinical environment: Results of a randomized trial. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 13(6), 404-412. https://doi.org/10.1097/SIH.0000000000000335 32 Parker, A. L., Forsythe, L. L., & Kohlmorgen, I. K. (2019). TeamSTEPPS: An evidence-based approach to reduce clinical errors threatening safety in outpatient settings: An integrative review. Journal of Healthcare Risk Management, 38(4), 19-31. https://www.doi.org/10.1002/jhrm.21352 Peadon, R., Hurley, J., & Hutchinson, M. (2020). Hierarchy and medical error: Speaking up when witnessing an error. Safety Science, 125. https://doi.org/10.1016/j.ssci.2020.104648 Shanks, L. C., Chiu, S., Zelko, M. I., Fleming, E., & Germano, S. (2020). Speaking up to authority in a simulated medication error scenario. Clinical Simulation in Nursing, 45(1), 28-31. https://doi.org/10.1016/j.ecns.2020.01.008 Speroni, K. G., McLaughlin, M. K., & Friesen, M. A. (2020). Use of evidence-based practice models and research findings in magnet-designated hospitals across the United States: National survey results. Worldviews on Evidence-Based Nursing, 17(2), 98-107. https://doi.org/10.1111/wvn.12428 World Health Organization. (2024). Patient safety. https://www.who.int/news-room/factsheets/detail/patient-safety 33 Appendix A Question Development Tool 34 35 Appendix B Research Evidence Appraisal Tool 36 37 38 39 40 41 42 43 44 Appendix C Nonresearch Evidence Appraisal Tool 45 46 47 48 49 50 51 Appendix D Pre-Simulation Survey Pre-Simulation Survey Q1 How confident are you with giving report using the SBAR format? o Not confident at all (1) o Somewhat confident (2) o Moderately confident (3) o Confident (4) o Very confident (5) Q2 How confident do you feel in using closed-loop communication to ensure clarity and understanding in clinical situations? o Not confident at all (1) o Somewhat confident (2) o Moderately confident (3) o Confident (4) o Very confident (5) 52 Q3 How confident do you feel about speaking up in clinical situations? o Not confident at all (1) o Somewhat confident (2) o Moderately confident (3) o Confident (4) o Very confident (5) Q4 How much responsibility does a student nurse hold for communicating effectively with other healthcare professionals? o No responsibility at all (1) o Little responsibility (2) o Moderate responsibility (3) o Significant responsibility (4) o Complete responsibility (5) 53 Q5 How much responsibility does a student nurse hold for speaking up about safety concerns? o No responsibility at all (1) o Little responsibility (2) o Moderate responsibility (3) o Significant responsibility (4) o Complete responsibility (5) 54 Appendix E Post-Simulation Survey Post-Simulation Survey Q1 How confident are you with giving report using the SBAR format? o Not confident at all (1) o Somewhat confident (2) o Moderately confident (3) o Confident (4) o Very confident (5) Q2 How confident do you feel in using closed-loop communication to ensure clarity and understanding in clinical situations? o Not confident at all (1) o Somewhat confident (2) o Moderately confident (3) o Confident (4) o Very confident (5) 55 Q3 How confident do you feel about speaking up in clinical situations? o Not confident at all (1) o Somewhat confident (2) o Moderately confident (3) o Confident (4) o Very confident (5) Q4 How much responsibility does a student nurse hold for communicating effectively with other healthcare professionals? o No responsibility at all (1) o Little responsibility (2) o Moderate responsibility (3) o Significant responsibility (4) o Complete responsibility (5) 56 Q5 How much responsibility does a student nurse hold for speaking up about safety concerns? o No responsibility at all (1) o Little responsibility (2) o Moderate responsibility (3) o Significant responsibility (4) o Complete responsibility (5) Q6 After participating in the simulation, do you feel more prepared to speak up in clinical situations? o Yes (1) o No (2) Q7 Please explain how the simulation has prepared you to speak up in clinical situations and/or any barriers that continue to make you feel unprepared to do so. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 57 Appendix F Student Overview: You are a new graduate nurse who has recently been hired to the Medical/Surgical unit. You have just completed your orientation and are beginning to feel like you truly belong here. One of the senior nurses that you are working with today asks you to help her insert a catheter into a newly admitted patient. You have time, so you agree to help. Go ahead and enter the room. Simulation Scenario Patient Name: Bernadette Jackson DOB: 5/10/1939 Weight: 121 lb Allergies: NKDA; seasonal allergies Time scenario begins: Thursday at 1500 Simulation should not exceed 15 minutes Core Objectives: • The student will provide quality care and maintain patient safety throughout the simulation. • The student will communicate clearly, effectively, and professionally with patients, families, and other healthcare team members. Simulation Target Objectives: • The student will be able to identify that sterile technique was broken during a urinary catheter insertion. • The student will demonstrate their ability to “speak up” with assertive but professional communication to advocate for a patient. • The student will outline and implement the necessary steps to correct a breach in sterile technique. EHR chart contains the following at start of simulation: History/Information: Admission diagnosis: Dehydration, urinary retention PMH: Mixed incontinence, appendectomy at age 52 Report: Primary care provider started her on oxybutynin 1 week ago for overactive bladder. For the past 5 days she has also been taking over-the-counter loratadine for seasonal allergies. An interaction of the two medications has resulted in urinary retention. She presented to the emergency department with weakness, lethargy, decreased appetite, and abdominal pain. She states that she has noticed a decrease in her urine output and has not voided today. A bladder scan has just revealed 620 mL of retained urine. Allergies: NKDA; seasonal allergies 58 Home Medications: Oxybutinin 5 mg PO TID; Loratadine 10 mg PO daily. Code Status: Do not resuscitate Social/Family History: Widowed. Lives in an assisted living complex. Assessment: Vital signs: 1445: Temp 37.3 C or 99.2 F; BP 138/68; P 90; RR 24; O2 Sats 93% on room air General Appearance: Mrs. Jackson appears weak and slightly confused, possibly related to an infection. A neighbor stated this confusion is new for Mrs. Jackson. Neurological: Talkative during admission history. Oriented X 2 (not oriented to time). Reorients easily. Cardiovascular: S1 S2, no murmurs; diminished pulses, 2+ radial and dorsalis pedis bilaterally Respiratory: Lungs clear, no cough GI: Active bowel sounds. GU: Complaining of “burning” in her urethra. A bladder scan just revealed 620 mL of retained urine. An order has been placed for an indwelling urinary catheter. Skin: Dry, intact, poor turgor; no skin breakdown noted. IV: Right antecubital 20-gauge, which is intact and patent, running 0.9% normal saline IV at 100ml/hr. Labs: CBC and BMP pending. A urinalysis needs to be sent after placing a Foley catheter. Fall risk: High Pain: 3/10 abdominal pain. Had Acetaminophen 500 mg at 1230. Initial Healthcare Provider’s Orders: These orders are already in the chart at the start of simulation. 1. Vital signs every 4 hours and as needed 2. IV fluids: 0.9% normal saline IV at 100 ml/hr continuous infusion 3. Medications: Acetaminophen 500 mg PO q6h PRN for temperature greater than 100.5 F (38.1 C) or pain – not to exceed 4 g in 24 hours. 4. Place indwelling urinary catheter; indwelling catheter care per hospital protocol 5. Strict intake and output 6. Labs: Urinalysis with culture; CBC and CMP in AM 7. Activity: Bathroom privileges with assist 8. Diet: Regular diet, encourage fluids State Simulator Scenario to be used: Events/Expectations Events: Prompts and Simulation TA script Primary Nurse: Prior to insertion: 59 Bernadette Jackson Scenario 2 (Confusion in Older Adult with Infection). #1: Initial Assessment T= 99.0 F (37.2 C) BP= 136/68 P= 104 RR= 22 O2 Sat= 94% (room air) Heart sounds: Regular Lung sounds: Clear bilaterally Abdominal sounds: Active Pulses: Diminished peripherally 1. Bernadette Jackson is • “Can you help me with this lying supine with the catheter insertion? My patient is head of bed at 45 really restless and confused. I degrees. Her sheets don’t think she will sit still for me are disheveled and half to put this catheter in. Her pulled off. She is bladder scan showed 620 ml of disoriented to place retained urine, and she hasn’t and time and is very voided all day!” restless. The primary • “I have a lot to do today with all nurse asks the student of my patients, so let’s try to get for help with placing this in quick!” the indwelling • “Okay, Mrs. Jackson, I need you catheter. to sit really still. I am going to 2. As the primary care insert this urinary catheter to nurse inserts the Foley drain all of the urine sitting in catheter, the sterile your bladder. It may be a little field is broken when uncomfortable as I put it in, but it the nurse fumbles and will feel much better once it brushes the tip of the drains your bladder!” catheter on the side of the patient’s leg. Patient: General: Expectations: • “My birthday is May 10.” 1. The student will help • “I do not have any drug allergies, the primary nurse calm just seasonal allergies.” the patient, lower the • “I have a son, Charles Jackson head of the bed, and Jr., and two grandchildren. They hold the patient’s legs usually visit me once a year.” for catheter insertion. 2. The student will During preparation for catheter recognize and speak insertion: up about the sterile • “Why are you uncovering me? I field being broken. want my blankets on!” • • • #2: Assessment: T= 99.1 F (37.3 C) BP= 142/74 P= 108 RR= 22 If the student speaks up: Events 1. The primary nurse will be dismissive about the broken sterile field as she is in a hurry. Expectations “Stop touching my legs!” “My stomach hurts, and I really have to pee!” “What are you doing down there?” If the student speaks up: Primary Nurse • “It’s ok. We think she already has an infection anyway.” • “It barely touched her, and I really just need to get this done fast for her sake and mine!” 60 O2 Sat= 94% (room air) The patient is anxious about the catheter insertion. 1. The student will insist sterile technique should be used. If the student does NOT speak up: 1. The primary nurse will continue with the insertion of the catheter. Patient • “Did you say something wasn’t clean? You better not put anything in me that isn’t clean! I get UTIs way too easily!” If the student insists: Primary Nurse • “Ok, you’re probably right. I don’t want to cause more problems for Mrs. Jackson.” Patient • “Thanks for making sure everything is done right!” If the student does NOT speak up Primary Nurse • “Alright, we are ready Mrs. Jackson. I’ll get this in as quickly as I can. Try to relax.” Patient • “Just hurry! I’m cold and uncomfortable!” Set up instructions Simulators Moulage Chart Medications to be stocked in MedDispense Bedside Drawers Overbed Table at foot of bed Simulator Set up – 1. Change the simulator to female sex. 2. Apply the correct patient identity band to the simulator. 3. Position the simulator in a supine position with the head of the bed at 45 degrees. 4. Twist the top sheet on the bed to appear disheveled and half pulled off the simulator. 5. Insert IV catheter into the right antecubital, secure with dressing, and infuse 1000 mL IV bag of 0.9% normal saline at 100 mL/hr. None needed. EHR for Bernadette Jackson. Tylenol 500mg PO Nothing needed. 1. Place a urinary catheter insertion kit (including sterile gloves) on the bedside table. 61 Counter Debriefing Room 2. Place a urine specimen container, 30 mL Luer-lock syringe, and alcohol wipes on the bedside table. Gloves Chairs, debriefing worksheets, and a television for viewing the video. Adapted from Fundamentals scenario 2 – Bernadette Jackson, by Elsevier, n.d. Copyright 2025 by Elsevier. 62 References Elsevier. (n.d.). Fundamentals scenario 2 – Bernadette Jackson (Simulation Learning System for RN 2.0) [Computer Software]. Evolve. 63 Appendix G Student Overview: You are a new graduate nurse working on a Med/Surg unit. You have been assigned to care for five patients during your 12-hour night shift and have already received a report on the following four patients: • Margaret Chan: A 68-year-old female who was diagnosed with advanced metastatic non-small cell lung carcinoma 1 year ago. She was admitted last night for the management of nausea, vomiting, and pain. • Keola Akana: A 70-year-old male with exacerbated heart failure. • Agnes Taylor: An 81-year-old female who underwent an open reduction internal fixation (ORIF) of her left hip 2 days ago. • Cynthia Bennett: A 34-year-old female with pyelonephritis. You will proceed into the room to receive a bedside report on your final patient, Tessa Walker. Simulation Scenario Patient Name: Tessa Walker DOB: 4/19/2000 Weight: 135 lb Allergies: NKA Time scenario begins: Sunday at 1100 Simulation should not exceed 15 minutes Core Objective: • The student will cultivate effective verbal and nonverbal communication skills, including using TeamSTEPPS tools, which will help them be effective members of the healthcare team, communicate, advocate for, and educate patients and families, and provide safe and quality care. Facilitator Reminders: As this scenario deals with mental illness and suicide, advise students that the scenario deals with a suicidal patient and give the option to opt out of the scenario if needed. Simulation Target Objectives: • The student will recognize the need for a suicidal patient to have a sitter. • The student will demonstrate their ability to “speak up” with assertive but professional communication to advocate for a patient. • The student will use therapeutic communication to de-escalate a patient. EHR chart contains the following at start of simulation: 64 History/Information: Admission Diagnosis: Depression PMH: Depression, suicide attempt by overdose 3 years ago, borderline personality disorder, migraines, alcohol use, marijuana use. Report: Presented to the emergency department with superficial cuts on bilateral wrists from a dinner knife. A patient recently broke up with her boyfriend, whom she had dated for 1 month. Allergies: NKA Home Medications: Sumatriptan 25mg by mouth daily PRN at onset of migraine; acetaminophen 325mg 1 or 2 tabs PRN pain. Code Status: Full code Social/Family History: Single white female. Lives with mother. Just broke up with her boyfriend. Works part-time as a cashier. History of sexual abuse from uncle. Assessment: Vital signs: 0700 Temp 98.5 F; BP 130/76; P 86; RR 18; O2 Sat 99% on room air General Appearance: Attention-seeking behaviors. Mood is labile. Affect congruent. No overt acting out or aggression. Neurological: Alert and oriented to person, place, and time. Pupils equal and reactive to light. Cardiovascular: Normal S1 and S2, apical strong and regular, peripheral pulses present and equal bilaterally. Respiratory: Lungs clear to auscultation GI: Abdomen soft and nondistended. Bowel sounds present. GU: Voids without complication Skin: Cuts in various stages of healing noted on upper arms. Gauze dressings noted on bilateral wrists. IV: None Labs: CBC with differential and BMP normal. Urine drug screen positive for marijuana. HcG negative. Fall risk: None Pain: 2/10 (Most recent pain medication 2 acetaminophen 325 mg tablets given at 0600 for pain 6/10). Initial Healthcare Provider’s Orders: These orders are already in the chart at the start of simulation. 1. Vital signs: Daily 65 2. Medications: Fluoxetine 10mg by mouth daily; Acetaminophen 325 mg 2 tabs PO q4h PRN for pain; Bacitracin ointment to bilateral wrist lacerations twice daily; Lorazepam 0.5mg PO q6h PRN for anxiety/agitation; Sumatriptan 25 mg PO daily PRN at onset of migraine X 1 dose. 3. Wound care: Bacitracin as ordered, cover with 2 X 2 gauze and gauze roll dressings. 4. Social worker to arrange family meeting with mother. 5. Continue suicide precautions 6. Diet: Regular 7. Activity: As tolerated State Events/Expectations Prompts and Simulation TA script #1 Simulator Scenario to be used: Tessa Walker Psych Sim 11 Report Events: The simulation starts with the student receiving their patient assignments. The student is given 5 patients, including one who is suicidal without a sitter. However, the student is not told that there is no sitter unless he or she asks. If the student asks if there is a sitter after receiving their patient assignment: Charge nurse: • “We simply just do not have enough staff to supply a sitter for this patient.” • “You will have to just do the best you can to watch her as often as possible.” Expectations: When the student receives their patient assignment, they will ask if there is a sitter assigned to the patient. If they do, they will speak-up for patient safety. The student will insist that it is protocol to have a sitter for a suicidal patient. Then, the student will go assess the patient until a sitter arrives. #2: Tessa Walker T= 98.5 F (36.5 C) BP= 130/76 P= 86 RR= 18 O2 Sat= 99% (room air) • Heart sounds: Regular Events: Tessa Walker will be pacing around the room, restless and agitated. She has removed the dressings from her wrists and is scratching at her open wounds. She is also proclaiming that she wants to die. (If an SP is not available for this scenario, a high-fidelity If the student insists on a sitter: • Charge nurse: “Ok, I guess you are right. I would hate for anything to happen to the patient. I’ll go ahead and pull a PCT off the floor and then send out a text to try to find a replacement for the PCT. Go ahead and sit with your patient until the PCT can get to the room.” Tessa Walker (restless and labile mood): • “Look. I scratched open my wounds.” • “I want to die. I’m so upset about my boyfriend.” • “I don’t want to hurt myself, but I don’t have a choice. I don’t feel safe by myself.” 66 • • • • Lung sounds: Clear bilaterally Bowel sounds: Active Pulses: 2+ throughout Pain 6/10 simulator manikin will be used, and a facilitator will act as the “voice” of the patient. The manikin will not be able to pace or scratch at her wounds, so the facilitator must emphasize the statements in the script.) Expectations: The student will use therapeutic communication and deescalate the patient. If the student has already been assigned a sitter: After de-escalating the patient, the student will explain the use of a sitter with the patient. • • • “I know smoking is against the rules, but can I please go outside to smoke? It really relaxes me.” “If you don’t let me smoke, I will cut myself again to relieve the stress.” “You don’t care about me.” General: • You can call me Tessa.” • “My birthday is April 19.” • “I am 24 years old.” • “I don’t have any allergies.” • “My pain is 6 out of 10.” If the student has not convinced the charge nurse to assign a sitter: Expectations: After de-escalating the patient, the student will call for help and insist a sitter be provided. State #3 Charge Nurse Responses: If the student speaks up and insists a sitter be supplied, the charge nurse will pull a PCT from the floor to sit with Tessa until a replacement can be found. The charge nurse will then text staff asking for help. He or she will also call staffing and the house supervisor for help. #3: Tessa Walker If the student still has NOT spoken up for a sitter: Events: Tessa Walker will ask for pain meds and a new dressing, forcing the student out of the room. Upon return, Tessa will be found crying with empty narcotic pill bottles from home on the bedside table. The patient admits to overdosing on home medications. If the student still has NOT spoken up for a sitter: Tessa Walker: • “My head is killing me. I get these migraines, and they are so hard to get rid of.” • “Can you please get me my pain meds and probably some new bandages for my arms?” If student is left alone: Tessa Walker (crying) • “I told you not to leave me alone!” 67 (If a manikin is used, a simulation facilitator will have to “voice” that she took a lot of pills and that she hid the empty pill bottles in the bedside drawers.) • • • “I took all of my home medications.” “I hid the empty pill bottles in those drawers over there” (points at bedside drawers). “Just let me die!” Expectations: The student will use therapeutic communication and de-escalate the patient. The student will call the provider for help. The student will call the charge nurse and insist a sitter be provided. Set up instructions Simulators Moulage Chart Medications to be stocked in MedDispense Bedside Drawers Overbed Table at foot of bed Counter Debriefing Room Simulator Set up – 1. Female SP for Tessa. If no SP is available, a high-fidelity simulator manikin will be used instead. 2. Apply the correct patient identity band to SP. 3. The simulation starts with Tessa pacing around the room, scratching at the wounds on her wrists. If a manikin is used, the patient will be lying in the bed with the head raised and moulage visible. Moulage for bleeding shallow cuts in various stages of healing (suggestion for recent cuts: draw narrow lines of varying lengths with red makeup pencil; older cuts; draw narrow lines of varying lengths with a brown makeup pencil). Fake blood will be applied to show mild active bleeding. EHR for Tessa Walker. Acetaminophen 325 mg 2 tab; Bacitracin ointment; Lorazepam 0.5mg tab; Sumatriptan 25 mg tab. Empty narcotic pill bottles. Two old roll gauze bandages with a small amount of blood on them. Hallway counter should have nonadhesive gauze, roll gauze, and tape. Chairs, debriefing worksheets, and a television for viewing the video. Adapted from Psychiatric Scenario 11 – Tessa Walker, by Elsevier, n.d. Copyright 2025 by Elsevier. 68 References Elsevier. (n.d.). Psychiatric Scenario 11 – Tessa Walker (Simulation Learning System for RN 2.0) [Computer Software]. Evolve. 69 Appendix H Student Overview: You are a new graduate nurse who was hired into the Float Pool at a large Urban Hospital 12 weeks ago. This morning, you were working on the Ortho/Neuro Med-Surg Unit, but the nursing supervisor has asked you to float to the ICU because they had just received multiple admissions and are short-staffed. You have not previously worked on this unit, but the nursing supervisor states, "You are such a great nurse! They will be so happy to have help and will assign you patients you feel confident managing.” You have just arrived at the unit and are meeting with the Charge Nurse for the report. Simulation Scenario Patient Name: Naomi Reed DOB: 3/23/1986 Weight: 185 lb Allergies: NKA Time scenario begins Monday 0845 Simulation should not exceed 15 minutes Core Objectives: • The student will cultivate effective verbal and nonverbal communication skills, including using TeamSTEPPS tools, which will help them be effective members of the healthcare team, communicate, advocate for, and educate patients and families, and provide safe and quality care. Facilitator Reminders: The student will be assigned multiple patients, but only Naomi will be set up. If a student attempts to visit another patient, redirect the student back to Naomi’s room (advise the student that someone else will address the other patients’ needs until Naomi is taken care of). Simulation Target Objectives: • The student will recognize an inappropriate patient assignment that could affect patient safety. • The student will demonstrate their ability to “speak up” with assertive but professional communication to advocate for safe patient assignments. • The student will prioritize patient care and ask for help when necessary. EHR chart contains the following at start of simulation: History/Information: Admission Diagnosis: Right hemispheric acute ischemic stroke 70 PMH: Diagnosed with endometriosis 5 years ago after episodes of pelvic pain and hypermenorrhea. Patient was treated with laparoscopic ablation 3 years ago and is currently on a monophasic oral contraceptive. Report: The patient was having coffee with her sister at 0600 when she experienced slurred speech, facial droop, and left-sided weakness. Her sister called emergency medical services, and she was rushed to the emergency department and then quickly admitted as an inpatient. Recombinant tissue plasminogen activator (rt-PA) therapy has been ordered, and her window to receive it ends in 15 minutes. Allergies: NKA Home Medications: Ortho-Cept daily Code Status: Full code Social/Family History: Ms. Reed is a small business owner who lives with her sister. She has no children. Assessment: Vital signs: 0830 Temp 98.7F; BP 160/98; P 70; RR 16; O2 Sat 96% on 2L NC General Appearance: Naomi is unable to answer questions because her speech is incomprehensible. She seems fearful. Neurological: Unable to assess orientation due to slurred speech. Left-sided weakness. Facial droop present. Cardiovascular: Regular rate and rhythm; peripheral pulses present and equal bilaterally. Respiratory: Lungs clear throughout. GI: Bowel sounds present in all quadrants. GU: Unable to assess. Has not voided yet. Skin: Skin intact with no redness, breakdown, lesions, or bruising. IV: 20-gauge right forearm that is saline locked; 18-gauge left forearm that is saline locked. Labs/diagnostics: Lab results indicated no bleeding disorders. CT scan ruled out hemorrhage. Fall risk: High Pain: No apparent pain. Initial Healthcare Provider’s Orders: These orders are already in the chart at the start of simulation. Monday 0835: 1. STAT order: Administer rt-PA IV 0.9mg/kg (to maximum of 90mg) over 60 minutes, with 10% of the total dose administered as an initial IV bolus over 1 minute. 2. During rt-PA treatment: 71 a. Continuous cardiac and oxygen saturation monitoring for 24 hours b. Blood pressure, heart rate, respiratory rate, Glasgow Coma Scale, and neuro check every 15 minutes for 2 hours after starting rt-PA infusion c. If systolic BP is higher than 180 mm Hg and/or diastolic BP is higher than 105 mm Hg on 2 readings 10 minutes apart, administer labetalol 10 mg IV over 2 minutes. May repeat x 1 if, 15 minutes after initial dose, systolic BP remains above 180 and/or diastolic BP remains above 105. d. If systolic BP is persistently higher than 180 mm Hg despite labetalol and/or if diastolic BP is higher than 140 mm Hg on 2 or more readings 10 minutes apart, administer sodium nitroprusside IV infusion (50 mg in 250 mL dextrose 5% in water). Begin infusion at 1 mcg/kg/min and titrate every 10 minutes to a maximum of 15 mg/hr to maintain systolic BP below 180 and diastolic BP below 105. Monday 0755: 1. 2. 3. 4. 5. 6. 7. Code status: Full code Admit to medical-surgical unit Diagnosis: Right hemispheric acute ischemic stroke Allergies: None known to food or medications Diet: NPO Activity: Bedrest Blood for pre-rt-PA labs drawn in the emergency department. Notify the provider immediately of the results. 8. Monitoring: Continuous cardiac and oxygen saturation monitoring. Neurologic assessment, to include Glasgow Coma Scale, every 15 minutes until initiation of rt-PA treatment 9. Vital signs every 15 minutes until initiation of rt-PA treatment, then every 15 minutes x 2 hours, then every 30 minutes x 6 hours, and then every hour x 18 hours 10. Intake and output every shift 11. Notify the provider of neurologic changes or if blood pressure remains higher than 185/110 after treatment (see orders) 12. Admission weight and weight daily 13. Oxygen: 2 L/min via nasal cannula 14. Daily labs in AM: Complete blood cell count with platelets, comprehensive metabolic panel, PT, aPTT, INR 15. Maintain 2 IVs 72 16. For pre-rt-PA treatment: If blood pressure is higher than 185/110, administer labetalol 10 mg slow IV push. May repeat x 1. Notify the provider if BP is not responsive to treatment. 17. Do not initiate rt-PA treatment until orders are received. State Simulator Scenario to be used: Naomi Reed Medical/Surgical Sim 21 Events/Expectations Events: The simulation starts with the student receiving their patient assignments. The student is advised that they are acting as a float pool nurse who is unfamiliar with the unit. This float pool nurse is given an inappropriate assignment of 3 ICU patients (1 more than normal). The assignment includes Naomi Reed, who needs rt-PA started within the next 15 minutes, a patient having an MI on a nitroglycerin drip, and an intubated patient on a dopamine drip. Prompts and Simulation TA script If the student speaks up against their patient assignment: Charge Nurse: • “The other nurses were assigned the same patients as yesterday, and they all wanted to care for the patients they already knew.” • “We are short-staffed, so I had to give someone a third patient.” If the student insists on a change in patient assignment: • “Alright, I see your point. You would not be able to monitor all three of these patients adequately.” Expectations: • “Let’s look at how we can When the student receives rearrange the assignments their patient assignment, they today.” will speak up for patient • “Go ahead and get the rt-PA safety by stating that the administered, and I will keep assignment is inappropriate an eye on your other two since all 3 patients will need patients until I can get the close monitoring. assignments changed.” This section is optional, depending on how your simulation unfolds. If the student accepts the patient assignments, move to state 2 #2: Events: Naomi: Naomi Reed Naomi is lying in bed. The *Incomprehensible slurring* T= 98.7 F (37.1 C) patient tries to speak, but BP= 170/91 her speech is so slurred that it Overhead HUC P= 84 is incomprehensible. As • “Hi, Mrs. Dixon just called to RR= 16 the student attempts to begin let you know that she has a O2 Sats= 96% with 2L her assessment/rt-PA massive headache and NC preparation, a ventilator dizziness. I can see on the alarms in the student’s other • Heart sounds: monitor that her blood room, and the student is also Regular pressure has dropped to advised that her MI patient is 85/40.” 73 • • • • • Cardiac monitor: Normal sinus rhythm Lung sounds: Clear throughout Abdominal sounds: Present Pulses: 2+ Pupils: equal and reactive calling with a major headache and dizziness (BP 85/40). Expectations: The student will recognize the urgency of attending to all 3 patients (administering the rtPA, assessing the ventilator alarm, and addressing the MI patient’s chest pain and low blood pressure). Therefore, they will ask for help and speak up against the unsafe patient assignment. *If the student only asks for help instead of asking for a revised assignment, a TA or facilitator will state that they will help the student right then, but they will likely be unavailable to help again because they are getting an admission soon. *If the student attempts to leave Naomi’s room to attend to her other patients, a facilitator or TA will meet them in the hall (because their other patients are not actually set up) and advise them that the student was able to correct the problem in whichever room they were going to, but that Naomi is now past her 3-hour mark for rt-PA and their third patient is decompensating. Set up instructions Simulators • “Also, if you can’t hear it, I think your ventilator is alarming in Mrs. O’Neill’s room.” Charge Nurse (only if the student speaks up about patient assignment): • “I’ll go check on that ventilator alarm and find someone to help Mrs. Dixon. Then, we will discuss the assignments.” • Upon return from helping the student’s other patients: “I can see how your current assignment makes it so that you can not adequately monitor your patients. I will rearrange the assignments.” Extra Nurse (only if the student asks for help) • “I’ll go check on that ventilator alarm and have someone else go check on Mrs. Dixon for you. However, I’m going to be pretty busy here in a few minutes when my admission comes, so I hope things slow down for you because I won’t be able to help you much longer.” Simulator Set up – 1. Change the simulator to female sex. 2. Apply the correct patient identity band. 3. Dress the simulator in a gown and position the simulator lying in bed with the head of the bed at 30 degrees. 74 Moulage Chart Medications to be stocked in MedDispense Bedside Drawers Overbed Table at foot of bed Counter Debriefing Room 4. Insert 20-gauge IV in the simulator’s right forearm, secure with dressing and saline lock. 5. Insert 18-gauge IV in the left forearm, secure with a dressing and saline lock. 6. Connect the cardiac monitoring leads and continuous pulse oximeter to the simulator. Turn on the simulator's monitor screen and position the monitor in clear sight in the patient's room. 7. Place a nasal cannula on the simulator and connect it to the oxygen flow meter running at 2L/min. 8. Stock supply cart with IV tubing and IV medication administration supplies. None. EHR for Naomi Reed. rt-PA (premixed bag labeled 75mg in 75mL sterile water). Labetalol 5mg/mL concentration in 20mL vial as a distracter. Nothing needed. NIH Stroke Scale Nothing needed. Chairs, debriefing worksheets, and a television for viewing the video. Adapted from Medical-Surgical Scenario 21 – Naomi Reed, by Elsevier, n.d. Copyright 2025 by Elsevier. 75 References Elsevier. (n.d.). Medical-Surgical Scenario 21 – Naomi Reed (Simulation Learning System for RN 2.0) [Computer Software]. Evolve. 76 Appendix I Student Overview: You are a new graduate nurse working on a Medical/Surgical unit and have just been notified that you are receiving an admission from the ED. The patient’s name is Lisa Rae. Please proceed to the nurses' station where you will use the computer to access SimChart. The nurse next to you is a nurse you have worked with several times. She has worked on the unit for about 10 years. Simulation Scenario Patient Name: Lisa Rae DOB: 11/24/1945 Weight: 110 lb Allergies: NKA Time scenario begins: Monday 1200 (to match chart) Simulation should not exceed 15 minutes Core Objectives: • The student will cultivate effective verbal and nonverbal communication skills, including using TeamSTEPPS tools, which will help them be effective members of the healthcare team, communicate, advocate for, and educate patients and families, and provide safe and quality care. Facilitator Reminders: Patient information is only supplied in case the student asks. The simulation is focused on incivility between two nurses in the hall, and the patient never actually arrives during the simulation. Simulation Target Objectives: • The student will recognize incivility in the workplace. • The student will demonstrate their ability to “speak up” with assertive but professional communication to advocate for a coworker. • The student will use therapeutic communication to encourage a distraught coworker. EHR chart contains the following at start of simulation: History/Information: Admission Diagnosis: Hypotension and mechanical fall PMH: Hypertension, falls, osteoporosis, and osteoarthritis in her right knee. Report: The patient was admitted Monday after having dizziness and falling at her assisted living facility. In the ER, the patient was hypotensive, and IV fluids were started. The patient 77 states she thinks she might have inadvertently taken 2 tabs (100mg) of her hydrochlorothiazide this morning. Allergies: NKA Home Medications: Hydrochlorothiazide 50mg PO every morning; Alendronate 10mg PO every morning; Calcium carbonate 600mg PO BID; Acetaminophen 1000mg q8h prn for right knee pain. Code Status: Full code Social/Family History: The patient lives in an assisted living facility, and her daughter lives in the area. Assessment: Vital signs: 1040 Temp 98.8 F; BP 94/70; P 84; RR 18; O2 Sat 93% on room air General Appearance: Mrs. Rae has been disoriented and complaining of grogginess. She almost fell trying to get to the bedside commode. Neurological: Alert and oriented X 2 (oriented to person and place, disoriented to day/time). Cardiovascular: S1, S2, regular rate, weak pulses bilaterally. Respiratory: Lungs clear throughout. GI: Bowel sounds in all 4 quadrants. GU: Some involuntary urinary incontinence. Skin: Ecchymotic area on right hip. IV: 18-gauge IV in right antecubital running 0.9% NS IV at 75mL/hr. Labs: Results from CBC and BMP are WNL. Fall risk: High Pain: 5/10 (was given 0.2mg hydromorphone IV at 1140). Initial Healthcare Provider’s Orders: These orders are already in chart at the start of simulation. Admission orders: 1. Code status: Full code 2. Admit to medical unit. 3. Diagnosis: Hypotension and mechanical fall 4. Allergies: No known allergies 5. Diet: 3 g sodium/day 6. Activity: As tolerated 7. Labs: Complete blood count in the morning 8. Monitoring: Vital signs every 4 hours and as needed 78 9. Intake and output every shift 10. Notify the physician of a temp greater than 101.0 F (38.3 C). 11. 0.9% normal saline IV continuous infusion at 75 mL/hr 12. Physical therapy: Evaluate and treat for safety with walker. 13. Occupational therapy: Evaluate and treat for ability to adhere to medication regimen; perform home safety evaluation. 14. Alendronate 10 mg PO daily 15. Calcium carbonate 600 mg PO twice daily 16. Acetaminophen 1000 mg PO every 6 hours as needed for pain. Do not exceed 4 g in 24 hours 17. hYDROmorphone 0.2 mg IV every hour as needed for pain State Simulator Scenario to be used: Student believes Lisa Rae is being admitted (Fundamentals Sim 5). However, patient does not actually arrive during the simulation. #1: Initial Assessment Events/Expectations Events: The simulation starts with the student preparing for an admission from the ER. Equipment such as an IV pump, extra pillows, briefs, and telemetry monitor stickers are sitting on the counter in the hallway for the student to take into the room to prepare for the admission. Meanwhile, a new graduate nurse asks a more experienced nurse a question in the hallway. The experienced nurse responds with incivility. Prompts and Simulation TA script Scripted Conversation: New graduate nurse (Hannah): • “Hi Denise, can I ask you a question?” Experienced nurse (Denise): • “Make it quick.” (Said in an annoyed tone of voice) New graduate nurse: • “I have a patient with COPD exacerbation, and her oxygen levels keep dropping to 88% on 5L NC. I tried putting a simple mask on her at 6L, but she is refusing to wear it and Expectations: says her O2 is okay to be at When the student overhears the 88% because she has COPD. experienced nurse treat the Is that true?” new graduate nurse with incivility, the student will speak Experienced nurse: • "Honestly Hannah? What up against this behavior. school did you even graduate from? Of course, a COPD patient can have an O2 of 88%. I’m so tired of our manager hiring nurses who don’t know anything. It’s a miracle you guys haven’t killed anyone yet.” 79 New graduate nurse (teary from the response) • “I’m sorry, I’m still learning, which is why I ask a lot of questions, so I don’t kill someone.” Experienced nurse: • “Well, no one should have to ask this many questions after graduating. You might want to do some extra studying.” New graduate nurse: • "I tried looking up how to manage a COPD patient before asking you, but it is hard to know what to focus on when I get so much conflicting information on the internet." Experienced nurse: • "Well maybe if you spent less time on Google and more time reading credible material, you would learn something." New graduate nurse: • "Could you tell me where to find good study materials?" Experienced nurse: • "I don't have time to hold your hand, Hannah. You're a big girl. Figure it out on your own." New graduate nurse: • "Ok, I'll do my best." Experienced nurse: • "You better, because at this rate, I don't know how you'll handle a real emergency." New graduate nurse: • *Teary* "Look, I get that it is frustrating, but I'm really just trying to learn here." Experienced nurse: 80 • "Trying isn't enough, you have real patients now. You should have learned this stuff in school. I don't have time to take care of my patients and teach you how to be a nurse. And stop crying, you need to grow a thicker skin if you want to survive in this job." New graduate nurse: • "I'm sorry, I'll do better, I promise." Experienced nurse: • "Promises don't mean anything if you can't keep them. Just don't expect me to save you every time you get stuck. I don't have the time for this." *Experienced nurse walks away in a hurry* This section is used only if the student does not speak up against incivility #2: Set up instructions Simulators Moulage Chart Event: The experienced nurse has left, and the new graduate nurse is seen crying over the hallway counter. New graduate nurse: • “She is probably right. I don’t know enough. I should probably look for a new job.” • “I wish someone would have said something to her. Maybe Expectations: I’m not as smart as her, but The student will use therapeutic communication to comfort the she still shouldn’t talk to me new graduate nurse. like that.” Simulator Set up – 2 simulated patients (SPs) should be used. One SP will be a new graduate nurse, and the other SP will be an experienced nurse. They will be talking in the hallway. None. EHR for Lisa Rae (in case the student wants to review her chart before the patient is admitted). 81 Medications to be stocked in MedDispense Bedside Drawers Overbed Table at foot of bed Counter Debriefing Room None. None. None. IV pump, extra pillows, briefs, and telemetry monitoring stickers. Chairs, debriefing worksheets, and a television for viewing the video. Adapted from Fundamentals scenario 5 – Lisa Rae, by Elsevier, n.d. Copyright 2025 by Elsevier. 82 References Elsevier. (n.d.). Fundamentals scenario 5 – Lisa Rae (Simulation Learning System for RN 2.0) [Computer Software]. Evolve. 83 Appendix J Project Timeline