Clinical Learning & Simulation

How I Heard

That Sunday morning, I awakened much later than usual for me on a weekend day. I looked at my phone to see the multiple HICS and trauma alerts that had been activated. As I watched the news and felt the reality of the situation, my heart ached and was full of deep sadness for the LGBT community. I had worked as an RN in New York City when AIDS was discovered and knew firsthand in taking care of those afflicted with the disease the terrible discrimination and death faced by the gay community. And now the LGBT community had suffered again. 

As many others, I wondered why I hadn’t been called in to help. I soon realized the appropriate Orlando Health team members had been present that morning to care for the immediate needs of the victims and their families. Through the culture of learning and simulation, these team members had been sufficiently prepared to appropriately treat and care for the patients.

Synopsis

As corporate director for clinical learning, one of my responsibilities is to oversee the Orlando Health Institute for Learning (OHIL). The institute is located only three blocks from the Pulse nightclub. On a typical day, the institute may have 250 team members onsite for various educational opportunities. Dedicated learning consultants lead the experiential learning through simulation.

Learning through the principles of simulation is utilized in many curricula, including the RN residency program, emergency nurse core curriculum advanced life support classes, and the critical care nursing specialty core courses.

Preparation

Prior to June 12, 2016, preparation through learning occurred for the Emergency Department (ED), the operating room (OR), critical care, medical-surgical and rehab inpatient units through various educational opportunities. Our system’s education team orients team members to our software applications such as the electronic medical records, guest relations and revenue management.  

Through the years, simulation and weekly mock alerts have played a role in the success of taking care of patients in the ED. Using high- fidelity simulators, the multi-disciplinary team had rehearsed various simulated scenarios followed by de-briefing sessions. Once a month, simulation had occurred with our local EMS partners led by a learning consultant certified in simulation. These sessions enabled inter-professional teams from nursing, physicians, respiratory therapy, radiology and other disciplines to refine their team dynamics. 

Response

Ironically, on June 12, I was called into the institute to deal with a building issue. I attempted to drive my usual route to OHIL, but immediately encountered difficulty and had to take an alternate route that avoided the scene at the Pulse nightclub. Over the next three hours as the repairs took place, I watched as the media, their trucks and entourage became increasingly evident.  From my office, I could see swelling numbers of spectators parking nearby and attempting to walk to the Pulse scene. 

It was now apparent that as a leader some decisions were needed to prepare for our normal Monday activities -- team members arriving to work, attending new hire orientation, teaching and leading the various courses scheduled at OHIL. Conference calls occurred, schedules were assessed, and the logistics and security related to protecting our team members who would be working or attending these activities were considered in whether to open the institute on Monday. A decision was made to proceed with business as usual. 

On Monday, there was heightened anxiety related to the event occurring so close to us and the enormous presence of the media camped out only a block from our doors. We could view the activity from our windows, passersby couldn’t see into our building. Helicopters circled overhead, making constant noise and reminding us of what had occurred just three blocks away. New team members arrived and expressed both their gratitude for not cancelling the new hire orientation and their pride in being an Orlando Health team member. 

The advanced critical care course for nurses was midway through its curriculum. The nurses were asked if they wanted to continue with the course due to the emotions, ongoing noise and disruption outside of the building. They unanimously agreed to continue without interruption.  Some had worked in the ED, intensive care units and critical areas with their preceptors on Sunday to care for the Pulse shooting victims. They had recently completed their basic critical care course, which had included weekly simulation through experiential learning. There were newly graduated registered nurses who had just begun their nursing career. 

During the next couple of days, I made rounds within OHIL, checking on the learning consultants and team members attending courses and providing assurance, comfort and support. Those in the learning and simulation world were thanked for their effort to provide the needed education and preparation that contributed to the patient care successes following the tragedy. 

Lessons Learned

It is important to provide emotional support and allow for healing. Reach out to team members to provide them with an environment to speak up and talk about their concerns and emotions. Group counseling was arranged at the downtown campus and OHIL, and team members were encouraged to attend or arrange a one-on-one session. We arranged for pet therapy at OHIL on that Thursday, and as Bella roamed the rooms, you could feel the tension decrease. She would lay on the floor surrounded by smiling people petting her while team members thanked her handler.  

What We Changed

RN Residency Program Mock Codes: Within the RN resident program for newly licensed registered nurses, we enhanced simulation to teach reflective communication skills. These enable clinicians to disseminate information for learning opportunities and professional team development, and to decompress after stressful events. Teaching through simulation with the Plus Delta techniques, nurses are asked to reflect about “What went well?”  “What is one thing you would change/incorporate next time?” to assist with the communication process. This empowers the nurses to take a proactive approach to support and learn from each other. As one participant said: “I like the idea of being able to take a few minutes to talk my thoughts out, so I do not worry if I did the right thing for the patient.”

Yearly Mass Casualty Drill:

The high volume of visitors and phone calls to the hospital after the Pulse tragedy showed us we needed more support and guidelines in place within our waiting rooms and triage protocols to support family, friends and phone calls in the immediate aftermath of the event. 

During the mass casualty drill, Orlando Health Orlando Regional Medical Center (ORMC) was assigned a minimum of 20 standardized participants to portray anxious family members seeking their loved ones. They entered ORMC similar to the family members during the Pulse event. This gave the support teams an opportunity to practice.

Medical Surgical Course:

Simulation has been added to this curriculum and includes teaching the use of software downtime paperwork and interactions with the patient’s family members. These interactions include when and how to ask the patient for permission to talk about their health care in the presence of others. 

Life Support Services:

Incorporated mid-fidelity simulators into the advanced life-support courses. The team developed a “Foundations to Simulation” workshop specifically for the instructors teaching the advanced adult and pediatric life support courses. 

Weekly ED mock trauma alerts as well as monthly simulation with our local EMS partners now have increased respect and participation. There is notable compliance with and enhanced positive attitude toward these drills, and an increased awareness of learning through simulation versus the use of a standard manikin.

Conclusion

Working behind the scenes, the learning and simulation teams had helped prepare our clinicians and non-clinical teams to care for the victims of Pulse and their loved ones. Handoff from ED to OR, from ED to inpatient (IP), from OR to IP drove success to the discharge of all 35 inpatients. 

Key Takeaways

• Appreciate the culture of learning, promote value of simulation.
• How can this be happening?Reminder that preparation for such events is vital to success.
• Focus on essential skills needed for accurate and efficient handoff from ED to OR, from ED to IP, from OR to IP then discharge.
• Use reflective communication skills for dialogue during and after simulation.
• Debrief after an event with team members and provide emotional support.
• Celebrate the success of the culture of learning and simulation.