Enhancing Registered Nurse Job Readiness and Patient Safety Outcomes Through Clinical
Simulation
Simulation Scenario Template
Adaptation of California Simulation Alliance (CSA)
Feb 23, 2014
Revised April 2014
University of Ottawa
Algonquin College
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
TABLE OF CONTENTS
ii
SECTION I
SCENARIO OVERVIEW
A. Title
B. Summary
C. Evidence Base
SECTION II
CURRICULUM INTEGRATION
A. Learning Objectives
1. Primary
2. Secondary
3. Critical Elements
B. Pre-scenario learner activities
SECTION III SCENARIO SCRIPT
A.
B.
C.
D.
E.
F.
G.
Case Summary
Key Contextual Details
Scenario Cast
Patient/Client Profile
Baseline patient/client simulator state
Environment / equipment / essential props
Case flow /triggers / scenario development
SECTION IV APPENDICES
A. Health Care Provider Orders
B.
B. Digital Images of Manikin / Milieu
C. Debriefing Guide
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
1
SECTION I: SCENARIO OVERVIEW
Mark Fisher (Part A) – End of life care
Original Scenario Developer(s):
Diane Alain, Valerie Fiset, Frances Bourbonnais-Forthergill and Susan
Brajtman, University of Ottawa
Date - original scenario
February, 2014
Validation:
Revision Dates:
Draft for peer review, week of Feb 24th
Pilot testing:
QSEN revision:
Scenario Title:
Estimated Scenario Time:
20 min
Debriefing time: 30-40 min
Target group: 4th year BScN students
Core case: Palliative Care/End of Life care
CNA

Position Statement: Providing Nursing Care at the End of Life (2008)
CNO





Practice Guideline “Authorizing Mechanisms (updated 2014)” (2014) re: delegation.
Practice Guideline “Consent” (2009)
Practice Guideline “Guiding decisions in End of Life care” (2009)
Practice Standard “Documentation” (2008)
Practice Standard “Medication” (2014)
RNAO: Best Practice Guidelines
 End of Life Care During the Last Days and Hours (2011)
CHPCA
 A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice.
Revised and Condensed (2013).
CASN

Palliative and End-of-Life Care: Entry-to-Practice Competencies and Indicators for Registered Nurses
(2011)
Standardized Tools
 Edmonton Symptom Assessment System (ESAS). Cancer Care Ontario.
 Palliative Performance Scale (2005) Cancer Care Ontario.
 Frommelt Attitude Toward Care of the Dying Scale (Frommelt, K. (1991). The effects of death
education on nurses' attitudes toward caring for terminally ill persons and their families. American
Journal Of Hospice & Palliative Medicine, 8(5), 37. As cited in RNAO BPG (2011))
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
ALL DATA IN THIS SCENARIO IS FICTICIOUS
2
Brief Summary of Case:
This is the part A of a two part unfolding scenario that can be used as a single, stand-alone scenario.
Part A: Mr. Fischer is a 55-year-old patient with small cell lung cancer (SCLC). He was diagnosed 15 months
ago. He received chemotherapy (Cisplatin and Etoposide) and some thoracic radiation therapy. In the last
two weeks the disease has recurred, the patient has lost weight and is experiencing general weakness,
dyspnea, chronic cough and hemoptysis. His pain is not well controlled at this stage. The prognosis is poor,
his current Palliative Performance Scale (PPS) is 50% (Cancer Care Ontario, 2005; Wilner & Arnold, 2006)
and the doctor is transferring the patient from oncology to the palliative service. He wants to die at home; a
plan for this has been established and is will be enacted by the palliative discharge team. In this scenario the
patient is prepared to switch their resuscitation status to “Do Not Resuscitate (DNR)”, and declaring his
spouse power of attorney and substitute decision maker. He is anxious about having a conversation about
this change with his spouse.
He has been married for 30 years and has 2 children and 3 grand-children that live out of town.
Spouse is present in hospital, but not currently with patient.
Part B: 55 year old male client is imminently dying of lung cancer with a PPS of 10%. He is married and
spouse is at the bedside in the home. Client has 2 adult children and 3 grand-children who live out of town.
One of which arrives at the home just after her/his father passes away. Nurses must provide comfort
measures to the dying client and support the spouse during final breaths of life, in addition to breaking bad
news to the child who arrives too late to say goodbye.
EVIDENCE BASE / REFERENCES (APA Format)
Canadian Association of Schools of Nursing (CASN) (2012). Palliative and end-of-life care: A faculty guide for
nursing education. Ottawa: CASN.
Canadian Association of Schools of Nursing (CASN) (2011) Palliative and end-of-life care entry-to-practice
competencies and indicators for registered nurses. Ottawa: CASN
Canadian Interprofessional Health Collaborative (2010). A national interprofessional competency
framework. Retrieved Feb. 3, 2014 from http://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf
Canadian Nurses Association (2008). Position Statement. Providing nursing care at the end of life. Retrieved
Feb 3, 2014, from https://www.cnaaiic.ca/~/media/cna/page%20content/pdf%20en/2013/07/26/10/43/ps96_end_of_life_e.pdf A classic in
field.
Canadian Patient Safety Institute (2008). The safety competencies. Retrieved Feb. 3, 2014 from
http://www.patientsafetyinstitute.ca/English/toolsResources/safetyCompetencies/Documents/
Safety%20Competencies.pdf A classic in the Field.
Cancer Care Ontario (2005). Edmonton Symptom Assessment System. Retrieved Feb 23, 2014 from
https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13262 A classic in the Field.
Cancer Care Ontario (2005). Palliative Performance Scale. Developed by the Victoria Hospice. Retrieved Feb
18, 2014 from https://www.cancercare.on.ca/toolbox/pallcaretools/ -A Classic
College of Nurses of Ontario (2009). Practice guideline. Guiding decisions about end-of-life care, 2009.
Toronto: College of Nurses of Ontario. A classic in the Field.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
ALL DATA IN THIS SCENARIO IS FICTICIOUS
3
College of Nurses of Ontario (2008). National competencies: in the context of entry-level Registered Nurse
practice. Toronto: College of Nurses of Ontario. Retrieved Feb. 3, 2014 from
http://www.cno.org/Global/docs/reg/41037_EntryToPracitic_final.pdf
Frommelt, K. (1991). The effects of death education on nurses' attitudes toward caring for terminally ill
persons and their families. American Journal of Hospice & Palliative Medicine, 8(5), 37.
doi:10.1177/104990919100800509 A classic in the Field.
Kissane, D., Clarke, D., & Street, A. (2001). Demoralization syndrome -- a relevant psychiatric diagnosis for
palliative care. Journal Of Palliative Care, 17(1), 12-21. A classic in the Field.
Jones, J. (2007). Do not resuscitate: reflections on an ethical dilemma. Nursing Standard, 21(46), 35-39. A
classic in the Field.
Murray, M.A., Miller, T., Fiset, V., O’Connor, A., & Jacobsen, M.J. (2004). Decision support: Helping patients
and families to find balance at the end of life. International Journal of Palliative Nursing, 10(6): 270-277. A
classic in the Field.
Wilner, L., & Arnold, R. M. (2006). The Palliative Performance Scale #125. Journal Of Palliative Medicine,
9(4), 994. doi:10.1089/jpm.2006.9.994 A classic in the Field.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
SECTION I
ALL DATA IN THIS SCENARIO IS FICTICIOUS
4
SECTION II: CURRICULUM INTEGRATION
A. SCENARIO LEARNING OBJECTIVES
Do What
Uses
Demonstrates
Demonstrates
Identifies
Competency
CASN
Competencies
Uses requisite
relational skills
to support
decision-making
and negotiate
modes of
palliative and
end-of-life care
on an ongoing
basis.
With What
requisite relational skills
For What
to support decision-making and
negotiate modes of palliative and
end-of-life care on an ongoing
basis.
knowledge of grief and
bereavement
Knowledge and skill in holistic,
family-centred nursing care
to support others from a crosscultural perspective.
of persons at end-of-life who are
experiencing pain and other
symptoms.
of palliative and end-of-life care
services, resources and the
settings in which they are
available.
the full range and continuum
Demonstrated Attributes Align
With Competency
CASN
Indicators of competencies
 Provides information and
assurance to the patient
and family members
regarding comfort
measures during the last
hours/minutes of living,
and documents the
information provided.

Communicates
respectfully,
empathetically and
compassionately with the
PEOL patient and family
members.

Invites, facilitates,
negotiates, and respects
the involvement of the
patient and family
members … in discussions
about the plan of
palliative and end-of-life
care.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
Demonstrated
Attributes Need Some
Improvement To Align
Demonstrated
Attributes Need Major
Improvement To Align

Somewhat
provides
information and
assurance

Does not/ avoids
providing
information and
assurance

Somewhat
communicates
respectfully,
empathetically,
compassionately
with patient and
family

Does not
communicate
respectfully,
empathetically,
compassionately
with patient
and/ or family

Somewhat
involves patient
and family

Does not involve
patient and/or
family
5
Demonstrates
knowledge of
grief and
bereavement to
support others
from a crosscultural
perspective.

Communicates and
documents decisions
made by the patient and
family members regarding
their goals for palliative
and end-of-life care.

Somewhat
communicates
and documents
decisions

Does not
communicate
and/or does not
document
decisions

Creates a safe,
therapeutic environment
to build patient and
family members’ trust
and facilitate palliative
and end-of-life decision
making.
Accurately assesses and
documents the patient’s
and family members’
needs related to loss,
grief and bereavement.

Somewhat
establishes safe
environment

Does not
establish safe
environment






Identifies individuals
experiencing, or at high
risk of experiencing, a
complicated and/or
disenfranchised grief
reaction, and discusses,
documents and makes
appropriate referrals.
Demonstrates
understanding of grief
theories and their
application to PEOLC.
Demonstrates
understanding of the
common, normal
manifestations of grief
(emotional, physical,
cognitive, behavioral).
Demonstrates
understanding in
individual, social,
cultural, and spiritual
variables that affect
grief.
Provides guidance,
support, and referrals to
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014

Somewhat
assesses and
documents need
of patient and
family related to
loss, grief, and
bereavement

Does not assess
and document
need of patient
and family related
to loss, grief, and
bereavement

Somewhat
identifies at risk
individuals and
discusses and
documents
and/or makes
referrals

Does not identify
at risk individuals
and only does
some of discuss
and/or document
and/or make
referrals

Somewhat
demonstrates
understanding of
grief theories

Does not
demonstrate
understanding of
grief theories

Somewhat
demonstrates
understanding of
common, normal
manifestations
of grief

Somewhat
demonstrates
understanding of
common, normal
manifestations of
grief

Somewhat
demonstrates
understanding of
multiple
variables
affecting grief

Does not
demonstrate
understanding of
multiple variables
affecting grief

Somewhat
provides

Does not provides
guidance,
6
bereaved family
members and
documents such practice
actions.

Listens, affirms, and
responds empathetically
and compassionately to
the patient and family
members working
through the tasks of grief
and bereavement.

Demonstrates
knowledge and
skill in holistic,
family-centered
nursing care of
persons at endof-life who are
experiencing
pain and other
symptoms.
Develops the capacity to
be in the presence of
patient and family
member’s suffering.

Identifies gaps in
knowledge, skills, and
abilities as a first step in
acquiring new
knowledge, skills, and
abilities for palliative
end-of-life care (PEOLC).

Demonstrates
understanding of the
concept of ‘total pain’
when caring for PEOL
patients and their family
members, total pain
being inclusive of
physical, emotional,
spiritual, practical,
psychological, and social
elements.

Applies principles of pain
and other symptom
management when
caring for PEOL patients.

Utilizes best practice
assessment tools for
baseline and ongoing
assessment of pain,
including word
descriptors, body maps,
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
support, and
referrals to
bereaved family
members and /or
does not
document

Demonstrates no
elements of
listening,
affirming and
responding
compassionately
Somewhat
capable of being
in presence of
suffering with
some discomfort
displayed
Somewhat able
to identify gaps
in knowledge,
skills, and
abilities

Displays much
discomfort/ not
capable of being
present for those
suffering

Unable to identify
gaps in
knowledge, skills,
and abilities

Somewhat able
to adopt new
knowledge
about pain at
end of life

Unable to adopt
new knowledge
about pain at end
of life

Somewhat able
to apply pain
and symptom
management
knowledge


Somewhat uses
best practice and
documents
partly
Unable to apply
pain and
symptom
management
knowledge
Does not use best
practice and/or
does not
document


guidance,
support, and
referrals to
bereaved family
members and
documents
partly
Demonstrates
elements of
listening,
affirming and
responding
compassionately


7
PQRST, and documents
pain assessments.


Utilizes and documents
evidence-informed nonpharmacological
approaches to pain,
including any potential
adverse effects.

Assesses and documents
common non-pain
symptoms at end-of-life.

Understands causes of
common non-pain
symptoms at end-of-life.

Identifies the
full range and
continuum of
palliative and
end-of-life care
services,
resources and
the settings in
which they are
available.
Utilizes and documents
evidence-informed
pharmacological
approaches to alleviate
pain, including intended
effects, doses and routes
of medication, and
common side effects.


Implements and
documents evidenceinformed
pharmacological and
non-pharmacological
approaches to non-pain
symptoms at end-of-life.
With compassion and
empathy, initiates
conversation with
patient and family
members about their
goals of care.
Provides available
relevant information
about resources to the
PEOL patient and family
members.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014




Somewhat uses
appropriate
medication
practice and /or
documents only
partly
Somewhat uses
nonpharmacological
approaches and
/or documents
partly
Somewhat
assesses and/or
partly
documents
common nonpain symptoms
at end-of-life.
Somewhat
implements and/
or partly
documents
approaches to
non-pain
symptoms at
end-of-life.

Does not use
appropriate
medication
practice and/or
does not
document

Does not use nonpharmacological
approaches to
pain and/or does
not document

Does not assess
and/or does not
document
common nonpain symptoms at
end-of-life

Does not
implement and/
or document
approaches to
non-pain
symptoms at endof-life.

Initiates
conversation,
but compassion
and empathy
lacking

Avoids
conversation

Somewhat
provides
information

Does not provide
information
8
C. PRE-SCENARIO LEARNER ACTIVITIES
Knowledge
Prerequisite Competencies
Skills/ Attitudes

Pain Assessment

Pain assessment using PQRST

Medication Administration

Medication administration as per CNO guidelines



Communicating with and supporting patient
near time of death
Stages of grieving
Care of patients who are near death, facilitating
communication of patient decision(s) to loved ones.
Principles of therapeutic communication

Resources/ supports regarding grieving


Consent and end of life decision making


Existential suffering, demoralization syndrome

CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014

Willingness to connect patient and family to
resources.
As per CNO guidelines “Consent” and “Guiding
decisions about end-of-life care”
Open to listening and being with patient in crisis
9
SECTION III: SCENARIO SCRIPT
A.
Case summary
Part A: Mr. Fischer is a 55-year-old patient with small cell lung cancer (SCLC). He was diagnosed 15 months ago.
He received chemotherapy (Cisplatin and Etoposide) and some thoracic radiation therapy. In the last two
weeks the disease has recurred, the patient has lost weight and is experiencing general weakness, dyspnea,
chronic cough and hemoptysis. He was been readmitted to the oncology unit via ER yesterday. His pain was
not well controlled overnight.
The prognosis is poor, his current Palliative Performance Scale (PPS) is 50% (Cancer Care Ontario, 2005; Wilner
& Arnold, 2006) and the doctor is transferring Mr. Fischer from oncology to the palliative service. He wants to
die at home; a plan for this possiblility has been established by Mr. Fischer, his wife and the oncology team in
consultation with palliative services while Mr. Fischer was an outpatient. It will be enacted by the palliative
discharge team. In this scenario, the patient is prepared to switch their resuscitation status to “Do Not
Resuscitate (DNR)”, and declaring his spouse power of attorney and substitute decision maker. He is anxious
about having a conversation about this change with his spouse.
B. Key contextual details


55 year old married man and father.
The patient has lost weight and is experiencing general weakness, pain, dyspnea, chronic cough,
hemoptysis over the last 2 weeks.
 Came into the hospital through emergency yesterday, admitted under oncology and is being
transferred to palliative service with a plan to go home under community palliative care.
 Plan of treatment:
o In process to transfer patient
 from oncology service to palliative care service
 and from hospital inpatient palliative service to home/community palliative care.
 This plan has been established and will be enacted by the palliative discharge team.
 The nursing student(s) do/does not need to undertake discharge planning responsibilities in this
scenario. Rather, they need to be able to re-assure Mr. Fischer that there is a plan and his and his
family’s needs will be met by the new team taking over his care.
 Mr. Fischer is ready to initiate “Do Not Resuscitate (DNR)” order and declare his spouse has power of
attorney and substitute decision maker but is very anxious to have this discussion with spouse and
team.
Pain
 Currently has mild to moderate pain (4-5 on scale of ten) that would be ameliorated to 2-3 (but not
relieved) by PRN morphine (if administered) and assisted repositioning (if offered).
 New order for Morphine 10 mg/mL infusion at 2.5 mg/hr with 1mg morphine q 30min for
breakthrough pain is on chart but not yet established.
 Pain is located in the left thorax, ongoing, provoked by coughing, stabbing, does not radiate.
 It is independent of any feelings of nausea, shortness of breath, or decreased appetite, but Mr. Fischer
does find it exhausting and the pain will be improved with reduction of anxiety through
communication.
Anxiety
 Ranging from 4-7 on 10 based on Edmonton Symptom Assessment System (ESAS).
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
10

Ameliorated by
o using therapeutic communication skills (body language conveying listening, reflection,
synthesis, reformulation, validation),
o reviewing and reassuring Mr. Fischer of plan of care re: DNR, PoA, substitute decision maker.
Shortness of breath
 Ranging from 2.5-8 on Edmonton Symptom Assessment System (ESAS).
 Ameliorated by assisted repositioning (if offered).
C. Scenario Cast
Patient/ Client




High fidelity simulator
Mid-level simulator
Task trainer
Hybrid (Blended simulator)
X
Standardized patient
Brief Descriptor
(Optional)
Leads patient care
Assists patient care
Dying client
Spouse
Resource person
Role
Primary Nurse
Secondary Nurse
Mr Fischer
Mrs. Fischer
NP or MD
D.
Confederate/Actor (C/A) or Learner (L)
Learner
Learner
Actor
Not present
Instructor
Patient/Client Profile
Last name:
Fischer
First name:
Mark
Gender: M or F
Age: 55
Ht: 6 ft
Wt: 150
Code Status: transition to DNR
Spiritual Practice:
Ethnicity:
Primary Language spoken:
Catholic
Caucasian
English and French
1. Past history
 small cell lung cancer (SCLC) diagnosed x 15 months
 received chemotherapy (Cisplatin and Etoposide) and some thoracic radiation therapy
 Was admitted to the oncology unit for cancer recurrence two weeks ago
 patient has lost weight and is experiencing general weakness, dyspnea, chronic cough and hemoptysis
Primary Medical Diagnosis
2. Review of Systems
CNS
Cardiovascular
Pulmonary
Renal/Hepatic
Gastrointestinal
Endocrine

small cell lung cancer (SCLC) diagnosed x 15 months; palliative
GCS = 14-15
Within normal limits, adequate perfusion.
Crackles, marked shortness of breath, increased respiratory rate.
Within normal limits, continent
Constipation secondary to opiod medications, bowel protocol in place
n/a
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
11
Heme/Coag
Musculoskeletal
Integument
n/a
Weakness, primarily sitting or lying down.
Pale, intact, good CMS to extremities, Braden score: Mild risk (17, points lost for mobility,
activity, friction & shear due to weakness and mainly sitting or lying down).
Developmental Hx
n/a
Mental Health/
Currently experiencing anxiety r/t major life transition, at risk for existential suffering,
Psychiatric Hx
demoralization syndrome.
Social Hx
No drug use; retired factory worker; smoked 1 pack/day for 30 years but stopped 5 years
ago; married 30 years, 2 grown children and 3 grandchildren living at a distance.
Alternative/ Complementary Medicine Hx
n/a
3. Current medications
Medication allergies:
Food/other allergies:
NKDA
None
Reaction:
Reaction:
n/a
n/a
Drug
Morphine 10mg/mL
[PPO for CADD pump:]
[on chart but not yet
established nor transcribed to
MAR]
morphine 1 mg/mL
[PPO for CADD pump: not yet
transcribed to MAR]
Morphine Sulfate 1 mg/mL
Dose
[2.5
mg/h]
Route
Frequency
[SC
[continuous]
infusion]
Reason
[Ongoing pain]
1 mg
[SC or
IV]
[q 30min
PRN]
[breakthrough pain]
1 mg
SC
q 2h PRN
For pain
Lorazepam 2 mg/mL
2 mg
PO
q 6h PRN
For anxiety, agitation
Haloperidol 1mg/mL
1 mg
SC
q 8h PRN
For nausea
Prochlorperazine
Glycopyrrolate
10 mg
0.2 mg
IV or PO
SC
q 4h PRN
q 4h PRN
For nausea
For secretions
4. Laboratory, Diagnostic Study Results: Not applicable
Na:
Ca:
Hgb:
PT
ABG-pH:
VDRL:
K:
Mg:
Hct:
PTT
paO2:
GBS:
Cl:
Phos:
Plt:
INR
paCO2:
Herpes:
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
HCO3:
Glucose:
WBC:
Troponin:
HCO3/BE:
HIV:
BUN:
Cr:
HgA1C:
ABO Blood Type:
BNP:
SaO2:
Cxr:
EKG
12
E. Baseline Simulator/Standardized Patient State
(This may vary from the baseline data provided to learners)
1. Initial physical appearance
Gender: Male
Attire: Hospital gown, pajama pants, socks
Alterations in appearance (moulage): Make up to show pallor, sunken cheeks, tired eyes.
X
ID band present, accurate
ID band present, inaccurate
ID band absent or not applicable
Allergy band present, accurate
Allergy band inaccurate
Allergy band absent or N/A
2. Initial Vital Signs Monitor display in simulation action room:
X No monitor display
Monitor on, but no data displayed
Monitor on, standard display
Vital sign information to be given in response to assessment by student(s):
BP: Slightly low: 105 to
HR: High range of
RR: Slightly higher than
T: 36.1 – 37.1
SpO²: 95110 systolic on 75 to 80
normal: 82 (asleep)
normal: 20-26 rpm,
degC
98%
diastolic
to 98 (awake,
irregular rhythm &
anxious)
depth, labored speech
CVP: n/a
PAS: n/a
PAD: n/a
PCWP: n/a
CO:
AIRWAY: patent,
ETC0²:
FHR:
Lungs: Left: crackles
Right: crackles
Symptoms: Occasional cough
Sounds/mechanics
Heart: Sounds:
Within normal limits
ECG rhythm:
Sinus
Other:
Bowel sounds: Slightly quiet LLQ (r/t constipation
Other: GCS=15, MMS= 29, PERRLB,
secondary to opiod treatment, lack of
CMS adequate to all extremities, no
bowel protocol ordered)
signs of dehydration.
3. Initial Intravenous line set up
IV #1
Site:
Fluid type:
L
DW5/0.45% NS
Main
X
hand
Piggyback
4. Initial Non-invasive monitors set up
Initial rate:
50mL/h
NIBP
n/a ECG First lead:
n/a
Pulse oximeter
x
Temp monitor/type
n/a
5. Initial Hemodynamic monitors set up
A-line Site:
n/a Catheter/tubing Patency (Y/N)
6. Other monitors/devices
n/a
Foley catheter
Amount:
n/a
Epidural catheter
n/a
Fetal Heart rate monitor/tocometer
Infusion pump:
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
IV patent
Yes
ECG Second lead: n/a
Other:
CVP Site: n/a
PAC Site: n/a
Appearance of urine:
Pump settings:
Internal
External
13
Environment, Equipment, Essential props
Recommend standardized set ups for each commonly simulated environment
1. Scenario setting: (example: patient room, home, ED, lobby)
Patient hospital room, start of day shift, receives report from o/n nurse.
2. Equipment, supplies, monitors
(In simulation action room or available in adjacent core storage rooms)
Foley catheter kit
Straight cath. kit
x Bedpan/ Urinal
Feeding pump
Pressure bag
x IV Infusion pump
ETT suction catheters x Oral suction catheters
x Nasogastric tube
Defibrillator
PCA infusion pump
X
IV fluid
Type:
Code Cart
Epidural infusion
pump
IV fluid additives:
12-lead ECG
Central line Insertion
Kit
D5 45% N/S
3. Respiratory therapy equipment/devices
X Nasal cannula
Face tent
BVM/Ambu bag
Nebulizer tx kit
X
Simple Face Mask
Non re-breather mask
Flowmeters (extra supply)
4. Documentation and Order Forms
x Health Care
x Med Admin
Provider orders
Record
x Progress Notes
x Graphic record
x
History & Physical
Lab Results
Anesthesia/PACU
record
Standing (protocol)
orders
Code Record
ED Record
Medication
Transfer orders
ICU flow sheet
reconciliation
Nurses’ Notes
Dx test reports
Prenatal record
Other:
Preprinted orders CADD pump, DNR status indicators for chart, Edmonton symptom
assessment flow sheet, Social history/palliative plan of care record for going home (initiated)
Pain flow sheet
5. Medications (to be available in sim action room)
# Medication
Concentration Route
#
SC
1
2 Morphine
1 mg/mL
Sulfate
PO
1
2 Lorazepam
2 mg/mL
1
x
Incentive spirometer
Wall suction
Chest tube kit
Chest tube equip
Dressing ∆
equipment
Blood product
ABO Type:
# of units:
Prochlorperazine
5 mg/mL
IV/PO
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
Medication
Haloperidol
Concentration Route
1mg/mL
SC
Glycopyrrolate 0.2 mg/mL
SC
14
CASE FLOW / TRIGGERS/ SCENARIO DEVELOPMENT STATES
Initiation of Scenario :
You are a 55 year old male who has been battling cancer over the past 15 months and now are at the end of life. You have a wife and
2 children ages 25 and 27 (and 3 grandchildren). You are very sad and know that you are dying. You are worried about your family
and how they will cope when you die. You are very tired of the interventions and would like to have a DNR order (do not resuscitate)
but you are worried your wife is not ready for this or will not support that choice. You want clarification about the DNR order and
what that means. You want to talk to the nurse and ask what you should do and how to talk to your wife. You become easily fatigued
and have difficulty breathing. Your name is Mark Fischer.
STATE / PATIENT STATUS
DESIRED LEARNER ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
1. Baseline
From the start and
throughout:
 easily fatigued
 difficulty
breathing/ out of
breath
 voice: soft and
raspy
Anxiety develops:
fidgety, sighing, worried
look, slightly inattentive to
nurse
Actor: You have difficulty
breathing (out of breath) say “Hi. I
am feeling not too bad this
morning” when the nurse asks
you. You are soft spoken and
quiet. “The pain was bad last
night”.
Learner Actions
Appropriate approach & safety
 introduces self & colleague,
washes hands, provides for
privacy, verifies pt identity
 Asks pt how he is feeling,
how was pain o/n, assesses
pain using OPQRST, explores
Pain overnight was upper left side
treatment options
thorax (chest and back), stabbing,
 Asks about shortness of
continuous and exhausting and at
breath, assesses, offers
8-9/10. Shortness of breath is
repositioning
helped by repositioning.
 Begins head to toe and vital
sign assessments
You answer the questions that the
 At some point should ask
nurse will ask you. Hold your
about patient appearing
concern about the DNR status until
anxious.
the nurse asks you why you are
 If student does not ask
anxious/upset.
about anxiety, actor will
proceed to section 2 after
Triggers: If the nurse does not ask
ca. 5 minutes
you what is in your mind after 5
Primary delegates appropriately to
minutes you can go to Section 2.
secondary nurse.
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
Debriefing Points:
What were the key assessment and
interventions in this situation?
What was the priority?
What influenced your actions during
the scenario?
How did you divide up what needed
to be done?
15
STATE / PATIENT STATUS
DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
Part 2.
Operator/Actor
Anxious
Afraid
Therapeutic communication:
“Can I talk to you about
something that has been bothering
 Shows active listening
me?”
through body language
(arms uncrossed, leaning
twds pt, eye level, looks at
“I think I am close to the end and I
patient)
am not sure how to tell my family
this.”
 Uses techniques of
communication such as
reflection, synthesis,
“I don’t want anything done to
reformulation, validation.
prolong all of this...I just want to
go peacefully but I am also scared
 Validates patient’s concerns
of how painful this might be”
& experiences
 Reassures and
“The doctor talked about this
creates/reviews plan
possibility and we made a plan at
 Explores stages of grief of
the beginning, but I can’t believe it
patient and his perception
is happening to me”
of his wife’s grieving.
 Restates and clarifies
“My wife will need to make
ambiguous statements to
decisions for me, but I don’t know
obtain clear information.
if she is ready for me to be dying”
 Provides accurate
information about DNR,
Triggers:
PoA, substitute decision
making as per CNO Practice
Either nurse asking you what is on
Guidelines, assigned journal
your mind or by 4-5 minutes
articles.
You are anxious, afraid of
suffering if you decide for
the DNR.
Teary
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
Learner Actions:
Debriefing Points:
How did you let the patient know
you were listening?
Do you think the patient felt
heard/understood?
How did you assess what the
patient already knew?
How did your pre-reading of CNO
guidelines and journal articles
help you with the factual
information the patient needed?
16
STATE / PATIENT STATUS
Part 3.
DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
Operator/Actor:
Learner Actions:
Concerned, anxious,
tearful
You are anxious because
you think your
wife/husband will not
agree with your decision. It
is not easy for you to open
to the nurse.
Weary
Restrained/Taciturn/
Withdrawn

“I don’t think my wife is okay with
that (DNR order) She wants
everything done. How can I tell
her I don’t want that?”
“I just can’t do this anymore. I am
so tired.”
“I want them to be okay, but I am
afraid they won’t be, especially my
kids…”
“I don’t want to drag them down”
Triggers: 6-7 min
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014


Explores/assesses the
possibility of existential
suffering, depression, panic
attack, demoralization
syndrome
Provides reassurance
Offers links to
assistance/resources
available in hospital &/or
community
Debriefing Points:
Are you comfortable with silence/
with being present for the patient
in this scenario?
What members of the
interprofessional team (in
hospital or in the community)
might be well prepared to deal
with this depth of suffering?
17
STATE / PATIENT STATUS
Part 4.
DESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATE
Operator/Actor:
Learner Actions:

“Can you talk to her and tell her
what I want?”
Assures patient that they
will be present as support
for his conversation with his
wife
“She might understand better from
you.”
Triggers:
6-10 minutes
Stock phrases can be used
throughout:
“I am not sure why this happened
to me.” “This is not what I
expected.” “Can I ask: will I be in a
lot of pain? (If this wasn’t
addressed elsewhere)
Scenario End Point: 20 minutes has passed or student & patient have exhausted the conversation.
Suggestions to decrease complexity:
Suggestions to increase complexity: CADD pump set up
CSA REV template (12/15/08; 5/09; 12/09; 4/11; 1/14)
Revised COUPN January 2014
Debriefing Points
Let’s discuss options for
supporting this patient.
18
APPENDIX A: HEALTH CARE PROVIDER ORDERS
Patient Name: Mark Fischer
Diagnosis: SCLC
DOB/DDN: 1958-10-01
Age: 56
Weight: 69 kg
MR#: 24516789
Room: 20
 No Known Allergies
 Allergies & Sensitivities
Date
Time
HEALTH CARE PROVIDER ORDERS AND SIGNATURE
Yesterday 1000 Lorazepam 2mg PO q 6h PRN if anxious
Morphine sulfate 1mg SC q 2h PRN for pain
Prochorperazine 10 mg IV/PO q 4h PRN for nausea
Haloperidol 1 mg SC/PO q 8h for nausea
IV: D5W + 0.45NS at 50cc/h
AAT, DAT
F. Quirran, MD R2
Today
0800 Sub-Q set for PRN and PCA pain
[Affix label or
stamp here]
Transcribed by
(initials &
signature):
NB
NB
NB
NB
NB
NB
Nathan Benoit, RN
CD
CD
Morphine 10mg/mL by SC infusion via CADD pump at rate of
2.5 mg/h
CD
Morphine 1 mg q 30min for breakthrough pain
CD
Discontinue previous morphine order
F. Quirran, MD R2
Carole Deno RN
*Ideally, the orders for today would be done on a PPO
See section 4, “Environment, Equipment, Props” on pg 12
CSA REV template (12/15/08; 5/09; 12/09; 4/11)
Revised COUPN January 2014
19
APPENDIX B: Digital images of manikin and/or scenario milieu
Insert digital photo here
Insertdigital
digitalphoto
photohere
of initial
Insert
scenario set up here
Insert digital photo here
Insert digital photo here
CSA REV template (12/15/08; 5/09; 12/09; 4/11)
Revised COUPN January 2014
20
APPENDIX C: DEBRIEFING GUIDE
General Debriefing Plan
With Video
Individual
Group
Debriefing Guide
Debriefing Materials
Objectives
Debriefing Points
Culture
Without Video
QSEN
CPSI Competencies to consider for debriefing scenarios
Teamwork/Collaboration
Identify safety risk
Communication
Issues in environment
Respond to safety risk
Sample Questions for Debriefing
Interprofessional Competencies to consider for debriefing scenarios
Role Clarification
Interprofessional Teamwork Functioning
Patient/Family /Client ? Community
Collaborative Leadership
centred care
Interprofessional Communication
Sample Questions for Debriefing
General questions:
•
What was the key assessment and interventions in this situation? What was the priority? What influenced your
actions during the scenario?
•
How do you think the simulation went? Were you comfortable in this role? Why or why not?
•
What were your favorite and least favorite aspects of the simulation?
•
What were some of your successes? What made you effective? Your difficulties? How could you become more
effective? Give me specific examples.
Additional questions:
•
What information did you have about this case?
•
Was the student assessing knowledge of the disease state? Was the student assess the knowledge of prognosis
CSA REV template (12/15/08; 5/09; 12/09; 4/11)
Revised COUPN January 2014
21
•
Was the patient's pain well controlled, by the nursing interventions? What are non-pharmaceutical techniques
we could use to help control pain? How and when should we re-evaluate the patient's pain?
•
What type of questions should we ask pt to assess her pain with the use of the PQRST (Provoke = what causes
the pain? Quality = is it dull, sharp, crushing, stabbing or burning? Radiates = where does the pain radiate?
Severity = how severe is the pain on a scale of 1 to 10? Time = time pain started?)
•
What kind of teaching needs to be done?
In summary (closing) :
These are the things you identified as going well, and these are the things you told me you need to work on...
The take home points include....
and finally I saw vast improvement in these areas...
What worked well:… Even better if:…
CSA REV template (12/15/08; 5/09; 12/09; 4/11)
Revised COUPN January 2014