June 2013

CUSON’s First Interdisciplinary Simulation Teaches Communication Skills During an Emergency

Maternal Health

A 32-year old woman has been in labor for two hours. Her blood pressure and pulse are normal, and her temperature is 98 degrees. Her water has just broken. Suddenly, the fetal heart rate drops to a dangerously low 80 beats per minute.

The attending nurse calls the midwife in to examine the patient. She discovers the baby’s umbilical cord has moved in front of the baby’s head, putting him at risk for asphyxia.

"There's a cord prolapse," says the midwife to the other team members. An immediate C-section is necessary to save the infant’s life. "I need the obstetrician and pediatrician in here, stat!" says the midwife. The head nurse rushes to find them.

A nurse anesthetist is called in and makes a snap decision to initiate general anesthesia.

The team works together to prevent complications in the woman and infant. Twenty minutes later, the baby is born. Mother and child are both stable.

But the mother and the baby weren’t real. Both were simulation mannequins, made of plastic. And none of the members of the healthcare team were working nurses, midwives, or nurse anesthetists. They were Columbia nursing students participating in the school’s first interdisciplinary emergency simulation exercise - organized by the nurse anesthesia and nurse midwifery programs.

Twelve midwifery students and two nurse anesthesia students participated in two simulated obstetrical emergencies during the event: the cord prolapse and a woman hemorrhaging after childbirth. The nurse anesthesia students played the role of certified nurse anesthetists and midwifery students served as pediatrician, head nurse, midwife, and obstetrician. The remaining students provided comments to the group during the debriefing session afterward about what worked best and what might be improved.

The students were briefed on crisis management and participated in a workshop on effective teamwork prior to the simulation by the event’s organizers, Assistant Professor Cliff Roberson, DNP, from the nurse anesthesia program and Assistant Professor Maria Corsaro, MPH, DNP, from the nurse midwifery program.

Corsaro had long wanted to recreate the chaotic atmosphere of an emergency in a controlled environment where her students could learn to effectively communicate with other members of the healthcare team. Last spring, she discovered an ideal partner for the project when Roberson joined the Columbia Nursing faculty. Roberson wrote his doctoral thesis on the use of simulation training for healthcare providers during obstetrical emergencies. He was immediately receptive to Corsaro's idea, and the two met regularly during the past year to plan the event and isolate teachable moments for students from both disciplines.

"A significant majority of negative health outcomes can be traced to poor team communication," says Roberson, citing the Joint Commission on Accreditation of Healthcare Organizations' statistic that 70 percent of such events can be traced back to a communication deficit. "Good communication saves lives. The benefit of simulation is that it provides a realistic experience for students to practice their communication skills with each other, and see the potential for errors without any risk to the patient."

One of the major lessons learned by Cassie O'Hara, who played the midwife in the hemorrhage scenario, was the need for closing the loop of communication.

"At one point, I was really focused on my task of massaging the uterus, and I didn’t know if Pitocin [used to stop uterine bleeding] had been administered," says O'Hara who graduates this fall. "During the debriefing, we agreed that it would have been helpful if each person clearly stated that she had finished a task after doing it."

Corsaro and Roberson are pleased with the affect the simulations seem to have had on the students based on their responses during the debriefing and from surveys completed following the exercise. Both instructors are analyzing the simulations, student comments, and survey responses and plan to conduct more exercises in the future.

"I knew how to manage a prolapsed cord from learning about it in my classes, but now it feels like I actually did it, and I will feel more competent during a real emergency," says Rachel Cooper, a nurse midwifery student who played the head nurse in the first simulation. Her only emergency experience before the exercise was as an observer when an infant needed resuscitation during a clinical rotation.

Another benefit of the experience was learning the role of other healthcare providers.

"I had a vague idea of what nurse anesthetists did, but now it's much clearer," says O'Hara. "During the hemorrhage simulation, my role was to stop the bleeding, while the nurse anesthetist was focused on monitoring the patients' blood pressure and pulse, and if the correct dosages of medicine were given. We were both working on solving the same problem, but each of us was focused on different aspects of the problem."

Corsaro feels that learning what other members of the team do before the students start their healthcare careers provides them with a distinct advantage: "They learn that it's the team that improves the patient's outcome, not the individual."