James Madison University

The Almost-Real Mom:

High-Tech Simulations Improve Nurse Training at JMU

By: Hannah Austin
Posted: April 12, 2013

PHOTO: JMU Students

Meet Ruth, an expectant mother in her third trimester who has just gone into labor. The young woman lies on a hospital bed, her chest rising and falling with each breath as she experiences the pain of a contraction. Nurses busily attend to Ruth, checking I.V. fluids, arranging her pillows, and tucking back wisps of her brown hair as they fall into her bright blue eyes.

From a distance, Ruth would appear to be an average woman in labor, and although she displays all the physical and verbal evidence to support this assumption, she is not alive. Ruth is a full-body “Sim-Mom” simulator, capable of portraying realistic birthing scenarios that provide nursing students with invaluable, risk-free training. Though she and the baby she carries are not real, the lessons learned through her simulation prepare nursing students to enter the workforce with experience and confidence, perhaps ultimately saving patient lives.

Sim-Mom arrived at James Madison University in late December 2012, and is the second birthing simulator utilized by the Nursing Department; however, her predecessor, Noelle, was a 2006 model with limited technological functioning. While there was no way to control the timing or details of Noelle’s delivery, every physical aspect of Ruth’s, including length of labor, rate of breathing, blood pressure, and mother and infant heart rates can be determined by behind-the-scenes faculty members controlling the simulation.

The physical construction of Sim-Mom is also much further advanced than the previous model. Although her 40 lb. body is made primarily of plastic, a softer material constitutes the shoulders, allowing an injection point for shots. Her pulse can be taken by pressure points in her wrist, and bendable limbs make it easy to reposition Sim-Mom, who can sit, lean, and even maintain alternative birthing positions, such as a hands and knees stance. A variety of accessories accompany the Sim-Mom, making it possible to enact twelve different high-risk, low-frequency birthing scenarios, including cases of post-partum hemorrhaging, difficult shoulders delivery, and an umbilical cord which precedes the infant, known as a “prolapse.”

Currently, Sim-Mom is used in the class “NSG 335: Women’s Health,” which dedicates nearly half of the semester to pregnancy and the labor cycle. The course is co-taught by Professors Karen Jagiello and Marjorie Scheikl, who work together to facilitate classwork and forty-five hours of hands-on clinical practice, 20% of which takes place in the simulation lab, the other 80% in a women’s health unit in a hospital. Sim-Mom is an excellent prep tool for the students, who are able to become comfortable working within a patient’s physical space before interacting with a live person.

PHOTO: JMU Faculty run simulation

As Scheikl shared: “I had a student who worked with Ruth prior to his first clinical, where he encountered a mom in labor. As the patient worked through a contraction, the student coached her with breathing exercises he had learned in the lab. When it was over the woman said it had helped, but that her back was hurting. The student then explained to the patient's husband how he could alleviate the pain by applying pressure to points in her lower back. Without the hands-on training that Ruth provides, the student may have found himself in an uncomfortable and stressful situation, and not known how to help.”

Although Sim-Mom is capable of portraying high-risk scenarios, Jagiello and Scheikl say they primarily use her to train nurses on the small and common details of labor and delivery.

“For example, almost every nurse at some point is going to treat a patient who is diabetic,” said Scheikl. “They need to be prepared to spot signs of things like hypoglycemia, and with Sim-Mom, we can simulate that.”

Jagiello added, “Doing a physical on a woman who has just given birth is completely different from giving a physical to any other adult at any sector of the lifespan. There are different things to look for, and Ruth displays these for example, the uterus should be hard post-birth, but we can make it soft, a sign of bleeding that the student can then identify and treat.”

The Simulation Lab and all participants are required to follow a list of specific guidelines from the Virginia Board of Nursing, which ensures that simulations are acted out under strictly educational and professional settings. Strategically placed cameras monitor student’s activities from various angles, allowing professors to observe, take notes, and provide cues by speaking as the patient through a microphone. The cameras also provide for the opportunity to record the students, who then hold a debriefing to watch and share feedback on each other's performances.

Jagiello said: “We are using her as a learning tool, not an evaluation. The debriefing allows students to learn from their own and other's mistakes. They see what others are doing that is right, and notice things they forgot to do or wish they had done differently. It builds the critical thinking process.”

Nursing students have to grasp these processes of critical thinking, but also show that they can maintain knowledge and confidence within a fast-paced and high-stress environment. Although simulations generally last only fifteen minutes, a lot goes on during this time that requires debriefing. Students must respond to all cues from the “patient,” answer phone calls from “attending doctors,” keep medical charts up to date, and communicate with efficiency just like in a real hospital setting.

“We can always tell immediately who has prepared and who has not, said Jagiello. “We also see leaders emerge, and it's these same people who remain student body leaders until their graduation.”

Student preparation is also assessed during a “rolling simulation” that seniors of Women's Health participate in at the end of each semester. Though the experience is meant to be educational, students are expected to be highly prepared and to complete a written segment prior to the simulation proving that they are familiar with the “patient's” history. Once inside the lab, groups of students take turns caring for the “patient” in various stages of labor or following delivery, reporting off to the next team when their “shift” is over. Just as nurses do not know what to expect on any given shift, students do not know what stage of birth or postpartum they will be assigned, and must be prepared to implement care in all possible scenarios.

Junior Lauren Vaccarello said: “The simulations are believable, mainly because the instructors act like patients and provide us with very real scenarios. They cry, moan, and ask questions, just like a real patient would. Being able to practice basic nursing skills on a close to real life patient is such a wonderful learning experience, and definitely gives us an advantage over other nursing programs that do not offer the same. We learn ways to carry out nursing in a learning environment, rather than just being thrown into situations at the hospital. I have definitely been able to take what I've learned and apply that knowledge to my clinical experience; for example, I now know and have confidence in appropriate ways to help with pain management that are not just drugs. This can include massaging the mother, offering ice chips, distracting her with imagery, and playing music.”

The JMU Nursing Department has experienced rapid expansion in the last decade, and access to clinical settings is somewhat limited. The lab not only provides an extra sphere of practice, but the possibility of providing all nursing students with the same base of knowledge and experience.

As Lab Coordinator Ira Rubenstein explained, “In a clinical setting, you never know what types of patients you will see, and therefore, you never know what you are going to learn. Here in the lab, we would have the capability of running every student through the exact same scenario, including ones that are rare or high-risk, and unlikely to be witnessed in a clinic.”

PHOTO: JMU Student with Sim baby

As technologies improve, simulations are growing more popular throughout healthcare education. The Nursing Department has recently expanded their collection with the addition of a high-tech Sim-Man, and future opportunities for the use of him and Sim-Mom are continuing to develop. A Master's of Midwifery program in association with Shenandoah University has recently been established, a small but growing group who could benefit from Sim-Mom training. Furthermore, the lab could potentially become a place where social work, psychology, health administration, and nursing students practice working with one another, necessarily cooperating as they so often do in the workforce.

“Medical professionals of all fields constantly have to work together and support one another, and the lab could become an excellent training ground for this aspect of their professional lives,” said Jagiello. “Simulations, like all technology, are going to grow and become more advanced what it provides nursing students now, not to mention its future possibilities, is absolutely invaluable to healthcare training.”

Junior Keith Hart agreed: “Quite honestly, it is like working with a real patient the technology is absolutely amazing. I wish I could use Sim-Mom weekly, because I think simulations are currently the best teaching tool available to nursing students.”

Ruth may not be alive, but her amazing capacities of simulation are changing the experience of nurse training at JMU. The possibilities are endless, and the Nursing Department plans to take every advantage of what she and other high-fidelity simulators have to offer.