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Nursing schools' simulations help students learn

The emergency-room patient is clearly manic.

"If you don't take care of me and let me leave this hospital, then I've going to march right out of here, and don't think you can bring in some security and tie me up. ... Because I am Andrea, and no one deals with Andrea except with respect, and understanding, because I am a talented artist and this world has yet to see what I can accomplish. ..."

"Andrea" in this case is a simulated patient dubbed Andrea Warhol. She's used by nursing instructor Ann Fallon at The College of New Jersey to help her students learn how to deal with a bipolar patient who has been brought into a hospital and is insisting on being released.

Fallon, who is also a psychoanalyst, knows artists who have bipolar illness and "they are sometimes in a manic phase where a lot of them don't believe ... what's happening to them. So in this simulation, we get to talk about the fine line between insanity and creativity."

For the simulation, Fallon wanted to give her students a vivid experience of what it is like to deal with a patient who talks nonstop, resists treatment and has grandiose ideas about herself and her importance to the world.

During the simulation, students stand next to a bed with a mannequin and Fallon delivers the audio from an adjoining control booth.

By the time they do the exercise, she said, the students have been taught about responding gently but firmly, listening carefully and going through a checklist on whether the patient is in danger of harming herself or others, or is abusing drugs or alcohol.

"If they're effective in their communication with me," she said, "I start to tone it down. If they're not effective, I escalate," even to the point where she lets out a blood-curdling scream.

The Andrea exercise is part of a growing trend in which nursing schools use simulations to expose students to real-life situations, sometimes using audio from an instructor and sometimes using actors to portray patients.

Gail Katz, a nursing professor at the University of Colorado, said schools are increasingly using medical mannequins, priced from $30,000 to $250,000, to teach students practical skills, especially in areas where it is hard to find enough training slots in hospitals.

Originally borrowed from the airline industry, simulations are designed to give students a chance to fail, if need be, in a safe environment.

"So if we do something wrong, we don't kill a patient, but we kill the mannequin," said Katz, who was the lead author on a recent paper on medical simulations.

The goal of the training, she said, is that "when you're faced with a crisis, you've already managed it in a real-life situation. ... When they come up against a situation, that part of the brain will kick in and people will say 'I know how to do this.' "

Psychiatric simulations have been some of the most difficult to create, she said, because even the high-end mannequins can't simulate facial expressions.

Though the Andrea simulation relies on Fallon's voice, one nursing student said it was effective enough that "at some points the situation and the patient seemed unmanageable, but afterward during the reflection, we discussed ways that we could better handle a patient like that."

Fallon said students are sometimes stressed out by the exercise. To relieve tension, she will have Andrea belt out a version of "Somewhere Over the Rainbow" when they leave the room.

She also has another student portray Andrea's sister, who sometimes is helpful, and sometimes is testy and will say things like, "I can't stand her anymore; take her off my hands."

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