Navigating a Disaster: A Capstone Simulation Integrating Leadership Skills, Ethical Principles, and Clinical Reasoning

Disaster preparation is a way of life in this southeastern coastal community that is home to the largest US Navy base in the US. Recent disasters include hurricanes, nor-easters, severe thunderstorms with tornados, and several aircraft incidents involving multiple injured patients. Likewise the heavy joint-forces military presence and the region’s reliance on bridges and tunnels for transportation provide a potential terrorist threat. The opportunity to practice disaster management skills prior to participating in a manmade or natural disaster has a realistic meaning for nursing students at this university.

Disasters can be natural or manmade, intentional or accidental, and may come with or without warning. Typically, the event overwhelms available resources. Health care professionals and community volunteers are forced to work outside of their comfort zone and find that patient care often stretches both human and material resources. When disasters occur without warning the community relies on providers having background knowledge of how to respond with emergencies occur. Until such time as pre-made plans are able to be implemented and resources assembled, search, rescue, and treatment of victims is accomplished by bystanders who may or may not have prior training.

Disaster preparedness content is required in all BSN programs accredited by the Commission on Collegiate Nursing Education. A literature review yielded few examples of the integration of disaster planning in nursing curricula. It is believed that faculty may not be adequately prepared to teach content. One study reported that nursing students were unaware of the scope of disaster nursing, lacked recognition of available resources, and did not understand the role of nurses during disasters.

Clinical simulation provides an opportunity to develop the skills nursing students need to respond to manmade and natural disasters. This simulation focuses on the response phase of a natural disaster that occurs without warning. Students are asked to use clinical reasoning to save life and limb. Additionally students must practice their leadership and communication skills when planning and provide care and apply ethical principles of beneficence versus non-maleficence and teleological versus deontological theory related to mass casualty triage.

Students in the final week of their BSN program participate in this capstone clinical simulation. The setting is the School of Nursing building in the aftermath of a severe thunderstorm causing partial building collapse of the adjacent bookstore and eateries.  Using a combination of live actors and simulation equipment, ten patients arrive in the skills lab seeking help for a variety of illnesses and injuries. The age range and clinical conditions of the patients represent each of the clinical courses in the nursing curriculum and include chest pain, hypoglycemia, injuries ranging from minor orthopedic injuries to life-threatening trauma, a non-English speaking female who is in labor, and a former military member who’s Post Traumatic Stress Disorder has been triggered by the destruction.  The lights in the lab are dimmed to mimic a power outage, running water is turned off, and students are able to use only the supplies found in the lab and do not have access to the supply closet that requires a prox card, thus electricity, to enter it.

Students are assigned to assume the role of nurse, triage nurse, or incident commander. Those in the nurse role assess their patients and use mass casualty triage tags to communicate pertinent information to the triage nurse and use existing supplies to provide care to patients as deemed necessary. The triage nurse collaborates with the incident commander to make immediate decisions on the severity of patients and to prioritize which two of the 10 patients will be transported from the scene- one by ground and one by air. Additionally, the incident commander is given the opportunity to ask for one piece of equipment from both the helicopter and the ground transport unit and collaborates with the team to establish what equipment meets the needs for the greatest number of remaining patients. The simulation lasts approximately 15 minutes.

During 45 minute debriefing session students analyze organizational challenges that arose as they made decisions based on patient status, immediate needs, and available resources. The legal and ethical consequences and emotional responses of mass casualty triage are explored. Faculty members provide students with feedback about assessment, clinical reasoning, and communication skills including clarity of report and the use of SBAR. As a team, students reflect upon the appropriateness of their decisions and predict how different decisions might have altered the outcomes affecting multiple patients, thus linking the simulation to patient outcomes.

Students are provided the opportunity to apply the nursing process, demonstrate leadership concepts, nursing skills, and effective communication to coordinate patient care. Designating patient triage categories provides an opportunity to initiate discussions about professional standards related to moral, ethical, and legal conduct and requires students to reflect on their beliefs. Additionally this disaster simulation addresses the best practices, core knowledge and nursing skills outlined by the Association of Community Health Educators and the Emergency Nursing Association including critical thinking, assessment, technical skills, and communication.

This capstone simulation incorporates the clinical reasoning and psychomotor skills learned throughout the program with leadership, team building and management skills learned during the students’ final semester. This novel approach uses simulation to meet the BSN curriculum requirements as well as provides the opportunity to practice the concepts in a realistic setting. This can easily be adapted for use in areas of the country where earthquakes, landslides, and other natural disasters are a concern.