Dr. Carter is Associate Professor, and Dr. Gaskins is Professor, University of Alabama, Tuscaloosa, Alabama.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Melondie R. Carter, DSN, RN, Associate Professor, University of Alabama, Capstone College of Nursing, Box 870358, Tuscaloosa, AL 35487; e-mail: firstname.lastname@example.org.
Since the events of September 11, 2001, and the following anthrax scare, the nursing profession has been encouraged to become prepared to care for victims of bioterrorist attacks. Although most areas of the country have not experienced a bioterrorist attack, schools of nursing have been challenged to include bioterrorism content in the curriculum. Bioterrorism content often is included with disaster management, which typically is covered in the community and public health course in baccalaureate nursing programs.
In preparation for teaching the bioterrorism content, faculty at a university in the southeastern United States consulted with the Emergency Preparedness and Epidemiology Office at the area Public Health Department to identify appropriate content areas and to develop a comprehensive and up-to-date presentation for nursing students. This department offers educational courses to health care providers on many emergency preparedness topics.
Critical bioterrorism content areas were identified as:
- The role of the Centers for Disease Control and Prevention (CDC) in a bioterrorist attack and the National Stockpile.
- Categories A, B, and C biological threats.
- Pandemic influenza.
Recommended content related to agents of bioterrorism includes detection and reporting of cases, treatment of casualties, implementation of control measures, resource acquisition, and managing public reaction. For each content area, not only was critical information identified but also teaching strategies and methods of delivering the content were determined, including films, PowerPoint®
presentations, handouts, lectures, and a patient simulation experience.
Patient Simulation Experience
Simulation techniques have been used to develop psychomotor and psychosocial skills in nursing schools for a number of years (Kardong-Edgren, Starkweather, & Ward, 2008). Simulation provides an experience for all students that is difficult to replicate in the classroom or in a clinical setting. In addition, simulation provides a mechanism for students to participate in clinical decision making and to observe the outcomes of those decisions (Brannon, White, & Bezannan, 2008).
In 2005, the school of nursing acquired a human patient simulator and the Program for Nursing Curriculum Integration (PNCI). All clinical courses were required to develop a case scenario using Medical Education Technologies, Inc. (METI) or to use one from the PNCI. The community health nursing faculty chose to use the simulated clinical experience from the PNCI entitled, Care of the Adult Patient Who Is a Casualty of Bioterrorism. This simulation addresses the care of a person who has possibly been exposed to smallpox (variola, major), one of the six infectious agents of highest concern for bioterrorist attack because of its high potential for easy dissemination and high mortality (CDC, n.d.a.).
Prior to the bioterrorism class, students were provided with:
- Learning objectives (Table 1).
- A health history.
- Patient signs and symptoms.
- Preparation questions.
- Required readings.
- Role assignments.
- Initial health care provider’s orders.
Table 1. Learning Objectives and Questions.
There were seven role assignments for each group of students (Table 2
). Because of the number of students, students were divided into two groups. One group provided care while the other group observed. A change of shift was planned half way through the simulation with a shift report as the groups changed places.
Table 2: Roles for the Simulation Experience
State 1: Baseline
For the initial assessment, students determine an abnormal finding of red lesions on the tongue, and the patient complains that his mouth and tongue feeling “strange,” which are early signs and symptoms of smallpox. Students are expected to describe the rash and to recognize it as an indication of an infectious and possibly communicable illness. Students also are expected to obtain a pertinent history about symptoms (duration and severity) and possible exposure (travel or contact with others with the same symptoms). Students are questioned about current orders and the rationale for each.
At this time, students contact the physician and report the rash, and airborne isolation precautions are initiated. Students need to recognize that airborne isolation means the infectious agent could be spread through coughing, sneezing, and exhalation; appropriate personal protective equipment; and the patient needs a private room with negative pressure. The student who has the role of the physician contacts the local health department and then the CDC, and learns that a number of smallpox exposures have been reported locally.
State 2: Respiratory Difficulty
During the change of shift report, the second-shift students are informed by the first-shift charge nurse that the physician has ordered full isolation. The students put on gowns, gloves, and masks before entering the patient’s room.
When the second-shift students assess the patient, his symptoms have changed and he is experiencing respiratory difficulty. Oxygen saturation has decreased from 98% to 92%, breath sounds now include bilateral wheezes, and the patient complains of shortness of breath.
Initially, the faculty encourages students to determine nursing interventions to alleviate breathing problems. With these assessed respiratory changes, it is expected that students will raise the head of the bed or place more pillows under the patient’s head and then call the physician. Students occasionally will want to administer oxygen when the shortness of breath occurs. This provides a wonderful teaching moment because faculty can reinforce that oxygen is not administered without an order.
When students call the physician, new orders are obtained. These include increasing the intravenous rate, as well as albuterol via a nebulizer, cidofovir, ribavirin, and oxygen administration if the saturation drops below 90%.
State 3: Improved Status
Students implement the new orders, and the patient’s condition improves. On assessment, the oxygen saturation improves to 96% and the respiratory rate decreases to 22. He reports, “my breathing is better.” This state is followed by the debriefing session.
A significant aspect of simulation is recapping the learning experience and reviewing key points. During this session, students are asked the following questions:
- When is smallpox most contagious?
- How do you differentiate smallpox from chickenpox?
- Who needs the smallpox vaccination?
- What is the treatment for a patient with smallpox?
Students are expected to know the virus causing smallpox generally is spread from person to person through contaminated aerosolized droplets from the mouth and pharynx. Symptoms begin 7 to 17 days following infection. During this incubation period, there is no evidence of viral shedding and the affected individual looks and feels healthy. The infected individual generally is not contagious during this time (Rotz, Dotson, Damon, & Becher, 2001).
Following the incubation period, a high fever, malaise, severe headache, and backache may occur. This is followed by an eruption of a maculopapular rash that progresses from papules to vesicles, then to pustules, and finally to scabs (Salazar & Kelman, 2002).
Chickenpox can be differentiated from smallpox by its much more superficial lesions. Chickenpox lesions are present more on the trunk than on the face and extremities, and groups of lesions develop over several days, resulting in lesions in different stages of development (Salazar & Kelman, 2002). Smallpox pustules are not in different stages, and progression is macular, papular, vesicular, and pustular followed by crusted scabs, and the rash is centripetal with most lesions most abundant on the face and extremities (Sy & Long-Marin, 2008).
Students recognize individuals exposed to the patient with smallpox and the health care providers that provided care will need a smallpox vaccination. They discuss how to give the vaccination using the 15-prong method and care of the site. Faculty review that even if an individual had been vaccinated previously, exposure to smallpox may involve risk because the immunity of the vaccination diminishes over time.
In describing the care of the patient with smallpox, students discuss palliative treatment including keeping the patient hydrated, controlling temperature, and assisting with breathing difficulty. In addition, the best site for providing care is included. Students emphasize a site that would limit exposure to others such as an individual’s home or apartment, which would lead to less exposure of others would be best. To prevent further exposure, a hospital setting is not viewed as an ideal site for care.
During the conclusion of the debriefing session, students are shown moulage from several biological agents including smallpox, anthrax, and mustard gas. Recognition of the level of hazard from each agent and the treatment of each of these agents is reviewed. Nursing students are interested in this part of the session, and they report they would be very anxious if caring for a smallpox patient. Their primary concern is for their own safety and their families’ protection and safety. Doran and Muhall (2007) reported students expressed a similar concern during their bioterrorism in the simulation laboratory debriefing session.
Strategic National Stockpile Video
Students watch a CDC video entitled Strategic National Stockpile (CDC, n.d.b.), which is a national repository of antibiotics, antitoxins, life support medications, and other medical supplies. These items are crucial to protect the American public if there is a public health emergency such as a bioterrorism attack or an influenza outbreak. The video includes the process of initiating access to medications and equipment, which requires a federal order from the U.S. Department of Homeland Security.
Students also rotate through a PowerPoint presentation entitled Planned Response to Pandemic Influenza. They learn pandemic influenza refers to the epidemic spread of influenza over several countries or continents. This PowerPoint presentation is conducted by personnel from the Emergency Preparedness and Epidemiology Office and includes issues the CDC and health department would handle during a pandemic influenza response.
Bioterrorism Categories A, B, and C
Another rotation conducted by personnel from the Emergency Preparedness and Epidemiology Office includes a PowerPoint presentation entitled Understanding and Preparing for Bioterrorism: Categories A, B, and C Agents. The U.S. public health system and health care providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States.
High-priority agents include organisms that pose a risk to national security because they can be easily disseminated or transmitted from person to person, result in high mortality rates and have the potential for major public health impact, might cause public panic and social disruption, and require special action for public health preparedness. Six Category A agents are considered to be of the highest concern: anthrax, plague, smallpox, botulism, tularemia, and selected hemorrhagic viruses (CDC, n.d.a.).
Category B, the second highest priority agents, includes those that are moderately easy to disseminate, result in moderate morbidity rates and low mortality rates, and require specific enhancements of the CDC’s diagnostic capacity and enhanced disease surveillance. Category C is the third highest priority and includes emerging pathogens that could be developed for mass dissemination in the future because of availability, ease of production and dissemination, and potential for high morbidity and mortality rates and major health impact (CDC, n.d.a.).
Students are evaluated on all of these content areas with test questions on unit examinations. Brannon et al. (2008) found using a human patient simulator made a positive difference in nursing students’ ability to answer questions on a test of cognitive skills.
Students also have an opportunity to provide a qualitative evaluation of the experience. One student commented:
I enjoyed the METI with smallpox today. It was an especially important experience because future health care workers need to be prepared for what our future holds. The threat of bioterrorism is real and is something that we need to be prepared to handle. The METI experience will help to make certain that not only are we made aware, but also will be prepared if something does happen. Thank you, faculty!
Students have evaluated the experience positively and seem to enjoy the smallpox simulation. Hopefully, students will not have an opportunity to experience firsthand the consequences of a bioterrorism attack and the nursing care of patients with an exposure. However, this simulation experience provided students with an opportunity to recognize signs and symptoms of exposure, practice skills, increase confidence, improve communication, develop critical thinking skills in a safe environment, and potentially enhance personal and public health.
- Brannon, J.D., White, A. & Bezannan, J.L. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47, 495–500. doi:10.3928/01484834-20081101-01 [CrossRef]
- Centers for Disease Control and Prevention. (n.d.a). Bioterrorism agents/diseases. Retrieved from http://www.bt.cdc.gov/agent/agentlist-category.asp
- Centers for Disease Control and Prevention. (Producer). (n.d.b). Strategic national stockpile: Guidance and overview for state and local planners [DVD]. (A vailable from the Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333)
- Doran, A.J. & Muhall, M. (2007). Bioterrorism in the simulation laboratory: Preparing students for the unexpected. Journal of Nursing Education, 46, 292.
- Kardong-Edgren, S.E., Starkweather, A.R. & Ward, L.D. (2008). The integration of simulation into a clinical foundations of nursing course: Student and faculty perspectives. International Journal of Nursing Education Scholarship, 5(1), Article 26. doi:10.2202/1548-923X.1603 [CrossRef]
- Rotz, L.D., Dotson, D.A., Damon, I.K. & Becher, J.A. (2001). Vaccinia (smallpox) vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. Morbidity and Mortality Weekly Report: Recommendations and Reports, 50(RR-1), 1–25.
- Salazar, M.K. & Kelman, B. (2002). Planning for biological disasters: Occupational health nurses as “first responders.”AAOHN Journal, 50, 174–181.
- Sy, S.F. & Long-Marin, S.C. (2008). Infectious disease and prevention and control. In Stanhope, M. & Lancaster, J. (Eds.), Public health nursing: Population-centered health care in the community (pp. 871–874). St. Louis, MO: Mosby.
Learning Objectives and Questions
|Recognize the need for isolation precautions to be initiated based on the patient’s history
|Identify the correct personal protective equipment
|Conduct an appropriate physical assessment and implement physician orders correctly
|Communicate with the patient to relieve anxiety and fear
|Describe smallpox including the pathophysiology, signs, symptoms, treatments, and complications associated with the exposure
|Describe the evolution of smallpox in an infected patient
|Explain the treatment for smallpox
|What agencies should be contacted when a patient with a communicable disease is identified?
|What are the privacy concerns related to reporting the patient’s condition to an outside organization?
Roles for the Simulation Experience
||No. of Students
|Public health department nurse