Public Health Nursing Vol. 27 No. 2, pp.

164173
0737-1209/r 2010 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2010.00838.x

SPECIAL FEATURES: EDUCATION

High-Fidelity Simulation and

Emergency Preparedness
Agnes Marie Morrison and Ana Maria Catanzaro
ABSTRACT Ongoing threats of bioterrorism and the consequences of natural disasters require nurses
entering the workforce to be competent in emergency preparedness. Nurses need to collaborate with multidisciplinary teams and use their critical thinking skills to provide safe nursing care during potentially
chaotic public health emergencies. Using Institute of Medicine recommendations and Quality and Safety
Education for Nurses competencies, the authors describe a public health emergency simulation exercise
with undergraduate senior nursing students enrolled in a public health clinical course. Students applied
chronic disease, mental health, and pharmacology knowledge acquired in previous nursing courses to an
unfolding infectious disease outbreak while practicing their assessment, treatment, delegation, organizational, and leadership skills. The students quantitative evaluation of the experience indicated that 90.36%
thought the purpose of the experience was clear, 91.5% thought the importance of delivering safe care
during a public health emergency was stressed, and 79.5% thought the presimulation briefing and postsimulation debriefing helped them understand and participate in the drill. Qualitatively, the students reflections of the exercise indicated that although they initially felt overwhelmed and anxious, they realized
the importance of participating in emergency preparedness and recognized their ability to apply nursing
skills learned in previous courses.
Key words: emergency preparedness, infectious diseases, public health nursing education, safety,
simulation.

Ongoing threats of bioterrorism and the consequences

of recent natural disasters clearly indicate a need for
nurses to participate in emergency preparedness. The
World Health Organization (2005) denes an emergency as a state in which normal procedures are suspended and extraordinary measures are taken in order
to avert the impact of a hazard on the community (p. 1).
Nurses have the potential to contribute on
multiple levels to the planning and implementation of

Agnes Marie Morrison, Ed.D., R.N., is Simulation and

Technology Coordinator, Nursing Programs, La Salle
University, School of Nursing and Health Sciences, Philadelphia, Pennsylvania. Ana Maria Catanzaro, Ph.D.,
R.N., is Associate Professor, Nursing Programs, La Salle
University, School of Nursing and Health Sciences, Philadelphia, Pennsylvania.
Correspondence to:
Agnes Marie Morrison,17 Woodstock Drive, Newtown,
PA18940. E-mail: nursespark@aol.com
164

emergency preparedness. For example, nurses have a

role investigating outbreaks, conducting risk communication, assessing signs and symptoms of disease,
dispensing medications, addressing the needs of the
medically fragile, organizing mass immunization initiatives, and using their psychiatric skills to curtail
panic and hysteria (Eid-Heberle, 2008). According to
the Association of State and Territorial Directors of
Nursing (ASTDN), public health nurses are integral
members of emergency planning and response teams.
However, nurses with acute care skills are also needed
to provide care specic to the acuity level of disaster
victims (ASTDN, 2007). It is therefore imperative that
nurses entering the workforce, whether they will be
working in acute care, long-term care, or public health,
have the knowledge and training to participate in
planning emergency preparedness and the implementation of response and recovery efforts. Yet, the opportunities for quality undergraduate clinical experiences
in emergency preparedness are limited, given the
often inexible scheduling of undergraduate clinical

Morrison and Catanzaro: Emergency Preparedness Simulation

courses, already content-packed courses, and the difculty of coordinating emergency preparedness drills
with local hospitals and public health departments.
The Association of Community Health Nursing
Educators (ACHNE) recommends that all nurses
should possess basic competencies for responding to
a public health emergent event. According to ACHNE,
basic essential curricular content for public health
emergency preparedness must include competencies
for disaster assessment, planning, implementing interventions, and evaluation of process and outcomes.
Examples of competencies related to assessment and
planning include recognizing uncommon presentations of common diseases, common presentations of
uncommon diseases, and emerging patterns or clusters of unusual signs and symptoms of illness or injury
that may be related to a terrorist event or emergent
infectious disease. Examples of competencies related
to implementing interventions include initiating population-based care, managing stress and anxiety during emergency events, initiating appropriate infection
control measures, responding to an emergency with
an emergency management system, and communicating with appropriate government and public health
agencies. Examples of competencies for evaluation of
process and outcomes include postevent debrieng
and assessment of response to be better prepared for a
future emergent event (ACHNE, 2008).
A recent study by Rebmann, Carrico, and English
(2008) identied gaps in emergency preparedness
from past disasters. These gaps included infection
prevention and control in mass casualty incidents,
public education, internal and external communication, and building partnerships with outside agencies
(p. 351). Participants in this focus group study, who
were primarily infection control and public health
nurses, indicated that one of the most difcult aspects
of disaster response is assessing and identifying uncommon diseases or conditions. The emergency preparedness exercise described in this paper addressed
these gaps using simulation strategies.
Simulation has been successfully used in nursing
education since the 1950s and is increasingly being
used across the curriculum. The Institute of Medicine
(IOM, 2000), in its classic book, To Err is Human:
Building a Safer Health Care System, advocates the
use of simulation for training health care practitioners
in problem solving and crisis management. The IOM
identies simulation as a training and feedback method in which the learners can practice tasks and proce-

165

dures in a realistic life-like environment. In addition,

the IOM proposes that realistic simulation can be
used to establish performance standards and expectations for patient safety. In health care, simulation
exercises are also useful strategies to develop collaborative teamwork. Simulation exercises can be used for
team training using the human factors of communication, decision making, and situational awareness to
enhance patient safety (Marshall & Manus, 2007).
The use of simulation can also be an excellent
method to help students learn and practice Quality and
Safety Education for Nurses (QSEN) competencies.
The QSEN competencies applicable to public health
emergency preparedness include safety, teamwork,
collaboration, and patient-centered care (Cronenwett
et al., 2007; QSEN, 2007). At our university, the QSEN
philosophy is an important component of nursing education and is expected to be incorporated into all
learning experiences. Baccalaureate nursing faculty in
the School of Nursing and Health Sciences developed,
implemented, and evaluated a day-long emergency
preparedness simulation in the Learning Resource
Center (LRC) as part of the public health clinical experience. An important underlying thread of this learning
experience was for the students to practice the QSEN
competencies in a realistic hands-on environment. The
following objective criteria for performance were used
to guide the development and execution of the infectious disease emergency preparedness simulation exercise: (a) practice personal safety precautions to
protect oneself from disease and injury, (b) recognize
the signs and symptoms of an infectious disease outbreak, (c) identify essential assessment parameters for
mass casualties during gastrointestinal (GI) and respiratory infectious disease outbreaks, (d) effectively participate in an interdisciplinary team, (e) apply
appropriate infection control standards and safe care,
and (f) demonstrate correct nursing actions to safely
and appropriately carry out nursing assessment and
triage responsibilities.

Public Health Emergency

Preparedness Experience
Students participated in two separate simulated infectious disease outbreaks and were required to assume various responder and leadership roles as well
as various casualty roles. The experience was planned
so that students would have to use their previously
acquired knowledge of acute and chronic illnesses,

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TABLE 1. Overview of Public Health Emergency Preparedness Simulation

Topic

Time frame

Methods

Introduction to emergency preparedness

1.5 hr

Lecture
PowerPoint
Videos
Public health ofcial presentation

Simulation scenario 1
Presimulation brieng

15 min

Students divided into responders and casualties;

roles assigned and explained
Student-led active learning

Simulation exercise
Gastrointestinal (GI) infectious disease agents
Day 1: Shigella infection
Day 2: Escherichia coli 0157:H7 infection
Day 3: Campylobacter infection
Postsimulation debrieng

1 hr

30 min

Lunch break
Simulation scenario 2
Presimulation brieng

1 hr

Simulation exercise
Respiratory infectious disease
Avian inuenza AH5N1 virus
Postsimulation debrieng

1 hr

their assessment skills, communication skills, triage

skills, patient safety skills, collaborative skills, documentation skills, and leadership skills to effectively
manage the presenting infectious disease emergency
while addressing other health-related conditions. The
simulation experience also required students to assume the roles of an interdisciplinary group of public
health professionals in managing and resolving the
emergency. Seventy-nine senior baccalaureate nursing students in the public health course participated
in the public health emergency preparedness immersion on their assigned clinical day. An overview of the
public health emergency preparedness simulation is
shown in Table 1.
The experience began with a presentation about
emergency preparedness. Instructional strategies included a lecture with a PowerPoint presentation and
videos that focused on infectious diseases and the
emergency response to an airplane crash. The presentation included the International Nursing Coalition for
Mass Casualty Education (INCMCE) core competencies, which are based on the American Association of
Colleges of Nursing Essentials of Baccalaureate Education. The INCMCE competencies included in the sim-

15 min

30 min

Discussion
Reective writing

Students divided into responders and casualties;

roles assigned and explained
Student-led active learning

Discussion
Reective writing
Written evaluation

ulation are (a) critical thinking, (b) assessment, (c)

technical skills, (d) communication, (e) illness and disease management, (f) information and health care
technologies, (e) ethics, and (f) care of diverse populations (Stanley, 2005). This was followed by guest
speakers from the Philadelphia Department of Public
Health (PDPH), who discussed the role of the PDPH in
preparing and responding to a mass casualty incident.

The Philadelphia Department of

Public Health
In order to protect the residents of Philadelphia, the
PDPH (n.d.) developed the Emergency Preparedness
and Bioterrorism Program. This comprehensive plan
to identify and respond to mass casualty incidents includes the following: (a) enhanced surveillance to recognize disease outbreaks; (b) increased laboratory
capacity to detect biological and chemical agents that
can cause human illness; (c) a plan for mass dispensing of medications and vaccines; (d) emergency preparedness drills; (e) coordination of efforts with
government and health care organizations for security, stafng, training, and dispensing; (f) coordination of communication systems among the PDPH,

Morrison and Catanzaro: Emergency Preparedness Simulation

health care organizations, and emergency response
personnel; and (g) a plan for communication of critical information to the media and public. The guest
speakers from the PDPH presented an overview of
federal requirements for emergency preparedness to
the students and then discussed in greater detail Philadelphias plans for mass dispensing of medications
and immunizations and the Philadelphia Medical Reserve Corps (MRC).

167

Philadelphia Medical Reserve Corps

The MRC is a program developed to recruit and train
needed health care personnel and lay volunteers to
respond to a bioterrorism incident or a naturally occurring epidemic. One example of how MRC volunteers
could contribute is by serving as extra health care staff to
assist in the POD clinics and help with mass immunization or mass prophylaxis administration (PDPH, n.d.).

Simulation Strategy
Federal requirements for emergency
preparedness
In response to the 2001 terror attacks, which included
the release of anthrax spores through the U.S. mail,
the federal government instructed the Centers for Disease Control and Prevention (CDC, 2008b) to develop
and implement an emergency preparedness plan to
respond to a bioterrorism incident. One component of
this plan was the development of the Strategic National Stockpile (SNS) program. The SNS is a system
in which large quantities of medical supplies and
medications have been gathered and are strategically
warehoused across the country by the federal government. The SNS program would enable the dispersion
of stockpiled medications and supplies to any local
region in the United States within 12 hr of a public
health emergency that is severe enough to deplete
local resources (CDC, 2008b). Another component of
this plan is the development of the Cities Readiness
Initiative (CRI), which is a federally funded effort to
assist major U.S. cities and metropolitan areas to dispense antibiotics to their entire identied population
within 48 hr of the decision to do so (CDC, 2008a).
Point of Dispensing
The federal government mandates that every public
health jurisdiction in the United States must develop
and maintain the capacity for mass prophylaxis
(Agency for Healthcare Research and Quality, n.d.).
In response to this mandate, Philadelphia has developed a Point of Dispensing (POD) plan to provide
mass prophylaxis or mass immunizations to the local
population in the event of a bioterrorism incident or a
naturally occurring infectious disease outbreak. A
component of this plan is to implement, if appropriate to the emergency response, multiple POD clinics
throughout the city in local neighborhood schools and
other facilities. Philadelphias POD plan is a component of the SNS and CRI programs (PDPH, n.d.).

The infectious disease outbreak exercises took place

in a simulated large, crowded urban high school that
served a vulnerable and underserved population of
high school students. The context for the simulation
included a history of higher than normal absentee
rates at the school due to various viral and bacterial
illnesses during the previous 2 weeks. There had also
been several sporting events at the school that had
brought together a large number of teams and fans
from other schools. Students from home and rival
teams were involved in an escalating series of pranks.
Three days earlier, 50 chickens were let loose in the
school during the night and were discovered the next
day. Public health ofcials were in the process of observing and testing the chickens for possible diseases.
As the infectious disease outbreak began, the
school nurse was in the process of performing a highrisk, low-frequency procedure to a high school student
with Lyme disease. The simulated student was a highdelity human mannequin simulator. The school
nurse was administering an intravenous antibiotic to
the simulated student via a peripherally inserted central catheter (PICC) when a large number of ill high
school students and staff arrived at the health ofce
with various signs and symptoms. Realizing that the
health ofce staff of three would be unable to handle
the sudden inux of ill students and staff, the school
nurse summoned additional help from district school
nurses and health care ofcials who were attending a
conference at the high school. Triage, assessment, and
treatment by the health care team were directed by
the lead school nurse. As the emergency unfolded, the
health care responders had to work as a team to assess, treat, and alert the appropriate ofcials of a possible infectious disease outbreak.

Presimulation briefings
The simulation experience began after the LRC and
PDPH presentations. The nursing students were

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randomly divided into two groups. Students in Group

A were assigned to be health care responders during
the morning simulation exercise and causalities during the afternoon simulation exercise. Students in
Group B were assigned to be causalities during the
morning simulation exercise and health care responders during the afternoon simulation exercise. The assignment of nursing students to Groups A and B
ensured that each student had the opportunity to participate in the simulation exercise both as a health
care responder and as a casualty. The students clinical instructors were assigned as causalities during
both simulations in order to promote student-centered leadership and learning during the simulation
exercises.
Once assigned to either the responder or the casualty groups, the nursing students were given information about their assigned simulation and role. They
were told that the purpose of the simulated public
health emergency was for them to develop condence
and skills related to emergency preparedness, practice
giving safe care in a chaotic situation, and work as a
high-functioning team during the student-led exercise.

Casualties
The nursing students and clinical instructors assigned
to be casualties were given role-playing prompts that
included a brief history and either GI or respiratory
signs and symptoms, depending on the specic infec-

March/April 2010

tious disease assigned to the simulation scenario. The

casualties were assigned to be high school students or
high school staff. To include a high-risk population
and a mental health component, the casualties
included a pregnant teenager, a mother with a baby
(a static mannequin), and a hyperactive, anxious teenager. Additionally, all of the high school staff and
some of the high school students had chronic conditions such as diabetes, cardiac disease, Crohns
disease, or asthma. Persons who were assigned a
chronic condition were also told that they were taking
a medication relevant to that condition, for example,
warfarin, aspirin, insulin, or antihypertensive and
cardiac medications. Assigning chronic diseases and
routine medications to the casualties added an additional dimension to the infectious disease outbreak.
Examples of the role-playing prompts for casualties
are displayed in Table 2.

Responders
Responders were assigned team roles to assume during the emergency preparedness drill. These roles included the lead school nurse, who assumed the
leadership role during the emergency, two other
school nurses assigned to the high school, the school
principal, and the school security guard. Other nursing students assumed the roles of additional school
nurses who were attending a leadership conference
at the high school and were able to respond as the

TABLE 2. Examples of Role-Playing Prompts for Casualties

Casualty assignment
Gastrointestinal casualties
Casualty A1

Casualty A6

Respiratory casualties
Casualty B8

Casualty B17

Role-playing prompt
You are a casualty in this scenario
You are a student in the high school
Past medical history: 12 weeks pregnant
Signs and symptoms: severe nausea and vomiting, abdominal cramps since last night
You are a casualty in this scenario
You are a teacher in the high school
Past medical history: hypertension, angina, on amlodopine, valsartan, metoprolol, aspirin
Signs and symptoms: dizziness, abdominal cramps, bloody stool, temperature 1011F
You are a casualty in this scenario
You are a teacher in the high school
Past medical history: arthritis, on high-dose NSAIDs
Signs and symptoms: coughing, throat red and sore, severe headache, temperature 104.21F
You are a casualty in this scenario
You are a student in the high school
Past medical history: healthy
Signs and symptoms: 5-hr history of nausea, now coughing and feels sick, temperature 1011F

Morrison and Catanzaro: Emergency Preparedness Simulation

169

emergency unfolded. Since some of the casualties had

chronic illnesses as well as acute symptoms, the
health care responders had to assess and think critically to decide whether the symptoms were related to
an unusual infectious disease outbreak, a mild infectious illness, a chronic illness, or adverse effects from
medications. It was the responsibility of the lead
school nurse to delegate tasks, assessments, and care
of casualties. In collaboration with the principal, the
lead school nurse also had the responsibility of communicating with the public health department.
The faculty member who coordinated the simulation assumed the role of a state public health ofcial
and communicated with the lead school nurse via
walkie-talkie. It was the responsibility of the lead
school nurse, in collaboration with the team, to gather
specic assessment data of the infectious disease outbreak for the public health department and determine
when the simulation exercise was completed. Students received minimal input from the faculty.

chickens left at the school had tested positive for

H5N1 avian inuenza. During this simulation, the students had to decide what kinds of infection control
methods were needed and what would be the appropriate disposition of the sick students and staff.
This more serious infectious disease outbreak would
require quarantine and a public health emergency
response.
During each of the morning and afternoon exercises, the public health department requested specimens and an exact count of the various symptoms
being experienced by the ill students and staff. The
health care team of the student-run exercise had to
obtain this information, initiate appropriate infection
control measures, complete the assessment forms,
and notify the public health department. The student
nurse leader was responsible for ensuring that all necessary actions were completed, and at that point, the
student nurse leader concluded the exercise.

Simulation exercises
Nursing students participated in the simulation exercises on their assigned clinical day. There were two
simulation exercises per day over a 3-day period. Each
exercise involved either a GI or a respiratory infectious disease outbreak. The challenge for the student
responders was to assess the casualties and determine
whether the symptoms were related to chronic diseases, medications, minor illnesses, or an infectious
disease outbreak.
During the morning simulation exercise, the scenario included a GI infectious disease outbreak. Each
day, a different GI infectious disease simulation
occurred. The three simulated GI disease agents were
Shigella, Escherichia coli 0157:H7, and Campylobacter.
For the morning exercise, the students had to decide
what kinds of infection control methods were needed
and what would be the appropriate disposition of
the sick students and staff. Twenty minutes into the
simulation, the school received a call from the health
department informing the principal that a chicken
had tested positive for the infectious disease assigned
to each exercise. The goal was to send the causalities
to the emergency room for further evaluation and
treatment.
The afternoon scenario on each of the 3 days was
a more serious respiratory infectious disease. Twenty
minutes into these exercises, the health care team was
informed by the health department that one of the

Evaluation
The simulation learning experience was evaluated
both qualitatively and quantitatively by the 79 students who participated. The purpose of the student
evaluation of this educational program was to determine whether participating in a simulated emergency
preparedness drill is an appropriate learning activity
for the undergraduate public health nursing course.
The university does not require approval by the Institutional Review Board (IRB) for student evaluations
of educational activities. The student evaluation component was not conducted as a research study.
The qualitative evaluation included a verbal debrieng as a group activity, led by faculty facilitators,
and a written reection completed by each individual
student after each simulation. During the debrieng,
students were asked open-ended questions and encouraged to discuss their feelings about participating
in the simulation exercise. Topics discussed included
their respective roles as responders, the tasks they
were assigned, the consequences of their actions, and
situations that required them to use knowledge
learned in prior courses. The purpose of the postsimulation debrieng was to allow the students to discuss
their feelings about participating in the exercise and
to self-evaluate their individual and team performance. Student comments during the debrieng were
not recorded.

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The facilitators then provided feedback about the

actions and events that occurred during the simulation. Using a question and answer format, the facilitators pointed out essential elements that need to be
considered by health professionals responding during
an emergency, including organizational, team building, and leadership skills. The instructors then shared
several observations with the students. The rst observation was that the students really did not know
each other well enough to optimize teamwork. A second observation was that the students had difculty
understanding their respective responder roles. A
third was the tendency of the student leaders to want
to provide hands-on care to the casualties rather than
delegate responsibilities to other members of the response team. A fourth observation was that during the
second simulation, the responders had learned from
the previous simulation the need to discuss plans and
delegate responsibilities before jumping in to address
the evolving emergency event.
Following Johns (2004) work on reective practice, the students were asked to complete the written
Emergency Preparedness Simulation Reection Activity, which consisted of four open-ended questions
as shown in Table 3. This qualitative student reection of the experience was collected and later analyzed
for common themes by the team of faculty facilitators.

March/April 2010

After the simulation experience was completed, the

faculty facilitators met to discuss the overall public
health emergency preparedness clinical activity as
well as student and faculty feedback.
The faculty facilitators identied several themes
that emerged in both the verbal and the written reective activity. The students commented that they felt
overwhelmed, anxious, and confused as to how to respond to a chaotic situation. They realized the importance of being involved in emergency preparedness
planning, and they recognized how they were able to
apply the assessment, diagnosis, and prioritizing skills
they had learned in previous courses as well as their
knowledge of chronic, acute, and communicable diseases.
In general, the students thought that the emergency
preparedness simulation experience gave them preparation for responding to a real emergency. Examples of
students written reections are included in Table 3.
In addition to the reective activity, which served
as a qualitative evaluation, a quantitative evaluation
was conducted at the end of each day. Seventy-nine
senior baccalaureate nursing students in the public
health course participated in the learning experience
and completed the evaluation. A seven-item Likert-type
scale instrument was used to elicit participant feedback
and to evaluate the clinical learning experience as
shown in Table 4. The respondents were instructed to

TABLE 3. Written Reective Questions With Examples of Student Responses

Emergency Preparedness Simulation Reflection Activity
1. What feelings arose for you during the simulated emergency experience?
Prioritizing wasnt easy with so many needing help.
I felt that the responders were overwhelmed with so many different people and illnesses.
I was overwhelmed and frustrated but I guess thats how it would be in a real emergency.
Anxious, scared, confused.
2. What do you think went well?
Working as part of a team and I realized that communication and delegation are important.
The assessments went well.
I think it helped to really prepare us more for a real life disaster.
The simulation scenario kind of explained many different things that you need to expect.
3. What did you learn?
I learned how preparing ahead of time was extremely important as well as communication.
I learned that everyone needs to be aware of what exactly their role is in the event of a disaster.
I learned that during a disaster your assessment needs to take into account any chronic conditions the person may have.
Need to stay calm. Patients dont need a panicky nurse.
I learned time management and prioritizing.
4. If you were given the task of redesigning todays simulation, what would you change?
I wouldnt redesign the simulation. I would just reassess how we handled the situation in controlling the chaos.
Responders should have more time to prepare for the emergency.
Honestly, I think it was well-organized and I would leave it as it is because we all learned a lot as nurses and casualties.
I think participating in the morning simulation as a nurse and in the afternoon simulation as a casualty provided us with a
good experience.

Morrison and Catanzaro: Emergency Preparedness Simulation

171

TABLE 4. Descriptive Analysis of Quantitative Evaluation of Learning Experience

Responses

Questions
The purpose of unfolding public health
simulation was made clear
The exercise was well organized and structured
The exercise scenarios were realistic
Participation in the exercise was an appropriate
learning activity for the public health nursing
course
The presentation Introduction to Disaster
Planning helped me understand and
participate in the simulated public health
emergency exercise
The pre- and postsimulation briengs helped
me understand and participate in the
simulated public health emergency exercise
The importance of delivering safe care during a
simulated public health emergency exercise
was stressed

Strongly agree
to agree (%)

Strongly
agree

Agree

Neutral

Disagree

Strongly
disagree

90.36

47

28

83.1
77.1
89.1

33
29
45

35
35
29

15
14
7

0
4
2

0
1
0

81.9

51

17

15

79.5

41

25

13

91.5

53

23

consider each of the seven statements related to the

experience and respond using the 5-point scale that
ranged from strongly agree to strongly disagree. The
statements elicited participant feedback on all major
aspects of the day-long clinical public health simulation
experience.
Results of the quantitative student evaluations
were reported descriptively. Overall, the respondents
positively evaluated the public health emergency preparedness experience. When asked whether the purpose of the unfolding simulated public health
emergency was clear, 90.36% either strongly agreed
or agreed that it was clear. Similarly, when asked
whether the importance of delivering safe care during
a simulated public health disaster was stressed, 91.5%
either strongly agreed or agreed. When asked whether
the presimulation and postsimulation briengs helped
them understand and participate in the simulated
public health emergency drill, 79.5% strongly agreed
or agreed, 15.6% were neutral, and 4.81% disagreed.

Conclusion
This public health emergency preparedness simulation
exercise of infectious disease outbreaks can be a useful
learning strategy at other educational institutions and
can be easily replicated. Based on our observations and

student evaluations of the simulation, we have several

recommendations for faculty who wish to replicate this
simulation exercise. Our rst recommendation is that
presimulation brieng time should be increased from
15 to 30 min. This extra time will enable the student
responders to introduce themselves to each other
and will allow time for the students to ask questions to
better understand the roles and duties of the members
of the responder team. We also suggest adding an informatics component in the actual simulation. This
would enhance the delivery of evidence-based care
and patient safety. During the simulation, after notication by the public health ofcials that an infectious
agent was isolated in the animal specimen, the lead
nurse would delegate to a team member to perform a
computer search of the CDC and/or the World Health
Organization Web sites to nd evidence-based information on the specic infectious disease. The information would be reported to the lead nurse during the
simulation to aid in decision making. The student who
researched the information would then be expected to
report about evidence-based practices related to the infectious disease during the postsimulation debrieng.
A limitation of this exercise is that although objective criteria for performance were developed and
implemented for the simulation, the objectives were
not formally evaluated by the participants. Therefore, a

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Likert-type evaluation tool was developed based on the

objective criteria for performance and will be used in
future emergency preparedness simulation exercises.
Sarpy, Warren, Kaplan, Bradley, and Howe (2005)
recommend that participants learning be evaluated 3
6 months following a simulation exercise. A dilemma
of offering the emergency preparedness simulation exercise at the senior level is that students graduate and
long-term learning cannot be evaluated. However, in
order to effectively participate and manage the complexities involved in an infectious disease emergency
simulation, nursing students need to use previously
acquired knowledge of acute and chronic illnesses.
Students also need to be able to apply assessment,
communication, triage, safety, collaboration, documentation, and leadership skills. This complex exercise is best suited for senior-level nursing students. It is
expected that as the senior nursing students graduate,
they will participate in further emergency preparedness simulations as registered nurses.
The senior nursing students who participated in
this simulation were engaged learners. They actively
participated and practiced collaborating as a team.
Students had to independently make decisions and
deal with the outcomes of their decisions. In a clinical
area with actual patients, the clinical instructor must
closely supervise students to prevent mistakes since
patient harm could result. An advantage inherent in
simulation is that since no actual patients are involved, students are able to lead and participate in
the actual simulation without teacher intervention.
Simulated experiences provide a safe environment in
which to practice, make mistakes, learn from ones
mistakes, and practice higher-level decision making.

Acknowledgments
We thank Zane Wolf, Shelley Johnson, and Rose Elliott for helping to make the public health simulation a
success. We acknowledge our participation in the
QSEN Pilot Schools Learning Collaborative Grant.
LSU received a QSEN grant funded by the RWJ Foundation through UNC, Chapel Hill School of Nursing,
Linda Cronenwett, Ph.D.

References
Agency for Healthcare Research and Quality. (n.d.).
Overview of mass prophylaxis. Retrieved

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May 27, 2008, from http://www.ahrq.gov/

research/cbmprophyl/cbmpgde1.htm
Association of Community Health Nurse Educators.
(2008, January). Disaster preparedness white
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nursing educators. Retrieved September 16,
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