Disaster simulation trains nursing students in mass casualty incident response

Nine master of professional nursing (MPN) students encountered an overwhelming, fog-filled scene as they entered the School of Nursing simulation center room on a mid-July morning. Actors with fake blood on their foreheads gasped, moaned, and cried out in panicked confusion. “Help me! I can’t get up!” “Where’s your sister?” “George! George! Is he OK? Why is he not moving?” This was part of a training exercise that simulated an explosion occurring during an admissions event on campus.

As Gene Janda, chief of fire and emergency services in the Division of Public Safety (DPS) arrived, acting as incident commander, he asked the students how many patients they had, conveying that an ambulance was coming. Nursing lecturer Sarah Logan portrayed the pregnant mother of an admitted student, and when it became apparent that she was in labor, the nursing students upgraded her triage assessment from a yellow tag to red, making her the priority for transport.

This was one of seven scenes in which 107 students taking Nurses Caring for and Across Communities, a clinical nursing course in the MPN program, were placed as part of a mass casualty disaster simulation. This involved triaging patients and communicating with patients and family members during a traumatic event, which included mock injuries and fatalities.

The event took place in the Helene Fuld Pavilion for Innovative Learning and Simulation and was organized by its director, Ann Marie Hoyt-Brennan, in collaboration with Penn Medicine, the School of Social Policy & Practice, and DPS. The volunteer actors included faculty and staff from Penn Nursing, Admissions, IT, and other divisions along with family members and neighbors.

“Penn Nursing’s disaster simulation—a prescient curricular step that we incorporated years ago in the Nursing in the Community course—provides students with the opportunity to put population health into practice in the broadest and most efficient possible way,” says Julie Sochalski, associate dean for academic programs.

Sochalski notes that the simulation aligns with new program standards from the American Association of Colleges of Nursing, which now include population health as a key domain in nursing programs and disaster preparedness as a cardinal feature.

View large image

The students received a pre-brief from Penn Medicine physician Jonathan Bar, director of emergency preparedness and assistant professor of clinical emergency medicine, and Jack Welsh, emergency preparedness specialist and a clinical nurse at the Hospital of the University of Pennsylvania.

Bar talked about his experience responding to a March 2022 incident in which dozens of children in Camden, New Jersey schools experienced nausea, vomiting, and diarrhea after drinking contaminated milk from cartons. After checking for safety—he sent police officers to every school in the city until everyone stopped drinking milk—the next steps were triage, treat, and transport, Bar recalled.

In the simulation, the nursing students were expected to use a system called START—which stands for simple triage and rapid treatment—to assess, triage, and tag victims. Bar highlighted another system that includes the designation “likely to survive given current resources,” which he said can give more room than START for clinical judgment. He advised the nursing students to look to their institution’s protocol for guidance on which system to use.

After the simulation, students debriefed in their respective rooms. Logan facilitated the discussion, helping students reflect on their reactions, medical management, and communication with each other, victims, and their families.

Students expressed that they felt overwhelmed, and that it was intense trying to manage all that was going on and determine who was the highest priority for transport. One reflected that saying “We’re doing the best we can” doesn’t give patients much comfort. “I think it is important for us to do scenarios like that, because the more you do that, the more you can learn to think on your feet,” MPN student Emily MacDaniel said.

Handling the emotional aspects

The disaster simulation was not only an education in triage and utilizing the Incident Command System—a standardized approach to emergency response—but also in talking to people in moments of acute stress and how that sets the stage for ongoing trauma and grief reactions over the death of a loved one, said SP2 associate professor Allison Werner-Lin.

An oncology social worker by training, Werner-Lin facilitated a large-group debrief on addressing traumatic loss in crisis care. She has been working with Hoyt-Brennan on interdisciplinary simulations on topics such as intimate partner violence and end of life decisions for a decade. In one scene for this simulation, Werner-Lin also portrayed the mother of a baby who died.

“There are social taboos in talking about death in nearly every culture on the planet,” Werner-Lin said. She acknowledged how hard it is to tell someone that their loved one has died but noted that while doing so could make the room more chaotic in the moment, it also begins the grieving process and allows nurses to continue providing lifesaving care. The longer this information is withheld, she said, the more elongated, complicated, and ambiguous the grieving process becomes. She gave tips on talking to people in crisis.

“We want to work with breathing. We want to make eye contact. We want to make sure our tone of voice isn’t as agitated as we might be feeling,” Werner-Lin said, noting that students can project a composed demeanor even if they’re terrified. “Fake it ‘til you make it.”

Werner-Lin also gave guidance to the students on processing what they’ve seen, in the event of an actual traumatic event. For her, that mechanism is her martial arts practice. She said for others, it might be running or being in community.

“Self-care, despite what TikTok says, is not lighting an aromatherapy candle, it’s not getting an adult coloring book, it’s not taking a bath,” she said. These are important in the moment, but Werner-Lin asked students to think about what they have in their lives that fills them up and gets their dopamine receptors moving.