Scenario involving the identification and management of elder abuse in the context of ongoing medical issues and an acute abdominal injury.
An 80-year-old woman presents after a fall at home. She is complaining of right sided upper abdominal pain since the fall. She is also complaining of intermittent palpitations and dizziness prior to the fall. Participants are expected to identify that the cause of the fall is due to elder abuse and to manage this along with her concurrent medical issues and abdominal injury
Overall Goal: To practice focused assessment and management of an elderly patient presenting with a fall and to identify signs of elder abuse
Specific Learning Objectives:
1. Demonstrate an effective team-based assessment of a geriatric patient presenting with a fall
2. Demonstrate a sensitive approach to a patient who is identified as a possible victim of elder abuse
3. Seek and treat causes and complications of geriatric falls
4. Recognize the unique signs and symptoms of elder abuse
5. Concurrently manage both a patient’s complex medical and social issues
Time Recommended: 60 minutes total (10 min Setup | 20 min Scenario | 20-30 min Debrief)
Patient Recommendation: Patient Actor
Medical Equipment:
Medications:
| Role | Description (Role, Behaviour, Key Moments, Script) |
| Patient |
You had a fall at home 3 days ago. You should only state initially that you fell down a few stairs in the garden. You should be cagey about what happened and withdrawn throughout the encounter with the team. You withdraw physically when being touched. You are reluctant to answer questions but will inform them you have had gradually worsening pain in your abdomen since the fall and you hit your head. You have also been experiencing some palpitations for the last 5 days before the fall. You have a history of AF, hypertension, COPD and type 2 diabetes. You are on multiple medications: a blood thinner, diabetic medication, BP medication and puffers. You have the medication list is in your bag (rivaroxaban, metoprolol, fluticasone, candesartan and metformin). You live with your son and you usually mobilize with four-wheel walker. Confederate to prompt the participants to call the son to take further history. As the scenario progresses if the team probes you further you should inform them your son was drunk and pushed you over. Unfortunately, you were standing at the top of a few stairs in the garden when this happened. You don’t think he meant to push you down the stairs he just doesn’t know his own strength sometimes. If asked, this is not the first time this has happened. Your son has a few whiskeys most nights after work. He gets angry with you when he is drunk and sometimes grabs your arm and tells you to go to your room and leave him alone. He accidently pushed you over whilst drunk about a year ago, but you were fine and didn’t want to cause a fuss. You don’t want to get him in trouble as he means well and does let you stay at home with him, but he has been struggling since his wife left him 2 years ago. He often blames you for this and tells you that you are a burden on him. Your medications ran out 10 days ago, but he has been too busy to collect it from the pharmacy for you and you have been having intermittent palpitations and dizziness since then. If asked further about the situation at home, let them know that you often don’t have lunch when your son is at work as you have difficulty making the food yourself. You rarely go out and spend most of your time at home alone. You only came to hospital because your pain is getting worse and you are worried you may fall again due to the dizziness and palpitations. You don’t want to end up in a nursing home and want to go back home with your son as you are happy managing as you are |
| Confederate | You are the son on the phone. You will give different story (she fell in the supermarket on slippery wet tiles, she has dementia and she forgets a lot and can make up some stories). You become flustered but then apologize. |
Moulage: Patient looks slightly unkempt. Multiple aged bruises. Bruises on the bony and non-bony areas of the arm. Bruising to upper right side of abdomen, right side of forehead, bruising of hand print pattern over the upper aspect of the chest.
Set-Up: Allow actors to read over script in preparation. Patient should be as though they were just brought in to the ED by a friend.
Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.
Credits:
Original Author: Dr. Rebecca Shaw, Dr. Nemat Alsaba, Dr. Victoria Brazil
Date: April 30 2018
Originally published on: emsimcases.com
Most Recent Modification: June 3 2022
Modified by: Mateo Orrantia, Dr Eliseo Orrantia, Dr Ryan Patchett-Marble
A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.
Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective2-4, and establish and maintain the simulation as a safe space for learning1,4,5.
Prebrief Guide (Sample Phrases in Italics)
Welcome learners. Introduce yourself, your role, and your experience with simulation.
Go over the time requirements for the simulation, when breaks will occur, how learners should handle incoming calls or texts, etc.
Clarify the learning objectives for the simulation1-5. Give information on the purpose of the simulation without giving out specific actions or information that might compromise the learning experience for participants.
Explain how participants will be evaluated (formative/summative/not evaluated). Briefly discuss the debrief process that will take place at the end of the simulation.
Give details on what expectations are for the learners' behaviour during the simulation, setting basic ground rules2-5. Go over expectations for yourself as the facilitator. Reinforce the simulation as a learning environment, where mistakes aren't something to be punished but opportunities for further learning.
This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.
Ensure all participants agree to the confidentiality expectations of the simulation. Often, this will follow the mantra of "What happens in the simulation stays in the simulation," where learners and instructors agree not to share information on others' performance or scenario details outside of the simulation environment.
Explain that you've done what you can to make the simulation as real as possible, but acknowledge the limitations. Ask the learner to commit to doing what they can to act as if everything was real, explaining that the quality of their learning will depend on their willingness to participate as fully as possible. For the first simulation with a new group, it could be helpful to explain the importance of a mutual fiction contract.
Explain the different roles in the simulation and assign learners to them. If you have predetermined scripts for certain roles, hand them out here.
Explain the resources that will be available for the participants to use, how they should call for help in the simulation, what your role will be in providing information.
Orient participants to simulation space, equipment, manikin, etc. This can also be done by allowing participants to explore the simulation space and manikin for themselves.
Ask for questions!
References
1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.
2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004
3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.
4. INACSL Standards Committee (2016, December). INACSL standards of best practice: SimulationSM Facilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.
5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.
Nora has been brought into ED after a fall at home 3 days ago. She is a bit tachycardic and complaining of some pain in her abdomen. She has a few bruises on the rest of her body.
|
Patient Chart |
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Patient Name: Nora Rogers |
Age: 80 |
Gender: F |
Weight: 50kg |
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|
Presenting complaint: Fall at home 3 days ago |
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|
Temp: 37.1C |
HR: 108 |
BP: 140/90 |
RR: 16 |
O2Sat: 96% |
FiO2: RA |
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|
Cap glucose: 5.2mmol/L |
GCS: 15 |
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|
Triage Note: Fell 3 steps in the garden 3 days ago hitting head and right side of abdomen. |
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Allergies: NKDA |
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|
Past Medical History: |
Current Medications: |
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Further History: Lives with son who is main caregiver. Patient spends most of her time in the house alone whilst son is at work. Mobilizes with four wheeled walker. Does not drink alcohol or smoke. ***Patient was pushed down the stairs by her son whilst he was drunk but will not reveal this initially. ***
| Physical Exam | |
| Cardio: Normal sounds, no murmur. Intermittent palpitations over last few days. | Neuro: Nil |
| Resp.: Chest clear | Head & Neck: Bruising to forehead |
| Abdo: Bruising and tenderness in RUQ | MSK/Skin: Bruising to anterior upper chest wall (vaguely hand-shaped). Bruising to upper arms bilaterally |
| Other: | |
Nora has been brought into ED after a fall at home 3 days ago. She is a bit tachycardic and complaining of some pain in her abdomen. She has a few bruises on the rest of her body.
|
Patient Chart |
|||||||||
|
Patient Name: Nora Rogers |
Age: 80 |
Gender: F |
Weight: 50kg |
||||||
|
Presenting complaint: Fall at home 3 days ago |
|||||||||
|
Temp: 37.1C |
HR: 108 |
BP: 140/90 |
RR: 16 |
O2Sat: 96% |
FiO2: RA |
||||
|
Cap glucose: 5.2mmol/L |
GCS: 15 |
||||||||
|
Triage Note: Fell 3 steps in the garden 3 days ago hitting head and right side of abdomen. |
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|
Allergies: NKDA |
|||||||||
|
Past Medical History: |
Current Medications: |
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The patient is slightly unkempt. Generally withdrawn and reluctant to answer questions. In obvious abdominal pain.
| Patient State/Vitals | ||||||
| Rhythm: AF | HR: 108 | BP: 140/90 | RR: 16 | |||
| O2SAT: 96% | T: 37.1C | GCS: 15 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Obtain history |
No analgesia by 3min ⇒ Patient complains of pain |
All actions OR 6 mins⇒ 2. Deterioration |
This is a normal CXR
This is a normal pelvis x-ray
There is free fluid in the RUQ.
|
LUQ
|
RUQ
|
Supxiphoid |
Pelvis
|
| Patient State/Vitals | ||||||
| Rhythm: AF | HR: 108 | BP: 140/90 | RR: 16 | |||
| O2SAT: 96% | T: 37.1C | GCS: 15 | ||||
|
LUQ
|
RUQ
|
| Supxiphoid |
Pelvis
|
Inclusion Criteria - Only apply to patients with GCS 13-15 and at least one of the following:
Exclusion Criteria - If any of the following are true, Canadian CT Head Rules do not apply:
Medium Risk Criteria - Presence of one or more indicate medium risk for brain injury on CT
High Risk - Presence of one or more indicate high risk for brain injury on CT and possible need for neurological
Source: MD Calc
Patient now more willing to answer questions. Reveals social history to participants.
Give Participants Lab Results
IF Facilitator Playing son and son is called: Son will give different story (she fell in the supermarket on slippery wet tiles, she has dementia and she forgets a lot and can make up some stories). Becomes flustered but then apologizes
| Patient State/Vitals | ||||||
| Rhythm: AF | HR: 120 (↑) | BP: 100/60 (↓) | RR: 16 | |||
| O2SAT: 96% | T: 37.1C | GCS: 15 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Call son for more history |
|
All actions complete or 6mins⇒ 3. Resolution |
| Nora Rogers | ||||
| MRN: 1234-567-890 | Age: 80 | |||
| Complete Blood Count | ||||
| WBC | 6.7 | x109L | ||
| Hgb | 70 | g/L | L | |
| Hct | 0.35 | |||
| Plt | 125 | x109L | L | |
| Electrolytes | ||||
| Na | 135 | mmol/L | ||
| K | 4.6 | mmol/L | ||
| Cl | 105 | mmol/L | ||
| HCO3 | 23 | mmol/L | ||
| Urea | 7.4 | mmol/L | ||
| Cr | 110 | µmol/L | H | |
| Glucose | 5.2 | mmol/L | ||
| Extended Electrolytes | ||||
| Ca | 1.1 | mmol/L | L | |
| Mg | 0.76 | mmol/L | ||
| PO4 | 0.84 | mmol/L | ||
| Albumin | 31 | L | ||
| Veinous Blood Gas | ||||
| pH | 7.34 | |||
| pCO2 | 48 | mmHg | ||
| PO2 | 34 | mmHg | ||
| HCO3 | 23 | meQ/L | ||
| Lactate | 1.8 | mmol/L | ||
| Patient State/Vitals | ||||||
| Rhythm: AF | HR: 120 (↑) | BP: 100/60 (↓) | RR: 16 | |||
| O2SAT: 96% | T: 37.1C | GCS: 15 | ||||
| Nora Rogers | ||||
| MRN: 1234-567-890 | Age: 80 | |||
| Complete Blood Count | ||||
| WBC | 6.7 | x109L | ||
| Hgb | 70 | g/L | L | |
| Hct | 0.35 | |||
| Plt | 125 | x109L | L | |
| Electrolytes | ||||
| Na | 135 | mmol/L | ||
| K | 4.6 | mmol/L | ||
| Cl | 105 | mmol/L | ||
| HCO3 | 23 | mmol/L | ||
| Urea | 7.4 | mmol/L | ||
| Cr | 110 | µmol/L | H | |
| Glucose | 5.2 | mmol/L | ||
| Extended Electrolytes | ||||
| Ca | 1.1 | mmol/L | L | |
| Mg | 0.76 | mmol/L | ||
| PO4 | 0.84 | mmol/L | ||
| Albumin | 31 | L | ||
| Veinous Blood Gas | ||||
| pH | 7.34 | |||
| pCO2 | 48 | mmHg | ||
| PO2 | 34 | mmHg | ||
| HCO3 | 23 | meQ/L | ||
| Lactate | 1.8 | mmol/L | ||
Patient is now very concerned about being taken away from son and put in nursing home
| Patient State/Vitals | ||||||
| Rhythm: AF | HR: 95 (↓) | BP: 125/85 (↑) | RR: 16 | |||
| O2SAT: 96% | T: 37.1C | GCS: 15 | ||||
| Expected Learner Actions | Modifiers | Triggers |
|---|---|---|
|
Address patient's social concerns |
|
All actions complete OR 6 mins ⇒ End and go to debrief |
| Patient State/Vitals | ||||||
| Rhythm: AF | HR: 95 (↓) | BP: 125/85 (↑) | RR: 16 | |||
| O2SAT: 96% | T: 37.1C | GCS: 15 | ||||
Choosing a Debrief Framework:
A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.
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Time |
Facilitator Level |
Prep Time |
Scenario Type |
Flexibility |
|
|
Moderate |
Novice |
Moderate |
Any |
High |
|
|
Short-Moderate |
Novice |
Low |
Short w/ Clear Objectives |
Low |
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Moderate |
Novice |
Moderate |
Any, esp. Team-focused |
Moderate |
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Very Short |
No experience |
None |
Any |
Low |
|
|
Short |
Novice |
Low |
Low number of non-technical skills |
Low |
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Very Short |
No experience |
None |
Any |
Moderate |
|
|
Moderate-Long |
Novice |
Moderate |
Any |
Moderate |
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Objective |
Task |
Sample Phrases |
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|
1. Setting the Scene |
Create a safe context for learning |
State the goal of debriefing; articulate the basic assumption |
“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
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2. Reactions |
Explore feelings |
Solicit initial reactions and emotions
|
“Any initial reactions?” “How are you feeling?” |
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3. Description |
Clarify Facts |
Develop a shared understanding of the case |
“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
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|
4. Analysis |
Explore a variety of performance domains:
|
See bottom of guide for details on the analysis phase |
For each item to be debriefed: 1. Preview Statement: (to introduce topic)
2. Pick Analysis method + Analyze: (see below for more info on each method)
3. Mini Summary: (to summarize discussion of topic)
Phase Wrap-up: "Any outstanding issues or concerns before we start to close?" |
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5. Application or Summary |
Identify take-aways |
Can be learner- or instructor-centered |
Learner-centered: “What are some takeaways from this discussion for our clinical practice?”
Instructor-centered: “The key learning points for the case were [insert learning points]”
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|
Analysis Phase Details |
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Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage): |
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Approach |
Objective |
Sample Phrases |
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Learner Self-Assessment
|
Promote reflection by asking learners to assess their own performance |
“What aspects were managed well and why?”
“What aspects do you want to change and why?”
|
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Focused Facilitation
|
Probe deeper on key aspects of performance, uncover mental frames guiding performance |
Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” "I noticed [observation] I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?” |
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|
Provide Information
|
Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed |
“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]” |
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PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Goal |
Actions |
Possible Scripts |
|
Gather (Listen)
25% |
|
|
How do you feel? |
|
How do you think it went? Can you tell me what happened? |
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Can anyone add anything to that account? |
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Analyze (Guide Reflection)
50% |
|
|
I noticed… |
|
I noticed…. What was the thought process behind…. When….happened, I saw….What do you think….. I saw…I think….How do you see it? |
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Tell me more about… How did you feel about…. I understand, but tell me about X aspect of the scenario |
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Summarize (Help gather Conclusions)
25%
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What are two things that you thought were effective or went well? |
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What do you think are some areas you/your team need to work on? |
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In today’s session, we…. Going forward, we should…. |
References/Adapted From:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Instructions:
|
Actions |
Gather |
Analyze |
Summarize |
|
Closed-loop communication
Clear Messages
Clear Roles
Knowing one’s limitations
Knowledge Sharing
Constructive Intervention
Reevaluation and Summarizing
Mutual Respect
|
Student Observations
Instructor Observations
|
Done Well
Needs Improvement
|
Student-led Summary
Instructor-led Summary
|
References/Adapted from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
|
Set learning objectives |
|
After Case |
How did it go? Address Concerns Review learning points Plan ahead |
Framework from:
(To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Diamond Debrief: Sample Phrases |
|
Description |
|
“So what happened?...and then what happened next?”
Continue asking until confident that the details of the scenario have been raised by the learners
“Let’s not judge our performance now, let’s just focus on what happened” |
|
Transition |
|
“This scenario was designed to show…”
“Let’s address technical and clinical questions. What is the protocol for…?”
“How do we normally deal with this clinical situation?”
“Everyone ok with that?” |
|
Analysis |
|
“How did that make you feel?” To participants, then group “Why?” Then use silence
“How did you/they do that exactly?” “Why did you respond in that way? “ or “Why did you take that action?”
“It feels like…was an issue. Did it feel like that to you?” What I’m hearing from you is…is that correct?”
“This is part of…” (identify the non-technical skill/human factor) “We refer to that as a human factor or non-technical skill, which means…” |
|
Transition |
|
“So, what we’ve talked about in this scenario is…” “What have we agreed we could do?” |
|
Application |
|
“What other kinds of situations might you face that might be similar? How are they similar?”
“How might these skills we discussed play out in those situations?”
“What are you going to do differently in your practice going forward?” |
|
Underlying Principles |
|
Description |
|
Reinforce a safe learning environment. Situate the debrief in the shared and meaningful activity that occurred. Keep the focus dispassionate—discuss what happened but avoid focus on emotions. Listen for emotional responses but resist the temptation to discuss emotions. Make sure everyone shares the same understanding of what happened.
|
|
Transition |
|
Transition into analysis by clarifying any technical and clinical issues |
|
Analysis |
|
Spend most of your time in Analysis. Deconstruct behaviours into specific actions, and explore what happened in detail. Ask about affective responses and validate them. Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario). Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”. Reflect responses back, allowing participants to amend or augment. |
|
Transition |
|
Transition into Application by reinforcing learning. |
|
Application |
|
Focus on moving from the specifics of the scenario to the more general world of practice. Break behaviours down into specific actions. Explore the other kinds of situations that these might apply to. Ask what participants will do differently in their practice. |
Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
Pluses:
Deltas:
|
Plus (+) |
Delta (∆) |
References:
((To learn more about this debriefing framework, visit our page on Debriefing resources)
If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic
|
Phase |
Purpose |
Process |
Sample Phrases |
|
Reactions |
|
|
How are you feeling? What are some initial reactions to what just happened? So, in that scenario… |
|
Analysis |
|
1. Observe an event or result. Comment on the observation.
2. Advocate for your position |
I saw that… I think… I noticed that…To me…
I saw…I’m concerned that… |
|
3. Investigate basis for learner’s thinking that led to the observed event or result |
What do you think? Why do you think that happened? How do you see it? What was the thought process behind….? |
||
|
4. Close the gap through discussion and didactics |
I hear…. What would it take for you to do this next time? How could we do this differently next time? I think a few good ideas that came up were… I’d like to say a little bit about…from my experience/literature |
||
|
Summary |
|
|
What are some takeaways from today? What went well today? What would you do differently next time?
In today’s session, we…. Going forward, we should… |
Adapted from:
Pearls Options:
