Construction and validity of a simulated design to assist victims of stab wounds

Abstract

Objective  To build and validate a simulated design for nursing care in the pre-hospital setting for victims of stab wounds.

Methods  This is a methodological study developed in three stages: content survey from the literature; clinical simulation design elaboration; and simulation design validity by a committee of experts. Data were collected through a validity form that assessed clinical simulation regarding its objective, relevance, presentation and structure. To propose face and content validity, the Content Validity Index >80% agreement was adopted.

Results  The design consisted of five stages, such as preparation, participation and debriefing, cognitive skills test, psychomotor and attitudinal skills checklist, and decision-making flowchart. The committee was composed of seven experts. Based on their responses, an agreement of >85% was obtained on all assessment items, considering “almost perfect agreement”. At the end, the total Content Validity Index was calculated, resulting in 99.3% agreement. The design and instruments were judged as valid, presenting relevance, clarity, coherence, scientifically correct information, and a logical sequence that allows the development of professional skills.

Conclusion  The design was considered valid in its content because it achieved “almost perfect agreement”. Therefore, this construct is reliable for planning and executing clinical simulation of nursing care for a victim of stab wound in a pre-hospital situation.

Keywords
Simulation training; Wounds, stabs; Education nursing; Emergency medical services; External causes

Resumo

Objetivo  Construir e validar um design simulado para atendimento de enfermagem no ambiente pré-hospitalar a vítimas de ferimento por arma branca.

Métodos  Estudo metodológico desenvolvido em três etapas: levantamento de conteúdo a partir da literatura, elaboração do design da simulação clínica e validação do design da simulação por um comitê de experts. Os dados foram coletados por meio de um formulário de validação que avaliou a simulação clínica quanto ao objetivo, relevância, apresentação e estrutura. Para propor a validade de face e conteúdo foi adotado o índice de validade de conteúdo >80% de concordância.

Resultados  O design foi composto por cinco etapas: preparação, participação e debriefing, teste de habilidades cognitivas, checklist de habilidades psicomotoras e atitudinais e fluxograma de tomada de decisões. O comitê foi composto por sete experts. Com base em suas respostas, foi obtido um resultado >85% de concordância em todos os itens de avaliação considerando uma “quase perfeita concordância”. No final, foi calculado o índice de validade de conteúdo total resultando em 99,3% de concordância. Foram julgados o design e os instrumentos como válidos, apresentando relevância, clareza, coerência, informações cientificamente corretas e uma sequência lógica que permite desenvolver competências profissionais.

Conclusão  O design foi considerado valido em seu conteúdo por atingir uma “quase perfeita concordância”. Portanto, esse construto é confiável para planejar e executar a simulação clínica do atendimento de enfermagem a uma vítima de ferimento por arma branca em situação pré-hospitalar.

Descritores
Treinamento por simulação; Ferimentos perfurantes; Educação em enfermagem; Serviços médicos de emergência; Causas externas

Resumen

Objetivo  Elaborar y validar un diseño simulado para la asistencia a víctimas de heridas por arma blanca por parte de enfermeros en ambiente prehospitalario.

Métodos  Estudio metodológico realizado en tres etapas: recopilación de contenido a partir de la literatura, elaboración del diseño de la simulación clínica y validación del diseño de la simulación por un comité de especialistas. Los datos fueron recopilados mediante un formulario de validación que evaluó la simulación clínica con respecto al objetivo, la relevancia, la presentación y la estructura. Para proponer la validez aparente y contenido, se adoptó el índice de validez de contenido >80 % de concordancia.

Resultados  El diseño estuvo compuesto por cinco etapas: preparación, participación y debriefing, prueba de habilidades cognitivas, checklist de habilidades psicomotoras y actitudinales y diagrama de flujo de toma de decisiones. El comité estuvo compuesto por siete especialistas. Con base en sus respuestas, se obtuvo un resultado de >85 % de concordancia en todos los ítems de evaluación, lo que se considera una “concordancia casi perfecta”. Al final se calculó el índice de validez de contenido total, que fue de 99,3 % de concordancia. El diseño y los instrumentos fueron considerados válidos y demostraron relevancia, claridad, coherencia, información científicamente correcta y una secuencia lógica que permite desarrollar competencias profesionales.

Conclusión  El diseño fue considerado válido en su contenido por alcanzar una “concordancia casi perfecta”. Por lo tanto, este constructo es confiable para planificar y realizar la simulación clínica de la asistencia a víctimas de heridas por arma blanca por parte de enfermeros en situaciones prehospitalarias.

Descriptores
Entrenamiento por simulación; Heridas punzantes; Educación en enfermería; Servicios médicos de emergencia; Causas externas

Introduction

In the context of emergencies, trauma is considered a public health concern, due to its high morbidity and mortality and high costs in the health system, occupying fourth place in the ranking of hospitalizations in intensive care units in Brazil.(¹)

Trauma is a mechanism that involves the exchange of energy from the environment to the body, resulting in injuries that can affect organs.(²)It presents, on a large scale, as precursors, social violence and traffic accidents, capable of causing traumatic injuries that are divided into two groups: blunt and penetrating.(³,⁴)

Stab wounds (SW) are one of the main examples of penetrating trauma, which can be caused by objects capable of piercing or cutting (points or blades). Such objects usually hit the trunk, upper limbs and head, compromising the integrity of organs. This leads to hemorrhage and shock, requiring immediate pre-hospital care (PHC) to reduce death rates.(¹,⁵)

Nursing is inserted in this context of PHC, playing a fundamental and complex role. This scenario requires facing the unexpected, immediate conduct, knowledge and technical and specific skills to perform interventions and treat people in acute and threatening conditions.(⁶,⁷)

In this scenario, higher education institutions in nursing seek to improve teaching-learning processes to facilitate the acquisition and improvement of cognitive, psychomotor and affective skills. Their pedagogical strategies must support the quality of education by training qualified professionals to provide safe and quality care to trauma victims in PHC.(⁸)

Thus, clinical simulation strategies are incorporated into nursing education. They can be defined as strategies that replicate real situations in a safe and controlled environment, where professional skills are developed to enhance critical thinking and ensure the retention of specific skills.(⁹-¹¹)

Clinical simulation is structured in three stages: preparation, participation and debriefing.(¹²) Preparation is divided into pre-simulation (preliminary preparation and skills training), pre-briefing (general presentation) and briefing (instruction to execute the scenario) phases.(¹³) Participation stage involves the execution of clinical scenario, and the debriefing stage involves analysis and discussion and/or reflection after simulation.(¹⁴-¹⁶)

To implement clinical simulation, the importance of developing and validating designs capable of guiding the development of this active strategy is highlighted, aiming to ensure its reliability, efficiency and applicability, thus supporting an effective teaching-learning process.(¹⁷)

However, despite its relevance, there is a lack of studies in literature on the development and validity of simulated designs on trauma in nursing and national and international scientific articles on the development and validity of clinical simulation designs on PHC for SW victims.(¹⁸)

A gap was observed in clinical simulation aimed at nursing in PHC for victims of SW. This reflects the importance of using educational strategies and offering meaningful learning so that students and professionals can develop the clinical skills desired in PHC.(⁷)

Given the importance of the topic for developing professional skills in nursing, and with a view to ensuring safe and quality care for victims of SW, this study aimed to build and validate a simulated design for nursing care in the pre-hospital setting for victims of SW.

Methods

This is a methodological study carried out at a university in Minas Gerais, Brazil, between March 2022 and February 2024. The design of a clinical simulation for nursing care for a trauma victim in PHC was constructed and validated. It is developed in three stages: content survey in the literature; simulation design elaboration; and clinical simulation design validity.

In the first stage, a literature review was carried out to support the design construction. We chose to follow “Healthcare Simulation Standards of Best Practice^TM”. These references guide and direct the implementation of clinical strategies, the current guidelines of Prehospital Trauma Life Support (PHTLS) and Mobile Emergency Care Service Basic and Advanced Life Support Protocol that support PHC.(⁵,¹²,¹⁹)

For validity, the study had a committee of experts. For their selection, the criteria for selecting experts for validity studies in nursing with two specific areas (clinical simulation and emergency care) were considered.(²⁰)

Professionals whose profile was compatible with a score ≥5 points were selected: clinical experience ≥4 years in the specific area (mandatory) (4 points); experience ≥1 year in clinical teaching (1 point); participation ≥2 years in a research group (1 point); doctoral degree in nursing (2 points); master’s degree in nursing (1 point); nursing residency (1 point) in specific areas; and research experience with published articles (1 point).(²⁰)

Experts with a degree in nursing, a score ≥5 and experience in teaching, training or experience in simulation and/or emergency care were included. Experts who submitted completed forms after the 30-day deadline were excluded.

Convenience sampling was used, and experts were selected based on the researchers’ resumes (Lattes Platform). In the search by subject, the keywords “simulation” and “urgency and emergency” were used in the databases of physicians and other researchers, without limiting nationality, using the filters “academic training” and/or “degree” and “professional activity”. Other fields were not delimited so as not to compromise the search.

To collect data from experts, a validity form in Google Forms was used. This process was conducted using questions that assessed three domains: objective; relevance; structure and presentation. In the validity form, the questions had alternatives governed by a Likert-type scale (5 points): (1) totally agree; (2) partially agree; (3) neither agree nor disagree; (4) partially disagree; and (5) totally disagree. After the questions in each assessed domain, the form had a free space for comments, suggestions, corrections or changes.(²¹)

Experts were contacted via email, including an invitation to participate in the study, a link to read and accept the Informed Consent Form, and access to the form; attached was clinical simulation design (Portable Document Format) for download and prior reading. Experts had 30 consecutive days from receipt to complete and return the forms with their considerations.

To propose content validity, a quantitative approach was used based on the Content Validity Index (CVI), adding the responses “1” and “2” of each item of the instrument and dividing the total by the number of responses.(²²)To analyze and verify the agreement and validity between the aspects of simulation design and the instruments, a result of ≥80% agreement of CVI was recommended among the responses obtained in each item judged.(²¹)

Finally, the total CVI of clinical simulation design was calculated by adding each CVI value and dividing the result by the number of items in the instrument.(²²) Classification was based on the result (in %): 0: no agreement; 0.1-20: poor agreement; 21-40: slight agreement; 41-60: acceptable or moderate agreement; 61-80: considerable agreement; 81-99: almost perfect agreement; and 100: perfect agreement.(²¹,²²)

This study was approved by the Universidade Federal do Triângulo Mineiro Research Ethics Committee through the Plataforma Brasil (Opinion: 6.233.029/Certificate of Presentation for Ethical Consideration 69756023.2.0000.5154).

Results

Clinical simulation design was constructed by describing the planning phase followed by the stages of preparation, participation, debriefing, a checklist of psychomotor and attitudinal skills, a decision-making flowchart and a cognitive skills test.

In the planning stage, design components were characterized to clarify the phase of their creation.(¹²) The preparation stage had three subdivisions: pre-simulation, pre-briefing and briefing.(¹³) Pre-simulation contains the theoretical framework for the preliminary study, with an explanation of aspects of simulation and its benefits to participants. Pre-briefing consisted of objectives, assessment mechanisms, details of the fictional contract and the functioning of simulation setting and materials. Briefing was structured with the clinical case and organization of the roles of participants involved.(¹³-¹⁵,²³)

Participation is the stage corresponding to the execution of clinical scenario by participants, and facilitators are responsible for mediation and assessment mechanisms, consisting of items that detail the scenario with essential information for its execution.(¹²,²⁴) A clinical case was constructed based on relevant information found in literature in order to develop clinical skills.(⁵)

The last stage (debriefing) consisted of method, technique, number of debriefers and estimated time. The G.A.S. debriefing technique was used, which is recommended in literature for enabling teaching and learning in emergency care.(²⁵)

Clinical simulation design was submitted to 34 experts for a priori validity. Responses were obtained from seven experts who agreed to participate and completed the forms within the pre-established deadline. In the validity process, experts were characterized according to the criteria indicated by the framework, having obtained ten points (3; 42.9%), nine points (2; 28.5%) and six points (2; 28.5%).

Experts assessed the items in relation to objective, relevance, structure and presentation, assigning scores from 1 (strongly agree) to 5 (strongly disagree) and considering responses 1 or 2 to calculate the CVI. Table 1 presents the assessed items and experts’ responses used to validate the design.

Table 1
Expert assessment of objective, relevance, structure and presentation of clinical simulation design

Assessment criteria	Answers 1 and 2	CVI (%)
Regarding objective
Is the content of each stage of simulation consistent with the proposed objectives?	7	100
Are the learning objectives clear and concise?	7	100
Does the scenario content facilitate clinical reasoning and meet the objectives?	7	100
Is the information presented scientifically correct?	7	100
Is there a logical sequence in the content proposed in the simulation design stages?	7	100
Does the information presented in simulation design cover the content on nursing work in the management of stab wound cases in pre-hospital care?	7	100
Are the information and content important for the quality of care provided and facilitate the development of professional skills?	7	100
Does the objective of clinical simulation invite and/or instigate changes in participants’ behavior and attitude regarding pre-hospital care for people injured by stab wounds?	6	85.7
Regarding relevance
Does the design of this simulation provide knowledge and learning regarding pre-hospital care for victims of stab wounds?	7	100
Does the topic of clinical simulation portray key aspects that should be reinforced?	7	100
Is simulation design appropriate and relevant to learning in different contexts of care for victims of penetrating trauma?	7	100
Does simulation design propose the construction of clinical skills?	7	100
Can this simulation be used to train nurses?	7	100
Can the design of clinical simulation in nursing care for victims of stab wounds in the pre-hospital setting circulate in the scientific community?	7	100
Regarding structure and presentation
Is simulation design clearly structured to be applied?	7	100
Is the writing used easy to understand for facilitators and participants?	7	100
Are the stages presented in a structured manner and lead to the objective of simulation?	7	100
Does the presentation format contribute to the construction of logical reasoning?	7	100
Does the design include at least four pieces of evidence and/or signs and symptoms so that participants can raise a diagnostic hypothesis?	7	100
Does the design include contextual details that provide cues based on the desired results?	7	100
Does the profile of victims of stab wounds provide sufficient data to make a clinical judgment and perform care?	7	100
Are the sections of each stage of simulation organized and do they contemplate clinical simulation structure?	7	100
Psychomotor and attitudinal skills checklist validity
Does the checklist contain the relevant and representative psychomotor and attitudinal skills needed to care for a victim of stab wounds?	7	100
Is the way in which the psychomotor and attitudinal skills are presented clear and precise, following a logical sequence of care?	7	100
Decision-making flowchart validity
Does the decision-making flowchart present relevance and representativeness in what is required in the simulated clinical scenario?	7	100
Is the flowchart clear and precise in providing cues to redirect the development of the scenario if participants need it?	7	100
Cognitive skills test validity
Are the questions presented in the test relevant and representative when associated with the topic and objectives of the proposed clinical simulation?	7	100
Are the questions clear and precise in their wording and answers, leading the participant to make clinical judgments and their cognitive abilities to answer them?	6	85.7
Is the number of questions adequate and does it allow for their application as a pre-test and post-test instrument to assess participants’ cognitive abilities?	7	100

• CVI - Content Validity Index

As shown, the CVI of almost all items reached “perfect agreement” among experts. Only two items related to the objective and the cognitive skills test showed “almost perfect agreement” among experts. However, a margin was considered to propose content validity at a value ≥80% in CVI. Therefore, it was not necessary to use the Delphi technique with the committee of experts because the results obtained were satisfactory. Then, the total CVI of clinical simulation design (99%) was calculated, showing “almost perfect agreement” among experts. Even with almost perfect agreement on the total CVI, experts made some considerations regarding clinical simulation design components (Chart 1).

Chart 1.
Expert considerations on clinical simulation design validity

Simulation components	Expert considerations
Preparation: pre-simulation	Determine which PHTLS edition in the pre-simulation text.
	Add the material to cover the evisceration.
	In the case of the three-point dressing, add the material, such as a clean plastic.
	Will the tourniquet be taught with bandages or with a device designed for this purpose? Since we are in the gym, I suggest teaching with the appropriate device.
	Remove the planking stage, as the 9th and 10th edition PHTLS guidelines do not recommend planking for victims of penetrating injuries.
Preparation: briefing	Since it is a stab wound, I suggest treating the abdominal wound with evisceration. This is a serious injury with considerable incidence.
	Emphasize exsanguinating bleeding as a trigger for using the tourniquet.
	Four evidences (signs and symptoms) also indicate respiratory distress.
	Add in case of signs of respiratory discomfort (three-point dressing).
	Add the presentation of the scenario and the available resources.
Participation	Add the evisceration covering material and three-point dressing.
	Remove the rigid board from the materials.
	Emphasize the bleeding and dyspnea. This is a patient who needs a tourniquet and a three-point bandage. I suggest including shortness of breath; the bleeding does not stop during the character’s speech.
Psychomotor and attitudinal skills checklist	Add a column for partially.
Decision-making flowchart	In the flowchart, I suggest that compression and coverage also be included as a treatment for injuries; they may be necessary.
	Include the SAMPLA mnemonic.
Cognitive skills test	According to the manual for writing multiple choice questions, it is recommended not to put questions with “except”.
	Reformulate the alternatives for question 1 and standardize the number of alternatives across all questions.

• PHTLS - Prehospital Trauma Life Support; SAMPLA - Signs and Symptoms (S), Allergies (A), Medications in continuous use (M); Liquids and last meal (L); Event-related setting (A).

After experts’ assessment, a consensus meeting was held among the researchers and the considerations were discussed. Thus, it was observed that they were generally in line with evidence in literature, enhancing the design structure and giving greater emphasis to the clinical case that supports the participation stage. In turn, this should align with learning objectives, enabling the development of clinical skills. Thus, considerations were accepted to enhance simulation design, and the final version was validated (Appendix 1).

Discussion

The present study is relevant, attributing originality to teaching, research and nursing care, providing a reliable and content-valid design for clinical simulation aimed at nursing care in a pre-hospital setting for an adult victim of stab wounds.

This design was structured and designed to achieve the proposed objectives and obtain the expected results, including a systematic design to develop experiential and meaningful learning and to be successful in the validity process.(¹²)Thus, the validity process made it possible to demonstrate the reliability, clarity and logic in the arguments presented, making this teaching-learning strategy effective.(¹⁷)

Regarding the validity process, the CVI achieved “almost perfect agreement” on the design objective items. Based on the adopted framework, we can infer that the construct presents coherence, clarity, and coherence of objectives, providing logical reasoning based on scientific information, a logical sequence that allows establishing theoretical content with practice and the development of the skills necessary to care for a trauma victim in pre-hospital settings.(¹²,²⁶)

It can be compared with a study that validated a clinical simulation scenario on postpartum hemorrhage management with CVI >95% in validating aspects related to the objective.(²⁷)

In relation to item validity on relevance, structure and presentation, the design achieved “perfect agreement”, indicating that its clear and logical wording facilitates understanding, allowing the construction of reasoning towards the proposed objective. Evidence is shown so that participants can propose a diagnostic hypothesis with sufficient data to make a clinical judgment and provide care based on the decision-making flowchart. We emphasize that easy understanding of stages ensures better performance in the execution of clinical simulation.(¹²)

The total CVI of the design reached “almost perfect agreement”, demonstrating scientific relevance in the elaboration and assessment of the content, enhancing the objectives of this clinical simulation in the PHC for a victim of SW so that the proposed conducts are effective and efficient as a pedagogical strategy.(²¹,²²)

This agrees with other national and international studies that validated simulation designs through CVI analysis by experts in various topics and contexts for teaching and learning in nursing, obtaining results with total CVI >80% in agreement.(²⁶-²⁹)

Regarding the experts’ considerations, the addition of penetrating injury to the abdominal region with the presence of evisceration was included due to its frequency and severity in SW victims, representing approximately 2/3 when added to thoracic injuries.(³⁰,³¹)

After this inclusion, care related to nursing PHC in cases of evisceration was inserted into the decision-making flowchart and the checklist of procedural and attitudinal skills. According to literature, in cases of evisceration by SW in PHC, the exposed viscera should be covered with a compress (preferably sterile) moistened with saline solution (0.9%) to maintain viscera moisture and occlude the injury orifice until reaching the hospital.(⁵,¹⁹,³²)

According to PHTLS guidelines, it is no longer recommended to plank SW victims with a stretcher and/or rigid board and fixation belts if there is no suspicion or evidence of spinal or cervical trauma.(⁵)

Concerning the triggers for recognizing clinical state and making decisions, speeches and symptoms presented by the simulated patient were modified, aiming to instigate the assessment process using clinical reasoning to carry out appropriate interventions given life-threatening conditions.(²,³³)

In the considerations, the procedures of “direct compression and use of primary gauze-based coverage” were included to control small and medium hemorrhages because they are effective and low-cost, can be performed by nurses, and are also recommended in evidence.(⁵,¹⁹)

The mnemonic SAMPLA (S: signs and symptoms; A: allergies; M: medications; P: past or personal history; L: liquids and foods last ingested; A: trauma-related setting) was considered and included in the psychomotor and attitudinal skills checklist due to its consistent recommendation in obtaining relevant information for PHC and facilitating communication or exchange of information between pre-hospital and intra-hospital services.(⁵,³⁴)

In the cognitive skills test, the main corrections were related to the wording of the questions. According to the recommendations for writing written tests for health sciences, it is not recommended to use the word “except” if most of the questions were expressed positively, because the inclusion of a negative item can be lost in the reading, making the question difficult and confusing the reader.(³⁵)

This study contributed to research, assistance and teaching in nursing by presenting the validated design of a clinical simulation in the care of a victim of SW in PHC, listing the initial conducts based on the best evidence to be performed by nurses.

The limitations of this research are related to the low number of experts who agreed to participate in clinical simulation design validity (even though it was within what the literature recommends) as well as the lack of assessment and validity with the target audience.

Conclusion

The design of this clinical simulation was constructed in three stages: preparation, participation and debriefing. It was based on evidence from scientific literature according to Mobile Emergency Care Service Basic and Advanced Life Support Protocol national recommendations and PHTLS international guidelines on prehospital nursing care and conduct in the face of stab wounds. The study achieved a total CVI characterized as “almost perfect agreement” in the face and content validity considering the objectives, relevance, structure and presentation. The design of this clinical simulation can be used by professors, facilitators and researchers as a teaching-learning strategy to develop cognitive, psychomotor and attitudinal skills of students and professionals in the search for clinical competences related to nursing care for victims of stab wounds in prehospital care.

Acknowledgements

In gratitude to the Coordination for the Improvement of Higher Education Personnel – Brazil (In Portuguese, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) for funding the master’s scholarship and supporting research – Financing Code 001.

Appendix 1

Clinical simulation: nurse care in a pre-hospital setting for an adult victim of stab wounds

Planning Description: Initial stage of simulation aimed at describing and organizing the process carried out by facilitators/instructors.
Component	Description
1.1 Learning topic	Pre-hospital nursing care for an adult victim of stab wounds.
1.2 General learning objective	To develop clinical competence in undergraduate nursing students or nurses for pre-hospital care for an adult victim of stab wounds.
1.3 Target audience	Undergraduate nursing students and nurses.
1.4 Theoretical pedagogical frameworks for simulation	INACSL Standards Committee, Watts PI, McDermott DS, Alinier G, Charnetski M, Nawathe PA. Healthcare Simulation Standards of Best PracticeTM Simulation Design. Clin Simul Nurs. 2023;58:14-21. Kolb DZ. Experiential Learning: experience as the source of learning and development. 2nd ed. Pearson Education; c2015. Ausubel DP. The Psychology of Meaningful Verbal Learning. Grune & Stratton; 1963.
1.5 Simulation mode	Clinical simulation.
1.6 Classification of simulation according to its structure	High-fidelity, in-situ clinical simulation, using a simulated patient (actor), aimed at undergraduate nursing students and nurses.
1.7 Facilitators (names) and responsibilities	(1) Main facilitator: (name) Responsible for organizing, coordinating, preparing all stages, conducting and answering questions. (2) Co-facilitator: (name) Responsible for providing assistance and support in skills training and completing the psychomotor and attitudinal skills checklist (Appendix 2). (3) Co-facilitator: (name) Responsible for providing assistance and support in skills training.
1.8 Explanation of how simulation will occur	Clinical simulation will take place in three stages: (1) provision of theoretical material for study; (2) skills training; (3) pre-briefing, briefing, participation and debriefing.
1.9 Skills training	Skills training may take place in a specific space (skills lab) or adapted so that participants can practice the technical skills required to perform the scenario. The skills that will be trained are: providing care following the XABCDE trauma protocol; applying a tourniquet; applying a three-point dressing; installing a supplemental oxygen device; applying compression bandages and dressings to control bleeding and evisceration; applying the Glasgow Coma Scale; taking a history and physical examination.
1.10 Simulation location	Extra-hospital setting that is characterized by a parking lot/garage and is subject to adaptation.
1.11 Alignment meeting among facilitators	A meeting is recommended to align the entire clinical simulation process between the facilitators involved to clarify any doubts.
2. Preparation Description: Stage that provides prior study and preparation on the learning topic and recommendations for participation in clinical simulation.
2.1 Pre-simulation
2.1.1 Preliminary study	It is recommended that theoretical material be made available for prior reading and study that addresses the concept of trauma, safety and kinematics of the scene, pathophysiology of trauma, sequence of pre-hospital care for an adult victim of stab wounds, practical instructions describing the procedures that can be performed during care for a victim of stab wounds, and brief information about clinical simulation. These materials will be made available 15 days before the participation stage. And reading of Pre-hospital Trauma Life Support (PHTLS) 10th Edition (or the most current edition) - Chapters 3-7, 10 and 12.
2.1.2 Explanation of participant benefits	This explanation will occur through prior contact with the participants, through the previously made available study material on how clinical simulation will be able to promote the development of professional skills. Depending on the purpose of using this simulation, the facilitator may provide a declaration of participation to those involved in the form of complementary training or as extension hours.
2.1.3 Application of cognitive pre-test	It is recommended to apply the validated pre-test, which should be applied in the participation phase, in the pre-briefing, in order to measure the level of cognitive knowledge prior to clinical simulation participation stage (Appendix 3).
2.1.4 Skills training	It is recommended that a training station be set up where participants will perform the initial assessment of trauma victim care, take measures to contain exsanguinating hemorrhage, provide supportive oxygen therapy, apply dressings to stabilize victims, and prepare victims for transport. It is suggested that this be done at least once by the facilitators and then by the participants. Required material: Training station: Room with adequate space for facilitators and participants to perform the techniques, low-fidelity mannequin (full body) to simulate victims, procedure gloves, tourniquet device, crepe bandages of varying sizes, sterile cotton compresses, 0.9% saline solution, clean plastic sheet for 3-point dressing, adhesive tape, gauze pack, pulse oximeter, stethoscope, non-rebreathing face mask with reservoir, plastic intermediary or extension for oxygen, humidifier bottle, oxygen torpedo/cylinder and stretcher for transport.
2.2 Pre-briefing
General presentation to participants
2.2.1 Learning topic	Nursing care in the pre-hospital setting for an adult victim of stab wounds.
2.2.2 General and specific objectives	General objective: Develop clinical competence in undergraduate nursing students or nurses for pre-hospital care for an adult victim of stab wounds. Specific objectives: 1 – Cognitive ability: Understand the sequence of care recommended by the PHTLS for a victim of stab wounds. 2 – Psychomotor ability: Perform the stage-by-stage pre-hospital care for a victim of stab wounds. 3 – Affective ability: Develop self-confidence and satisfaction regarding pre-hospital care for a victim of stab wounds.
2.2.3 Assessment mechanisms	To assess cognitive skills, use the validated pre-test and post-test questionnaire (Appendix 3), to be applied in the pre-briefing stage and after the debriefing. To assess psychomotor and procedural skills, use the checklist that includes psychomotor and attitudinal skills, to be completed by the facilitators in the participation stage. And to assess affective skills, we suggest using the “Learning Satisfaction and Self-Confidence Scale” (ALMEIDA et al., 2015) to be completed by the participants after applying the post-test.
Fiction contract
2.2.4 Explanation of simulation setting	Simulation setting can be carried out in a parking lot or in a room that simulates the space. At this time, silence is requested from participants who will not be performing the scene, seriousness with the moment of execution of the simulated scenario and that at the time of debriefing, the floor is requested to speak in the discussion.
2.2.5 Explanation about materials	The materials to be used at the time of the scene consist of backpack with procedure gloves, tourniquet device, crepe bandages of varying sizes, sterile cotton compresses, 0.9% saline solution, clean plastic sheet for 3-point dressing, adhesive tape, gauze pack, pulse oximeter, stethoscope, non-rebreathing face mask with reservoir, intermediary or plastic extension for oxygen, humidifier bottle, and there will be an oxygen torpedo/cylinder and stretcher for transport available at the scene.
2.2.6 Explanation of the instrument used in simulation	In the skills training, a low-fidelity mannequin will be used so that participants can perform the techniques provided. In clinical scenario, a simulated patient will be used, previously trained by the responsible facilitator to perform simulation of a victim of stab wounds with injuries to the face, upper limbs and chest. The simulated patient will be conscious, oriented, will talk to the participants who will be performing the scenario and will provide an account of what happened.
2.2.7 Explanation of scenario time	The scenario can be executed in an estimated time of 15 minutes.
2.2.8 Determining start and end triggers	The scene will begin after reading the clinical case, the facilitator will direct the participants by saying “You can start the scene, identifying yourselves and asking how victims is and what happened” and the scene will end after victims is ready for transport with the facilitator saying: “Scenario closed”.
2.2.9 Explanation of cues for the scenario	The main facilitator may provide cues through the decision-making flowchart (Appendix 4) by verbal command in which he will say them if the participants are unable or do not perform as expected, in an attempt to redirect the development of the scenario.
2.3 Briefing
2.3.1 Clinical case	Henrique, 26, was involved in a fight over gambling debts when he arrived at a parking lot about 20 minutes ago. A parking attendant called the rescue team and reported what had happened. Soon after, she called the police to report that the attacker had left the location, fled on a motorcycle and was carrying a knife. Henrique is oriented, anxious, agitated, complaining of respiratory distress, pain, and has exsanguinating bleeding and several puncture wounds throughout his body. The police are already on site, which indicates that the scene is safe, and Henrique is sitting and leaning against the wall waiting. The rescue team nurses arrive to begin care. They can initiate the scene, identifying themselves and asking how victims is and what happened.
2.3.2 Organization of roles for the participation stage	Roles of facilitators: Main facilitator: Reading clinical case, the triggers for starting and ending the scene and the tips contained in the decision-making flowchart. Co-facilitator 1: Verification of the psychomotor and attitudinal skills checklist (Appendix 2). Simulated patient: Responsible for acting as victims in the scenario, must appear oriented, anxious, agitated, complaining of respiratory discomfort and pain and will present exsanguinating bleeding and several puncture wounds on the body that will be produced by moulage, artistic makeup and fake blood. Participant 1: Lead nurse: responsible for initiating the scene, approaching victims and verifying what are the primary procedures for care and decision-making in light of what is expected for the clinical case. Participant 2: Nurse who will assist in the execution of techniques and care, and may take action if the lead nurse does not pay attention to key points in the execution of the scenario.
2.3.3 Clarification of doubts	The main facilitator will be responsible for answering questions and, if necessary, explaining the expected role of participants in executing the scenario and the materials to be used.
3. Participation Description: It corresponds to the execution of clinical scenario simulated by participants.
3.1 Scenario title	Nurse care in the pre-hospital setting for an adult victim of stab wounds
3.2 Local	See item 1.10
3.3 Materials	Consumables: Procedure gloves, tourniquet device, crepe bandages of varying sizes, sterile cotton compresses, 0.9% saline solution, clean plastic sheet for 3-point dressing, adhesive tape, gauze pack, glasses-type nasal catheter, face mask, face mask with reservoir, oropharyngeal cannula, laryngeal mask and intermediary or plastic extension for oxygen. Permanent materials: Backpack, pulse oximeter, stethoscope, humidifier bottle, oxygen cylinder/torpedo and stretcher for transport. Materials for facilitators: Clipboard, pen and printed material necessary for assessments. Materials for the simulated patient: Daily clothing for an adult, artistic makeup, moulage to simulate injuries and fake blood.
3.4 Learning objectives	See item 2.2.2
3.5 Scenario fidelity	High fidelity.
3.6 Instruments and injury pattern	Simulated patient: Actor or person trained by the facilitators to simulate the clinical case and interact with the participants at the time of simulation, it is necessary to simulate the injuries (injuries caused by the sharp weapon) with moulage and artistic makeup. Injury pattern: Simulate a chest wound on the right anterolateral wall, a 4 cm long piercing wound with regular edges and a small to medium amount of artificial blood. A 3 cm long piercing wound on the anterior region of the right arm, regular edges in a concave shape and with a large amount of artificial blood to simulate arterial hemorrhage. A 4 cm long piercing and communicating wound with an entry point and regular edges on the palm and a 3 cm long exit point and regular edges on the back of the left hand and a medium amount of artificial blood. A 6 cm long superficial cutting wound with regular edges on the left region and a small amount of artificial blood. A 7 cm long wound on the right flank region, regular edges with the presence of evisceration (moulage can be used to create the wound and a bladder or plastic bag to simulate an intestinal loop) with the presence of a medium amount of artificial blood.
3.7 Number of participants	The authors suggest that it be applied in groups of up to 10 participants, of which 02 will perform the scenario, and they can perform the scenario up to 02 times (depending on facilitators’ time for the execution of clinical simulation) reversing the roles of participants. The other 08 participants will remain silent observing the scene, after completion of the scenario with the first participants it can be repeated once more, respecting the reversal of roles.
3.9 Skills to be developed	Cognitive, psychomotor and affective skills in understanding the systematization and execution of care for a victim of stab wounds and gaining satisfaction and self-confidence to act in these cases.
3.10 Time	The scenario is expected to last 15 minutes.
3.11 Description of clinical case with statements	See item 2.3.1 and analyze the possible speeches of participants described below: Participant 1 – Good afternoon, my name is (participant’s name), I’m a nurse and I’m here to help you. What’s your name and tell me what happened? Simulated patient – My name is Henrique, I was arriving here in the parking lot and I saw a guy I met at a gambling house, he came to collect a debt from me and I told him I didn’t have the money to pay him at the moment and he already took out the knife and came at me. Participant 1 – Okay, Henrique, how old are you and do you have any health problems? Simulated patient – I’m 26 years old, I don’t have any problems, I’m worried because this bleeding won’t stop. Participant 1 – We are going to do some procedures on you to stop the bleeding, on a scale of 0 to 10, how much does it hurt? Simulated patient – 08 is in a lot of pain now that the blood has cooled and the shortness of breath is only increasing. Participant 1 or 2 – We’ll get something ready to help you, I need you to take a deep breath and try to stay calm. Simulated patient – Oh, but don’t take long, please, I’m really scared of dying here.
3.12 Start and end triggers	See item 2.2.9.
3.13 Monitoring activity in the simulated scenario	The responsible facilitator will be in charge of the decision-making flowchart (Appendix 4) and the co-facilitator will complete the psychomotor and attitudinal skills checklist (Appendix 2).
4. Debriefing Description: analytical moment of reflection/discussion of the simulated scenario, carried out and observed by participants, led by a facilitator
Method	G.A.S debriefing (see item 2.2.4), guided by questions related to the method: 1) G (gather) – “How are you feeling after the experience? 2) A (analyze) – “What are the positive points of this service?”; “What points can be improved?” 3) S (summarize) – “What caught your attention the most?”; “What do you take with you to your professional life?”
4.2 Technique	The oral debriefing technique will be used by only one facilitator.
4.3 Number of debriefers	Only 01 facilitator or 01 co-facilitator in charge.
4.5 Time	Estimated time 30 minutes or until the expected objectives are achieved.
References
Almeida RG, Mazzo A, Martins JCA, Baptista RC, Girão FB, Mendes IA. Validation to Portuguese of the Scale of Student Satisfaction and Self-Confidence in Learning. Rev Lat Am Enfermagem. 2015;23(6):1007–13. Ausubel DP. The Psychology of Meaningful Verbal Learning. Grune & Stratton; 1963. INACSL Standards Committee, Watts PI, McDermott DS, Alinier G, Charnetski M, Nawathe PA. Healthcare Simulation Standards of Best PracticeTM Simulation Design. Clin Simul Nurs. 2023;58:14-21. Kolb DZ Experiential Learning: experience as the source of learning and development. 2nd ed. Pearson Education; c2015. National Association of Emergency Medical Technicians. PHTLS: Prehospital Trauma Life Support. 10th ed. Burlington: Jones & Bartlett Learning; 2023.

Appendix 2

Psychomotor and attitudinal skills checklist

Facilitator name: _______________________________________________________________.

Name of participants: ____________________________; _______________________________.

Description of skills and attitudes Yes Partial No 1. Correctly uses the PPE required for care: procedure gloves and mask; 2. Approaches victims, stating their name, function or job title; 3. Asks victims’ name and what happened; 4. Informs that they will begin care; 5. Initiates care in accordance with the PHTLS protocol; 6. X – Recognizes bleeding from large vessels in the upper limb; 7. Informs that they will apply a tourniquet as a measure to stop the bleeding; 8. Apply a tourniquet as a measure to control bleeding; 9. A – Visualizes airway patency and investigates the need for the use of a cervical collar; 10. Asks victims if at any time he or she fell or received strong blows to the spine to rule out the use of a cervical collar; 11. B – Begins ventilation and oxygenation assessment, noting that victims’ breathing pattern is altered; 12. Identifies penetrating and aspirating chest injury; 13. Informs that they will apply a dressing to victims’ chest; 14. Apply a three-point dressing to ensure immediate intervention; 15. Installs a pulse oximeter on victims; 16. Starts oxygen therapy with a non-rebreathing face mask at 15 l/min; 17. C – Starts assessing circulation and controlling other bleeding; 18. Performs care on an abdominal wound with evisceration with a sterile compress moistened with saline solution over the viscera; 19. Reports that they will perform the dressing/bandaging of other injuries; 20. Performs compressive dressing with compresses or gauze and crepe bandage or manual compression on other piercing injuries; 21. Assesses peripheral perfusion of the limb with tourniquet and of the limb free of injuries; 22. D – Begins neurological assessment by applying the Glasgow Coma Scale 23. E – Begins assessment by exposure; 24. Reports the need to expose victims to look for other injuries (expose at least the chest due to the possibility of other injuries); 25. Exposes victims in search of other injuries or evidence; 26. Assesses the level of pain through verbal questions; 27. Uses the mnemonic SAMPLA for additional assessment; 28. Communicates with a teammate the stability of victims to proceed with transport; 29. Asks and supports victims to settle on the transport stretcher; 30. Signals to the team that patients are ready for transport.

Description of skills and attitudes	Yes	Partial	No
1. Correctly uses the PPE required for care: procedure gloves and mask;
2. Approaches victims, stating their name, function or job title;
3. Asks victims’ name and what happened;
4. Informs that they will begin care;
5. Initiates care in accordance with the PHTLS protocol;
6. X – Recognizes bleeding from large vessels in the upper limb;
7. Informs that they will apply a tourniquet as a measure to stop the bleeding;
8. Apply a tourniquet as a measure to control bleeding;
9. A – Visualizes airway patency and investigates the need for the use of a cervical collar;
10. Asks victims if at any time he or she fell or received strong blows to the spine to rule out the use of a cervical collar;
11. B – Begins ventilation and oxygenation assessment, noting that victims’ breathing pattern is altered;
12. Identifies penetrating and aspirating chest injury;
13. Informs that they will apply a dressing to victims’ chest;
14. Apply a three-point dressing to ensure immediate intervention;
15. Installs a pulse oximeter on victims;
16. Starts oxygen therapy with a non-rebreathing face mask at 15 l/min;
17. C – Starts assessing circulation and controlling other bleeding;
18. Performs care on an abdominal wound with evisceration with a sterile compress moistened with saline solution over the viscera;
19. Reports that they will perform the dressing/bandaging of other injuries;
20. Performs compressive dressing with compresses or gauze and crepe bandage or manual compression on other piercing injuries;
21. Assesses peripheral perfusion of the limb with tourniquet and of the limb free of injuries;
22. D – Begins neurological assessment by applying the Glasgow Coma Scale
23. E – Begins assessment by exposure;
24. Reports the need to expose victims to look for other injuries (expose at least the chest due to the possibility of other injuries);
25. Exposes victims in search of other injuries or evidence;
26. Assesses the level of pain through verbal questions;
27. Uses the mnemonic SAMPLA for additional assessment;
28. Communicates with a teammate the stability of victims to proceed with transport;
29. Asks and supports victims to settle on the transport stretcher;
30. Signals to the team that patients are ready for transport.

Appendix 3

Cognitive skills test on care for victims of trauma and stab wounds

( ) Pre-test ( ) Post-test

Name: _________________________________________________________________________.

Question 1 - This is a phase that assesses whether the scene is safe for the team and patients as well as carefully considering the exact nature of the situation and what happened. Select the alternative below that corresponds to what was described.

1. XABCDE assessment sequence.

2. Victim assessment.

3. Scene assessment.

4. Assessment of the safety of those involved.

5. Assessment of additional risks to victims.

Question 2 - The primary assessment of a trauma victim should be performed in a dynamic and integrated manner according to the initial care protocol for polytrauma victims, according to Prehospital Trauma Life Support (PHTLS). The first and final stage of trauma care protocol consists of:

1. Airway opening and neurological dysfunction assessment.

2. Exsanguinating hemorrhage control and neurological dysfunction assessment.

3. Airway opening and exposure of victims with environmental control.

4. Exsanguinating hemorrhage control and airway opening.

5. Exsanguinating hemorrhage control and exposure of victims with environmental control.

Question 3 - Injury resulting from the entry of air into the space between the visceral and parietal pleura caused by a penetrating and aspirating chest wound that culminates in lung collapse. Which of the following conditions is characterized by the one described above?

1. Closed hemothorax.

2. Open pneumothorax.

3. Pleural effusion.

4. Hypertensive chest.

5. Flail chest.

Question 4 - One of the main causes of death in trauma is exsanguinating hemorrhage, which is usually associated with limb amputation or rupture of large vessels. This requires effective and immediate intervention. In this case, choose the alternative below that should be used in the pre-hospital setting to control exsanguinating hemorrhage in the upper or lower limbs:

1. Local compression with compressive bandaging.

2. Direct pressure on injury size.

3. Vessel cauterization.

4. Tourniquet.

5. Tranexamic acid administration.

Question 5 - According to the PHTLS care protocol, the mnemonic XABCDE is a standard to guide care for a trauma victim. Select the alternative that best describes what is assessed in letter A:

1. Airway opening.

2. Cervical spine ventilation, oxygenation and stabilization.

3. Airway opening and cervical spine stabilization.

4. Ventilation and oxygenation.

5. Airway opening, ventilation and oxygenation.

Question 6 – In pre-hospital care, within the protocol for treating trauma victims, nurses must assess patients’ ventilation, breathing and oxygenation in an orderly and precise manner to identify possible signs of respiratory pattern deterioration. Which of the alternatives below is this conduct based on?

1. Count the heart rate and classify it as asystole, bradycardia, normosphygmia or tachycardia.

2. If chest trauma such as hemothorax or pleural effusion is detected, perform relief thoracentesis with Abocath 14 in the anterior axillary line in the 6^th intercostal arch.

3. Assess the quality and quantity of breathing, signs of hypoxia, cyanosis and observe the presence of signs of respiratory effort.

4. Check whether patients are well oxygenated by measuring the capillary perfusion time.

5. If victims are conscious with preserved reflexes, but with difficulty breathing, insert an oropharyngeal cannula and supplemental oxygen device.

Question 7 – A rescue team is called to assist a victim of stab wounds at home, caused by domestic violence with attempted murder, and victims is in serious condition, according to information gathered. The team arrives at the scene and does not see the civil police team there, in this case they should:

1. Proceed with the assistance, given the serious condition of victims, and wait for the police to arrive at the scene.

2. Call and wait for the police to arrive at the scene and allow the rescue team to provide assistance, even knowing the possible seriousness of victims.

3. Call and wait for the police, and when they arrive, go together to the scene of the incident.

4. Proceed with the assistance independently if the police are on the way.

5. Proceed with the assistance and call the police, if necessary.

Question 8 – Select the correct alternative with the recommended conduct in cases of penetrating injuries, in which the object causing the injury remained inserted in victims, the pre-hospital care team must:

1. Keep the penetrating object in victims and immobilize victims to prevent further injuries during transportation.

2. Remove the penetrating object when it is identified and apply pressure to injury site with a sterile cotton swab.

3. Remove the object immediately and proceed with manual techniques to stop any bleeding.

4. Keep the penetrating object in victims and leave the wound exposed to assess blood loss.

5. Remove the penetrating object and suture to stop the bleeding.

Question 9 – Nurses need to know how to identify life-threatening injuries in order to prioritize care and expedite the care that will be provided. Regarding care for open pneumothorax, select the correct alternative.

1. Chest drainage is the first intervention performed by nurses in the care of open pneumothorax.

2. The three-point dressing on the chest injury is an intervention exclusively performed by a physician and only they can perform it since it is an invasive procedure.

3. Open pneumothorax causes decreasing respiratory discomfort and saturation rates always above 98% because it does not alter the ventilatory pattern.

4. The three-point dressing on the open chest injury is an emergency intervention indicated in primary care of polytrauma patients.

5. The use of a laryngeal mask is indicated in this case to optimize the respiratory pattern, regardless of patients’ clinical presentation.

Question 10 – Indicate the alternative procedures that are part of the pre-hospital care provided by the nursing team to a trauma victim who presents any type of hemorrhage;

1. Perform control by means of measures to stop/interrupt blood flow and preferably puncture two peripheral and large-caliber venous accesses.

2. In deep wounds, clean with an appropriate solution and suture the muscles and skin to stop bleeding.

3. Perform volume replacement through intravenous fluids without a medical prescription, given the hypotension due to blood loss.

4. Collect blood for blood typing.

5. Administer anti-hemorrhagic medications without medical support.

Appendix 4

Decision-making flowchart

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Edited by

• Associate Editor:
  Juliana de Lima Lopes (https://orcid.org/0000-0001-6915-6781) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  07 Nov 2025
• Date of issue
  2025

History

• Received
  12 Mar 2024
• Accepted
  22 Apr 2025