# Single-Point Sim Bank — v1 **Audience:** Proctor **Count:** 20 sims **Run time per sim:** 3-5 minutes **Status:** Review draft; pending Nexus / CPI / risk / legal validation --- ## How to Use This Bank - Pick one sim per shift, or one per week if shift cadence is not feasible. - Rotate through the bank. Do not repeat the same sim in the same week. - The sims are grouped by judgment point. Pick by what the unit is seeing, not in order. - Each sim is a single judgment point. Do not stack. ## Group A — De-escalation Judgment (SIM-001 to SIM-005) ### SIM-001 — The Door - **JUDGMENT POINT:** Approaching a patient who is standing at the closed door. - **SCENE:** A newly admitted teen is standing at the closed door of the room, speaking quietly to no one. Two staff are at the nurses' station. - **MISSED STEP:** Walking past the patient to check the chart first. - **JUDGMENT Q:** What's the first move? - **RIGHT RESPONSE:** One staff member approaches, names themselves, asks an open question, and stays at a safe distance. - **THRESHOLD:** We do not touch the door or the patient without a verbal exchange first. ### SIM-002 — The Sensory Flood - **JUDGMENT POINT:** A patient in a noisy common area is covering their ears. - **SCENE:** Mid-afternoon, the common area is loud. A patient is seated on the floor covering their ears. - **MISSED STEP:** Telling the patient to "calm down" or to "go to your room." - **JUDGMENT Q:** What does this patient need in the next 30 seconds? - **RIGHT RESPONSE:** Lower the noise source first (TV, peer group), then offer a quieter space, then offer a grounding option. - **THRESHOLD:** We do not move the patient before we lower the stimulus. ### SIM-003 — The Quiet Refusal - **JUDGMENT POINT:** A patient declines an offered activity with a flat "no." - **SCENE:** A patient has been on the unit for three days. A tech offers a group activity. The patient says "no" and turns away. - **MISSED STEP:** Insisting once, then walking away. - **JUDGMENT Q:** What's the next move? - **RIGHT RESPONSE:** Acknowledge the "no," name what was offered, and offer a lower-demand alternative. Document the refusal in the treatment plan note. - **THRESHOLD:** We do not treat a quiet "no" as a behavior problem. ### SIM-004 — The Family Call - **JUDGMENT POINT:** A family member calls upset about a unit rule. - **SCENE:** A parent calls the unit, voice raised, asking why their child was not allowed to keep a phone. - **MISSED STEP:** Debating the rule on the phone. - **JUDGMENT Q:** What's the first response? - **RIGHT RESPONSE:** Acknowledge the parent's concern, name the unit's role (safety, not punishment), and offer a callback from the treatment team within the shift. - **THRESHOLD:** We do not negotiate unit rules on the phone with an upset caller. ### SIM-005 — The Mismatch - **JUDGMENT POINT:** A patient and a staff member are clearly not connecting. - **SCENE:** A staff member has been the primary contact for a patient for two days. The patient turns away each time. - **MISSED STEP:** Pushing through the same approach. - **JUDGMENT Q:** What does the team do? - **RIGHT RESPONSE:** Change the primary contact. Brief the new staff member on what has been tried. Document the change in the treatment plan. - **THRESHOLD:** We do not leave a mismatch in place for more than one shift without a team review. ## Group B — Team and Coverage Judgment (SIM-006 to SIM-010) ### SIM-006 — The Split - **JUDGMENT POINT:** Two staff are giving a patient two different messages in the same hour. - **SCENE:** A tech tells a patient they can go to the sensory room. A nurse, ten minutes later, tells the patient the sensory room is closed. - **MISSED STEP:** Letting the contradiction stand. - **JUDGMENT Q:** What does the team do in the next five minutes? - **RIGHT RESPONSE:** The senior staff member names the contradiction to the patient, apologizes for the mixed message, and the team aligns off-unit. - **THRESHOLD:** We do not let a patient carry a mixed message into the next hour. ### SIM-007 — The Understaffed Hour - **JUDGMENT POINT:** Coverage is short for the next hour. - **SCENE:** A staff member called out. The unit is one RN short for the next hour. Two admissions are pending. - **MISSED STEP:** Quietly absorbing the gap without naming it. - **JUDGMENT Q:** What does the charge nurse do? - **RIGHT RESPONSE:** Names the gap at the huddle, delays the lower-risk admission if possible, and escalates to the DON if the gap extends past the hour. - **THRESHOLD:** We do not run a shift below the staffing plan without a named decision and a named escalation. ### SIM-008 — The Agency Hand - **JUDGMENT POINT:** An agency staff member is on the unit for the first time. - **SCENE:** An agency RN is on the unit for the first shift. The regular team is busy with a discharge. - **MISSED STEP:** Treating the agency RN as if they have full unit context. - **JUDGMENT Q:** What does the charge nurse set up in the first 30 minutes? - **RIGHT RESPONSE:** A named buddy, a printed unit map, and a clear list of the three things the agency RN should not do alone today. - **THRESHOLD:** We do not leave a first-shift agency RN without a named buddy. ### SIM-009 — The 2 a.m. Quiet - **JUDGMENT POINT:** A patient is awake at 2 a.m., sitting upright in bed, not disturbing anyone. - **SCENE:** Night shift. A patient is sitting up, eyes open, not calling out. Vitals are due. - **MISSED STEP:** Waking the patient to take vitals on schedule. - **JUDGMENT Q:** What does the nurse do? - **RIGHT RESPONSE:** Approach, name themselves, ask the patient how they are, and decide with the patient whether to take vitals now or in 15 minutes. - **THRESHOLD:** We do not perform a routine task on a sleeping or resting patient without an exchange first. ### SIM-010 — The Handover Gap - **JUDGMENT POINT:** A patient returned from an off-unit appointment with a different presentation. - **SCENE:** A patient returns from an off-unit appointment. The handoff note is brief. The patient is more withdrawn than before. - **MISSED STEP:** Trusting the handoff note without a direct check. - **JUDGMENT Q:** What does the receiving nurse do? - **RIGHT RESPONSE:** A direct visual check, a brief exchange with the patient, and a callback to the sending unit if anything does not match. - **THRESHOLD:** We do not accept a handoff we cannot see for ourselves. ## Group C — Threshold and Restraint Judgment (SIM-011 to SIM-015) ### SIM-011 — The Escalation - **JUDGMENT POINT:** A patient is raising their voice and stepping toward staff. - **SCENE:** A patient is standing, voice raised, taking a step toward the nearest staff member. No contact yet. - **MISSED STEP:** Matching the voice or stepping back without a plan. - **JUDGMENT Q:** What does the staff member do in the next 30 seconds? - **RIGHT RESPONSE:** Lower their own volume, widen the stance without stepping back, name the behavior, and create a one-staff-to-one-patient line. - **THRESHOLD:** We do not match volume or close distance on an escalating patient. ### SIM-012 — The Object - **JUDGMENT POINT:** A patient is holding a hard object in a way that suggests possible self-injury. - **SCENE:** A patient is seated, holding a plastic cup, pressing it against their forearm. - **MISSED STEP:** Reaching for the cup. - **JUDGMENT Q:** What does the team do first? - **RIGHT RESPONSE:** One staff member speaks, the rest of the unit is cleared of other patients, and the team moves at the pace of the patient, not the pace of the alarm. - **THRESHOLD:** We do not reach for an object in a patient's hand. ### SIM-013 — The After-Hold - **JUDGMENT POINT:** A patient has just been released from a hold and is silent. - **SCENE:** A patient has just been released from a brief hold. They are seated, silent, looking at the floor. - **MISSED STEP:** Walking away once the patient is "settled." - **JUDGMENT Q:** What does the staff member do in the next two minutes? - **RIGHT RESPONSE:** Sit at a safe distance, offer water, and ask one open question. The debrief and the treatment-plan note are scheduled before the shift ends. - **THRESHOLD:** We do not leave a post-hold patient alone for the first ten minutes. ### SIM-014 — The Door Hold - **JUDGMENT POINT:** A patient is blocking the door to their room. - **SCENE:** A patient is standing in the doorway of their room, blocking entry. They are not speaking. - **MISSED STEP:** Asking the patient to move without an offer. - **JUDGMENT Q:** What does the team do? - **RIGHT RESPONSE:** One staff member speaks, the team reduces stimulation in the hallway, and the team offers a reason and a place to go that is not the room. - **THRESHOLD:** We do not ask a patient to move from a doorway without offering somewhere to go. ### SIM-015 — The Peer Audience - **JUDGMENT POINT:** A patient is escalating in front of peers. - **SCENE:** A patient is raising their voice in the common area. Three other patients are watching. - **MISSED STEP:** Resolving the situation in front of the audience. - **JUDGMENT Q:** What does the team do? - **RIGHT RESPONSE:** One staff member engages the patient, the other staff member quietly moves the audience, and the conversation moves to a private space. - **THRESHOLD:** We do not resolve a peer-witnessed escalation in front of the peers. ## Group D — Treatment Plan and Continuity (SIM-016 to SIM-020) ### SIM-016 — The Plan Out of Date - **JUDGMENT POINT:** A treatment plan is more than two weeks old and the patient has changed. - **SCENE:** A patient has been on the unit for 18 days. The current plan was written on day three. The patient's triggers have shifted. - **MISSED STEP:** Treating the old plan as still current. - **JUDGMENT Q:** What does the team do? - **RIGHT RESPONSE:** Flag the plan at the next team meeting, document the change in presentation, and schedule a plan update within the unit's defined window. - **THRESHOLD:** We do not run a shift on a treatment plan we know is out of date. ### SIM-017 — The Discharge Worry - **JUDGMENT POINT:** A family expresses worry about discharge that the team has not addressed. - **SCENE:** A discharge is planned for tomorrow. The family tells the tech they are "not ready." - **MISSED STEP:** Treating the family's concern as a social work issue only. - **JUDGMENT Q:** What does the team do? - **RIGHT RESPONSE:** The treatment team hears the concern before the discharge meeting, the discharge plan is reviewed, and the family is offered a concrete next step. - **THRESHOLD:** We do not discharge into a family that has named an unaddressed worry. ### SIM-018 — The Cultural Moment - **JUDGMENT POINT:** A staff member uses a phrase or approach that does not fit the patient's background. - **SCENE:** A staff member uses a casual phrase that lands wrong with a patient from a different background. - **MISSED STEP:** Letting the moment pass without repair. - **JUDGMENT Q:** What does the staff member do? - **RIGHT RESPONSE:** Name the moment, apologize without over-explaining, and ask the patient what would work better. The team debriefs the learning off-unit. - **THRESHOLD:** We do not let a cultural miss pass without a repair. ### SIM-019 — The Shutdown - **JUDGMENT POINT:** A patient is not responding to any verbal approach. - **SCENE:** A patient has been nonverbal for 20 minutes, seated, eyes down. - **MISSED STEP:** Increasing the verbal approach to draw a response. - **JUDGMENT Q:** What does the team do? - **RIGHT RESPONSE:** Reduce verbal input, ensure safety from a distance, and assign one staff member to stay present without speaking. The team checks vitals and recent medication if relevant, per unit policy. - **THRESHOLD:** We do not raise volume to reach a shutdown patient. ### SIM-020 — The After-Hours Call - **JUDGMENT POINT:** A former patient calls the unit after discharge, distressed. - **SCENE:** Evening. A former patient calls the unit, voice shaky, asking to speak to "anyone." - **MISSED STEP:** Taking the call onto the unit without a plan. - **JUDGMENT Q:** What does the staff member do? - **RIGHT RESPONSE:** A brief, warm exchange, a transfer to the on-call clinician or crisis line per unit policy, and a documented log entry. The treatment team is informed the next morning. - **THRESHOLD:** We do not manage a post-discharge crisis call without the on-call pathway.