The CSBL simulation team has conducted several in situ simulation projects successfully with the surrounding hospitals over the past years and is happy to help hospital partners develop new patient safety related projects. Please contact our in situ simulation director, Julie Pace, to learn more.
Advantages:
- Uses authentic staff, learners and environment thus enhancing fidelity
- Uses simulation to identify workplace-based patient safety/system issues
- Highlights latent patient safety threats in clinical settings that may not otherwise be known
- Allows interprofessional teams to work through team dynamics or issues in response to an incident
- Ease in recruiting interprofessional teams who share a working environment
- Can be utilized for space design (i.e. undetected technological failures, poor room ergonomics, compromised access to medications or equipment, communication structure breakdown)
Challenges:
- Securing clinical space for educational activities
- Securing health care professional time away from clinical duties
- Managing distractions present in the workplace
- Keeping simulation and patient care equipment and setup separate
- Securing a separate environment to allow participants to emotionally disconnect from the simulation for debriefing
- Reduced access to support technologies and personnel including housing, maintaining and troubleshooting simulation and debriefing equipment
Other important considerations when planning an in situ simulation:
Carefully consider the need to be addressed. If the need involves addressing team or patient safety/system issues, which are best uncovered and addressed in the workplace, then in situ simulation may be the right instructional environment.
Any in situ simulation session design must follow the basic simulation session design principle to ensure its educational value. This includes:
- Needs assessment
- Identifying target audience
- Defining learning objectives
- Choosing appropriate simulation modality for the objectives
- Scenario design to achieve objectives
- Debriefing plan
- Type of assessment
- Final evaluation process
A template to aid the development process is available at the CSBL.
The need for in situ simulation often arises from the local healthcare staff, who perceive performance gaps in their teams. The objectives and session content must be applicable for that specific healthcare environment/team in order for them to benefit from the training. The overall objectives and the flow of the session must be communicated to the target audience before the session.
Because in situ simulation frequently involves team or system learning objectives, the planning committee should represent and understand the team requirement and system factors that resulted in the learning needs. A committee planning approach is strongly suggested, which includes all healthcare professional disciplines involved in the simulation.
Successful in situ programs require access to clinical space and often require staff members to have protected time away from their clinical duties. It is highly recommended that the clinical manager (or other applicable personnel) for the proposed location be involved in the planning. This team member’s buy-in and participation will be invaluable in ensuring that adequate resources are available to meet the learning objectives. The clinical manager also forms a crucial link to the clinical department to help engage the broader department, ensure support and affect change based on any systems issues uncovered through simulation.
It is important to plan feedback loops alongside the development of educational objectives. If the educational objective is to uncover systems issues, then a plan must be in place to deal with these identified issues. The planning committee should engage the clinical department where the simulation takes place, and plan in advance how system issues should be communicated and who will be responsible for leading any resulting system change. For instance, the planning committee may decide to generate a written report emailed to stakeholders to inform them of system issues identified and the clinical manager may be entrusted with enacting change.
Enlist the clinical manager, unit educator and medical/allied health leads to identify time periods during the day where space and personnel resources are not stretched. This minimizes the chance of distractions and maximizes the chance of using a preferred location and recruitment of health care professionals, if on-shift personnel are to be invited.
Where in situ simulation sessions are conducted on a recurring and predictable basis, clinicians and staff working in that particular clinical setting quickly become accustomed to the goals and objectives of the simulation activities. They also become familiar with the process of in situ simulation and their roles in the process. Together, this results in increased engagement and support from those in the host environment. As in situ simulation requires reciprocity between the educational and clinical agendas, building relationships between educators interested in the educational components, and managers interested in the team or system components, will optimize the chance of a successful program.
Ensuring psychological safety is critical as simulation may cause fear or anxiety when performing in front of their peers or supervisors. Added stress can potentially alter cognitive and behavioral flexibility thereby reducing a positive learning experience. During in situ simulation, a blame-free, risk free culture is maintained which allows learners to feel safe.
Privacy and confidentiality is maintained by letting learners know what is or is not being evaluated. This transparency helps build trust with between learners and simulation teams. Learners will get a sense of what to expect in the in situ simulation so the use of a fiction contract helps establish fidelity.
Work related distractions can be managed by relieving participants temporarily from their clinical duties in order to remove unwanted distractions such as pagers or being pulled into clinical duties mid scenario. When it is difficult to do so, the educator should decide prior to the beginning of the session how to handle the situation of participants needing to exit the simulation. This may include pausing the session, allowing the participant to leave to attend clinical duties and reassigning their roles to other participants.
It is also important to protect patients who are unintentionally observing the simulation from undue distress. During in situ simulation activities, patients, their families and other visitors may unavoidably become aware of the simulation. Particularly when the simulation involves high-acuity scenarios (i.e., managing a crisis, resuscitation), they can become acutely aware that something serious is happening and could become distressed by things that they perceive. This risk must be mitigated by approaching them before the simulation begins to ensure that they are aware that the activity is a simulated clinical experience. Patients, their families and other visitors should be offered a basic understanding of the purpose of the simulation and the opportunity to ask questions and convey concerns (i.e., “To provide the best care, it is important that we practice as a team. What we are about to do gives us the opportunity to practice and improve. Do you have any questions or concerns?”)
Debriefing is a vital component of most scenario-based simulation. Adult learning theory suggests that participants must reflect and construct meaning from their experiences in order to learn. Debriefing in situ simulations should be planned in advance and an appropriate amount of time should be allocated. Often, this is at least as long as the scenario and is frequently 45 minutes. There are multiple methods of conducting debriefing. The CSBL has literature on different techniques.
It is important to secure a separate area for debriefing. When the scenario is complex, participants need a change of scenery to signal the end of the scenario. This allows an emotional letdown, which is usually required to allow for thoughtful reflection on performance and achievement of learning objectives. When videotaping is used for video-assisted debriefing, consider in advance how the video will be replayed and when it will be erased. As a general rule, it should be erased after the debriefing session to protect the privacy of participants and the safety of the learner.
Many participants will want to return to the simulation environment to retry the use of equipment or verify an uncovered system issue. This is certainly welcomed. Consider finishing the debrief first and then re-entering the simulation environment.