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Behind the curtain: Creating an in situ simulation experience


It’s 7:15 AM and day-shift obstetric (OB) unit nursing staff members are receiving report from their colleagues who worked overnight. Suddenly, a call for help comes from room 306. The patient in this room is a multiparous, 36-year-old, full-term woman who is scheduled for a vaginal trial of labor.

Several nurses run into the room to find that, without warning, the woman began to experience severe abdominal pain associated with a large discharge of blood from her vagina. The labor nurse notes deep decelerations on the fetal monitor.

Both mom and baby are in trouble and will need an emergency C-section if either is going to survive.

Recognizing the seriousness of the emergency, the labor nurse prepares the mother for transport to the unit’s operating suite while the rest of the OB staff springs into action. Phone calls are made, instrument packs are opened, assignments are given, and the patient is prepared for surgery. The pediatrician and a pediatric nurse arrive in anticipation of the delivery.

“Where is the anesthesiologist?” shouts the obstetrician, “I need to get this woman under immediately.”

“He was called,” says the nurse, “He should be on his way.”

“I can’t wait, get me the local anesthesia kit,” replies the obstetrician.

A tense 2 minutes pass until a nurse finds the kit and opens it for the physician who begins injecting lidocaine 1% in the abdomen to provide some local anesthesia if a cesarean incision is necessary before the anesthesiologist arrives.


“Her BP is now 80/60 [mmHg],” someone calls out.

Just then the anesthesiologist rushes in. A collective sigh of relief fills the room. He is briefed about the case and successfully anesthetizes the patient.

The above scenario is an excerpt from an emergency in situ drill conducted on our OB unit. The drill involved maternity and pediatric nursing staff, an obstetrician, an anesthesiologist, a pediatrician, and simulation clinical educators.

The drill continued with the delivery of the baby, institution of the protocol to manage massive hemorrhage, successful resuscitation of the newborn, and a debriefing with all involved.

This drill was conducted at the request of the OB department to help them prepare for the start of their Vaginal Birth After Cesarean (VBAC) program. The drill lasted about 1 hour, including the debriefing session, but was planned over the previous 4 weeks.

In situ simulations are often relatively simple scenarios, but may take many hours of planning and preparation to ensure the time the participants attend is meaningful. Holding a simulation in the care delivery area allows for more situational reality, but requires more contingency planning beforehand.

This article describes the process our simulation program uses to plan and implement in situ training using simulation.

The wizard will see you now

In situ simulations are a great way to practice and plan for low-volume but high-risk patient scenarios. We have used them to prepare staff for pediatric emergencies, new surgical procedures, orientation to new inpatient units, and application of new emergency protocols.

These simulations allow staff the time to work together, practice communication and leadership styles, and evaluate equipment and protocols in an environment that doesn’t compromise patient safety. They also give participants a place where they can safely make mistakes, ask questions, make suggestions, discuss different people’s perspectives of a situation, and interact with colleagues from other units they may not work with on a regular basis, all in the relative comfort and security of their home unit.

Our program initially struggled with complex requests such as “Can you have an OR patient code, hemorrhage, go into shock, allow everyone a chance to defibrillate, and then develop malignant hyperthermia? In an hour? Next Tuesday?” Experience has taught us to take these requests and break them down into several short simulation sessions instead of a single lengthy one. This enables us to meet achievable objectives, rather than create something so complex it becomes a sub-optimal learning experience.

A new request triggers a pre-planning meeting with one or two key people from the unit making the request and the simulation team. In this meeting, the team assists the unit planners, who are also the content experts, identify the overall goals and objectives for their proposed program and how simulation can be used to achieve these.

Although it’s important to determine from the beginning the main goals of any educational program, the design of a program that includes simulation must be flexible and dynamic. We have found that the unexpected learning opportunities that come up are often the most important outcomes from a simulation. We work with the requesting unit’s team to develop three to four objectives for each simulation session. Next, the team determines when the program will be held, how many sessions, program length, and who the key participants are.

Generally, we are invited to work with one discipline, such as nurses, but to promote reality and teamwork, we encourage multiple disciplines from the area to participate together. This requires buy-in from management, medical staff, and department heads, as well as active encouragement and recruitment, but in the end everyone feels it was worthwhile to have the team train together. Nurses have commented that running an operating room simulation without the anesthesiologist, or a labor scenario without an obstetrician, feels wrong, and diminishes the reality and flow of the scenario.

Once the general goals are determined, the simulation team meets to get to the detail work. The team varies depending on the content and scope, but most require three to five key members. We choose scenarios, plan for different outcomes, pick props we will need, divide up the tasks, and create a timeline.

If new scenarios are created, then we schedule several meetings to run through them in the simulation lab. It’s common to have 6 to 8 hours of meetings, with three to five simulator experts to plan for a 1-hour simulation, in addition to individual work by individual simulation team members.

On the day before the simulation, we log another 2 to 3 hours of prep time, which includes packing and moving the simulator(s) from the simulation lab to the location of the program, paperwork, packing props, and final details.

The morning of the simulation begins 1 to 2 hours before the start time, when we set up the equipment, move education emergency equipment to the in situ environment, and clarify any last-minute concerns of those working on the unit.

Ignore the man behind the curtain

Once the participants have arrived, we brief them on the plan, including the goals and objectives, and the use of simulation. Instructions on interacting with the simulator are given to ensure learner and manikin safety, and to enhance reality; “It’s ok to defibrillate the manikin.” “Please don’t use betadine on the manikin.”

Next, we give a brief “patient” history, assign roles to care for the simulated patient, and start the scenario. For the next 30 to 40 minutes participants assess the high fidelity mannequin, which can breathe and comes with adjustable heart and lung sounds, bowel sounds, a monitored rhythm, measurable blood pressure, and oxygen saturation. As needed, we give cues such as, “Wow, look at that petichial rash the patient is developing,” or “He seems a little pale and diaphoretic.” (Even high-tech mannequins don’t always sweat or move much yet.)

From these assessments the team has the opportunity to correct rhythm disturbances, locate and operate new equipment, demonstrate competencies, and practice their teamwork skills. Behind the curtain, the wizards work to make everything seamless by anticipating actions, changing vital signs, and offering simulated “patient” responses that reflect the care being delivered.

After the simulation, the participants, observers, and the simulation team immediately participate in a debriefing session. The scenario debrief ideally is conducted in a nearby conference room, but due to space constraints may need to occur in the simulation area.

The debriefing session is facilitated by a trained simulation debriefer who maintains the focus on what the team did well, areas for improvement, and whether the team had all the equipment, personnel, and skills needed to manage the case. Specific questions that may be posed to the team are, “How did it look from different participants’ perspectives?” “How did it feel when things got tense?” “Did you know what the leader was planning?” “What could have been said to allow others to anticipate the next steps?”

We always end the debriefing session by asking each person involved: “What is one positive outcome you got from this case?” This allows people to leave on a positive note, which helps to enhance their learning and encourages them to participate in more simulations.

There’s no place like home

After the program, we often have to move quickly out of the area to allow patient care to resume. The simulator and equipment need to be packed, transported, and then unpacked back in the simulation lab.

We check the equipment and arrange for repairs, if needed. Paperwork, especially the evaluations from the participants, needs to be reviewed and filed. The simulation team meets within 1 week for our own debriefing. We focus on the high points of the simulation, any criticisms or recommendations from the participants, areas for change or improvement, ways to expand or simplify the scenario, and recommendations for follow up.

This information is put into a report and sent to the clinical education director and the requesting unit’s manager. Finally, we usually send a thank you to the unit for inviting us and allowing us to participate in their training. We briefly summarize the objectives, who participated, and most importantly, praise the unit for things they did well (excellent teamwork, knowing the equipment, putting patient safety first). Often the managers will share our comments with the participants with a few paragraphs in the unit newsletter.

Education funds are always a concern. Promoting the work you do, the positive impact on patient safety, and proven benefits of simulation are always needed to maintain support of the program. Some malpractice insurances offer a discount for participating in simulations, so providing continuing medical education credits has helped to engage the medical providers and garnered praise from risk management.

Cue happy ending

Simulation is a powerful tool for educating staff and improving patient safety. Our experience in coordinating simulation programs has taught us to incorporate sufficient preparation time, involve content experts early, keep objectives simple, allow the scenario to play out, be flexible, and always leave time for debriefing and reflection to maximize learning and retention.

Simulation is more than just an educator with a doll. Active and successful simulation teams need resources, especially time, to allow them to build on past successes and learn from past experiences. Encouraging simulation teams to think outside the box, involve themselves in quality improvement initiatives, do research, and share experiences, will lead to a greater experience for all involved.

Melissa Pollard and Michael Nickerson are professional development specialists at Exeter Hospital in Exeter New Hampshire.

Selected references

Hamman WR., Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving operational changes in a labor and delivery ward. Qual Manag Health Care. 2010;19(3):226-30.

Jeffries PR. Simulation in Nursing Education: From Conceptualization to Evaluation, New York, NY: National League for Nursing; 2007.

Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of CRM-based team training on obstetric outcomes and clinicians’ patient safety attitudes. Jt Comm J Qual Patient Saf. 2007;33(12);720-5.

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