In Situ Simulation: Integrating into the Clinical Environment Mike Nickerson DNP, APRN, FNP/GNP-BC, CEN, NREMT-P Clinical Simulation Coordinator Exeter Hospital, Exeter, NH

Disclosures NONE

Objectives Discuss the process of integrating In Situ simulation into clinical education. List the “Pros” & “Cons” of In Situ simulation Demonstrate a practical application of In Situ simulation in a clinical setting

Definition In Situ 1 –“in the natural or original position or place” –Latin for “in place” In Situ Simulation –Simulation that occurs in the physical environment of the target audience. –A way to practice and plan for low volume but high risk patient scenarios 1 Merriam-Webster, 2011,

SimLab vs. In Situ Simulation SimLabIn Situ Environmental Fidelity  Control of Scenario  Less Stress on Educators & Learners  Logistical Control  Team & Systems Evaluation  Realism  Time 

“But Mike, how do you do that voodoo you do so well?”

Assemble your team –Representative of all stakeholders Educators, Simulation Experts, Senior Management, Unit Management, Clinical Staff, Medical Staff, and Support Staff Usually, one person can answer for multiple stakeholders in order to avoid a large team. Identify your champions Have policies & procedures in place prior to first meeting

Your Program Is Only As Good As Your Plan The Plan –Should follow an already established procedure –Always start by identifying the program objectives “Who is our target audience?” “What do we want to achieve with training?” “When will we do the training?” “Where should we do the training to best achieve our desired outcomes?” “Why should we do this training” “How will we achieve our desired outcomes?” Plan, Plan, Plan

The Objectives –When possible use an already established curriculum as a guide –Learner-centered, experiential objectives work best with simulation –After writing the objectives, ask this question: “How will simulation enhance the curriculum and help achieve the objectives?” Plan, Plan, Plan Simulation Should Fit Your Objectives, Not Your Objective To Fit Simulation

The Simulation Questions Low tech or high tech? SimLab or In Situ? Written scenario or “on-the-fly”? Fidelity, Fidelity, Fidelity –“What level of realism do I need?” Environmental Psychological Physical Plan, Plan, Plan

Building The Program

Establish your SimLab educational program – Credibility of Sim Educators – Less stressful environment for learners  enjoyment Helps establish simulation as a viable educational tool Get used to using interactive scenarios and manikins – Incorporates a more traditional educational approach Can meet multiple learning styles “See One, Do One, Teach One” Time frames much more dynamic The Foundation

Introduction of In Situ simulation program – Build off of lessons learned from your SimLab program Curriculum design Scenario design Working with stakeholders – Educate your educators More than just a mock code Logistical constraints – Educate your Champions Unit disruptions Time constraints A much richer educational experience The Foundation

Logistics, Logistics, Logistics Equipment –“What equipment do we need?” –“How will we get it to the unit?” –“Who will be responsible for moving the equipment?” –“Where will we set-up the equipment?” –“How much time do we need to set up and take down the equipment?” –“What unit equipment & supplies can we use?” The Foundation

Logistics, Logistics, Logistics Equipment –Develop an equipment & supplies checklist –Assign 1 person to be in charge of moving equipment –Put together travel totes –Color code all connections; Label all cables & cords –Plan ahead; be prepared for the unexpected The Foundation

Logistics, Logistics, Logistics The In Situ simulation –Develop policies and procedures “Does proposed program meet our Simulation Program’s mission, vision and values?” “Who is the lead simulation educator for this program?” “Who is the unit point person?” “Do the program objectives require this level of environmental fidelity?” –Scenario Development Should be a joint effort between all stakeholders Follow a prescribed outline The Foundation

Logistics, Logistics, Logistics The In Situ simulation –The Participant Wrangler Need to “encourage” the unit leadership to take on this role Identify the key players How many and what types of participants do we need What is the plan if unable to secure key participants –No shows and Cancellations Who can cancel a program? Timeframe for cancellation? If no shows up, what next? The Foundation

Theoretical Framework Find one that fits with your organizational mission, visions and values Consider the choice of a TF a journey of discovery with your educators Use it as your guide to curriculum design The Structure

Adapted from: Jeffries, P. R. & Rogers, K.J., 2007, Theoretical Framework for Simulation Design. In P. R. Jeffries (Ed.), Simulation in Nursing Education: From Conceptualization to Evaluation (p. 23). New York: National League for Nursing.

Evaluate the Request “Is this consistent with overall simulation program goals?” “Do we have the personnel available to undertake this request?” “Are the objectives of the proposed In Situ simulation better achieved in the simlab?” The Structure

Evaluate the Request “Does the proposed location meet the requirements for a successful In Situ simulation experience?” –Size of space Observer space Debriefing space –Achieves necessary fidelity “How likely are the proposed participants to show up?” The Structure

Standardized Request Form

The Structure Plan the In Situ Simulation Assign a lead sim educator Representative sample of stakeholders –Choose a lead stakeholder –Refine objectives –Develop scenario(s) Meet with sim team –Logistics –Assignments Equipment & Supplies Operator Facilitators Lead Debriefer Evaluation Recorder Pictures/Video Set-up & Take Down

The Structure Use an established outline Plan the In Situ Simulation

The Finish Work Test the scenario –With the educators and stakeholder lead(s) –In the SimLab –If possible, on the unit Huddle with sim educators prior to start –Review roles –What’s not working! Plan B, C, & D –Sync watches “An ounce of prevention is worth than a pound of cure.”

Completion Debriefing –Separate room or same room? –Use of video Equipment constraints Time constraints –Control of the crowd –Keeping to the objectives –“What do we do with all of the excellent suggestions for process improvement we are getting?” –Leave time for evaluations

On-going Structural Maintenance Evaluations –Review & collate to look for trends Follow-up –Sim educator lead to meet with unit team to continue process improvement discussions –Summary of simulation Sim educator lead meets with recorder Send to all stakeholders Acknowledge the learners time commitment and dedication to learning

On-going Structural Maintenance Sim Education Team Debrief –Review evaluations –What went well; What didn’t go so well –Suggestions for improvement –Equipment & supplies –Assure follow-up with stakeholders

In Situ in Action Vaginal Birth After Cesarean

VBAC Simulation Planning

Things to do for preparation: Mock up uterus/skin Equipment up to EH day prior Gail getting paperwork prepped week prior (roster, eval, certs) Observers/educators with badges and/or colored scrubs Emphasize to participants that educators and observers may not talk, prompt or help. If they need more help they need to request who they would want to help (i.e RRT Pedi; Code Maroon-OBS) Look for role clarification Educate OB where the abdomen is to make incision on manikin Use non-staining product to use for mock blood VBAC Simulation Planning

VBAC Simulation The Scenario

VBAC Simulation The Scenario

VBAC Simulation Implementation Set-up

VBAC Simulation Implementation Set-up

VBAC Simulation Implementation Simulation Begins

VBAC Simulation Implementation

Making the Incision

VBAC Simulation Implementation

Facilitating & Preparing for Newborn

VBAC Simulation Implementation Newborn Resuscitation Team

VBAC Simulation Implementation

Closing the Abdomen Scenario Ends

VBAC Simulation Follow-up

QUESTIONS? Is there an interest in starting a local simulation networking group?