1. 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 Mnickerson@ehr.org

2. Disclosures NONE

3. 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

4. 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, http://www.merriam-webster.com/dictionary/in%20situ

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

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

7. 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

8. 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

9. 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

10. 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

11. Building The Program

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. Standardized Request Form

23. 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

24. The Structure Use an established outline Plan the In Situ Simulation

25. 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.”

26. 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

27. 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

28. 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

29. In Situ in Action Vaginal Birth After Cesarean

30. VBAC Simulation Planning

31. 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

32. VBAC Simulation The Scenario

33. VBAC Simulation The Scenario

34. VBAC Simulation Implementation Set-up

35. VBAC Simulation Implementation Set-up

36. VBAC Simulation Implementation Simulation Begins

37. VBAC Simulation Implementation

38. Making the Incision

39. VBAC Simulation Implementation

40. Facilitating & Preparing for Newborn

41. VBAC Simulation Implementation Newborn Resuscitation Team

42. VBAC Simulation Implementation

43. Closing the Abdomen Scenario Ends

44. VBAC Simulation Follow-up

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