in situ simulation: integrating into the clinical environment mike nickerson dnp, aprn, fnp/gnp-bc,...

In Situ Simulation:Integrating into the Clinical

Environment

Mike Nickerson DNP, APRN, FNP/GNP-BC, CEN, NREMT-PClinical Simulation Coordinator

Exeter Hospital, Exeter, [email protected]

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

DefinitionIn Situ1

– “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

1Merriam-Webster, 2011, http://www.merriam-webster.com/dictionary/in%20situ

SimLab vs. In Situ SimulationSimLab In 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

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 StructurePlan 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 SimulationPlanning

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 SimulationPlanning

VBAC SimulationThe Scenario

VBAC SimulationImplementation

Set-up


Simulation Begins


Making the Incision


Facilitating &

Preparing for

Newborn


Newborn Resuscitation

Team


Closing the Abdomen

Scenario Ends

VBAC SimulationFollow-up

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

in situ simulation: integrating into the clinical environment mike nickerson dnp, aprn, fnp/gnp-bc,...

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