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
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 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 Simulation
SimLab

Environmental Fidelity
Control of Scenario
Less Stress on Educators &
Learners
Logistical Control





Team & Systems Evaluation
Realism
Time
In Situ

“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
Plan, Plan, Plan
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
Simulation Should Fit Your Objectives, Not Your
Objective To Fit Simulation
• 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
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
Building The Program
The Foundation
• 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
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–
–
–
–
“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 Structure
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.
The Structure
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?”
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
Plan the In Situ
Simulation
• Use an established
outline
The Finish Work
“An ounce of prevention is worth than a
pound of cure.”
• 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
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
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
The Scenario
VBAC Simulation
The Scenario
VBAC Simulation
Implementation
Set-up
VBAC Simulation
Implementation
Set-up
VBAC Simulation
Implementation
Simulation
Begins
VBAC Simulation
Implementation
VBAC Simulation
Implementation
Making the
Incision
VBAC Simulation
Implementation
VBAC Simulation
Implementation
Facilitating
&
Preparing
for
Newborn
VBAC Simulation
Implementation
Newborn
Resuscitation
Team
VBAC Simulation
Implementation
VBAC Simulation
Implementation
Closing the
Abdomen
Scenario Ends
VBAC Simulation
Follow-up
VBAC Simulation
Follow-up
VBAC Simulation
Follow-up
QUESTIONS?
Is there an interest in starting a
local simulation networking
group?