In-situ simulation: The Holy Grail or just another distraction?

Over the last fifteen years there has been a shift from only delivering simulation sessions in a designated simulation area to more simulation being delivered in clinical areas in so called in-situ simulations. Clearly in-situ simulation offers the ability to increase simulation capacity and become more inclusive, but sometimes it is claimed to be the optimal place to deliver simulation - it may offer lots of benefits but it isn’t without some degree of risk.

Benefits - the ability to simulate in the participants clinical area, with their clinical equipment and their team has clear benefits and we know that all to often staff sent for simulation in a dedicated area, will be cherry picked and will not be representative of the skill mix in the real environment. Also, as it is the real working area, it also enables detection of those ergonomic issues (or latent issues) i.e. when people coming from different areas can’t find the location, equipment isn’t available etc.

Workload / learning outcomes - the first and most obvious consideration is the clinical workload and how simulation can be an extra clinical burden in an already busy clinical area. Delivering a simulation scenario once a month is probably more achievable than delivering one a day, but you need to be cognisant of who and what you are teaching. Planing a programme to teach new starters / trainees a range of clinical (emergency) procedures may be ambitious in a busy clinical area as may be running multiple simulations for all staff - again consider the number of people working in your area - if the aim is to train them all to manage a certain condition how many times will it be needed to be run to enable all staff including the night staff to attend? There may be ways to achieve more likelihood of running the simulation i.e. considering when and where it is run and considering other ways to maximise people to attend i.e. adjusting the rota but this will not work every time. Really sitting down and thinking what I am trying to achieve with simulation is important. 

Learning Outcomes - this links well into considerations around the learning outcomes if we recognise it is going to be difficult / unlikely to deliver simulations for the entire cohort maybe we need to rethink how we deliver this - as mention previously (link) I really think there is a need to break down the learning thus procedural elements may be initially taught more as a walk through, or really low level simulation and may even be unprofessional i.e. a session for a group of new starters. Our bigger simulations should focus more of team working and looking at the organisational elements and latent errors -  thus it doesn't really mater the clinical theme. 

Even better consider augmenting the simulation programme with other on line learning or even a library of previous recorded simulation (with consent) as this library could be a benefit to people wanting to review certain conditions or areas for example on returning from sick leave or transferring to a different clinical area.  

It is also evident that sometimes there is pressure to include other elements of training, perhaps more mandatory elements for example a resuscitation update as part of a simulation - I think some care is needed here as we will end up doing very different things with different educational methods in what could be seen as a way to save the time on sending staff to external sessions- we need to think of the quality of such events. 

Delivery - often there will be less time available for in-situ simulation and they will often be done on the rush - before the next interruption arrives. Sometimes the shortened time can see the debriefing affected, there are some debriefing models available that may be more amenable to more rapid debrief cycles for example the Sharp tool, often though it will be necessary to consider the length of the scenario and potentially deliver a hey part of a situation rather than recognition, management and aftercare. 

Engagement  - starting a departmental simulation programme can be a challenge and although I cover more of this in a separate blog, it is clear that staff are less likely to engage if they see simulation as increasing their workload, adding stress to their job or compromising patient safety. Its sometimes too easy to push on with simulation in a busy clinical area and dismiss concerns by saying “well if this was a real patient we would need to respond” this probably isn't a good way to engage with staff. 

Risk to patients - There are numerous considerations of how simulations can effect patient safety apart from loss of staffing these include unavailability (staff can’t find) clinical equipment as it has been moved for a simulation, or sterile equipment has been opened, risk of out of date equipment or drugs being used inadvertently on real patients. There has even been times were equipment has been deliberately misconnected / broken to see if staff can locate the issue and here there is a clear risk of this being overlooked and harm occurring. You need to consider what will happen if mid simulation there is a clinical emergency - whilst the norm is to stop the simulation and transfer the existing / established team to the emergency this expectation does need to be explicit. It is actually quite a strange situation for faculty too i.e. in the middle of a simulated cardiac arrest to suddenly go into the middle of a real cardiac arrest. 

Any simulation programme needs to be risk assessed and documented, of course, a lot of the risks can be mitigated i.e. by using real (in date) drugs and limiting what sterile equipment is opened - particularly where there is a lack of replacements available. 

Risk to simulation safety - The safe learning environment is an often used catch phrase of simulation - so how does in-situ simulation affect this safety. There are a couple of potential issues firstly the faculty running the simulation will often be fellow colleagues - and will potentially be working with the staff in minutes following the simulation this puts an added pressure on both faculty and learners. A friend and colleague of mine interviewed participants following in-situ simulation and there was a feeling that in-situ also felt a less safe area as the participants were aware of the proximity of other colleagues, and potentially also of patients and relatives. I think care needs to be taken that there is not a growing body of people watching what is happening in the simulation. 

Simulation isolation - a departmental simulation programme can become quite isolated in an organisation - led by one or two vocal champions it may loose momentum if these individuals are not around. Additionally it can become hidden away, this lessens opportunities to spread lessons learnt across the organisation, ensuring robust quality assurance of education and potentially missing out on support from staff in other departments. Techniques and equipment may be limited to those available in the department rather than using organisational ones for example working with Simulated Persons. The isolation can also affect faculty development, maintenance of equipment and securing resources to support simulation delivery. Having support and engagement from an organisational simulation group can help promote activity and ensure that educational governance is embedded. 

Despite focussing on the risks that can be associated with in-situ simulation I do believe that embedding an in-situ simulation programme is a major benefit to staff development, patient safety and has potential to improve staff well being, but see that this should be as part of a simulation programme that has access to both other areas and potentially other delivery methods. I think we need to consider what we are delivering in-situ and ask are we doing this here because it is the best place to deliver this element of learning or am i delivering it here as there is no other place I can access.