August 4, 2022
Simulation has become an integral part of clinical education for physicians, nurses and others. In early health care training, most simulation occurs in a simulation lab. There, sophisticated manikins and other equipment are centralized and simulation educators can provide a wide variety of learning opportunities.
However, as learners advance and become practicing medical professionals, simulation-based training doesn’t stop. It just evolves. For Jump Simulation, we take our simulation-based training out of the lab and into the live clinical environment at sites across OSF HealthCare. This is called in-situ simulation.
For educators and simulation staff, in-situ simulation is like producing a play. There must be an available venue, people to fill all of the necessary roles, a live-action story that will immerse all concerned and an after-action review in the form of a thoughtful dialogue about how the action unfolded.
Just as great plays have the potential to instruct, to make us think and to help us take a look at what does and doesn’t work in our world, so too does in-situ simulation.
It is impossible to replicate the nuances of a live clinical environment in the simulation lab, no matter how hard we try. Taking simulation to learners in the places where they work allows them to use their own equipment, processes and each other in the manner they normally would. Thus, processes feel natural, the rhythms of the clinical unit continue even as the scenario unfolds and participants’ immersion into the simulation is enhanced.
Secondly, taking simulation to learners allows educators and others to identify process gaps and workarounds that have emerged to plug holes in a system that does not fully serve those caring for patients, nor patients themselves. When workarounds are necessary, the likelihood of errors and system malfunction increases dramatically.
For example, a chronic shortage of a particular set of supplies for a procedure might necessitate opening multiple trays and packs to assemble the necessary item. This may increase costs and potentially enhance the risk of contaminating sterile supplies because of the extra steps required.
Clinicians are often too busy to stop and consider the extra steps they must take to accomplish their work. But in-situ simulation shines a spotlight on problems and provides an opportunity to reflect on how to improve a challenging situation.
Besides diagnosing process gaps and identifying how they are managed, in-situ simulation provides an excellent venue to practice teamwork in urgent patient care situations. Simulation with one’s immediate team or a larger, interprofessional group isn’t always comfortable, however. The fear of making an error that is observed by others and then discussed openly during debriefing can be a psychologically threatening experience.
Thus, it is the responsibility of the facilitator to create a psychologically safe space for learning. This is done in the same way it is in the simulation lab: treating participants with respect, asking learners to respect one another and maintaining confidentiality around what happens in simulation and debriefing. It is similarly incumbent on the facilitator to ask questions in a psychologically safe manner and to maintain genuine curiosity about what was happening for participants as the simulation unfolded.
In-situ simulation is also a powerful tool for diagnosing problems in a new clinical area before it opens. The literature is replete with stories of in-situ simulations uncovering phones that didn’t ring into call rooms where providers were to stay overnight, or into staff lounges and other locations where the ability to stay in communication with clinical areas is necessary and expected. Had such problems not been discovered until these areas were in use, both urgent and routine patient care could have been delayed.
Another important benefit of in-situ simulation is its potential for cost-savings. While OSF is blessed with the availability of the Jump Trading Simulation & Education Center, not all facilities have the space or capital to invest in a dedicated simulation lab.
In-situ simulation, on the other hand, requires only a manikin, computer and a skilled facilitator. The space, most equipment and supplies are already present in the live clinical environment. Simulations must occasionally be rescheduled due to lack of space to conduct the scenario. But leadership commitment to an in-situ program can help maintain a regular schedule of simulations.
Just as doing a full run of a theatrical production is challenging, so too are regularly-scheduled in-situ simulations. World-famous dancer and choreographer Martha Graham said this about theatre: “theatre is a verb before it is a noun, an act before it is a place.” The same could be said of in-situ simulation.