Lynn heads the simulation lab at Milborough Hospital. One of the tenets she preaches to her learners is the “safe space” in a simulation lab, an environment in which learners can make mistakes without fear of judgment. Recently, she has read about in-situ simulation sessions happening across the country. These sessions take the simulation mannequins into the real-life trauma bays to add another level of fidelity to the scenarios. While intrigued, Lynn wonders whether her learners will still feel as “safe” to learn and ask questions when in the Emergency Department, where the audience is not as controlled and other allied health professionals may not be accustomed to the “safe space” rules of simulation.
Simulation is arguably one of the most powerful teaching tools for Emergency Medicine providers. In-situ simulation has the potential to involve a greater variety of learners and address real-life challenges in running resuscitations. This Feature Educational Innovation (FEI), titled “Interdisciplinary Staff Simulation” was originally posted by the CAEP EWG FEI Team on November 25, 2015 and answers the question: “What is a way for in-situ simulation to be implemented among senior providers–staff physicians, nurses and respiratory therapists?” A PDF version is available here. A CAEP cast is available here.
Description of the Innovation
The purpose of the staff interdisciplinary simulation sessions at the University of Calgary is to give Emergency staff (physicians, nurses and respiratory therapists) exposure to in situ critical care scenarios and encourage practice of real time skills they will use in their daily practice of Emergency Medicine.
Simulation training has been shown to be an extremely valuable tool that allows learners to develop the cognitive, procedural, communication and teamwork skills that can improve patient safety. 1,2 In situ simulation, that is conducting simulations in the clinical environment, offers further advantages by aligning with the actual “work” of health care providers, improves training efficiencies and provides an opportunity to review at frequent intervals the skills related to high-risk of infrequent events.
This project involves weekly interdisciplinary in situ simulation sessions with emergency physicians, emergency nurses and respiratory therapists. Participants attend these sessions in the resuscitation area of their usual work environment and function in teams made up of 2 physicians, 3-4 nurses and 1-2 respiratory therapists. Throughout the 2.5 hour sessions, teams run through 2-3 scenarios. Physicians rotate through the role of team leader, nurses divide up their duties (documentation nurse, fluids nurse or medications nurse) while respiratory therapists balance their role in airway management and arterial lines. Scenarios last about 20-25 minutes followed by a 30-35-minute debriefing session where participants explore and troubleshoot communication, teamwork and knowledge issues that arose during the session. To offer a safe open environment for physicians, residents and medical students are not allowed to participate in these sessions. The activity is accredited and providers can earn CME credits for their participation.
Over 125 Emergency physicians and 400 nurses have participated in the last 4 years with consistently excellent feedback. After each session participants complete a survey where they rate various components of the activity on a 5-point Likert scale with the following descriptors:
1. Strongly disagree
5. Strongly agree
Mean scores of participant response for each rating are reported below.
1. Overall experience was excellent (4.77/5)
2. Relevant to my practice (4.78/5)
3. Debriefing helpful (4.77/5)
4. Assessed knowledge base and performance well (4.48/5)
5. Improved my own performance during critical ED care
6. Improved team performance during critical ED care (4.46/5)
7. Improved communication and team work skills (4.47/5)
This activity supports interdisciplinary learning and incorporates several features of high-fidelity simulation that lead to effective learning: providing feedback, allowing for repetitive practice, supporting a range of difficulty, and capturing clinical variation.4
Furthermore, features specific to in situ simulation that enhance learning include reinforcement of individual and team behaviors, identification of active and latent systems issues and the ability of the in situ simulated scenario to be a catalyst for change in clinical care systems and lead to improved clinical outcomes.3 As demonstrated in the results, program evaluation has been done using trainee reactions to the training which corresponds to level 1 of the Kirkpatrick framework for program evaluation.5 This framework would suggest that for future evaluation different outcomes (learning, behavior or results) should be considered.
(1) Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm in pediatric medical education: Teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics 2000; 106: E45. 5.
(2) Reznek MA, Rawn CL, Krummel TM. Evaluation of the educational effectiveness of a virtual reality intravenous insertion simulator. Acad Emerg Med 2002; 9: 1319-25.
(3) Henriksen K, Battles JB, Keyes MA, et al. editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. In SituSimulation: Challenges and Results.
(4) Issenberg SB, Mcgaghie WC, Petrusa ER, Gordon DL & RJ Scalese (2005) Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review, Medical Teacher, 27(1): 10-28.
(5) Kirkpatrick D.L. (1959). Techniques for evaluating training programs. Journal of American Society of Training Directors, 13(3): 21–6.
How do you ensure a safe space environment in in-situ simulation? What challenges have you faced or overcome? Share your experiences below!
More About the CAEP FEI
This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.
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