In Situ Simulation: Bridging the Gap between Learning and Practice

““He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.””

— William Osler

This wonderful quote is one I often think of when teaching medical students. The temptation to hide in the library as a medical student and study without venturing to the wards is similar to the temptation to hide on the ward as a doctor without ever venturing back to the library. In talking to medical students and talking to doctors I fear this gap between the “wards” (service provision) and the “library” (education) is widening.

In situ simulation seeks to bridge this gap.

It might be 5am but it’s never to early for a Cardiac Arrest Sim in the Toilet. Learning about the logistics of how you manage a cardiac arrest in a small space, and where help comes from when the bell 🔔 goes. 💔 It was lead by one of our FY2s.Coordinated by @drsarahedwards pic.twitter.com/ytxZxdOH6k

— EastMidsFOAMed (@EM3FOAMed) February 4, 2019

In the emergency department staff are challenged with the demands of ever-increasing queues of patients versus their need to stay up to date and competent through ongoing professional development. This winter our department is likely to see record highs of sick patients flow through our doors. This year, trainees face ever higher professional hurdles to jump over to demonstrate competencies for revalidation. Something has to give.

If we don’t support education eventually the quality of care for our patients will fall too. If we give too much to education, we also risk under-resourcing our service given current staff pressures. Where is the middle ground? How can we stay afloat? More importantly, how can we all learn to thrive and not survive?

Okay, so in situ simulation might not offer us the whole answer. But let’s look at it carefully. An effective in situ simulation programme has the potential to deliver bite-sized high impact education to a multi-professional audience tacking a broad range of topics ranging from team dynamics to procedural skills to knowledge deficits. Beyond individual learning, it can foster team togetherness and solidify groups of practice. In situ simulation offers us the possibility to tick all our boxes. Convenient, relevant, practical, effective, team-based, memorable and powerful learning delivered right on the shop floor practising skills we need for the patients we see. Wow. The literature is awash with the potential benefits of this style of education.

If it’s done ineffectively, however, it does risk negatively impacting learners and at its worst even endangering patient safety. So how do we traverse this challenge? In short: with care.

This week we helped run some BLS simulations for @dmuleicester student nurses on their training day @Leic_hospital A&E.

Scenarios ranged from a collapse in the staff toilets, admin office, and even the storeroom! Well done to everyone that took part 👏 pic.twitter.com/4PsJnZaIth

— EastMidsFOAMed (@EM3FOAMed) February 1, 2019

There are many sources of advice for running an effective in situ simulation. Here are three examples of some top ten tips for in situ simulation…

Example #1 by RCEM Learning

1. Think about your location and equipment

2. Encourage departmental leaders to support simulation

3. Agree on your learning objectives for participants and the department

4. Be a multiprofessional simulation programme

5. Make your simulations as real as you can

6. Start simple, then get complex

7. Make sure everyone knows the rules and feels safe

8. Link what you find in simulation to your clinical governance systems

9. The debrief is (almost) everything; be careful, skilful and safe

10. Keep the real patients safe and remember where you are

Example #2 by Sim and Choppers

1. Always run an in-situ simulation with well-defined goals and objectives

2. Always ensure there’s a debriefing period that’s adequate

3. Use in-situ simulation to improve teamwork and coordination especially in acute care settings and high-risk situations

4. Use in-situ simulation as a method of testing the ergonomics of your current clinical setting

5. Separate in-situ simulation equipment from real equipment

6. Notify others that in-situ simulation is in process

7. Maximize learning for on-duty personnel by running an in-situ simulation

8. Multi-disciplinary is key for In-situ simulation

9. Seek departmental support to run in-situ simulation regularly

10. Be creative!

Example #3 by St. Emlyn’s

1. Get on and do it

2. Focus on what’s important

3. Beg, borrow, acquire and recycle your kit.

4. Who, When & Where

5. Debrief is (almost) everything

6. Reflect some authority

7. Go beyond the ED.

8. Learn from your own (and others) mistakes

9. Keep to time and make it real

10. Have fun

What do they have in common?

1. Have well-defined learning objectives

2. Debrief is almost everything

3. Make learning safe and fun!

With this in mind, here in Leicester, I am planning ahead. Taking from my own and other’s experiences our department will be delivering regular in situ simulation over the winter period that will be…

1. Based on RCEM/RCN curriculum and competencies to be learner focused

   Participants will receive credit for participation which they can link to their portfolios.

2. Protecting time for debrief

   Faculty will ensure the timely running of simulation, to ensure adequate debrief protecting the safety and enjoyment of learners.

3. The simulation will focus on being safe and fun for all

   Through preparation of selected scenarios, we will be stimulating, interactive and memorable, not scary, intimidating or menacing.

In situ simulation is integral to supporting improvement and safety in the high-risk area of emergency medicine. Deliberate practice, team working and skills training under real simulated pressures is a rich resource to be tapped. Obstacles about including people’s prior negative experiences, cultural challenges and system issues. Performance anxiety is the elephant in the room. But if we can overcome these obstacles we can look to the horizon and sail confidently forwards serving not only our patients but ourselves by embracing the opportunity of in situ sim.

Further Reading & Resources

• NICE Guidance: Summary of Osgood-Schlatter disease
• Pediatric EM Morsels: Osgood Schlatter’s Disease

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2. Spurr J, Gatward J, Joshi N, et al, Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments, Emerg Med J 2016;33:514-516.
3. Trippick S, Buckley A, HOW TO DEVELOP AN EMERGENCY DEPARTMENT IN-SITU SIMULATION PROGRAM, Emerg Med J 2016;33:921-922.
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