In Situ Simulation: Bridging the Gap between Learning and Practice
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.
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.
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
Think about your location and equipment
Encourage departmental leaders to support simulation
Agree on your learning objectives for participants and the department
Be a multiprofessional simulation programme
Make your simulations as real as you can
Start simple, then get complex
Make sure everyone knows the rules and feels safe
Link what you find in simulation to your clinical governance systems
The debrief is (almost) everything; be careful, skilful and safe
Keep the real patients safe and remember where you are
Example #2 by Sim and Choppers
Always run an in-situ simulation with well-defined goals and objectives
Always ensure there’s a debriefing period that’s adequate
Use in-situ simulation to improve teamwork and coordination especially in acute care settings and high-risk situations
Use in-situ simulation as a method of testing the ergonomics of your current clinical setting
Separate in-situ simulation equipment from real equipment
Notify others that in-situ simulation is in process
Maximize learning for on-duty personnel by running an in-situ simulation
Multi-disciplinary is key for In-situ simulation
Seek departmental support to run in-situ simulation regularly
Example #3 by St. Emlyn’s
Get on and do it
Focus on what’s important
Beg, borrow, acquire and recycle your kit.
Who, When & Where
Debrief is (almost) everything
Reflect some authority
Go beyond the ED.
Learn from your own (and others) mistakes
Keep to time and make it real
What do they have in common?
Have well-defined learning objectives
Debrief is almost everything
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…
Based on RCEM/RCN curriculum and competencies to be learner focused
Participants will receive credit for participation which they can link to their portfolios.
Protecting time for debrief
Faculty will ensure the timely running of simulation, to ensure adequate debrief protecting the safety and enjoyment of learners.
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
- Anpananthar A, Parikh A, Galea J, USING IN SITU SIMULATION TO GET PAEDIATRIC CODE RED RIGHT, Emerg Med J 2016;33:936.
- 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.
- Trippick S, Buckley A, HOW TO DEVELOP AN EMERGENCY DEPARTMENT IN-SITU SIMULATION PROGRAM, Emerg Med J 2016;33:921-922.
- Sunley R, Moloney K, Parker J, et al, 55 ‘Mini Sim’ – innovative bite sized simulation teaching in a busy children’s emergency department, Emerg Med J 2017;34:A899-A900.
- Tabrett S, Harris S, Meredith G, et al, PO-0711 Sim: Scary, Intimidating Or Menacing Or Sim: Stimulating, Interactive And Memorable, Archives of Disease in Childhood 2014;99:A486.
- McGaghie W, Issenberg SB, Petrusa E, Scalese R. A critical review of simulation-based medical education research: 2003-2009. Med Ed 2010: 44: 50-63.
- McFetrich J. A structured literature review on the use of high fidelity patient simulators for teaching in emergency medicine. Emerg Med J. 2006; 23: 509–511.