Simulation is a well-recognised and increasingly commonplace educational tool for healthcare professionals. Advances in technology have led to a wide diversity of training methods, utilising equipment ranging from low-fidelity models for skills practice to the high-fidelity manikins used in simulation centres for scenario-based learning.
In the latest CICM trainee survey, simulation training was rated in the top three teaching methods, and the vast majority of trainees were keen for the College to create courses to address technical and non-technical skills.
“Bringing the mountain to Mohammed…”
Traditionally, simulation training has occurred in specialised centres, which offer a variety of courses aimed at healthcare professionals. These courses are usually expensive, involve taking study leave and usually do not provide team training: doctors and nurses tend to be trained separately and practitioners often end up training with strangers.
In recent years, simulation training has been brought into the workplace. In 2005, Weinstock et al described how they took simulation training into various parts of their hospital using a mobile cart (1). Since then, this type of training, known variously as ‘point-of-care’, ‘in-situ’, or ‘mobile’ simulation, has gained momentum. As a result, several simulation programs have been set up in ICUs around the world. In the South West of the UK, for example, the Foundation Training School has funded the establishment of programs in five ICUs across the region (2). In Sydney, Staff Specialists Carole Foot and Liz Steel and Clinical Nurse Educator Greg Thomson have set up the ICU-STAR programme (see below).
In-situ simulation occurs in the normal working environment, using normal workplace equipment. Healthcare professionals act in their normal roles, in ‘intact teams’, during normal working hours. These factors are thought to enhance realism and validity, improve working relationships, and decrease the anxiety that some practitioners associate with traditional simulation training (1). In addition, scenarios can be tailored to reflect local case-mix and critical incidents, and site-specific system errors may be identified.
Simulation equipment is expensive, right?
Well, it doesn’t have to be.
The two programs mentioned above use a similar set up which can be achieved in an ICU near you for minimal cost. The training involves the use of a simple resuscitation manikin, for example, a Laerdal Resusci-Annie™ or Mega Code Kelly Basic™ model. These are low-fidelity manikins, with very few moving parts. They are therefore a fraction of the cost of a high-fidelity simulator, involving much reduced servicing costs. It is better if the manikin has a realistic airway (for example, the Mega Code Kelly Basic™ has an anatomically realistic Airway Trainer™ head with an inflatable tongue to simulate difficult intubation, and a neck in which cricothyroidotomy and tracheostomy can be performed).
Vital signs are simulated using a laptop computer running the Laerdal SimMan™ software (downloaded free from the Laerdal website), connected to a standard CRT computer monitor, which represents the patient monitor.
Fake Blood, Make-Up and Imagination!
Moulage, patient notes, charts and investigations, various bits of ward equipment and a bit of imagination are used to enhance realism, but the low-fidelity nature of the manikin means that a dialogue is required between the facilitator and the team, much like during life support course scenarios. Participants are briefed before the scenario with the ‘ground rules’, the signs they might be expected to find and those they will be told.
The simplicity of the set-up allows for training to occur either in planned sessions or on an ad-hoc basis when there is a quiet period on the ICU. The manikin can be placed in an empty bed and training commenced within 15 minutes. Alternatively, if there is space, the manikin can be left set up permanently.
One of the advantages of in-situ training is that it can involve intact, multi-professional teams. Team training courses are emerging in healthcare, especially addressing ‘non-technical skills’ or ‘human factors’. Feedback from in-situ simulation training programs reveals that this strategy is popular; participants enjoy training with staff from other disciplines.
To Err Is Human…
Training sessions can cover general clinical scenarios or be targeted to address recent critical incidents or problems unique to the hospital. Technical skills can be practiced and clinical knowledge revised, but training sessions can also emphasise non-technical skills or ‘human factors’ such as situational awareness, decision making, task management, team working, communication skills and calmness under pressure.
These skills are increasingly being emphasised in crisis management and life support training, and human factors training (also sometimes called ‘Crew Resource Management’ or CRM training) is being included in many undergraduate and postgraduate curricula. Flin et al’s Safety at the Sharp End is an excellent guide to non-technical skills, which covers the theory and practical application of the skills and how to teach and assess them (3).
Debriefing sessions, which should accompany all simulation based training, are where most of the learning takes place. Formative feedback is one of the top two strategies for enhancing learning (the other one being active participation) (4).
There are many different methods and models for debriefing, but as a general rule, in team training, feedback should be given on the whole team performance during a focused, structured session involving all participants and observers. Feedback should concentrate on performance rather than the characteristics of team members, and should be given as soon as possible after completion of the scenario. Videotaping of scenarios to aid feedback is common but by no means mandatory.
Debriefing sessions can contain didactic teaching to cover learning points, or concentrate on non-technical skills, or be a combination of both.
The Final Score
Increasingly, simulation is being used as a form of assessment: for example, many novice anaesthetists must pass a simulation-based competency assessment before being allowed to go on the on-call roster. These assessments may be checklist-based or use a global rating scale. An example of a global rating scale used to assess non-technical skills is the Anaesthetists’ Non-Technical Skills (ANTS) system. This is validated by anaesthetists, breaks the skills down into simple categories and gives examples of ‘good’ and ‘bad’ behaviours (5,6).
“Physician, Heal Thyself”
It is important, as with all educational interventions, to seek feedback from the participants of simulation training. This type of evaluation is essential in order that the training is relevant, pitched at the right level, and continues to adapt and improve over time.
Simulation training does not need to be complicated or expensive. With a bit of teaching experience and some insight into debriefing techniques, you can make a start. There are several courses out there for would-be simulation trainers, and a wide range of equipment available, covering every body part and clinical situation. Please see my website (www.mobilesim.wordpress.com) for more information about mobile simulation training. There are lots of resources and several scenarios on the site: feel free to use them and to send me some of yours!
The ICU-STAR Program: “An Extra Patient On the Ward Round”
The ICU-Simulation Training at RNSH (ICU-STAR) program was developed by consultants Carole Foot and Liz Steel and clinical nurse educator Greg Thomson at the Royal North Shore Hospital, Sydney.
A unique feature of the program is that the simulated scenarios run as 5-day long “patient journeys”. Each day, one or two nurses take a patient handover then perform their usual checks and examination before the medical team attend a few minutes later. The same medical team sees the patient every day for the five days as “an extra patient on the ward round”, typically mid-to-late morning after the “real” ward round is finished. ICU charts and notes are made for the scenarios, which are updated by the team each day. ECGs, blood gases and radiology are also available. On some days, the team may just do “housekeeping”, but on other days, things can go badly wrong….
The training sessions may last 45 minutes or more per day including interactive teaching and debrief, and the program runs about once every four to six weeks. Fortunately, ICU-STAR has its own space in an old side room, which allows for equipment storage and means that the manikin can be left set up.
The program has been running for two years now, has been successfully incorporated into the working day, and is universally popular. Please contact us via the ICN website for more information or visit www.mobilesim.wordpress.com
Some Advantages of In-Situ Training
Simulation is educationally effective: it improves performance of technical and non-technical skills (7)
It is useful for practicing a team response to low-frequency, high-risk clinical events
Staff can act in usual roles, using usual ward equipment; enhancing realism and validity (1)
Working in ‘intact teams’ may improve inter-professional relationships and decrease the anxiety sometimes associated with simulation
Staff do not have to leave the workplace or take leave
Real ward events and case-mix can be re-created
Local system errors are easily identified
Insights can be gained from all inter-professional team members during debrief
Weinstock PH et al. Simulation at the point of care: reduced-cost, in situ training via a mobile cart. Pediatric Critical Care Medicine 2005; 6: 635-41.
Cook SC, Gatward JJ, Kelly FE, Bell J, O’Higgins FM, Thomas MJ. Simulation training at the point of care to decrease the incidence of airway complications on the intensive care unit. Critical Care 2010; 14 (Supplement 1): 463.
Flin R, O’Connor P, Crichton M. (2008). Safety at the Sharp End. A Guide to Non-Technical Skills. Farnham: Ashgate Publishing.
Petty G. (2009). Evidence based teaching – a practical approach. Cheltenham: Nelson Thornes
Fletcher G, McGeorge P, Flin R, Glavin R, Maran N. (2003). Anaesthetists’ Non-Technical Skills (ANTS). Evaluation of a behavioural marker system. British Journal of Anaesthesia 2003; 90: 580-8 and online.