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Is It Time to Rethink the Way We Deliver Simulation in the Clinical Setting?

Brown, Kristen Michelle, DNP, CRNP, CPNP-AC

Journal of Pediatric Surgical Nursing: July/September 2018 - Volume 7 - Issue 3 - p 69–70
doi: 10.1097/JPS.0000000000000180
Guest Editorial

Assistant Professor & Advanced Practice Simulation Coordinator, Johns Hopkins University School of Nursing, 525 N. Wolfe Street Room 452, Baltimore, MD 21205. E-mail:

The author declares no conflict of interest.



There has been a shift from content-focused to competency-based curriculum in healthcare (Schumacher & Risco, 2017). It is not surprising that competent providers provide better care, recognize acute changes, and may prevent significant morbidity and mortality. The bottom line is that experienced and well-trained providers contribute to improved patient outcomes. So how do we train better providers? To be better at a skill or task, one needs to practice. The phrase “practice makes perfect” means that it is possible to learn something or develop a skill if you practice enough—but what if you practice it wrong? Are you still perfect, or are you only reinforcing bad behaviors? Repetitive practice with proper “coaching” has been shown to be an effective means to achieve competency (Hunt et al., 2014). In a recent publication by the American Heart Association (Cheng et al., 2018), mastery learning and deliberate practice are discussed as a means to improve resuscitation techniques. The authors remind us of the famous football coach Vince Lombardi’s important spin on the “practice makes perfect” notion—“perfect practice makes perfect” (Cheng et al., 2018). They stress the importance of repetitive practice with coaching. This is analogous to the deliberate practice work of K. Anders Ericsson. Deliberate practice involves repetitive performance of defined skills with specific assessment and feedback, ultimately resulting in the development of expertise (Ericsson, 2008).

Simulation training allows the learners to practice with a “coach” to improve performance and ultimately improve competency. Simulation has been proven to be an effective educational tool for training providers to manage multiple patient scenarios, including high-risk situations (Boling & Hardin-Pierce, 2016), and it may be particularly important for training where exposure in real patients is inconsistent. Simulation has been proven as an effective means of training in multiple industries, including health care. So why aren’t all health care settings implementing simulation training on a regular basis, and how do we deliver this education in a cost-effective, timely manner?

The biggest barriers to simulation training include cost, time, and personnel. Implementing simulation experiences can be costly. First, there is the cost of the actual simulation space, equipment, and staff and faculty to facilitate the simulation. Second, simulation training takes time. It is difficult to educate nurses and other team members in the acute care setting. Most simulation experiences require the participants to attend on a day off from clinical care. In addition, it can be extremely difficult to bring together professionals from multiple disciplines for training on the same day. This poses another time and expense requirement.

To bridge the gap in exposure to simulation experiences, in situ simulation has been shown to be an effective educational opportunity in the clinical setting. In situ simulation is simulation that occurs in the actual clinical environment during a typical workday (Patterson, Blike, & Nadkarni, 2008). Weinstock, Kappus, Garden, and Burns (2009) described in situ simulation over a decade ago. This simulation methodology has been increasingly utilized as a tool for skills acquisition and team communication training. In situ simulation is a great way to train multiple providers during the course of the workday, and this methodology allows for identification of latent threats and identification of systems issues within the actual clinical environment.

One of the biggest roadblocks to implementing a successful in situ training program is the perception that it disrupts the flow of the workday. Practice isn’t going to change, and patient care will always come first. When implementing an in situ simulation program, one needs to take into account the rigors of the providers and deliver simulation in quick bursts that can be absorbed into the working day. In situ simulation needs to be done in a predictable manner. In addition, there needs to be a system in place that allows for sustainability. The staff needs to know that there is a set time frame. The time allotted for the simulation will depend on the complexity of the case. Usually, 30 minutes is an acceptable time to implement a short and effective simulation experience. To do so, there needs to be specific learning objectives. It is more important to educate providers regarding a few concepts more often than to forego the opportunity altogether.

When implementing a simulation initiative, it is important to have trained simulation educators. In situ simulation is usually well received when resources are allocated for the training. A resource available to help deliver effective simulation education is the International Nursing Association of Clinical Simulation Leadership (INACSL) Standards of Best Practice: Simulation (The INACSL Standards Committee, 2016). According to INACSL, these standards reflect best practices or polices “that provide a foundation of decisions and actions defined by shared values, beliefs, and principles” (p. 1876). The INACSL standards of simulation cover four domains: rationale, outcome, criteria, and guidelines.

It is critically important that nurses involved in the care of surgical, trauma, and burn patients have proper training regarding the management and up-to-date policies and procedures. Implementing an in situ simulation program is an excellent educational strategy for multidisciplinary surgical training. Multiple providers are usually involved in the management of these patients, and off-sight simulation training may not always be feasible. Implementing short, time-specific, routine in situ simulation training in an acute care surgical unit may be a reasonable approach to train multiple providers in the management of these complex patients.

With the proper resources, staff, and leadership, in situ simulation may be an effective tool for educating providers in the acute care setting. Providing consistent in situ simulation in clinical practice with committed resources may improve team communication, identify latent systems and environmental threats (Patterson, Geis, LeMaster, & Wears, 2013), and allow an opportunity to provide “just-in-time” training and education to providers.

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