Simulation is a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or gaining understanding of systems or human practices.1 In situ simulation refers to simulations taking place in the actual patient care setting or clinical environment. These activities usually occur for a shorter period, compared with simulation center-based activities, so that staff can resume their usual work. In situ simulation training is valuable to assess, troubleshoot, or develop new system processes, as well as to address system preparedness, unearth latent safety threats, and promote teamwork and communication within clinical units.1–7 In situ simulation has the potential to improve reliability and safety in high-risk clinical areas by allowing participants to practice and reinforce skills in their own working environment, during their scheduled work hours.6
In our clinical unit, in situ simulation has been used in various ways to enhance efficiency, safety, and teamwork. For example, before reopening a clinical unit, in situ simulation drills were enacted with all returning staff members as an orientation to the new clinical environment. After a sentinel event, unannounced in situ drills were held to test and refine the process of system escalation and communication between departments. In addition, when new technology or equipment has been introduced to the unit, scheduled in situ drills have aided in the transition.
No matter the incentive for developing an in situ simulation program, once a program is implemented, it is important to consider the environment of the actual clinical unit at the time of simulation. By nature, high census and high acuity units will benefit from in situ simulations designed to stress the system; however, those running the simulations must be sensitive to the current conditions already in place on the unit.6 This article explores the specific areas of patient and staff safety, logistical considerations, and establishing a confidential learning environment with regard to in situ simulation.
As reviewed by Kearney et al,8 there are both benefits and challenges to in situ simulation. In situ simulation allows actual clinical teams to practice their response to clinical events in their own patient care areas, use their own emergency call systems, and use their own equipment specific to their units. Learning opportunities can be discovered in the recreation of patient care events, including sentinel events, that may reveal important factors for improved clinical management and system processes.8 In situ simulation may also be used to critically review general patient care to improve the patient experience. It can provide the opportunity to apply simulation as a tool for quality improvement and patient safety in institutions, both inside and outside of academic centers.8
Nonetheless, the potential value of in situ simulation is simultaneously tempered by potential risks, because it takes place in an actual and active patient care setting. Some examples of potential safety issues include the following: the administration of simulated medications to a real patient; soiled equipment being returned to patient use; the use of actual resources (human and others) for simulation; and staff not recognizing the risks of in situ simulation.9 Therefore, the development of a successful in situ simulation program requires the review of these and other potential safety issues that may be present and the respective precautionary measures to prevent them.
Logistical challenges must also be addressed. The planning and execution of this platform can be time intensive and have to be woven into clinical scheduling. Scenarios may be labor intensive in terms of setup and equipment transfer, because the simulation equipment is not permanently placed in the clinical unit.
Another significant challenge of in situ simulation is maintaining a safe and confidential learning environment. This can be difficult to preserve in a clinical care setting, because the monitoring of which individuals float in and out of the clinical space can be challenging. For example, the presence of assessors from an unscheduled regulatory site visit or unit leadership in charge of staff evaluation may pose threats to psychological safety during an in situ simulation experience. In addition, it may be difficult to keep staff engaged in the simulation scenarios if they are met with other responsibilities and stressors during their educational event, for example, phone calls, pagers, and patient care tasks. In this regard, educational drills may be viewed as a “distraction” or “nonessential activity.” Although these factors may deter from involvement in the simulation, these factors may also reflect the reality of actual patient care and can potentially enhance the “real-life” nature of the learning experience8 by addressing the unit's potential capacity to respond to the everyday perturbations that are an inherent part of healthcare.
These challenges can be mitigated by having unit leadership and staff gain agreement to the in situ simulation ground rules before launching an in situ simulation program in the unit. The same ground rules relative to confidentiality apply to the in situ setting. The routine re-evaluation of the successes and challenges met during in situ drills is a necessary process for hospital leaders and the simulation program staff. Leadership has the difficult task of ensuring that there is an appropriate response mechanism to address any threats to clinical care that may arise during in situ drills, while simultaneously supporting the value of in situ educational opportunities.
When considering all the potential issues that in situ simulations may pose, it may be difficult to balance competing priorities to determine when it is appropriate to launch an in situ simulation program. Leadership and staff who do not have a shared mental model around when to deploy this educational experience may decide not to hold the simulation on the unit. As a result, the in situ simulation program runs the risk of having more cancelations than delivered educational experiences.
First introduced by Patterson et al,7 we propose that as part of a comprehensive strategy to ensure the safety of in situ simulation, it is essential to identify and establish “no-go considerations” that are specific to each clinical unit, ie, considerations by which we would opt not to perform simulations. Doing so will allow more appropriate and safer planning of in situ simulation drills. These precautionary measures allow simulations and debriefings to be performed on the clinical unit, while being mindful of staff and patient care safety constraints. Developing and negotiating appropriate no-go considerations are essential elements of the establishment of a sustainable in situ simulation program.
In addition, the development and implementation of no-go considerations provide an additional opportunity to obtain acceptance from staff members by encouraging their input into planning. Staff appreciate that the simulation team is respectful of their clinical responsibilities. As such, it is important for no-go considerations to be adapted or developed by interprofessional stakeholders, including those stakeholders who may not be on the unit but are occasionally called in to assist with events on the unit. An effective development strategy would likely include a series of meetings involving both stakeholders and frontline staff to provide input and refine the considerations. To be successful, no-go considerations must be transparent and should be clearly communicated to all staff members once the in situ simulation program is embedded. These considerations should be reviewed by the simulation team and select staff members (eg, charge nurse or supervisor) immediately before any planned in situ simulation to ensure that the simulation is not detracting from the physical and psychological safety of the unit, its staff, and its patients and families. Finally, no-go considerations should be reviewed regularly and updated periodically as needed.
The authors have developed and run in situ simulation programs in a variety of healthcare settings, each with hundreds of training encounters. Here, we outline a pragmatic approach for the establishment of no-go considerations synthesized from those experiences. We believe that these practices can be universally applied to a variety of clinical units, recognizing that each factor may be considered to a greater or less extent depending on the context of the program within the unit. From our experience, approximately 15% to 30% of in situ simulations will be canceled based on these no-go considerations. On occasion, a simulation may also need to be interrupted secondary to unanticipated actual patient needs. For example, during a planned simulation event, a patient may clinically decompensate unexpectedly on the medical floor requiring added attention from personnel. As a result, the in situ simulation will be canceled to address the clinical needs of the deteriorating patient.
Key Essentials for the Development of No-Go Considerations
- i. Staffing Needs: The clinical unit should be adequately staffed with providers, nurses, and support staff for that shift, taking into consideration staff to patient ratios and acuity. Most clinical units are staffed with a set number of various providers and staff members for each shift. These pre-set values are usually determined from the average clinical volume and acuity of the unit. Ideally, having adequate staffing per the individual unit's recommendations would allow coverage of clinical care to continue, while select staff members (eg, those whose patients can be covered by colleagues who are without a currently assigned patient or those whose patients do not require 1:1 care at the time of simulation) are removed from clinical care for a predetermined period to participate in an in situ simulation exercise. In addition, if responders to the in situ simulation are required to move from their primary work area to participate in a simulation, attention must be given to ensure clinical coverage of their work area during that time; for example, in the case of pediatric staff responding to an in situ simulation on labor and delivery. In situ simulations may still be held in units that are historically understaffed as well, by having preshift huddles with team leaders to assess the staffing, volume, and acuity of the unit before the start of any shift during which an in situ simulation is scheduled. This allows the staff to be active in the planning of their own educational opportunities while promoting patient safety and clinical care first.
- ii. Work Flow Patterns: In situ simulations should not be held during periods of scheduled shift changes, sign outs, breaks, or during a scheduled procedure, to decrease potential threats to clinical care. During the periods mentioned, staff are tasked with the duty to both provide clinical care while ensuring complete hand-offs to oncoming staff or are actively involved in potentially high-risk patient procedures with individual patients, necessitating cross-coverage of other patients' care. During these times, we find it inappropriate to further distract from patient care by pulling staff to participate in simulations. The interprofessional nature of in situ simulations requires that these considerations be made for all disciplines and departments that work together in delivering clinical care.
- iii. Clinical Load/Acuity: The patient census must be taken into account. No-go considerations should factor in both the volume of patients and cases scheduled, as well as the acuity and complexity of current patients and scheduled cases. For some units, certain days of the week are challenging because of typical procedural or surgical scheduling. Alternatively, in the case of a high-risk, high-complexity situations, more staff members than usual may be called upon to assist, leaving less patient coverage available. To ensure clinical safety, simulations should not be scheduled under these circumstances.
- iv. Equipment Needs: In situ simulations should not use low-stocked equipment. If the par level for a piece of equipment is low, it would be unsafe to use that piece of equipment for an in situ simulation, because it would then become unavailable for clinical use if required at the time. For example, if only one defibrillator is available on the unit, it would be unsafe to use that device for an in situ simulation, in the event that an actual clinical emergency occurred simultaneously. As an alternative, a back-up defibrillator could be procured before the simulation for use by the clinical unit, or a defibrillator “owned” by the simulation program could be substituted for the simulation. Another possible equipment consideration may arise when the electronic medical record is being updated or is “down.” In these situations, workflow is changed and may require more attention to detail by staff to avoid patient care mistakes. In situ simulations may overburden participants who are at risk of medical error.
- v. Unanticipated Events/Threats to Psychological Safety: In situ simulations should be postponed in the event of a serious clinical event occurring in the department on the same shift or day depending on the severity of the event. In the case of a serious clinical event, respect and attention should be given to both the clinical care of the involved patient, as well as the emotional well-being of staff involved. When there are unscheduled site visits or other regulatory visits, the simulations may be rescheduled. During regulatory site visits, staff should be primarily focused on appropriate patient care, but also complying with and demonstrating hospital policy and procedure. In addition, if there is no adequate space available for confidential debriefing after simulation activities, the safe learning environment may be compromised. For staff members, these are not psychologically safe times to hold simulation scenarios, and doing so could potentially deter from both patient care and the educational impact.
Our initial recommendations for no-go considerations that were created in the development of our in situ simulation program on labor and delivery can be found in Table 1. We propose the previous recommendations as considerations that should be modified and adjusted to specific clinical units. With ongoing feedback from staff members, there is an opportunity to expand on and further develop these considerations. In addition, the experience of the authors has shown that as healthcare professionals become more comfortable with in situ simulation and recognize its value, the no-go considerations may evolve and adapt to permit a larger proportion of in situ simulations to be performed.7 This may include using a treatment room when no identified patient room is available. In other cases, staff asked to hold an in situ simulation even when a trauma evaluation was in progress in another of the trauma suite bays.7
Future directions include a survey of in situ simulation programs to ascertain what is (or is not) being done related to no-go considerations as part of a comprehensive simulation safety program. Furthermore, the development of a checklist of key no-go considerations will aid teams as they develop considerations specific to their program. In addition, it is possible that modeling no-go considerations before initiating an in situ simulation program may help identify systems and unit problems based on “modeled” cancelations before starting the program. Evaluating reasons for cancelations may aid understanding around conditions that impede or enhance the likelihood of conducting in situ simulation. This may also help in determining which units would most benefit from embedding a program as well as identify what learning objectives should be the focus of the program. Lastly, investigation of adherence to no-go considerations may pose as a proxy for quality, risk, and rigor of an in situ simulation.
Facilitators of simulation-based programming have an ethical imperative to consider safety in determining when in situ simulation should take place. It is expected that despite careful planning, simulations will be canceled because of unanticipated circumstances that meet the no-go considerations. This is not a failure but reflects the program's accountability to the clinical staff and patients. These no-go considerations aid in mitigating the risk of simulation within the clinical environment and builds trust among the participants.
2. Gaba DM. Simulation as a critical resource in the response to Ebola virus disease. Simul Healthc
3. Garden AL, Mills SA, Wilson R, et al. In situ simulation
training for paediatric cardiorespiratory arrest: initial observations and identification of latent errors. Anaesth Intensive Care
4. Gardner AK, Ahmed RA, George RL, Frey JA. In situ simulation
to assess workplace attitudes and effectiveness in a new facility. Simul Healthc
5. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety
of new healthcare teams and new facilities. Simul Healthc
6. Patterson MD, Blike GT, Nadkarni VM. Advances in patient safety in situ simulation
: challenges and results. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools)
. Rockville: Agency for Healthcare Research and Quality (US); 2008.
7. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation
: detection of safety
threats and teamwork training in a high-risk emergency department. BMJ Qual Saf
8. Kearney JA, Deutsch ES. Using simulation to improve systems. Otolaryngol Clin N
9. Raemer DB. Ignaz Semmelweis Redux? Simul Healthc