Simulation is by no means a new phenomenon in medical education; it is an ever-developing learning modality. When agreeing the learning objectives and goals of the simulation, consideration of the locality of your session is essential to maximise the focus of the learning.
In Situ Simulation Versus the Simulation Centre
In situ simulation can be generally taken to mean simulation that is integrated into the real environment. In its broadest sense within healthcare, this could include actual clinical areas where patients are managed, and areas set aside solely for simulation but within a wider clinical area (e.g. a side room of a labour ward permanently set up for simulation). To take this further, it is clear that the in situ environment must be the actual clinical environment for the specific people participating in the simulation. They may be participating in the simulation as part of their normal working day while simultaneously engaged with the clinical care of real patients, or participating solely in simulation with no other responsibilities. The importance of this difference is highlighted under the heading of safety for patients. This is contrasted with simulation centre simulation, which will be isolated either physically or functionally from real clinical areas. Although an isolated simulation set up may not be referred to locally as a ‘Centre’, it clearly should be considered as such. In either case, the simulation modality could of course be anything from a paper-based drill walk-through in the real clinical environment to fully immersive, real-time, psychologically high-fidelity simulation.
What are the Similarities Between In Situ Simulation and Simulation in a Dedicated Centre?
Similarities: Aims of Simulation
With the potential exception of systems assessment (discussed below in What Are the Differences?), the simulation centre and the in situ environment can be used for all the same aims. You will almost certainly soon get tired of people asking you to ‘come and do some simulation’. The first question you should be asking is, ‘What do we need to achieve?’ This needs to be followed up with a serious consideration of whether simulation (in all its many forms) is the most efficient and effective way to achieve that aim for your learner/organisation.
In terms of volume of learning for time spent, constructively aligned, planned learning through debriefing of actively driven simulation is probably the most efficient. This may make use of anything from simple table-top exercises to fully immersive real-time, real-team events. The planned learning content could be equally diverse from practising an uncommon drill in a step-by-step way, to learning how to hand over information in real time. Simulation for formative assessment is commonly used, but in reality, is only efficient for a minority of high-performing, well-trained stable teams: there is usually some planned learning that could be delivered first. Summative assessment of individuals, teams, equipment or work processes can clearly be done in both environments, but the simulation centre is usually better placed in terms of resource and research expertise to create a validated assessment tool which would stand up to scrutiny.
Once the aims are clarified and the specific objectives defined, you will select the cheapest and most efficient simulation modality to deliver what you plan, both in situ and in a simulation centre. You will consider everything from table-top exercise simulation, through individual task trainers, to full-body manikin immersive simulation.
Similarities: Structured Developmental Conversations and Debriefing
A developmental conversation of some form is equally important in both in situ and simulation centre environments. This is both to ensure the objective of the simulation is achieved, but also to maintain the psychological safety of the participants. Of prime relevance here is Ericsson’s assertion that practice merely makes permanent. Development is unlikely without deliberate practice; the sandwiching of active efforts to improve through reflection, facilitated reflection or feedback, between episodes of performance (Ericsson et al., 1993).
When participants are engaging with simulation in their real clinical environment, where there may be resource pressure in terms of time or space, they still require the same amount and quality of debriefing as they would for the same objectives in the centre. If time is tight and you think you may have to cut some debriefing, you’re trying to pack too much in and the simulation activity or scenario needs to be shorter.
What are the Differences Between In Situ Simulation and Simulation in a Dedicated Centre?
Differences: Aims of Simulation
The main potential difference in what objectives can be achieved using in situ simulation pertains to ‘the system’, or the interaction of staff, patients and system with the healthcare process. If a real-time immersive simulation can allow participants, the system and the simulation itself to act and react exactly as they do in real life, then there is a relevance to using this technique. If any of these aspects depart from reality, the data that are discovered are at best less likely to be representative and at worst dangerously misrepresentative of the system being analysed. By extension, this means that using real-time immersive simulation to test a system must have the sole objective of testing the system. Any interference in the running of the ‘scenario’ activity in order to create learning for participants within debriefing is highly likely to pollute and therefore invalidate the systems testing information.
So where does this leave in situ real-time immersive simulation for systems testing? There are various publications associating in situ simulation with the detection of latent safety threats (Patterson et al., 2013; Wetzel et al., 2013; Auerbach et al., 2015). This includes assessment of new facilities and systems before patients are treated, as practised by the UK army for several years (Ingram, M. Col., Clinical Director Army Medical Services Training Centre, personal communication; Kobayashi et al., 2006). However, consider how latent safety threats could be discovered in a more efficient way, or put another way, consider how many of these latent threats are truly ‘hidden’ if we actually look for them in the right way. Gathering key relevant staff together from the top of the organisation all the way to the clinical floor will allow you to identify a process map for the specific ‘system’ that requires testing. Overlaying a failure mode and effects analysis will identify the majority of ‘system problems’, which could be eliminated or mitigated before the manikin even gets out of the box. More importantly, this approach provides you with a structure for data collection if and when you decide to run a real-time immersive in situ simulation system test. In a way, you can sit around the table and conceptually drive a patient through a system within your department. Because our systems within healthcare are complex, as for any other complex system, we would expect errors or latent threats not to be independent. Therefore, running a manikin through the system in real time will only pick up one error chain; one snapshot of things that happened once and not a rich overview of how the system works and what it needs for resilience. Having considered this, you may get to the end of the table-top exercises and then decide that an in situ simulation is in fact warranted, but it certainly should not be your first port of call. Other methodologies for understanding your systems are available and specifically the functional resonance analysis method (FRAM, available at: http://functionalresonance.com/index.html; Hollnagel, 2012) is gaining utility within healthcare, and the reader with aspirations of improving healthcare systems is directed to further reading on this.
Taking a step back to look at the whole picture, perhaps one of the broader aims of in situ simulation is to promote learning in the workplace and a culture of continual support for improvement. Using simulation to make debriefing and learning an everyday occurrence can create a learning opportunity from every clinical encounter, fostering a culture that is continually striving to improve through recognising and understanding success and learning from mistakes. Linking your simulation activity to the clinical governance systems within your organisation will help stakeholders see relevance and value in what you are doing. Perhaps this is the true added value of in situ simulation versus the simulation centre.
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