Simulation-based education (SBE) has been widely accepted in the medical literature as an effective means to teach and refine clinical skills. In this modality, students and health care providers enter a “safe haven” wherein they can practice and perfect procedural skills, difficult techniques, and team-building exercises. Course facilitators provide the participants with real-time feedback or video playback (or both) of their performance to enhance the learning even further. When done properly, SBE has the means to ultimately improve quality care, patient safety, and clinical outcomes.
SBE is so well respected that many medical and allied health care schools designate simulation days into their curriculum, allotting time for their aspiring practitioners to participate in this dynamic and interactive learning experience. Unfortunately, many practicing providers do not have the luxury of protected education time as students do, and they often miss out on this continuing education opportunity purely due to logistical and time constraints. The challenge of leaving their units for a predetermined and substantial portion of time and traveling to a simulation center is significant considering nurse-to-patient ratio and patient acuity.
Thus, in recent years, in situ simulation (ISS) has emerged as a unique, viable, and realistic opportunity to bring leading edge SBE to clinical units, anytime and anywhere. This learning modality occurs directly where patient care is given, eliminating the need for providers to travel to a simulation center. Simulation specialists and technicians bring their simulators or task trainers to clinical units and outpatient centers, and the participants act in their real-life professional roles, using their own equipment and resources to replicate contemporary clinical practice. Using their own equipment in their own spaces enhances the validity of the training. This type of education overcomes the logistical challenges providers face, such as traveling to an off-site simulation laboratory or center, thus saving time and money. Research has also shown that ISS promotes teamwork and communication, providing participants with opportunities to critically review general patient care, to improve the patient experience, and to apply simulation as a tool for quality improvement (Bajaj et al., 2018).
However, several logistical obstacles with ISS remain: securing locations for education in the units, using nurse educators to run simulations, and pulling the providers away from their duties for a full ISS session. Furthermore, the ISS education often produces increased cancellations due to patient care priorities, lack of room availability to conduct sessions, and lack of specialized course facilitators for teaching and briefings (Sørensen et al., 2017). Others have reported that ISS can be challenging due to technical, administrative, logistical, cultural, and financial constraints (Alkhulaif et al., 2015) and may lead to nuances in personnel, equipment, or logistical issues (Clapper, 2013). This article describes an innovative solution devised to overcome some of the typical ISS challenges.
The authors noted these ISS challenges and sought to develop an innovative and robust method to educate their providers in the most convenient and effective ways. The two main ideas to overcome typical ISS challenges were to provide succinct education and to educate anywhere. Educating providers via customized concise modalities for a specific skill or procedure would help reduce the time spent away from patient care. Moreover, enabling the education to occur not only where patient care is given but also anywhere within that institution (i.e., unoccupied patient rooms, nursing stations, break rooms) would alleviate the issue of securing special education rooms. This easy mode of education could be offered in the form of a traveling educational cart (Figure 1).
Traveling education cart in action.
This cart is a form of ISS that is easily transportable, used to deliver efficient and effective education wherever and whenever it is needed. The cart contains all the teaching materials and simulators needed to provide individualized, customized education in any space, at any time. The cart can also contain a laptop equipped with internet and audio/visual capabilities providing the opportunity for immersive clinical skills feedback. The laptop also contains simulated electronic health record software to ensure learners' knowledge of accurate documentation. This “playground” area is a virtual simulated environment that replicates the actual clinical medical records. All information including patient demographics is fictitious. The cart enables the educators to provide succinct education by focusing its teaching on one single skill or procedure at a time. They are committed to a deep dive of one topic at a time to ensure learners' full theoretical understanding and perfected skills.
The simulation nurse educator trains individuals using simulations in one-to-one or small group settings to keep the potential disruption to the unit minimal. The authors have found that the traveling education cart can accommodate up to 10 providers at once; however, the ideal sample is five or fewer. The education is customized to the current issues of concern with the unique health care providers, such as the placement of Foley catheters, crash cart review, and proper hand washing technique. The dynamic education is customized to meet the unique learning needs of each small group. For example, a nurse educator can use the traveling education cart to provide catheter-associated urinary tract infection (CAUTIs) education to groups who need a refresher. The educator can use the pelvic task trainer and the catheterization equipment on the unit to review proper cleaning and insertion techniques. The educator can also demonstrate noninvasive equipment to prevent CAUTIs.
Formal training room reservations with staffing assignments becomes obsolete with this cart because the education is offered by simulation nurse educators in whatever space is available. At 34” × 20” × 34,” it is a flexible means to provide relevant, succinct, real-time education that allows the providers to return to their patient responsibilities as quickly as possible.
Simulation nurse educators are experts in SBE and provide thorough education complete with prebriefing and debriefing components. The nurse educators provide traveling educational cart participants with an overview of learning objectives and expected outcomes for the session followed by the ISS. This ISS usually varies in length between 5 and 10 minutes depending on the topic and the needs of the learners. Each session is customized to ensure the learners are provided with the educational tools for clinical success. After the session, these experts provide real-time one-to-one feedback to the learners regarding their skills/performance.
The educational experts also provide the unit managers, nurse educators, and quality/safety team members with aggregated feedback if requested or if “need to know” pertinent information arises. These findings are communicated via an internally created “Findings Report” sheet, which is a six-item form that standardizes communication between the education experts and the institution's leadership. This information can be anything discovered in the units that affects safe, quality care. Simulation nurse educators check off which hospital process had the issue, identify the potential severity of the issue if left untreated, and the estimated frequency with which they estimate the issue would likely occur. The simulation nurse educators detail the issue and explain why it is a concern and devise recommended solutions.
Education via this traveling cart can be requested by individual providers, clinical unit managers, or nurse educators. Patient safety and quality educators can also request education as they monitor data related to hospital acquired infections (HAIs), or when a new product is being introduced. Moreover, this cart can be used as tool to provide ongoing and proactive education regardless of HAI rates. Requests are simply made by emailing or calling the SBE specialists. Once requested, the simulation nurse educator will review learning objectives and the expected outcomes with the requestor, as well as devise a specific educational learning session to meet their unique learning needs. The authors periodically email reminders to staff members promoting the availability of the traveling education cart, its purpose, and how to schedule a learning session. Detailed information on the cart is also posted on the network's intranet site.
During a 6-month period from April to September 2019, 219 learners underwent training via the traveling education cart and 152 learners submitted a completed author-developed evaluation, yielding a solid response rate of 69%. This evaluation was a 14-item, paper-and-pencil, anonymous and confidential survey following their education session. The survey comprised three demographic items, 10 closed-ended evaluative items, and one open-ended item for comments and suggestions. Learners were asked to rate how much they agreed or disagreed with five aspects of the simulation education and five aspects of the traveling education cart modality on 5-point Likert scales.
Most respondents identified their professional role (n = 146; 96%) and most of them identified as a nurse (n = 102, 70%), followed by nurse assistants (n = 31, 21%). Figure 2 displays the professional role composition of the responding sample.
Professional role composition. Note. ASLT = advanced life support technician.
A little more than half of the learners (n = 78; 51%) indicated which specialty area they currently work. These responding clinicians worked in a variety of different specialties, with most of them working in the emergency department (n = 37, 47%), followed by the intensive care unit (n = 17, 22%). Figure 3 displays the frequency distribution of respondents as a function of specialty area.
Frequency distribution of specialty areas. Note. ICU = intensive care unit; PCU = patient care unit; Rehab = rehabilitation unit.
Most respondents agreed or strongly agreed that the simulation training provided them with the opportunity to think critically, taught them something new, was helpful to their professional role, was sufficiently realistic, and was worth their time. All these items had affirmative percentages at or above 85%. Table 1 lists the agreement frequency distributions to these items.
Frequency Distributions of Agreement with Course Items
Only eight respondents (5%) wrote comments or suggestions in the open-ended item of the evaluation. All written comments were positive. The most frequent comment was expressions of gratitude (n = 5; 63%). Table 2 lists the learners' positive comments.
Learners' Comments Verbatim
Results from this case study provide supporting evidence of the in situ simulation traveling cart educational modality. This well-received education is concise and mobile, making it flexible with the potential to develop a cost-effective educational system for training practicing providers. The limitation of this case study is variations in allotted education time due to the critical needs of the department. Issues such as patient acuity, an unexpected reduction in staffing, and unexpected emergencies often limit the time that can be devoted to the education, and specifically to the debriefing component. However, these challenges are nearly unavoidable. Other institutions who wish to educate their providers may implement a replicate program.
- Alkhulaif, A., Julie, I., Barton, J., Nagle, E. & Yao, A. (2015). Implementation of in-situ simulation training: Advantages, challenges and obstacles. Medical Training Magazine. https://www.halldale.com/articles/13025-implementation-of-in-situ-simulation-training-advantages-challenges-and-obstacles
- Bajaj, K., Minors, A., Walker, K., Meguerdichian, M. & Patterson, M. (2018). “No-go considerations” for in situ simulation safety. Simulation in Healthcare, 13(3), 221–224 doi:10.1097/SIH.0000000000000301 [CrossRef] PMID:29621037
- Clapper, T. (2013). In situ and mobile simulation: Lessons learned…authentic and resource intensive. Clinical Simulation in Nursing, 9(11), e551–e557 doi:10.1016/j.ecns.2012.12.005 [CrossRef]
- Sørensen, J. L., Østergaard, D., LeBlanc, V., Ottesen, B., Konge, L., Dieckmann, P. & Van der Vleuten, C. (2017). Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation. BMC Medical Education, 17(1), 20 doi:10.1186/s12909-016-0838-3 [CrossRef] PMID:28109296
Frequency Distributions of Agreement with Course Items
|The Hands-On Simulation…||n||Strongly Disagree/Disagree||Neutral||Agree/Strongly Agree|
|Provided me the opportunity to think critically.||150||0 (0%)||22 (15%)||128 (85%)|
|Taught me something new.||150||0 (0%)||7 (5%)||143 (95%)|
|Was helpful to my role.||150||0 (0%)||4 (3%)||146 (97%)|
|Was sufficiently realistic.||149||0 (0%)||7 (5%)||142 (95%)|
|Was worth my time.||149||0 (0%)||1 (1%)||148 (99%)|
Learners' Comments Verbatim
|“Thank you—we needed this!”|
|“Learned about the colonization of Co2H! Thx”|
|“Like this kind of teaching”|
|“No one ever comes on night! Thank you!”|
|“Thank you for coming on nights!”|
|“Will get a Foley out today!”|