Twelve tips for developing and implementing an effective critical care simulation programme

Abstract

Simulation training in healthcare settings has become a valuable training tool. It provides an ideal formative assessment for interdisciplinary teaching. It provides a high fidelity and highly immersive environment where healthcare staff and students can practice developing their skills in a safe and controlled manner. Simulation training allows staff to practice skills that better prepare them for clinical emergencies, therefore possibly optimising clinical care. While the benefits of simulation education are well understood, establishing a programme for use by critical care staff is complex. Complexities include the highly specialised scenarios that are not typically encountered in non-critical care areas, as well as the need for advanced monitoring equipment, ventilation equipment etc. These 12 tips are intended to assist healthcare educators in navigating the complexities in the establishment of a critical care simulation programme, providing advice on selecting target audiences, learning outcomes, creating a critical care simulation environment and recommendations on evaluation and development of the programme.

Keywords:

• Simulation
• anaesthetics
• clinical skills
• medical education research
• staff development

Introduction

Simulation training provides a significant advantage for knowledge and skills acquisition (Guerrero et al. 2022). This format for experiential learning has multiple dimensions that make it the ideal modality for teaching and formative assessment. It creates a high fidelity, highly immersive and safe environment for healthcare education, allowing participants to act at the higher level of performance in Millers pyramid of medical competence (Miller 1990). Each scenario is designed to improve core technical and non-technical skills needed in healthcare settings (Gaba 2004).

Patients in the intensive care unit (ICU) require invasive monitoring and efficient interprofessional team performance in a high-stakes environment fraught with potential complications. Simulation training is particularly well suited to safely learning and practicing both the technical and team skills needed for critical care practice (Seam et al. 2019). Simulation training develops both psychomotor and critical thinking skills. These are vital skills for all healthcare professionals providing care to patients in ICU settings (Cantrell 2008).

Despite the known benefits of simulation education, there are particular challenges in creating a simulated ICU setting. The ICU requires specialist equipment needed for managing critically ill patients requiring organ supports (Bion and Dennis 2016). Critically ill patients require high levels of support (invasive monitoring, ventilatory assistance, renal replacement therapy, extracorporeal membrane oxygenation etc), and for this reason, expensive equipment must be provided to reflect the ICU environment, adding to the substantial expense of creating a critical care simulation facility. In this article we provide some tips on how to circumvent some costs that could be incurred when establishing an ICU simulation programme, that do not jeopardise the realistic setting being portrayed.

This 12 tips article is designed by critical care educators with experience in designing and implementing a critical care simulation education programme. It is expected that these 12 tips will guide healthcare educators in navigating through the complexities involved in the development of a critical care simulation programme. Tips 1–4 are intended to help with the initial steps needed for planning a simulation programme, tips 5–10 were created to help with designing and implementing a simulation programme tailored for patients in ICU, meanwhile, tips 11–12 are intended to assist with critical appraisal and the continuous development of a critical care simulation education programme.

Planning

Tip 1

Select target audience and plan programme with staff management

The first step when designing a critical care-based simulation programme is to choose the target audience. This is a vital step to ensure the scenarios are designed in line with scope of practice for each discipline concerned. The programme can be interdisciplinary, involving nurses, doctors and allied healthcare professionals or discipline specific, e.g. nursing staff only. Understanding the disciplines involved is just one step in choosing the target audience and it is equally important that attention is given to the skill level of the target audience. Within the nursing profession, skill level can vary from student nurse to advanced nurse practitioner and within medicine, participants can vary in skill level from medical student to consultant level. Understanding the skill level of the target audience is a fundamental component in the planning and design phase. Participants should be challenged on their skills, but they should not be expected to perform skills that are beyond their professional scope.

In conjunction with the generation of your target audience, focus should also be toward identification of overall goals and outcomes, in the early stages of creating a simulation programme. Once the audience and overall goals of the programme are created then the process of how to create a simulation programme can begin.

Gaining the support of staff management to aid in organising and supporting the simulation programme is also vital to establish a worthwhile and co-ordinated simulation-based training programme. Staff is a limited resource in an ICU setting and therefore co-ordinating a detailed schedule with management is imperative to the success of the programme (Seidel et al. 2006).

Tip 2

Gather a simulation team to develop and deliver a critical care simulation simulation programme

A key component to any successful simulation programme is gathering a simulation team with experience in creating appropriate simulation scenarios and with the ability to deliver effective simulation-based teaching that allow the target audience to get the best learning experience. Faculty development has been identified as crucial for the success of simulation programs (Peterson et al. 2017).

The planning and development of critical care-based scenarios requires input from senior nursing and medical staff with extensive experience in clinical practice and education. It is therefore vital to design a curriculum catering for healthcare staff of varying levels of experience and competency. Simulation-based skills education requires highly realistic or challenging scenarios in order to hold value and be perceived as contributing positively to skill acquisition (Bath and Lawrence 2012).

The facilitator is key to participants learning. The facilitator guides and supports participants to understand and achieve the objectives (Boese et al. 2013). Their role is vital in directing participants through the simulation session and delivering a productive debriefing to maximise learning and development. Some institutions offer a formal simulation education programme that should be utilised if available.

Tip 3

Explore established simulation programmes

The development of practice scenarios is a process with challenges that must be addressed for the full learning potential of simulation-based training (SBT) to be realized. Scenario templates are useful tools for assisting with SBT and navigating its inherent challenges (Benishek et al. 2015). A template should be adopted for the simulation programme that is well established within the simulation network where it is being used and therefore all staff and technicians involved with the design and delivery of each scenario will be familiar with it. Some institutions publish existing scenarios that can be reproduced at other sites. They may publish in Open Access journals or upload to an institutional repository. Some organisations also provide templates and scenarios on their websites that can be reproduced with permission, or used to guide the development of new scenarios.

When establishing our critical care simulation teaching programme, we reviewed an established medical intern simulation programme that was designed and hosted by our teaching network. Through this we could identify templates for creating scenarios, resources, and potential challenges within our teaching network.

Tip 4

Identify gaps in target audiences’ competencies and create site specific scenarios with clear learning objectives

Now that our target audience, overall goals and simulation programme team have been created, it’s time to focus on specific scenarios and learning objectives.

The simulation scenarios need to explore the competencies of participants, each scenario must be designed to stimulate the participants to apply their knowledge and competencies as well as allowing the participants to identify their limitations.

Clearly defined learning objectives (LOs) should be at the forefront of each simulation scenario and these learning objectives should be identified through discussing with senior member of staff the areas in which participants need to improve. Senior management might be aware of knowledge gaps among staff and may be familiar with areas identified for improvement through audit and benchmarking. Simulation sessions can then be targeted towards addressing these gaps. Revision of critical incident reports, common complications and near misses experienced in a given critical care unit can also be used to design site specific scenarios. Training should focus on measurable LOs. Additionally, the LOs should be adjusted to participants’ levels so as not to cause frustration or boredom. Literature subdivides LOs into knowledge, skills (procedural or technical), and behaviours or teamwork (Naylor and Torres 2019).

A simulation case for raised intracranial pressure in a neuro-ICU setting is an example of a target scenario for staff working in a neuro-ICU where LOs can be carefully designed in order to improve participants competencies. Identification of raised intracranial pressure, patient examination and management strategies would all be key LOs in this case.

Programme design and implementation

Tip 5

Create scenarios appropriate to target audience using common critical care scenarios that will translate to real life

In order to gain the most benefit from simulation scenarios, they need to be designed to replicate true to life situations that the participants will face in their day-to-day life within the ICU. Scenarios may also include a teaching opportunity for the application of poorly adhered to guidelines in critical care as shown by Toft et al. (2023).

In the ICU some events are rare but possible. These events include dislodged tracheostomy, migrated endotracheal tube (ETT) and many more. Staff in ICU do not manage these scenarios in day-to-day practice. Nonetheless, they must be prepared to manage these events. In reality, staff are often ill-equipped to deal with these complex and life-threatening scenarios due to lack of exposure (Pacheco Granda and Salik 2022). Simulation offers the opportunity to maintain and practice these skills to ensure staff are prepared for emergency situations within the ICU. Participants must also be expected to perform roles and tasks in these simulation cases as they would in their professional role. The primary goal of each scenario is to increase confidence in critical care situations that the participants will face in their clinical role (Bullard et al. 2017).

For example, sepsis can be identified during ICU stays in 29.5% of patients and overall ICU mortality rates for sepsis are 25.8% (Sakr et al. 2018). Scenarios are created to ensure that participants are trained to achieve competencies such as recognising sepsis, implementing the sepsis six bundle and escalation of care in an appropriate manner (Burke et al. 2019). Therefore, ICU staff can be trained to identify and manage deteriorating patients to prevent mortality. Through simulation training, ICU staff can be exposed to these scenarios and develop competencies needed to manage medical emergencies. Scenarios like sepsis are vital to staff training, they provide exposure to critical care scenarios and improve staff preparedness and confidence (Table 1).

Table 1. Sample ICU scenarios.

Dislodged ETT in a proned patient	Overdose- calcium channel blocker, beta blockers, digoxin etc.	Patient transfer to radiology	Bleeding post cardiothoracic surgery
Septic shock and cardiac arrest	Blocked tracheostomy	Subarachnoid heamorrhage re-bleed	ARDS proning

Tip 6

Gather all available equipment and examine challenges in creating a simulation ICU setting

One particular challenge in generating simulation in critical care is providing a realistic ICU setting. Emphasis should be placed in creating an authentic ICU setting with all the available equipment. A functional ventilator, invasive monitoring and haemodynamic support equipment should all be available and attached to the simulated patient in order to mirror a standard patient in the ICU that participants are working in. Simulation training should be set within the construct of real-life situations as closely as possible (Kneebone 2010). An example of how a simulated ICU looks incorporating ventilator and advanced monitoring can be found in Figure 1.

Figure 1. Simulated ICU patient.

Additionally, some companies providing simulation equipment (mannequins etc) will train and certify facilitators. In the context of critical care-based simulation programmes, facilitators need to be creative in their thinking. Designing a simulated ICU with advanced monitoring and ventilatory equipment requires careful consideration. Furthermore, even some high-fidelity mannequins cannot be invasively mechanically ventilated. This limitation can be somewhat overcome by incorporating strategies to simulate invasive mechanical ventilation through the use of test lungs and other equipment.

The use of screens with graphical user interfaces (GUI) to replicate screens used at patients bedside in ICU offer an opportunity to create an identical environment. These GUIs allow participants to be fully emersed in an ICU scenario using hardware that they will experience in the real ICU setting. It will allow simulation faculty the ability to display information in real time and give participants the opportunity to develop skills in interpretation of this information, such as ventilator functionality and invasive monitoring. Additionally, GUI screens can provide a cheaper alternative for hardware such as a fully operational ventilator.

Tip 7

Orientate participants to simulation setting at the start of the scenario

On initiating the scenario, participants should be orientated to their location and the patient as they would be in a normal clinical setting. A patient handover should be prepared and provided to the participants in a verbal and written manner prior to entering the simulated ICU (Watts et al. 2014). This will improve participant immersion in the scenario and facilitate improved communication skills when escalating patient care. Some participants will have no experience in simulation training which may impede or limit participant engagement. A brief explanation of how the equipment works, outlining any ‘ground rules’ is imperative to encourage participation. Other limitations might exist and should be explained to participants including the ability to perform phlebotomy, the maximum size ETT that can be placed, inability to use water-based lubricants for intubation and the inability to attach the mannequin to a ventilator without specialised equipment being installed. These are just some of the considerations to be aware of when orientating participants to the simulation setting.

With experienced participants it may be more appropriate to provide a brief introduction to the scenario and allow the participant to use their own skills to assess and consider the situation as they approach a critically ill patient. They will therefore take a senior role and enhance their problem-solving skills and situational awareness skills. ICU practitioners need to be able to apply their clinical skills outside the ICU during inter/intra-hospital transfers as well as reviewing patients in the emergency department and on inpatient wards.

Tip 8

Provide participants with the tools to focus on developing key technical and non-technical skills

The main objective from participation in simulation is to develop core technical and non-technical skills that can translate into practice (Magill and Tolley 2020). Patient safety depends on both technical and non-technical skills, with a higher rate of non-technical skills failure leading to patient harm (Lynch 2020). The simulation scenario should provide a lifelike experience with participants working in a manner that they would in practice, particular emphasis should be put on clinical skills, communication, teamwork and situational awareness in the management of an acutely deteriorating patient. Where possible, incorporate tools used in the clinical setting where participants work. Clinical skills might include application of ventilatory support, adjusting ventilator settings, ability to transfer a patient safely to theatre/radiology department, drug prescription and administration, insertion of invasive monitoring devices as well as gaining central and peripheral intravenous access in a timely manner.

For example, scenarios should be designed to have a similar number of participants of varying levels of experience to reflect that of an ICU. Role allocation is important to consider before commencing a simulation session so that all members of the team have clear roles and responsibilities.

Tip 9

Implement a standard of care that is advocated within the local ICU

Scenarios should follow local protocols and guidelines; patient care pathways should reflect those adopted in ICU. Participants should be able to access local standards of care as they would in a normal clinical environment. Adherence to established protocols improves participants performance in critical situations and may improve survival for in-hospital arrests (Eppich et al. 2006).

For example, use guidelines that are implemented by the hospital participants are affiliated with. Use the simulation as an opportunity to explain to participants where they can find these tools, protocols and guidelines on return to the clinical setting. This ensures participants can adopt these standards and protocols in clinical practice.

Each simulation should give the learning opportunity to implement local guidelines, such as care pathway for dislodged tracheostomy, migrated endotracheal tube (ETT), signs of raised intracranial pressure and sepsis.

Tip 10

Provide structured and interactive debrief session after each scenario

In the immediate aftermath of the simulation scenario there is a strong need for debriefing following its conclusion to help participants decompress and integrate the experience into their knowledge base (Cantrell 2008). Personal feedback from participants should also be gathered. Simulation faculty should seek initial feedback from participants to allow participants to reflect on their performance, discuss gaps in knowledge and discuss any potential uncertainties. Additionally, it will provide a non-judgemental environment to discuss negative emotions experienced during the scenario.

Key learning outcomes can be discussed, and this debriefing session provides participants with feedback on what went well and areas that can be improved upon allowing for reflection and overall improvement in practice. Effective debriefing can allow participants to reflect on their previous knowledge and what they have learned through simulation. Participants can therefore implement change in their own practice to improve following each simulation session (Koshy et al. 2017).

Despite the well described benefits of debriefing in the ICU, there continues to remain a disconnect between knowledge of the importance of conducting debriefing sessions and their actual implementation. This can be due to various circumstances including, time pressures and demands in patient care (Rajwani 2019). Debriefing in simulation gives critical care staff and opportunity to discuss their experiences with complex patients that they may not get exposure to in their clinical environment. Debriefing affords ICU staff the opportunity to explore their emotions and gives time for addressing gaps in knowledge. With the ICU being a fast-paced environment, staff teaching on an individualised basis such as debriefing is not always feasible and therefore dedicating valuable time for debriefing affords participants a learning opportunity that is a limited commodity in their normal working schedule.

It is also important to be mindful that the ICU is a high-stake, high-pressure environment. Simulation sessions could potentially evoke unwanted memories of a particular case or real-life clinical scenario that did not go well. Facilitators must be aware of this and be willing to offer support and advice at times like this and to direct these participants to staff counselling services that are available.

Continuous improvement

Tip 11

Gain structured feedback, evaluate and continually improve simulation programme

Following each simulation session structured feedback should be sought from participants and faculty in order to continually improve the simulation scenarios and settings. Adopting sound educational principles, collaborating with others, and ensuring a quality control process is essential to creating a quality simulation programme (Alinier and Platt 2014). Feedback from participants working within the ICU will allow improvements regarding scenarios, their set up and the environment created. Feedback should also provide the simulation faculty with valuable insight into the need’s specific to ICU staff.

As previously mentioned, simulation scenarios should incorporate relevant clinical guidelines and polices. When updating and continuously improving these scenarios, it is important to ensure the guidelines and policies are up to date to ensure the teaching provided incorporates the latest evidence-based recommendations.

Tip 12

Evaluate the effects of the simulation programme on patient outcomes in the ICU

A long-term plan for the delivery and improvement of the programme should be implemented. The overall aim is for quality improvement amongst staff in critical care. Therefore, research should be completed to identify if standards and protocols are adhered to within the ICU and if overall competence of staff has improved following the introduction of a critical care simulation programme. The Kirkpatrick classification is a valuable evaluation of training tool used for simulation, level 4 on the Kirkpatrick classification should be the overall goal of simulation reflecting its benefit on patient outcomes (Kirkpatrick 1996; L’Her et al. 2020). Previously, simulation-based education was associated with small-moderate patient benefits when examining simulation across a host of clinical areas (Zendejas et al. 2013). However, a focused evaluation of the effect of simulation on patient outcomes in ICU is needed. There are a number of potential ways to measure the effects of simulation training programmes on patient outcomes including measuring adherence to protocolised care, assessing completion rates of patient safety checklists, establishing the incidence of adverse events where simulation training aims to avoid certain events.

Staff satisfaction should also be included in the evaluation of the program. It is important that participants’ perception of their ability to manage critical care situations improves. Increasing staff satisfaction and ability to cope with the demands of intensive care medicine will retain staff and alleviate the widening staff shortage in healthcare, workplace disruption and improving patient care (Elpern and Silver 2006; Toft et al. 2023).

Summary/conclusions

Studies on the effectiveness of simulation in healthcare have shown its benefits in improving learner, patient and healthcare system outcomes. Simulation can be implemented to train ICU staff to work effectively in an emergency and to allow each team member to practice appropriately performing clinical skills, so they can best care for patients in life-threatening circumstances.

An organised and structured plan for creating an ICU simulation programme is vital to developing a sustainable and worthwhile simulation programme. All stakeholders should be involved in the organisation and continuous development of the programme. Careful consideration should begiven to creating a high-fidelity simulation facility to reflect that of an ICU, along with producing realistic simulation scenarios that occur in the context of critically ill patients. Through following these twelve tips, educators involved in critical care simulation education programmes can produce a maximal learning experience for participants that can translate into clinical practice.

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Disclosure statement

The authors report no conflict of interest.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Aidan T. O’Dowd

Aidan T. O’Dowd, Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland.

Natalie L. McEvoy

Natalie L. McEvoy, Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland.

Christopher Read

Christopher Read, Beaumont Hospital, Beaumont Road, Dublin, Ireland.

Dara O’Keeffe

Dara O’Keeffe, Department of Surgical Affairs, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland.

Gerard F. Curley

Gerard F. Curley, Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland. Beaumont Hospital, Beaumont Road, Dublin, Ireland