Simulation operations refers to the coordination and management of the multiple aspects required to plan and deliver simulation-based education. It usually includes:
The HSSOBP™ criteria for meeting the Operations standard are:
(Charnetski & Jarvill, 2021)
©2021 INACSL. Used with permission.
Operators, technicians, or specialists are the masters of the equipment. Often these terms are used interchangeably.
Simulation specialists support the set-up, operation, take-down and maintenance of the equipment for simulations. There can be many components in a simulation, from inventory maintenance to troubleshooting complex equipment. Manikins often have software associated with them. Having a specialized person available to run this component of the simulation allows the facilitators to focus more on assessment. They may also provide technical education to others (Lioce et al., 2020).
Facilitators are responsible for guiding participants through the simulation experience. This role is sometimes referred to as instructors, faculty or simulationists.
Facilitators perform the prebrief and assist with flow through the simulation while observing and evaluating the participants. They encourage discussion while highlighting learning objectives in the debrief and may act as subject matter experts (Lioce et al., 2020). Facilitators are usually involved in planning simulation experiences. They:
Learners, or participants, are the target audience of the simulation-based education intervention.
Learners participate in the activity by:
(Lioce et al., 2020)
Simulated patients, or standardized patients, are individuals trained to portray a patient in simulation education. They are often referred to as SPs or patient actors.
SPs receive specialized training to deliver a high-fidelity and safe simulation experience, particularly for simulations with objectives related to communication. Ideally, they are trained by simulated-patient educators or healthcare simulation educators. They may also provide feedback and evaluate learners (Lioce, et al., 2020).
Embedded participants are individuals who are scripted in simulation roles other than patients. For example, an embedded participant may act as a family member or another healthcare provider.
Embedded participants are often members of the simulation team or other healthcare providers. Their role is to:
The term 'simulated participant' is also used to describe embedded participants (Lioce et al., 2020).
An observer is an individual present for the simulation who is not playing an active role. Observers may include members learning about the simulation process or learners who are not participating in the scenario but will participate in the debrief of the scenario.
Literature suggests that observers who receive clear instructions throughout the experience and participate in the debrief have equal learning opportunities to participants with active roles (O’Regan et al., 2016).
A more exhaustive list of roles and other terms related to simulation can be found in the Healthcare Simulation Dictionary.
Simulation-based education can occur in a variety of environments. Dedicated simulation space may not be available to all; however, it is possible to deliver SBE almost anywhere with the right tools. A dedicated simulation centre is not required to incorporate SBE.
Dedicated simulation space that includes a simulated patient care area, a control room and a separate debriefing space supports the flow and fidelity of SBE. The following images show an example of this configuration.
QEII Simulation, Sim Bay location. ©Nova Scotia Health
QEII Simulation, Sim Bay location. ©Nova Scotia Health
When a formal control room is not available, simulation screens can be used to obscure the learners’ view of facilitators and operators to improve fidelity of the scenario.
©Nova Scotia Health
©Nova Scotia Health
In-situ simulation-based events occur in the actual clinical setting that they apply to. This may be helpful for maximizing fidelity and reaching a variety of active team members; however, the experience might be impacted by organizational culture and be subject to current demands within the patient care area. For example, if an in-situ simulation is planned for staff who are currently on shift in the emergency room, patient care needs supersede participation. The intended participants may not be able to attend, or the physical space intended to be used may be occupied by a patient. In-situ simulation is particularly useful in assessing systems and processes in the clinical setting.
Figure 2: Training using in situ simulation by Marcus Jee, et al, is licensed under CC BY 4.0.
To learn more, check out this webpage about in-situ simulation.
Having a dedicated debriefing space outside of the simulation scenario environment is recommended. This allows learners to step away from the simulation environment to reflect and discuss in a calm, private setting while promoting psychological safety. At a minimum, debriefing spaces should include a table and comfortable chairs.
Moulage involves the use of special-effects and various make-up techniques on simulated patients, manikins, or task trainers to replicate physical signs of illnesses and injuries.
Moulage enhances the physical, conceptual, and emotional realism of a scenario and contributes to authentic learning. For example, a scenario may be more believable if there are important visual cues as the scenario progresses, increasing the learner’s emotional engagement (Stokes-Parish et al., 2019).
Research by Stokes-Parish and colleagues (2020) shows the use of high-authenticity moulage impacts learners’ prioritization and task completion in a simulation scenario. This indicates that using highly authentic moulage optimizes learning conditions. Watch the following video about using moulage in healthcare simulations:
Quality moulage can be time-consuming to prepare, and at times moulage can be distracting to learners. Its use must be assessed to ensure its benefit in the SBE intervention. Keep it simple and real. Only apply what is needed for the specific scenario.
Simulationists may acquire moulage skills through training and/or reviewing resources on moulage. Skill in moulage application requires practice. Before deciding to use moulage in your SBE, it is important to determine whether it enhances the learning outcomes of the simulation. Is moulage use necessary? Will moulage use enhance learner engagement through creation of conceptual, physical, or emotional fidelity in the scenario? Moulage should not be used as a distractor (Stokes-Parish, 2021).
There are differing perspectives on the necessity of moulage and the level of authenticity required in various settings. Simulationists can use the Moulage Authenticity Rating Scale (MARS) to measure the level of authentic moulage in simulation (Stokes-Parish et al., 2019).
The following resources provide more information on moulage:
Manikins are full-body simulators with capacity for multi-system simulation. They vary in complexity depending on the model. Manikins are sometimes referred to as patient simulators.
Visit the QEII Simulation Trainers webpage to see examples of manikins.
A task trainer is a piece of equipment intended for practicing a particular procedure, rather than a holistic manikin or simulator.
Visit the QEII Simulation Trainers webpage to see examples of task trainers.
Headwalls are mounted setups featuring gas and suction connections for use in the absence of piped gas.
©Nova Scotia Health
Compressors may be used with headwalls to generate sufficient pressure and flow to the headwall to allow negative pressure and flow through the gas outlets.
©Nova Scotia Health
3D Printing allows design and reproduction of equipment, adapters, or supplies that can be used in simulation. This might include caps, connectors, 3D-printed HMEs, or silicone molds that may be more cost-effective than standard patient care approved variations. Printers are available for multiple mediums such as plastic and resin.
©Nova Scotia Health
Silicone molding can be used to enhance moulage for task training and simulation scenarios. It is most frequently used to mimic body tissues. For example, silicone can be used to create:
©Nova Scotia Health
©Nova Scotia Health
We have discussed the concept of psychological safety already, but there are many other safety considerations to be considered in simulation. The Foundation for Healthcare Simulation Safety is an excellent resource for simulation safety information. Please review their Simulation Safety Pledge.
Simulation safety incidents should be reported through the proper channels within your own institution. The Foundation also promotes confidential reporting through their organization to increase international awareness of safety-related concerns.
Participant safety must be considered during all steps of a simulated experience. This includes:
For infection control and safety purposes, simulation equipment should be used solely for simulation-based education. Standards for upkeep are much higher for equipment and supplies intended for human use. Equipment that has been used clinically must be processed appropriately for infection control purposes.
The Foundation for Healthcare Simulation Safety designed this universal label intended for simulation supplies and equipment to promote consistency in practice following an incident where an order of simulated IV fluid was mistakenly received by a clinical area and 40 patients received this non-sterile simulated fluid. The label template is available for free online.
©Foundation of Healthcare Simulation Safety.
You must also consider environmental factors when assessing the safety of SBE. If the simulation occurs in a publicly accessible space , advance notice and signage may be necessary so that the events are not interpreted as a real emergency. If the scenario could be alarming or traumatic to passersby, consider the use of privacy screens, curtains, or more private spaces. When transporting manikins, make every effort to make it apparent that it is, in fact, a manikin and not a real person or body.
Please read the following article about safety in simulation.
Consider using a checklist like this one to promote safety in SBE:
Brazil, V., & Purdy, E. (2019, January 8). Simulation safety spotlight - A call for safety briefings in sim? International Clinician Educators Blog. https://icenet.blog/2019/01/08/simulation-safety-spotlight-a-call-for-safety-briefings-in-sim/
Charnetski, M., & Jarvill, M. (2021, September). Healthcare Simulation Standards of Best PracticeTM Operations. Clinical Simulation in Nursing, 58, 33-39. https://doi.org/10. 1016/j.ecns.2021.08.012
Foundation of Healthcare Simulation Safety. (2017, September 5). Pledge. https://healthcaresimulationsafety.org/simulation-pledge/
International Nursing Association for Clinical Simulation & Learning. (2021). Operations [Infographic]. https://www.inacsl.org/simfographics. Used with permission.
Jee, M., Khamoudes, D., Brennan, A. M., et al. (2020, April 28). Figure 2 [Photograph]. COVID-19 outbreak response for an emergency department using in situ simulation. Cureus, 12(4): e7876. DOI 10.7759/cureus.7876
Lioce, L. (Ed.), Lopreiato, J. (Founding Ed.), Downing, D., Chang, T.P., Robertson, J.M., Anderson, M., Diaz, D.A., and Spain, A.E. (Assoc. Eds.) and the Terminology and Concepts Working Group. (2020). Healthcare simulation dictionary, second edition. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/simulation/sim-dictionary-2nd.pdf.
Moulage Sciences & Training, LLC. (2020). Home. https://www.moulagesciences.com/
Nickson, C. (2020, November 3). In situ simulation. Life in the Fast Lane.https://litfl.com/in-situ-simulation/
O’Regan, S., Molloy, E., & Watterson, L. (2016). Observer roles that optimise learning in healthcare simulation education: a systematic review. Advances in Simulation, 1(4). https://doi.org/10.1186/s41077-015-0004-8
Raemer, D., Hannenberg, A., & Mullen, A. (2018). Simulation safety first. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 13(6), 373–375. https://doi.org/10.1097/sih.0000000000000341"
Stokes-Parish, J., Duvivier, R. & Jolly, B. (2019). Expert opinions on the authenticity of moulage in simulation: A Delphi study. Advances in Simulation, 4(16). https://doi.org/10.1186/s41077-019-0103-z
Stokes-Parish, J.B., Duvivier, R. & Jolly, B. (2020). How does moulage contribute to medical students’ perceived engagement in simulation? A mixed-methods pilot study. Advances in Simulation, 5(23).https://doi.org/10.1186/s41077-020-00142-0
Stokes-Parish, J. & Roiter, G. (2023, November 11). Moulage. Simulcast. https://simulationpodcast.com/wp-content/uploads/2023/04/Simulcast-Self-Development-Module-Moulage.pdf
Wilson, L., & Wittman-Price, R.A. (2019). Review manual for the Certified Healthcare Educator (CHSE) Exam (2nd ed). Springer.