Simulation in Nursing Practice: The Impact on Patient Care

Michelle Aebersold, PhD, RN

Dana Tschannen, PhD, RN

Abstract
Simulation has a well-known history in the military, nuclear power, and aviation. It is also a recommended
teaching and learning strategy supported by several landmark studies. Although in the past 20 years
simulation has become more integrated into the education of nurses and physicians, it has not been as well
integrated into the development of skills for practicing nurses. This article will provide an overview of
simulation techniques and uses and review of selected simulation research. Despite recommendations for
using simulation and growing integration of simulation into education, we still lack empirical evidence of its
impact on patient outcomes. Our discussion provides a review of the current uses of simulation in the
nursing practice environment with several exemplars and offers recommendations to develop a simulation
program.
Citation: Aebersold, M., Tschannen, D., (May 31, 2013) "Simulation in Nursing Practice: The Impact on
Patient Care" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 6.
DOI: 10.3912/OJIN.Vol18No02Man06
Key words: Simulation, patient safety, staff education, nursing education, learning methods, practice,
critical care, staff development, quality, training
Simulation has a well-known history in the military, nuclear power, and aviation industries. The aviation
industry uses flight simulators for pilot training and has developed Crew Resource Management for the
training of non-technical skills for flight crews. The nuclear power industry trains for disasters, and the
military has used war games and simulation very successfully in their training programs. Simulation in the
area of medicine and nursing has become an important part of the education of students and practicing
healthcare providers. Many institutions have made recommendations around the use of simulation in
healthcare training. The Institute of Medicines report on nursing work environments recommends simulation
as a method to support nurses in the ongoing acquisition of knowledge and skills (Page, 2004). In
the Future of Nursing report (a Robert Wood Johnson Initiative), simulation is mentioned as a strategy to
support interprofessional education (National Research Council, 2011). The Carnegie Foundation for the
Advancement of Teaching report; Educating Nurses, highlights simulation as an effective strategy for the
education of nursing students (Benner, Sutphen, Leonard, & Day, 2010).
Simulation has become more integrated into the education of nurses and physicians in the past 20 years,
but is not fully integrated into the development of skills for practicing nurses. Despite recommendations for
use of simulation, and growing integration of simulation into education, empirical evidence for the impact of
simulation on patient outcomes is still underdeveloped. This article will provide an overview of simulation
techniques and uses; review selected emerging research linking simulation to patient outcomes; discuss
current uses of simulation by practicing nurses; and recommend strategies to develop a simulation program.

Overview of Simulation
Simulation is a technique, not a technology, to replace or amplify real experiences with guided experiences,
often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive
fashion (Gaba, 2004, p. i2). As the science of simulation grows, there is ongoing work towards a common
guiding taxonomy and set of practices; however, there is not currently one universally accepted framework

or theory in use. One common framework used in nursing education is The Nursing Education Simulation
Framework, developed by Jeffries (2007). Medicine and nursing have also used the Event Based Approach to
Training (Rosen et al., 2008) to guide simulation development. The International Nursing Association for
Clinical Simulation and Learning (INACSL) has developed a common set of definitions for use in simulation
as well as a set of 7 Best Practice Standards (Kardong-Edgren et al., 2011).
Even though there is not a common simulation framework, most simulations follow a similar design. There
is usually some pre-work, or preparation learning, by the participant before the simulation. This is followed
by the implementation of the simulation, which is subsequently followed by a debriefing session. Debriefings
are generally conducted as a reflective learning experience in which participants review their performance in
the simulation and the facilitator provides additional feedback. Commonly used terminology in simulation is
highlighted in Table 1. Simulation techniques in nursing have also been well defined in an article by Galloway
(2009) in which the various types of simulation techniques are described, such as role play and full mission
simulation.
Table 1. Simulation Definitions

Term

Description

Clinical Scenario

*The plan of an expected and potential course

of events for a simulated clinical experience.

Debriefing

*An activity that follows a simulation

experience and that is led by a facilitator.

Facilitator

*An individual who guides and supports

participants toward understanding and
achieving objectives.

Fidelity

*Believability, or the degree to which a

simulated experience approaches reality; as
fidelity increases, realism increases.

High-Fidelity Simulations

Simulations that utilize computerized manikins

Mid-Fidelity Simulations

Simulations that utilize standardized patients,

computer programs or video games

Low-Fidelity Simulations

Simulations that use role play, non-

computerized manikins or task- trainers

Task-Trainers

Simulators that are used to practice a skill such

as an IV arm that is used to practice IV
insertions skills

In-situ simulation

This refers to bringing the simulation (and

simulator) to the site where the learner is
practicing. This could occur in an ER trauma
bay or surgical suite.

*These definitions are directly from the INACSL Standards of Best Practice: Simulation (Kardong-Edgren et
al., 2011, p. S4-S5) .

Review of Selected Simulation Research

This article is not an exhaustive review of the literature on simulation or the impact of simulation on patient
outcomes, but rather considers selected publications to direct readers to emerging evidence and provide
some context for the later discussion about simulation in nursing practice. There are several review articles
the reader may want to consider. Cumin, Boyd, Webster, and Weller (2013) published a systematic review of
simulation for multidisciplinary team training in operations rooms. Eighteen articles were reviewed and
contained measures of both technical and non-technical skills. A critical review of simulation-based
education (SBE) was conducted by McGaphie, Issenberg, Petrusa, and Scalese (2010) and contains
recommendations for best practices in SBE. A systematic review of simulation exercises as a patient safety
strategy was published by Schmidt, Goldhaber-Fiebert, Ho and McDonald (2013) and reported on 38 studies
containing outcomes during care of real patients after simulation interventions. Orledge, Phillips, Murray,
and Lerant (2012) reviewed recent studies on the impact of simulation on patient outcomes and skill
retention in addition to other findings. Many review articles in nursing have focused primarily on nursing
education (Harder, 2010; Lapkin, Levette-Jones, Bellchambers, & Fernandez, 2010; Shearer, 2013). There
are some articles that have included nursing staff in hospital settings that have also measured patient
outcomes. Those studies are reviewed in Table 2. The studies primarily involved team training for operating
room teams or emergency response teams.
Table 2. Review of Simulation and Patient Outcomes

Outcomes

Study

Design
Sample Size
(e.g., descriptive
nonexperimental)

Major Findings

Patient
Outcomes

Regular in situ
simulation

Prospective
cohort study of

Deteriorating patients
were recognized more

All unplanned
admissions to

training of
paediatric
medical
emergency team
tp improve
hospital response
to deteriorating
patients
(Theilen et al.,
2012)

all deteriorating
in-patients
requiring
admission to a
PICU for one
year before and
after
implementing a
pediatric
medical
emergency team
(pMET) and
concurrent team
training which
was comprised
of in situ
simulation.
pMET team
included
physicians and
nurses.

the PICU were

audited for one
year. There
were 56
admission pre
pMET and 54
admissions post
pMET.

promptly post pMET

(p<.0001), were
transferred more often to
high dependency care
(p=.021) and more
rapidly escalated to
intensive care (p=.024).

Patient
Outcomes

Teamwork: crew
resource
management in a
community
hospital
(Shea-Lewis,
2009)

Pre/post design.
All staff
members in L &
D (nurse and
physician) were
trained in Team
Performance
Plus (based on
CRM). Includes
didactic and
simulation
training.

Unknown. All
current staff of
L & D between
April and May
2006.

Adverse Outcome Index

(overall rate of deliveries
with an adverse event)
improved significantly
after training. The
Weighted Adverse
Outcome Score (total
weights of all adverse
events divided by the
total number of
deliveries) improved
significantly after
training. The Severity
Index did not change
significantly.

Patient
Outcomes

Didactic and
simulation
nontechnical
skills team
training to

Pre/post design.
One hospital
received
TeamSTEPPS
didactic only,

36 participants
in the
didactic/sim (18
nurses). 60
participants in

The Weighted Adverse

Outcome Score
significantly improved in
the didactic/sim hospital
(p=.05). There was not a

Safety
Culture

Patient
Outcomes
Safety
Culture

Patient
Outcomes
Selfassessment

improve
perinatal patient
outcomes in a
community
hospital
(Riley et al.,
2011)

one hospital
received
TeamSTEPPS
didactic plus
simulation and
one hospital was
designated as
the control. All
three were
small-sized
community
hospitals.

didactic only
(30 nurses) and
38 in the control
(17 nurses)

significant change in the

didactic only hospital.
The AHRQ safety culture
surveys generally high
pre intervention and
remained high post
intervention. There was a
significant improvement
(p=.05) on teamwork for
the didactic/sim hospital.

Outcomes from a
labor and
delivery team
training program
with simulation
component
(Phipps et al.,
2012)

Pre/post design.
Staff were
trained in CRM
principles
through
MedTeams
course. Training
consisted of
didactic and
simulation
components

72% of the 256

L & D staff
were trained in
2007. This
included nurses
and physicians.

There was a significant

decrease in the Adverse
Outcome Index post
training. The safety
culture was measured
using AHRQ Hospital
Survey on Patient Safety
Culture. The overall
perception of safety was
high pre-training and
remained high post
training.

Simulation-based
mock codes
significantly
correlate with
improved
pediatric patient
cardiopulmonary
arrest survival
rates
(Andreatta et al.
2011)

Longitudinal,
mixed methods
design. The
clinicians who
were
responsible for
pediatric
resuscitations in
a childrens
hospital
participated in
mock codes
over a 48 month
period. This
included
physicians,
pediatric

228 junior and

senior residents
participated in
mock codes
over the 4 year
period.

Six categories of key

learning themes (clinical
techniques, team factors,
supplies/resources,
management, diagnostic
factors, and safety
techniques) were
identified. Residents
rated themselves as being
above average in their
abilities to lead an actual
code following the mock
code event. Survival rates
increased to
approximately 50%
(p=.000) and correlated
with increased number of

intensive care
unit nurses and
acute care
nurses.

mock codes (r=.87).

Few studies measured the impact of nursing alone on patient outcomes. Buckley and Gordon (2010 ) studied
the effectiveness of high-fidelity simulation on medical-surgical nurses ability to recognize and respond to
clinical emergencies. This study was a self-report of the participants (38 registered nurses) ability to
respond to emergencies after they received simulation training. Wolf (2008) reported on a simulation
intervention to improve registered nurses triage ability in the emergency department. The six nurses who
completed the simulation and didactic training showed improvement in their ability to accurately triage
patients as measured through chart review of triage documentation. This brief review of the literature
around simulation effectiveness demonstrates the extension of inquiry beyond the nursing education
environment to consider how the use of simulation may impact patient outcomes. The next section will
highlight some examples of how nurses are using simulation in the practice environment.

Use of Simulation in the Nursing Practice Environment

Simulation has been used in a variety of ways in the practice setting. At Massachusetts General Hospital in
Boston, a simulation program was developed to target both nurses and the interdisciplinary team. They
redesigned a classroom into a simulation room and purchased a Laerdal Sim Man. The program was so
successful that they were able to obtain funding for a simulation center and capital funding for additional
simulators, which included the addition of infant and birthing simulators. They currently have seven
simulation programs, five of which are focused on nurses with varying levels of experience, including new
graduates, and different types of work environments (e.g. critical care, acute care). Each program includes
several scenarios, lecture/practice, and debriefing. The scenarios include respiratory arrest, asthma, postpartum hemorrhage, and acute changes in mental status (Nagle, McHale, Alexander, & French, 2009).
Some hospitals have included simulation as part of their critical care orientation. Georgetown University in
Washington, DC, created a simulation program when it opened a new cardiac surgery unit and developed
scenarios to focus on high-frequency, high-acuity situations (Vauen, 2004). In Canada, a Critical Care eLearning program was developed that uses simulation as part of a three part approach, which also included
on-line courses and a mentored clinical experience. Participants in this program completed 39 hours of highfidelity simulation training. The simulations were developed using a scaffolding approach; this technique
starts with learning stations, minor cases and then major cases. The major cases included cardiogenic
shock, acute respiratory distress syndrome, abdominal aortic aneurysm, and septic shock. Simulation cases
ran for 20 to 25 minutes followed by a 30 minute debriefing. The simulation training was offered through a
partnership with nine universities and colleges and included both weekend and weeklong formats.
Participants were evaluated using a pre/post knowledge test for each learning station. Feedback from
participants consistently described the benefits such as increased confidence, engagement, and active
learning (Goldsworthy, 2012).
Acute stroke care has become a priority in healthcare in many countries, including the United Kingdom.
Providers in one London hospital used simulation with a goal to improve management of stroke patients in
hyper-acute stroke units. A pilot stroke simulation study day was developed and included simulations on
post-thrombolysis, raised intracranial pressure, seizures, and accelerated hypertension. The debriefing
sessions focused in part on evaluating non-technical skills, such as teamwork, to see what improvements
could be made. Pre and post questionnaires showed a self-reported improvement in leadership,
communication skills, and confidence in managing hyper-acute stroke clinical situations in six of seven
respondents (Roots, Thomas, Jaye, & Birns, 2011). In another project conducted with stroke unit nurses,

high-fidelity simulation was incorporated into stroke unit education for registered nurses during their
orientation to the acute stroke unit at a large tertiary care center. Nurses participated in three scenarios
based on areas they felt were important to providing successful care for stroke unit patients. Overall
evaluation by nursing staff after the simulation and debriefing was very positive; 100% of the participants
ranked the effectiveness of the simulations as excellent (Aebersold, Kocan, Tschannen & Michaels, 2011).
Obstetrics is an area where much work in simulation has been done, most with a focus on teamwork skills in
obstetric emergencies. For example, simulation has been used effectively in obstetrics to improve teamwork
skills in the inter-professional team (Birch, et al., 2007;Fransen, et al., 2012). Several strategies using
simulation education for practicing nurses have focused on infants and children. In the neonatal ICU,
simulation has been used as a part of new graduate orientation, with scenarios focusing on the most
common neonatal diagnoses: sepsis, seizures, respiratory distress syndrome, and codes. Participants play
different roles in each scenario, thus allowing them to learn roles and responsibilities of all team members
(Pilcher et al., 2012). Mobile in-situ simulation has been used to improve staff team performance in
community settings and address breakdowns in communication that led to poor perinatal and neonatal
outcomes (Pilcher et al., 2012). At Lucile Packard Childrens Hospital in Palo Alto, California, simulation is
used as part of the annual training. The focus is on communication and, in particular, communication with
families. Actual parents from the hospital advisory group participate in these scenarios (Pilcher et al., 2012).
Simulation has demonstrated benefits in nursing in preparation of newly graduated nurses for the practice
environment. In a pilot study conducted at Ninewells Hospital in Scotland, in conjunction with the University
of Dundee, a ward simulation program was developed with a focus on developing the capabilities of newly
qualified nurses. The pilot study was small and included only four nurses who participated in eight ward
simulation exercises, including debriefing every four weeks. The participants also kept a reflection and
critical thinking journal. A focus group was conducted after the simulations were completed and the
following themes were identified; increase in confidence, development of stress management skills,
improved management of the acutely unwell patient, transfer of skills learned in the simulation to the clinical
setting and development of communication skills and reflection skills (Stirling, Smith, & Hogg, 2012).
Simulation in virtual environments has also emerged. This work has primarily occurred in academic settings
using Second Life (Linden Labs). Second Life is an open access virtual environment that has been used by
nurse educators to develop competencies related to leadership and management skills (Aebersold &
Tschannen, 2012). Virtual simulations can also focus on non-technical or interpersonal skills. In a small pilot
study with nursing students that targeted non-technical skills, improvement was noted over a series of two
virtual simulations conducted in Second Life. Both communication and professional behavior skills showed
significant improvement over the two virtual simulations that focused specifically on non-technical skills
(Aebersold, Tschannen & Bathish, 2012). Further evaluation also showed that nursing students who
participated in virtual scenarios were able to demonstrate significantly better performance in a subsequent
high-fidelity mannequin-based simulation when compared to students who only received the usual education
(Tschannen, Aebersold, McLaughlin, Bowen & Fairchild, 2012).
In the practice environment, Second Life has been used as an environment for deliberately practicing
handoffs in an intensive care unit. In this simulation, the handoff process of an intensive care unit patient
was recreated in Second Life. Staff nurses engaged in the virtual practice environment to improve patient
care skills primarily in the area of communication, with particular emphasis on nurse to nurse handoffs.
Within the simulation the nurses practiced key steps in handing over the care of an intensive care unit
patient to another nurse. They have successfully recreated their unit, including admission and shift transfer
documents, so nurses can practice using the documents as well as the verbal exchange that occurs during
handoffs (Brown, Rasmussen, Baldwin, & Wyeth, 2012).
An additional focus of research in the simulation arena is patient deterioration and failure to rescue. FIRST
ACT is an education model with a simulation day incorporated into a course that focuses on improving
nurses emergency management skills. On simulation day, participants complete a knowledge assessment

questionnaire and then participate in two 7 to 8 minute high fidelity simulations or live actor simulations.
Their performance is videotaped and scored and they participate in reflective debriefing that includes specific
feedback from the expert who rated them. This program has been used with undergraduate nursing
students, graduate nursing students, and registered nurses. To evaluate the effectiveness of the educational
model, patient records were reviewed before and after the FIRST2ACT program. Researchers found that
nurses were more likely to record observations at applicable intervals, record pain scores, and deliver/apply
oxygen therapy correctly after this educational intervention (Buykx et al., 2012).
In another study, medical-surgical nurses participated in a simulation aimed at improving nurses
performance in failure to rescue events. The nurses completed a knowledge assessment test and the
Learning Transfer Tool (self-assessment of overall critical thinking skills) before the simulation, immediately
after the simulation, and two weeks later. Results showed a significant increase in knowledge mean scores
and critical thinking (pre and immediate post). However at the two week posttest, improvement was not
sustained (Schubert, 2012).
In summary, this brief review of the recent literature on nursing simulation in the practice environment
shows the variety of ways simulation is being integrated into the education of practicing nurses. However, it
also demonstrates that most of the work has not been rigorously evaluated for its impact on patient care
outcomes, which can be challenging to measure. A few studies have looked at the impact on patient
outcomes but these have been primarily focused on evaluating performance in very specific areas such as
code teams (Wayne et al. 2008). The next section will focus on how to get started using simulation in
nursing, primarily focusing on the practice area.

Developing a Simulation Program

Developing a simulation program can be done as an institutional endeavor in which target areas for
simulation are identified or it can be created on a unit or program level. This article will not focus on the
acquisition and/or design of simulation space but rather on how to use simulation to support improving
patient outcomes. Many resources available (see Table 3) to assist nurses to understand potential use of
simulation.

Table 3. Simulation Resources

Organization
International Nursing
Association for Clinical
Simulation and Learning

Description
supports simulation
in both the practice
and academic side
learning seminars

Contact
https://inacsl.org/

(INACSL)

Simulation Innovation
Research Center (SIRC)
sponsored by the National
League for Nursing
(NLN)

Society for Simulation in

Healthcare (SSIH)

Peter M. Winter Institute

for Simulation Education
and Research (WISER)

Drexel University

a journal focused on
simulation in
nursing
an annual conference
each year
resources and on-line
courses
simulation center
design information
designing and
developing
simulations
guidelines for
simulation research
international
supports educators
and researchers
a journal focused on
simulation
conferences
simulation
certification
programs
classes
newsletters
information on
simulation center
design
conferences
symposium on
nursing simulation
certificate in
simulation
conferences
center for
interdisciplinary
clinical simulation
and practice

http://sirc.nln.org/

http://ssih.org/

www.wiser.pitt.edu/

www.drexel.edu/cnhp/about/CICSP/

The first step in developing a simulation is determining the overall purpose and goals of the training, as well
as to consider the desired methodology or technique of simulation. Gaba (2004), one of the early pioneers
of medical simulations, describes the diverse applications of simulation in healthcare and may be a useful
resource in the initial step of simulation development. Dimensions to consider include (1) purpose and aims
of the simulation activity; (2) unit of participation; (3) experience level of participants; (4) healthcare

domain in which the simulation will be applied; (5) healthcare discipline of personnel who will participate;
(6) type of knowledge, skills, attitudes, or behavior to be addressed; (7) age of the patient being simulated;
(8) technology applicable or required; (9) site of simulation participation; (10) extent of direct participation;
and (11) feedback method. Any particular application of simulation can be categorized as a point or range in
each dimension. For example, dimension 1 (purpose and aims of the simulation activity) ranges from
educational, training, and performance assessment to research (e.g., clinical, human factors) purposes.
Jeffries (2005) designed features of a well-developed simulation, including clearly written objectives; fidelity
or realism that mimics real life situations; building a level of complexity; providing cues for participants as
the simulation progresses; and debriefing during and after the simulation is finished. Jeffries framework is
helpful in the actual design of a simulation and debriefing. Another method for overall simulation
development that has been successful includes a five step process: (1) key concept identification; (2)
competency and standard mapping; (3) scenario building; (4) debriefing development; and (5) beta testing
and refinement (as needed) of the scenario (Aebersold & Tschannen, 2012). In the first phase, key concepts
are identified. Key concepts are subsequently mapped to clinical standards in Phase 2. This is an important
step to ensure that the focus of the simulation is in alignment with current requirements and standards.
Building of the scenario (Phase 3) includes brainstorming clinical scenarios that will stimulate the desired
response/behavior. It is important to have clinical experts involved in this phase of the work to ensure
realism and fidelity in the scenario.
Once the scenario has been developed, debriefing questions should be developed. The final phase, beta
testing, involves running the scenario with a group of faculty, nursing staff, and/or students (depending on
the topic) to test the implementation of the scenario. Feedback should be requested from participants for
all aspects of the scenario, including fidelity, implementation process, and overall experience. Participants
should be asked to provide feedback about all aspects of the simulation (e.g., scenario, implementation
process, fidelity). A variety of simulation development frameworks can be used in Phase 3 to design the
actual simulation. Phase 4 (debriefing development) should utilize the appropriate method of debriefing
based on the simulation scenario goals and objectives.

Exemplars of Simulation in the Practice Area

Even the brief review above provides multiple examples of simulation in a variety of practice settings using
several different simulation techniques. A variety of simulation methodologies can be used for education and
training of practicing nurses. This can include high and low fidelity mannequins, virtual environments, and
unfolding video case simulations. This section will provide some exemplars from the authors own work in
which a range of simulation techniques have addressed various areas, all with the goal of improving patient
safety and outcomes.
Video Unfolding Case Simulations
In an effort to improve the overall effectiveness of the annual competency blitz at a large Midwestern health
system, educators and faculty collaborated to develop an interactive delivery method. This included two 20
minute simulation videos based upon nurse sensitive quality indicators, including restraint alternatives;
pressure ulcer prevention; fall and catheter-associated urinary tract infection (CAUTI) prevention; infection
control; venous thromboembolism/deep vein thrombosis (VTEDVT) prophylaxis; and stroke recognition and
intervention. Participants were placed into groups of 8 to 10 staff where the videos were reviewed and
discussed. Throughout each video, there were opportunities to pause and ask debriefing questions related to
content. For example, one of the videos showed a patient who was placed in restraints inappropriately. The
discussion centered on how the use was inappropriate and possible alternatives to restraints.
Ambulatory Care

A multi-faceted educational approach aimed at improving nurse competencies in diabetes self-management

was initiated with 21 ambulatory care nurses. Simulations were conducted in the virtual environment,
Second Life, to allow nurses an opportunity to practice empowerment-based skills in the context of Type 2
diabetes. The scenarios required the nurses to interact with three patients: one patient identified as noncompliant; one patient who required education in medication management; and one patient who had
extensive psychosocial needs that created barriers to effectively manage the diabetes. Each scenario
required nurses to identify underlying issues for the patient, collaboratively create mutual goals, and
consider next steps for the patient.
High-Fidelity Simulation
In an adult unit, simulation was used to support education aimed at improving the nurses ability to
recognize and manage the deteriorating patient. Three unfolding scenarios were developed using highfidelity simulation. The simulation scenarios focused on acute respiratory failure requiring intubation; atrial
fibrillation requiring treatment; and mental status changes. These were areas of high volume on the unit and
important for overall patient care. In an intensive care unit, several simulation scenarios were developed and
implemented to support nurses who needed to learn a new procedure using complex technical equipment for
very critically ill patients. The focus here was on troubleshooting alarms with the equipment and managing
patient responses to therapy.

Conclusion
Simulation has demonstrated effectiveness as a method to train practicing nurses for new procedures,
communication processes, and both skill based and non-skill based techniques. This can be done using a
variety of methodologies, ranging from simple role-play to use of high-fidelity and virtual simulatorsThe
above described exemplars provide an overview of the variety of ways simulation can be integrated into staff
nurses training.
Simulation can provide an effective mechanism for improving competency in a given area. For example, if a
manager reviews unit data and notes an increase in response time to codes (e.g. early identification of
deteriorating patients is not occurring), simulation may provide an opportunity for the team to practice
assessment and subsequent treatment of the deteriorating patient. Similarly, unit leadership may note a
reduction in collaboration occurring among the multi-disciplinary team. Simulation scenarios requiring
communication among the team may assist in improving collaboration and subsequent patient care.
Simulation could also be included in a new orientation program, requiring new orientees to participate in
standardized simulations that depict issues most experienced by a given units patient population.
Simulation can also be considered as an evaluation method. For example, new hires could be required to
successfully complete a series of skill-based simulations (e.g. mastery of suctioning tracheostomies,
assessing chest tubes, IV insertion) prior to completing orientation. Simulation could also be used to ensure
annual competencies (as described in the unfolding case exemplar) or to remediate poor performing
employees.