Starship simulation – high fidelity and child actors

1 October 2011

A busload of kids draped in bandages hop and stumble into Starship, some crying, some not. And probably some giggling, as the “injured” are not accident victims but students of a local school roleplaying to test Starship emergency department’s contingency plans.

“The children loved it and some of them were great actors,” recalls Trish Wood, nurse educator for Starship’s ED. “We’d been to school and spoken to the teachers and they’d prepared the children with bandages and they all had a (prompt) card that said ‘hop’ or ‘cry’.”

Simulation does not have to involve whizz-bang mannequins, but Wood and nurse educator colleague Dawn Tucker from the Paediatric Intensive Care Unit (PICU), are also advocates for the important role high-fidelity simulation plays.

Tucker says while nursing has used low-fidelity mannequins since “God-invented apples” in 2007, the pair has been using the high-fidelity mannequins, SimBaby (pictured) and SimMan for teaching either in situ or at Auckland District Health Board’s Clinical Skills Unit. “Obviously our kids in intensive care are very sick and so we use a lot of equipment,” says Tucker. “Using the high-fidelity simulation (in situ) allows us to run very realistic scenarios, where we attach SimBaby to our ventilator and plug it into our monitors.”

Simulations on site are convenient for staff and provide a safe environment to challenge and build staff skills, and also to test out protocols and identify system problems without putting patients or staff at risk. Some staff initially find high-fidelity simulation stressful and some push back or resist, says Tucker. “They argue it’s a mannequin and if it was a real patient they’d handle it differently. But the more simulations people do, the more buy-in you get”. And while high-fidelity simulation can be stressful, it is also visual, hands-on and relevant.

Creating a high-fidelity simulation scenario is time-consuming in itself, let alone running the simulation and skillfully managing the de-briefing process to maximise learning. So the educators usually reserve it for testing a nurse’s or team’s response to an unstable patient or a particular patient condition and leave the more straightforward teaching and practising of procedural skills to low-fidelity simulation.

Tucker runs a high-fidelity simulation for PICU nursing staff once a month and another for paediatric registrars. Woods offers fortnightly multidisciplinary teaching using simulation and a more complex simulation every six weeks. High-fidelity simulation is also a regular component of in-house study days at Starship.

The pair says simulation can also be developed opportunistically in response to a skill gap being highlighted, like revisiting securing a breathing tube for a child, or to recreate a critical incident and test staff’s ability to respond.

For instance, if there was an incident such as a medication error by infusion, a scenario could be set up so the mannequin received an incorrect infusion and responded just as the patient did. The nurses in the simulation would then have to identify and solve the problem. “In reality, we wouldn’t let somebody’s inaction run its consequence,” says Wood. She points out that adult learners need the chance to make mistakes and correct themselves, rather than have somebody else correct them. Simulation makes this possible. “In the clinical setting we would never allow that to happen, so it’s a luxury to have this teaching tool.”

The educators can monitor whether somebody has taken the lead in directing care, whether staff are communicating effectively when delegating and carrying out tasks, and whether a team keeps a global perspective of a patient’s condition rather than fixating on a minor aspect of their care.

Tucker and Woods add that an essential part of the learning is the post-simulation debriefing that needs to be skillfully led by the experienced educators to identify problems, whether these are equipment shortages or communication breakdowns, and how to work around or resolve these.


NB: Read alongside: Keeping it real simulation in education