Sim Workshop at TTC Copenhagen

This post is a resource for the Sim Workshop being delivered as part of dasTTC – The Teaching Course Copenhagen.

Thursday 22nd June 2017 – SOHO 0900-1200

Time Component Brief Description Faculty
0900-0920 Intro, Welcome and Psychological Safety Jesse Spurr
0920-0950 Sim for Elite Performers Plenary Talk Chris Nickson
0950-1030 Hive Mind Solutions


3 groups with a coach each

1.     In Situ Conundrums

2.     Communication and CRM

3.     More than one way to debrief

Objective: Develop a 15min teaching session

1. Chris Nickson

2. Sandra Viggers

3. Jesse Spurr


1030-1050 BREAK
1050-1140 Hive Mind Teach-Back Nominated facilitator(s) from groups 1, 2 and 3 teach back their group’s products to the whole delegation
1140-1150 Coaches Right of Comment Coach summary/take home points if any.  
1150-1200 The Future Agenda for sim Wrap-up and areas for inquiry Sandra Viggers

Psychological Safety Resources –

Breakout Group 1 – The In Situ Conundrum

Coach – Chris Nickson

You’ve been running fortnightly scenarios in the nearby simulation centre. These are part of the resident training program and from time to time may get a nurse or two along depending on how busy the department is. While well evaluated, you see the residents go back to the shop floor and struggle to apply any of the lessons that the group agreed had been take homes from the previous sim session. They can’t find equipment, struggle to coordinate the multidisciplinary team and seem much slower to achieve critical actions in the real resus. You approach the Department director and the nurse manager and suggest starting to conduct one of the sim sessions in the department in a real resus bay once a month. This is met with resistance, “we’re too busy theirs not enough staff or time”, “the staff have done mock codes before, they really disrupt things and they hated them”. You go back to your office and try to come up with how you will make this happen. (Stimulus by Prof. Victoria Brazil, Simulcast)


Questions to address:

  1. What domains are particularly relevant in considering the use of in situ versus simulation lab?
  2. How do we manage the competing workloads and lack of buy in for in situ sim?



Brazil, Spurr, Petrosoniak, Simulcast Episode 5, November 2016 – Put the Rubber to the Road

Life in the Fast Lane, Critical Care Compendium – In Situ Simulation, revised November 2016.

Petrosoniak, A., M. Auerbach, A. H. Wong and C. M. Hicks (2017). “In situ simulation in emergency medicine: Moving beyond the simulation lab.” Emergency Medicine Australasia 29(1): 83-88.

Spurr J, Gatward J, Joshi N, et al Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments Emerg Med J 2016;33:514-516.

Breakout Group 2 – Communication and CRM through SIM, is it working?

Coach – Sandra Viggers

“McDonalds drive thru attendants are much better at Closed Loop Communication than health care professionals.”

David replayed the conversation in his head again, he had ordered the meal, she had checked what he’d ordered, there was a visual display of his order on the drive thru screen, he’d confirmed his order and she’d told him it would be available soon. It was textbook perfect. Call out. Check back. Confirmation. Completion.

“How do they do it so well?” he thought.

Maybe people get angrier when pickles turn up on their double cheeseburger than when we give their grandma the wrong drug? The world is a strange place when we can’t do something so simple when it’s critical, but we do it so well when the outcomes are meaningless.

“This demands more research.” he thought as he turned his car keys and backed out the car park.

“I’d better come back tomorrow.” (Stimulus by Dr Ben Symon, Simulcast)



  1. Are CRM and Closed-Loop communications reductionist when applied to health?
  2. What explicit behaviours are we looking for and how can we functionally align our education strategies to achieve these?



Härgestam M, Lindkvist M, Brulin C, et al

Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training

BMJ Open 2013;3:e003525. doi: 10.1136/bmjopen-2013-003525

Lorello, G, Hicks, C et al.

Mental practice: a simple tool to enhance team-based trauma resuscitation. CJEM. 2016 Mar;18(2):136-42. doi: 10.1017/cem.2015.4. Epub 2015 Apr 10.

Petrosoniak, A and Hicks, C

Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anaesthesiol. 2013 Dec;26(6):699-706. doi: 10.1097/ACO.0000000000000007.

Symon, B and Brazil, V. Simulcast Journal Club Podcast March 2017

Breakout Group 3 – Debriefing. Which way is best?

Coach – Jesse Spurr

Ellen felt anxious walking into the debrief room.

The ED team had just finished an in situ simulation where the focus was on rapid sequence intubation (RSI) in head injury, and using the new intubation checklist. This was the third sim session in a series the department had agreed to run following 3 patient cases where significant desaturation occurred during intubation attempts.

Ellen thought they’d done OK but had recognized a lot of the usual ‘bad habits’ that frankly irked her when she worked on the floor with these guys – no nasal prong O2, a pretty vague conversation about who was going to actually do the tube, and low level grumbles about the time it takes to do the checklist. She was particularly disappointed that those things had come up in the last sim, and that a couple of the nurses had participated in that previous sim. “How can we actually get this into their heads?” she thought.

Entering the debrief room, Ellen knew what she wanted to bring up, but felt her stress level rising. Reactions first, she thought, and then facts. What would be a good advocacy inquiry question? What else did they say in that debriefing course…..? Should she let the learners dictate the topics?

And she knew that the ED consultant who was in the scenario was not a big fan of sim, and anticipated he might be difficult. His performance is probably off limits for today, she thought.

Deep breath.

“OK guys that was great. Well done”…….. (Stimulus by Prof. Victoria Brazil, Simulcast)



  1. Is there one perfect way to debrief?
  2. Produce a mind map for applying different debrief contexts.



Brazil, V. Article review: Is there really more than one way to debrief? Debrief2Learn Sept 2016.

Brazil, Spurr and Eppich, Simulcast Episode 2, August 2016 – Eppich Debriefing

Cheng, A., K. J. Morse, J. Rudolph, A. A. Arab, J. Runnacles and W. Eppich (2016). “Learner-Centered Debriefing for Health Care Simulation Education: Lessons for Faculty Development.Simulation in Healthcare 11(1).

Eppich, W. and A. Cheng (2015). “Promoting Excellence and Reflective Learning in Simulation (PEARLS): Development and Rationale for a Blended Approach to Health Care Simulation Debriefing.Simulation in Healthcare 10(2).

Rudolph, J; Simon, R; Dufresne, R; Raemer, D (2006)

“There’s No Such Thing as Nonjudgmental Debriefing: A Theory and Method for Debriefing with Good Judgment”

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare., 1(1):49-55, Spring 2006

Symon, B, Simulcast Journal Club Summary August 2016 – Debrieifer Knows Best



Goal Directed Simulation at TTC Downunder


On July 13th we will be facilitating a super-charged techniques of simulation workshop to some brilliant clinician educators at The Teaching Course Downunder. In order to maximise our 4hrs together, we have curated some of the best FOAM simulation resources available.

Learning Objectives

1)      Participants will learn how to identify opportunities for quality improvement that may be addressed through simulation.

2)      Participants will learn how to manipulate stress to optimise learning outcomes in simulation.

3)      Participants will learn the importance of pre-brief and debrief in simulation and how this differs between workplace and simulation centre course.

4)      Participants will learn how to enhance the psychological realism of simulation.

homeworkThe course participants are asked to complete the following exercise in readiness for the workshop: SMART Goals for Simulation. We will be reviewing and discussing examples in the small group break out sessions.

The sessions will include:

Goal Directed Sim – Jesse Spurr & Clare Richmond

Titration of Stress – Chris Nickson

The Fiction Contract – Confederates, Acting and Simulated Patients  – Clare Richmond & Will Sanderson

Pre-brief – the Foundation of Safe and Effective Sim – George Willis & Jen Williams

Debriefing Q&A Panel – George Willis, Clare Richmond, Jen WIlliams and Ross Fisher – moderated by Jesse Spurr


General Overview of In Situ Goal-Directed Sim

Injectable Orange –  Simulation Basics – Back to the Future Podcast

St Emlyn’s – Top Ten Tips for In Situ Sim Blog and Podcast

Injectable Orange – Tips for Team Simulation blog

ICN — Guerilla Sim: Anyone, anytime, Anywhere (Jon Gatward’s talk at SMACC 2013)

LITFL CCC — In situ simulation (overview of pros and cons and safety issues in in situ simulation)

Building Fidelity in In Situ Simulation – Fiction Contract

Injectable Orange – Plants in Simulation Vodcast

St Emlyn’s – Actors in Simulation (Nice review of Natalie May’s simulation experiences at SWEETs 15)

KI Docs — Tim Leeuwenburg’s excellent Simulation apps review

Sanko et al Establishing a Convention for Acting in Healthcare Simulation

Titration of Stress in Simulation – Stress Inoculation

SMACCUS Stress Inoculation Training – Intro podcast from the Swami

Life in The Fast Lane – Review of Stress Inoculation Training workshop + resources a plenty

EMCrit – Stress Inoculation Training (a brilliant post from Mike Lauria)

Pre-briefing and Debriefing – The Bread of the Sandwich

Jenny Rudolph and Harvard Sim Team – Establishing a safe container for learning in simulation: The role of pre-simulation briefing – Journal article 

iTeachEM  Thorough Vodcast overview of Simulation Debriefing from Sim expert Danielle Hart

St Emlyn’s – A great blog on real world Debriefing from Natalie May – not specific to simulation, but incredibly applicable to In Situ sim.

MobileSim – Excellent blog resource on Debriefing with a great structured approach to In Situ Sim debrief

Injectable Orange – Debriefing: a little carrot, a little stick – blog with quick beginners guide tips for debrief.

In Situ Simulation Resources for Quality Improvement

MobileSim –  MobileSim (Jon Gatward’s excellent in situ simulation website including guides, templates and scenarios

INTENSIVE – ICU-IS-SIM (resources for the in situ simulation program at The Alfred ICU, including scenarios)

EMSimCases – EM Sim Cases(ever growing repository of free peer-reviewed simulation cases)

SMACCDUB – Leave the Sim Lab Behind Workshop Scenario Template (Template optimised for In Situ Simulation)

Plants in Simulation

The following video presentation is a brief overview of the role of the confederate in simulation. Quite simply, the confederate is one of the best tools I have found in the quest to enhance the fidelity/realism for participants in immersive simulation. I will be presenting soon at the Laerdal SUN Conference – giving a workshop on In Situ Simulation for Patient Safety – ‘Waking Sleeping Giants’ and this video is going to be given as part of a flipped workshop approach in pre-attendance. It’s my first attempt at a screen recording and I learned a great deal (mostly how not to do it next time). I would love for others to share your experiences in simulation or in production of better quality videos than mine. I am really keen to learn.


Sanko et al. 2013 Establishing a convention for acting in healthcare simulation: merging art and science.


Tips for Team Simulation Training

Simulation is a technique–not a technology–to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.

David Gaba MD

Absolute golden rule – The scenario is not an entree for a lecture.

teamwork funny

This post is pretty simply intended to be a roadmap of my own learning in delivering team-focused scenario based training. There are a number of very smart people I have been privileged to have worked with in the past few years and I thought it may be useful, as much for myself as a collection of thoughts and reflective practice, to put down some structure. I think reflective practice is an important consideration in our education pursuits as much as our clinical roles. I have intentionally steered away from an overly academic approach for this post, as unfortunately I think “simulation” has been somewhat professorialised into a niche industry of it’s own. After all is said and done, simulation is just one teaching technique, there is no great mystery. When it is done well it has the capacity to facilitate learning in a way I have not found through any other teaching technique. When it is done badly, it can damage participants’ self-efficacy and also your credibility as an educator. So feel free to read a bit of a practical overview of what I have learned, much from those with minds greater than my own.

Design Phase

Learning Outcomes – Scenario based simulation is about practise. As such, each scenario should have very focused learning outcomes. Two-to-three would be recommended as an absolute maximum. If you have more, split them into separate stages of scenarios or run a pause and discuss). It is important to note that scenario based simulation is about practise and application of previously learned theory within work-like context. Inputs should be drawn from a range of sources – real adverse clinical events, safety and quality standards, organisational procedures, audit results and consumer feedback. Having robust inputs sets measurable results for evaluation.

Scenario Complexity – Consider the needs of the participants, if they are novice or junior low ‘noise’ and high ‘signal’. Essentially this means consider the core objectives and make them relatively obvious (eg. Prominent diagnostic cues & available resources) and avoid confounding variables such as screaming relatives, aggressive colleagues or the death of a patient (unless these are your core objectives). In more experienced or expert teams higher ‘noise’ and lower ‘signal’ may be appropriate. A useful inclusion is the role of confederate – an informed participant/actor who knows the scenario and endpoints and can steer the scenario from within and increase ‘noise’ if the scenario is too easy or increase ‘signal’ if the case is derailed or the team are in a holding pattern.



Delivery Phase

Set-up – From a technical perspective, you can’t check a manikin too many times before a scenario. A structured top-to-toe including visualising airway, bagging to assess chest rise and fall, auscultating lung and heart sounds, checking rhythms, defibrillation and pacing to assess response and checking all bolts, screws, attachments and limbs are secure. Also it is very useful to have a list of all peripheral equipment and drugs that are needed.

Pre-brief – Participants hate feeling set-up to fail. The key to participants engaging in a scenario is their ability to buy into the ‘fiction contract’. We are using a manikin, it has limitations. We are often not in the real work environment. Gain consent for the open and challenging conversation. Often, before the scenario, explaining to the participants that, on completion of the scenario, we are going to come back in as a group and have an open and honest conversation about the strengths, weaknesses, opportunities and threats experienced in the scenario and ask the group “Is everyone ok with that?” It is amazing what this does to the group dynamic once permission is granted.

It pays to consider what things may jolt participants out of a scenario and provide a thorough overview of the rules of engagement. Give a top to toe familiarisation with the manikin and it is often good to refer to the manikin by name/character and have it clothed. This assists the ‘buy-in’. Some points to present in the pre-brief include:

  • Is it to be an immersive scenario or a pause and discuss?
  • Are participants allowed to call for more help and who/how?
  • Where are they (setting, time and context)? If in the workplace it is strongly recommended to not say you are somewhere else or at a different time.
  • How do the participants get information they can’t get from the manikin?
  • How will the instructor respond if participants ask for information that they could obtain through assessing the patient/manikin?
  • How will they know when the scenario is finished?
  • Are charts, ECGs, blood results available?
  • Acknowledge safety considerations, i.e. Live defibrillator, expired drugs, sharps, etc.
  • If in the workplace, are participants allowed to open consumables/drugs, etc?
  • Do you want participants to actually connect and give fluids, drugs or just simulate/state they have done so?
  • In essence consider any variables that may cause the participants to lose focus on the scenario and address these with solutions or rules.

Scenario – In the scenario the end point is crucial. Try not to let participants flounder in holding patterns, it is best to end the scenario and debrief what has happened. If the scenario becomes derailed consider: 1) Is it recoverable? 2) Should I end scenario and start debrief immediately? A strategy for recuing a scenario may be a phone call to the room with very obvious pathology results or medical imaging, sending in a ‘confederate’ as nurse, doctor or family member to steer the scenario back or pause enter as facilitator, conduct a recap and direction and restart.

Debrief – Debriefing is something that improves greatly with experience. From experience and a composite of reading here are a few tips:

  1. While a structure is good, don’t be a robot.
  2. Observe others’ debriefing style, but don’t try and replicate exactly, you’ll come off as insincere.
  3. Remember what the core objectives of the scenario were and consider leading questions that may draw out the learning from the participants.
  4. The object of scenario based learning is a constructivist approach to knowledge in which the learners engage and build their knowledge through social interaction and arrival at agreed ‘truths’.
  5. Be flexible. If they didn’t achieve the goal of the scenario, but committed thoroughly and correctly to a course of treatment based on an accidental incorrect cue, debrief the scenario you observed, not the one you intended and try and make links back to the team based learning objectives.
  6. Play to your strengths and enlist help from the room. (There is often expertise beyond the facilitator in the room. If you get a challenging question throw it back to the group for comment/answer).


Evaluation Phase

Evaluation Tool – Consider the development of the appropriate tool to measure internal validity of the program, i.e. was it well organised, well delivered, areas for improvement and also measure external validity i.e. were learning outcomes achieved at an individual level. Consider what you are planning to do with this data as it may be useful to gain consent at the time for evaluations to be used for quality improvement research as it may assist with ethics waiver or low/negligible risk approval later. Secondary to this is the consideration as to whether a measurable change occurred in relation to the inputs. For example, did training in aseptic non-touch technique correlate to decrease in catheter related bloodstream infections in a particular unit.


Review – Set minor and major review schedules for your scenarios to ensure that the objectives and content still align with best practice and current procedures, supporting documentation is current and compliant with your setting and any latent risks uncovered during the simulation (particularly in situ) are articulated back to the owners of that risk. Remember reflection and self-awareness makes you a much better teacher.

I think this is piss


David Gaba (2004), The future vision of simulation in health care.

Barry Issenberg et al (2005), Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review.

Debriefing: a Little Carrot, a Little Stick

Donkey analogies aside, with the growing uptake of immersive team simulation, there is certainly a risk of falling into the softly-softly debrief trap. Thanks for sharing this video Luke Wainwright (@lukie27). Although slightly tongue in cheek (only slightly), it elucidates some of the things that have sat uneasily with me when observing some recent debriefs. The goal in education is to generate change. Change in attitude; change in culture; change in skill; change in confidence. Be very careful to not let your students debrief themselves into poor practice, misconceptions or overconfidence.

It is only practise that truly develops the skill of debriefing for learning. Try it, practise it and have an open and honest conversation with your team/trainees/students. While I don’t profess to be an expert in any capacity, I have made some mistakes and learned from them and have also debriefed up the hierarchical gradient (having lead debriefs of consultant medical staff – very daunting as a nurse). Below I have thrown in some ideas for debriefing.


Absolute rule – The scenario is not an entree for a lecture.

1) Have very focused learning outcomes (2-3 as absolute maximum. If you have more, split them into separate stages of scenarios or run a pause and discuss).

2) Be flexible. If they didn’t achieve the goal of the scenario, but committed thoroughly and correctly to a course of treatment based on an accidental incorrect cue, debrief the scenario you observed, not the one you intended.

3) Gain consent for the open and challenging conversation. I find, before the scenario, explaining to the participants that we are going to come back in on completion, and have an open and critical conversation about the strengths and challenges experienced in the scenario and ask the group “Is everyone OK with that?” It is amazing what this does to the group dynamic once permission is granted.

4) While a structure is good, don’t be a robot. Observe others’ debriefing style, but don’t try and replicate exactly, you’ll come off as insincere.

5) Play to your strengths and enlist help from the room. (There is often expertise beyond the facilitator in the room. If you get a challenging question throw it back to the group for comment/answer).

I find the two papers below to be really helpful and applicable offerings on the art and science of debriefing with good judgement.

Eppich and Cheng (2015)

Jenny Rudolph et al (2007)