Article Text

Download PDFPDF

Creating a sustainable simulation programme for enhancing patient safety in a critical care setting
  1. Susana Lucena-Amaro
  1. Correspondence to Susana Lucena-Amaro, Adult Critical Care Unit, The Royal London Hospital, London E1 1BB, UK; susana.lucena-amaro{at}

Statistics from


Clinical incidents and near misses resulting in patient safety breaches are meticulously examined and analysed in our critical care unit. The outcomes of such investigations often highlight these events as multifactorial in nature, and not just a consequence of poor clinical knowledge.1 Once established that human factors were a major contributor to some incidents, simulation training was introduced, primarily aiming at the improvement of clinical judgement and decision-making skills.2

The aim of this project was to design and deliver a simulation training programme for enhancing patient safety, which could be consistently and sustainably delivered in our 44-bed tertiary critical care unit in a 675-bed major trauma centre in London, UK.

In this context, simulation training was initially offered in our critical care unit in 2015. It consisted of a medium fidelity programme delivered in situ to 200 nurses over a period of a year.3 The project was led and implemented by two critical care clinicians (a doctor and a nurse) who left the unit prior to its conclusion. Relying so heavily on a small number of facilitators compromised its quality and delivery due to the lack of facilitators and the inexperience of the team taking over the training. This highlighted the need to create a more sustainable model of simulation training that could be consistently implemented to our large nursing workforce.


The new programme consisted of 16 simulation sessions over a period of 5 months. Six of these were in situ and the remaining 10 took place in a simulation centre. In total, the training was delivered to 157 nurses, equating to 80% of our nursing workforce. Each participant evaluated the programme through the completion of a short survey at the end of each training day.


Securing attendance through contracted study leave was essential in order to run a credible and quality course. This posed a considerable challenge given the size of our nursing workforce and was achieved by incorporating mandatory elements of training into the day, such as airway updates.

Nurses attended simulation days as part of their team days, meaning that each cohort comprised an established team who knew each other and were used to working together. Role allocations were predetermined by the facilitators, taking into consideration the varying degrees of expertise within the teams.

Faculty facilitators

Five practice development nurses were involved in the project and attended formal training in debriefing techniques run by the Trust. There was a nominated lead who liaised with key stakeholders. Engaging with a medical lead early and securing their commitment was fundamental to our ability to provide consistent standard debriefs,4 particularly for the airway-related scenarios. This had been a major issue in the previous training, however, in our more collaborative approach; seven senior critical care clinicians became part of the programme delivery.

The Trust’s simulation centre provided invaluable guidance throughout the whole process. This ranged from the technical aspects of operating the console and providing mobile cameras and information technology infrastructure for the in situ sessions, to support with the conceptual framework and performance feedback on the programme.

Training facilities

Despite the growing popularity of in situ simulation,5 and in contrast to the previous programme, we decided to deliver the training in the purpose-built simulation centre within the Trust. Due to our unit’s high bed occupancy rate, access to an actual bed space to conduct the scenarios was problematic. As such, we felt that resorting to an adapted teaching room (within the intensive care unit) did not provide a realistic enough environment, detracting the programme from the main advantage of in situ simulation.5 Interestingly, anecdotal feedback from participants attending both settings reported that the scenarios felt more real in the simulation centre.

We did, however, run six of the 16 sessions in situ because of the limited availability of the simulation centre. Instead of using a teaching room, we converted a procedure room used for storage into a simulation facility, as having piped oxygen was essential to maintain fidelity during the simulation. The rest of the set-up involved logistical and technical adjustments, such as allocating network points for live streaming through mobile cameras.


Three scenarios addressing training needs identified through clinical governance processes were written using the Trust’s standard framework and replicated across all sessions. An example of one of the scenarios is presented in figure 1. As a novice faculty, we felt that repeating the scenarios helped us build confidence in the set-up and debriefs. However, we also realised that some teams were already aware of the scenario themes prior to the training. Therefore, in future, it would be beneficial to develop more clinical scenarios in order to adapt simulation training to a wider range of learning outcomes.

Figure 1

Airway management scenario for simulation.


All 157 (100% response rate) nurses completed the evaluation survey. From a series of questions where people either agreed or strongly agreed, the results showed the following:

  • 94.3% felt the course had improved their clinical skills.

  • 92.4% felt the course introduced new concepts important to patient safety.

  • 90% felt it improved their communication skills.

  • 96% felt their practice will change as a result of what they had learnt.

  • 98% would recommend the course to a colleague.

The text analysis to the question ‘Name three things you learnt from today’ showed communication, teamwork and airway as the key trends.


The initial goal of designing and delivering a sustainable model of simulation training to a large cohort of nurses was achieved, as all simulation sessions were delivered with an optimal number of skilled facilitators in a high-fidelity facility. The positive responses from the participant survey indicate that the high quality of the programme was maintained consistently throughout.

From an educational perspective, this programme highlighted the lack of understanding by some nurses on topics usually taught through conventional classroom-based methods, such as the management of epidurals. This was an unexpected outcome which we would like to explore further in future programmes.

The organisational considerations in the sustainability of our programme cannot be underestimated. Participant and faculty rotas, as well as facilities and equipment, were planned and booked at least 6 months in advance. Two nursing teams were allocated to each simulation day, running back-to-back sessions in the morning and afternoon. However, while this approach allowed us to maximise resources, in future, we would balance it against the number of facilitators available per debrief, limiting it to two each to avoid overload.


Thanks to Rachel Crisp and the Barts Health Simulation Centre for their support and guidance with this programme. Thanks to Julie Whittaker, Steph Schwarze, Peachi Subramanian, Nuala Oughton and James Pennington for their contribution to the development and delivery of the simulation sessions.



  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.