December 14, 2017By Dr. Kim Baily

Healthcare Simulation Learning Experiences – Better In Situ or Off-site?

Learning context is defined as the situation in which something is learned or understood, a situation that can impact how something is learned or what is taught. If this is true for healthcare simulation, then the ideal location would be to hold simulation in situ (ISS) in the patient care areas of the hospital. Many facilities do hold educational sessions such as mock codes in the clinical areas. Alternatively, learning activities occur in custom built simulation labs where learners come to the center. Everyday another sim lab pops up at a medical center or academic institution. The Cedars Sinai Simulation Center in Los Angeles is so realistic that it can be used in an emergency to treat actual patients. But how do the participation experiences compare between ISS and off-site (OSS) simulation locations. A recent study by Sorensen et al in Copenhagen attempted to illuminate the general assumption that context and fidelity affect how different kinds of simulation -based medical education is experienced and that ISS is a more effective learning methodology.

The study included twenty five volunteers who were divided into four groups. The participants were comprised of consultant and trainee obstetricians, midwives, consultant and trainee anesthesiologists, auxiliary nurses, operating room nurses and nurse anesthetists. The trial included two multidisciplinary simulation cases conducted using ISS or OSS: an emergency caesarean section and the management of postpartum hemorrhage.

A number of interesting results came from the study:


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  1. An initial preference for ISS was apparent in the four focus groups, but as discussion progressed this preference waned and the amount of value participants put on an ISS setting as a crucial factor for their experience of learning in simulation shifted as other factors were deemed as more crucial.
  2. Some participants argued that the OSS setting in a small room, where things were organised differently and not in their normal place, forced them to see their own routines from the outside. This was considered positive even though it increased the risk of failing to follow normal procedures.
  3. The participants emphasised a heavy preference for simulation in authentic roles in their own professional groups. Examples of comments:
    1. “If you have to play other roles it becomes too much of a caricature”
    2. “The people are the most important and then perhaps the place (ISS participants)”
  4. Positive and negatives factors by the participants were not related to the location of the sim. For example:
    1. One positive factor was wearing usual uniform during simulation.
    2. “With regard to the manikin, I have a hard time remembering when it was a manikin and when it was a patient. It must mean that it’s close to reality when you can’t tell the difference (ISS participant)”
    3. Participants thought that it was disruptive if participants or facilitators laughed, giggled or joked during the simulation as this behaviour influenced how seriously they became involved in performing the simulation, which in turn affected their learning outcome negatively. This was the case for both ISS and OSS
  5. ISS and OSS participants viewed debriefings as a central, exceedingly positive factor for ensuring learning.
  6. The participants noted that their interprofessional communication, collaboration and teamwork skills improved. Participants noted that both ISS and OSS provided an opportunity to practice their own actions and interactions and to investigate the roles of their colleagues. Participants gained insight into the roles of other team members and identified assignments that took longer than they would have expected.
    1. “It occurred to me along the way, [….] something that I might have let frustrate me on a daily basis. It’s that a team consists of many small subprocesses. And you know what the others are doing, but not in any detail (ISS participant)”.
    2. “Once again this just shows that you have to talk to people, look at them, say their names, ask them to do something and then note whether they’ve actually understood. Because that’s the only way that we can work together as a team. We bury ourselves in our own tasks (OSS participant)”.
  7. Although both experiences generated suggestions for changing organizational practices, more suggestions were mentioned by the ISS participants.

Overall, the learners in this study did not find that either in-situ or off-site learning labs provided a better learning experience. One difference noted was that ISS did provide more suggestions for system improvements within the facility.

Only a few of the findings of the study have been included in this review. However, the entire article is an excellent resource for anyone needing a reference about why simulation either in-situ or off-site is an excellent method for training staff particularly as the training relates to inter-professional education.


Today’s article was guest authored by Kim Baily PhD, MSN, RN, CNE, Simulation Coordinator for Los Angeles Harbor College. Over the past 15 years Kim has developed and implemented several college simulation programs and currently chairs the Southern California Simulation Collaborative.

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