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Simulation-based training for pediatric OR nurses

Publish Date: 3/27/2013

Medical simulation is a training and feedback method in which learners practice tasks and processes in lifelike circumstances using models or virtual reality, with feedback from observers, peers, actor patients, and video cameras to assist improvement in clinical skills.1 Simulation is a growing practice that can teach principles in many situations including, but not limited to, competency training, policy implementation, quality improvement, and crisis resource management. Crisis resource management is currently the basis for simulation training in the ORs at Boston Children’s Hospital (BCH), and is supported by CRICO, a patient safety and medical professional liability company owned by and serving the Harvard medical community. As one of the insuring organizations that represent CRICO, the Risk Management Foundation of the Harvard Medical Institutions, Inc. is a not-for-profit medical and educational membership organization that focuses on claims management and patient safety on behalf of the insured organizations.2 

Adapted from the airline industry, the principle behind simulation training is the recognition that the cause of undesirable outcomes is often poor team performance, rather than a lack of expertise.3 Boston Children’s Hospital developed the first simulation program in New England that runs its scenarios in actual ORs.3 Based on Kolb’s theory of experiential learning, simulation addresses patient safety through the deliberative practice of high risk, low frequency events in a high-fidelity environment.4 “High-fidelity” can be defined as learning experiences that employ highly sophisticated, interactive computer programs, which incorporate lifelike models. The design and realism of this type of simulation are more likely to result in transference of learned behaviors to the clinical setting than other forms of behavior-based education, such as online course models or didactic lectures.5 Traditionally, training for perioperative nurses has included didactic learning activities, followed by individual, apprenticeship-like mentoring. Experiences for individual staff members varied widely during their preceptorships, depending on many factors. In addition, opportunities for responding to emergent situations occurred on a random basis, with little preparation.

Simulation at BCH

At BCH, anesthesiologists, surgeons, and perioperative staff nurses are brought together to participate in a collaborative five-hour workshop led by a member of the simulation training team. The facilitator is an expert clinician with a background in adult learning theories. After a period of didactic preparation and orientation to the capabilities of an extremely sophisticated pediatric simulation mannequin, the participants are given basic background information about a specific clinical scenario that evolves into a critical or emergent event. The particular scenario is written with clearly defined clinical and behavioral objectives. Simulation occurs at the point of care with the mannequin in the OR. When the simulation concludes, participants return to a separate conference room to engage in a structured and systematic debriefing. During debriefing, facilitators assist in distinguishing medical facts from feelings and attempt to elicit participants’ frames of mind, so that strategies can be employed that will provide the tools needed to improve future performance.

In situ simulation training offers many benefits. Training occurs with native teams that are already present in their own workplace and environment, increasing the reality of the experience. Also, discovery of latent safety issues may occur.6 As more staff members participate in simulation training, the culture of patient safety will continue to improve as language among multiple disciplines becomes standardized and behavioral responses to emergencies become consistent among all team members. Efforts should be made to generalize the concepts that are elicited during debriefings so that they are transferable to other clinical environments.

Currently, BCH runs approximately a dozen simulations per year specific to the perioperative setting, including scenarios in general surgery, otorhinolaryngology, orthopedics, and for neurosurgical procedures that occur in its magnetic resonance imaging-dedicated surgical suite. Thanks to the work being done with simulation and team training at BCH, perioperative staff nurses and team members from multiple disciplines can come together in a safe, structured environment and practice without risk to each other or patients.


  1. Institute of Medicine. Kohn, LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building A Safer Health System. Washington, DC: National Academy Press; 1999.
  2. CRICO. Harvard Medical Community. http://www.rmf.harvard.edu. Accessed March 12, 2013.
  3. Weinstock PH, Kappus LJ, Kleinman ME, Grenier B, Hickey P, Burns JP. Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. Pediatr Crit Care Med. 2005;6(6):635-641.
  4. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2(2):115-125.
  5. Merchant DC. Does high-fidelity simulation improve clinical outcomes? J Nurses Staff Dev. 2012;28(1):E1-E8.
  6. Weinstock PH, Kappus LJ, Garden A, Burns JP. Simulation at the point of care: reduced-cost, in situ training via a mobile cart. Pediatr Crit Care Med. 2009;10(2):176-181.

Guidelines for Perioperative Practice


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