Drs. Liz Steel and Carol Foot, and Nurse Educator Sarah Webb, in conjunction with Dr. Kim Vidhani, discuss how creativity and innovation are used to develop low cost medical simulation for intensive care medical training at Royal North Shore Hospital in Australia.

Drs. Liz Steel and Carol Foot, and Nurse Educator, Sarah Webb from Royal North Shore Hospital, Sydney, Australia, in conjunction with Dr. Kim Vidhani, Princess Alexandra and Ipswich Hospitals, Queensland, Australia, describe how they have used movie and theater techniques to develop low cost simulation for training for intensive care medicine professionals.

In the current climate of stretched resources, innovative, creative approaches for delivering high value, low budget programs to meet clear educational goals are needed1. Simulation centres and in-situ simulation set-ups in clinical settings are established environments for creating realistic, experiential learning opportunities2-3. Utilisation of these environments, however, may be limited by administrative costs and clinical workload4.

The ability to deliver effective simulation based learning anywhere is attractive. A major obstacle to this is the need to provide an experience for learners that is sufficiently realistic to generate immersion and emotional activation. The degree of fidelity required to achieve effective learning remains a topic of much debate in the medical simulation world.

Influences of Theatre and Film Industries

The theatre and film industries arguably have rivaled the aviation industry as sources of influence on the development of simulation in healthcare. Practitioners of the performing arts create fictional contracts with participants as a matter of course. It is well documented that convincing environments may be created with the suggestion of reality rather than providing every detail5. Scenography is the process whereby set designers (for film, theatre or TV) create the physical world and mood of a production. Backgrounds or “sets” can transport the observer to another time and place. Movie directors traditionally worked with set designers to create artificial realities to minimise production costs. On ‘Sabotage’ (1936) it was cheaper for Alfred Hitchcock to have a set built for one shot rather than go to London to film the real event in the script6.

Healthcare simulations are also “performances” and in our industry theatrical features create what we call the “fidelity” of the scenario. The popular and engaging Sim Wars concept7 has been effectively carried out in conference facilities as part of the Simulation In Healthcare Conference for a number of years. In a competitive but friendly and educationally unique context, engaging scenarios are created for teams, who perform in front of large audiences. Simple but visually interesting props are used to draw both the teams and audiences into the sessions. This has demonstrated the achievability of running mannequin-based scenarios outside a healthcare setting and arguably the power of theatrical events as learning episodes.

We are a group of clinicians with a passion for education who have benefited greatly from these insights. Due to a lack of resources, our experience over the last three years has been one of necessity driven solutions for designing and delivering low cost but effective educational programs for Intensive Care Medicine professionals. Unable to utilise the expensive and therefore inaccessible simulation centre at our institution, we turned our efforts to expanding our expertise, firstly in in-situ simulation and then adopting a “simulation anywhere” approach. This has been an exciting venture, which has enabled us to express our creativity and reinvigorate our teaching by delivering simulation based learning with a fresh approach.

In 2009, we established an in-situ, multidisciplinary simulation program in our ICU under a mandate of utilising only existing resources. This was called ICU STARSimulation Training at Royal North Shore Hospital ICU. A simulated ICU bed space was recreated in a room previously used for equipment storage using an existing Mega Code Kelly with Vital SimTM, supplemented by common ICU equipment and simple moulage (see photograph 1). Junior and senior ICU doctors manage a simulated patient through realistic events for five consecutive days as part of their usual ward round. Prior to the ward round, nurses make an assessment, then interact on the round when the medical team arrives. A management plan is reached as a team, then a debrief follows. The emphasis is on technical skills and knowledge development, particularly regarding teaching of longitudinal care of a critically ill patient. This means that each chapter reflects the expected course of an ICU patient over a week. Medical crises, “housekeeping” issues, such as attention to care bundles, and other topics ranging from strategic thinking to progress patient care are covered. Although this is not the primary focus of the sessions, there is some attention to non-technical skills and discussion about topics such as inter-professional communication teamwork. By adding the extra patient to the clinical teams’ workload, the temptation to abandon daily teaching due to time pressures is overcome, as a “real” patient would never be neglected. The environment evolved, with exploration of varying levels of fidelity coupled with feedback from large numbers of participants guiding “titration” of complexity of the moulage and “set” design.

CIT Course

The CIT (Consultant Intensivist Transition) Course was developed in 2010 for new Australasian Intensivists transitioning in their role from registrar to consultant. This not-for-profit management program was designed as a three-day course utilizing four clinical scenarios on the first day. These scenarios are set in an ICU to create a context and buy-in for the subsequent modular program that explores the various skills needed to deal with the complex challenges raised by each case. These include non-technical skills for managing clinical crises, understanding self and interpersonal personality differences including the utility of the Myers Briggs Type Indicator, Conflict Management and the Thomas Kilman Conflict Styles Inventory, team work concepts and Belbin team roles, negotiation skills, managing politics and sociograms, managing committees and meetings, legal and ethical dilemmas, clinical governance, patient quality, safety and change management principles. These topics are subsequently taught using various educational approaches including table-top simulations, role plays and games.

The faculty decided initially to utilise a simulation centre for the first day and then move to a venue away from the hospital environment for the remaining two days of the course. The expense of the simulation centre was significant. The need to reduce costs, prompted the search for a less expensive but effective solution for the manikin-based clinical simulations.

The entire program was subsequently held in hotel conference facilities designed for corporate clients. The clinical scenarios are now carried out using a theatre-in-the-round approach with a highly transportable, inexpensive "set". Free-standing conference posters of high quality clinical environment photographs create the back-drop. These posters are very light-weight and conveniently retract into the base and along with backing structural posts fit into a small carry bag.

Debriefing after clinical simulation.
Debriefing after clinical simulation.









Simulated Learning in Critical care Emergencies (SLICE).
Simulated Learning in Critical care Emergencies (SLICE).

Using experience from our ICU STAR program, a moulaged mannequin with ICU equipment, creates the foreground. “Actors” playing key roles assist us in meeting specific scenario driven learning objectives. Scenario agendas are then debriefed. Observers watch the scenarios sitting in comfortable couches at the edge of the set. There is an intimate feel to the experience created by the close proximity of the “audience” as well as the lighting style, which is focused on the set.

Our faculty has significant experience in simulation centre-based program development and have worked in state-of-the-art major centres, including Queensland Health Skills Development Centre and leading UK centres. Buy-in by participants to the clinical scenarios has been equal to that experienced in other simulation environments, and the course evaluations supported the conclusion that created scenarios met the curricular objectives. Feedback has included comments such as "I normally hate simulation but I felt really comfortable with my colleagues all around me in this intimate environment", "It felt very real", "I prefer it to the big brother is watching, video camera, one way glass approach".

The hotel approach has significantly reduced course costs and provided more comfortable facilities for learning while meeting the goals of the program.

In 2011, a multidisciplinary team Crisis Resource Management course was created in our ICU at Royal North Shore Hospital called SLICE (Simulated Learning in Critical care Emergencies). Building on the previously described courses, this one-day program was carried out entirely in our large ICU conference room, a non-clinical setting, previously used almost exclusively for lecture-based teaching sessions and team handover meetings, using the same approach as the scenarios in the CIT course (see photograph 5). The feedback for this program continues to be positive.

We will continue to develop this approach. It has enabled our educational course costs to be significantly minimised. Entire courses can be run in non-hospital and non-clinical environments, enabling a blend of clinical and management topics to be addressed in a single venue. More formal exploration of the utility of such an approach is warranted. It appears to be another attractive and feasible alternative for running mannequin-based scenarios. Looking outside healthcare to other industries may be a key driver of ongoing innovation and inspiration.


About the Authors

Professor Dr. Carole Foot, and Dr. Liz Steel are Intensive Care Specialists at Royal North Shore Hospital, Sydney, New South Wales, Australia. Sarah Webb is a Nurse Educator. Dr. Kim Vidhani is an Anaesthetist and Intensive Care Specialist at Princess Alexandra and Ipswich Hospitals, Queensland, Australia. All have extensive training and simulation backgrounds. Foot, Steel and Vidhani wrote the examination, Intensive Care Medicine for community members in Australia and Europe.



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