Simulation

What is Simulation?

Simulation integrates cognitive, technical, and behavioral skills into an environment where learners “believe” the setting is real, act as they would in an actual resuscitation, and feel safe to make mistakes for the purpose of learning from them.

Effective teamwork and communication are essential to patient safety. For this reason, the Simulation and Debriefing component of the NRP Provider course is required.

Why Use Simulation

  • Adults learn better by active participation than by passive observation.

  • Simulation does not focus on doing everything correctly. Often, the best learning comes from making a mistake.

  • When learners are placed in a space with key visual auditory, and tactile cues that make them think and feel as though they are in a real resuscitation, they are able to “suspend their disbelief” and immerse themselves in the scenario, effectively re-creating real-life events.

  • Simulation allows learners to practice technical skills, rapid decision-making, and problem-solving during infrequently encountered crisis situations without endangering an actual patient.

Preparing for Simulation

Scenario Learning Objectives

The scenario is the clinical situation used for simulation. Each scenario should be based on 3 categories of learning objectives:

  • Cognitive skills—knowledge about newborn physiology and evidence-based resuscitation practices

  • Technical skills—hands-on skills, such as positive-pressure ventilation (PPV)

  • Behavioral skills— skills described in NRP Key Behavioral Skills that help ensure effective communication and teamwork

Creating the Scenario

Creating scenarios takes preparation and forethought. Effective scenarios help learners achieve the learning objectives as well as set the stage for the important learning that occurs during debriefing. A well-written scenario compels learners to integrate cognitive, technical, and behavioral skills while working under intense time pressure.

The instructor assesses the team's needs and bases scenarios on those learning objectives. The instructor has specific learning objectives in mind and sets up a plausible scenario when answering the 4 pre-birth questions from the team. For example, a simple PPV scenario should include an apneic baby who requires at least the first couple of MR. SOPA steps before the team can achieve chest movement with PPV and an increasing heart rate. The experienced instructor facilitates the scenario so that the learners have the opportunity to demonstrate the cognitive, technical, and behavioral skills required in a plausible clinical scenario.

An experienced instructor may be able to create a scenario "on the fly" by answering the team’s four pre-birth questions and stating “additional risk factors” that make sense for the desired resuscitation skills the team should demonstrate in order to meet the scenario learning objectives.

However, there are advantages to using a Scenario Template form to create (and avoid re-creating!) your scenarios.

  • The Scenario Template gives the instructor a form for organizing an effective scenario based on the team’s learning objectives.

  • The Scenario Template helps your assistants and other instructors set up for the simulation exercise, know which visual, auditory, and tactile cues are important to include, and know what to expect from learners during the scenario.

  • The Scenario Template give the person who will debrief the team a place to make notes during or immediately after the scenario, which helps guide debriefing.


Here is how the Instructor Toolkit can help you create scenarios while you are developing your skills, when creating a complex scenario (for example, when using embedded participants), and when you want to create scenarios as lasting documents for use by different instructors:

  • Formulate learning objectives. Before you create a scenario, assess learners’ needs and formulate the learning objectives. For examples of learning objectives, go to the Performance Checklists at the end of each textbook lesson.

  • Use the NRP Scenario Builder. The Scenario Builder will help you create scenarios for newborn resuscitation by letting you choose which resuscitation skill(s) meet your learning objectives, providing plausible answers to the four pre-birth questions, and providing “additional risk factors” that make sense for your scenario’s level of complexity.

  • Fill in the Scenario Template. The Scenario Template is a form that you can customize to create a complete scenario. The Scenario Template details the specifics for the scenario. This includes setup, props, required number of participants, roles of scenario assistants, and expected interventions from learners. During the scenario, you may use this form for making notes to help guide debriefing. It also includes debriefing questions.

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Instructor Tip

After you develop a new scenario, do a “dry run” with NRP volunteers to make sure it works as you intended. You may discover that you have forgotten an important visual, auditory or tactile cue. Record any changes on the template. Ultimately, you will build a library of tested and proven scenarios.

Preparing the Setting

After you have designed a plausible scenario, set up the scenario environment to seem as realistic as possible. You may have access to an actual setting, such as an unoccupied delivery room, newborn stabilization room, or operating room where cesarean birth occurs.

If not, set up a newborn resuscitation area that resembles the actual birth setting as closely as possible. You don’t need every detail of an actual birth setting. Decide which visual, auditory, and tactile cues are most important for eliciting learner actions to meet the learning objectives. Here are some strategies for creating a realistic setting:

  • A radiant warmer is a powerful visual and auditory cue. Allow learners to turn on the heat, start the Apgar timer, and operate the other functions. On some models the suction and oxygen equipment may be on the warmer.

  • If you use a T-piece resuscitator, make it operational by connecting it to a compressed air source (from the wall, from tanks, a compressor, or aquarium pump).

  • It is not essential to use blended oxygen during simulation as long as the learners can "adjust" the oxygen concentration by turning a knob (an actual knob or an image of a knob) from 21% to 100% oxygen.

  • If you must practice resuscitation on a conference room table, try to set up visual cues for the heat source on a radiant warmer, suction and oxygen, and whatever system is used at your hospital to call for additional help. A mock head wall poster, such as the NRP Equipment Poster, is a simple model that allows learners to simulate preparing equipment for resuscitation.



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Simulation on radiant warmer and on a conference room table

Preparing the Manikin

Consider using simulated body fluids to enhance realism. Easy recipes for blood, vernix, and meconium, as well as application and clean up strategies, are available in the The Art of Moulage: Guidelines, Recipes, and Easy Techniques

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If you do not want to spend a lot of time with moulage, moisten a blanket or towel to simulate body fluids and spray it lightly with simulated blood.

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Instructor Tip

Technology is not the key to quality simulation and debriefing. The methodology, such as auditory and visual cues used for realism, and the instructor skills during debriefing, have more to do with the quality of the experience than the use of high-tech equipment.




Video Recording

Video recording is beneficial to a complete learning experience, and filming can be done on your phone, tablet, or video recorder. Learners should be assured that video will be deleted immediately after use, and the recording is not used for any purpose outside the individual’s NRP Provider Course without written consent from the individuals in the video.

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Instructor Tip

The video can be used during debriefing to review selected time periods, interventions, and examples of key behavioral skills. Pause the video for discussion. Do not show the video from start to finish.

Conducting the Scenario

Before beginning the simulation exercises, it is important to prepare learners, other instructors, and faculty (see table below). You may find it helpful to use the “Ready Set Go” Checklist for Simulation and Debriefing as you conduct your simulation exercise.

Because you incorporated short practice scenarios before the Integrated Skills Station and your learners participating in Simulation and Debriefing already passed the Integrated Skills Station, your learners already know a lot about how scenarios are conducted.

If you conducted your Performance Skills Stations on a radiant warmer, your scenarios for Simulation and Debriefing may happen in the same place. If you conduct Simulation and Debriefing in a different place and/or with a different type of manikin or use a different method for conveying vital signs, learners will need orientation before beginning. Consider a “warm-up” scenario for learners who are inexperienced at simulation. This will give them the opportunity to pause and ask questions during a scenario before beginning the simulation exercise.

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Instructor Tip

Scenarios follow this sequence:

“You have been asked to attend a birth.”

  • Learners ask the 4 pre-birth questions: Gestation? Clear fluid? How many babies? Additional risk factors?

  • Learners choose the leader if not already done; leader delegates tasks.

  • Learners conduct the Equipment Check and prepare needed supplies.

  • Learners ask Rapid Evaluation Questions right after birth. 

  • Leaners consider delayed cord clamping.

  • Learners resuscitate the newborn.

“That ends your scenario. Let's debrief.”

Learner Preparation

ORIENT LEARNERS TO:

  • Simulation and Debriefing Ground Rules, which include learner roles and responsibilities

  • Supplies and equipment location and how to use simulated equipment, such as a picture of an oxygen blender or a suction gauge

  • Manikin features and how vital signs will be conveyed

  • Where heart rate and pulse oximetry numbers will appear on the monitor/phone/tablet

  • Dress code for simulation

  • If learners are not wearing scrubs, supply large-size scrub jackets or cover gowns to wear over street clothing

  • Learners should wear gloves during patient care and masks if appropriate to the scenario.

  • How to prepare for the birth (4 pre-birth questions, team briefing, equipment check)

  • How to manage communication with the obstetric provider about delayed cord clamping

  • How to call for additional help


REMIND LEARNERS TO:

  • Think out loud

  • Perform the actions, do not pretend

  • Act as a team

  • Suspend disbelief

  • Maintain professional behavior and a serious demeanor


Instructor/Faculty Preparation

ORIENT INSTRUCTORS AND FACULTY TO:

  • Scenario design and learning objectives

  • Who conveys vital signs

  • How vital signs are conveyed

    • If learners attach pulse oximetry, oxygen saturation and heart rate should be visible on the monitor screen/phone/tablet as long as the newborn’s heart rate is more than about 60 bpm. If learners attach ECG leads, the cardiac monitor will display the heart rate.

  • Who takes notes for the debriefing

  • Who leads the debrief

  • Who is filming and how to prepare the film for viewing during debriefing


GIVE SCENARIO INFORMATION, INCLUDING ANY ACTIONS AND STATEMENTS, TO THE:

  • Mother (and her support persons, if applicable)

  • Obstetric provider (this role may be played by the NRP instructor)

  • How to simulate delayed cord clamping

  • Embedded participants, if applicable. See also the Simulation and Debrief Videos for an example of an Embedded Participant in action

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Instructor Tip

If you are using an electronic simulator, demonstrate its capabilities. It is important that learners have an opportunity to see, hear, and feel the physiologic capabilities of the simulator before beginning a scenario. Give learners an opportunity to:

  • Listen to heart and breath sounds

  • Palpate the umbilicus (and remind learners that palpation is not the preferred method for assessing heart rate).

  • Visualize the trachea if intubation is a learning objective

  • See central cyanosis

  • Hear vocalizations such as crying and grunting respirations

  • Feel differences in muscle tone

Immediately Before Beginning

  • Start filming. Record interventions and team dialogue. It is not important to film team members' faces.

  • Begin by saying, "You have been asked to attend a birth. What would you like to know before you begin?"

  • Allow learners to ask the four pre-birth questions and prepare for the resuscitation.

Beginning the Scenario

The scenario begins with the “delivery” as follows:

  1. The obstetric provider “delivers” the baby (if appropriate for scenario).

  2. The neonatal and obstetric providers share their rapid evaluation of the newborn (eg, term, tone, breathing) to determine if the newborn can stay with the mother or should be moved to the radiant warmer for initial steps.

  3. If delayed cord clamping is clinically possible and the newborn is not immediately vigorous, the obstetric provider or neonatal team member (as discussed prior to the birth) may gently suction the mouth and nose with the bulb syringe and briefly stimulate the newborn.

  4. If the newborn does not respond to this stimulation, the obstetric provider simulates clamping and cutting the umbilical cord. Then the baby is moved to the radiant warmer.

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Instructor Tip

One Method for Simulating Delayed Cord Clamping

The newborn is “delivered” from under a sheet that covers the mother’s legs and abdomen. The mother holds one end of the long, simulated umbilical cord under her sheet and the obstetric provider holds the other end against the newly born manikin’s abdomen. When ready, the obstetric provider states that the cord is “clamped and cut” and simply lets go of the simulated umbilical cord. The newborn already has a clamped umbilical cord in place and is ready to move to the radiant warmer.

One nurse holding a manikin baby and another holding a simulated umbilical cord.Delayed cord clamping can be simulated with a piece of braided rope from the hardware store.

During the Scenario

During the scenario, do the following:

  • Convey vital signs as needed if you are using a low fidelity manikin. (For complete details, see Strategies for Conveying Vital Signs.)

  • Only provide clinical information in the following situations:

    • When the learner indicates readiness (eg, places stethoscope on the chest)

    • When the learner asks for information, such as “Is the baby breathing?”

    • When you want to elicit a learner action by telling learners, for example, “The baby is gasping” or “The baby has grunting respirations.”

  • Stay quiet and out of the way. Allow the learners to take the scenario down its own path.

  • Take notes on your completed Scenario Template.

  • Mark events to discuss at the debriefing.

  • Note which segments of the film will be valuable.

  • Allow learners to manage unexpected events.

    • Plausible events can present unanticipated learning opportunities. Some examples are dropping an item on the floor, responding to a pager, or problem solving a minor equipment issue.

    • For events that are not plausible (eg, a manikin’s arm falls off), learners should handle it in the best way possible and continue the scenario.

  • If the scenario has continued for some time and learners are far afield of the learning objectives, you must decide how to proceed. Sometimes, pausing the scenario and giving more information can help get learners back on track.

Ending the Scenario

  • Unless the scenario objectives include making end of life decisions, don’t let the manikin “die” due to poor performance by learners. If they perform so poorly that the manikin’s “life” is at risk, stop the scenario. Review the NRP Algorithm. Then practice technical skills before attempting additional simulation exercises.

  • Signal the end of the scenario without judgment, usually at the point when learning objectives have been met, the baby’s heart rate is over 100 bpm, and the airway is secure. Simply state, “That ends the scenario. Let’s debrief now.



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