Implementing and Sustaining In Situ Simulation programs

By: Victoria Brazil (@SocraticEM)


Greg was rushing into the ICU, juggling bags of simulation equipment, when he received the text message.

Sim cancelled today. Sorry. No staff

Damn it, he thought. We spent ages on that manikin so we could do the post cardiac surgery ‘re-open’ scenario. And I thought we’d been through the staffing, and this was the best time to run it for their team.

Amidst his frustration, Greg reflected that this was the 3rd time this month that ICU had cancelled. It seemed like they enjoyed the simulation and debrief when they did happen, and as an ex-ICU RN himself, he knew the scenarios were realistic. But he also wondered whether anyone actually read his simulation event reports, dutifully emailed to the departmental leadership team.  Maybe it’s just going to take time to really get them engaged….


Simulation faculty are often challenged with ‘buy in’ and engagement from clinical teams when running simulations, especially those conducted ‘in situ’, i.e., within the clinical environment. There are obvious tensions: teams are busy with patient care, the purpose of the simulations may not be clear, clinicians may have anxiety about the simulation process, and leadership may not perceive simulation activities as offering adequate return on investment of time and resources. However, we also know that in situ simulation (ISS) can offer significant benefits for shaping the culture and behaviours of teams, for testing systems and processes that affect patient outcomes, and for identifying latent safety threats in clinical environments. How do simulation faculty overcome the challenges so that these potential benefits can be realised?

Fortunately, a recent contribution to the simulation literature may help. Eller and colleagues offer us a framework for achieving ISS implementation and sustainability in their article – Leading change in practice: how “longitudinal prebriefing” nurtures and sustains in situ simulation programs. The authors interrogate their ISS programs’ successes and failures and offer us eight leadership steps that might help optimise success. They are “(1) identifying goals of key stakeholders, (2) engaging a multi-professional team, (3) creating a shared vision, (4) communicating the vision effectively, (5) energizing participants and enabling program participation, (6) identifying and celebrating early success, (7) closing the loop on early program successes, and (8) embedding simulation in organizational culture and operations.”1

Figure1. From Leading change in practice: how “longitudinal prebriefing” nurtures and sustains in situ simulation programs1

Figure1. From Eller, S., Rudolph, J., Barwick, S. et al. Leading change in practice: how “longitudinal prebriefing” nurtures and sustains in situ simulation programs. Adv Simul 8, 3 (2023).

These suggestions may seem intuitive, but the authors take the next step of giving some practical illustrations of what that looks like in practice. Leveraging patient stories, engaging ‘top down’ and ‘bottom up’, actively marketing and communicating successes, integrate simulation in institutional governance and policy, and many more. The authors draw obvious parallels with Kotter’s eight steps for organisational transformation. My take home message is that this is not to be underestimated. It takes time, persistence, and patience.

So, read the article for the thoughtful guidance on ISS, but also as an exemplar for those interested in qualitative research methods, and particularly “insider research”.

And, if you’d like to hear a podcast interview with the lead author, Susan Eller, here’s the Simulcast episode. Interested in other thoughts, successes and failures in implementation and sustaining ISS programs…


1.Eller S, J Rudolph, S Barwick et al. Leading change in practice: how “longitudinal prebriefing” nurtures and sustains in situ simulation programs. Adv Simul. 2023; 8(1):3.

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