Overview of Simulation and In Situ Simulation

Reading assignments, lecture presentations, or dramatized video reenactments on active shooter events provide passive learning but do not allow learners to rehearse and demonstrate an understanding of the educational message. Simulation is an educational method that attempts to immerse the learner in as-authentic-as-possible conditions through the use of trained actors or mannequins, scripted scenarios, and realistic responses to learner behaviors. It has previously been shown to generate physiological stress and therefore be an ideal method of training for low frequency, high stakes events.Reference Keitel, Ringleb and Schwartges ^{4 -} Reference Langhan, Rigby and Walker ⁶ It provides a safe space for first-time exposure, allowing participants to realistically experience their true reactions and to experiment with behaviors without consequence. Immediate debriefing following simulation allows for optimal learning because it contributes to a shared understanding of transpired events by the learner group. Discussions on what went well during the simulation help reinforce successful behaviors. Input on what the group thought should have gone better during the simulation provides a springboard for education on correct or improved actions in a future circumstance.Reference Wang ^{7 ,} Reference Zigmont, Kappus and Sudikoff ⁸

In situ simulation, which takes place not within a separate educational space but instead in the learner group’s own workplace, has several advantages. In addition to providing psychological fidelity, as with standard simulation, participants are able to learn in context due to an even higher environmental fidelity – during training, they have access to familiar tools and must maneuver within the true footprint of the physical space encountered at work.Reference Spurr, Gatward, Joshi and Carley ^{9 ,} Reference Sorenson, Lottrup and van der Vleuten ¹⁰ Additionally, in situ simulation contributes to organizational learning, in which unanticipated opportunities for improvement in processes, equipment, or even the physical workspace may arise as a result of the simulation itself.Reference Patterson, Geis and Falcone ^{11 ,} Reference Barbeito, Bonifacio and Holtschneider ¹² It is also easier for on-duty personnel to attend. Given these benefits, in situ simulation education for active shooter training is particularly useful because the key actions are to RUN away from the active shooter through the nearest egress pathway, HIDE behind physical barriers, and FIGHT using any means possible, including the use of nearby objects as weapons.Reference Blair and Schweit ²

Potential drawbacks of in situ simulation for active shooter education in a hospital setting are delays in patient care while the simulation is taking place and threats to the physical and psychological safety of learners or uninvolved passersby. Further, in situ simulation can only capture a small group of learners with each session. The repetition of sessions to educate the entire cohort is not only costly with regard to time, but also amplifies the aforementioned concerns regarding productivity and cognitive ramifications.

In this study project, we aimed to create an in situ active shooter training model with minimal impact on ED patient care, staff, and patient/family safety, and with maximal educational reach for ED staff.

Simulation Scenario Overview

Planning occurred through an initial meeting of our disaster preparedness group followed by several more meetings of key leaders. The disaster preparedness group includes representatives from nursing (staff nurses, nurse education specialist, and nurse manager), physician (staff and resident), social work, security (officers and supervisor), patient registrars, and emergency preparedness (manager and coordinators). The key leaders met several times over the following months and included a nurse education specialist, a disaster management lead physician, a simulation education physician, and an education chair physician. Two different scenarios were created and conducted on separate days in different locations within the ED. No patients were present during the simulation. Patient care areas not in active use were used to ensure no interference with real patient care. Total time, including pre-briefing, scenario, and post-scenario debriefing, was limited to 10 minutes. The first scenario was conducted in a closed adult patient care area and centered on a simulated victim of domestic violence ( Table 1 ; Figure 1 ). In the nine-bed hallway, simulated patients were represented by vignettes involving mannequins playing the part of patients in some rooms and paper descriptions of a patient in others. Employee participants did not know of the topic of the simulation beforehand. Participants were assigned to specific areas at the start of the scenario and instructed to care for patients as normal. The active shooter played the role of an estranged abuser who entered the area shouting the name of the intended victim with demands to see her. He was immediately approached by a confederate staff member who shouted, “Put down the gun, sir. Don’t shoot me.” The confederate staff member was then “shot” and fell to the ground. The shooter then interacted with participants by proceeding to walk down the corridor searching for the victim while shouting her name and looking in various patient rooms shouting the name of the patient. The simulation was stopped when the shooter arrived at the room of the patient. This scenario took approximately 1 minute followed by a 10-minute debrief. This simulation was duplicated with different participant groups three times during a 1-hour time frame, with short breaks in between.

Figure 1

Scripted Plan for First Simulation

Table 1

Physical Layout for First Simulation

The second scenario was conducted in the 12-bed pediatric patient care area of the ED. Once again, it was conducted during a time when no patients were present. Based upon feedback after the first simulation, actors were used to represent patients rather than mannequins. This more closely simulated a true patient-provider relationship and enhanced the ethical dilemma of possibly needing to run away without taking a patient who is unable to ambulate independently. This scenario centered on the estranged father of a child who was a patient in the pediatric area. An actress played the part of the mother, and a teenage actor played the part of the patient. The remainder of the scenario was unchanged.

Scenario Logistics

For both scenarios, all members from across disciplines were invited to participate. This included physicians, advanced practice providers, nurses, nursing assistants, security personnel, social workers, respiratory therapists, child life specialists, environmental service personnel, phlebotomists, electrocardiogram technicians, radiology technologists, and care team assistants. The simulations were conducted during a departmental faculty meeting when many physician providers were on-site but not involved in patient care. These department meetings occur on the third Wednesday of the month during the morning hours. Other members of the team participants were assigned to attend by supervisors outside of work duties or were simply tapped during their shift and asked to participate in a 10-minute simulation after ensuring that others were providing care for their patients. The brevity of the simulation allowed for high numbers of staff participants.

The scenario was intentionally planned without involvement by local law enforcement or any outside agencies. Our institution does not have on-site representation by local law enforcement. We did not involve local law enforcement or any other outside agencies with this specific educational initiative because we rely upon our internal resources and security for the initial response to an active shooter situation. The focus of each session was the initial minutes of the response; this time frame would not include the involvement of our local law enforcement.

The sessions were announced overhead as only a “drill” and only in the care areas used. We did not want the participants to be aware of what the drill specifically involved. Our goal was to try to create as much realism as possible to evaluate their response without any potential for rehearsal or planning.

When the team was gathered, the facilitator read a pre-brief script ( Figure 2 ). After the pre-brief was completed, participants were placed strategically throughout the patient care pod in patient rooms, in the center staff work area, or in the corridors. Confederate security workgroup members were placed outside each care pod exit to guard against any participation of bystanders who might come across the simulation and to detain any simulation participants who “ran” out of the area during the scenario. Telephones in the area were unplugged to ensure that the reach of the simulation stayed within the patient care pod. Members of the in situ simulation planning group were also stationed in the area and identified by yellow caution tape worn as a sash/necklace. Once everyone was in place, the simulated active shooter was cued to enter the area, and the simulation began. Members of the planning group were assigned to observe and record participant reactions and were instructed to end the simulation if there were signs of participant duress. No intervention was required during any scenario. The simulation was timed to end after approximately 1 minute, and debriefing occurred immediately within the patient care hallway.

Figure 2

Facilitator Pre-Brief Script

The debriefing was co-lead by the Chief Security Officer and Staff Physician expert. The model of debriefing focused initially on expressing gratitude for the staff participation and allowing participants to freely describe initial emotions and reactions for a short time. This was followed by structured reflective questioning regarding the observation of how the participants reacted to the scenario and an exploration of what prompted them to do so. The final minutes of the debriefing focused on the feelings that were elicited by the simulation (especially in regard to the issue of patient abandonment), a review of “Run-Hide-Fight” instructions, and the pragmatic need to remain close to the hospital to be available after the event to begin victim resuscitation. During the debriefing, members of the planning group again were present to observe for signs of emotional or psychological distress stemming from the simulation. For any staff participant who appeared shaken or unusually affected, a member of the planning group approached them immediately and then again after a few days to assess for any lasting effects.

Firearm Specifics

Varied opinions existed among the planning group on whether the active shooter actor should carry a simulated gun due to concerns about psychological and physical safety for scenario participants and uninvolved bystanders. Our institutional policies also explicitly exclude guns from the hospital and clinic premises. Consensus was reached that the actor would not carry a simulated gun. Instead, participants were alerted that the actor had a gun when a confederate workgroup member would loudly yell through the confederate staff member’s scripted exclamation: “Put down the gun. Don’t shoot me.” Gunshot noise was simulated by striking a hard box against the counter.

Scenario Outcomes

The response from participants was quite varied and included many choices from staying with patients, leaving the department, and engaging the simulated assailant to fight. Several participants did verbalize a plan to call security for immediate help. No confederate staff intervention was required during any of the scenarios, and all simulations were run to completion. No participants reported any lasting traumatic effects as a result of participating in the simulation. In contrast, participants expressed gratitude for the exercise and were given the opportunity to reflect upon their reactions. A scenario evaluation was conducted both through a structured evaluation instrument ( Table 2 ) and through an anonymous online survey conducted within 2 weeks of the simulation. The response rate was 47/93 (50.5%). Results for the overall rating of the activity were positive and are listed in Table 1. Specific participant comments are provided in Figure 2. Observations of participant reactions by planning group members are listed in Figure 3 .

Figure 3

In Situ Simulation Evaluator Observations

Table 2

Active Shooter Simulation-Structured Observer Evaluation Form