Feasibility and Acceptability of a Low-Tech Simulation

www.aana.com/aanajournalonline AANA Journal December 2020 Vol. 88, No. 6 445

Simulation is an effective tool to learn or refresh skills and knowledge, but numerous barriers prevent the routine use of simulation. The purpose of this proj-ect was to assess the feasibility and acceptability of the use of a low-tech simulation kit by the hospital’s personnel for overcoming those barriers. A phenom-enological qualitative approach using semistructured interviews was conducted with a convenience sample of 5 Certified Registered Nurse Anesthetists (CRNAs) and a student registered nurse anesthetist at a rural community hospital. Additionally, a CRNA served as the facilitator and was interviewed. After the data were independently analyzed by 2 individuals, 6 themes emerged. A low-tech simulation was acceptable, although the sense of stress was difficult to replicate.

The facilitator found that simulation preparation and execution were easier and less work than expected. A low-tech simulation kit is a viable option for increasing the frequency of simulating anesthesia emergencies and overcoming the barriers that prevent the frequent use of simulation in the clinical setting. Psychological fidelity can be enhanced through innovative methods (flip book containing screenshots of an electrocardio-graphic monitor, video) to overcome the limitations of a low-tech simulation.

Keywords: Certified Registered Nurse Anesthetists, community hospital, local anesthetic systemic toxicity, low-fidelity simulation, low-tech simulation.

Feasibility and Acceptability of a Low-Tech Simulation Using Local Resources in a Rural Community Hospital

Seth K. Mogler, DNAP, CRNAJoshua A. Cochrane, DNP, CRNALaChelle J. Wieme, DrAP, CRNAMary E. Shirk Marienau, PhD, CRNA

Simulation is a method of experiential educa-tion widely used in the aviation industry and credited with improving its safety record. As an early adopter of simulation in healthcare, anesthesiology has a similar success story of

improved safety over the past decades.1 The purposes of simulation include practicing a new skill, simulating an infrequent emergency, and teamwork training. This method of simulation has been shown to be effective for learning.2,3

Simulation fidelity has been the subject of much dis-cussion and research. High-fidelity simulation is defined as an extremely realistic situation with a high level of interaction for the learner. It can include humanlike manikins, task trainers, or virtual reality. Low-fidelity simulation can include task trainers, case studies, or role playing, and it does not need external involvement for the learner to participate.4 Because fidelity is a continuum, the term medium fidelity is sometimes used to describe simulation that does not have an interactive manikin but has higher fidelity than a task trainer. It has been pre-sumed that high-fidelity simulation is superior. However, much of the research compared high-fidelity simulation with lecture or informal clinical instruction (also known as opportunistic instruction). When high-fidelity and

low-fidelity simulation were compared, the gains made by participants were not statistically different.5 Although most people may believe that fidelity refers to the level of technology in the simulation, known as engineering fidelity, the terms low tech and high tech are used to describe the amount of engineering fidelity. High-tech simulation uses technology, including a computerized manikin and an electrocardiographic (ECG) monitor, whereas low-tech simulation forgoes the use of technol-ogy and uses a static manikin or a patient-actor instead. Another component of fidelity is psychological, which encompasses the accuracy of the simulation and the specific activities that the participant uses to complete the task.5 The value of high-fidelity simulation comes at the expense of its rare frequency compared with the in-creased frequency possible with low-fidelity simulation.5 Therefore, the value of each simulation method must be understood so that education and simulation objectives can be aligned with the appropriate simulation method.

The location of the simulation, whether in situ (ie, conducted in the actual clinical environment) or in a simulation center, has been the focus of much research. Knowledge, stress, intrinsic motivation, and safety at-titudes of participants were similar between simulations conducted in a simulation center and those conducted

446 AANA Journal December 2020 Vol. 88, No. 6 www.aana.com/aanajournalonline

in situ; however, participants rated in situ simulations as more authentic.6 Authentic simulation is important to healthcare professionals, as was shown when they par-ticipated in an actual clinical role in a realistic scenario, regardless of the location of the simulation.7 In situ simu-lation is useful for identifying deficiencies in organiza-tional processes by providing an opportunity to identify and address system deficiencies without putting patient safety at risk and to avoid relying on actual system fail-ures or near-miss events to elicit change.7-9 The location of the simulation does not determine the level of fidel-ity or the amount of technology used because both in situ and simulation center locations can provide similar levels of fidelity or technology. Examples of anesthesia-related in situ simulation scenarios cited in the literature include malignant hyperthermia, anaphylactic shock, cardiac arrest, pediatric postoperative laryngospasm, and obstetric emergencies (eg, hemorrhage, amniotic fluid embolus, and umbilical cord prolapse).10

The cost barrier of simulation must be overcome to have a successful simulation program. For example, the Mobile Obstetric Emergencies Simulator (MOES) high-fidelity simulation kit, which was developed for the military healthcare system and is used with TeamSTEPPS curriculum (a teamwork training program developed by the US Department of Defense), costs $25,000 for implementation and $500 for annual maintenance.11 However, low-cost simulation has been effective in in-creasing knowledge.9 In fact, medium-fidelity manikins can provide similar gains in the domains of clinical reasoning, knowledge acquisition, and participant sat-isfaction at 20% of the cost of high-fidelity manikins.12 A low-fidelity manikin cannot talk or simulate respi-rations or heart rate like a high-fidelity manikin, but

chest compressions and airway skills can be performed. A cost-effective method of overcoming the barriers to simulation is a PRONTOPack simulation kit (PRONTO International), which provides the basic equipment (birth simulator pants worn by a patient-actor, a static baby manikin and placenta, and a simulated blood system) and the curriculum to conduct a simulation. Owing to its low cost and minimal technology, the primary end users of the PRONTOPack are hospital systems in low-resource countries, including Mexico, India, Guatemala, Ghana, Uganda, Namibia, Ethiopia, and Kenya. The kit provides the opportunity to simulate numerous obstetric emergen-cies, such as postpartum hemorrhage, neonatal resuscita-tion, and shoulder dystocia.13 Use of the PRONTOPack decreased neonatal mortality by 40% and risk of cesarean delivery by 21% in a pair-matched trial involving 24 hos-pitals in Mexico.14 Although the patient characteristics, hospital resources, and preventable morbidity and mor-tality may be quite different between Mexico and a devel-oped country such as the United States, patient outcomes research using simulation has been limited.

A low-tech simulation kit could potentially be used to overcome the barriers to simulation, including partici-pant time, access to simulation equipment and resources, and cost. The purpose of this project was to pilot the use of a low-tech simulation kit facilitated by the hospital’s Certified Registered Nurse Anesthetists (CRNAs) and to assess its feasibility and acceptability through a phenom-enological qualitative design. This project was designed to address a gap in current research about simulation kits in community hospitals.

MethodsThe Mayo Clinic institutional review board determined that this project was exempt from requiring board ap-proval. A simulation curriculum was developed based on the Standards of Best Practice: Simulation Standard IX.15 The scenario chosen was local anesthetic sys-

Figure 1. Low-Tech Manikin

Figure 2. Flip Book Screenshot of Electrocardiographic Monitor


temic toxicity (LAST), and treatment was based on the American Society of Regional Anesthesia and Pain Medicine (ASRA) 2017 guidelines.16 A kit was assembled that contained consumable and nonconsumable supplies necessary to conduct the simulation. A static, low-tech manikin (Figure 1) was borrowed from the simulation center at the principal investigator’s (S.K.M.) institu-tion. To enhance psychological fidelity while minimizing technology, a flip book containing screenshots of an ECG monitor was created (Figure 2). Another low-tech simu-lation method used to enhance psychological fidelity was playing a video during the simulation to show the “pa-tient’s” altered mental status and seizure. The video was created for this simulation with a patient-actor wearing a gown, wig, and arm splint like the manikin’s. This helped the simulation participants relate the patient in the video to the manikin. A step-by-step instruction book described the setup and facilitation of the simulation, and a just-in-time debriefing training was developed.

A dry run at the rural community hospital with the facilitator was used to provide feedback on the scenario, fidelity, and feasibility and to verify that the scenario matched local processes. The simulation was conducted twice to assess the flow of the simulation, and then a faculty member (J.A.C.) assumed the facilitator role to assess the feasibility of conducting the simulation inde-pendently. Improvements were made as needed accord-ing to these tests and to feedback received before the simulation at the community hospital was implemented.

Qualitative, quantitative, and demographic data were collected from the simulation participants and facilita-tor to assess the acceptability of the simulation method. Surveys administered before and after the simulation used a 10-point Likert-type scale to collect quantitative data on the individual’s perceived confidence in man-aging LAST. Data were summarized with means and medians. The simulation facilitator conducted qualitative interviews after the simulation debriefing. Interviews

were audio recorded with permission from the partici-pants. The principal investigator developed qualitative questions with guidance from the qualitative research unit at the investigator’s institution, conducted the inter-view with the facilitator, audio recorded the interview, and transcribed it verbatim. The principal investigator analyzed the data and extracted themes with assistance from an experienced qualitative researcher. Saturation of concepts was obtained.

Before the simulation was implemented with par-ticipants, the facilitator completed a dry run of the entire simulation with assistance from the principal investiga-tor, who designed the simulation curriculum. The simu-lation facilitator conducted the simulation sessions inde-pendently with the simulation instruction book included in the implementation kit. If the facilitator encountered simulation issues, the principal investigator was available by telephone. The facilitator conducted the simulation twice: once during a regularly scheduled meeting time, which allowed the entire staff to participate as a group, and a second time with a student registered nurse anes-thetist (SRNA).

ResultsA convenience sample of 5 CRNAs, 1 SRNA, and 1 anes-thesia technician participated in the simulation. Although an anesthesia technician is a valuable member of the an-esthesia team, those data were excluded from the results because of differences in education. The CRNAs were experienced and had previously participated in simula-tions (Table 1). Mean values for self-assessed confidence were 7.5 before the simulation and 9 afterward. Owing to the small sample size, inferential statistics were not conducted. Estimated supply costs are shown in Table 2.

Six themes were identified from analysis of the quali-tative interviews (Figure 3).

• Theme 1: Reviewing and Updating Clinical Information Helps Participants Enhance Their Knowledge. The participants discussed the opportunity to refresh their knowledge on the protocol and management of LAST. They explained that although they knew about the therapy for LAST, because of the infrequency that LAST emergencies are encountered, they appreciated the expe-riential education to learn about and discuss the changes to the LAST treatment guidelines.

• Theme 2: Simulation Provides Opportunities for

Table 1. Demographic and Quantitative Data of Simulation ParticipantsAbbreviation: LAST, local anesthetic systemic toxicity.aFor 5 Certified Registered Nurse Anesthetists. One of the 6 participants was a student registered nurse anesthetist.bMaximum of 10 points.

Mean Category (Median)

Age, y 42.5 (40)

Gender: M:F 3:3

Years as anesthesia providera 11.9 (10)

Number of times of previous participation 22 (6) in simulation

Presimulation confidence in managing LASTb 7.5 (7.5)

Postsimulation confidence in managing LASTb 9 (9)

Table 2. Estimated Supply Costs

Category Cost, $

Airway 80.80

Manikin accessories 32.15

Miscellaneous 44.98

Medication 173.56

Total 331.49


Identifying Latent Threats, Including Opportunities for Improving a Facility’s Resources and Protocols. The staff discussed how the simulation made them think about how they would intervene in an actual clinical emergency and what barriers they may encounter related to the facil-ity’s resources and protocols. The participants discovered that their facility needed to obtain more lipids and update their LAST checklist.

• Theme 3: Frequency of Simulation to Refresh Knowledge and/or Skills Depends on the Content of the Scenarios. The participants suggested various frequencies for participat-ing in simulation, ranging from quarterly to every 2 years. They said that the low-tech method, with brief, anesthesia-focused scenarios in the clinical setting, was a feasible simu-lation tool and that this experiential learning format was valuable and could be applied clinically.

• Theme 4: Overcoming Barriers Beforehand Is Important. The staff identified that the barriers to con-ducting simulation in their facility were having time dedicated to the simulation and gaining support from the staff. The staff recognized the difficulty of finding dedi-cated time to conduct a simulation when the operating room (OR) schedule was busy and of not inconvenienc-ing staff by asking them to participate in a simulation outside their scheduled shift. A prepared, low-tech simu-lation could help overcome the time barrier. The partici-pants discussed motivating staff by choosing a relevant anesthesia topic where simulation could provide more education benefit than a lecture.

A simulation kit with a prepared scenario, supplies, and instructions allowed the facilitator to launch the simulation quickly. The facilitator found the simulation easy to set up and conduct. A high-quality simulation kit containing curriculum and supplies helps the facilitator provide a successful simulation.

• Theme 5: Scenarios Conducted in the OR Decrease the Need for High-Fidelity Tools to Feel Realistic, but the Sense of Stress Is Hard to Replicate. The participants discussed how being in the OR decreased the need for simulation technology to enhance realism. The partici-pants commented that the prerecorded videos and ECG screenshots were a simple way to provide clinical data for making decisions during the simulation. Participants em-phasized the importance of matching the learner’s needs with the simulation goal. A single-discipline simulation worked well with a low-tech approach.

The participants did not sense the stress experienced during an actual clinical emergency. They said that the stress would be difficult to simulate. The principal inves-tigator noted it may be related to the group simulation method, which had an abundance of resources that an actual clinical emergency would not have.

• Theme 6: Developing a Skilled Debriefer From Local Personnel Is a Challenge. The just-in-time debriefing training was not sufficient for the facilitator to develop the

necessary skills to lead debriefing. The facilitator excelled at guiding the discussion and education related to LAST. However, the debriefing did not include self-reflection by the participants or exploration of their emotions.

DiscussionUse of a simulation kit is an effective method for over-coming barriers to conducting simulation while im-proving participants’ confidence during an anesthesia emergency. The participants consistently commented that lack of time was the barrier to conducting simula-tion in their department. One participant said, “You need less time to do [low-tech simulations].… [Time] always used to be the biggest barrier.… [I]t’s pretty easy to run a quick simple sim[ulation] and have a discussion.” When planning for a simulation, it is important to determine the most feasible time to conduct a simulation, such as during a regularly scheduled education time (as was done in our facility), during OR delays, or on low case-volume days. The simulation kit was designed to be implemented in any of those situations. The prepared low-tech simula-tion decreased the barriers of planning and executing a simulation in a busy OR environment.

The emphasis in healthcare simulation has been on high-fidelity simulation, but the barriers for conduct-ing high-tech simulation prompted development of this low-tech simulation kit. However, if participants do not accept the low-tech model as valuable, the effectiveness of their learning and their motivation could be hindered. The participants in our project appreciated the low-tech

Figure 3. Qualitative ThemesAbbreviation: OR, operating room.


simulation with innovative enhancements to obtain key patient information. One participant commented favor-ably on the video used to show the “patient’s” altered mental status and seizure and on the screenshot prints of the ECG monitor (see Figure 2). The simulation fidel-ity was enhanced by conducting the simulation in situ instead of in a simulation center. One person said, “It felt more realistic because of the setting where it could actu-ally occur.” Providing healthcare professionals crucial patient information in alternative manners (instead of simply being stated by a facilitator) and conducting the simulation in the actual clinical environment can enhance the psychological fidelity and overcome the limitations of low-tech simulation.

Use of the simulation kit required minimal preparatory work by the facilitator. The facilitator said that the kit was designed to be set up quickly, that the simulation was less work than expected, and that the preparation and execu-tion of the simulation were “easy.” Decreasing the anxiety and workload of the facilitator may reduce the barriers to conducting simulation and potentially increase the fre-quency of simulation for anesthesia emergencies.

The simulation was designed to replicate stress by requiring participants to prioritize multiple tasks. When interviewed, however, participants said that they did not feel a sense of stress and recognized the limitations of simulation because “only in a true emergency can someone feel the stress.” However, participants have experienced similar mental strain in high-fidelity and low-fidelity simulations.17 Low-tech simulation may be limited in the amount of stress it can induce compared with high-tech simulation. A future low-tech simulation could include the use of an app-based ECG monitor, such as SimMon (Castle+Andersen ApS). The app pro-vides a display of a simulated ECG monitor and includes the changing pulse oximeter tone that anesthesia provid-ers are accustomed to hearing.18

Another explanation for the lack of stress experienced was how the simulation was conducted. It was designed to have 2 anesthesia providers manage the emergency and carry out all tasks, including drawing up and admin-istering medications, providing airway management, and providing advanced cardiac life support care. However, the simulation involved all 5 CRNAs. Some tasks, such as drawing up medication, were verbalized, so the sense of stress from having limited resources and task overload may have been decreased. However, this example shows that the simulation design was flexible and allowed adap-tations to accommodate the facility’s objectives.

The simulation participants found benefit in the group approach, which allowed them to discuss their own prac-tice and the changes needed in the practice. The in situ simulation allowed the team to identify latent threats, a frequently cited benefit of this method of simulation.6-9 The simulation helped participants realize that the LAST

treatment kit needed to be updated by increasing its supply of lipids and updating its LAST checklist. The fa-cility increased its stock of 20% lipid emulsion (from 250 mL to 1 L) on the basis of the ASRA’s updated checklist for LAST treatment.16

The training of local personnel to be skilled debriefers is a challenge. The just-in-time debriefing training was developed in consultation with a debriefing expert at a simulation center, but the debriefing training completed by the facilitator was not sufficient. Although the facilita-tor did not feel that the debriefing was a challenge, the fa-cilitator’s qualitative interview provided information that exceeded what a debriefer should provide. Debriefing is based on the experiential learning theory of constructiv-ism. Participants should use their current knowledge and experience with the simulation experience to enhance or change their knowledge. The debriefer’s role is to guide the reflective learning and provide formative feedback on the simulation.19 During the qualitative interview about debriefing, the facilitator included phrases that might limit participants’ reflections, such as “hitting all the points,” “group discussion,” and “keeping on task.”

Further research is needed to identify methods for de-veloping skilled debriefers from local personnel instead of relying on simulation experts. However, the scripted template used in our simulation was superior to an un-scripted debriefing.20 One possible solution is to ask the facilitator to participate in an online simulation debrief-ing course, or a simulation expert could conduct the debriefing through a video conference, but that would require the debriefer to observe the simulation and that would add a level of complexity to the simulation.21,22

One unexpected finding was that the simulation pro-vided a unique way to review the updated LAST guide-line, which was published 1 month before the simulation. One staff member commented, “[I]t was a good way to accomplish that [review of the updated LAST protocol] instead of just here’s the new protocol. You had to think about it and run through it.” Another participant said, “[I]t keeps staff abreast of what’s going on and also prompts discussion and inquiry.” The simulation en-couraged staff to think about how they would respond to the situation and critically evaluate the practice change related to their resources.

• Cost. The cost of the low-tech simulation was rela-tively low. The total cost of the consumable items and the capital cost of the initial simulation session was estimated at $331.49, which does not include development of the prerecorded video or the cost of the borrowed manikin. The retail price of a static manikin meeting the needs of the simulation scenario is $1,335 to $2,770. The miscel-laneous supplies and manikin wig (in the manikin acces-sories category; see Table 2) were the only supplies not readily available in a clinical area. They cost $61.87. An estimated cost of $59.68 was for consumable medication


supplies, which could be used during multiple simula-tion exercises in a short period. Each simulation exercise was estimated to cost $4.15. The cost estimates are based on list prices from a medical retailer, so costs for many institutions could be considerably less.

• Strengths and Weaknesses. This project tested the feasibility and acceptability of using a prepared low-tech simulation kit to conduct a simulation with local resourc-es at a rural community hospital. A qualitative approach allowed themes to be developed to enhance an under-standing of the views that practicing anesthesia providers have toward this innovative educational method.

The project does have some limitations. It was con-ducted at a single site with a small sample size, so its generalizability to other institutions is limited. Bias cannot be excluded because the qualitative interviews were conducted by the facilitator of the simulation and the principal investigator. The simulation was conducted only 2 times, so the amount of data collected was limited. The qualitative interviews were conducted by an inter-viewer within the time constraints of a busy OR schedule, thus limiting reflective insight and the quality of the data. The facilitator’s debriefing training consisted of only the just-in-time training provided in the simulation kit, so the participants’ educational gains may have been limited.

ConclusionA low-tech in situ simulation kit is a useful option for overcoming the barriers that prevent the frequent use of simulation in the clinical setting. The anesthesia provid-ers appreciated the low-tech equipment used to display crucial scenario information during the in situ simula-tion, and they critically considered and discussed practice changes and discovered latent threats to their practice. The simulation kit seemed to decrease the preparatory work and make conducting and facilitating the simula-tion easier in a rural community hospital setting.

REFERENCES 1. Green M, Tariq R, Green P. Improving patient safety through simula-

tion training in anesthesiology: where are we? Anesthesiol Res Pract. 2016:4237523. doi:10.1155/2016/4237523

2. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simula-tion for health professions education: a systematic review and meta-analysis. JAMA. 2011;306(9):978-988. doi:10.1001/jama.2011.1234

3. Teteris E, Fraser K, Wright B, McLaughlin K. Does training learners on simulators benefit real patients? Adv Health Sci Educ Theory Pract. 2012;17(1):137-144. doi:10.1007/s10459-011-9304-5

4. Lopreiato JO, ed; Terminology & Concepts Working Group. Health-care Simulation Dictionary. 1st ed. Society for Simulation in Health-care; 2016. Accessed October 15, 2019. https://www.ssih.org/Por-tals/48/Docs/Dictionary/simdictionary.pdf

5. Norman G, Dore K, Grierson L. The minimal relationship between simulation fidelity and transfer of learning. Med Educ. 2012;46(7):636-647. doi:10.1111/j.1365-2923.2012.04243.x

6. Sorensen JL, van der Vleuten C, Rosthoj S, et al. Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial. BMJ Open. 2015;5(10):e008344.

doi:10.1136/bmjopen-2015-008344

7. Sorensen JL, Navne LE, Martin HM, et al. Clarifying the learning experiences of healthcare professionals with in situ and off-site simulation-based medical education: a qualitative study. BMJ Open. 2015;5(10):e008345. doi:10.1136/bmjopen-2015-008345

8. Osman H, Campbell OM, Nassar AH. Using emergency obstetric drills in maternity units as a performance improvement tool. Birth. 2009;36(1):43-50. doi:10.1111/j.1523-536X.2008.00294.x

9. Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving operational changes in a labor and delivery ward. Qual Manag Health Care. 2010;19(3):226-230. Retracted in: Qual Manag Health Care. 2011;20(1):86. doi:10.1097/QMH.0b013e31820c1c31

10. Owei L, Neylan CJ, Rao R, et al. In situ operating room-based simulation: a review. J Surg Educ. 2017;74(4):579-588. doi:10.1016/j.jsurg.2017.01.001

11. Deering S, Rosen MA, Salas E, King HB. Building team and technical competency for obstetric emergencies: the Mobile Obstetric Emergen-cies Simulator (MOES) system. Simul Healthc. 2009;4(3):166-173. doi:10.1097/SIH.0b013e31819aaf2a

12. Lapkin S, Levett-Jones T. A cost-utility analysis of medium vs. high-fidelity human patient simulation manikins in nursing educa-tion. J Clin Nurs. 2011;20(23-24):3543-3552. doi:10.1111/j.1365-2702.2011.03843.x

13. Walker DM, Cohen SR, Estrada F, et al. PRONTO training for obstetric and neonatal emergencies in Mexico. Int J Gynaecol Obstet. 2012;116(2):128-133. doi:10.1016/j.ijgo.2011.09.021

14. Walker DM, Cohen SR, Fritz J, et al. Impact evaluation of PRONTO Mexico: a simulation-based program in obstetric and neonatal emergencies and team training. Simul Healthc. 2016;11(1):1-9. doi:10.1097/SIH.0000000000000106

15. Lioce L, Meakim CH, Fey MK, Chmil JV, Mariani B, Alinier G. Stan-dards of best practice: simulation standard IX; simulation design. Clin Simul Nurs. 2015;11(6):309-315. doi:10.1016/J.ECNS.2015.03.005

16. Neal JM, Woodward CM, Harrison TK. The American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity. Reg Anesth Pain Med. 2018;43(2):150-153. doi:10.1097/AAP.0000000000000726

17. Meurling L, Hedman L, Lidefelt KJ, Escher C, Fellander-Tsai L, Wallin CJ. Comparison of high- and low equipment fidelity during paedi-atric simulation team training: a case control study. BMC Med Educ. 2014;14(1):221. doi:10.1186/1472-6920-14-221

18. Castle+Andersen ApS. SimMon medical simulation app. AccessedOc-tober 6, 2020. http://static.castleandersen.dk/

19. Neill MA, Wotton K. High-fidelity simulation debriefing in nursing education: a literature review. Clin Simul Nurs. 2011;7(5):e161-e168. doi:10.1016/j.ecns.2011.02.001

20. Cheng A, Hunt EA, Donoghue A, et al; for the EXPRESS Investigators. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr. 2013;167(6):528-536. doi:10.1001/jamapediatrics.2013.1389

21. Briefing, debriefing, and facilitating simulation (online interactive course). Simulation Canada. Accessed October 16, 2019. http://www.sim-one.ca/courses/course/briefing-debriefing-and-facilitating-simulation-online-interactive-course

22. Strategies for debriefing healthcare scenarios. Standford University. Accessed October 16, 2019. https://online.stanford.edu/courses/som-xcape110-strategies-debriefing-healthcare-scenarios

AUTHORSSeth K. Mogler, DNAP, CRNA, is a staff anesthetist at Mayo Clinic in Rochester, Minnesota. Email: [email protected]

Joshua A. Cochrane, DNP, CRNA, is the CRNA supervisor at Mayo Clinic Health System in Red Wing, Minnesota. He is an instructor in anes-thesiology at the Mayo Clinic College of Medicine and Science, Rochester, Minnesota.

LaChelle J. Wieme, DrAP, CRNA, is a staff anesthetist at Mayo Clinic


in Rochester, Minnesota, and was a core faculty member in the Doctor of Nurse Anesthesia Practice Program at the Mayo Clinic School of Health Sciences. She is an instructor in anesthesiology at the Mayo Clinic College of Medicine and Science.

Mary Shirk Marienau, PhD, CRNA, is the Program Director for the Doctor of Nurse Anesthesia Practice Program at the Mayo Clinic School of Health Sciences. She is an assistant professor of anesthesiology at the Mayo Clinic College of Medicine and Science. Dr Marienau holds the position of career educator consultant at Mayo Clinic.

DISCLOSURESThe authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article.

ACKNOWLEDGMENTSThe authors would like to express their deep appreciation to the CRNAs at Mayo Clinic Health System – Southeast Minnesota region, Red Wing and Denise A. Foy at the Mayo Clinic Multidisciplinary Simulation Center for their contributions to make this project a success.

Documents

Feasibility and Acceptability of a Low-Tech Simulation