SP Safety Considerations for Integration

Disclaimer: This page makes reference to certain products or websites as examples for amplifying safety with integrated SPs. This is not a sponsorship or endorsement of any of the websites or products listed. Individuals are welcome to use like-products or like-resources.

Introduction

SPs are healthy participants (or have a managed, stable chronic condition). Therefore, it is very important their safety is at the forefront of designing the assessment or case. Consider all the supplies that would be required for a real life assessment/case and then consider how those supplies would be a potential risk to a healthy person. The examples below are a good start, but are not considered an exhaustive list. 

What are key physical safety considerations for integrating in an SP?

  • General rules:

    • A safe word should be established for the SP to stop the simulation or skill should there be a risk for physical injury. This safe word should be introduced at the beginning of the session to everyone participating in the simulation or skills station.

      • A safe word is a word that does not belong anywhere in the simulation/assessment (i.e. Pineapple, Fishcakes, etc.) that can be easily caught by learners, SPs, and faculty to pause the simulation to assess for risk and ensure safety.

    • Ideally, one instructor/facilitator should be assigned to observing all actions on and around the SP to specifically ensure the SPs physical & psychological safety and stop learner action as required. 

    • Key tips & tricks for keeping the SP safe, and your simulation space safe can be found at the following website: https://healthcaresimulationsafety.org/ (Foundation for Healthcare Simulation Safety, 2022).  

  • Sharps safety:

    • Sharp safety should be taken seriously during training events as you would in regular clinical practice.  Consider avoiding sharps when possible (e.g. syringes without needles), when training with SPs unless necessary to meet the specific learning objectives. 

    • General rules:

      • If sharps are deemed absolutely necessary, they should be new, unused, and non-expired.
      • The sharps must meet local institutional policy for safety features.
      • There must always be a sharps bin within reach/close proximity.
      • Learners must have already been oriented to sharps safety principles and safe disposal principles.
      • The area must be prepared if a sharp stick injury does occur which includes first aid supplies, a sink for rinsing, and incident/accident forms.

    • For cases:

      • The SP should not be exposed to any sharps.
      • Cases can become chaotic by their nature, and the facilitator/instructor may not be able to observe every learner’s actions.
      • To ensure SP safety, use of sharps, if necessary should be done to a task trainer off to the side (i.e. IV insertion, medication administration, etc.), and this should be explained in the pre-brief (example in the Templates and Resources tab).
      • Sharps such as IV spikes, etc. can still be present provided they will not be linked to direct SP contact and sharps safety is referenced in the pre-brief. Example in the Templates and Resources tab.

    • For assessments or procedural skills:

      • If sharps are not necessary to complete the assessment or procedural skill, then they should not be present to minimize risk.
      • If the sharp is deemed necessary, the SP must be equipped with a task trainer that has a very broad width and depth to ensure a significant margin of error for the learner to complete the skill or assessment, with a puncture proof base (rigid plastic or equivalent).
      • The learner must be oriented in advance to where they will perform the skill or assessment, and should have been oriented in advance to insertion/puncture depth considerations for safety.
      • A facilitator should observe at all times to ensure SP physical safety.  

  • Simulated medications & fluids safety: 

    Injection IV/IM/SubQ administration:

    • The SP should never be at risk for being administered medication (expired or non-expired) at any point. All simulated or real medication must be removed from the learning space to avoid confusion. 

    • Ideally, no medications (simulated or real) should be administered during the case or skills station. If possible, the participant should practice the medication administration with empty vessels. This will limit all risk of the SP receiving something unintended during the case or skill. 

    • If medication administration/reconciliation is an absolutely necessary skill that require fluids to properly calculate dosage or mixing, the following principles should be followed:

      • Non-expired normal saline vessels should be used and have applied an easily identifiable FAKE medication label (University of California Los Angeles (UCLA), n.d.) (Free sign-up) that only has the necessary information to draw up the fluid. The vessel should have the ‘Not for Human Use’ sticker (Foundation for Healthcare Simulation Safety, 2022) prominently displayed. 

      • The simulated medication should be administered into an injection pad or line that is off to the side or away from the SP. Learners must be oriented to this location and all safety rules during the pre-brief (example in Templates & Resources tab). 

      • This exception does not apply to in-situ (i.e. in-department) simulations, where bringing expired or not for human use medications should be avoided. This is because of the risk that the medication may be mistaken for real medication and used in an emergency scenario on a real patient if misplaced in the real patient environment. 

    PO administration:

    • The SP should never be at risk for being administered medication (expired or non-expired) at any point. All simulated or real medication must be removed from the space to avoid confusion.

    • Should one of the objectives be to convince a SP to take oral medications, the instructor can have a Tic Tac or like-container with Tic Tacs or like-candies with a FAKE medication label that only provides the medication name and dosage ((University of California Los Angeles (UCLA), n.d.) (Free sign-up)), and has the Not for Human Use – Educational Purposes Only (Foundation for Healthcare Simulation Safety, 2022) sticker affixed.

      • This process needs consent of the SP beforehand to assess food allergies and willingness to take the candy. The learners must be oriented to this process in advance. Immediately following the case or skill, the label is to be torn off the Tic Tac or like-container. 

    • This exception does not apply to in-situ (i.e. in-department) simulations, where bringing expired or not for human use medications should be avoided. This is because of the risk that the medication may be mistaken for real medication and used in an emergency scenario on a real patient if misplaced in the real patient environment. 

  • Exposure safety (electricity and radiation): 

    • Under no circumstances should the SP ever be at risk of having electricity exposure during the case, skills station, or assessment. If delivering electricity is a required learning objective, the pads should be placed on the SP by the faculty and hooked up to nothing (the faculty should literally hold up the unconnected line beside the SP). The two options for practice can include:


    • Under no circumstances should the SP ever be at risk of radiation exposure. Portable X-rays can be mimicked with OR lights, cardboard set-ups (Rock the Registry, 20202) or other devices. The objective of situating an SP for an X-ray should not be overturned by the risk of radiation exposure to both learner and SP. Spacing and positioning can be replicated without the real-life device. Free medical image files can be obtained at https://radiopaedia.org/ (Radiopaedia, n.d.) to display on a laptop/monitor for the simulation. 

  • Restraints safety: 

    • Restraint application can be psychologically stressful and physically unsafe with incorrect application (Crisis Prevention Institute, n.d.).

      • Learners should be shown a video for demonstration and instructed on manikins or a perfectly-still SP on restraint application prior to the SP applying resistance or conducting a full case. This usually is available by the actual restraint provider, for example, Pinel Medical (2023) has a series of videos available here: (https://www.youtube.com/@pinelmedical6088/videos).

      • Facilitators should be right beside the SP to ensure their safety and ensure correct application by learners.

      • Ensure that the SP is always able to vocalize their safe word as required.  

  • Additional physical safety considerations: 

    • Slips, trips, and falls: inform SPs in advance of what equipment may be in the room so they know to anticipate potential trip hazards if mobile (i.e. IV lines & cords, oxygen tubing, crash cart, etc.). Tape down any wiring and remove trip hazards as much as possible prior to the case. 

What are key psychological considerations for integrating in an SP? 

  • Performing certain assessments or cases may be psychologically taxing on either the SP or the learner. Certain questions or phrases may unknowingly trigger SPs or learners to a point of becoming psychologically unsafe. 

  • Guidelines                                      

    • Establish a safe word to pause or stop a simulation should the case or assessment become psychologically unsafe. This word should be distinct and not related to any part of the case or assessment. Have this word introduced to the SP during training and the learners during the pre-brief. 

    • On intake of the SP, provide a clear description of the objectives of the case/assessment and the anticipated actions they will be expected to perform. Allow the SP to opt out during this point should they feel they are unable to safely fill this role. This is described in greater detail in the SP Recruitment, Training, and Hiring tab.

    • During the training of the SP, provide a script and description of expected learner actions. Allow them time to voice concerns they may have about fulfilling the role, and work through additional accommodations or safety protocols that may make the case or assessment safer for them and/or the learners. This is described in greater detail in the Recruitment, Training, and Hiring tab. 

    • Create a non-judgemental space where learners and SPs feel safe to pause the simulation to take a breath and resituate themselves. Have an area for SPs separate from learners to take breaks and prepare. More info here (https://advancesinsimulation.biomedcentral.com/articles/10.1186/s41077-017-0043-4#citeas) (Lewis et al., 2017). 

    • If the SP is to participate in the debrief, provide coaching on what topics may be approached and how their feedback may be useful to guide/inform the learners. Allow the SP to have an exit strategy should the debrief be overwhelming. NOTE: debriefs can also be empowering or psychologically beneficial to SPs as it provides them insight into the learners frame of reference, and further shows the value of the patient lens in informing future professional practice (Block et al., 2018). This is described in greater detail in the SP Recruitment, Training, and Hiring tab.

    • If either the SP or the learner feels triggered or overwhelmed by the experience, allocate time to have a one-on-one debrief for emotional release. Have further contacts (mental health hotlines) if a full debrief cannot occur or the situation is outside your scope. 

References

Block, L., Brenner, J., Conigliaro, J., Pekmezaris, R., DeVoe, B., & Kozikowski, A. (2018). Perceptions of a longitudinal standardized patient experience by standardized patients, medical students, and faculty. Medical Education Online, 23(1), 1548244.

Crisis Prevention Institute. (n.d.). (https://www.crisisprevention.com/CPI/media/Media/elearning/flex/PDF_NCI-Risk-of-Restraints.pdf)

Foundation for Healthcare Simulation Safety. (2022, March 10). Home. Foundation for Healthcare Simulation Safety. (https://healthcaresimulationsafety.org/)

HealthySimulation.com. (2022, November 2). About | Healthcare Simulation | HealthySimulation.com. (https://www.healthysimulation.com/healthcare-simulation/)

iSimulate (n.d.). Realiti360 by iSimulate. iSimulate. (https://www.isimulate.com/realiti360)

Laerdal Medical. (n.d.). ShockLink. (https://laerdal.com/ca/products/skills-proficiency/defibrillation-cardiology/shocklink/)

Lewis, K.L., Bohnert, C.A., Gammon, W.L. et al. The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP). Adv Simul 2, 10 (2017). (https://doi.org/10.1186/s41077-017-0043-4)

McMaster University (2017). Policies and procedures manual for standardized patients. McMaster University Centre for Simulation-Based Learning. (https://simulation.mcmaster.ca/documents/PPForStandardizedPatients2017.pdf)

Mills, A. (n.d.). Healthcare Simulation Standards of Best PracticeTM. (https://www.inacsl.org/healthcare-simulation-standards)

Pinel Medical (2023). Pinel Medical. [Video]. YouTube. (https://www.youtube.com/@pinelmedical6088/videos)

Prestan Products (n.d.). Professional AED trainer plus. Prestan. (https://www.prestan.com/products/aed-trainers/professional-aed-trainer-plus/)

Radiopaedia (n.d.). Radiopaedia.org, the peer-reviewed collaborative radiology resource. (<Radiopaedia.org>)

Rock The Registry. (2020, April 15). Cardboard X-ray machine [Video]. YouTube. (https://www.youtube.com/watch?v=DuSkIxZgCdI)

University of California Los Angeles, (n.d.) Simulated online pharmaceutical image editor. UCLA Simulation Center. (https://www.sim.ucla.edu/sophie/)