Digital Repository Masters Theses Spring 2026 Efficacy of High-Fidelity Simulations in the Perioperative Setting Hannah Smith Weber State University Follow this and additional works at: https://dc.weber.edu/collection/wsudoctoral Smith, H. 2026. Efficacy of High-Fidelity Simulations in the Perioperative Setting. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/WSUDoctoral This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Efficacy of High-Fidelity Simulations in the Perioperative Setting Project Title by Hannah Marie Smith Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY 04-25-2026 Ogden, UT Date Hannah Smith, RN, BSN, MSN Student 04-25-2026 Student Name, Credentials (electronic signature) Date 04-25-2026 MSN Project Faculty (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 04-25-2026 Date 1 Efficacy of High-Fidelity Simulations in the Perioperative Setting Hannah Smith Annie Taylor Dee School of Nursing Weber State University Trish Gibbs MSN Project March 29, 2026 2 Abstract Purposes/Aims: This project aims to improve self-reported confidence among hospital-based perioperative staff by implementing high-fidelity simulations (HFSs) as an annual educational practice. Rationale/Background: Standard training (E-learning and orientation) for perioperative staff may not always provide frequent exposure to high-stress or emergent situations (Howard et al., 2024; Kazior et al., 2021). The literature supports integrating simulation-based learning (SBL) into healthcare training. Methods: Using the Iowa Change Model, an 18-month project will be implemented, including the creation of an initial simulation and the measurement of staff confidence using the Simulation Effectiveness Tool – Modified (SET-M). Facilitators will use standardized prebriefing and debriefing to maintain continuity while emphasizing psychological safety during the simulations. Staff will be re-evaluated at the 12-month mark, with another simulation. Data from both simulation scenarios will be analyzed to assess overall confidence and simulation effectiveness. Results: Anticipated outcomes following project implementation include increased participant confidence after each simulation scenario and the perceived effectiveness of simulation-based training in preparing participants to manage emergent clinical situations. Conclusions: By implementing HFSs in perioperative units, participants will improve communication, confidence, and clinical skills during rare, high-risk events, thereby supporting the overall development of multidisciplinary teams and improving patient safety outcomes. Keywords: Simulation standards, perioperative, high-fidelity simulation, simulation-based learning, nursing education 3 Efficacy of High-Fidelity Simulations in the Perioperative Setting High-fidelity simulations (HFS) have been utilized in education and training across various hospital units and specialties (Carey & Rossler, 2023). However, there are some areas where simulation training has not been as abundantly used, such as same-day surgery (SDS) units, operating rooms (ORs), and post-anesthesia care units (PACUs). When evaluating learning and enhancing skills, HFSs are valuable yet underutilized tools in the perioperative workplace, particularly among nursing staff and other personnel (Burnett & Goldhaber-Fiebert, 2024). HFSs provide a safe space to practice skills, communication, and collaboration, which improves patient safety (Bray & Østergaard, 2024). This project will evaluate the efficacy of HFSs compared with standard required educational modalities, including quarterly online education modules and annual skill pass-offs, in the perioperative setting. Statement of Problem Teamwork and communication are crucial for maintaining patient safety, particularly in perioperative units, which are often high-risk clinical areas. Newer registered nurses (RNs) often struggle to develop these skills during standard training, such as precepting, clinical coaching, and required education modules. Standard training may not always provide frequent or standardized exposure to complex or rare situations (Howard et al., 2024; Kazior et al., 2021). Additionally, standard training, including quarterly online required education modules (QEMs) and a yearly skills pass-off sheet, may be insufficient to maintain hands-on skills. Elearning is an effective tool for integrating knowledge within practice and promoting professional development. However, it can be challenging to keep staff engaged during participation, which may reduce the overall effectiveness of the approach (Alfaleh et al., 2023). 4 HFS offers realistic and interactive learning environments that replicate critical clinical events, including intraoperative hypoxia, hemodynamic instability, malignant hyperthermia, and code blue situations, all within a controlled setting (Kazior et al., 2021). Training across facilities and specialties has not been standardized nationwide and may not be supported by evidencebased research. This could perpetuate knowledge retention and skill maintenance gaps. Furthermore, a lack of simulation-based learning (SBL) can impair interdisciplinary communication, prevent the integration of current best practices, and increase the risk of patient safety errors (Alshehri & Harrison, 2023). Significance of the Project This project is essential as it will contribute to research in the field, using evidence-based tools (e.g., simulation effectiveness tool, modified [SET-M] tool) to evaluate the impact of HFSs. It will also enhance self-reported confidence among hospital-based perioperative staff in their daily practice (Guerrero et al., 2021). Implementing HFSs may improve communication and teamwork among interdisciplinary team members (Kaldheim et al., 2021), enabling staff to practice effective communication and role clarity in a patient-safe, low-risk setting. Implementing HFSs has the potential to promote learning, optimize overall clinical performance, and improve communication among team members in high-stress scenarios (Alshehri et al., 2023; Guerrero et al., 2021). Lastly, the standardization and implementation of HFSs will help fill potential gaps in education within the specific unit where they are implemented. The implementation of HFSs into perioperative education standardization has the potential to significantly increase staff confidence in standardizing training and improve patient outcomes (Alshehri et al., 2023; Cook et al., 2013; Guerrero et al., 2021; Kaldheim et al., 2021). 5 The literature highlights the importance of using HFSs across various scenarios and calls for further research, particularly in the perioperative setting. Review of the Literature SBL is a teaching tool increasingly used in healthcare and emergency services. It is used for nursing students, medical students, and by licensed medical professionals for continuing education (Burnett & Goldhaber-Fiebert, 2024; Shahrezaei et al., 2024). Simulation training has also started to be used in the accreditation processes. For example, in some areas, trauma teams are required to complete simulations to obtain trauma certification (R. Wilcox, personal communication, November 16, 2025). Simulation can be differentiated into HFS and low-fidelity simulations (LFS). Although the use of simulations is increasing, some areas of healthcare still do not use this technique because it is not required for continuing education. This literature review explores potential solutions to improve perioperative nurses’ confidence in performing skills. One proposed approach is to apply simulation in the perioperative setting annually, which may enhance both confidence and clinical proficiency. Additionally, the review examines how simulation can support overall learning for perioperative staff and contribute to the implementation of multidisciplinary teams within baseline training and education requirements (Alshehri et al., 2023; Guerrero et al., 2021; Kaldheim et al., 2021). Three themes emerged during the review of the literature: a) learning effectiveness, b) the importance of instructional design, and c) the impact of fidelity in SBLs. These themes will be used to address the PICOT question: In hospital-based perioperative staff (P), how does participation in simulation-based competency training and hands-on skills days (I), compared to current practice (C), affect self-reported confidence (O), after 12 months (T)? Framework 6 The Iowa Model for Evidence-Based Practice (EBP) will be utilized in this project due to its inclusion of interprofessional, operational, and educational topics (Melynk & FineoutOverholt, 2023). The model is easy to read and understand, and it includes multiple feedback loops for re-evaluation. The steps of the Iowa Model for evidence-based practice include: 1) Identify the trigger or issue. Is it a problem or new knowledge? 2) What are the organizational priorities? 3) Form a team. 4) Gather evidence. 5) Ensure the pilot is research-based, critiqued, and synthesized. 6) Is there sufficient evidence? 7) Redesign the pilot if needed. 8) Is the change suitable for adoption into practice? 8) Widespread implementations with continual monitoring of outcomes 9) Disseminate the results (Gawlinski & Rutledge, 2008; Cullen et al., 2022). The Iowa Model encourages clinicians to identify opportunities to enhance their practice and improve healthcare. The steps of the Iowa Model include gathering evidence to ensure the practice gap is appropriate for this model. Next, a team is assembled to help implement the project and collect evidence, followed by creating a pilot scenario and redesigning it as needed. If the evidence is sufficient, the change is then implemented. Additionally, the Iowa Model utilizes pilot testing and evaluates changes as needed throughout the process, which aligns well with the 12-month timeframe in the PICOT question and the measurable outcomes required for this project (Cullen et al., 2022). Strengths and Limitations The Iowa model will provide a strong, supportive framework for this project, specifically because of its emphasis on both identifying and improving the problem (the lack of HFSs in the perioperative setting) and continuing steps to solve the problem through multiple re-evaluation feedback loops (Gawlinski, 2008). 7 The model has been widely used globally and has consistently proven effective over time as a practical, application-oriented, and theory-based model (Melynk & Fineout-Overholt, 2023). Further, the Iowa model of EBP helps to create a common language for evidence-based implementation, which is foundational for improving science (Cullen et al., 2022). Due to the complexity of coordinating and implementing HFSs, the Iowa model will ensure that the PICOT question is addressed thoroughly. Although the multiple steps and feedback loops can be beneficial, they could also create limitations. If team members have differing interpretations of the process, the numerous steps could cause delays or confusion. It is also essential to evaluate the evidence supporting the problem or question. If sufficient evidence is lacking, a different process model may be more appropriate, or additional research may be needed before proceeding. This could further prolong the process (Earl, 2013). Search Strategies A literature search was conducted using Google Scholar and Weber State University’s Stewart Library’s OneSearch and Advanced Search. A total of 15 articles were used. These articles were written between 2020 and 2025, except for a seminal work from 2013. The search included the following keywords: “simulation, qualitative, quantitative, perioperative, highfidelity simulation, operating room, simulation-based learning, education, nursing, guidelines, healthcare, simulation standards, and best practice”. These were used in various combinations throughout the search. Synthesis of the Literature The literature reviewed highlights the benefits of simulation in healthcare. It includes systematic reviews, expert opinions, professional standards, and meta-analyses. It also combines 8 qualitative, quantitative, and expert opinion reviews. All articles are healthcare-related, with an emphasis on the nursing role; some articles specify the perioperative specialty. Overall, the literature revealed three key themes for SBL to be considered: a) the effectiveness of learning in SBL, b) the instructional design of simulations, and c) the role of fidelity in SBL (HFS vs. LFS) (Burnett & Goldhaber-Fiebert, 2024; Carey & Rossler, 2023; Cook et al., 2013; Kaldheim et al., 2020). Learning Effectiveness in SBL: Learning effectiveness is referenced in multiple SBL-related articles as a key factor in determining whether simulations are effective for participants. Overall research indicates that SBL has the potential to improve knowledge, practical skills, clinical reasoning outcomes, and overall clinical competence (Alshehri et al., 2023; Burnett & Goldhaber-Fiebert, 2023; Cook et al., 2013; Guerrero et al., 2021; Hardie & Lioce, 2020; Herrero-Izquierdo et al., 2025; Kaldheim et al., 2020; Mitchell et al., 2023; Osborne et al., 2022; Tong et al., 2024). Nursing students who engaged in interprofessional SBL reported that it enhanced mental preparedness for clinical practice and helped develop key competencies, particularly in teamwork and communication (Kaldheim et al., 2020). In addition to benefits for students, SBL also improved the practical and clinical performance of licensed nurses (Alshehri et al., 2023; Hardie & Lioce, 2020; Mitchell et al., 2023). Repeated exposure to HFSs was shown to increase proficiency and readiness for clinical practice (Guerrero et al., 2021). Furthermore, SBL has been associated with enhanced knowledge retention and improved performance in nursing programs, thereby boosting students' confidence and the ability to apply their learning in real clinical environments (Carey & Rossler, 2023). 9 Further, research suggests simulation is a beneficial tool for training multidisciplinary teams. The collaborative aspect of the learning helped to improve communication and teamwork among members, which was also found to promote patient safety (Burnett & Goldhaber-Fiebert, 2023). Instructional Design of SBL The literature demonstrates that the structure of simulations was key to their success. SBL typically involves three stages: briefing, simulation session, and debriefing, with most studies and protocols emphasizing the importance of debriefing (Burnett & Goldhaber-Fiebert, 2024). Additionally, Cook et al. (2013) and Kaldheim et al. (2020) found that taking adequate time for briefing and debriefing was vital. During SBL, ensuring facilitators have adequate time to clarify learning objectives, encourage reflection on interactions and reactions, and provide constructive feedback helps maximize learning outcomes (Cook et al., 2013; Decker et al., 2021; Kuszajewski, 2021). Different SBL scenarios were customized for specific clinical and student areas, incorporating content and learning objectives at an appropriate level of complexity. This tailored design integrated repetitive practice, active cognitive engagement, diverse learning strategies, extended time for skill development, and exposure to clinical variation, thereby fostering deeper understanding, improving skill acquisition, and enhancing learner confidence. By aligning simulation experiences with learners’ needs and practice environments, customization strengthened knowledge retention, supported critical thinking, and ultimately improved clinical competency and readiness for real-world application (Cook et. al., 2013; Guerrero et. al., 2021). Fidelity in SBL 10 SBL can be considered high-fidelity or low-fidelity. Carey and Rossler (2023) state that fidelity in SBL is a nuanced concept often misunderstood and inconsistently defined in the literature. While HFS is often mistakenly equated with full-body, high-complexity patient simulators, fidelity itself refers to the degree of realism (physical, conceptual, psychological, functional, sociological). (Carey & Rossler, 2023). There is a common misconception that higher simulation fidelity leads to better outcomes, but this is not always true. HFSs can increase satisfaction and immersion; however, they are not always superior to LFSs (Mitchell et al., 2024). High levels of fidelity can increase cognitive load, potentially overwhelming participants and reducing overall learning effectiveness (Carey & Rossler, 2023). The desired learning outcomes should determine the fidelity level, and the participants themselves should be considered in the assessment. When these steps are taken, all SBL forms, whether HFS or LFS, can provide relevant learning experiences to the participants and improve patient safety outcomes. (Alsheri et al., 2023; Burnett & GoldhaberFiebert, 2024; Kaldheim et al; Mitchell et al., 2023). Limitations There were some limitations relating to the literature used for the project. First, many studies exhibited high heterogeneity due to variations in different study contexts, populations, protocols, and assessment tools (Alshehri et al., 2023; Cook et al., 2013; Herrero-Izquierdo et al., 2025; Mitchell et al., 2023; Osborne & Mostafa, 2022). Many studies also included smaller sample sizes and collected data over short periods, whereas long-term studies would have yielded more accurate results (Cook et al., 2013; Guerrero et al., 2021). Lastly, because more research is still needed and standards for SBL remain inconsistent, some studies were limited by variations in the terminology, definitions, and descriptions of HFS and LFS. 11 Summary of Literature Review Findings and Application to the Project Research related to SBL commonly refers to learning outcomes, simulation design, and the role of fidelity in achieving these outcomes. SBL allows the learners to gain critical experience performing specific tasks and skills in a safe environment. It can also address any limitations of traditional on-the-job training that could expose patients to harm during first-time procedures (Burnett & Goldhaber-Fiebert, 2024; Carey & Rossler, 2023; Cook et. al., 2013). Using high-fidelity equipment is not the only factor. However, scenarios should be carefully customized, learning objectives should be clear, and structured pre-briefing and effective debriefing are needed to optimize learning (Kaldheim et. al., 2020). The evidence from the review strongly supports integrating SBL into healthcare training. SBL enhances clinical skills and supports the development of multidisciplinary teams. Continued implementation of SBL programs and ongoing research are essential to advancing education and practice in healthcare. Project Plan and Implementation This section outlines a plan to implement HFS regularly in a local six-bed pediatric operating room as part of an annual skill pass-off. The Iowa Model for Evidence-Based Practice will be used to develop a structured SBL plan tailored to the OR, aiming to enhance the team’s preparedness for infrequently occurring high-risk scenarios and to improve interdisciplinary teamwork and communication (Decker et al., 2021). The project aims to incorporate HFS by creating a scenario, running a pilot, collecting and analyzing the participants’ feedback, and repeating and evaluating to assess its overall effectiveness. By doing this, the project will evaluate the efficacy of HFSs in the perioperative 12 setting compared to standard required educational modalities, which include quarterly online education modules and annual skill pass-offs. Plan and Implementation Process The Iowa Change Model will be used to plan and implement this project systemically. Initially, a needs assessment will be conducted to ensure adequate resources are available for the simulation, including supplies, time, scheduling, and personnel to assist with its rollout. The needs assessment will also help identify specific gaps in education and communication, allowing for the simulation to be more realistic and tailored to the unit (Cullen et al., 2022). Based on the needs assessment, one realistic simulation scenario will be created to address current learning gaps within the unit. Examples of perioperative-specific scenarios include code blue events, local anesthetic systemic toxicity (LAST), and malignant hyperthermia (MH). Next, the plan and simulation scenario will be presented to stakeholders to ensure understanding and support of the project. Stakeholders will include department leadership, anesthesia leadership, the simulation learning department leads, and the perioperative department educator. Following stakeholder approval, a team of facilitators will be established to support the rollout of this project. This will include staff from both the unit (e.g., the perioperative educator and other unit leaders) and the simulation center. These facilitators will undergo HFS training to ensure the consistent use of a standardized simulation structure, with a strong focus on the prebrief, simulation, and debrief sections (Carey & Rossler, 2025). Meetings will be held either in person or virtually to adjust the simulation as needed. This will be accomplished by 13 incorporating input from all facilitators. A schedule will be created for staff and anesthesiologists to sign up and participate. The pilot simulation will be implemented next. Staff confidence and skills will be evaluated using the SET-M after the simulation. To ensure that all unit staff can participate, multiple simulations will be conducted to keep group sizes manageable. Each session will include a pre-brief, orientation to the simulation environment, the simulation itself, and end with a debrief. After all groups have completed their simulations, the facilitators will meet to assess what went well and what could be improved in each group. Staff will be reassessed approximately 12 months after the initial assessment, at which time the simulation will be repeated. The SET-M will be used again after the simulation. Data from the tool will be recorded, analyzed, and presented to stakeholders to determine whether simulation should be continued, modified, or fully adopted as a component of annual skills training. Interdisciplinary Team For the implementation of this simulation to be effective, it will require collaboration across multiple teams. These teams will include: the perioperative leadership team, the simulation center members, registered nurses (RNs), certified surgical technologists (CSTs), anesthesia monitoring technicians (AMTs), and pediatric anesthesiologists. Perioperative Leadership. Perioperative leadership consists of the perioperative educator, the unit manager, and shared leaders. The educator will specifically play a role in creating the simulation scenario, supporting facilitator training, and by becoming a facilitator themselves to assist with the simulation. Other members of leadership will assist in obtaining 14 approval for simulations, and after training, may also serve as future facilitators. The unit manager will provide oversight regarding the budget and staff scheduling needs. Simulation Center Members. The simulation center team comprises simulation specialists who already assist other units and hospitals across the state in incorporating simulation into their departments. These team members will provide expertise in creating the scenario, managing simulation equipment (e.g., mannequins, monitors, defibrillators), and assisting as facilitators. Their involvement will provide consistency across the multiple simulation sessions. RNs. The RNs will participate as learners in the scenarios and provide feedback using the SET-M after each simulation. The nursing staff’s experience and feedback will address any nurse-specific knowledge and communication gaps. CSTs and AMTs. The CSTs and AMTs will participate as learners in the scenarios. These clinicians will also provide feedback using the SET-M after simulations. These participants’ involvement will address any tech-specific knowledge and communication gaps and reinforce the scope of practice. Anesthesiologists. The anesthesiologists will serve as the clinical experts in these scenarios, both in developing them and in participating, ensuring the clinical accuracy of the scenarios used. These clinicians will also participate in the scenario, providing realistic leadership. This will help evaluate team communication and delegation between all the team members. The anesthesiology participants will also provide feedback using the SET-M. Description and Development of Project Deliverables 15 Deliverables will be used throughout this process to support the project's implementation. They will include an example of the simulation scenario to be used, the evaluation tool (SET-M), and a facilitator guide. Simulation Scenario: A realistic, evidence-based scenario will be created specifically for the pediatric perioperative unit at PCL. The scenario will reflect recent or potential safety events that have occurred and been researched during the needs assessment phase (See Appendix A). Sections will include a) planning, b) environment and equipment plans, c) scenario states, and d) learning objectives. Evaluation Tool. The evaluation tool used after each simulation will be the SET-M (see Appendix B). This tool is used to evaluate reported confidence and perceived effectiveness of the simulation (Leighton et al., 2018). Facilitator Guide. A guide will be created and provided to the facilitators to standardize the pre-briefing and debriefing process. This tool is intended to promote consistency and fidelity across all simulation experiences (see Appendix C). Stakeholder Presentation PowerPoint. A presentation will be created to formally introduce the project to hospital and unit-level stakeholders and to facilitate project approval. Further, stakeholder engagement will include opportunities for feedback and collaborative refinement of the project to ensure it is responsive to clinical needs. (see Appendix D). Timeline The proposed timeline for this project spans approximately 18 months (see Appendix E). Month one will consist of conducting the needs assessment, creating the pilot simulation scenario, presenting the project to stakeholders for approval, and solidifying project planning. 16 Once the project is fully approved and finalized, month two will consist of creating and training the team of facilitators, if new-facilitator training is needed, as well as finalizing preparations for simulation creation based on stakeholder feedback and scheduling. Months three through five will be used to conduct HFS simulation sessions. Next, evaluation and data collection from the SET-M will occur during months three through six. Follow-up simulations will occur 12 months after the initial simulations occurred. During months 15-18, data from both rounds of simulations will be reviewed, analyzed, and compared. The data will be presented to stakeholders by month 18 to determine whether simulations will be adopted, modified, or rejected, in accordance with the Iowa Model for Evidence-Based Practice (Melynk & FineoutOverholt, 2023, p. 477). In summary, this project is scheduled to be completed over an 18-month timeframe. It will follow a structured approach based on the Iowa Model for Evidence-Based Practice, which incorporates built-in processes for evaluating, refining, and repeating as necessary. Project Evaluation This project will be evaluated using both formative and summative methods. Formative evaluation will occur throughout the process due to the use of the Iowa Change Model. Using this model allows for multiple feedback loops of re-evaluation throughout the entire process (Melynk & Fineout-Overholt, 2023, p. 477). The evaluation process will begin with the creation of the simulation. Continuous evaluation from facilitators and other stakeholders involved in the planning process will ensure an applicable scenario is created. The immediate verbal debriefings that will occur after each simulation will serve as another form of formative evaluation. Structured debriefing allows the participants to reflect on the scenario, participant performance, 17 what went well, and what could be improved. Staff can also provide feedback on the scenario content directly to the facilitators in real-time. Summative evaluation will focus on participants’ confidence using the SET-M, which is an open-access simulation evaluation tool. The survey will be administered to all participants immediately after the initial simulation and again a year later. The SET-M is validated and specifically designed to evaluate the effectiveness of clinical simulation scenarios. This evaluation tool focuses on pre-briefing, scenario, and de-briefing specifically (Leighton et al., 2018). Ethical Considerations As the project lead, there is a potential bias stemming from previous simulation education experiences. To avoid the project being influenced by this potential bias, the tools used will be standardized, data will be collected objectively, and the pre-brief, simulation, and debrief will all use the same structure. These steps will help to mitigate any potential bias. Ethical considerations will be addressed throughout the project for all participants, facilitators, and any other involved parties. The key principle throughout this project is the ethical principle of beneficence – to do no harm – which is a critical component of creating a psychologically safe simulation experiences as simulation can be stressful (McKenna, 2024). During the pre-brief, psychological safety will be emphasized for all participants, and the assumption of good intent will be made. A key role of the facilitator is to create a safe environment where participants can make mistakes without being rated or measured. Facilitators will do this by using a psychological safety algorithm that is taught during the two-day facilitator training course. (R. Wilcox, personal communication, March 20, 2026). 18 Facilitators will reinforce to participants that this is an educational activity, not a performance evaluation. This project will operate under the “basic assumption” that all participants are intelligent, capable, skilled, care about doing their best, and motivated to improve their practice (Center for Medical Simulation, 2024). While participation in the project will be recommended to all staff, it will remain voluntary, and there will be no negative consequences for non-participation. Confidentiality will be maintained throughout the project. Information from each group’s simulation will remain private, and data from the SET-M will be collected anonymously, without any identifying information. Participants will be explicitly instructed not to include any identifying information on their evaluation tool. A designated researcher will be assigned to enter the data from the SET-M into an Excel sheet. If any identifying information is present, the researcher will remove it and assign a tag number to each evaluation tool response to ensure deidentification and data integrity. Discussion This section will discuss how the project will be disseminated to relevant groups, including hospital unit stakeholders, MSN faculty, and classmates. It will discuss the project's significance in advancing nursing practice, especially regarding staff confidence and improvement in interdisciplinary communication. Lastly, it will address the strengths and potential limitations to be addressed prior to implementation. Evidence-Based Solutions for Dissemination The findings from this project will be disseminated through evidence-based methods to ensure knowledge and findings are shared effectively. The primary way will be through a virtual poster presentation to peers and faculty during the final semester of the MSN program. 19 Additional methods will include a presentation to hospital and unit stakeholders and a written summary of the findings after the project results have been analyzed. These dissemination strategies align well with sharing the results in educational and healthcare settings. Significance to the Advancement of Nursing Practice This project has the potential to advance nursing practice in many ways. HFSs are an effective way to increase interprofessional communication and improve clinical skills. Implementing HFSs in clinical practice helps RNs be better prepared for rare and high-risk events. Engaging in both team-based communication exercises and hands-on skills practice has been shown to enhance clinician confidence and ultimately improve patient outcomes (Burnett & Goldhaber-Fiebert, 2024; Guerrero et al., 2022). Implications This project has several strengths, the first of which is alignment with evidence-based practice and the use of a validated evaluation tool (Leighton et al, 2018). Additionally, SBL provides a safe, judgment-free environment that can help identify safety gaps and reinforce best practices without risk to patient safety (Guerrero et al., 2022). SBL has also been shown to help develop both technical and non-technical skills (Burnett & Goldhaber-Fiebert, 2024; Guerrero et al, 2022). Additionally, SBL provides structured opportunities for immediate feedback and reflection through the debriefing process. Engaging in these learning activities is expected to result in positive outcomes for the team, including increased confidence, enhanced skills, and enhanced team performance. Although SBL has many strengths, it also has limitations. Cost and resource intensity are major factors in implementing SBL (Kazior et al., 2021; Shahrezaie et al, 2024). To reduce the impact of potential barriers, the simulation team at Intermountain Health will provide support. 20 This team has access to multiple manikins, monitors, and the necessary software for simulation use. However, staff education hours, scheduling, and the cost of facilitator training will require approval from department stakeholders. If approved, the project will be incorporated into the staff schedule, using education time to prevent excess stress on staff from working extra hours. Other limitations could include a lack of standardization across simulations and increased stress that could lead to a lack of psychological safety. These limitations will be addressed through standardized facilitator training and a standardized simulation format, including a prebrief, simulation, and debrief. The simulation will use predefined states, ensuring consistent progression across groups. A guide will be prepared for the facilitators to ensure key discussion points are covered during the pre-brief and de-brief sections of the simulation. Implementing these changes and being aware of these limitations should strengthen the overall project's results. Recommendations This project includes only the initial implementation of SBL and a follow-up to evaluate its initial effectiveness. Recommendations to sustain the program’s success include continuing HFS scenarios annually and updating high-risk scenarios. If it is determined that this project will be used long-term, further long-term research could show the program’s overall success or lack thereof. Conclusions In conclusion, the problem highlighted is the lack of HFSs in certain hospital settings, particularly in perioperative areas. The literature provides strong evidence supporting the effectiveness of SBL as an educational tool across multiple settings. Despite this, the sustained implementation of SBL programs and ongoing research are essential to advancing education and practice in healthcare. 21 This project will support ongoing research to implement HFS in the perioperative areas. The proposed project will follow the Iowa Change Model as an evidence-based approach to implementation and will encompass a comprehensive process including an evidence review, needs assessment, stakeholder approval, implementation, and reassessment. The anticipated outcomes of this project are improved overall nursing practice, strengthened interdisciplinary communication, increased clinician confidence, and improved patient safety. 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F., & Slettebø, Å. (2021). A qualitative study of perioperative nursing students' experiences of interprofessional simulation-based learning. Journal of Clinical Nursing, 30(1–2), 174–187. https://doi.org/10.1111/jocn.15535 Kazior, M. R., Ianchulev, S., Nguyen, J., Trainer-Albright, B., & Shah, P. (2021). Creation of simulation-based curriculum of perioperative emergencies for residents in anesthesiology. Cureus, 13(6), e15901. https://doi.org/10.7759/cureus.15509 Kuszajewski, M. L. (2021). Nursing simulation debriefing: Useful tools. Nursing Clinics of North America. 56(3), 441–448. https://doi.org/10.1016/j.cnur.2021.05.003 Leighton, K., Ravert, P., Mudra, V., & Macintosh, C. (2018). Simulation effectiveness tool – modified (SET-M). HealthySimulation.com. https://www.healthysimulation.com/tools/evaluating-healthcare-simulation/simulationeffectiveness-tool-modified-set-m/ McKenna, L. (2024). Ethical considerations in reporting simulation-based education research. 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(2024). The impact of surgical simulation and training technologies on general surgery education. BMC Medical Education, 24(1297). https://doi.org/10.1186/s12909-024-06299-w Tong, L.K., Li, Y.Y., Au, M.L., Ng, W. I., Wang, S. C., Liu, Y., Shen, Y., Zhong, L., & Qiu, X. (2024). The effects of simulation-based education on undergraduate nursing students' competencies: A multicenter randomized controlled trial. BMC Nurs 23, 400. https://doi.org/10.1186/s12912-024-02069-7 Wilcox, R. (2025, November 16). Personal Communication. Wilcox, R. (2026, March 20). Personal Communication. 26 Appendix A Simulation Scenario Simulated Patient - 1510 Ped CRM OR, LAST, Code Blue Date Service Line/Type 10/04/2025 Surgical Services Region Facility Canyons Primary Children’s Hospital Lehi Author Overview Wilcox, Robert 13-year-old female in OR just after removal of dermoid cyst on forehead and umbilical hernia repair. Patient experiences Local Anesthetic Systemic Toxicity (LAST) and codes. Other Author Bailey, Jenaleigh Smith, Hannah Harlo, Mar Objectives 1 Understand the risk factors associated with initial development of LAST. 2 Recognize and effectively activate a code blue response. 3 Utilize Crisis Resource Management and Error Prevention techniques to communicate and work effectively as a team. Recognize symptoms of LAST and implement effective team-based treatment for 4 LAST. 27 Patient Report - 1510 Ped CRM OR, LAST, Code Blue SBAR: Situation, Background, Assessment, Recommendation Situation Liz Xtest is a 13-yr-old female in OR just finished combo case with plastics - dermoid cyst on forehead and finished case with general - umbilical hernia repair. The back table had to be torn down and re-set to prevent contamination after first portion due to pus found in the cyst. Background Surgeons are out of the room; anesthesia is still present preparing to extubate patient before transporting patient to PACU. 40 kg. No significant medical history. Assessment Patient is under anesthesia and currently not responsive. Still intubated. Propofol and Sevoflurane just turned off Bupivacaine 10 CC’s of 0.5% with epi 1:100,000 given to forehead at the end of the plastics case. 20 CC’s of Bupivacaine 0.5% with epi 1:100,000 was just given to umbilicus, and lap sites x2 for hernia repair. All sites are sutured closed and dressings just placed. Forehead site bandaged w/skin adhesive & 2x2 gauze. Wounds clean, dry, intact. Dressings have just been placed on lap sites and patient is still under surgical drapes. Debrief has been done and local has been given. Recommendation Surgery is finished, get your patient ready to transfer to PACU 28 Patient Set Up - 1510 Ped CRM OR, LAST, Code Blue Manikin Resusci Anne (Teenager) Clothing Gown (bunched up around chest and neck area so it is not on surgical field) Blanket on leg mid-thigh down Accessories Socks Female Wig Patient ID band Blue Drapes Leads, SPO2, BP cuff, Etco2, Temp, EKGs Pupils Normal Skin Steri Strips left & right side of umbilicus & on umbilicus. 2x2 gauze on forehead Access PIV x 2 any size/location. 2nd IV site covered with ACE/Coban. Oxygen on Patient Intubated and connected to ventilator with anesthesia circuit (ventilator will not be running) Body Fluids None 29 Room Set Up - 1510 Ped CRM OR, LAST, Code Blue Simulated Location OR Manikin will be on operating table (flat sheet with draw sheet will be under manikin) Have gurney set up with flat sheet outside of room if needed Available Medications --- Omnicell --Lorazepam (2 mg/mL) 1 mL vial LAST Kit (put in hallway AFTER all participants enter - prevent spoilers!) x2 Intralipids (20%) in 250 mL bag in light sensitive Ziploc bag Adrenalin (1mg/ml) 1 mL vial NS 100 mL bag Anesthesia cart Crash cart for response (simulation crash cart) Fluids NS 1000 mL bag x1 LR 1000 mL bag x1 Pumps Carefusion Brain 1 syringe pump standard channel Pump Rate LR 1000 bag, 75 ml per hour Paperwork Emergency Drug Card (40 kg) in patient folder Lipid Rescue Kit doc LAST Kit Contents doc Handoff report tool Available Oxygen Nasal Canula Nonrebre ather Anesthesia Bag & Adult Mask 30 Other Supplies/Setup --- LAST Kit Contents --LAST Kit Contents doc Lipid Rescue Kit doc x2 Intralipids (20%) in 250 mL bag in light sensitive ziploc bag Adrenalin (1mg/ml) 1 mL vial NS 100 mL bag IV Carefusion pump tubing 1.2-micron filter extension tubing Green Light protecting tubing cover 3 mL syringe x2 50 mL syringes x3 18g blunt fill needles 18g filter needle OR Set Up ST has gown/gloves on General Minor Set, basin/fluids General Pack, on Mayo ? dressings, suture, needle holder, closing instruments the team is finished with. Room equipment (OR set-up) and case cart. Simulated Patient - 1510 Ped CRM OR, LAST, Code Blue Full Name DOB Allergies Liz XYtest Height 167 cm Weight 40 kg 01/01/2012 NKDA Age 13 years Gender Female Temp 36.2 Arm EtC02 37 Preductal Postductal ABP Work on getting drapes taken down and preparing patient to transport to PACU Leg CVP Patient/Simulation States State # 1 State Name HR RR Sp02 Initial 102 18 98 BP 110/82 Correct Treatment Patient Vocals None - intubated PAP Incorrect/Non Treatment Advance to Next Frame When Other Not assisting anesthesia and/or prepping to move patient When team starts to remove drape (BEFORE they transfer to gurney) 31 Heart Sounds Normal Bowel Sounds Normal Heart Rhythm Sinus Rhythm Left Lung Sounds Normal Primary ECG Lead Right Lung Sounds Normal Secondary ECG Lead Eyes Closed Additional Comments State # 2 State Name HR RR If participants ask CRT is 3, patient is Pale 36.6 Arm Leg CVP BP 83/40 Correct Treatment EtC02 50 Preductal Postductal ABP Recognize deterioration. Call for additional help Patient Vocals None Advance to Next Frame When Heart Sounds Normal Bowel Sounds Heart Rhythm Bradycardia Left Lung Sounds Normal Primary ECG Lead Right Lung Sounds Normal Secondary ECG Lead Eyes Closed Sp02 Deterioration 55 26 26 Additional Comments State # 3 State Name HR RR Temp PAP Incorrect/nontreatment Other Team doesn’t recognize deterioration Team does not call for additional help Once team calls for additional help and recognize deterioration N/a Heart Rhythm: Bradycardia with PVC Pulseless V-Tach Temp 36.6 Arm 200 0 EtC02 Preductal 18 Leg CVP 32 Sp02 0 BP 0/0 Correct Treatment Postductal ABP PAP Patient Vocals Code blue called Compressions started CRM – role designation Get crash cart Get last kit Administer lipids (bolus 60 mL, followed by infusion of 10 mL/min) None Heart Sounds Normal Heart Rhythm Ventricular Tachycardia (VT) Incorrect/NonTreatment Other CPR not started CRM not occurring Exceeding dose of lipids greater then 12 ml/kg Advance to Next Frame When Bowel Sounds Once lipids are administered Left Lung Sounds Normal Primary ECG Lead Right Lung Sounds Normal Secondary ECG Lead Eyes Closed Absent Additional Comments State # 4 State Name HR RR Recovery 36.5 BP 102/66 Correct Treatment EtC02 60 Preductal Postductal ABP Recognize change in patient condition Patient Vocals None-Intubated Heart Sounds Normal Heart Rhythm Sinus Rhythm Sp02 105 22 Temp 95 Arm Leg CVP PAP Other Incorrect/NonTreatment Advance to Next Frame When Bowel Sounds End scenario after recognition of change in patient's condition Normal Left Lung Sounds Normal Primary ECG Lead Right Lung Sounds Normal Secondary ECG Lead Eyes Closed 33 Actor Role - 1510 Ped CRM OR, LAST, Code Blue Role: Anesthesiologist Simulation Actor Instructions Will run the ANES machine and maintain airway. Prompt that pt is in deteriorating and needs LAST kit Prompt to check for a pulse Simulation Actor Script (Will help run code, but DO NOT assign roles unless staff in the room are not doing it) 1st Stage: start asking for the stretcher and getting stuff to move pt over, if RN starts to take leads off tell them to stop until pt is extubated 2nd stage: "The patient is going into an arrythmia, everyone quiet down" if staff doesn't recognize last/local overdose ask "how much local was given total?" 3rd: if someone else doesn't start code response (checking for pulse, prompt for that as well to press code button if other people aren't there yet) 4th stage: after lipids given ask for pulse check Moulage and Wardrobe Green scrubs History and Medications Hx of meds: 30 CC's total of local (bupivacaine 0.5% with epi 1: 100) were given during case Will get from ANES (box and top drawer of ANES cart were sent out in email) 34 Appendix B Simulation Effectiveness Tool - Modified (SET-M) (5-Point Version) 35 Appendix C Simulation-Based Learning Facilitator Key Points Infographic 36 Appendix D Presentation for Stakeholders 37 38 39 40 Appendix E Project Timeline