SIMUPICS: Simulation-based training for post-ICU syndrome prevention

Abstract

Introduction

Post Intensive Care Syndrome (PICS) can be prevented by applying the components of the ABCDE bundle (mainly pain management, sedation, delirium and early mobilization).

Objective

To design and validate the simulation-based SIMUPICS course to train knowledge and skills related to the application of the ABCDE bundle.

Methods

Descriptive study of metric characteristics. Analysis of the face and content validity of the course with experts from the working groups of the Spanish Society of Intensive Care Nurses and Coronary Units (SEEIUC). Pilot test with at least 30 intensive care unit (ICU) nurses to assess applicability of the course in ICUs.

Results

Two Delphi rounds were carried out until 85% of the items were agreed as optimal and an Aiken V between 0.82 and 1. The nurses who participated in the pilot test (n = 38) considered that the simulation received had helped them to identify key actions in the prevention of post-ICU syndrome (5 [4–5]) with a Likert scale from 1 totally disagree to 5 totally agree, and that the structure of the course (stations, duration, dynamics) facilitated practical learning (5 [4–5]).

Conclusions

The SIMUPICS course, validated by nursing experts in analgesia, delirium and mobilization practices, is useful for training skills and knowledge related to the ABCDE bundle. Its design based on clinical simulation makes it a suitable strategy for the continuing education of health professionals, both in situ in the ICU itself and in simulation centers.

Resumen

Introducción

El síndrome post-UCI (en inglés, Post Intensive Care Syndrome -PICS-) se puede prevenir aplicando los componentes del paquete ABCDE (principalmente manejo del dolor, sedación, delirio y movilización precoz).

Objetivo

Diseñar y validar el curso SIMUPICS, basado en simulación, para entrenar conocimientos y habilidades relacionados con la aplicación del paquete ABCDE.

Métodos

Estudio descriptivo de carácter métrico. Análisis de la validez facial y de contenido del curso con expertos de los grupos de trabajo de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Prueba piloto con mínimo 30 enfermeras de unidades de cuidados intensivos (UCI) para valorar aplicabilidad del curso en las UCI.

Resultados

Se realizaron dos rondas Delphi hasta conseguir el acuerdo del 85% de los ítems como óptimos y una V de Aiken entre 0.82 y 1. Las enfermeras que participaron en la prueba piloto (n = 38) opinaron que la simulación recibida les había ayudado a identificar actuaciones clave en la prevención del síndrome post-UCI (5 [4–5]) con escala Likert de 1 totalmente en desacuerdo a 5 totalmente de acuerdo, y que la estructura del curso (estaciones, duración, dinámicas) facilitaba el aprendizaje práctico (5 [4–5]).

Conclusiones

El curso SIMUPICS, validado por expertos/as enfermeros/as referentes en prácticas de analgosedación, delirio y movilización, es útil para entrenar habilidades y conocimientos relacionados con el paquete ABCDE. Su diseño basado en simulación clínica, lo convierte en una estrategia adecuada para la formación continuada de profesionales de la salud, tanto in situ en la propia UCI como en centros de simulación.

What is known / What it contributes

Post-Intensive Care Syndrome (PICS) has a significant impact on the quality of life of critically ill patients after discharge. The scientific literature notes how the implementation of the ABCDE bundle can prevent the onset of this syndrome, focusing particularly on aspects such as a correct management of analgesia, sedation, delirium and the application of early mobilisation. Nevertheless, there remains a large gap between evidence-based recommendations and clinical practice in terms of the application of the measures included in the ABCDE bundle.

This work presents the development and validation of the SIMUPICS course, an innovative training programme based on clinical simulation, designed to develop nursing skills for the prevention of PICS via the practical application of the ABCDE bundle. Its bimodal structure, which combines an autonomous digital phase with interactive feedback and an in-person phase with simulated scenarios and standardised patients, enables integration of autonomous learning, promoting safe and replicable clinical decision-making in care and training environments, as well as the training of key skills for critical care nurses.

Implications of the study

The practical and replicable approach of the SIMUPICS course makes it a high-impact training tool to improve care quality and safety for critically ill patients, and to standardise care interventions. Moreover, it favours the application of evidence in clinical practice, a key issue in order to implement high-value practices that make the healthcare system sustainable, as in the case of the ABCDE bundle.

;1;

Introduction

Post-Intensive Care Syndrome (PICS) is characterised by the physical, functional and psychological impairment experienced by patients who survive a prolonged stay at an intensive care unit (ICU), and which significantly impacts their quality of life.¹ At 3 and 12 months after ICU discharge, one or more PICS dimensions are present in 64% and 56% of patients, respectively.² In order to mitigate the effects of PICS, clinical guidelines recommend implementing the ABCDE bundle, an evidence-based multimodal strategy aimed at optimising patient recovery in the ICU.^3–6 This bundle includes the following specific measures: (A) assessment, prevention, and management of pain; (B) spontaneous awakening and breathing trials; (C) selection of adequate analgesic and sedative agents, taking into account factors such as metabolism, dosing and necessary adjustments; (D) application of protocols to prevent and manage delirium; and (E) promotion of early mobilisation and exercise.⁷

Multiple studies have shown that the application of the ABCDE bundle significantly improves survival,^8–12 decreases the duration of ICU and hospital stay,^3,11,13 reduces readmission rates,¹³ and lowers the incidence of delirium and coma.^8–10,13,14 In addition, it is associated with fewer days of invasive mechanical ventilation (MV),^3,8,11,13 reduced administration of analgosedation,¹⁵ and a decreased use of physical restraints.¹³ However, implementation of the ABCDE bundle in clinical practice also entails significant challenges,¹⁶ varying widely between countries and even between regions within the same country.^12–14,17 In Spain, recent studies have revealed low rates of implementation of the components of the ABCDE bundle.^18,19 In general, the first three components (ABC) are only partially applied, which hinders an adequate implementation of the last two (DE), since a correct management of analgosedation is essential to reduce delirium and promote both patient interaction and mobilisation.^3,20,21 In light of this situation, it becomes a priority to implement strategies that promote adherence to the ABCDE bundle in Spanish ICUs.

Over the past decade, clinical simulation, a training strategy based on reproducing a specific set of conditions which replicate real-life situations,²² has become established as an optimal tool to impart knowledge and skills in the continuous training of nurses,²³ as it bridges the gap between theory and practice. In spite of this, there is a lack of studies evaluating the impact of such simulations on patient outcomes (morbidity, mortality, and complications related to nursing interventions) and on patient safety, including reducing and preventing adverse events.²⁴

The objective of this project is to design, develop, and validate the simulation-based SIMUPICS training course, aimed at imparting knowledge and skills to critical care nurses through implementation of the ABCDE bundle, in order to prevent PICS.

Methodology

This was a descriptive, cross-sectional and metric study, conducted in 3 stages, following the COSMIN guidelines²⁵:

First stage: design of version 1 (SIMUPICS_V1)

The research group, comprised by experts in simulation and critical care, all of them members of the simulation working group of the Spanish Society of Intensive Care and Coronary Unit Nursing (Sociedad Española de Enfermería Intensiva y Unidades Coronarias, SEEIUC), developed the training course. The course was designed to be imparted both at hospitals and universities. The first stage consisted in developing the baseline version of the document entitled “Ayudas cognitivas para el curso SIMUPICS” (cognitive aids for the SIMUPICS course) (SIMUPICS_V1), which includes the stations comprising the course, as well as the assessment scales/instruments to be applied by participants at each station.

Table 1 summarises the content, organisation, duration, and number of participants of the course, following best practice standards in simulation.²⁶

Table 1.

Summary and organisation of the SIMUPICS course for 50 participants and a duration of approximately 2 h.

Description	Training participants on how to apply patient assessment scales/instruments and, based on these assessments, make care decisions related to the components of the ABCDE bundle
Pre-briefing: establish a psychologically safe environment; provide instructions on visualisation of videos and use of material in the simulation; define roles for participants; establish the fiction contract and confidentiality document		Conducted by the instructors of the simulation, minimum 4Total: 10 min
Stations
Phase 1: patient assessment scales/instrumentsSimZones Zone 0:^39 training via videos with feedback provided by the digital system	1. Assessing cooperation2. Assessing pain3. Assessing sedation/agitation4. Assessing delirium5. Assessing mobilisation	Requires Internet access to view videos on a mobile device.Each stations has a maximum duration of 10 min, and should be viewed individually (total: 50 min)
Phase 2: clinical decision-making through the application of the instruments/scales learned in Phase 1SimZones Zone 2:^39Standardised patient at an ICU bay	6. Assessing the risk of muscle weakness. Application of nomogram7. Identifying which interventions to carry out8. Determining the mobilisation objective according to the algorithm	Station 6 is based on clinical cases on paper. Requires Internet access to calculate the nomogram (total: 15 min)Stations 7 and 8 are conducted with a standardised patient; 25 participants at each station, rotating; 4 participants act while the rest observe (ideally, video recorded).15 min per station
Debriefing: Feedback on the activities and decisions made during the simulation at each station of Phase 2; Review of the evidence leading to correct decisions.		Led by simulation instructors; minimum 4Total: 15 min

Second stage: face and content validity of SIMUPICS_V1

In order to verify that the course covered all the necessary dimensions to be trained in the prevention of PICS, and to ensure that the evaluation instruments were relevant, the face and content validity of the course were established through expert judgement. In accordance with the COSMIN recommendations,²⁵ a qualitative analysis of all the dimensions and domains of the course required a minimum of seven experts. Following the criteria set out by Skjong,²⁷ the experts should be selected based on their experience in forming judgements and making decisions based on their expertise and knowledge of the subject (e.g. publications), recognition by the scientific community, availability to participate, impartiality, and inherent qualities like self-confidence and adaptability.

Various members of the analgesia, sedation, restraints and delirium group (grupo de analgesia, sedación, contenciones y delirium, ASCyD) of SEEIUC, were contacted, as well as researchers in the national multi-centre project on early mobilisation group (proyecto multicéntrico nacional sobre movilización precoz, MOVIPRE), all of them authors of international publications about the ABCDE bundle. Those who accepted to participate were asked to evaluate the following parameters, for each SIMUPICS_V1 station, following the methodology described by Escobar-Pérez et al.²⁸: SUFFICIENCY. The item is sufficient and necessary; it is adequate to measure this dimension (or should other items be included to measure the dimension?). CLARITY. The item is easily understood; that is, its syntax and semantics are appropriate. COHERENCE. The item has a logical relationship with the dimension or indicator that it measures. RELEVANCE. The item is essential or important, and should be included. Following the expert assessment, Version 2 of the document (SIMUPICS_V2) was produced.

Third stage: pilot study

A pilot study was carried out in which SIMUPICS_V2 was imparted to a minimum of 30 nurses from different Spanish ICUs, following the recommendations of the adaptation and validation guidelines.^29,30 This was done during the annual congress of SEEIUC, in order to evaluate the applicability of the course in the clinical practice of an ICU, as well as the level of understanding of what was being asked from participants at each station. Once the pilot study was completed, the final version of the course (SIMUPICS-V3) was produced.

Data analysis

The expert judgement process employed a scoring scale from 1 to 4 for each parameter. In addition, open-ended questions were included to obtain more detailed opinions from experts, including suggestions to add more items/stations or modify the patient evaluation scale/instrument. Aiken’s V coefficient was used to determine the degree of consensus among experts. Successive rounds were conducted until 85% of the items were rated as optimal (mean score of 4 and 100% expert agreement), and Aiken’s V ranged between 0.82 and 1.

Results

SIMUPICS_V1 was modified according to the comments provided by experts in stage 2. The response options for stations 1, 2, 3, 4 and 7 were modified. Only 47% of the items were rated as optimal in the first Delphi round, but the objectives proposed were achieved in the second round (Appendix S1, supplementary material). The final structure of the course is shown in Tables 2 and 3. The clinical cases of station number 6, as well as their resolution, are shown in Appendix S2, supplementary material, entitled “Cognitive Aids Document for the SIMUPICS course.” For stations 7 and 8, based on zone 2 simulation, the roles of participants, actors, duration and necessary material are indicated in Tables 4 and 5, respectively.

Table 2.

Stations comprising Phase 1 of the SIMUPICS course (completed autonomously by participants before attending in-person sessions of Phase 2).

	Learning objective	Simulation	References	Response options
Station n°1 Cooperation	To determine the level of cooperation of patients	Interactive video (3.15 min)	Hermans et al.^40	The patient:
		https://aulavirtual.seeiuc.org/	SEEIUC web protocol ^41: https://seeiuc.org/study-movipre/	- Is sedated
				- Does not understand; responds to some questions
				- Collaborates; responds to all questions
Station n°2	To determine the degree of pain of patients	Interactive video (5.45 min)	International Association for the Study of Pain: numerical rating scale (NRS)	- No pain (NRS/ESCID of 0)
Pain		https://aulavirtual.seeiuc.org/	https://www.iasp-pain.org/	- Mild/moderate pain (NRS/ESCID 1–3)
			Behavioural indicators of pain scale^42 (ESCID)	- Moderate/intense pain (NRS/ESCID 4–6)
				- Very intense pain (NRS/ESCID 7–10)
Station n°3	To determine the degree of agitation-sedation of patients	Interactive video (4.45 min)	Richmond Agitation Sedation Scale^43 (RASS)	- Deep sedation (RASS -5 to -4)
Agitation-sedation		https://aulavirtual.seeiuc.org/		- Moderate sedation (RASS -3)
				- Mild sedation (RASS -2 to -1)
				- Awake and calm (RASS 0)
				- Anxious-agitated (RASS + 1 to +4)
Station n°4	To determine whether the patient presents delirium and what type	Interactive video (10.3 min)	Confusion assessment method for ICU^44,45 (CAM-ICU)	- Not assessable
Delirium		https://aulavirtual.seeiuc.org/	Classification of delirium subtype ^8,46	- No delirium
			https://www.icudelirium.org/medical-professionals/downloads/resource-language-translations	- Delirium present:
				Hyperactive
				Hypoactive
				Mixed
Station n°5	To identify the current level of mobilisation of the patient	Interactive video (5.63 min)	ICU Mobility Scale^36,47 (IMS)	- None: immobile (IMS = 0)
Mobilisation		https://aulavirtual.seeiuc.org/		- Low: exercises in bed or passive transfers (IMS = 1−2)
				- Moderate: active mobilisation in bed or out of it (IMS = 3−5)
				- High: walking (IMS = 6−10)

Table 3.

Stations comprising Phase 2 of the SIMUPICS course (in-person sessions).

	Learning objective	Simulation	References	Response options
Station n°6	To select which patient has a higher likelihood of developing muscle weakness during the first week of ICU admission, with a score ranging from 0.01 to 0.9 according to the nomogram	Clinical cases on paper (15 min).	Nomogram for the risk of developing ICU-acquired muscle weakness^48,49	- Clinical case patient n°1
Muscle weakness		Nomogram calculator, 15 min		- Clinical case patient n°2
		https://www.ub.edu/nursearch/en/scientific-publications-2/		- Clinical case patient n°3
Station n°7	To select therapeutic objectives regarding the degree of pain, sedation/agitation and monitoring of delirium for the patient in station n°6	Standardised patient in ICU bay (15 min)	Decision-making algorithm^7,50	- Patient requiring deep sedation: maintain RASS -4 to -5
Decision-making				- Patient not requiring deep sedation: achieve RASS -2 to 0, ESCID < 4. Assess RASS and ESCID every 4 h and after applying a procedure (e.g. suction of secretions)
				- Patient presenting RASS>-3: assess cooperation to measure MRC, NRS or ESCID every 4 h, and after applying a procedure (e.g. suction of secretions), assess CAM-ICU every 12 h, applying non-pharmacological measures. Mobilisation objective: IMS>3
Station n°8	To determine the appropriate level of mobilisation for the patient selected in station n°6	Standardised patient in ICU bay (15 min)	Decision-making algorithm ^50	- None: immobile (IMS = 0)
Decision-making			Mobilisation table ^51	- Low: exercises in bed or passive transfers (IMS = 1−2)
				- Moderate: active mobilisation in bed or out of it (IMS = 3−5)
				- High: walking (IMS = 6−10)

MRC: Medical Research Council Scale.

A total of 12 muscle groups are assessed with scores ranging from 0 (no visible or palpable contraction) to 5 (normal contraction strength, strong resistance).^40,41

Table 4.

Station number 7 based on Zone 2 simulation.

Participant roles	Four ICU nurses (two on each side of the bed of the patient)
Description of the case for participants	Sara Grande Marlaska, 73-year-old woman, whose MRC was evaluated on 5^th day of ICU admission. She did not present hyperactive delirium and was not actively mobilised at any point. She received renal replacement therapy on days 4 and 5.
	She was identified in the preceding station (n°6) as a patient with risk of 0.8 out of 1 for developing ICU-acquired weakness. Today is day 6 of ICU admission. On the previous afternoon, she presented with RASS -3 (in the morning it was -1). The confirmed diagnosis is sepsis secondary to community-acquired pneumonia.
	Based on the assessment conducted at this moment with the various scales/instruments learned in stations 1–4, you are asked to select therapeutic objectives regarding degree of pain, sedation and monitoring of delirium
Script for the standardised patient	Patient connected to mechanical ventilation, currently undergoing weaning (support pressure of 10, FiO2 0.3, PEEP + 5). Haemodynamically stable without vasopressors, awake and calm, immobile, communicating pain by nodding. Participants are expected to assess the level of cooperation (station 1: responds to all questions), select NRS to measure pain (station 2: able to self-report pain/manifests mild-moderate pain, NRS = 1−3); assess level of consciousness (station 3: alert, RASS = 0); assess CAM-ICU due to fluctuation in the level of consciousness in the previous 24 h (station 4: squeezes indiscriminately when hearing A or any other letter, RASS = 0 must assess cognitive alterations and makes 1 error in question 3. Must continue assessing commands. Raises fingers on one hand correctly when shown how to do it, but cannot do it correctly with the other hand. A total of 2 errors; hypoactive delirium)
Correct resolution	Patient does not fulfil criteria for deep sedation. Currently presenting with RASS>-3: assess cooperation to measure MRC, NRS or ESCID every 4 h, and after applying a procedure (e.g. suction of secretions), assess CAM-ICU every 12 h, apply non-pharmacological measures. Mobilisation objective: IMS> 3
Material	Bed or table for standardised patient (1), auxiliary trolley for material (1), bed blanket (1), saline solution with infusion equipment to connect to the catheter (1), perfusion pump equipment (1), stickers to show the type of medication (2, midazolam, morphine hydrochloride), central venous pressure monitoring equipment (1), invasive mechanical ventilation material (orotracheal tube, fixation system, tubing, box simulating ventilator), gloves (1 box), hand sanitiser (1)

Table 5.

Station number 8 based on Zone 2 simulation.

Participant roles	Four ICU nurses (two on each side of the bed of the patient)
Description of the case for participants	Sara Grande Marlaska, 73-year-old woman, whose MRC was evaluated on 5^th day of ICU admission. She did not present hyperactive delirium and was not actively mobilised at any point. She received renal replacement therapy on days 4 and 5.
	She was identified in the preceding station (n°6) as a patient with risk of 0.8 out of 1 for developing ICU-acquired weakness. Today is day 6 of ICU admission. On the previous afternoon, she presented with RASS -3 (in the morning it was -1). The confirmed diagnosis is sepsis secondary to community-acquired pneumonia.
	You are asked to select the appropriate level of mobilisation for this patient. she could not be assessed by the physical therapist, as it is a weekend
Standardised patient script	Patient connected to mechanical ventilation, currently undergoing weaning (support pressure of 10, FiO2 0.3, PEEP + 5). Haemodynamically stable without vasopressors, without arrhythmias or signs of myocardial ischemia, awake and calm, although disoriented in space and time. Can move arms and legs against gravity
Correct resolution	Participants are expected to use the table to assess haemodynamic and/or respiratory risk factors (there are none) and to assess whether the patient can move arms and legs against gravity. Her pelvis is stable, as there is no prior traumatism. She can transfer from the bed to a chair (IMS = 5). She is able to move to the chair walking or shuffling her feet. This entails an active transfer of weight from one leg to the other to reach the chair. If the patient has stood with the help of a staff member or a medical device, she should reach the chair walking (does not include transfer using a walking frame).
	It should be noted that this patient requires RRT. According to the mobilisation algorithm^50 she can only move within the room (maximum IMS of 6), due to difficulty in stretching treatment lines and power cables. In addition, exceeding 90◦ hip flexion in the presence of femoral catheters is not recommended
Material	The same as for station number 7, plus a femoral catheter for RRT and a box simulating a dialysis machine

The pilot study with SIMUPICS-V2 included 38 nurses, of whom 78.9% were female, with a mean age of 40.3 ± 7.9 years, with 16 [10–23] (median [P25–P75]) years of experience as nurses in general, and 11 [8–18] at an ICU specifically. Out of the total, 76.3% had received postgraduate training in critical care. Only nine nurses (23.7%) would add an actor into the simulation to represent a relative, in order to explore the degree of family involvement in patient care. On a 1–5 Likert scale, participants scored both the usefulness of the course for clinical practice and the probability of recommending it to their colleagues with a 5 (5–5).

Participants reported that the simulation had helped them to identify key actions in the prevention of PICS, reflected in a score of 5 (4–5), and that the structure of the course (stations, duration, dynamics) facilitated practical learning, reflected in a score of 5 (4–5).

Discussion

The SIMUPICS course has been validated by expert nurses specialising in analgosedation, delirium and mobilisation. It has been designed according to the most recent evidence regarding these practices. The pilot study, conducted with ICU nurses from different Spanish regions, was assessed as positive, and the course was considered to be highly applicable in clinical practice, potentially constituting the basis for a nationwide training project. The authors chose not to add a family member into simulation scenarios in order to maintain the focus on the clinical management of PICS, without the additional F component. The expert group believed that addressing PICS-F would require a different simulation approach, using other instruments, and this would give rise to a new course, to train the ABCDEF bundle (Family engagement and empowerment [F]), potentially going further, to include application of the Good communication, Handout materials, Redefined ICU architectural design, Respirator, Nutrition (GHIRN) framework.⁷

Given that evidence-based recommendations are only partially implemented in clinical practice,³¹ promoting simulation-based training in both academic (postgraduate training) and clinical settings (continuous professional training) could increase the uptake of evidence-based nursing interventions. According to the review by McNett et al.,³² the most commonly adopted interventions include: measures to prevent ventilator-associated pneumonia (14.6%), nutrition protocols (10.9%), ABCDE/ABCDEF bundles (8.5%), prevention of catheter-related bloodstream infection (7.3%), MV weaning protocols (7.3%), mobilisation protocols (4.8%), and the use of checklists (4.8%), among others.

However, according to Fernández-Domínguez et al.,³³ who conducted a multi-centre survey in Spain including 934 nurses, the barriers to implementing evidence-based practices include a lack of spaces to discuss research, an absence of mentors, resistance to change, and insufficient time. On the other hand, training in evidence-based practices acts as a facilitator.³⁴ This includes the SIMUPICS course, based on a simulation methodology to recreate the clinical environment, but with feedback focused on the participant and with no risk for patients. In the review by McNett et al.,³² none of the strategies identified to implement evidence-based clinical practices employed simulations, even though this methodology enables professionals to receive interactive training in events that do not occur frequently in clinical practice or that, when they do occur, do not allow for reflection, since the response expected from professionals at that moment is a fast and effective intervention to resolve the problem.

In addition, the systematic implementation of the SIMUPICS course at Spanish ICUs could lead to a significant improvement in patient safety. First, through the transfer to clinical practice of the knowledge and skills acquired (Kirkpatrick level III³⁵), and ultimately through the positive impact on patient care, by reducing the incidence of PICS (Kirkpatrick level IV³⁵). Specifically, the daily use of patient assessment scales/instruments could be improved to reduce adverse events deriving from over- and under-sedation, including delayed awakening, prolonged MV and weaning, ventilator- associated pneumonia, and loss of invasive devices, among others. Moreover, it could also contribute to prevent the development of delirium and muscle weakness secondary to immobilisation. For example, a better knowledge of the ICU Mobility Scale (IMS)³⁶ and the criteria to determine the appropriate level of mobilisation could, in the medium and long term, promote early mobilisation during the first 72 h of ICU admission, according to the recommendations of the most recent evidence.³⁷ In spite of the controversy regarding the optimal timing and level of mobilisation, there is a consensus regarding the need to implement best practices that facilitate it, such as optimisation of analgesia, sedation and, management of delirium.³⁸

Limitations

During the methodological design phase of the present study, the possibility of a formal aesthetic validation of the SIMUPICS document was considered, using a checklist structured into seven categories: (1) legibility and typography; (2) organisation and visual structure; (3) formatting consistency; (4) clarity of instructions; (5) use of visual and graphical elements; (6) visual load and white spaces; and (7) overall satisfaction with the visual design. However, this phase was not carried out, as flexibility of use at different ICUs was prioritised. Imposing a fixed visual format could limit its implementation in contexts with specific graphical structures, thus reducing its practical utility.

It is worth noting that, although the concept of “aesthetic validity” is not clearly defined in the classical literature, some authors point out that the visual design of instruments can affect their understanding, the cognitive load of survey respondents and, consequently, the reliability of the data obtained. In this regard, the aesthetic factor was not considered as an independent dimension of the validation process, but it was recognised as a factor that could indirectly influence the quality of measurement.⁴⁶ In line with this notion, the development of a complementary course including audiovisual material, an interactive calculator, and aesthetically optimised versions of the instruments is being considered, with the aim of facilitating a consistent implementation of the SIMUPICS programme at ICUs nationwide.

Conclusions

The SIMUPICS course, validated by nurses with extensive experience in analgosedation, delirium, and mobilisation practices, is useful to train skills and knowledge related to the ABCDE bundle. Its design, based on clinical simulation, makes it an adequate strategy for continuous training of healthcare professionals, both in person in the ICU and in simulation centres.

Ethical considerations

This study obtained the approval of the Bioethics Commission of Barcelona University. The approval document issued by the Commission to conduct this study is attached with the rest of the documentation.

Financing

This study did not receive financing. The authors declare that they have no financial connections that could give rise to a possible conflict of interests.

Acknowledgements

The authors wish to thank the experts who comprise, or comprised, the analgesia, sedation, restraints and delirium (ASCyD) group of the Spanish Society of Intensive Care and Coronary Unit Nursing (SEEIUC).