In Situ Simulation Bolsters Paediatric Cardiac Intensive Care Unit Nurse Satisfaction & Retention

Workforce shortages and employee retention present major challenges to medical institutions. Contributors to ICU nurse job satisfaction include opportunities for continuing education/personal growth, positive interprofessional team dynamics, and a safe learning environment. We will evaluate how participation in a longitudinal interprofessional simulation programme affects paediatric cardiac ICU nurse job satisfaction and retention across the experience continuum.

Introduction

In the paediatric cardiac intensive care unit (PCICU), the bedside nursing team’s attention to detail and vigilance are among the most important components of early recognition when a patient is clinically deteriorating. Typical nurse staffing models in the intensive care unit rely on a balance of senior, mid-career and newly qualified nurses to ensure appropriate clinical coverage, mentorship and a continuum of experience levels. National nursing shortages have unfortunately altered this ideal balance in intensive care units, leading to knowledge, experience and clinical coverage gaps. In the PCICU, where variations in pathophysiology are guaranteed and patients are among the most fragile in the hospital, these gaps can affect early recognition of clinical deterioration, and patient safety.

In the years preceding, during, and after the COVID-19 pandemic, the healthcare community has seen a profound nursing shortage (Martin et al. 2023). While this shortage affects many areas of healthcare, intensive care units have been among those most affected (Galvin 2021). This shortage has led to decreases in senior nursing staff and increases in newly qualified nurses caring for critically ill patients. Importantly, it has likely affected patient safety (ECRI 2022).

In situ simulation is widely used in paediatric critical care medicine to improve team performance, address knowledge gaps, strengthen communication, and identify safety threats in the clinical environment (Hammontree and Kinderknecht 2022). Simulation-based interventions have been shown to enhance interdisciplinary coordination and crisis management skills. These skills often extend beyond the simulated environment into routine clinical care, as in this case through improved closed-loop communication patterns (Ulmer et al. 2022).

As we implement an in situ simulation-based interprofessional education programme in our paediatric cardiac intensive care unit, we will evaluate programme effects on multiple levels. Importantly, we will evaluate how participation in an in situ simulation-based interprofessional education initiative affects paediatric cardiac ICU nurse job satisfaction and retention across the experience continuum.

Background

The highly specialised field of paediatric cardiac intensive care has rapidly grown in complexity over the past 20 years. With this growth nursing continuity and confidence have been identified as barriers to ensuring appropriate patient care (Allan et al. 2010). Nursing shortages and high turnover have had a substantial negative impact not only in the paediatric cardiac intensive care unit (PCICU), but across the broader healthcare system, leading to increased morbidity and mortality, increased length of stay, and higher overall cost (Bae 2022).

The World Health Organization estimates a global nursing shortage of 7.9 million and predicts up to a 12.9 million deficit by 2035 following the COVID-19 pandemic (Tamata and Mohammadnezhad 2022). Moreover, a 2022 COVID-19 impact assessment survey indicated that 23% of registered nurses intended to leave their position in the following six months, listing inadequate staffing and inability to consistently provide quality care as contributing factors (Woodward and Willgerodt 2022). The Emergency Care Research Institute (ECRI) publishes its Top 10 Patient Safety Concerns annually. Over the past several years’ Top 10 publications, staff shortages, healthcare team member wellbeing, culture, and successfully progressing new graduates to clinical care have consistently been identified as threats to patient safety. In three years of statements, staffing shortages and staff mental health (2022), healthcare workers’ emotional and physical health and obstacles to transitioning from new graduate to patient care/ practice (2024), ongoing workforce shortages and blame culture’s impact on learning and working toward system improvement (2026) have all been included in the Top 10 (ECRI 2022, 2024 and 2026). This underscores an ongoing and urgent need to mitigate staffing shortages and turnover while optimising healthcare worker retention. These themes also highlight opportunities to improve workplace culture, team member mental, emotional and physical health and wellbeing, and optimise support for new graduate healthcare workers beginning clinical practice.

In 2023 Folden and colleagues identified themes related to nurse turnover and retention. They implemented table-top simulations with nurses at various levels across the practice continuum and facilitated reflection as nurses progressed through a simulated workday. Facilitated group discussion after each simulation highlighted themes related to nurse turnover and retention. Themes and subthemes were identified; new graduate nurses and nurse supervisors shared their impressions related to these. While new graduate nurses emphasised clinical competency (personal insight, development, evaluation and competency-aligned patient care), nurse supervisors focused on professional goals and continuing professional development. Collaboration among nurses and with other members of the interprofessional team, culture and collegiality were important to nurses across the experience continuum (Folden et al. 2023).

In their 2022 systematic review, Woodward and Willgerodt evaluated factors affecting turnover and retention among registered nurses in the United States. Turnover was defined per Hom and colleagues as “the separation of an employee from a job or organisation” (Hom et al. 2017). Retention was defined as "an employee staying in a job” (Lee et al. 2018). The authors’ findings underscored longstanding contributors to nurse turnover and retention in the United States. These included job satisfaction, organisational commitment, supportive unit leadership, positive professional relationships and teamwork. At the organisation level, Magnet designation, urban location, affiliation with an academic centre, and hospitals with over 400 beds positively affected retention and turnover. Continuing education, career development, orientation programmes, and challenging and exciting work also contributed positively to retention and turnover. Workplace abuse or hostility negatively impacted turnover, as did disparities in equity and diversity and related adverse professional experiences. Nurse health and well-being effects on turnover and retention was noted to be underrepresented in the literature. The authors also emphasised a dearth of current literature supporting successful initiatives to improve nurse retention and turnover rates (Woodward and Willgerodt 2022). The study identified potential focus areas to improve nurse turnover and retention; it also underscored the great variation in published studies investigating this important topic.

A positive perception of workplace relationships and teamwork is associated with improved job satisfaction and nursing retention (Woodward and Willgerodt 2022). Interprofessional in situ simulation offers an opportunity to reproduce realistic clinical scenarios in an immersive and safe learning environment. Moreover, evidence supports that incorporating simulation into acute and critical care settings exposes nurses to valuable clinical education, promotes improvement in team dynamics, and fosters supportive and effective communication (Hunt et al. 2007; Yuen et al. 2023). These positive simulation-based critical care nurse and team outcomes underscore the potential for simulation-based ICU initiatives to affect nurse retention.

Nursing administrators surveyed from 25 U.S. paediatric heart centres defined successful nurse retention as having an experienced nurse remain in their role for 3 years and a newly qualified nurse for five years (Connor et al., 2025). This interprofessional qualitative analysis identified several potential positive contributors to nurse retention. These included increasing staff engagement, providing opportunities for professional development and education, and promoting an inclusive and healthy work environment. Study participants across multiple disciplines expressed the importance of providing and encouraging just-in-time learning for bedside nurses, specifically via unit-based education during regular working hours.

In another 2025 study, Cordon et al. evaluated the effects of a multi-modal nurse education programme, TIPS (Transition to Independent Practice Support). In addition to evaluating clinical knowledge and competence for new nurses participating in the TIPS programme, the authors assessed early markers of nurse retention. When assessed at the end of the six-month study period, all programme participants were still in their current positions (Cordon et al. 2025). In 2011 Edwards and colleagues assessed the effects of 33 diverse programmes on new nurses’ transition to clinical practice. The studies varied in modality (intern/externship, residency, preceptorship, mentorship, orientation and simulation among others) and outcomes (nurse graduate-centric and employer-centric). Among employer-centric outcomes, recruitment, retention and turnover were evaluated. Nurse-graduate focused outcomes included job satisfaction, knowledge and skills attained, confidence, teaching, collaboration, interpersonal skills and communication. Studies demonstrated early improved job satisfaction in participants. Interestingly, several studies showed initial improvement in nurse graduate job satisfaction, a down-trend in job satisfaction around 6 months, then return to levels near but not at initially improved levels (Edwards et al., 2011). Some studies also reported initially decreased rates of turnover, with a return to pre-programme turnover rates around the 12-month mark. It is possible that nurse retention and turnover rates will have sustained improvement if such programming is offered in a recurring fashion.

Stark and colleagues performed a qualitative analysis of nurse satisfaction in the PCICU in 2023. Results emphasised nursing affinity for their colleagues along with collaboration, approachability, and support as major contributors to improved nurse retention. Further, the ability to learn in a non-intimidating forum without perceived judgement was deemed crucial to maintaining positive unit culture (Stark et al. 2023). In a setting with high personnel turnover, implementing an iterative interprofessional simulation programme may improve nursing retention and job satisfaction, perhaps secondarily positively affecting patient outcomes.

Interprofessional education (IPE) occurs when learners from two or more different healthcare professions come together to learn about, from, and with each other to improve patient safety and health outcomes (Van Diggele et al. 2020). There are many patient benefits to incorporating interprofessional education in any institution, including reducing hospital stays, fewer medical errors, and increasing patient satisfaction (Kamal et al. 2025). Furthermore, studies have shown that interprofessional education is valuable to healthcare professionals in increasing respect, a deeper understanding of roles and responsibilities, enhanced communication, and higher job satisfaction (Kamal et al. 2025). Through IPE, healthcare professionals learn to value the skills of each discipline and the strategies that can be applied to interprofessional education endeavours to improve clinical care, share case management strategies, and provide better health services to patients and the community (Gilfoyle et al. 2017; Shakhman et al. 2020).

In an intensive care unit (ICU), nurses collaborate closely with a range of healthcare professionals, engaging daily in continuous communication and shared decision-making. Proficiency in critical care is grounded in knowledge, technical competence, and interprofessional teamwork (George and Quatrara 2018). This reliance on teamwork, one of the four core competencies of interprofessional collaboration (George and Quatrara 2018), emphasises the importance of IPE. Interprofessional education equips nurses with the skills necessary to function effectively within multidisciplinary teams. Interprofessional education is particularly valuable in the ICU as it supports managing complex patients, facilitates time-sensitive interventions, enhances clinical decision-making, and promotes safe, high-quality patient care (Kamal et al. 2025).

Simulation-based interprofessional education interventions have demonstrated efficacy in improving team members’ perceived confidence and comfort in managing a variety of patient crises in the paediatric cardiac intensive care unit (Allan et al. 2010). In addition to improved confidence in crisis-management related skills including team leadership, simulation-based IPE has been shown to improve interprofessional communication during real patient emergencies in the paediatric cardiac intensive care unit (Figueroa et al. 2013).

In the critical care environment, effective collaboration among nurses, physicians, and allied health professionals requires not only strong clinical knowledge but also well-developed communication and teamwork skills (George and Quatrara 2018). Simulation-based learning represents a key advancement within interprofessional education (Sung and Hsu 2025), offering a structured, low-risk environment in which ICU nurses and other members of the interprofessional team can develop these skills.

Interprofessional in situ simulation-based education engages the multidisciplinary team in relevant, targeted multifaceted learning opportunities that can be continually adapted and refined. Iterative adjustments to simulation-based curricular content, including medical, procedural, and teamwork objectives, tailor ICU team learning to current unit needs in the rapidly changing ICU setting. Simulating events that closely mirror actual patient scenarios enables learners to refine technical skills, enhance team communication, and build confidence in interprofessional interactions (Sung and Hsu 2025). Simulation-based educational content at recurring intervals provides ongoing opportunities to optimise team dynamics and critical patient care activities in high-risk clinical situations. Drawing from Edwards and colleagues’ 2011 research findings, recurring (as opposed to infrequent or standalone) simulation-based interprofessional education may lead to sustained improvement in interprofessional team member retention and turnover.

With these many factors in mind, we will evaluate how participation in a longitudinal interprofessional in situ simulation programme affects paediatric cardiac intensive care unit nurse job satisfaction and retention across the clinical experience continuum.

Methods

Study Design: We are implementing an in situ simulation-based interprofessional education programme in our paediatric cardiac intensive care unit. We will evaluate the multifaceted effects of this programme with a mixed methods pre/post intervention study, incorporating qualitative and quantitative analysis components.

Population: Full complement of interprofessional team members in the Johns Hopkins Children’s Centre Paediatric Cardiac Intensive Care Unit including bedside nurses, respiratory therapists, paediatric critical care medicine nurse practitioners, paediatric critical care medicine fellow physicians, paediatric pharmacists, and attending paediatric cardiac intensivists. For ECMO and ECPR simulations, ECMO specialists, the paediatric cardiac operating theatre team, paediatric cardiothoracic surgeon and paediatric cardiothoracic surgery physician assistants will also be present.

Setting: The Johns Hopkins Children’s Centre Paediatric Cardiac Intensive Care Unit.

Intervention

We will institute weekly interprofessional in situ simulations in the Johns Hopkins Children’s Centre paediatric cardiac intensive care unit. Simulation participants will include bedside nurses, respiratory therapists, paediatric critical care medicine nurse practitioners, paediatric critical care medicine fellow physicians, attending paediatric cardiac intensivists and paediatric pharmacists.

Medical content for in situ simulations will be based on common and rare clinical scenarios encountered in the paediatric cardiac intensive care unit. Medical content will be iteratively adjusted according to a baseline unit needs assessment, evolving unit needs, and identified latent safety threats. Simulation scenarios will be focused on recognition, stabilisation/ resuscitation, medical, surgical and post-operative management of paediatric and congenital heart disease illnesses (Figure 1). Scenario topics will include (but not limited to) the following: ductal-dependent systemic or pulmonary blood flow, single ventricle anatomy/ physiology (management and emergencies pre- and post-op along the stages of single ventricle palliation), PAPVR, TAPVR, myocarditis, ALCAPA, pulmonary hypertension, VSD, AV canal/ variants, cardiomyopathy, dysrhythmia, VA ECMO cannulation, ECMO-related emergencies, and ECPR.

Primary Outcomes

Primary outcomes will focus on interprofessional team members’ knowledge, skills, attitudes/ behaviours and teamwork skills. Knowledge will be measured in the context of cognitive load change as assessed by the NASA-TLX questionnaire. The NASA-TLX questionnaire will be administered via a Quick Response (QR) code following each simulation (before the debrief). We will track the average trend and delta over time. Skills will also be measured via the NASA-TLX questionnaire, using cognitive load as a surrogate. Psychomotor and communication skills will be assessed with both a critical action checklist and the clinical teamwork scale. These will be completed by trained observers during simulations and/or via video review. Video review will allow for inter-rater reliability and ensuring accuracy. Attitudes/ behaviours and teamwork skills will also be assessed via the same aforementioned Clinical Teamwork Scale (Figure 2).

Secondary Outcomes

Secondary outcomes will focus on contributors to bedside nurse job satisfaction and retention. We will assess bedside nurses’ job satisfaction, likelihood of staying at our institution, and feeling like they are an important member of the team. These will be measured via anonymous survey at pre-implementation and 6-month and 12-month intervals. Focus groups will be utilised to clarify and refine responses in the future.

Conclusion

In the rapidly advancing and evolving practice of medicine internationally, workforce shortages and employee retention present a significant challenge in healthcare. Importantly, this global healthcare workforce shortage and retention issue affects the quality and safety of patient care. Before, during and after the COVID-19 pandemic, workforce shortages and employee retention have presented significant barriers to reliably providing safe, effective, quality patient care. Studies have demonstrated that interprofessional education initiatives bolster interprofessional team members’ confidence in medical management, communication and teamwork. Improved confidence in medical management, team member engagement, and teamwork all enhance employee retention in the healthcare context.

We are implementing an in situ simulation-based interprofessional education programme in our paediatric cardiac intensive care unit. We will evaluate the multifaceted effects of this study with a mixed-methods approach, incorporating qualitative and quantitative components. We will focus our evaluation on critical components of medical management and teamwork, team member confidence/ readiness to care for complex patients, team member job satisfaction, likelihood to remain at our institution, and feeling like an important member of our paediatric cardiac intensive care unit team. We seek to demonstrate the value of simulation-based interprofessional education in both direct patient care and in the equally important but less elucidated measures of job satisfaction and other key contributors to employee job satisfaction and retention, especially as it pertains to our bedside nursing colleagues.

Conflict of Interest

None.