Acute respiratory distress syndrome carries a 40% mortality rate. Prone positioning remains underused owing to clinicians’ low degree of confidence, concern about the risk of adverse outcomes, and lack of staff competency training.

Local Problem and Purpose

A prone positioning protocol and educational program were needed in an intensive care unit to achieve compliance with best practices for treating acute respiratory distress syndrome patients.


An initial survey was conducted to measure staff confidence and competency in prone positioning. A literature review was performed, and a plan-do-study-act approach was used to develop a protocol through in situ simulation involving mock patients. A training video and a simulation scenario using a high-fidelity manikin were developed to facilitate staff education. Staff were surveyed again after training.


During the simulation scenario, interdisciplinary clinicians learned to apply the protocol and resupinate the patient during a simulated emergency. The training video was later used for “just in time” education minutes before actual prone positioning events.


A total of 25 critical care nurses, 11 respiratory therapists, and 10 physicians completed the initial survey and simulation training. The survey showed that staff lacked confidence and competency in prone positioning. Staff demonstrated competence during the simulation sessions, and posttraining surveys indicated increased confidence. After the educational program, prone positioning was successfully used for 6 critically ill acute respiratory distress syndrome patients.


In situ simulation and interdisciplinary collaboration increase standardization of high-risk, underused procedures, improving staff confidence and competence as well as patient safety.

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