*Implementation Barriers*

One of the concerns of the core team involved videotaping sta ff during the simulation and debriefing. In the past, videotaping simulated scenarios had not been a positive experience, as expressed by many NICU sta ff. We used a handheld iPad for recording and moved it around to attempt to capture the best views; this served to constantly remind sta ff that they were being filmed. The sta ff also expressed concern that mistakes made during simulation would be highlighted during playback during debriefings. For all these reasons, we had ceased recording simulated scenarios. At the beginning of *Simulating Success,* the core team was concerned that the videotaping and playback could make sta ff resistant to participating in this QI collaborative. These issues were addressed with sta ff members by the core team via one-on-one discussions and presentations to groups of professionals working in the NICU and Labor and Delivery. The core team assured sta ff that recordings would be used only as a debriefing tool to enhance training and not as a formal critique of their abilities. We also emphasized that our core team's debriefing technique was backed by CPQCC and CAPE as a recommended technique. Nursing Leadership also approved the purchase of a "GoPro" camera (which has a small physical footprint) making recording less noticeable to the sta ff. As a result, many sta ff commented that they actually forgot that they were being videotaped during the scenarios. As the months progressed, the sta ff learned to "debrief themselves" as they watched the playback and became comfortable with CAPE's debriefing methodology.

Another barrier was the challenge of a limited number of sta ff present during the simulations and the inability to bring on-duty NICU sta ff to Labor and Delivery for the simulated scenarios. We therefore utilized areas in the NICU such as a back corner or the isolation room and simulated as if we were in the labor and delivery area. We also ensured that each simulation and debriefing was completed in 30 min or less at the end of each shift. This allowed sta ff to complete all or most of their work prior to participating.

As with any QI project, there were barriers to participation. We, therefore, established that unit and organizational stakeholders shared our mental model as to how the program should proceed prior to its start. This shared mental model involved various context factors, such as financial and sta ff resources, in order to e ffect change and provide overall accountability for the implementation process and simulation program. To help with the program's sustainability, we also actively engaged and started initial training with other interprofessional team members.
