An Educational Strategy for Clinical Simulation in Lothian: supporting expertise through Deliberate Practice* *Deliberate Practice 1 highly structured & intentional activity engaged in with the specific goal of improving performance repetitive performance of intended cognitive or psychomotor skills combined with immediate focused feedback Authors: Dr Anna Dover, Nathan Oliver, Dr Simon Edgar Publication date: December 2016 Planned Revision Date: December 2020 v 4.3 01.04.18. 1
1. Introduction This document sets out a new 5-year strategy [supported by clinicians, clinical managers and service users] to build workforce competence, further promote clinical safety and support organisational resilience using clinical simulation and performance rehearsal. It builds on, and replaces, the first Clinical Simulation Strategy for NHS Lothian, published in October 2012. 2 The document describes the rationale for such a strategy and how the proposals will interface with and support the clinical services offered by NHS Lothian. Included in the strategic aims is an overall vision for clinical simulation to support health and care services in NHS Lothian by 2020. The developmental interventions proposed will be responsive to the clinical and educational needs of NHS Lothian staff, the services in which they work and the patients that they serve, and therefore will be reviewed on a regular basis to ensure alignment with current practice and priorities. 2. Strategic Aim of the Clinical Simulation Strategy Our vision is that NHS Lothian will be at the forefront of healthcare simulation in Scotland by 2020 through embedding simulated practice in healthcare education for all NHS Lothian staff and clinical students specifically to: Develop competence and support mastery of clinical skills Test and rehearse clinical performance to provide greater understanding and improve control over clinical complexity, build staff resilience and promote safety Develop and support team working and team performance The strategic aims will be achieved through the following strategic plan. 3. Strategic Plan The clinical simulation strategy for Lothian aims to describe a high quality programme of simulation-based training which is fully costed, funded and provides value for money; supports NHS Lothian s multi-professional workforce in such a way as to be patient-centred and service driven; is educationally coherent, innovative and evidence based; and ultimately contributes to safer & high quality patient care. This new plan builds on v1 which was informed by NHS England s national strategy for technology enhanced learning 3 It will be: Clinically led The programme will be supported by the Medical Education Directorate [MED] and the clinical simulation team but led by site based clinical teams. It is informed by strong links to the Medical, NMAHPs and HR Directors in NHS Lothian and their v 4.3 01.04.18. 2
nominees. The clinical simulation leads within Lothian will act in a network providing expertise, support and advice for local teams to optimise decisions relating to focus, fidelity and measurement of impact [ROI] linked to simulation based education. Activity is organised by a Programme manager ensuring coordination across sites and links with networks in Scotland and beyond to safeguard against unnecessary duplication of effort and promote exchange of learning with partner organisations. Operationally aware The clinical leads and programme manager will ensure that were simulation is an appropriate intervention to address areas of organisational or local clinical need, the impact of these interventions are evaluated to ensure resources are directed to areas of clinical priority and to best effect. Relationships with the Postgraduate deanery, partner Universities and professional bodies will ensure that developmental needs of staff and students are identified and addressed where appropriate. Links to local and board level governance structures relating to patient safety and quality will help target current concerns and focus on patient safety issues relating directly to healthcare provision. Activity will be further informed by significant event analysis through Datix and local intelligence, new clinical developments and onboarding of novice or new clinical staff. Finally, in a welcome addition to the governance of NHSL clinical processes, the insitu simulation programme will provide capacity to test and evaluate current and novel systems of care and ways of working. Educationally literate With oversight from the MED and the Lothian Education Board, the strategy will help to maximise training opportunities needed to develop required competence within and across professional curricula. Activity will be facilitated and learning encouraged through best practice by faculty trained and developed in using simulation as an educational intervention. This faculty will have their roles recognised and will be supported to develop in a coordinated way with quality assurance (QA) supported by the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF). Evaluation of impact (return on investment, ROI) of these educational interventions on clinical process and outcome measures will be integrated into the programme. 4. Background to Simulated Practice in Lothian Clinical simulation can promote the learning & retention of new or enhanced knowledge, clinical skills (both technical and non-technical) and raise awareness of individual or healthcare team behaviours which maximise patient safety and improve patient care. Simulation lends itself to experiential learning and reflection (facilitated during debrief) and can promote a quicker and safer transition from novice to competent practitioner by transferring the steep part of the learning curve into the simulated environment. Within healthcare systems there is evidence for the application of Simulation Based Education for: Improving patient safety 4 v 4.3 01.04.18. 3
Development of communication skills 5 Enhanced team working 6,7 Inter-professional practice within complex healthcare systems 8 In October 2012, NHS Lothian produced its first strategy for clinical simulation and set out to enhance the performance of NHS Lothian staff (targeted groups) and clinical students in delivering safe patient care: by targeting current concerns with a focus on patient safety issues directly relating to healthcare provision, e.g. through the Foundation Simulation Programme by raising awareness of the increasing complexity of health care and testing new systems and processes through in-situ simulation in RIE ED and WGH AMU, to ensure the right thing is done right by maximising training opportunities to develop required competence within professional curricula e.g. Skills Mastery Programme for Lumbar Puncture, Central line insertion & Tube Thoracocentesis by optimising practice and facilitating clinical experiences in time constrained training environments. The first simulation programme was rolled out in three distinct, but overlapping phases: Phase One was to establish a dedicated simulation environment and suite of simulation modalities at St John s Hospital (SJH) and the Royal Infirmary of Edinburgh (RIE); with enhanced facilities to the WGH and RHSC and support for simulation based activity in the REH. Additionally, a core programme of simulation scenarios was developed and replicated throughout all hospitals within NHS Lothian with a target group of Foundation Yr 1 and undergraduate doctors. A core group of clinical educators were established at this time. Phase Two sought to engage and train a wider group of simulation faculty across NHS Lothian sites, evaluate organisational needs and identify patient safety risks to develop programmes for undergraduate and postgraduate multiprofessional cohorts. Phase Three focused on developing simulation education for the in situ environment with an agenda linked to known safety concerns or complex team interactions e.g. PROMPT [PRactical Obstetric Multi-Professional Training] & in situ system testing for H@N teams, ICU and Acute care environments. 5. Current position As a result of phased implementation of the original simulation strategy, NHS Lothian is in the enviable position of having a robust infrastructure on which to gain strategic benefit from further targeted simulation activity. Infrastructure (staff and equipment) v 4.3 01.04.18. 4
Within the MED a full time simulation programme manager, administrative staff and simulation technicians support clinical simulation leads (with expertise in simulation based education and research) on 4 of our acute hospital sites; their shared aim is to oversee and support clinical teams in developing simulation programmes or interventions. Dedicated simulation facilities now exist at St John s Hospital and RHSC, and work is currently in progress to develop comparable accommodation on the RIE and WGH campus. Pending organisational support we aspire to further develop and support clinical simulation opportunities and facilities on the Royal Edinburgh campus, thereby delivering for Lothian a standard and opportunity that is comparable for all staff across the board. A wide range of staff across all specialties and disciplines have received training in design and delivery of effective simulation based learning, and strong relationships have been forged with the team at the Scottish Centre for Simulation and Clinical Human Factors. This link promotes shared learning and peer review of our simulation based education and support of our faculty development programme. In addition to our dedicated simulation Clinical Teaching Fellow, many members of the faculty have expertise in both the design and delivery of nationally recognised simulation programmes. Leadership/Innovation The development of the Simulation Lead role on four sites within Lothian (RIE, WGH, SJH and RHSC) has created a foundation of regional leadership resulting in a high level of engagement with simulation programmes from both the medical and nursing professional groups. Additionally, multiple innovative simulation programmes have been developed in various clinical areas across Lothian e.g. PROMPT providing targeted training as well as team based rehearsal of complex clinical situations. Staff report increased confidence and appreciation of the educational opportunities that arise from simulation. Furthermore, the creation of site based open sim meetings has promoted local ownership and sharing of knowledge and experiences, leading to collaborative approaches, better engagement and enhanced local training and targeted support. Core activities The simulation team have demonstrated a clear ability to deliver effective evidencebased educational interventions, examples are provided in Appendix 1. Current Challenges Return on Investment As the simulation programme further develops within Lothian it will be critical to demonstrate an appropriate return on investment. Simulation in healthcare can increase clinical confidence and technical competence and thus may contribute to improved patient outcomes. 9 Evaluation of our existing simulation programmes consistently demonstrates high learner engagement and attainment of specific learning outcomes. The next step is to demonstrate positive behavioural change in clinical practice aligned to high quality clinical outcomes within NHS Lothian. 10 v 4.3 01.04.18. 5
Engaging Professional Groups Local engagement and support from clinical and managerial teams is pivotal to the success and multidisciplinary aspirations of this strategy. Many examples of effective simulation programmes have occurred where local clinical managers have made such training a priority; as our current faculty are predominantly medical, future efforts will focus on developing faculty and leadership for simulation activities from within the nursing profession. With the imminent introduction of mandatory simulation training within medical curriculae, and the clear links to patient safety, it will be imperative to find ways to deliver quality-assured [efficient, effective & timely] simulation more widely within the health board. The challenges of time and space pressures in such busy clinical environments cannot be overlooked, but with carefully designed approaches, synergistic benefits for both clinical care and education are possible 6. The Strategic Aims will be met through a focus on developing excellence in 3 core components of simulation based clinical education: Excellence of faculty & feedback This strategy aims to continue building a programme of externally reviewed and quality-assured training for those designing and delivering simulation based education; to ensure a high quality and educationally literate faculty who are leaders in their field; to promote a culture of educational excellence across NHS Lothian and beyond. The priorities include: A focus on the continued professional development of the Clinical Simulation Facilitator including: o o o a coaching programme for educators providing local accreditation, performance evaluation and revalidation evidence for clinical practice a site based network of simulation educators to support professional development a Hub-and-spoke model linking NHS Lothian to ongoing training and support from the national centre at SCSC HF Support (time, training) from clinical managers for career grade professionals wishing to contribute regularly to simulation programmes locally and regionally Local coaching and support of clinical leaders and managers to promote understanding of the utility and effectiveness of clinical simulation as a business strategy Contributing to the national development of an accredited programme of study for Simulation Technical Support Assistant role [University of the West of Scotland] v 4.3 01.04.18. 6
Promoting collaborative practice and sharing of faculty and resources with the implementation of Simulation Users Groups at all sites to unite and connect simulation users across all specialities and professions. Excellence of fidelity & educational design Our strategy seeks to promote a systematic approach to simulation programme design; to maximise learning by optimising engagement with staff through appropriate fidelity, scenario design and local investment. Priorities include: Standardisation of simulation design using evidence-based and tested scenario templates. Ensuring a rolling programme of investment to guarantee availability of high quality equipment and simulation spaces to facilitate excellence of simulation Standard operating procedures for clinical simulation, from booking of equipment through to reporting of outcomes from in-situ testing. Excellence of programme feedback and evaluation The strategy will promote high quality, cost effective simulation by: Ensuring standardised collection of feedback following simulation and continual quality assurance of programmes including ROI Providing a governance and reporting structure for raising concerns and providing feedback following simulation activities Establishing metrics by which to measure outcomes from simulation activity [clinical, cost and staff/user experience] 7. Promoting & supporting engagement with Clinical Simulation in Lothian A substantial investment has already been made in both staff and equipment to support clinical simulation activities within NHS Lothian. The opportunities to use this methodology are unlimited beyond our current areas of focus on specific skills attainment, team based training, access to curricular competence opportunities and focussed training to address local educational or patient safety needs. Our goal is that access to these resources is readily available to all sites, clinical units and staff members through: Managerial Support Clinical and non-clinical managers are supported to understand and appreciate the benefits that simulation for competence attainment, rehearsal of performance and testing of clinical systems can bring to their teams and clinical units. The activity is embedded as a core part of team development and service improvement with resources allocated for staff to train as educational faculty, individuals and teams to v 4.3 01.04.18. 7
participate in clinical simulation activity and feedback from simulation episodes seen as a valuable data source on which to build new models of care or enhance current. Educational Support The NHS Lothian Clinical Simulation manager and site based Simulation Leads will provide leadership and on-going educational support in the planning, developing, delivery, and evaluation stages of new or existing simulation programmes or interventions. This team, from a range of clinical backgrounds and professions, share a passion for high quality simulation that positively contributes to work place culture and positive clinical outcomes. Technical Support Simulation Technical Support Assistants based at the RIE, WGH, SJH, and RHSC will provide advice on, access to and support of a range of mannequin, part task trainer, Audio-Visual and role play/simulated patient resources for new and existing simulation programmes. The aim of the support team is to reduce the significant burden of technical expertise, as well as time consuming set ups and pack downs for the simulation user. Additionally, the support team will be available to provide advice on simulation fidelity in all stages of development. Administrative Support A Simulation Administrative Officer, based at the WGH is available to manage simulation suite and technical support bookings. Current administrative support also includes the provision of relevant consent, registration and evaluation forms, alongside simulation scenario templates. For support and guidance in engaging with Clinical Simulation in Lothian contact can be made through the Clinical Simulation Manager or the site based Clinical Simulation Leads at medsimulation@nhslothian.scot.nhs.uk 8. Consultation This document was opened for wide consultation for comment and suggestion and presented to the Clinical Management Group on February 17 2017. Consultation closed on March 7 2017 and the document has been finalised and approved thereafter. v 4.3 01.04.18. 8
9. References 1. Ericsson A Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine, vol. 79, no. 10 2004 2. A Clinical Simulation Strategy for NHS Lothian. Simon Edgar; Pub October 2012 MED website http://www.med.scot.nhs.uk/simulation/pages/introduction.aspx 3. Framework for Technology Enhanced Learning. Department of Health; November 2011.https://www.gov.uk/government/publications/a-framework-for-technologyenhanced-learning 4. Draycott TJ, Crofts JF et al Improving neonatal outcome through practical shoulder dystocia training. Obstetrics & Gynecology 112 (1), 14-20 5. Kameg K, Mitchell AM et al.communication and human patient simulation in psychiatric nursing. Ment Health Nurs. 2009 Aug;30(8):503-8. 6. Miller K, Riley W, Davis S. J Nurs Manag. 2009 Mar;17(2):247-55. Identifying key nursing and team behaviours to achieve high reliability. 7. Shapiro, M. J., Gardner, R., Godwin, S. A., Jay, G. D., Lindquist, D. G., Salisbury, M. L. and Salas, E. (2008), Defining Team Performance for Simulation-based Training: Methodology, Metrics, and Opportunities for Emergency Medicine. Academic Emergency Medicine, 15: 1088 1097. 8. Van Soeren M et al Development and evaluation of interprofessional care practices through clinical simulation Journal of Interprofessional Care 23(3):304-6 Mar 2009 9. McGaghie WC, Draycott TJ, et al. Evaluating the Impact of Simulation on Translational Patient Outcomes. Simulation in healthcare : Journal of the Society for Simulation in Healthcare. 2011;6(Suppl):S42-S47. 10. Kirkpatrick DL. Evaluating Training Programs, 2nd edn. San Francisco, CA: Berrett-Koehler 1998. v 4.3 01.04.18. 9
Appendix 1: Examples of core simulation programmes FY1 Simulation Programme A programme of high-fidelity, curriculum-aligned simulation is now offered to all Year 1 foundation trainees in NHS Lothian. The programme includes training on key identified clinical policies and processes during FY1 induction, exposure to acute critical events during their second rotation in Lothian, and the exploration of more complex care scenarios as they complete their first year of training. The feedback from FY1 participants and faculty staff alike has been hugely positive. The Mastery Programme This programme was established in direct response to clinical incidents and offers a robust training in several invasive procedures associated with clinical risk of adverse outcomes if performed inconsistently. One-onone training is available for core clinical procedures such as chest drain insertion, central venous catheterisation and lumbar puncture and is undertaken in both the simulated and in situ environment. FY2 Communication Programme This newly piloted programme builds on the success of FY1 simulation and is the result of an extensive learning needs analysis. Designed to address difficulties widely reported around communication in a high pressure and often challenging environment, and mapped to the Foundation programme curriculum, a full day workshop exploring this theme has been developed for all foundation year 2 doctors. Obstetrics The simulation team provides regular support to the nationally development multi-professional PROMPT course on several locations across Edinburgh. The course provides training and rehearsal opportunities to obstetricians, anaesthetists, and midwives involved in the care of a pregnant or birthing mother. H@N In an effort to provide training and rehearsal opportunities to the highly skilled clinicians within the HAN team, a simulation training programme has been developed and piloted within the SJH site with highly favourable evaluation reports. In-Situ Drills The simulation team continues to work closely with many departments to provide realistic simulation sessions held locally within the in-situ environment providing opportunities to rehearse rare but significant clinical events. Utilising high fidelity mannequins, camera playback technology, and highly trained simulation faculty a safe and authentic environment is used to facilitate team based learning. System testing Increasingly, simulation is being used within NHS Lothian to test systems and processes for the purpose of optimising patient care and reducing adverse events. Systems tests are informed by datix or adverse event reporting, and also for optimising new processes which are being developed for patient use. Examples include collaboration with the deteriorating patient workstream to test new change bundles and identify ways to improve response times for deteriorating patients. v 4.3 01.04.18. 10