It's Simulation Jim But Not As We Know It

The Centre for Simulation and Patient Safety broke new ground recently, taking simulation into a care home environment.



Challenging behaviours, challenges for simulation



We began our formal collaboration with Positive Care Partnerships (a business unit within the NHS mental health trust Mersey Care) just over a year ago. We were asked to develop a package of simulation based education, focussing on three specific areas. These were dementia, self harm and care homes. More about dementia and self harm in future blogs, today I would like to share our lessons learned from our foray into the care home arena.

There are two things to say about this exercise. Firstly, this could have been carried out at the simulation centre. This would have given us greater control, and debriefing the simulated scenarios would have been much easier. We could have used screens to hide the technical kit, placed carpet on the floor, and thrown in some furniture. This would have been quite effective. However, why go to such lengths to recreate reality, when it actually exists down the road in a local care home.

Secondly we would recommend you leave the simulator behind (unless you are planning medical emergency or basic life support training). Claire Denton, our Simulation in Mental Health instructor explains why an actor was chosen over a mannequin "We wanted to provide the staff with as realistic a situation as possible. our aim was to see them interacting with a real person, and being able to take their cues from non verbal communication and tone, just as in reality. A simulator just couldn't achieve that. We were really challenging them, but we also wanted to give them a chance to reflect upon what happened and then have another go."

In order to provide that opportunity for accurate reflection post scenario, we had decided to utilise video. As stated above, at the centre this would have been a simple task, but outside of that environment we had to improvise. We opted to use a handheld high definition video camera (cost in the region of £100). This connected easily to a laptop (it would equally have linked with a TV that supported USB connectivity) allowing instant playback post scenario.

Our senior trainer Toni Shanahan explained some of the draw backs, "We had to get fairly up close in some of the locations within the home. This meant we were very visible to the subjects, and this would have felt somewhat inhibiting. That said they really gave it their best shot, and still felt the exercise was useful." Toni was also taken aback by the level of enthusiasm for the training from the staff. Many had turned up on their days off to take part. "We had more than we were expecting to contend with." Said Toni "We didn't feel we could turn them away, in future we would stipulate clearly that small numbers would be more manageable. The main issue was bystanders potentially adding to the stress for the subject".

Despite the obvious anxiety it induces, the use of video in the debrief did prove to be a very powerful tool. "The trainees were able to see aspects of their behaviour and tone that they would have been otherwise unaware of" explained Claire "I am sure some would have found it this uncomfortable, but to their credit really valued the experience. Many stated they would alter their approach and tone as a result of seeing themselves on video."

One scenario involved a "resident" collapsed on a staircase. The challenge was that another confused resident was obstructing the care home staff attempts to help, fearing they wanted to do harm her. The learning objectives were based around communication, and empathy. Another scenario allowed Claire to explore useful tools to distract agitated patients from disruptive behaviours and engage them, rather than restraining them.

Another scenario was built around a dissatisfied relative complaining about the care received by their mother. This was a particularly difficult scenario, and staff impressively defused the situation, maintaining a polite and professional approach. In the absence of a professionally trained actor the "daughter" was played by a senior member of the care home team. It has to be acknowledged that this has limitations, although it is a low cost solution.

Toni and Claire agreed that because the staff knew some of the "actors" in a professional capacity, this made it difficult for them to completely 'suspend their disbelief' in the scenarios. This understandably led to one or two giggles, which potentially could have derailed the exercise. Thankfully due to the professionalism of those involved this was kept to a minimum, but it could easily have gone the other way. In future sessions professional actors, volunteers or drama students will be used.

Toni explained "In essence the only thing that matters is that the actor playing the resident or the relative should be unknown to the trainees. Therefore with enough planning a sim centre team could in theory provide the actors from its own faculty, However, this would make the exercise very labour intensive from a centre staffing point of view."

This was a successful exercise, that was well received by participants. In terms of our investment we ran it with two members of the simulation centre team. additional support came in the form of two senior staff from the care home. Mersey Care also provided the support of Joy Prescott, a senior community mental health practitioner. The video technology was cheap and very easy to use, and we simply played the footage back on a centre laptop. The market for this sort of training is huge. In looking to develop and roll this out we will greatly benefit from our collaboration with mental health services.

Claire agrees. Reflecting on her experiences twelve months into her secondment from Mersey Care to the Centre for Simulation and Patient Safety, she feels that having a foot in both the mental health and simulation camps has enabled her to pull together these exercises. It has also put her in the ideal position to promote the benefits of this type of training in simulations "frontier territories". It may not be simulation as we know it, but actually we may only have discovered a fraction of what simulation is really capable of delivering.

Undergraduate Simulation The Journey So Far

We've been on quite a journey. Back in 2004 the flagship course at our centre was 'Medsim'. This was a one day simulation based course for medical students in their 5th year. It was mandated by the University of Liverpool, and mapped to the undergraduate curricula, and we trained 360 students per year over 30 days. It always ran on a Friday in the early days and was a great way to round the week off.

 

The day would run the same way every time, same four scenarios same four lectures, and it has to be said the same excellent scores from the students in the post course evaluations. By 2010 it had become a comfortable old friend, beloved by all. Actually that's not strictly true, The post course evaluations were beginning to mention how the scenarios were predictable. Students talk to each other, and it is no surprise that we lost the element of.......well, surprise. Aside from that an increasingly common suggestion from the students was "This would be so much better if we had real nurses in the scenarios".

Undergraduate nursing and medical students train together

At the time centre faculty would play the role of a junior nurse in the scenario, but even though we went to great lengths to 'blend in' we were always seen as at best a facilitator or worse an instructor. The students were telling us that they didn't understand what the role of the nurse in an emergency was. They also had anxieties about how they should interact with nurses, what tasks could they delegate and how skilled were the nurses?

 

There was also a perceived inequity on the part of the undergraduate nursing schools in Cheshire and Mersey. Although the higher Education Institutes were providing their nursing students with simulation there was only limited access to the Regional Simulation Centre for them.

 

Then along came 2010 and a renewed focus on Inter-professional Learning, or Team Based Learning in the region. As it happened we had a great deal of experience of delivering Team based Simulation, nearly all of our courses focused ensuring that teams who work together train together. Examples of this multi-disciplinary approach to simulation included, paediatric intensive care, trauma, and outreach teams amongst others. Ironically we only ran two single speciality courses and one of those was 'Medsim'.

 

However, we had managed to build up strong links with Higher Education in the six years since the centre opened, including the nursing schools. In 2010 we piloted nurse sim, and three Universities participated. It was time to start exploring these links, and in particular their appetite for inter-professional Simulation. looking back it seemed a 'no brainer'. The nurses were coming to the centre, the medical students were coming, why not combine them into one course. Hey Presto! Team Based learning delivered.

 

Of course it wasn't that simple. logistically there was a lot to consider. 450 Nursing students across three Universities, and 360 medical Students. Coordinating that lot into 60 one day courses from September to June was quite a headache. Fortunately we were able to get the key stakeholders around the table. Somehow after pouring over spread sheets and crunching numbers we were sort of able to cobble together a pilot project. Funding for this was forthcoming after a successful application to the local Health Education Innovation Cluster.

 

The students loved it. We ran 10 days to test out our programme, and iron out the kinks. One of the big advantages was that we were able to place the students into scenarios in a realistic skill mix, and explore issues of communication, team work and shared mental models. students were able to better appreciate each others roles, and reported increased confidence at the end of the course. there were also opportunities to identify gaps in knowledge, feedback to the university anonymously, and develop interventions to address these.

 

STABILISE 1 was born (Simulated Team Based Learning 1). We also run a STABILISE 2 which puts foundation year doctors and junior nurses together on the same basis. It is our aim to develop a continuum of simulation based education in the region. We have now developed a library of 24 scenarios and randomly pick 6 on each course day. This minimises the anticipation of scenarios by students.

 

We have now been running the courses for two full years. They are not without problems. The course is mandated for medical students, but not yet for the nurses. This has meant turn out is variable. It is also important to mix the students at the start of the day to avoid the formation of an 'Iron Curtain' down the middle of the lecture room, nurses on one side medical students on the other. Ice breakers are also important.

 

The challenge for us now is providing opportunities for inter-professional learning for other undergraduate groups. We are already exploring the possibilities with student midwives, paramedics, and pharmacy students. This will require imagination and strong buy in from the Universities, but we are not daunted. The journey goes on.

 

Sometimes a Mannequin Just Won't Do

  

Despite our best efforts he's still a plastic man with clothes on

 

When I joined the field of simulation in healthcare it is fair to say I had a very narrow view of what this educational modality was for. Primarily, I thought it should be used purely for recreating acute clinical emergencies. This was possibly because I first met 'Sim Man Classic' as a Clinical Skills Instructor, and immediately saw how we could utilise it to teach a range of technical skills such as, ECG rhythm recognition, ABC assessment, Basic Life Support etc etc.

 

You could say I was looking at it from the wrong stand point. I was starting with the mannequin and what it could do, and designing the teaching around that. Instead I should have been thinking about the learning objectives and then deciding whether the mannequin was appropriate at all.

 

Of course I eventually did make the necessary leap of putting educational goals before the  "what can we get the simulator to do today" style of teaching. Although I have to confess it is only relatively recently that I began to realise that I still hadn't quite got the point.

 

I wasn't thinking of simulation in its broader sense. That is I was thinking of it in terms of technology, and not the more rounded view that Simulation is just the recreation of real life for an educational goal. Where in that definition is there any reference to mannequins and simulators?

 

I began to think about this seriously about 4 or 5 years ago. Our centre began running simulation courses for Primary Care, and in particular community nurses. Working closely with commissioners we began designing scenarios that would take place in the patients home. We went to great lengths to recreate a domestic environment in the sim suite. We stripped out the technical kit, put carpet on the floor and added furniture and a TV. We used sound boards to screen off the rest of the sim suite. A few potted plants and books on shelves, a family photo here and there. It looked very realistic. Then we stuck the simulator (fully clothed) in the chair. Gone was the realism.

 

Suddenly it became about what relevant clinical scenarios could we recreate for community nurses that would get the most out of the mannequin, rather than what do they actually need to learn, and does simulation have a role to play at all?

 

I believe it did, but perhaps we didn't need the mannequin. The nurses would have got far more out of the scenarios if they were communicating with a real actor. Yes there may have been points were the psychological fidelity would have fallen down even with a real person. Try getting an actor to develop a rash on cue, or swell up their tongue for example. They don't like being stabbed with needles either. However, we can get round this with make up and facilitation to a degree. We can utilise hybrid simulation (attaching part task trainers such as cannulation arms to the actor) to create an even greater degree of realism. The actor can pull the arm away or flinch at the point of injection, in a way that the mannequin can't. Again, though I'm obsessing about technical skills.

 

Where actors really come into their own is in the teaching of communication skills, breaking bad news, history taking, patient education and counselling. These are all fertile territory for simulation, if we just abandon the notion of always having to have a mannequin. I am not suggesting a revolution here. Mannequins will always be vital in acute clinical emergency training which mixes technical rehearsal with non technical skills training. Nor am I saying anything ground breaking, many sim centres utilise actors regularly in their training, but I doubt it is as widespread as it could be.

 

As our centre begins to expand its portfolio of courses in response to demand we are finding an ever growing need to explore utilising actors in our scenarios. The Francis report is a significant driver for this. Trusts are beginning to look for innovative ways of training staff in attitudes and behaviours, rather than just mandatory training. Requests have been received to run simulation training around dealing with visitors, and for managers on how to coach and interact with staff. customer care, safety and quality are high on the agenda. Simulation has a lot to offer in this area, though I admit it is not a panacea. In pitching sim training to executives these issues should be born in mind.

 

At our centre we are finding a need to utilise actors in scenarios more often, relegating the simulator to the role of extra. Whether it is us playing the role of team members and deliberately making errors in order to allow the trainees to practice challenging team members, or seniors, or dealing with a colleague who is struggling or performing badly the possibilities are limited only by our imagination.

 

Other areas include pharmacy students who would gain far more from interacting with an actor playing the role of the patient that with a simulator. Then there is organ donation where actors as relatives or careers is essential to palliative care simulation where we have successfully utilised  both actors and mannequins to create realistic end of life scenarios, allowing trainees to rehearse complex decision making, breaking bad news and advanced communication skills in a safe environment.

 

From our standpoint I see a growing need for the use of actors in simulation. This is a potential gap in the market that needs filling. Employing professional actors is costly. Fees are around £30 per hour. This cost needs to be factored into training budgets making it beyond some centres, and certainly unrealistic if we are thinking of making this available to the wider workforce. Perhaps we need to engage with the professional and amateur drama schools to explore partnerships enabling centres to negotiate more cost effective partnerships in return for more regular work for the actors. Utilising internships, and drama students is another path we are exploring, as well as looking at funding an actor in residence as stated in a previous blog.

 

Mannequins will always have a role to play in simulation training in my view, but increasingly they will need to share the stage with actors as Trusts and HEI's begin to see the wider applications of simulation post Francis report.

Imitation of Life

I have a theory, and it goes like this..........

 

Scratch beneath the surface of any Simulation Centre and you will find hoards of frustrated artists. No I am not talking about the type who perform best on a Christmas night out, I am talking about people with a natural flair for creativity. Most don't see what they do as art (if any) but I wouldn't mind wagering that working on a simulation course is not a million miles removed from developing a film or a stage play.

 

Let me explain. take the different aspects of commissioning, designing, facilitating and debriefing a course. First you have the producers. They identify the need and pull together the finances and resources to get the course off the ground. They choose the director and put together the cast. Then come the writers who weave the stories that are the scenarios. Without doubt every great scenario is a story with a leading man or lady (the patient) we have the conflict, something will inevitably come between our hero and a quiet life. There's always some kind of drama, we just hope there's going to be a happy ever after. thankfully there usually is.

 

Now we throw our actors into the mix. Some unwitting (the students/trainees) others are in on the act. These are the phone operators, the facilitator who blends in with the trainees, quietly waiting for their cue then jumping in and steering the scene one way or another, dropping subtle plot clues here and there and always having a key role in the final scene. Behind the mirror we have the patients voice. Here the ability to act and convince is vital if our trainees are to suspend their disbelief. Some of us are better than others.

 

Then we come to the director in the control room, making sure the movie stays on time and doesn't wander off plot, before finally we come to the post shoot edit - the debrief. Here we make sense of what we just shot. We try to throw out the stuff that didn't work and accentuate the positive before often attempting a reshoot. Ultimately we are looking to produce a directors cut at the end of the day - the rest can stay in the bloopers reel (that we never show to anybody promise).

 

Of course just like every great film crew we have the team behind the team. The make up artists and FX guys producing wounds, burns, bruises, and prosthetics. We have set designers reconfiguring the room to look like a theatre one minute and a patient's living room the next, not to mention wardrobe who dress the mannequin and make it look just like a real boy!

 

So with all this in mind it is quite fitting that our simulation centre has entered into what I think is an incredibly exciting partnership with a local Arts team. Type Partia into google an you may get a Polish Political Party first but keep going and you will come to Promoting Art in Aintree. A group run by Paula O'Malley, Aintree Hospital Arts Coordinator and a team of hardworking volunteers. Their focus is improving the quality of the patient experience through ward based art projects. There is much for staff too with a writers group and much, much more.

 

This partnership promises much, however we are very excited at the prospect of teaming up with local universities to provide drama students with opportunities to hone their skills in medical simulation scenarios. Having them play the role of relatives and carers and even patients will greatly enhance the realism of our scenarios. In short it's a win win. Who knows where this will lead. Is there a role for students studying movie make up techniques, budding special effects technicians or even a simulation centre actor in residence.

 

I will confidently state this though, if the life of our simulation centre can be likened to a epic movie, we are no were near the final act!