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.