Simulation based education strategy

Our strategy aims to enhance interprofessional learning (IPL) through Simulation Based Education (SBE). This initiative seeks to reduce professional isolation by fostering SBE collaboration across Medical, Nursing, Midwifery and Allied Health Professional Education. The goal is to improve teamwork, staff morale, interprofessional communication, and, ultimately, patient care and safety. Interprofessional SBE across a workforce team helps create cohesion and understanding of the specific responsibilities of individuals with unique skills in high-pressure scenarios. Conducted in a low-risk environment, it allows professional anxieties to be identified, addressed and resolved with minimal additional expenditure

NHS Borders covers a geographical area of 4,732 square kilometres, with a population of 116,000 inclusive of a 52.8% increase within the 65-74 age group with the over 75 age group increasing rapidly. Overall, the Scottish Borders is considered to have a more demographically fragile population than the Scottish average. With our care provision becoming increasingly more complex and acute, patients’ needs cannot be met by a single health or care professional group, therefore, it is fundamental that professionals work collaboratively to sustain the delivery of integrated high quality safe and effective person-centred care.

The diversity of the health and care team means that each profession brings a unique set of skills, which are most effective when combined. However, historically, SBE has been directed at a single professional group (uniprofessional). Whilst adopting a uniprofessional training stance is appropriate and necessary in some situations, it can result in learning in silo, potentially generating stereotypical views of health and social care colleagues’ roles within the team. Alternatively, IPL SBE helps to challenge these stereotypes and has been identified as a means of enhancing the development of professional identity, not as a single profession but as a team collaborative. IPL should therefore be created as a deliberate, structured endeavour with proactive engagement from key stakeholders from each professional group to ensure IPL sessions are supported, relevant, achievable, and sustainable whilst forging safe, effective person-centred team working and avoiding the risk of interprofessional hierarchies.

This document sets out a new 2-year strategy to embed SBE into our core Continuing Professional Development (CPD) for our Nursing, Midwifery & Allied Health Professional (NMAHP) workforce, inclusive to students and collaborating with Medical Education to include both uniprofessional and interprofessional simulations, across all professions to meet the needs of individuals, teams and the patients within our care at NHS Borders.

The benefits to SBE can promote the learning and retention of new or enhanced knowledge, skills (both technical and non-technical) and raise self-awareness of individual or healthcare team behaviours through critical reflection. These skills develop the complex cognitive and interpersonal skills that underlie effective teamwork required to maximise patient safety and improve patient care. Additionally, simulation lends itself to experiential learning and reflection, facilitated during the debrief and can promote a quicker and safer transition from novice to competent practitioner. Furthermore, research has shown that learners involved in active learning retain knowledge longer, leading to an international and national investment of SBE as an education methodology.

The simulation setting:

• Provides a safe environment where staff can learn without the risk of harming a patient
• Provides an environment that is fully attentive to the learners’ needs
• Supports experiential learning
• Enables safe exposure to gradually more complex clinical challenges
• Provides training opportunities for both single discipline and multi-disciplinary teams
• Supports the development of communication skills and critical thinking
• Enhances team working
• Advocates interprofessional practice within a complex healthcare system
• Targets current concerns with a focus on patient safety issues directly relating to healthcare provision.

Currently, most education is delivered through a combination of traditional, teacher-centred didactic classroom lectures, small practical sessions, and online platforms for the majority of our AHP and nursing staff. However, C&PD has recently appointed a Simulation-Based Educator, primarily focused on nursing and associated professional staff. Their role is to utilize and embed simulation to maximize learning opportunities for all staff, fostering a student-centred approach to learning and development through feedback and reflective practice. This will help develop a robust core educational program that accounts for individual differences in learners—such as background, beliefs, motivation, and skills—further supporting our diverse workforce and enhancing interprofessional cohesion.

Within the Medical Education team there is currently a simulation technician, clinical practice educator and a newly appointed Clinical Teaching Fellow, all with expertise in SBE and funded by Additional Cost of teaching (ACT) to support undergraduate and post graduate medical education. In addition, they have a medically-led faculty, all with experience in SBE, who support the delivery of both undergraduate and post graduate SBE. Current Medical Education Simulation curriculum is shown in Appendix A.

Our midwifery teams, both in acute and community, have IPL SBE established into their CPD with the National Practical Obstetric Multi-Professional Training (PROMPT) and Care of the Critical Ill Pregnant or Postpartum Woman (CiPP) both delivered in-situ every two years. This gives a pre-established example where interprofessional SBE has already contributed to improving standards of care and increasing patient safety.

SBE will not replace any current existing educational delivery; instead, it will further enhance and broaden the current curriculum by inclusion of the psychosocial realm into the biomedical world, inclusive to the dynamic 2,600 clinical workforce (approx.). It aims to provide an awareness of interprofessional roles through IPL, thus improving team cohesion and morale, reducing professional isolation and increasing interprofessional communication, strengthen recruitment and retention whilst simultaneously ensuring clinical excellence and leadership. Example of potential uniprofessional and interprofessional SBE opportunities is shown in Appendix B.

The mission of this strategy to develop a culture of patient safety within NHS Borders through collaborative and distributed practice. Integrating SBE as an educational strategy to enhance interprofessional collaboration, where professionals from two or more professions learn with, from and about each other, during simulated care scenarios will optimise teamwork, integrate a collaborative culture of CPD, ultimately improving patient care.

Both Nationally and Internationally, training of established interprofessional teams through SBE is well established (e.g. PROMPT, CiPP, Resus Council training). This substantiates the need for all health professionals to see themselves as part of individual teams relevant to their role. In this aspect, SBE can be helpful in providing safe opportunities for different professionals to engage with various teams and their differing skillsets. This helps with team cohesion whilst also identifying knowledge/skill gaps in a risk-free setting.

This strategy will be the first for our NMAHP and Medical workforce and supports the vision set out by NHS Education for Scotland Strategy 2019-2024 to ‘scale up simulation skills training to support clinical skills and human factors training for a skilled, adaptable and compassionate workforce’. Additionally, it supports and acknowledges that both teams and individual team members are the cornerstones of patient care and safety.

Therefore, they must be nurtured, supported, and continuously improved to provide the safest care. Embedding SBE serves as an effective method for developing, assessing, and evaluating the entire team. Furthermore, it will be the first to include a planned, purposeful, concerted endeavour to ensure comprehensive provision of quality care which transcends demarcations between professions and practice settings across Health & Social Care as set out by the Centre for the Advancement of Interprofessional Education, and the World Health Organisation.

Integrating this strategy is likely to enhance & improve processes, perceptions and cultures within the workplace at individual, team, and organisational level, ensuring NHS Borders is a leader of change.

Currently, healthcare professionals adopt SBE as a strategy for learning, across a range of activities from acquisition of practical skills to immersive simulation scenarios. The integration of SBE into the current NMAHP CPD development programme and Medical Education Programme is vital and must be related to everyday clinical activities, based on the analysis of training needs such as patient safety data or knowledge and skills tests for which the impact of the training can be measured. Integrating SBE will add an experiential framework to create a robust programme, recognising the diverse learning styles adult learners have, thus supporting the professional development of each individual. Furthermore, by integrating into the current undergraduate curriculum and post graduate development, this ensures staff are not required to be released from clinical practice for any more time than they currently are.

Simulation scenario design, both uniprofessional and interprofessional will be aligned using the principles of constructive alignment to achieve the intended Learning Outcomes (iLOs), on which drives the entire scenario. Constructive alignment is an approach that optimises the conditions for quality learning; constructive ensures the learners construct meaning through relevant learning activities individually, not merely transmitted from the educator, opportunities carefully aligned by the educator writing the scenario. Constructively aligned scenario storyboard is exampled in Appendix C.

This strategy aims to build a programme of externally reviewed and quality assured training for those designing and delivering SBE to ensure a high quality and educationally literate faculty and promote a culture of educational excellence across NHS Borders.

Evaluation of all SBE sessions will be structured and adapted based on Kirkpatrick’s four-level model:

• Level 1: The reaction level, measures the participants’ responses to and satisfaction with the intervention
• Level 2: The learning level, illustrates the degree of change in the individuals’ knowledge, skills or attitudes
• Level 3: The behavioural/organisational level, illustrates change of behaviour or impact on operating procedures or both.
• Level 4: The patient outcome level, describes the benefit for the patients or the consequences of the training programme

Consideration of the reaction criteria, learning criteria, behaviour criteria and results criteria provides feedback that is rich, fine-tuned, multilevel and considers not only the immediate but also the long-term outcomes.

NHS Borders currently have a dedicated simulation suite within the Education Centre with ongoing technical support and maintenance provided by the simulation technician. A list of our simulation equipment is illustrated in Appendix D.

The most effective way to generate a safe, positive learning environment which harness the ethos of SBE is to develop a faculty of experts. These experts are required to have an appreciation of the educational theories which underpin SBE, including constructivism, experiential learning and reflection. Our current train the trainer programme is a two-day programme aimed at Clinical Development Fellows and ST3+ trainees.

The strategy aims to develop a faculty development programme mapped to the Scottish National Outcomes Framework for Simulation Faculty Development, inclusive of both medical and NMAHP to ensure a high quality, interprofessional and educationally literate faculty and promote a culture of educational excellence across NHS Borders.

Phased implementation of this strategy will ensure NHS Borders is in a leading position of having a robust infrastructure on which to gain strategic benefit from embedding simulation as an educational methodology. These phases are distinct and concise, however may overlap to meet clinical demand.

Phase 1: 0-6 months

• Appoint a registered Nurse/ Midwife/ Allied Health Professional with Post Graduate qualification in Simulation Based Education
• Secure half a day per week of a Consultant through Supported Professional Activity (SPA) dedicated entirely to SBE. Their role will be to work alongside the programme leader and grow the team and maximise interprofessional training opportunities
• Create a local SBE strategy which is clinically relevant, credible, innovative, sustainable and responsive to change to drive integration, development and ensure sustainability.
• Observe and support the current Medical Education faculty with any current SBE sessions, ensuring sessions are audited, evidenced and evaluated.
• Establish open, honest and collaborative relationships with current Medical Education faculty and network Nationally, ensuring NHS Borders is established as a dynamic, diverse and transparent organisation.
• Co-ordinate and grow SBE activity by collaboratively working with Quality Improvement and identifying key stakeholders within the NMAHP and Medical workforce to identify simulation based learning opportunities, both uniprofessional and interprofessional whilst simultaneously creating a core group of interprofessional educators.
• Review and develop current NMAHP C&PD study days to incorporate SBE, creating scenarios constructively aligned and driven by the iLOs of the programme.
• Create an interprofessional steering group to drive the creation of a robust and diverse programme for EC4H to include Uniprofessional & Interprofessional workshops, to meet the needs of individuals, teams and the organisation.
• Create and maintain a database for all simulation sessions for audit and quality assurance purposes.

Phase 2: 6-18 months

• Engage, motivate and develop an interprofessional planning team to represent the needs and perspectives of all professions to plan and develop IPL, to meet the needs of individuals, teams and the organisation.
• Develop and create an interprofessional, sustainable and robust faculty development programme mapped to the Scottish Faculty Development Programme, developed by NHS Education for Scotland and includes IPL.
• Network and develop a relationship with the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF) to support shared learning and ensure quality assurance through peer reviews of our SBE and support ongoing faculty development.

Phase 3: 18 – 24 months

• Work collaboratively with members of NMAHP and medical teams across primary and community care, including the care home team, home first, hospital at home and advanced practice teams to develop and implement evidence based SBE scenarios for their areas.
• Collaboratively develop interprofessional SBE for the in-situ environment with key stakeholders from in-situ environments to include simulation based team training (SBE). Ensuring ownership, accountability, sustainability and intended learning outcomes for specific teams.

Key stakeholders required will include the current Medical Education faculty and individuals from all professions across NMAHP, either team leads or those with an interest in SBE who can collaborate and form an initial planning team for IPL which will represent the needs and perspectives of the whole workforce. The newly appointed simulation educators’ role is to dynamically engage these key stakeholders in a shared sense of purpose, fostering a group commitment to act collectively for the mutual benefit of all involved. This planning group will meet regularly to share ideas, feedback, and perspectives, to maintain engagement. The simulation educator will also share the most up to date evidence from NHS Education for Scotland and National initiatives around IPL. This planning group will grow and develop to meet the needs of the organisation, with key stakeholders acting as leaders of change, thus promoting the value of IPL, and
ensuring sustainability.

Simultaneously, the simulation educator will collaborate with key stakeholders to support uniprofessional SBE requirements, scenario design and facilitation of learning.

Quality assurance will be verified by ensuring SBE is carefully aligned to meet the professional standards of the General Medical Council, Nursing and Midwifery Council and Health and Care Professions Council. Professional relationships will be established with NHS Education for Scotland and the Centre for the Advancement of Interprofessional Education to ensure scenarios are externally reviewed and quality assured and NHS Borders is established as a dynamic, diverse and transparent organisation.

As Simulation Based Medical Education is already implemented within NHS Borders, there is no additional funding required to implement across NMAHP curriculum, both uniprofessional and interprofessionally, as this is covered within the funding application for the recently appointed simulation educator role.

The investment in the appointed simulation educator will be beneficial by aligning our current educational approach and fostering collaboration across boundaries. This will lead to more efficient and cost-effective care delivery, enabling us to provide the best care for our patients while supporting one another across disciplines

Embedding SBE for NMAHP and IPL, to include the whole workforce, may be perceived as challenging and threatening. Therefore, we must play close attention not only the achievement of the intended learning outcomes but also the process of group dynamics and individuals’ psychological safety. Additionally, ‘top down’ implementation of SBE activities may also result in resistance because learners do not have a sense of ownership, therefore we must build interprofessional relationships with team leads across all professions to ensure their perspectives are included for all scenario designs to ensure ownership and quality assurance.

In addition to working collaboratively with team leads, both clinical and non-clinical managers will be supported to understand and appreciate the impact that SBE can bring for competence attainment, rehearsal performance and testing of clinical systems can bring to their teams and clinical areas. SBE will be embedded as a core element of CPD and service improvement with support provided for staff to train as educational faculty, individuals and teams to participate in SBE and feedback utilised as a valuable evidence-based resource to enhance patient care.

SBE is an effective way of providing experiential learning under controlled circumstances without putting patients at risk, all the while helping the learners develop their cultural, professional and ethical competencies under proper guidance. Incorporating SBE for our NMAHP alongside our Medical Education would lead to significant improvement in the staffs’ ability to deal with ethical challenges they inevitably encounter.

Careful development and implementation of IPL SBE as outlined within this strategy is an ethical imperative and has the potential to reduce the numbers of medical and human errors, facilitate open exchange across disciplines in training situations, enhance patient safety and ensure NHS Borders is viewed as both accountable and ethical by the population we serve.

The principles of IPL align closely to current priorities in health and social care, including safe care, integrated values-based health care, quality improvement, collective leadership in the workforce and the need for transformative thinking to challenge traditional boundaries. It is recognised that facilitating professional learning is challenging, with facilitating interprofessional learning even more so, therefore transformational leadership, collaboration, change management in addition to implementation science is required to ensure sustainability of SBE within NHS Borders.

Briefing for learners:

The purpose of this simulation is to support you in developing your skills to recognise, respond and prioritise the deteriorating patient.

You are a SN working in the medical assessment unit (MAU). It is 08:00 and you are about to commence your morning drug round after receiving handover from the night team. The nurse in charge is with you in the department looking at staffing for the next shift.

Your colleague has handed over that the patient in bed 3 is for discharge home today, he has passed physio and OT and his observations are stable. He has had a settled night, no complaints of pain and has been continent. He is keen to get home. His family were concerned he had a new confusion yesterday but your colleague didn’t find him confused overnight.

Location of simulation scenario:

Clinical simulation laboratory set up as a hospital ward

Main Equipment/Resources required:

• High fidelity manikin dressed in a hospital gown
• High fidelity monitors
• Observation machine
• Sepsis trolley
• IV fluids & Medication Kardex
• Blood tubes
• Catheter equipment
• Oxygen masks
• Fluid balance
• Blood cultures
• Sepsis six pathway
• Confederate

NHSB Scenario Storyboard - PDF

Appendix D: Current Medical Education Simulation Equipment (work under construction) - PDF

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