The role of simulation-based education, co-design and co-delivery in improving patient safety

Summary

Dr Kirsten Howson, Specialist Education Lead at SimComm Academy, discusses the role Simulation-Based Education (SBE) can have in patient safety. Kirsten highlights some of the techniques used in SBE, the benefits for staff and patients, and the importance of involving people with lived experience in the design and delivery of SBE.

Content

Background

Initially used within the aviation industry, Simulation-Based Education (SBE) has now been adopted within healthcare education and training.[1] Clinical SBE began several decades ago[2] and has continued to successfully grow, providing learners with the opportunity to put their knowledge and skills into practice within a psychologically safe environment.

Effective SBE includes a debrief following on from the simulated exercises. Research outlines that the debrief has been identified as a key component of impactful SBE, with the simulated scenarios acting as a catalyst for further reflection, conversation and sharing of experiences and ideas.[3]

There are a range of techniques used within SBE:

• Forum theatre: Participants observe a complete simulated scenario played out in front of them, followed by a group reflection. The scenario is then run again, giving participants the opportunity to pause the scenario at multiple points and change the behaviours and language of one of the simulated characters in an attempt to improve the outcome of the interaction.
• Fishbowl simulation: Participants are given a scenario and task and interact with simulated characters while their peers observe the interaction and completion of the task. This is followed by a facilitated debrief in which participants are able to explore alternative methods, obtain feedback, discuss learning objectives, and reflect and share ideas.
• Observational simulation: Participants observe a simulated scenario which is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas.
• Monologues: Participants observe while a simulated character delivers a monologue, which may include the character’s reflections, experiences or feelings. This is then followed by a facilitated debrief in which participants are able to explore alternative methods, discuss learning objectives, and reflect and share ideas.

How simulation-based education impacts on patient safety

SBE has been shown to have a wide range of benefits, many of which impact on patient safety, including:

Participant skills and knowledge: SBE enhances participant skills[4] through practice, reflection and feedback, and can span not only technical skills, such as performing procedures and examinations, but also non-technical skills, such as leadership, communication skills, teamwork or prioritisation.[5] Enhancement of the skills and knowledge of clinical staff will likely result in an increase in patient safety.

Participant confidence: Simulation training can increase the participant's confidence by providing participants with the opportunity to practise a new skill in a simulated setting in which there will be no safety implications; participants can build their confidence to the point at which they feel safe to use the skills in a non-simulated environment.[6]

Participant teamwork: Teamwork skills are often a key focus and improve through the use of simulation training.[7] Dependent on the participant group, this can be on both an intraprofessional and interprofessional basis. Although these skills can be practised within the simulation scenarios, the debrief period also provides the opportunity to share differing points of view within the team, which can enhance teamwork, and again will likely result in an increase in patient safety.

Participant mental health, burnout and sick leave: Medical and allied healthcare staff face high levels of mental health concerns and burnout, with the recent General Medical Council (GMC) report, 'The State of Medical Education and Practice in the UK Workplace Experience 2024' stating, “a third of doctors are struggling and feel unable to cope.”[8] Staff burnout impacts negatively on patient safety.[9] Simulation training has been found to have beneficial effects on anxiety, stress and burnout among some staff groups[10] and could also act as a protective factor against sick leave.[11]

The importance of co-design and co-production in simulation-based education

In 'Learning from Experience', The Royal College of Psychiatrists states, “The involvement of people with lived experience of mental illness either as a patient or carer in educational programmes can provide unique and relevant learning opportunities and teaching experience for doctors and psychiatrists in training.”[12] The GMC have also outlined the patient role within education in 'Patient and Public Involvement in Undergraduate Medical Education.[13] We believe that this concept should be extended across healthcare education. We endeavour to include the perspectives of a range of people with lived experience in the design and delivery of our courses, such as members of staff, parents, relatives, carers and patients where possible and appropriate.  Not only does this enrich the quality of the education, bringing a broader perspective, but it also carries benefits to the patients involved, including a sense of fulfilment.[14][15]

Some examples of  the methods of co-design, co-delivery and stakeholder involvement we have used in our training, include

• The involvement of one of our Equity and Inclusivity Advisors, who is also a member of the transgender and gender diverse community, in co-design and co-delivery of courses aimed at exploring and outlining the challenges and assumptions that LGBTQIA+ individuals face.
• The incorporation of staff reflections and experiences into scenarios when designing courses on the following topics::
  - cultural allyship
  - fostering workplace belonging
  - Band 5 and 6 leadership
  - managing disability
  - supporting internationally educated nurses.
• The incorporation of patient and carer feedback and experiences when designing our course, 'What Matters to Me'.
• The incorporation of parent experience when designing filmed training scenarios surrounding communication with parents during neonatal resuscitation.

You can read more about one of our co-design projects in 'Involving patients and relatives by translating their experiences into simulation-based education'.[16]

Conclusions

SBE is now widely used across healthcare training to a variety of multi-disciplinary professionals, within a range of specialities, covering both technical and non-technical skills, which demonstrates the degree of versatility of SBE. It is important to incorporate the voice and perspective of people with lived experience where possible to ensure authenticity. This is an extremely exciting time for SBE as new innovative methods, uses and programmes are developed with the ultimate aim of continuing to enhance patient safety.

References

1. Oman S P, Magdi Y, Simon L V.  Past Present and Future of Simulation in Internal Medicine. In StatPearls. StatPearls Publishing, 2023.
2. Nehring WM, Lashley FR. Nursing Simulation: A Review of the Past 40 Years. Simulation & Gaming, 2009; 40(4): 528-2.
3. Jaye P, Thomas L, Reedy G. 'The Diamond': a structure for simulation debrief. The Clinical Teacher 2015; 12(3): 171–5.
4. Issenberg SB, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999; 282(9): 861–6.
5. Pearson E. McLafferty I. The use of simulation as a learning approach to non-technical skills awareness in final year student nurses. Nurse Education in Practice 2011; 11(6):399–405.
6. Alrashidi N, et al. Effects of simulation in improving the self-confidence of student nurses in clinical practice: a systematic review. BMC Medical Education 2023; 23(1); 815.
7. Gilfoyle E, et al. & Teams4Kids Investigators and the Canadian Critical Care Trials Group. Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention. Pediatric Critical Care Medicine 2017; 18(2): e62–9.
8. General Medical Council. The State of Medical Education and Practice in the UK Workplace experience, 2024.
9. Garcia CL, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas, Lithuania) 2019; 55(9): 553.
10. Couarraze S, et al. Short term effects of simulation training on stress, anxiety and burnout in critical care health professionals: before and after study. Clinical Simulation in Nursing 2023; 75: 25–32.
11. Schram A, et al. Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites. BMJ Open 2023; 13(10): e076163.
12. The Royal College of Psychiatrists. Learning From Experience. Working In Collaboration With People With Lived Experience To Deliver Psychiatric Education, May 2021.  
13. General Medical Council. Patient and Public Involvement in Undergraduate Medical Education, February 2011.
14. Dijk SW, Duijzer EJ,  Wienold M. Role of active patient involvement in undergraduate medical education: a systematic review. BMJ Open, 2020;10(7): e037217.
15. Gutteridge R, Dobbins K. Service user and carer involvement in learning and teaching: a faculty of health staff perspective. Nurse Education Today, 2010; 30(6): 509–14.
16. Hamilton CJ, et al. Involving patients and relatives by translating their experiences into simulation-based education. A31. Abstract from Association for Simulated Practice in Healthcare Annual Conference 2018, Southport, United Kingdom.

About the Author

Kirsten has over 10 years’ experience working in medical practice, the majority of which have been working as a psychiatrist, and she has a keen passion for clinical education, particularly within psychiatry and Equality, Diversity and Inclusivity. As a Fellow of The Higher Education Academy with a Post Graduate Certificate in Clinical Education, Kirsten has significant experience in the design and delivery of training and education and is passionate about improving mental health, wellbeing and patient care through education.