“So where do we start with simulation in our department?”

When you discuss starting a simulation programme with individuals in a department (or ward etc) there is often a point where the opportunities of simulation almost become overwhelming. There are so many potential simulation areas that could be addressed that often people are unsure where to start. 

Over a period of time I have developed a mental model on how to engage and develop a departmental simulation programme in a step wise approach within a department or area. It also works at an organisational level though this blog concentrates on the department level. 

The first thing is to realise that all the different groups need to be engaged with the simulation; there is no point in having one professional group, leading and mandating others attend - as there is a risk that it will be seen as the group needs these people as “props” for their own training - the other people will feel that they will not get anything from the sessions. It is important that all the groups have ownership of the session .

The programme

The basic structure is a pyramid, the programme starts at the base and works up - the higher elements take more planning but are run less often. The program can be started incrementally first with the bottom layer and progressing up when engagement and capacity allows it.

The basic layer is uni-professional skills simulation training. At first this may seem counter intuitive but this is were the professional group can plan a core programme of simulation for new starters and junior staff - often asking what are the key procedures we want our these staff to be able to do competently. These will be routine process, not emergency ones and often may be focussed around setting up equipment or doing solo procedures / skills - the focus will almost entirely be on procedural compliance. In reality this basic layer will be made up of a number of different uni-professional programmes for the different professional groups.

The next layer - multi-professional emergency drills. For this stage email / ask the staff across the department what scenarios would they like you to run and rank all the responses. Go to the management / governance group and ask a similar question - what are the concerns / risks from this level. Often the local staff will cite rare emergency events where management / governance will identify specific risk elements. The opportunity is now for the faculty to blend the emergency events and include the specific identified risks. These sessions will focus on procedure and team elements. These sessions will without doubt identify issues with system / organisational process that do not work as imagined and there is also an opportunity to use a quality improvement approach to develop these iteratively with the staff using the process. 

The top two layers are simulations across departments or organisations - these will be rare events and will much more focus on learning for the organisations rather than the individuals.  

Remember as well the opportunities to deliver some of the sessions, or components of the sessions online and virtually as an example capturing some of the scenarios on video (with consent) and using these as a growing library for staff to access when they want either before or after can help to prevent skill and knowledge fade but also allow the participant to be more in control of their learning. 

Thought will have to also be given about the frequency of the events  - i.e. what is achievable and when is the best time to deliver them. Is there a regular training / audit session? is there a shift change over where more staff are available? can you rota on staff that need the training? and how will you ensure the faculty is also available?  Sessions will get cancelled due to unexpected events - but often setting a target of once a month, or once every two weeks will give an achievable target and also start to make the sessions part of the routine. 

Quality Assurance

Quality assurance is important as is attracting the correct mix of faculty - both professionally but also with the skills required. Remember as well as clinical competence, there will need to be knowledge in simulation scenario development, facilitation and debriefing, quality improvement, human factors (both team working and system elements) and someone with technical knowledge to get all the elements working together. Scenarios need to be developed robustly to ensure the application of both human factor and clinical elements. Don’t forget to draw on expertise elsewhere in the organisation or further afield. Additionally some sessions may be delivered away from the department in a more formal simulation area this often allows for longer sessions to be planned for certain (often junior) groups. 

Two areas are worth specific mention firstly around using real drugs / equipment in clinical practice - of course there will be a cost to this and it needs to be risk assessed but often the use of real equipment including actual drawing up of drugs gives the opportunity to highlight errors and issues that otherwise may not be seen - it maybe you decide that you decide to use drugs (except expensive or controlled ones) routinely. The other element is around escalation of errors, particularly around system errors. Often routinely there will be no way to formally report a simulated error - if we used the routine reporting system as our event does not involve a patient the degree of risk may well not be apparent - it is worth discussing this with governance / risk as it may be possible to get agreement to have a “ghost” reporting system for simulation incidents that activate an appropriate response (mirroring a real event) indeed the potential of governance to proactively look into these elements is something they often will enthusiastically engage with.  

Don’t forget evaluation is going to be important and capturing data to demonstrate improvement of processes is fundamental to demonstrating the effectiveness and importance of the sessions. And sharing is important across the organisation of the work and findings as this will allow the learning to spread further than just the department. 

Staff engagement 

The engagement is fundamentally a critical component, some of the staff may never have undertaken simulation like this, there maybe concerns as to why this is being done and what “failing” the simulation will mean. 

The earlier engagement starts the better- really engage with staff to decide the content, put a board up explaining the process and structure. Consider doing a small video not only demonstrating a short scenario but also the equipment they will be working with i.e. manikin or simulated person. 

Giving feedback after simulations is also important - a thank you email, especially summarising points learnt can assist in engagement as staff can see positive outcomes. Staff being engaged in finding solutions using simulation is also important. 

Developing a departmental simulation programme is rewarding and can positively impact patient safety and staff well being. The planning and engagement element should not be underestimated and the faculty needs to be large enough that it reflects the different professional groups and also ensures the programme doesn’t just fall on one individual.