Analysis of the use of a mobile simulation unit using the principles of a managed educational network.

INTRODUCTION: One of the challenges of delivering safe, reliable, quality health care is ensuring the workforce have access to the right training at the right time wherever they are practising. Like other high reliability fields, healthcare education has recognised the important role of simulation based education in embedding a culture of readiness for practice. Managed clinical networks (MCNs) have a proven track record in enhancing services for patients. Adapting this approach to ensuring the healthcare workforce has access to the right training at the right time can provide a more equitable national approach to simulation based education. One of the advantages of the MCN concept has been the flexibility to respond to local needs while reliably delivering national standards. METHODS: This article shares 5 years of data from a mobile simulation unit (MSU) analysed using the principles of a national managed educational network (MEN). An action research approach was used to identify how the MSU was changing the delivery of simulation based education as part of a national MEN for clinical skills education. One of the key deliverables of the Scottish Clinical Skills Strategy was to support the training needs of the National Health Service workforce, particularly in remote and rural Scotland. The MSU was proposed as part of the solution to the 'inequity of provision of clinical skills education using simulation'. Between 2014 and 2018, data were collected by the Clinical Skills Managed Educational Network (CSMEN) team on the performance of the MSU. Venues visited, job titles of participants and courses attended (a mix of local and national) were recorded by the venue hosts and collated by CSMEN staff. RESULTS: Evidence of the impact of the MSU using the seven MEN principles to analyse the data (functioning with explicit management arrangements, embedding systems of accountability, agreed expected outcomes, using an evidence base, having a multiprofessional and multidisciplinary focus, engaging in a system of dissemination, generating better value for money and engaging in research and development) are shared. CONCLUSION: Few examples of mobile simulation facilities exist in the UK, and none have the longevity of the CSMEN MSU. The results of the analysis supported the business case for an upgraded new MSU and identified the need to explore in more depth the variation in impact across the venues visited. However, some localities did not use the MSU during 2014-2018 and there are still some unanswered questions around its impact in some venues, which require further exploration.

Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

WHY IS THE AREA IMPORTANT?: A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable. WHAT IS ALREADY KNOWN AND GAPS IN KNOWLEDGE?: We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. FUTURE AREAS FOR ADVANCING RESEARCH AND PRACTICE: Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Pharmacists' experiences and perceptions about simulation use for learning and development of clinical skills in Kuwait.

Background There has been a worldwide exponential rise in simulation use in health professions education. Most of the evidence about simulation-based education (SBE) comes from Western educational systems. Little is known about simulation use in the education and training of pharmacy students and pharmacists in the Middle Eastern countries. Objective To explore pharmacists' experiences, perceptions and attitudes toward simulation use for learning clinical skills in Kuwait. Setting Different governmental hospitals across the State of Kuwait. Method This was an exploratory descriptive study of pharmacists' perceptions about SBE. A mixed-method research design was employed whereby 110 hospital pharmacists participated in focus groups and completed self-administered surveys. The focus group interviews were audio-recorded, transcribed verbatim and analysed using framework analysis. Descriptive statistics were used to describe characteristics of study participants and survey findings. Main outcome measure Pharmacists' experiences, perceptions and attitudes toward SBE. Results A total of 110 pharmacists participated in the focus groups, of whom 88 completed the survey (80% response rate). The focus groups revealed that pharmacists had different experiences in relation to simulation use which included learning, assessment, and less frequently reported in their training as practitioners. They identified many benefits of simulation such as enhancing knowledge retention and allowing learners practice and rehearse clinical skills in safe environments. Participants' perceived barriers to simulation use in pharmacy students' training included the need for qualified faculty and simulated patients, time constrains to incorporate simulation in faculty teaching and reluctance of learners/educators to use simulation. Most participants expressed positive attitudes toward simulation and welcomed its integration in pharmacy students' learning. In response to survey, 26.1% of pharmacists reported having no prior experience in the use of simulation. The top reported barriers to using simulation for learning were time constrains (22.7%) and the need for qualified faculty (6.8%). Conclusion Pharmacists in Kuwait have diverse experiences regarding simulation use for learning. They expressed positive attitudes toward simulation use for learning clinical skills. Efforts are needed to standardize and expand simulation use in the education and training of pharmacy students, trainees and practitioners to equip them with the clinical skills essential for pharmacy practice.

Validity and reliability of metrics for translation of regional anaesthesia performance from cadavers to patients.

BACKGROUND: Our goal is to develop metrics that quantify the translation of performance from cadavers to patients. Our primary objective was to develop steps and error checklists from a Delphi questionnaire. Our second objective was to show that our test scores were valid and reliable. METHODS: Sixteen UK experts identified 15 steps conducive to good performance and 15 errors to be avoided during interscalene block on the soft-embalmed cadaver and patients. Thereafter, six experts and six novices were trained, and then tested. Training consisted of psychometric assessment, an anatomy tutorial, volunteer scanning, and ultrasound-guided needle insertion on a pork phantom and on a soft-embalmed cadaver. For testing, participants conducted a single interscalene block on a dedicated soft-embalmed cadaver whilst wearing eye tracking glasses. RESULTS: We developed a 15-step checklist and a 15-error checklist. The internal consistency of our steps measures were 0.83 (95% confidence interval [CI]: 0.78-0.89) and 0.90 (95% CI: 0.87-0.93) for our error measures. The experts completed more steps (mean difference: 3.2 [95% CI: 1.5-4.8]; P<0.001), had less errors (mean difference: 4.9 [95% CI: 3.5-6.3]; P<0.001), had better global rating scores (mean difference: 6.8 [95% CI: 3.6-10.0]; P<0.001), and more eye-gaze fixations (median of differences: 128 [95% CI: 0-288]; P=0.048). Fixation count correlated negatively with steps (r=-0.60; P=0.04) and with errors (r=0.64; P=0.03). CONCLUSIONS: Our tests to quantify ultrasound-guided interscalene nerve block training and performance were valid and reliable.

Simulation for Continuing Pharmacy Education: Development and Implementation of a Simulation-Based Workshop on Medicines Reconciliation for Pharmacists.

INTRODUCTION: Simulation has been increasingly used to train health care professionals on clinical skills. Little is published on simulation-based education in the context of continuing pharmacy education (CPE) of pharmacists. This article describes the development implementation and evaluation of simulation-based workshop to train hospital pharmacists on medicines reconciliation in Kuwait. The study aimed to explore pharmacists' perceptions about simulation use in CPE. It also assessed the impact of the workshops on pharmacists' attitudes toward, knowledge, and comfort level to apply medicines reconciliation. METHODS: One hundred ten pharmacists attended 11 simulation-based workshops. Data were collected using focus groups and self-administered surveys in a mixed-method research design. Focus groups were audio-recorded, transcribed verbatim, and analyzed for content. Descriptive statistics were used to report surveys' findings. RESULTS: The workshops were well-received by pharmacists. Few pharmacists recalled previous exposure to simulation in CPE activities. Pharmacists' perceived challenges to simulation integration into their professional training were the need for good preparation/setting, qualified faculty, well-trained simulated patients, and time constrains. Participants felt that simulation enhanced their attitudes toward, knowledge, and comfort level to apply medicines reconciliation. They rated their knowledge level as having increased by 62.3% and comfort level as having increased by 37.0%. They overwhelmingly welcomed more integration of simulation in CPE activities. DISCUSSION: A simulation-based continuing education workshop was well-received by pharmacists and enhanced their self-reported knowledge, comfort level, and preparedness to apply medicines reconciliation. Efforts are needed to expand simulation use in the development, refinement, and maintenance of clinical skills of pharmacists throughout their educational continuum including CPE.

Implementing the medicines reconciliation tool in practice: challenges and opportunities for pharmacists in Kuwait.

BACKGROUND: Using the medicines reconciliation tool which involves preparing an updated list of patient's medications at each transition of care can significantly enhance patient safety. The pharmacist has been leading this process in western healthcare systems. Little is known about pharmacists' role in medicines reconciliation in Middle Eastern Countries. OBJECTIVES: To explore the implementation of medicines reconciliation in Kuwait hospitals, pharmacists' role in this process and perceptions of the challenges in implementing it in practice. METHODS: This was an exploratory descriptive study of medicines reconciliation practices at eleven secondary/tertiary hospitals in Kuwait. A mixed-methods research design was used whereby 110 hospital pharmacists participated in 11 focus groups and 88 of them completed self-administered surveys. RESULTS: Participants reported that medicines reconciliation is poorly applied in hospitals and that they had limited role in the process. The current medicines reconciliation policy does not assign any responsibilities for pharmacists in this process. The most significant barriers to applying medicines reconciliation by pharmacists were inadequate staff numbers, lack of time, difficult access to patient information, lack of policy to support pharmacist role and patients' poor knowledge about their medications. CONCLUSIONS: Hospital pharmacists in Kuwait advocate implementing medicines reconciliation but report significant strategic/operational barriers to its application. Efforts are needed in policy reform and team training to enable pharmacists provide effective patient care services including medicines reconciliation.

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search.

BACKGROUND: Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. METHODS: A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. RESULTS: The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. DISCUSSION: Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. CONCLUSION: Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Using video-reflexive ethnography to capture the complexity of leadership enactment in the healthcare workplace.

Current theoretical thinking asserts that leadership should be distributed across many levels of healthcare organisations to improve the patient experience and staff morale. However, much healthcare leadership education focusses on the training and competence of individuals and little attention is paid to the interprofessional workplace and how its inherent complexities might contribute to the emergence of leadership. Underpinned by complexity theory, this research aimed to explore how interprofessional healthcare teams enact leadership at a micro-level through influential acts of organising. A whole (interprofessional) team workplace-based study utilising video-reflexive ethnography occurred in two UK clinical sites. Thematic framework analyses of the video data (video-observation and video-reflexivity sessions) were undertaken, followed by in-depth analyses of human-human and human-material interactions. Data analysis revealed a complex interprofessional environment where leadership is a dynamic process, negotiated and renegotiated in various ways throughout interactions (both formal and informal). Being able to "see" themselves at work gave participants the opportunity to discuss and analyse their everyday leadership practices and challenge some of their sometimes deeply entrenched values, beliefs, practices and assumptions about healthcare leadership. These study findings therefore indicate a need to redefine the way that medical and healthcare educators facilitate leadership development and argue for new approaches to research which shifts the focus from leaders to leadership.

Exploring situational awareness in emergency medicine: developing a shared mental model to enhance training and assessment.

Non-technical skills (NTS) are gaining increasing prominence within the field of emergency medicine. Situational awareness (SA), one key component of NTS, is a key skill for emergency physicians (EPs) during initial training and throughout their career. Furthermore, the majority of frameworks used to evaluate clinical performance incorporate SA as one key component. This review seeks to define and explore the concept of SA within the context of emergency medicine. We describe SA at an individual, team and departmental level. Development of this ability enables EPs to function effectively within the challenging environment of the emergency department (ED). Enhancing our understanding of SA may develop the cognitive process that underpins our clinical performance. We propose a model for consideration to support evaluation and training of SA within the ED, linking the model to the novice expert continuum.

Leadership and followership in the healthcare workplace: exploring medical trainees' experiences through narrative inquiry.

OBJECTIVES: To explore medical trainees' experiences of leadership and followership in the interprofessional healthcare workplace. DESIGN: A qualitative approach using narrative interviewing techniques in 11 group and 19 individual interviews with UK medical trainees. SETTING: Multisite study across four UK health boards. PARTICIPANTS: Through maximum variation sampling, 65 medical trainees were recruited from a range of specialties and at various stages of training. Participants shared stories about their experiences of leadership and followership in the healthcare workplace. METHODS: Data were analysed using thematic and narrative analysis. RESULTS: We identified 171 personal incident narratives about leadership and followership. Participants most often narrated experiences from the position of follower. Their narratives illustrated many factors that facilitate or inhibit developing leadership identities; that traditional medical and interprofessional hierarchies persist within the healthcare workplace; and that wider healthcare systems can act as barriers to distributed leadership practices. CONCLUSIONS: This paper provides new understandings of the multiple ways in which leadership and followership is experienced in the healthcare workplace and sets out recommendations for future leadership educational practices and research.

Dimensions, discourses and differences: trainees conceptualising health care leadership and followership.

CONTEXT: As doctors in all specialties are expected to undertake leadership within health care organisations, leadership development has become an inherent part of medical education. Whereas the leadership literature within medical education remains mostly focused on individual, hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation. This gap between theory and practice indicates that there is a need to understand what leadership and followership mean to medical trainees working in today's interprofessional health care workplace. METHODS: Epistemologically grounded in social constructionism, this research involved 19 individual and 11 group interviews with 65 UK medical trainees across all stages of training and a range of specialties. Semi-structured interviewing techniques were employed to capture medical trainees' conceptualisations of leadership and followership. Interviews were audiotaped, transcribed verbatim and analysed using thematic framework analysis to identify leadership and followership dimensions which were subsequently mapped onto leadership discourses found in the literature. RESULTS: Although diversity existed in terms of medical trainees' understandings of leadership and followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy and personality were commonplace in trainees' understandings. This indicated the dominance of an individualist discourse. Patterns in understandings across all stages of training and specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily influenced trainees' conceptualisations of leadership and followership. CONCLUSIONS: Our findings suggest that UK trainees typically hold traditional understandings of leadership and followership, which are clearly influenced by the organisational structures in which they work. Although education may change these understandings to some extent, changes in leadership practices to reflect contemporary theory are unlikely to be sustained if leadership experiences in the workplace continue to be based on individualist models.

A national approach for the use of simulation to educate and train the NHS workforce: the First National Clinical Skills Strategy.

INTRODUCTION: There have been a number of drivers for the use of simulation in healthcare education for the NHS workforce. The development of an accessible and efficient national approach to its implementation has been challenging. METHODS: An action research approach was used to develop a national strategy using several data inputs. RESULTS: From sampling across practitioners and territorial health boards geographical and professional groups, access was the main challenge to the use of simulation. CONCLUSION: Four priority areas were identified, which formed the basis of the national strategy Partnership for Care, which included a mobile unit, a managed educational network, a programme board and an alliance of stakeholders.

Introducing simulation-based education to healthcare professionals: exploring the challenge of integrating theory into educational practice.

BACKGROUND: Introducing simulation-based education to the curricular programme of healthcare professionals can be challenging. This study explored the early experiences of healthcare professionals in the use of simulation. This was in the context of the Kuwait-Scotland transformational health innovation network programme. METHODS: Two cohorts of healthcare professionals undertook a simulation module as part of faculty development programme in Kuwait. Participants' initial perceptions of simulators were gathered using a structured questionnaire in the clinical skills centre. Their subsequent ability to demonstrate the application of simulation was evaluated through analyses of the video-recordings of teaching sessions they undertook and written reflections of their experiences of using simulation. RESULTS: In theory, participants were able to identify simulators' classification and fidelity. They also recognised some of the challenges of using simulators. In their teaching sessions, most participants focused on using part-task trainers to teach procedural skills. In their written reflections, they did not articulate a justification for their choice of simulator or its limitations. CONCLUSION: This study demonstrated a theory-to-practice gap in the early use of simulation by healthcare educators. The findings highlight the need for deliberate practice and adequate mentorship for educators to develop confidence and competence in the use of simulation as part of their educational practice.

Pharmacy support in developing prescribing skills.

BACKGROUND: Prescribing medicines is one of the most common interventions in health care, so even a small percentage of prescribing errors can affect many patients. Many of these errors are prevented by the intervention of pharmacists. Research has identified gaps in medical education and training that contribute to these errors. More effective learning opportunities for prescribing at undergraduate level will help to improve the preparation of junior doctors for their role. CONTEXT: Traditionally, doctors have acquired their prescribing skills through an apprenticeship model. Given the complexity of current health care and increasing polypharmacy, a more systematic approach to safe prescribing is required. The pharmacist can have a key role in education and the practice of safe prescribing. INNOVATION: Final-year students at the University of Dundee Medical School are invited to undertake sessions to rehearse safe prescribing practices using an objective structured clinical examination (OSCE) format. This helps to recreate the time pressures of practice with a focus on the elements of safe prescribing for patients. On a simulated ward, students rehearse six situations that represent the basis of commonly reported prescribing errors. Each scenario has four prescribing related tasks, one of which is feedback from a pharmacist. An evaluation of this approach and students' self-reported learning indicated that it was a useful way of enhancing awareness of errors and of increasing confidence. The pharmacist can have a key role in education and the practice of safe prescribing IMPLICATIONS: There are several benefits for students in having pharmacists design and facilitate the OSCE clinical scenarios, which include the immediate learning of accurate prescribing as well as the advisory role that the pharmacists play.

Innovative teaching in situational awareness.

BACKGROUND: In the UK the publication of the Health Select Committee Report highlighted the need to incorporate human factors training in health care education. In response there has been a rise in health care professional training in human factors, focusing on non-technical skills, such as teamwork, leadership and situational awareness. CONTEXT: Using simulation and contextualised learning, we have developed a non-technical skills programme for undergraduate medical students that introduces situational awareness training in the first year. Early integration of human factors into the undergraduate programme can be built upon in a constructivist approach throughout the undergraduate curriculum. Initially no formal ethical approval was required as this was an integral part of the undergraduate teaching programme and did not involve patients; however, ethical approval was gained for the analyses of this session from the local University Research Ethics Committee. Approval included the information sheets and consent forms provided to students, which permitted use of data 'in future posters/publications/presentations'. INNOVATION: Students were introduced to hazards and cues that they may find in clinical areas, encouraged to explore the simulated clinical areas gathering information, interpret their findings and then consider future states. There has been a rise in health care professional training in human factors, focusing on non-technical skills IMPLICATIONS: Initial feedback from both the students and the tutors involved has been positive. In addition, the opportunity for linking this to other non-technical skills developments in different clinical settings and in interprofessional settings is being considered. The next stage is to explore students' perceptions of this session and their learning through questionnaires and focus-group interviews before developing further.

Developing clinical skills bundles.

BACKGROUND: This article describes an innovative method of learning clinical skills. A care bundle is defined as a small set of evidence-based interventions that, when implemented together, results in significantly better patient outcomes than when implemented individually. Care bundles improve the consistency of standards of care delivered, and hence reduce harm. CONTEXT: In 2007 The Scottish Clinical Skills Strategy identified the use of simulation-based education to ensure all health care staff can deliver a consistently high standard of clinical skills practice throughout the National Health Service in Scotland (NHS Scotland). INNOVATION: Clinical skills bundles were developed to underpin a number of evidence-based care bundles. Grouping the clinical skills together and learning them as a clinical skills bundle may improve the reliability of skills delivery for each care bundle. Three groups were recruited and asked to identify a consensus of the essential technical and non-technical skills for clinical skills bundle for a central venous catheter (CVC) maintenance care bundle. As a pilot, six clinical skills bundle workshops were held for junior doctors, nursing and medical students, and clinical skills educators. The aims of the workshops were to introduce the concepts of clinical skills bundles and to give participants a chance to practice the underpinning clinical skills bundle for a care bundle using simulation. The majority of participants rated the workshop as excellent or good. Self-reported learning included refreshing their clinical skills in a different context. Care bundles improve the consistency of standards of care delivered IMPLICATION: Learning skills together as a bundle may enhance the reliability of clinical skills performance for care bundles, and may also reinforce the use of care bundles.

Constructing and evaluating a validity argument for the final-year ward simulation exercise.

The authors report final-year ward simulation data from the University of Dundee Medical School. Faculty who designed this assessment intend for the final score to represent an individual senior medical student's level of clinical performance. The results are included in each student's portfolio as one source of evidence of the student's capability as a practitioner, professional, and scholar. Our purpose in conducting this study was to illustrate how assessment designers who are creating assessments to evaluate clinical performance might develop propositions and then collect and examine various sources of evidence to construct and evaluate a validity argument. The data were from all 154 medical students who were in their final year of study at the University of Dundee Medical School in the 2010-2011 academic year. To the best of our knowledge, this is the first report on an analysis of senior medical students' clinical performance while they were taking responsibility for the management of a simulated ward. Using multi-facet Rasch measurement and a generalizability theory approach, we examined various sources of validity evidence that the medical school faculty have gathered for a set of six propositions needed to support their use of scores as measures of students' clinical ability. Based on our analysis of the evidence, we would conclude that, by and large, the propositions appear to be sound, and the evidence seems to support their proposed score interpretation. Given the body of evidence collected thus far, their intended interpretation seems defensible.