The potential and challenges of utilising multiprofessional in situ simulation

Simulation allows the practice of clinical skills in a risk-free, controlled environment. It is followed by facilitated self-reflection and constructive feedback via a ‘debrief’ from trained faculty. Initially pioneered by the aviation industry, it has now been enthusiastically embraced by healthcare as an approach to dealing with safety critical and complex clinical scenarios. Simulation is widely adaptable and its use has been applied to diverse clinical areas, specialities and topics from communicating in difficult circumstances to major incident responses.

Realisation that fidelity of simulation is improved if it accurately reflects real clinical working environments has led to the transition of simulation out of the skills laboratory into the workplace, and the inclusion of the complex multidisciplinary teams which deliver care in the clinical setting. By increasing the complexity of the environment, we provide an immersive experience which allows us to explore performance in the context of the full breadth of competing tasks/priorities/resource difficulties which happen in real life. Testing the team's responses in real clinical environments gives an unprecedented ability to analyse failures of care as and when they occur, that is, latent error identification, and can direct targeted remedial improvement projects to remedy them. Practical skills and theoretical knowledge will always be a feature of simulation; however, awareness that a high proportion of clinical incidents arise from failures of situational awareness, leadership, judgement, decision-making, communication and teamwork has meant an increasing component of simulation is exploring and developing human factor skills.

The article by Uttley et al,¹ published in this journal, adds to the increasing literature supporting the use of multidisciplinary in situ simulation in the field of gastroenterology. Their programme was able to identify latent errors within the gastroenterology ward. These latent errors included both systemic and human factors issues, namely education and training, equipment, medication and team working, with considerable overlap between categories. A system of improvements was made to address these latent errors, with observed improvement in performance on repeat testing. A secondary outcome was developing collaborative multiprofessional working by improving confidence and individual role recognition. Qualitative data were recorded by participants on post simulation feedback forms, which strongly endorsed improved role recognition and improved confidence with emergency scenarios.

Realisation that infrequently occurring emergency scenarios are often suboptimally managed suggests we need to move away from reliance onfallible memory and inaccessible hospital policies. Uttley et al addressed this by providing copies of advanced life support algorithms and major haemorrhage protocols on the trust resuscitation trolleys. Previous work in this area, testing use of ‘crisis checklists’ in simulated theatre environments, has shown a 75% reduction in variance from agreed guidelines compared with reliance on memory alone.²

By demonstrating applicability and positive outcomes for their organisation, Uttley et al have been able to roll out an in situ programme across seven clinical areas. Reproducing this in organisations without existing or well-established in situ simulation is a challenge to aspire to.

Measuring effectiveness of desired outcomes is complex. Developing more robust evidence for simulation, we believe, would drive quality in simulation programmes and provide evidence for its wider adoption.

Ideally, we would be able to follow participants from simulation exercises into their clinical environment, to determine if training has had a lasting positive impact on their practice (Kirkpatrick level 3—Behaviours), and whether this has resulted in positive patient outcomes (Kirkpatrick level 4—Results). However, this is challenging given the many complexities, confounding issues and limitation of resources within the systems within which we work. As such, non-validated scores of participant’s perceived confidence in dealing with similar scenarios in the future are often used as surrogate markers for learning (Kirkpatrick levels 1–2).

Given we are now moving towards the inclusion and assessment of cognitive skills, that is, non-technical skills/human factors, this makes measuring learning outcomes even more problematic. A recently developed tool which partly addresses this is the Human Factor Skills in Healthcare Instrument (HuFSHI).³ This has been validated across multiprofessional groups in simulation-based learning and measures pre and post simulation self-efficacy in key non-technical skill domains. Using this instrument in addition to other assessment tools for team behaviour, communication and task completion, coupled with following participants across repeated simulation exercises over time, could provide this higher quality evidence for simulation-based education. We have shown through analysis of our own established trust-wide in situ simulation programme a statistically significant correlation with the number of times staff have attended in situ simulation and their confidence in performing a range of non-technical skills.⁴

We are currently planning a multicentre study of in situ simulation in the endoscopy department using standardised scenarios. To provide an objective measure of performance, video recording and structured assessment will be used. Assessment of team performance will be achieved through use of validated assessment scales. We envisage that sharing of data across sites will allow more rapid data acquisition and earlier identification of effective simulation practices.

In our own specialty, the importance of human factors has been acknowledged by the Joint Advisory Group for Gastrointestinal Endoscopy (JAG), which is implementing an Improving Safety and Reducing Error in Endoscopy (ISREE) strategy.⁵ An aspect of this work is identifying and learning from safety incidents and providing training in endoscopy non-technical skills (ENTS). A combination of JAG-approved e-learning modules including human factors training and implementation of multidisciplinary in situ simulation in endoscopy units will provide a core component of the response to this.

Evidence shows that medical error is the third leading cause of death in the USA.⁶ We suggest implementing a closed loop system of learning, both locally and nationally. Scenarios for simulation should be obtained from patient safety incidents within the organisations within which we work. Running simulations allows additional latent errors to be identified, actioned and the intervention tested by repeat simulation. We suggest reporting latent errors into the hospital clinical risk governance system, so they can be addressed in the same manner as safety incidents that are identified in the normal course of clinical practice. Lessons learnt from incidents reported locally should be conveyed back to the reporting department, and if appropriate, shared outside the organisation. Incidents reported on trust systems are mapped to incident categories and uploaded to the National Reporting and Learning System (NRLS). Detectable national patient safety trends are cascaded back to trusts via patient safety alerts. However, there are criticisms regarding the quality and utility of the data generated by this national system.

In parallel to the work by the ISREE group is the National Endoscopy Database (NED) project.⁷ Its principal aim is to facilitate quality assurance of endoscopy and improve research and training. Part of this will involve identifying and reporting patient safety incidents related to endoscopy activity. It is envisaged that in the future, NED will evolve to capture real-time and delayed endoscopic complications, feeding back to the NRLS with more accurate data than is possible with the existing systems. Patient safety issues identified from this process could be used by endoscopy units for their in situ simulation programmes, thereby closing the loop, and enhancing patient safety.