Empowering healthcare professionals to return to work through simulation training: addressing psychosocial needs

Introduction

In the UK, 10% of trainee doctors are out of clinical practice at any given time, for reasons including personal health, carer duties, further education, research and parental leave. ¹

Doctors report that leaving work often invokes feelings of isolation and sadness, as well as concerns around a lack of support from colleagues and organisations, and even negative views from their families. ¹ Self-stigmatisation sees doctors internalise negative views about themselves, promoting self-esteem issues and a lack of help-seeking behaviour, which also relates to the constructs of personal and professional identity. ² Addressing and tackling the barriers related to returning to work is not only beneficial for a doctor’s well-being but for patient care too. One systematic review found that doctors with higher occupational well-being adhere more to treatment guidelines, are more optimistic and helpful, and direct more attention to patient’s psychosocial health. ³

Although programmes exist to support returning doctors, there is a shortage of evidence-based interventions. This report outlines a training intervention and subsequent evaluation for returning healthcare professionals, in which they can develop their clinical skills and needs as well as their own psychosocial skills and needs.

Methods

Training course

The 4-day course aimed to update doctors returning to work on their clinical skills and knowledge, while creating an open space to address personal and psychosocial needs regarding returning (see table 1 for learning activities and scenarios). The course was delivered in a simulation centre in South London, with each day lasting approximately 8 hours, by a multiprofessional faculty of clinical educators and simulation experts, including doctors, nurses and psychologists. All faculties had received debrief training using the Diamond model. ⁴

Table 1.

Boot camp timetable with an overview of learning activities

	Title	Learning activity
Day 1 AM	Welcome & Introduction	Housekeeping, introductions, establishing safety and confidentiality, and course overview
	Build a Bridge	Team-building activity involving building a bridge with limited resources, followed by a debrief
Day 1 PM	Hopes & Concerns	Facilitated discussions, video from a returner, Q&A and circle of care
	System Changes	Going through changes in NHS, HEE, CCG, 5-Year Forward, and so on
	Self-care & Well-being	Self and group care activities: 5 ways to well-being, wheel of life, body scan
Day 2 AM	Skills Stations	SBARD, NG tube insertion, phlebotomy and cannulation
Day 2 PM	Communications Skills Scenario 1	Introduction to the first patient. History of tonic–clonic seizures, now experiencing non-epileptic seizures. The task is to take a history of the presenting complaint. Debrief
	Scenario 2	Discuss and explain medically unexplained symptoms and the potential causes of the patient’s worsening symptoms with the patient. Debrief
	Scenario 3	Refer the patient for psychiatric review, using the SBARD tool to hand them over. Debrief
Day 3 AM	High-Fidelity Simulation Scenario 1	Meet new patient, 74 years old. Son has requested a home visit due to reduced mobility and a lack of self-care from grief. Tasked to review and assess. Debrief
	Scenario 2	1 month later. The son is concerned that his mother is ‘out of sorts’ over the phone and maybe unwell. Take a further assessment of the patient. Debrief
Day 3 PM	Scenario 3	The patient is admitted to the hospital with sepsis secondary to a chest infection. Called for a review as staff are concerned at increased agitation, paranoia and confusion. Debrief
	Scenario 4	In the hospital, the patient develops a rash and swollen face following antibiotic administration. The underlying cause of this is acute anaphylaxis. Debrief
	Scenario 5	The patient goes into cardiac arrest as a result of the anaphylaxis. Debrief
Day 4 AM	Scenario 6	Son arrives, angry and threatening regarding the level of care the patient has received and the medication error. Debrief
	Scenario 7	The patient is scheduled to be discharged but is reluctant to leave. A neighbour has moved into her house and is asking for money. When the neighbour arrives on the ward, he is suspicious and defensive if this is brought up. Debrief
	Actor Feedback	Simulation actors give additional feedback to the participants on the perspectives of their characters, and what techniques were helpful or unhelpful from participants as a group
Day 4 PM	Participant check-in	Check-in with the participant’s emotions and thoughts. Review any areas left uncovered, for example, whistleblowing, changing cultures
	Unfolding stories	Activity in which all participants write a positive, anonymised comment on each other, which is reflected on as a group
	Wrapping up	Learner led methods of keeping in touch. Take away learning points
	Social event	Refreshments in a local venue to continue connections, optional

*The cited information (table 1 scenarios) is not from an actual patient. Any resemblance to real person living or deceased will be coincidence.

CCG, clinical commissioning group; HEE, Health Education England; NG, nasogastric; NHS, National Health Service; SBARD, Situation, Background, Assessment, Recommdentation, and Decision.

The course was developed by the multiprofessional faculty in consultation with healthcare professionals who were returning to practice or had recently done so, as well as educational psychologists and programme lead for supporting returning healthcare professionals. The course outcomes and learning activities were mapped to the evidence on the needs of returning clinicians, including from a UK-based project to gather the needs of returners to the National Health Service (NHS). Learning activities were based on experiential learning theory and national standards of simulation practice from the Associated for Simulated Practice in Healthcare.

The first day involved team-building exercises, overviews of changes in practice, and self-care and well-being sessions, with the aim to build a strong group dynamic to allow participants to express their concerns. Days 2–4 focused on simulation training, including practical skills session based on mastery learning, communications skills stations, and high-fidelity simulated scenarios and reflective debriefs using the Diamond model. ⁴ Simulated patients played by professional actors training to play patients, manikins and practical equipment were used, with 10–15 min simulated scenarios shared with the group via live video link, followed by a 30–40 min debrief session. These methods ensured that the principles of high-fidelity simulation were adhered to. Day 4 concluded with a review of their progress, action planning for their return to work journeys and final reflections on their personal and health needs.

Procedure

Facilitators delivering the training (n=6) and researchers not delivering the training (n=2) conducted naturalistic observations of the participants, considering their needs, experience of the training, and the outcomes and impact of the training. Field notes and unstructured observation notes were collected throughout all days of the training course. A Thematic Analysis ⁵ of observational data was conducted by collating the data, reviewing for familiarisation, coding key pieces of data and acknowledging emerging reoccurring themes across the data set. This was reviewed by the researchers and facilitators, with final emergent themes agreed.

Preliminary findings

A total of 64 participants attended five separate courses running between September 2018 and June 2019 in South London. Of these, 89.4% of participants were medical doctors, 2.1% were nurses, 6.4% were allied health professionals and 2.1% had an unspecified clinical role. Emergent themes from the thematic analysis were psychosocial needs of learners, psychological concepts as subject matter, and the value of peer support and learning.

Psychosocial needs of learners: discussions in debrief suggest that there is a greater need to provide psychosocial support alongside clinical skills for healthcare professionals returning to work and that it is important to be able to build rapport over multiple days, in an environment dedicated to doing so. This allowed for open discussions to reflect the concerns and needs of the learners. Additionally, learners were enthusiastic about discussions that concerned their psychosocial functioning, well-being, work-life balance and internal concepts that underpin performance and engagement in the workplace.

Psychological concepts as subject matter: participants were responsive to psychological concepts that were effectively brought into the training, from group reflective practice to behaviour change approaches such as goal setting. Self-esteem, self-identity and self-care were identified as being highly important to develop alongside clinical skills, with confidence being the main concern regarding returning to work. Participants reported having more self-worth and feeling more valued as a healthcare professional after the course, and that the opportunity to develop confidence in one’s role and a peer support network of others with relatable experience was valuable.

Value of peer support and learning: another major theme of concern for returners was the sense that they felt alone in their worries. After the course, based on peer support, senior support and networking, many were relieved to know they were not the only ones who felt concerned about returning and that the peer support and mutual respect and experience was an important facilitator of their personal growth. This aspect of shared experience raised the possibility of social capital being a powerful tool to harness in supporting returners, engaging them in their work and connecting with shared values.

Discussion

Findings highlighted a gap in psychosocial support for returning clinicians, and offered preliminary findings on supporting returners through simulation training boot camps that engage with personal needs, psychological concepts and peer support. Having a psychologically safe environment where people feel comfortable to share experiences as well as dedicated sessions to practice self-care as a healthcare professional are important to build confidence and feel able to return successfully.

Being able to build rapport through time with peers and trainers allowed for more in-depth discussions and created a safe and trusting space for participants to be able to express themselves and their concerns. The evidence suggests that developing internal skills relating to psychosocial well-being could be valuable for participants, alongside developing external clinical skills. Therefore, subsequent training delivery and research may wish to focus on addressing these factors for clinicians planning on returning to work. Significantly, it was noted that addressing clinical matters alongside personal or psychosocial factors that underlie clinical practice was well received and even sought after by participants throughout the training.

To the author’s knowledge, this is the first study to address the psychosocial needs of doctors returning to work. A larger mixed methods study is underway to evaluate the effect of the simulation training boot camp on participants’ well-being, resilience, self-efficacy, confidence and knowledge, with additional qualitative methods aiming to understand their experience and development from the training.