Clinical skills are the ‘touchpoint’ of any health service and are “any direct measurable actions undertaken by health care practitioners with patients" (Cachia 2008). They are key to the delivery of high quality, personalised care. Dr. Jean Ker, Dr. Andrea Baker, Dr. Michael Moneypenny and Lynne Hardie report.
One of the challenges we all face as educators is ensuring the workforce has access to the right training at the right time in the right place without compromising the service, namely a safe, reliable education and training system (adapted from Cook and Rasmussen 2005). In other high reliability organisations such as aviation, simulation-based education (SBE) has been one of the key factors in achieving this (Tolk et al 2015). Creating sustainability requires agreed national standards of SBE with flexibility for local adaptation.
Over 40% of Scotland’s population of five million people live in remote and rural areas; this requires a distributed model of education and training for the health and social care workforce to ensure both quality and equity of access. It was the first country in the world to develop a national Clinical Skills Strategy ‘Partnerships for Care’ (2007) (Table 1) which advocated a national systems based approach to using simulation (Ker 2015).
The Clinical Skills Managed Educational Network (CS MEN) is an innovative evidence-based approach designed to implement this “once for Scotland” approach to the use of simulation and follows the framework in Table 2.
When we undertook a comprehensive consultation exercise (2006-2008) there was a clear consensus on the need for a mobile facility, as part of CS MEN, accessible to all health care practitioners, delivering SBE where front line staff were working, especially in remote and rural locations. We have developed five overarching aims for the mobile facility for CS MEN to deliver skills at the front line- ‘at your door’.
The first aim was for the mobile facility to provide added value through delivering a workforce informed by Scottish Government policies such as the 2020 Vision for Health and Social Care, and in particular the overarching ambition to deliver safe, effective and person-centred care (www2.gov.scot/Topics/Health/Policy/2020-Vision), and by the National Clinical Strategy for Scotland which highlighted the need for the workforce to deliver care in multi-disciplinary and multi-organisational settings (www.gov.scot/publications/national-clinical-strategy-scotland/pages/3/) and with a clear focus on remote and rural communities (www2.gov.scot/resource/doc/222087/0059735.pdf).
The next aim was to design a system for the use of simulation at micro, meso and macro levels for the workforce. This recognised that while SBE is a powerful learning tool, it is also resource intensive both in terms of faculty and finance, so the mobile facility needed to be value for money.
The third aim, sustainability of the mobile facility, is achieved by providing relevant learning at the right time - for example, providing opportunities for health and social care practitioners to safely learn new skills for changing advanced or specialist roles or enabling easy access to reinforcing learning.
This is closely linked to the fourth aim which is for the mobile facility to promote local ownership of the educational programmes while assuring national standards. Achieving this balance has been addressed through CS MEN providing a national programme of local faculty development and the establishment of a national quality assurance system involving local faculty.
The fifth overarching aim for the mobile delivery unit, is to provide opportunities for local community involvement to develop health and social skills. This is achieved by facilitating access to simulation-based learning for the wider emergency services (i.e. fire service, coastguard, RNLI, mountain rescue) and for school children to have access to rehearsing skills for roles and to support local recruitment to health and social care careers.
One of the most useful ways of sharing the detail of how this was done in Scotland is by answering the following series of questions. This should help when considering a similar development in your own organisation.
- What are the key ingredients for a reliable and sustainable system of SBE?
This network approach ensures that the delivery units provide education and training that is underpinned by explicit management arrangements with a system of accountability and uses an up-to-date evidence base. The CS MEN Team (4 FTE) ensures multi-professional and multidisciplinary learning support for NHS Scotland staff. The Mobile Skills Unit (MSU) also supports other organisations, for example Remote and Rural Healthcare Educational Alliance (RRHEAL) and the third or voluntary sector (Independent Living Scotland Conference). The MSU is funded centrally so has no charge at the point of delivery and provides a visible example of how Scottish Government policies can be integrated at the point of delivery. There are five key ingredients which contributed to the development of a reliable and sustainable model of simulation-based education as part of the CS MEN framework.
1. The establishment of a national quality assurance system for SBE.
2. The development of national evidence-based online resources aligned to the face to face SBE teaching .
3. Agreed consensus on the reporting and dissemination of learning about SBE.
4. A collaborative SBE research and development programme.
5. An agreed SBE delivery facility.
2. What is the mobile simulation facility?
The MSU was designed to be easily transported on all major ferries and roads. By virtue of an innovative power management system including a silently run generator and solar panels, the unit is truly mobile and can work anywhere whether it is parked in a field on an island, a supermarket car park or next door to a community hospital. It has a separate control room (with one-way glass), a large flexible teaching area which can be partitioned, and specially designed cupboards enabling easy use and storage of equipment. The MSU is equipped with state-of-the-art facilities including interactive manikins and contextual screens to re-create home or hospital environments (equivalent standards to a fixed simulation centre). There are innovative teaching aids such as cupboard doors that also double as floor to ceiling whiteboards and a plasma screen for face-to-face teaching, video debrief and video-conferencing.
The MSU has also been designed to provide different simulated clinical contexts for learning using the latest interactive manikins integrated with video debriefing technologies. The MSU is also innovative in that it provides the opportunity to video, using a linked mobile camera system, to analyse local practice to identify both excellent practices to share, as well as concerns of the system.
3. Where does the mobile facility go?
The mobile facility visits approximately 18-21 venues annually (Fig. 1) including some of the 95 inhabited Scottish Islands.
4. Who uses the mobile facility?
Over the past 10 years the MSU has delivered quality assured SBE to over 12,000 multi-professional practitioners whether they are delivering care in remote and rural Scotland i.e. Yell in Shetland, or in the central belt i.e. Wishaw in Lanarkshire. The MSU enables health and social care practitioners to rehearse relevant aspects of their practice in a safe learning environment, for example learning or updating procedural skills or practising for prehospital and hospital emergency situations.
The number of people trained on the unit according to job family is shown in Figure 2. Eighty-seven percent of participants were from the NHS (Nursing 51%, Medical 21%, Scottish Ambulance 7%, Dentistry 3%, Allied health Professionals 3%, Midwifery 2%). Six percent were from emergency services (coastguard, fire service, police), 3% were members of the public and one venue also trained two social care staff.
5. What do they use the facility for?
The key skills priorities for the MSU delivery unit relate to the needs of the government, the perceived need by employers, and individual needs. These include procedural skills, team working and pre-hospital emergency care.
Over half of the training sessions are emergency related – ranging from accredited resuscitation council courses to immersive simulation related to deteriorating patients and trauma emergencies (see Figure 3). Procedural Skills training accounts for almost 25% of the sessions. In addition, there are also sessions covering team training. Sessions vary in length from two hours to two days.
The MSU brings added value in that it helps to build resilience within local communities by equipping them with relevant skills to look after themselves, for example by involving the voluntary sector in local multi-agency exercises where simulation is used to test the emergency response system or training the public as part of the “save a life” campaign.
6. How much does it cost to run?
The approximate cost to CS MEN of getting the MSU to each venue, providing either trainers and/or support varies considerably and ranges from £250 in central region to £2500 in the islands. The figures per course per head ranges from £8- £67 but this can be set against the cost of service cover and travel and accommodation. Some rehearsals such as teamwork in more remote parts of Scotland could not be rehearsed if the MSU was not parked outside the workplace as staff teams could not leave the service for several days.
7. What do users think of the mobile facility?
Overall User Satisfaction
In the past 10 years, the MSU has engaged and visited every one of 14 territorial Health Boards in NHS Scotland. In 2018/19 for example the unit had a total of 27 visits and was showcased at four conferences. Over 100 separate training sessions were held, training a total of 1151 individuals. In relation to feedback from users;
- 100% rated the MSU positively,
- 100% thought the MSU was an appropriate learning environment,
- 98% agreed that having training on the MSU was of benefit,
- 87% considered the MSU provided
training that they would otherwise
In relation to impact the following examples demonstrate how we have established both a sustainable education system of delivery as well as having an impact on the service we provide to patients.
Building SBE Capacity in Remote and Rural areas
The MSU has the capability to run immersive simulations using mid-fidelity manikins. Most remote and rural healthcare staff do not have the educator skills required to make the best use of this resource.
The Faculty Development course provides educators from across Scotland with the basic skills required to design, run and debrief immersive simulation-based scenarios aligned to specific learning objectives.
Working with Communities
A local concern on the island of Islay (population of 3,288) is ensuring that the health services and volunteer services can work together as a multi-agency team in an emergency.
The MSU during one visit trained 150 NHS (including hospital staff and paramedics), RNLI, coastguard and police personnel in the use of emergency equipment, safe alert and handover of injured patients. A simulated exercise of three separate incidents (a group of hill walkers who were missing and two sets of kayakers who got into trouble) was used to test the multi-agency response. Members of the public took part by undertaking simulated roles as hill walkers and kayakers. The resilience of the teams was tested in terms of coordination of personnel and use of specialised equipment, with changes to practice protocols agreed at the debrief.
Mental health training for Practitioners in Remote and Rural Areas
Remote and rural healthcare staff in NHS Scotland are required to manage patients experiencing mental health crises. Although many Health Boards have Psychiatric Emergency Plans, these have mostly never been rehearsed. Furthermore, pre-hospital care requirements and the associated training of healthcare practitioners has not been identified.
Key clinical skills in relation to mental health were identified. Training was developed in partnership with RRHEAL and delivered using the MSU.
The mobile facility is a complex educational intervention and we are using a realist evaluation to provide the evidence of why it works in some venues better than others and also to inform us how it can function more reliably and be sustainable in all venues.
Originally published in Issue 4, 2019 of MT Magazine.
About the Authors
Dr. Jean Ker a general practitioner and Emeritus Professor of Medical Education is the Scottish clinical lead for simulation and has published widely and worked as a consultant for the WHO, British Council and GMC.
Dr. Andrea Baker is the CSMEN manager who led the development of the updated new MSU, launched in 2018 and has organised international simulation meetings.
Dr. Michael Moneypenny is an anaesthetist and the Director of the Scottish Centre for Simulation and Clinical Human Factors who provide the national MSU faculty programme.
Lynne Hardie is the mobile facility senior administrator. Together they are part of the team who were awarded the international ASPIRE Award for Simulation in 2018.
1. Cachia P., (2008) The Scottish Clinical Skills Strategy Scottish Clinical Skills Roadshow Oral Presentation
2. Cook R., Rasmussen J., (2005) ‘Going solid’- a model of system dynamics and consequences for patient safety
3. NHS Education for Scotland (2007) Partnerships for care taking forward the Scottish Clinical Skills Strategy East Deanery; Dundee, HMSO
4. Ker J., Cachia P., Beasant B., (2015) A national approach to the use of simulation to train and educate the NHS workforce: the first national Clinical Skills Strategy, Scottish Medical Journal 60(4) 220-222
5. Tolk J N., Cantu J., Beruvides M., (2105) High Reliability Organisation Research - A literature review for health care Engineering Management Journal 27(4) 218-237