Scotland’s Story: World-leading Innovation

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.

The Mobile Skills Unit is equipped with state-of-the-art facilities. All images: NHS Education for Scotland.

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).

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The Clinical Skills Managed EducationalNetwork (CS MEN) is an innovative evidence-based approach designed to implementthis “once for Scotland” approach to the use of simulation and follows theframework in Table 2.

When we undertook a comprehensiveconsultation exercise (2006-2008) there was a clear consensus on the need for amobile facility, as part of CS MEN, accessible to all health carepractitioners, delivering SBE where front line staff were working, especiallyin remote and rural locations. We have developed five overarching aims for themobile facility for CS MEN to deliver skills at the front line- ‘at your door’.

Health and social care practitioners rehearse aspects of their practice in a safe learning environment.

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 theuse of simulation at micro, meso and macro levels for the workforce. Thisrecognised that while SBE is a powerful learning tool, it is also resourceintensive both in terms of faculty and finance, so the mobile facility neededto be value for money.

The third aim, sustainability of the mobilefacility, is achieved by providing relevant learning at the right time - forexample, providing opportunities for health and social care practitioners tosafely learn new skills for changing advanced or specialist roles or enablingeasy access to reinforcing learning.

This is closely linked to the fourth aimwhich is for the mobile facility to promote local ownership of the educationalprogrammes while assuring national standards. Achieving this balance has beenaddressed through CS MEN providing a national programme of local facultydevelopment and the establishment of a national quality assurance systeminvolving local faculty.

The fifth overarching aim for the mobiledelivery unit, is to provide opportunities for local community involvement todevelop health and social skills. This is achieved by facilitating access tosimulation-based learning for the wider emergency services (i.e. fire service,coastguard, RNLI, mountain rescue) and for school children to have access torehearsing skills for roles and to support local recruitment to health andsocial care careers.

One of the most useful ways of sharing thedetail of how this was done in Scotland is by answering the following series ofquestions. This should help when considering a similar development in your ownorganisation.

1. What are the keyingredients for a reliable and sustainable system of SBE?

This network approach ensures that thedelivery units provide education and training that is underpinned by explicitmanagement arrangements with a system of accountability and uses an up-to-dateevidence base. The CS MEN Team (4 FTE) ensures multi-professional andmultidisciplinary learning support for NHS Scotland staff. The Mobile SkillsUnit (MSU) also supports other organisations, for example Remote and RuralHealthcare Educational Alliance (RRHEAL) and the third or voluntary sector(Independent Living Scotland Conference). The MSU is funded centrally so has nocharge at the point of delivery and provides a visible example of how ScottishGovernment policies can be integrated at the point of delivery. There are fivekey ingredients which contributed to the development of a reliable andsustainable model of simulation-based education as part of the CS MENframework.

1. The establishment of a national qualityassurance system for SBE.

2. The development of nationalevidence-based online resources aligned to the face to face SBE teaching .

3. Agreed consensus on the reporting anddissemination of learning about SBE.

4. A collaborative SBE research anddevelopment programme.

5. An agreed SBE delivery facility.

2. What is the mobile simulationfacility?

The MSU was designed to be easilytransported on all major ferries and roads. By virtue of an innovative powermanagement system including a silently run generator and solar panels, the unitis truly mobile and can work anywhere whether it is parked in a field on anisland, a supermarket car park or next door to a community hospital. It has aseparate control room (with one-way glass), a large flexible teaching areawhich can be partitioned, and specially designed cupboards enabling easy useand storage of equipment. The MSU is equipped with state-of-the-art facilitiesincluding interactive manikins and contextual screens to re-create home orhospital environments (equivalent standards to a fixed simulation centre).There are innovative teaching aids such as cupboard doors that also double asfloor to ceiling whiteboards and a plasma screen for face-to-face teaching,video debrief and video-conferencing.

The MSU has also been designed to providedifferent simulated clinical contexts for learning using the latest interactivemanikins integrated with video debriefing technologies. The MSU is alsoinnovative in that it provides the opportunity to video, using a linked mobilecamera system, to analyse local practice to identify both excellent practicesto share, as well as concerns of the system.

3. Where does the mobile facility go?

The mobile facility visits approximately18-21 venues annually (Fig. 1) including some of the 95 inhabited ScottishIslands.

4. Who uses the mobile facility?

Over the past 10 years the MSU hasdelivered quality assured SBE to over 12,000 multi-professional practitionerswhether they are delivering care in remote and rural Scotland i.e. Yell inShetland, or in the central belt i.e. Wishaw in Lanarkshire. The MSU enableshealth and social care practitioners to rehearse relevant aspects of theirpractice in a safe learning environment, for example learning or updatingprocedural skills or practising for prehospital and hospital emergencysituations.

The number of people trained on the unitaccording to job family is shown in Figure 2. Eighty-seven percent ofparticipants were from the NHS (Nursing 51%, Medical 21%, Scottish Ambulance7%, Dentistry 3%, Allied health Professionals 3%, Midwifery 2%). Six percentwere from emergency services (coastguard, fire service, police), 3% weremembers 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 MSUdelivery unit relate to the needs of the government, the perceived need byemployers, and individual needs. These include procedural skills, team workingand pre-hospital emergency care.

Over half of the training sessions areemergency related – ranging from accredited resuscitation council courses to immersivesimulation related to deteriorating patients and trauma emergencies (see Figure3). Procedural Skills training accounts for almost 25% of the sessions. Inaddition, there are also sessions covering team training. Sessions vary inlength from two hours to two days.

Figure 3 – Training sessions run on the mobile skills unit.

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 gettingthe MSU to each venue, providing either trainers and/or support variesconsiderably 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 againstthe cost of service cover and travel and accommodation. Some rehearsals such asteamwork in more remote parts of Scotland could not be rehearsed if the MSU wasnot parked outside the workplace as staff teams could not leave the service forseveral days.

7. What do users think of the mobilefacility?

Overall User Satisfaction

In the past 10 years, the MSU has engagedand visited every one of 14 territorial Health Boards in NHS Scotland. In2018/19 for example the unit had a total of 27 visits and was showcased at fourconferences. Over 100 separate training sessions were held, training a total of1151 individuals. In relation to feedback from users;

In relation to impact the followingexamples demonstrate how we have established both a sustainable educationsystem of delivery as well as having an impact on the service we provide topatients.

Building SBE Capacity in Remote andRural areas

Identified gap/challenge

The MSU has the capability to run immersivesimulations using mid-fidelity manikins. Most remote and rural healthcare staffdo not have the educator skills required to make the best use of this resource.

Simulation solution

The Faculty Development course provideseducators from across Scotland with the basic skills required to design, runand debrief immersive simulation-based scenarios aligned to specific learning objectives.

Working with Communities

Identified gap/challenge

A local concern on the island of Islay(population of 3,288) is ensuring that the health services and volunteerservices can work together as a multi-agency team in an emergency.

Simulation solution

The MSU during one visit trained 150 NHS(including hospital staff and paramedics), RNLI, coastguard and policepersonnel in the use of emergency equipment, safe alert and handover of injuredpatients. A simulated exercise of three separate incidents (a group of hillwalkers who were missing and two sets of kayakers who got into trouble) wasused to test the multi-agency response. Members of the public took part byundertaking simulated roles as hill walkers and kayakers. The resilience of theteams was tested in terms of coordination of personnel and use of specialisedequipment, with changes to practice protocols agreed at the debrief.

Mental health training for Practitionersin Remote and Rural Areas

Identified gap/challenge

Remote and rural healthcare staff in NHSScotland are required to manage patients experiencing mental health crises.Although many Health Boards have Psychiatric Emergency Plans, these have mostlynever been rehearsed. Furthermore, pre-hospital care requirements and theassociated training of healthcare practitioners has not been identified.

Simulation solution

Key clinical skills in relation to mentalhealth were identified. Training was developed in partnership with RRHEAL anddelivered 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 andEmeritus Professor of Medical Education is the Scottish clinical lead forsimulation and has published widely and worked as a consultant for the WHO,British Council and GMC.

Dr. Andrea Baker is the CSMEN manager wholed the development of the updated new MSU, launched in 2018 and has organisedinternational simulation meetings.

Dr. Michael Moneypenny is an anaesthetistand the Director of the Scottish Centre for Simulation and Clinical Human Factorswho provide the national MSU faculty programme.

Lynne Hardie is the mobile facility senioradministrator. Together they are part of the team who were awarded theinternational ASPIRE Award for Simulation in 2018.

References

1. Cachia P., (2008) The Scottish ClinicalSkills Strategy Scottish Clinical Skills Roadshow Oral Presentation

2. Cook R., Rasmussen J., (2005) ‘Goingsolid’- 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 EastDeanery; Dundee, HMSO

4. Ker J., Cachia P., Beasant B., (2015) Anational approach to the use of simulation to train and educate the NHSworkforce: the first national Clinical Skills Strategy, Scottish MedicalJournal 60(4) 220-222

5. Tolk J N., Cantu J., Beruvides M.,(2105) High Reliability Organisation Research - A literature review for healthcare Engineering Management Journal 27(4) 218-237