This article will discuss the use of high fidelity simulation in Southport and Ormskirk Hospital Trust in the north west of England. High fidelity simulation is used in the Trust for a few different purposes: during the biannual study day on ‘Managing the sick obstetric patient’, for live skills and drills on the maternity wards, and during the annual emergency training, which is incorporated into the mandatory training of staff. Each of these occasions includes the multidisciplinary team.
Simulation-based training was initially introduced to improve patient safety, addressing the factors surrounding substandard care during clinical incidents, while reducing clinical litigation (Fransen et al, 2012; National Patient Safety Agency, 2013). Lathrop et al (2007) suggest that poor teamwork is the cause of many critical incidents in health settings, and having a simulated learning environment where no harm can be caused is crucial in building experience and enhancing competence and confidence. Maternal death in the UK has been linked with poor standards of care and a lack of training to recognise acute emergencies or the ‘sick obstetric patient’, including failure to start treatment promptly (Manktelow et al, 2017). Simulation is proven to reduce clinical risk (Thompson et al, 2004) and results in enhanced teamwork and team performance (Fransen et al, 2012). As the National Maternity Review (NHS England, 2016), clearly states that ‘those who work together should train together’, simulation plays an important role in both undergraduate midwifery education and continuing professional development. Simulation therefore has a role to play in training staff to deal with emergencies effectively with a view to avoid and reduce maternal mortality and morbidity in the UK.
Background
Simulation is an educational teaching technique that aims to recreate an aspect of reality in a safe and controlled environment (Cioffi et al, 2005). Simulation is somewhat different to other training techniques, such as problem-based learning, as the aim is to recreate a real life situation that has been expertly planned and meets specific learning outcomes (Elfrink et al, 2010). Simulation uses mostly high fidelity equipment, although this can vary, with a wide range of options available. It often includes a re-creation of the clinical environment using a simulation lab, and is fully immersive for students and participants, making the experience as real as possible (Sabus and Macauley, 2016). In contrast, problem-based learning focuses on setting real or simulated problems that need to be solved using didactic intentions designed to cause hypothetical thought processes (Loureiro et al, 2009). Problem-based learning aids critical thinking and reflection, and aims to increase the students' autonomy, communication and social skills (Loureiro et al, 2009), similar to that of simulation.
Skills and drills exercises are closely linked to simulation, as they aim to recreate a real emergency situation in real time using the multidisciplinary team (Pauley and Dale, 2016). Live drills, although also simulated, take place at random within the clinical area when the staff do not expect to be assessed. This creates more realism as it aims to re-create a real-time emergency that needs to be dealt with effectively. At Southport and Ormskirk Hospital Trust, skills and drills are often be undertaken in the simulation suite during mandatory training and are pre-planned; whereas the live drills take place within the clinical area and are often spontaneous. Both incorporate an element of problem-based learning: a scenario would be set and staff would aim to solve the problem effectively as a team.
Simulation in midwifery education and continuing professional development
The use of the multidisciplinary team during the simulation is key to achieving effective teamwork and is an opportunity to practise together in a simulated environment. Simulation-based learning is more often used in a university setting for teaching purposes (Dow, 2012); however, in a hospital setting, simulation can often be forgotten and under used, due to lack of funding, time and staff (Mason and Davies, 2013). Thankfully, obstetric emergencies are infrequent and some considered rare: the Royal College of Obstetricians and Gynaecologists (RCOG) estimates that shoulder dystocia rates vary between 0.58-0.7% (RCOG, 2012), and the prevalence of eclampsia is noted to be falling, although hypertension in pregnancy remains a leading cause of maternal death in the UK, with 5% of women admitted to intensive care (National Institute for Health and Care Excellence (NICE), 2011). In general, due to falling rates and relatively low incidence of obstetric emergencies, midwives, obstetricians, medical staff and students may not have the opportunity to gain much experience before these situations occur in practice, even after being qualified for many years.
Students, on the other hand, may not be exposed to such emergencies in the clinical area very often, but are assessed on their ability to manage obstetric emergencies via the Objective Structured Clinical Examination (OSCE) and are therefore familiar with the simulation process (Nursing and Midwifery Council (NMC), 2009). Diminishing opportunities in clinical practice means alternatives such as simulation are the next best option to practice such emergency skills (Coffey, 2015), although simulation should be complimentary to clinical practice and not used as a replacement (Van Wagner, 2012). Lack of experience or exposure could lead to loss of competence and confidence when dealing with emergencies and thus it is important to not only assesses competence during the simulation but also to give the learners the opportunity to practice their skills in a safe environment and give effective feedback to aid further learning (Norris, 2008; Scholes et al, 2012).
Simulation to develop skills
The idea of simulation is to enhance learners' knowledge, skill base, confidence, competence, communication and decision making skills (Arundell and Cioffi, 2005; Cioffi et al, 2005). Lathrop et al (2007) state that there are multiple domains employed during simulation: the cognitive domain, which focuses on the knowledge gained for an effective performance; the psychomotor domain, which focuses on the skills required to deal with the event; and the affective domain, which requires the learner to assume the appropriate role, manage their own stress responses and maintain effective relationships with the team. The third domain is often the hardest to achieve and is not thought to be targeted enough in clinical education (Lathrop et al, 2007). However, it is arguably one of the most important to address when dealing with an emergency involving the multidisciplinary team, as it aims to enhance professional relationships and enable professionals to work effectively together.
Most staff are considered to have the required skills and knowledge to achieve a safe outcome; however, using teaching techniques such as simulation can also identify a learning need or gap in knowledge, on which further training can be provided. Furthermore, due to communication errors or lack of understanding of roles, ineffective teamwork is often an identified cause of mistakes when dealing with an emergency situation (Lathrop et al, 2007; Manktelow et al, 2017).
RCOG and the Royal College of Midwives (RCM) recommend annual skills and drills training in the clinical area using the multidisciplinary team (RCOG, 2016). This aims to not only act as a refresher for staff, but also to enable professionals to practice working as a team without the pressure of a real emergency situation (Norris, 2008). Furthermore, in line with the recent National Maternity Review (NHS England, 2016), multiprofessional working is advocated to allow the breakdown of barriers between doctors, midwives and other professionals. NHS England (2016) suggest that this should be facilitated via training which should be multidisciplinary in order to create a better understanding of each other's roles and responsibilities, thereby enhancing teamwork and providing the public with safe and effective care. This is supported by Kumar et al (2014), who suggest that increased collaboration between teams improves patient outcomes.
Rationale
At Southport and Ormskirk Hospital Trust, skills and drills simulation forms part of the midwives annual mandatory training, where they have a full day dedicated to practising emergencies. Maternity staff are all expected to attend annual mandatory training, where they will undertake skills and drills. In addition, all staff that rotate to delivery suite are also expected to attend the ‘Managing the sick obstetric patient study day’ every 3 years in addition to the annual skills and drills training. This study day is facilitated twice a year.
This was not always the case, however: it was previously noted by the staff that training programmes were inadequate and did not meet their leaning needs, which was supported by findings from the the Care Quality Commission (CQC). In most cases during mandatory training, staff were simply reminded of the steps involved in each emergency, and sometimes old and unrealistic models were used to practice. This was the motivation for the Trust to focus on improving training and making simulation a priority. Looking at the evidence to support enhanced learning through high fidelity simulation, the Trust decided to purchase a high fidelity simulator, and a group of staff were trained to use the equipment. Although the team already ran a high dependency study day twice a year called ‘Managing the sick obstetric patient’, the new simulator would also enable the study days to re-create a situation in real time for annual mandatory training and live skills and drills in the clinical areas. It is important to note that obstetric emergency training at the local Trust, although grounded in evidence-based practice, does not use packages such as Advanced Life Support in Obstetrics (ALSO) and PRactical Obstetric Multi-Professional Training (PROMPT), as the Trust does not have trained staff to cascade and deliver this form of in-house training.
Setting
The Southport and Ormskirk Hospital Trust study day, ‘Managing the sick obstetric patient’ is dedicated to teaching in-depth information on maternal resuscitation, airway management, circulation and haemorrhage, sepsis, pre-eclampsia, the maternal early warning score and human factors in healthcare. All of these contribute to maternal morbidity and mortality each year (Manktelow et al, 2017) and therefore inform obstetric guidelines, policies and practice. The multidisciplinary team (Box 1) are involved in the simulation exercise, both as facilitators and as participants. The simulations are recorded and then played back to the staff to aid discussion, debrief and constructive feedback.
The annual mandatory training focuses on specific emergency situations and involves discussion and practice of the required skill. Simulation is a key part of mandatory skills and drills training in order to practice emergencies. The same equipment is often used, but the simulation is usually on a smaller scale, using low fidelity simulation and models. It is not filmed and normally takes places in the clinical area. Both the study day and annual mandatory training are occasions when staff expect their skills to be tested and discussed.
The live drills differ, as staff on shift are expected to deal with the emergency simulation without warning, just as they would with a real emergency. The live drills are in place to assess competence, promote reflection and improve team working for the future. The live drills take place in the clinical area to add to the realism, and occur at random so that the clinical staff on shift are unaware that there is a simulated emergency, making them act spontaneously and in real time.
The annual mandatory training focuses on specific emergency situations and involves discussion and practice of the required skill. Simulation is a key part of mandatory skills and drills training in order to practice emergencies. The same equipment is often used, but the simulation is usually on a smaller scale, using low fidelity simulation and models. It is not filmed and normally takes places in the clinical area. Both the study day and annual mandatory training are occasions when staff expect their skills to be tested and discussed.
The live drills differ, as staff on shift are expected to deal with the emergency simulation without warning, just as they would with a real emergency. The live drills are in place to assess competence, promote reflection and improve team working for the future. The live drills take place in the clinical area to add to the realism, and occur at random so that the clinical staff on shift are unaware that there is a simulated emergency, making them act spontaneously and in real time.
Study design
To analyse the effectiveness of high fidelity simulation on multidisciplinary working, feedback forms were given to participants following the simulation session that formed part of the annual mandatory maternity training that took place on 17 March 2017. These forms were then used to derive themes for analysis, in order to determine if simulation was effective in enhancing confidence and competence among the multidisciplinary team. During the mandatory training session, ten midwives and four obstetricians (all grades) participated in the simulation, which was organised and run by a multidisciplinary team consisting of an obstetric consultant, senior practice education/development midwife and a consultant midwife. The simulation exercise took place during the course of one afternoon and two scenarios were incorporated: shoulder dystocia and eclampsia. These scenarios were chosen by the simulation team so that all participants could achieve their required learning outcomes, which included working as a team in theatre, airway management, maternal resuscitation and dealing with obstetric emergencies.
Results
Tables 1 and 2 show the raw data that was initially transcribed and collated from the questionnaires and Table 3 highlights the main themes and sub themes that were identified from the raw data.
| Session evaluation questions | Yes n (%) | No n (%) | No difference n (%) | No answer n (%) |
|---|---|---|---|---|
| Was simulation beneficial to your role? | 12 (100) | 0 (0) | 0 (0) | 0 (0) |
| Has simulation enhanced your communication skills? | (80) | (10) | 0 (0) | (10) |
| Do you feel using the multidisciplinary team was beneficial for simulation? | (100) | 0 (0) | 0 (0) | 0 (0) |
| Did the simulation meet your learning needs? | (90) | 0 (0) | 0 (0) | (10) |
| Do you feel more self-competent as a result of the simulation? | (70) | 0 (0) | (20) | (10) |
| Did you feel pressured to participate? | (25) | (75) | 0 (0) | 0 (0) |
| Was the feedback given constructive? | 0 (0) | 0 (0) | 0 (0) |
| Qualitative questions | Positive qualitative comments | In need of improvement qualitative comments |
|---|---|---|
| Was simulation beneficial to your role? |
|
|
| Has simulation helped you to better understand roles and responsibilities within the multidisciplinary team? | ||
| Is there anything that needs to be improved? | ||
| What went well? | ||
| Are there any scenarios you would like to see included in the future? | ||
| Did you feel pressured to participate?* | ||
| Was the feedback given constructive? |
| Theme | n |
|---|---|
| Main themes | |
| Improved teamwork | 8 |
| The high fidelity model used was realistic and added to the realism | 6 |
| Helpful refresher on how to deal with emergencies | 7 |
| Sub-themes | |
| Feedback was practical and efficient | 4 |
| Increased confidence and communication skills | 4 |
| Needs to be more real, e.g. going to get equipment from wards | 4 |
There were three main themes that were identified:
There were also three sub-themes that were identified:
The feedback forms showed that most participants found the simulation exercise useful in improving teamwork within the multidisciplinary team. Participants commented that the realism of using high fidelity simulation helped them to better understand roles and responsibilities, and increased communication skills and confidence. Although efforts were made to make the simulation as realistic as possible, staff commented that it could have been made even more so if they had had other responsibilities, such as collecting equipment and preparing drugs, with the scenario running in ‘real time’ (Lateef, 2010). Most comments were positive, with the only constructive comments suggesting more time for the scenario and for feedback, concurrent with Garden et al (2015) who suggest that the feedback process should take as long as the simulation.
Although most respondents did not feel pressured into participating, those who reported feeling pressured commented that this was partly due to their own anxieties surrounding simulation. These participants nevertheless recognised that it was important, as lifelong learners, to enhance knowledge and skills. As voluntary participation enhances learning (Davys and Jones, 2007) and a supportive environment increases enjoyment of training, allowing staff to volunteer for the skills and drills study day ensured that participation was not forced and therefore formed a conducive learning environment.
Discussion
High fidelity simulation refers to the ability of the participant to ‘suspend disbelief’ and react as they would do in the clinical area (Lathrop et al, 2007).
Involving the multidisciplinary team during simulation is important to achieve learning outcomes and to ensure the reality of the scenario (Scholes et al, 2012). In addition, this adds another layer of expertise and helps all participants to understand each other's roles during an emergency situation (NHS England, 2016). Poor communication within the multidisciplinary team often results in ineffective teamwork and has been identified as being at the root cause of most clinical errors (Hamman, 2004; Lathrop et al, 2007). As a result, the ability to understand roles within the multidisciplinary team and to improve communication skills within the team is paramount to achieving safe and effective teamwork.
Simulation can be a daunting prospect, so learners should feel supported. The importance of effective feedback was highlighted by the facilitators as being key to effective learning. Ramani and Krackov (2012) suggest that feedback should be a two-way process between the learner and facilitators, and advise that discussions should be led by the learner to aid self-reflection.
The debrief gives the opportunity for feedback, analysis and identification of strengths and areas for improvement to enhance future clinical practice (Murphy-Tighe and Bradshaw, 2012). The debrief should be undertaken by a skilled facilitator (Scholes et al, 2012) and should aim to increase participants' confidence and competence. Allowing participants to self-reflect promotes critical thinking and aids reflection on accountability (Yuill, 2017). Garden et al (2015) also suggest that the debrief must contain meaningful discussions for it enhance learning effectively. Critical self-reflection can transform learning (Olsen, 2013) and starting the debrief with open questions enables learners to self-reflect and facilitators to explore points further.
In the Trust, the debrief uses self-reflection to enhance discussion between the learners and facilitators, making the feedback effective in capturing discussions of any areas that went well or were in need of improvement. This is conducted by the multidisciplinary team in order to gain perspectives from all disciplines and enhance team working. The feedback is given as a group and takes the form of a general team discussion, so that no one feels singled out. If a poor individual performance were noted, the individual would be spoken to separately to discuss any further training or support that might be required.
During the ‘Managing the sick obstetric patient’ study day, learners participate in taught sessions, including a session on ‘Human factors’, which shows learners that human error is natural (Akroyd et al, 2016; Kortum, 2017). This message was also reinforced during the preliminary briefing before simulation to allow the learners to relax and not feel that they were being scrutinised. As a result, learners were noticeably more relaxed and willing to engage in the simulation, although this was an observation made by the team and was not formally measured. This is important to note, as this creates a more welcoming, supportive and encouraging environment and aids learning (NHS England, 2016). This is supported by studies that suggest that voluntary participation and an environment that promotes encouragement and support increases learning both in terms of quality and quantity (Davys and Jones, 2007; Scholes et al, 2012). The staff were observed to be nervous about the simulation, which was also evidenced by comments that indicated increased confidence and relaxation. Furthermore, the staff were observed to feel more relaxed after human factors training and were more able to actively engage in simulation. As a result, the human factors training has now become an important element that is now incorporated into the annual mandatory maternity training and the live skills and drills.
Implications for future practice
In the future, the team plan to continue to use high fidelity simulation as part of the monthly mandatory training for skills and drills training, including the discussion around human factors. The staff had previously used basic equipment to practice and talk through the process of obstetric emergencies; however, high fidelity simulation will encourage the staff to become immersed into simulation-based learning and promote an open and honest culture of supporting each other and enhancing care. In addition, the Trust has also started to run live drills on the maternity wards using the high fidelity simulation mannequin, making the simulation even more realistic as the staff are unaware that the simulation is about to occur and can react in real time and in the clinical area. With the addition of the ‘Managing the sick obstetric patient’ study day, this should ultimately enhance the staff's ability to participate in simulated learning, allowing it to become embedded into their continuing professional development. Working with the multidisciplinary team will enhance teamwork and improve understanding and knowledge of individual roles. In future, feedback will be retrieved and analysed from staff allocated to the ‘Managing the sick obstetric study day’, as this usually consists of a more varied multidisciplinary team. This will give further insight into the effectiveness of high fidelity simulation with the multidisciplinary team. Furthermore, as this is a discussion paper, to further develop and build a robust picture analysing the effectiveness of high fidelity simulation using the multidisciplinary team, a qualitative research study using semi-structured interviews and/or focus groups would be beneficial to capture and analyse data in more depth for future practice.
Limitations
It is important to note that this evaluation of events took place after only one simulation session and further evaluation and survey forms would need to be conducted in order to build a reliable picture to illustrate the value of high fidelity simulation using the multidisciplinary team within the Trust.
Conclusion
High fidelity simulation plays a major role in training and assessing the competence of staff. In addition, when used with the multidisciplinary team, learning is enhanced due to the realism of a scenario, the ability to give constructive feedback, and the opportunity to gain knowledge and understanding of roles within the team and improve communication skills. This article highlights the importance of effective teamwork and how it can be achieved with high fidelity simulation. High fidelity simulation will continue to be an integral part of continuing professional development in the Trust in order to continually improve the competence and confidence of staff and students and enhance patient care and safety.