Abstract
Introduction
There have been a number of drivers for the use of simulation in healthcare education for the NHS workforce. The development of an accessible and efficient national approach to its implementation has been challenging.
Methods
An action research approach was used to develop a national strategy using several data inputs.
Results
From sampling across practitioners and territorial health boards geographical and professional groups, access was the main challenge to the use of simulation.
Conclusion
Four priority areas were identified, which formed the basis of the national strategy Partnership for Care, which included a mobile unit, a managed educational network, a programme board and an alliance of stakeholders.
Introduction
Scotland has a long history of being innovative, recognising the need for change and finding solutions within healthcare. Since the publication of To Err is Human in the USA 1 and An Organisation with a Memory in the UK, 2 there has been an increasing focus across healthcare systems to reduce the incidence of adverse events. Simulation can provide a safe learning environment, where an adverse event can be deconstructed into learnable chunks, which can be paced to the needs of the learner(s) and then reconstructed to provide a rehearsal of the entire event. It can also be used to refine practices or redesign systems, 3 but is costly and can be inefficient if not well coordinated.
Machines, Manikins and Polo-mints 4 recommendations on safer practice from the CMO in England in 2009 highlighted the crucial role simulation could play in enhancing the consistency of standards of clinical practice given its successful use in high-reliability organisations such as aviation and the military. Scotland had already harnessed the expertise and innovative practice in the use of simulation in NHS Scotland by launching the first National Clinical Skills Strategy in 2007 to support workforce development in Scotland. This was in part driven by policies including Building a Health Service Fit for the Future 5 and Better Health Better Care. 6 A further driver was the increase in purpose built simulation centres like that in Dundee developed to meet the requirements of the new ‘Tomorrows Doctors’ curriculum 7 for undergraduate medical education. This paper shares how the strategy, Partnerships for Care 8 was developed through a consultation process.
Methods
An action research approach was used to conduct the consultation process for the development of the Partnership for Care strategy. This was the most appropriate approach to use 9 as it provided evidence that could be then used to develop the strategy.
Reports and blueprints
In 2002, NHS Education for Scotland (NES) commissioned a review of simulation education and training facilities both in the NHS and Higher Education Institute (HEI) sectors. One of the findings was a lack of accessibility for different healthcare practitioners in the use of simulation for training.
The multi-professional Scottish Clinical Skills Network (SCSN) at its national conference in 2005 agreed a Blueprint for Clinical Skills for Scotland highlighting the need for national standards of skills practice to enhance recognition of clinical skills capabilities across health boards.
An internal report from the executive team within NES collated this information to identify concerns that there was inequity of provision of high quality clinical skills education provision using simulation across regions and across specialties and professional groupings.
These reports and the Blueprint led to the appointment of a team to investigate, assess and recommend a proposal to address the concerns raised around the provision of clinical skills education using simulation.
Site visits
A series of site visits around Scotland were undertaken over a six-month period in 2005–2006. The purpose of the visits was to sample opinion on simulation-based education. The choice of visits was based on developing a ‘big picture’ of current provision. These one-day visits did include sites, where there were no simulation facilities, as well as those that had purpose-built centres. Visits were undertaken in different regions both rural and urban, in NHS, across the Royal Colleges and in Higher Education Institutes and involved different professional groupings. A pro forma of topics was used for each site visit to gather evidence, which covered aspects such as the breadth of programmes, access to facilities, staffing for units, specialist manikins and funding streams.
Regional meetings of key stakeholders
Following the visits, three regional meetings based on the workforce strategic planning units were organised for all those involved in education and simulation-based education and training in NHS, NES and HEIs as well as the public to feedback the opportunities and challenges that had been identified from the visits. In addition, individual experts of all institutions were invited at senior level to participate. These regional meetings were run as one-day workshops and incorporated a series of presentations and a question and answer session to develop consensus on what was currently provided and required nationally.
Results
All 13 territorial Health Boards in Scotland were visited during the sampling of opinion. A total of 22 site visits were undertaken. One of the main findings from remote and rural Scotland was the lack of access to a simulation facility within a 100-mile radius. There were also several examples of duplication of effort across Health Boards with an example being the existence of 20 different venipuncture-training packs. There was also no quality assurance process in place, so if a practitioner was trained in a procedure in one Health Board, training had to be redone if they moved Boards. In some specialist simulation facilities access was available to certain professional groups and in some undergraduates could only use the facilities. This was often due to different funding streams. There was no coordination between those units providing specialised training and no national standards of skills practice.
At each of the three regional meetings, there were between 30 and 50 participants representing individual expertise and institutions. They were presented with the above findings and the potential solutions. These were then refined through discussion in the question and answer session. The consensus was for
A supported network to develop a quality assurance process The development of a mobile skills facility for remote and rural practitioners to increase accessibility to all health care professionals A national system for the development of evidence-based resources Research and development funding to support ongoing innovation
Those working in clinical skills education using simulation recognised the added value of being in an alliance of stakeholders to ensure this costly intervention in terms of money; space and faculty could be managed more explicitly at national level.
Discussion and conclusion
There has been evidence of inefficient use of simulation-based education facilities in developing health care practitioners due to inappropriate planning and coordination. There are published reports of the under-use and inappropriate use of manikins due to lack of trained faculty as well as facilities.
The findings from the reports, the SCSN Blueprint, site visits and regional meetings of key stakeholders identified a lack of consistency in standards of skills practice across Scotland and a lack of geographical and multi-professional access. It was essential, when developing a strategy, that these three main areas were prioritised. The composition and skills of the workforce provide the capability to respond to changes in demand. The implementation of a clinical skills strategy would ensure the safe and sustainable service delivered by up-to-date practitioners.
Four priority areas were identified from this consultative process that formed the first National Clinical Skills Strategy Partnership for Care
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Establishment of a national alliance on clinical skills Establishment of a national managed education network for clinical skills Establishment of a Programme Board to manage specialist units Piloting of a mobile skills facility in remote and rural settings
The added value of having a national approach to the use of simulation to train and educate the NHS workforce is to enhance patient experience, to improve patient safety and to achieve best value for the money already invested in clinical skills education.
Footnotes
Authors’ contributions
JK developed the SCSN Blueprint, participated in a site visit and regional meeting and drafted the manuscript. PC and BB led the site visits and regional meetings and contributed to the critical review of the paper.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical review
Formal Research Ethics Committee (REC) was not obtained but NHS REC guidance was adhered to. Under the ‘Governance Arrangements for Research Ethics Committees' in the UK, ethical review is not required for research that involves NHS staff recruited as research participants by virtue of their professional roles: 
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The strategy development was funded by NHS Education for Scotland.