This article describes a point-of-care simulation training program to improve acute disease management in a community hospital environment
With the shift to more localized healthcare, new education and training models are needed to improve quality and safety, while involving employees and empowering them. As a training method, bedside simulation is becoming more and more popular in the healthcare field and has many advantages over standard simulation. This article describes the design, implementation, and evaluation of a real-time simulation training program to improve the identification and management of acute diseases in a community hospital environment. The project evaluates skills, provides tailored educational content and re-evaluates learning. It promotes the implementation of organizational safety changes, and improves employees’ knowledge and confidence in identifying and managing patients with worsening conditions.
Citation: Clotworthy K et al. (2021) use real-time simulation to better manage acute exacerbations. Nursing time [online]; 117: 12, 39-43.
Authors: Kim Clotworthy is the chief clinical coordinator; Jay Over is the senior resuscitation officer; both are cooperating with the NHS Foundation Trust Fund in Cornwall. Adam Pollard is the head of demographics at the Royal Cornwall Hospital NHS Trust.
The NHS long-term plan of NHS England (2019) aims to move healthcare to a place closer to home, which requires a new service model. This includes strengthening and developing community services to reduce the increasing burden on emergency hospitals.
Cornwall cooperates with the NHS Foundation Trust Fund to provide community services in 10 adult physical health community hospitals and people's homes on an isolated peninsula. The area is a rural area with a wide population distribution and only one emergency hospital provides services. The development of community hospitals in the area is critical to achieving the goals of the NHS's long-term plan, improving the quality of patient care, ensuring the long-term sustainability of county-wide services, and reducing unnecessary acute hospitalization rates.
A community workforce with improved skills and cohesion is essential for this. It requires sufficient competent and skilled employees to be able to meet healthcare needs and provide consistent, safe and effective care. Patients need to receive care commensurate with their needs in the right care environment and at the right time with the right nursing professionals. This brings a variety of challenges, including training around; real-time simulation is a potential solution to this problem.
When focusing exclusively on emergency management, simulation education has been shown to improve the team’s knowledge, confidence, and communication skills (Crowe et al., 2018). Effective use of simulation has been identified as a key priority to support the development of healthcare personnel. Former Chief Medical Officer Sir Liam Donaldson described it as "an important part of building a safer healthcare system" (Donaldson, 2009).
Simulation training has also been validated as a learning method by the Royal College of Nursing (2017), Ministry of Health (2011) and Medical Council (2011); Health Education in England (2018) has published a framework for its use. It provides a real learning environment that reflects real life scenarios and enables employees to put knowledge and skills into practice.
Traditional medical simulation training is standardized, conducted in a controlled, highly technical environment, and usually conducted by employees from the same professional team. It is provided in a non-clinical environment, simulated to look like a clinical environment. In contrast, newer and more innovative point-of-care or in-situ simulations allow multidisciplinary teams to train together in their usual patient care environment.
Learning in a familiar team and environment has some advantages over traditional simulation training. Sleeman et al. (2018) showed that training a multidisciplinary team in an emergency hospital environment can improve employee morale and strengthen education at the coal mining face. They found that the key is to ensure that employees use their knowledge, resources, and equipment when running simulations in real time. It has also been found to be useful for addressing human factors and teamwork dynamics to improve patient care.
The medical community is increasingly supporting simulation-based learning as an effective teaching and training method (So et al., 2019). Studies have shown that simulation can improve the identification and intervention of patients with worsening conditions (Lee et al., 2019), as well as nursing skills and confidence in handling complex emergencies (Crowe et al., 2018). This contributes to safer patient care.
There are fewer articles on bedside simulation training, although it is expected to bring similar benefits. It is well known that highly interactive and immersive learning is much more effective than traditional learning that is only driven by content (Pagano, 2013). Health Education England’s simulation framework (2018) states that blended learning that uses simulation in conjunction with other technologies should become commonplace in training pathways and continuous professional development.
Medical staff still receive education in professional "silos" mainly through classroom methods. It can be said that traditional education methods are not conducive to inter-professional learning or improving multi-disciplinary cooperation and communication (Vyas et al., 2012). Future learning needs to be inclusive, accessible, and time-sensitive; these are key elements for employee development in today's stressful healthcare work environment.
Shrestha et al. (2020) showed that the knowledge and skills of junior doctors have increased after in-situ simulation, and recommended that it be incorporated into existing medical education. Smith and Jankowski (2014) found that involving nurses in regular simulation training can improve skills, knowledge, and confidence. They also proposed that it has the potential to save costs by improving patient clinical outcomes. The real-time simulation of the multidisciplinary team can also sort out potential safety processes or clinical issues that are not always obvious in the simulation room to improve patient safety (Shah et al., 2019).
Simulation training provides an opportunity to bridge the gap between theory and the translation of knowledge into practice (Brown, 2019). Our trust requires registered resident nurses:
Due to the geographical distribution of our hospital team, remote community location and reduced on-site doctor capacity, these are enforced for safety. This should provide staff with basic knowledge and skills, including the use of ABCDE (airway, breathing, circulation, disability, exposure) methods to identify, evaluate, manage and treat, and resuscitate adult patients who are acutely unwell. However, the review of local systemic incidents and the staff's response showed a lack of confidence in turning the acquired knowledge and skills into practice.
There are many theories about the different ways learners learn; these need to be taken into account in order to make teaching practice suitable for different groups of learners, while helping to transfer knowledge and skills to clinical practice.
Kolb's (1984) experiential learning cycle theory proposes a four-stage continuous learning process and quantifies why the skills and knowledge learned in the classroom may not be completely transitioned to the clinical environment. Many obstacles have been recorded as affecting learning.
In the first "specific learning" stage of the classroom, obstacles may include unmet needs in the environment and different learning styles. In the second "reflection" stage, due to work needs, lack of time to reflect on the knowledge learned may be an obstacle. The third stage of "conceptualization", including teaching in the classroom, lacks a background in a clinical environment. Finally, in the final stage of "active experiential learning", employees must be able to:
Certain (if not all) identified barriers may prevent the transition of skills and knowledge to practice. Bedside simulation is a way to promote Kolb's learning process, enabling employees to explore and reflect on the real situation in the team in the usual work environment. This helps to increase confidence and embedded knowledge, as well as improve the team's responsiveness and performance in emergency situations.
With the shift to more localized healthcare, new education and training models are needed to improve quality and safety, while providing employees with participation, motivation, and empowerment. Therefore, we believe in choosing bedside simulation as an educational technology to improve the recognition and management of acute diseases in the community hospital environment.
The overall vision is to develop a reproducible and transferable bedside simulation program, which, if successful, can be promoted in all wards and departments of the trust. The specific goals and objectives are outlined in Box 1.
Box 1. The goals and objectives of the bedside simulation project
We used the plan, execute, research, act (PDSA) cycle for this project (Aguayo, 1990). It was chosen because it has a pragmatic approach and lasting effectiveness in implementing changes and helping the team improve the quality of care.
The project is planned to be carried out in three phases. Each involves a series of planned activities and is subject to its own PDSA cycle, allowing evolution and progress to the next stage. Three simulation scenarios are determined and designed:
The project was delivered by the ward teams of the two hospitals at different times over 12 months. A 20-bed ward of a hospital was used to test the model. Modified after review, and then simulated in the two wards of the second hospital. The advanced simulator model with high fidelity function was used and the patient simulation scene was developed.
Three evaluation tools were designed to measure potential improvements:
The pre-project and post-project employee confidence surveys are used to analyze employees’ knowledge and confidence in the management of patients with deterioration and their views on their participation in the management of cardiac arrest. The questionnaire used a five-level Likert score to allow respondents to specify their level of agreement with a statement; the pre-project survey asked additional questions about previous experience and participation in simulation training.
Staff are required to provide formal feedback after each mock meeting. The feedback was based on six questions related to the value of bedside simulation work experience, improving confidence and ability, and modifying practice.
Three simulation scenarios are provided without advance warning or additional training; in each game, the performance of the staff uses an agreed hypoglycemia and sepsis performance standard tool and another performance for cardiac arrest Standard tools for evaluation. Score whether employees fully, partially, or do not meet the evaluation criteria in each area listed in Box 2.
Box 2. Employee performance evaluation: Phase 1
Hypoglycemia and sepsis simulation scenario
The seven areas evaluated include:
The second stage involves evaluating the results of the first stage and implementing safety measures and customized training when needed.
The next step is to use the same evaluation tool to provide the same simulation to evaluate performance. However, in the first hospital site, this only applied to hypoglycemia and sepsis, because clinical and organizational challenges prevented us from running a cardiac arrest simulation. Due to Covid-19, we are also unable to run the third phase at the second hospital site.
In total, 107 participants participated in 31 simulations, including nurses (32%), medical assistants (38%), doctors (5%), nursing students (18%), and others (7%). Providing training at the point of care enables different occupations to train and learn together.
A preliminary survey revealed that more than half (58.2%) of employees had previously participated in some form of simulation training, but only one-third (32.7%) had participated in bedside simulation training. The comparison of the survey feedback before and after the project shows that after the project is completed, the staff feel more knowledgeable and confident (Figure 1). The confidence of employees in the management of sepsis and hypoglycemia has been greatly improved. The area with the least improvement was the confidence in using the SBARD (situation, background, assessment, recommendation, decision) communication tool, but the confidence did not decline.
The measurement of performance improvement in all seven areas of sepsis and hypoglycemia showed that more standards were fully met in the third phase than in the first phase, and all performance standards were at least partially met in the third phase. The largest increase in the percentage is the use of all elements of the SBARD communication tool by employees (60%), followed by the provision of appropriate patient treatment (49%). In the use of protocol tools (2%), the performance of staff improved the least, and there was little improvement in the use of structured ABCDE to assess patients with worsening conditions (7%).
The feedback analysis at the end of the project showed that bedside simulation was popular with employees as a learning resource; for all six questions, the average value score was 4.6 points (out of 5 points).
We have proven that bedside simulation training has several advantages, including providing experiential learning opportunities that promote cross-professional experience. This is in line with the vision of the NHS (2014) Five-Year Vision, which is to integrate services around the patient journey and involve multidisciplinary teamwork.
There are two main advantages of bedside simulation:
This is a concept that has been well developed among nursing students, for example, through practical collaborative learning methods that use collective skills, knowledge, and attitudes to interact with others (Hill et al., 2020).
We train the entire team in real time, across different employee disciplines, and use familiar equipment to work in their usual environment. This is very beneficial to employees' learning and recording results. Our results show improvements in all three evaluation measures used.
Interestingly, at the end of the project, although employees expressed the least trust in the use of SBARD, this was considered to be the area where employee performance improved the most. The least improvement is the use of protocols/policies to help manage patient deterioration, although the correct treatment plan for sepsis and hypoglycemia is well provided in the third phase.
Since our clinical staff receive regular training on the ABCDE method to identify deterioration, they should be confident and perform well in both stages. However, in the pre-project survey, only 22% of employees felt very confident in assessing and identifying patients with worsening conditions (including the ABCDE method); after the project, this proportion rose to 50%. Overall, the percentage of fully meeting performance standards has increased from 30% before the project to 65% after all simulations are delivered, an increase of 35%.
We have already mentioned the obstacles in the transition of knowledge from classroom to practice, and hope that bedside simulation can help bridge the gap between theory and practice. Reporting opportunities are an integral part of the simulation and are also important to help meet the role expectations of graduate nursing education (Ali et al., 2020). Before the project, most employees did not know any reporting mode and emphasized that reporting rarely occurs after an emergency. We use the learning dialogue of Denning and Davis (2018) to explore the performance during the post-simulation presentation.
When focusing on skills, leadership, human factors, and non-technical skills, feedback is also critical to the learning process. A fruitful dialogue initiated and led by the learner — and mediation through active listening and advocacy and inquiry as needed — has proven to be very valuable. Employees learn from each other and learn from each other, which further supports their growth and development.
The benefits of embedding real-time simulation are obvious, not only in addressing the developments and changes identified in the NHS plan, but also in promoting measures to safely and effectively provide high-quality care. The immediate simulation also led to the identification of several clinical and patient safety issues, as well as organizational risks (such as incorrect equipment and protocols in the first aid kit); this allowed them to be corrected before the injury occurred.
In the second half of the project, the UK was hit by the Covid-19 pandemic. In order to reduce the pressure on emergency hospitals, our trust has developed a community assessment and treatment unit (CATU) that accepts direct referrals from general practitioners or ambulances.
The first CATU was developed on the site of the second project, where simulation training proved to be beneficial, improving staff knowledge and clinical development. Without it, launches may be delayed, and services in the area may not be able to cope.
As mentioned earlier, we encountered some challenges in providing and evaluating bedside simulation training:
Simulation training is a time-tested educational method. It is increasingly used to provide training for various professions and organizations around the world. Bedside simulation has many advantages over standard simulations and is becoming more and more popular in the healthcare field. It solves space, transportation, and employee time constraints, while providing an immersive experience at the point of care to help employees understand, retain, and recall. It also increases confidence in handling emergencies and multidisciplinary teamwork.
It makes sense to train a multidisciplinary team in their usual workplace and is supported by the literature. If delivered on a regular basis, it may help create a more flexible workforce.
The exposure of patent safety issues, as well as process, ergonomics, or environmental errors, are also unique to the bedside training process. It allows remedial measures to be taken before the real incident, thereby improving patient safety.
Our project shows that real-time simulation can be used to update employee knowledge and improve their ability and confidence in acute disease management. It makes staff more confident when dealing with emergencies, while encouraging multidisciplinary team integration, inter-professional learning and effective care delivery. As shown by our qualitative and quantitative project evaluation feedback data, bedside simulation is an innovative training tool that is popular with employees as a learning model.
We intend to consolidate the success of this project by creating and embedding a sustainable instant care simulation program within the scope of trust. This can be replicated by other organizations to develop acute disease recognition and management training.
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Cornwall Cooperative NHS Foundation Trust
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