INTERPROFESSIONALISM Working Better Together The GAPS Team, St George’s Advanced Patient Simulation & Skills Centre

The challenges to delivering multi professional simulation . . . …. In order to create Inter-professional learning @GAPSsimulation www.gapssimulation.com

SIMULATION FOR REAL TEAMS, IN REAL TEAMS WE DELIVER Multi-professional team training WE DELIVER Multi-professional skills training All our courses look to re-create the ‘real team’ in order to look at the non bias human factors / non technical skills required in routine and complex clinical management We train teams to work and look at team performance FEEDBACK Mission Statement : GAPS enhances patient care through learner-centred simulation and skills training. We design and deliver high quality programmes which recognise the essential place of multi-professional teams in the delivery of healthcare. INTER-PROFESSIONAL STUDENTS, POSTGRADUATE TRAINEES, TRAINED NURSES, DOCTORS AND ALLIED HEALTH PROFESSIONALS

IPE - A social idea of learning & safety Sharing information and encouraging feedback giving and seeking – feedback slides Engaging in proactive and preemptive analysis with others about risks to safety – pre brief – what could go wrong? Being supportive and responsive to others with you – safety time outs – speaking up – reviewing together to identify the gaps and how we can fill them in the future Changing our perceptions of learning as a structured individual activity – group work, organisational learning as a team as opposed to individual Hollnagel et al. 2000; Weick and Roberts 1993; Reason 2004

Professional bodies using the GAPS learning centre. Over the 2015-2016 period of 365 days or 253 working days the department of 5 full time employees has produced 339 individual courses which is an average of 1.4 courses per working day. The 339 courses have had 1069 faculty and 4334 participants ‘booked on’ to attend courses in the GAPS centre.

Three different discussions: Challenges to Inter-professional learning Over the next 45 mins – Three different discussions: Challenges to Inter-professional learning Remedies Ideas Three programmes that answer these questions to create interprofessional @GAPSsimulation www.gapssimulation.com

So….We have to learn to work inter-professionally But before we can do this, isn’t it true that we have to learn to learn inter-professionally? Design and setting IPE objectives @GAPSsimulation www.gapssimulation.com

Resources & Leadership Challenges to IP SBT Funding Educational Design Faculty Resources & Leadership www.gapssimulation.com

HEE & Specialty Funding Duplication of programmes Tariff Mobile Duplication of programmes Postgraduate Where it has previously come from and where will it come from in the future? More emphasis on the individual Trust to prepare and train their workforce? – Are they starting to realise the effect of ‘team training’ within the core of the hospital (Nursing ) to assist and provide that safety net for medical staff rotating through? Reduction in duplication of effort Reduction in fragmentation of care Enhancement of patient safety Promotion of high quality care Cost effectiveness www.gapssimulation.com

HEE SERVICE LEVEL AGREEMENT FOR FOUNDATION YEAR DRS 1.6.3 To promote understanding of inter-professional working and provide multi-professional education, the Simulation training for Foundation Year Doctors in Training should also be encouraged for nursing staff (although these are not to be reported on as part of the evaluation). 1.6.4 The Provider must deliver the Programme as per the learning outcomes and simulation scenarios focussing on clinical skills mapped to the Foundation curriculum - http://www.foundationprogramme.nhs.uk/pages/home/training-and-assessment 1.6.5 As well as the rehearsal of clinical skills the Programme should enable candidates to enhance their understanding of communication skills, team-working, crisis resource management and the impact of human factors on patient safety 1.6.8 Each scenario and participant will undergo debriefing encouraging reflective practice and a deeper understanding of the learning points

Enhancing UK Core Medical Training through simulation-based education: An evidence-based approach A report from the joint JRCPTB/HEE Expert Group on Simulation in Core Medical Training Non-technical and human factors skills Aside from its clear role in enhancing the effectiveness of teaching procedural aspects of the CMT curriculum, SBE also offers an opportunity to deepen understanding and awareness of the importance of non-technical skills, such as communication and ‘human factors’ in healthcare delivery. Teaching human factors using SBE has the potential to help individuals recognise and devise coping strategies for dealing with challenging non-technical issues, such as task prioritisation in times of high workload, managing distraction and avoiding ‘fixation error’. It can also improve patient safety by ensuring a team-working approach. HEE October 2016

MEERKATS Medical Emergencies: Evaluation, Response and Keeping Attention on Team Communication and Patient Safety FOUNDATION 11 x planned courses. 4 x FY2’s per Course (44 total) 4 x FY1’s per course (44 total) 4 x senior nurse places (44 Total) 8 x junior nurse places (88 Total) MEDICAL SCHOOL 192 places for nursing staff – 330 MEDICAL STUDENTS CMT 49 x CT1’s 37 x CT2’s 88 x Band 6-7 Nursing TOTALS = DRS 504 NURSES 368 St George's acute care inter-professional courses for Doctors, Nurses, HCA’s, Medical & Nursing Students.

Educational Design www.gapssimulation.com Curriculum Mapping Specialty vs Team LOBs Workshops Programme Efficiency Programme Design We need to think about the inter-professional agenda and alignment across curriculums, and think about a team as a unit of success- pitstop analogy www.gapssimulation.com

Alignment Re-examination of speciality curriculum Complex competencies Constructive alignment (Biggs 1999) Learning objectives Scenario design Scripted triggers In-scenario learning We think that simulation is all about promoting ‘reflective learning’. We help learners to identify the gaps between the appropriate standard and the observed behaviour. And then help them identify what causes these gaps. Generally is is not much to do with knowledge and a lot to do with managing oneself and the environment. And that environment is a complex one. There is more than one patient, teams are multi-professional, families and ethical issues come into the picture, and so on… The foundation program curriculum defines a set of knowledge, skills and attitudes which include decision-making and prioritization of tasks, team working, communication with patients and recognition and management of the acutely ill patient. How do you teach these complex activities? Simulation is probably a good tool for this. We use an educational concept called ‘constructive alignment’, espoused by John Biggs, in which desired educational outcomes, the learning experience and assessment are supposedly ‘in tune’ with one another. It is an approach not without its critics but we find it useful for developing the whole educational experience. We script our scenarios using triggers to progress towards explicit learning objectives. This also requires faculty training and we developed faculty guides to facilitate this progression. We think this approach encourages in-scenario learning as well as enhances reflection in feedback sessions and, perhaps, later in the workplace. We also use the concept of ‘spiral learning’, familiar to most. Through the day themes are revisited and each learner experiences a second simulation scenario having had the opportunity to reflect on his or her earlier experience.

Constructive alignment “Outcomes are what people see. But your real art is to shape the pathways” - From E techne macre (Art is Long), Vahe A. Kazandijan

What makes for a compelling Experience? CHALLENGE DRAMA SOCIAL Mental simulation, emotion Bonding, sharing co-operation Physical & mental challenge

1 Lab Centre A B GROUPS Final Year Medical & Nursing Simulation Course   ROOM ALLOCATIONS A GROUPS B Faculty Lead 0830-0900 COFFEE, REGISTRATION, Treasure Hunt 0900-1000 INTRODUCTION & MEET the MANNEQUIN Triage 1000-1020 SIM 1 SKILLS 1 1020 -1040 DEB 1 1020-1040 1040-1100 1100-1125 SIM 2 COFFEE 1125-1145 DEB 2 1145-1215 SIM 3 1215-1245 DEB 3 1245-1315 LUNCH 1315-1345 SKILLS 2 1345-1415 SIM 4 1415-1445 DEB 4 1445-1515 1515-1545 SIM 5 1545-1615 DEB 5 1615-1630 EVAL & CLOSE 1615-1645 1645-1700

Foundation Simulation IPE TIME SIM LAB 1 SIM LAB 2 WARD (Skills Lab) 8:15 – 8:45 REGISTRATION/TREASURE HUNT 8:45 – 9:00 Team Introduction/Departmental Orientation/Overview of programme PPoint 9:00 – 9:40 Meet The Mannequin – Triage Game   4 GROUPS - rotating to see 4 patients See Triage notes at end of document 10 mins per patient: 1. Georgina Blackshaw (Head injury, 2. Paul Rogers (Asthma/tension), 3. Anne Marshall (GI bleed) 4. Human patient ( GAPS Member) 9:40 – 10:00 INTRODUCTION TO SIMULATION – GROUP DEMONSTRATION RUN THROUGH (A-E assessment of a manikin, getting test results, ECG, PACS ETC) 10:00 – 10:35 SEPSIS/SEPTIC SHOCK (Pt. A – Mary Lanes) (SIM LAB 1) COPD (Pt. B – Albert Blackstock) (SIM LAB 2) + ACTOR (as relative) 1. Ascitic Tap (Actor) Joseph Harold 2. Seizure (ETOH) Hamish Grady 3. End of Life (Noelle + Phone call) Anne Smith 10:35 - 11:10 Group Feedback & Table top discussion 11:10 - 11:25 COFFEE Individual Feedback to F1 11:25– 12:00 AKI/↑K+/↓HR MI/↓HR 3. End of Life (Noelle + Phone call) Anne Smith 12:00– 12:35 12:35– 13:15 LUNCH Individual Feedback to F1 (12:35 – 12:50) 13:15 – 13:50 ↑GLU/HHS (Pt. C – Lisa Morley) ACUTE ABDOMEN (Pt. D – Ronald Burgundy) ACTOR (as patient) (SIM LAB 2) 13:50 – 14:25 14:25 – 14:40 14:40 – 15:15 ↓GLU/SEIZURES ( Pt. C – Lisa Morley) POSTOP DELIRIUM ( Pt. D – Ronald Burgundy) ACTOR (as patient) (SIM LAB 2) + 15:15 – 15:50 16:05 – 16:30 EVALUATION & CLOSE Foundation Simulation IPE

Core Medical Training 1 2 3 4 08:00 08:30 09:00   ~~~~~~~~~~Faculty Meeting~~~~~~~~~~ 08:30 Registration & Treasure Hunt 09:00 Introduction Lecture & HF (LT) 09:40 Meet the Mannequin ROOM Clinic (OBS 1) Sim 1 Sim 2 Clinic (Obs 2) Ward Round 10:00 1 CT1 CT1 and CT2 (Bleep 8200) Michael Vincent CT1 & CT2 (Feedback) Ivan Black CT 2 CT1 & CT2 Joseph Harold, Hamish Grady, Anne Smith 11:00 C O F F E E 11:15 2 12:15 L U N C H 13:15 3 CT1 and CT2 (Bleep 8200) John Smith CT1 & CT2 (Feedback) Arthur Foot 14:15 4 CT1 & CT2 Joseph Harold, Hamish Grady, Anne Smith 15:15 15:30 Q&A / Summary and scenario re-runs 16:00 Evaluations & Close

Partnerships In design Faculty Partnerships In design Multi-professional Training Q&A / SPOT Inter- professional learning aiming to map on to a positive and contributing inter-professional workforce agenda isnt possible without inter-professional faculty… www.gapssimulation.com

Faculty Development GAPS currently runs three styles/modules of the Train the Trainer series: Train the Trainer Classic Train the Train for Practice Nurse Educators International Train the Trainer in Greece.

Faculty Development Topics Covered   Research in High Risk Organisations and resilience Educational theory and feedback Teaching techniques with mobile and fixed patient simulators Team assessment with behavioural observation tools Developing inter professional conversations about practice Learning Outcomes Participants should be able to: Apply a variety of small group teaching strategies and techniques with simulation to enhance the learning environment for their teams. Draw from an extended repertoire of feedback techniques Be advocates for multi-professional team training using simulation and be able to refer to its evidence base for patient safety. Apply new skills in delivering mobile and fixed simulation training.

FERRETS FOUNDATION SIMULATION FACILITATOR GUIDE: GROUP A INTRODUCTION This is a brief guide to the FERRETS (Foundation Exercise using Realistic Resources and Effective Team Simulation) Foundation Programme simulation course at St Georgeʼs. It will tell you about the course aims, the key learning outcomes, the role of the facilitator and a step-by-step timetable for your day. The important features of the FERRETS programme are: it is multi-professional (the ʻfaculty nursesʼ and the student nurses are essential in achieving the learning outcomes of each scenario). it is complex (a key theme of the day is the development of safe and effective practice in the context of a chaotic environment) it focusses on team interactions (the F1 and F2 must be encouraged to communicate during their parallel scenarios) each scenario has a number of specified learning outcomes which are underlined by particular expected interactions within the scenarios. (Trainees are likely to achieve these as the scenarios develop. If they donʼt, they must be ʻtriggeredʼ by the faculty nurse, a phone call or the patient.) AIMS The FERRETS course is designed to recreate the complex experience of acute medical care in hospitals and help trainees reflect on how they work in this environment. It is not designed to be a clinical tutorial nor is it merely a ʻteam-buildingʼ and communication exercise. It focuses on the practical things which translate knowledge into action in patient care. Importantly, we aim to develop skills and confidence among trainees so that they can participate in professional conversations about practice. Opportunities for all trainees to provide and to seek feedback on individual and team performance should be exploited. LEARNING OUTCOMES By the end of the day, the participants should be able to: Explain how human factors are an integral component of how they deal with clinical problems •Explain how improving team functioning can improve safety and efficacy in clinical performance. •Apply the language of NTS to analyse own and otherʼs performance in group discussions Demonstrate an ability to plan and order initial assessment and management Identify what causes the gaps between an ideal clinical outcome and an observed one Faculty support and pre – loading as well as continual feedback on design and learning outcomes © Huon Snelgrove, Nicholas Gosling, Vaughan Holm, Greg McAnulty, GAPS, St Georgeʼs Advanced Patient Simulator, October 2011

Discussion & Experiences Table top example & discussions: Mobile Examples- GP, Dental, Ward & Max Fax Educating the mobile Educators – TtT / PNE SWAMPI - Simulation Workshops At the Mental-Physical Interface Over the next 45 mins – Three different discussions: Challenges to Inter-professional learning Remedies Ideas

Resources & Leadership Release of Staff Mobile In Situ Data Success Criteria www.gapssimulation.com

We would love to discuss your thoughts afterwards, and possible collaborations including your ideas of best practice Please stay in touch! www.gapssimulation.com @GAPSsimulation www.gapssimulation.com

Resources & Leadership SUMMARY INCREASING IPE USING SBT Reduction in duplication of effort Reduction in fragmentation of care Enhancement of patient safety Promotion of high quality care Cost effectiveness Challenges to IP SBT Funding Educational Design Faculty Resources & Leadership www.gapssimulation.com

We would love to discuss your thoughts afterwards, and possible collaborations including your ideas of best practice Please stay in touch! Details on GAPS Web @GAPSsimulation www.gapssimulation.com

Questions? Evaluation (kirkpatricks hierachy) Reactions Knowledge skills attitudes Behavioural transfer Institutional changes Criticism of Biggs (educational psychologist) Is learning cause and effect Even if we create this learning tool (cause) will it lead to learning (effect)???? Reference: “Teaching for Quality Learning @ University” book by Biggs Open University Press 1999 https://gapssimulation.com/cnwl-interprofessionalism-conference-22nd-february-2017/