Background Many healthcare professionals experience challenges when returning to practice after absence, potentially affecting their health and wellbeing outcomes as they might relapse and need to take another leave of absence. These challenges may also affect patients by impeding the quality of care provided by the professional. Research suggests that managerial support can ameliorate some challenges that professionals encounter when returning to work. Objectives This pilot study evaluates a simulation training intervention offered to multidisciplinary supervisors of returning doctors in order to improve doctors’ reintegration into the workplace Methods Participants (n = 38) were healthcare leaders who completed a 1-day training course consisting of didactic and experiential components. Results Thematic analysis identified that participants noticed changes in their social skills, management abilities, values in their managerial roles and implementation of structure in the workplace. Conclusions Simulation training might improve managerial competency when supervising doctors return to work. Future studies should address inconsistencies in feedback form completion and limitations of self-reporting questionnaires. Additional assessments of returning doctors’ outcomes following intervention delivery could also be beneficial, as these were not evaluated in the present study. A larger study is currently being conducted to evaluate impact and increase understanding of how simulation training can improve managers supporting doctors returning to practice.

In this chapter, we outline the prerequisites for an effective response to patient flow pressures and discuss two case studies of work practices that have evolved to manage flow across organisational boundaries. An argument is presented calling for a better coordinated, more effective and sustainable approach to patient flow transitions across boundaries.

Objective: Effective teamwork is critical to patient safety across multiple healthcare settings. However, current observational tools assessing teamwork performance tend to be developed for specific settings or tasks and do not capture temporal features of interaction. This study aimed to develop a valid and reliable observational teamwork behaviour framework, which is based on healthcare practice, applicable across a variety of healthcare contexts and can be used to capture temporal team dynamics. Methods: Team interactions were audio-visually recorded during routine simulation training at two large clinical education centres specialising in physical and mental healthcare. The framework was based on theoretical models of teamwork and was developed in three steps: 1-micro analysis of verbal and nonverbal behaviour during recorded scenarios (n = 20); 2-iterative test and refine cycles; 3-final behavioural framework applied to a cohort of acute emergency scenarios (n = 9) by two raters to assess inter-rater agreement. Results: The framework contains twenty-three specific verbal and nonverbal behaviours that can be identified during observations. Behaviours are grouped conceptually based on their function resulting in thirteen behavioural functions, which cluster into five overarching teamwork domains. Inter-rater agreement was excellent (Cohen's Kappa = .84, SE = 0.03). Conclusion: We present a valid and reliable behavioural framework, grounded in teamwork theory and empirical observations of clinical team behaviour. This framework enables analysis of the nuances and temporal features of clinical practice in depth and across a wide range of clinical contexts and settings. Use of this framework will advance our understanding of team-working in healthcare.

Background: Hospital Emergency Departments (EDs) face variable demand and capacity issues affecting timely discharge of patients. This is due in part to a lack of integration of routine monitoring data, affecting anticipation and response. Methods: Patient flow was modelled (four hour target breaches; time to decision-to-admit; subsequent time to admit-to-hospital) in a busy ED. Patient and organisational data were collated, screened and conceptualised using Resilient Health Care (RHC) theory. Data were collected for all patients presenting during a 24-month period (May 2014-April 2016; n = 232,920) and analysed via multivariable logistic regression for four hour target breaches, and ordinary least squares regression for time. A measure of effect size was calculated for each independent variable. Overall model fit was assessed using percent concordant. Results: Length of stay is related to demand, capacity and process indicators including: number of patients; night shift; first location being resuscitation or major injury area(s); urgent or very urgent triage patients; patients readmitting from up to 7 days previous; bed capacity; recent ambulance arrivals; and patients where the primary presenting complaint (PPC) is related to mental health or difficult to ascertain. Conclusions: Understanding variation in performance through RHC theory can support staff and organisations in monitoring, anticipating and responding. A set of reliable core predictors has been identified to help design future ways to facilitate resilient performance through early indicators of pressure.

The WHO Surgical Safety Checklist is shown to reduce mortality from 1.5% to 0.8% and inpatient complications from 11% to 7%.1 Following a review, the National Patient Safety Agency added briefing and debriefing to the checklist to create the 5 Steps to Safer Surgery (5SSS). At Guy’s and St Thomas’ NHS Foundation Trust, the Care Quality Commission (CQC) and local audits reported less than optimal compliance with the 5SSS across all operating theatres, particularly with the debrief, where completion of this was as low as 0% in some departments. One reason was a lack of engagement from surgical consultants.2 Studies have shown that a high regard for the checklist and participation in team training with a focus on healthcare crew resource management (also known as Non-Technical or Human Factor (HF) skills) is associated with fewer post-operative complications.3 4 Therefore, we created an in-situ simulation based training programme to enhance compliance with the 5SSS and the safety culture within the Trust. The half-day training programme was run three times between August and November 2017 for doctors, nurses and radiologists of the Interventional Radiology (IR) department, a para-surgical specialty with one of the lowest compliance rates in the Trust. Each day began by going through an introduction, including an icebreaker, aims for the day, an overview of the 5SSS and HF and their contribution to preventing errors and improving safety. The group was then taken …

This chapter describes a study of resilience in the Older Persons' Unit (OPU) of a large London teaching hospital in which they developed practical tools to study resilience and identify potential quality improvement initiatives. It reports initial results from the OPU site to illustrate how the author have used Resilience Engineering (RE) principles to inform quality improvement. Despite increasing interest in the principles of RE there is little guidance available for applying the ideas in practice in health care. The Concepts for Applying RE theoretical model was developed and used to design data collection instruments, analysis methods and interpretation of the data. Concepts from the RE literature were also identified: goal trade-offs, learning from what goes right and the four resilience abilities of responding, monitoring, anticipating and learning. The narratives coded with RE theoretical concepts were analysed to identify opportunities for improvement.

Background A significant morbidity and mortality rate is attributable to surgical errors. The extension of the World Health Organisation Surgical Safety Checklist, known as the 5 Steps to Safer Surgery (5SSS), ¹ is designed to minimise this but a lack of compliance with these steps has been demonstrated in local audits and reports by the Care Quality Commission, particularly in para-surgical specialities, such as Interventional Radiology (IR). Therefore, we created a training programme to address this. Summary of education programme A half day programme was run for doctors, nurses and radiologists in the IR department. It started with an introduction to the 5SSS, Human Factors (HF) and their contribution to preventing errors and enhancing safety. A simulation-based scenario then ran in the IR lab to allow repeat cycle deliberate practice of the 5SSS with the opportunity to interrupt and suggest changes to the checklist that could localise it and improve implementation. These were then shared with departmental leads. Summary of results 31% of doctors, 36% of nurses and 20% of radiographers attended. The effect was measured though pre and post participant questionnaires and audits on compliance with the 5SSS. The questions looked at development in two categories: attitude towards the 5SSS, including confidence in using it and opinions on its value; self–efficacy in HF skills, measured by the validated Human Factors in Healthcare Instrument. ² There was a significant improvement in the former (p Discussion, conclusion and recommendations The driving force towards compliance with the 5SSS and an enhanced safety culture is the attitude and skills of the staff that work within the organisation. This can be influenced by in-situ simulation based training programmes, such as this one, that emphasise the importance of safety measures and empower staff to make changes to implement them effectively. References National Patient Safety Agency. ‘How to guide’ five steps to safer surgery 2010. London: NPSA. Available at: http://www.nrls.npsa.nhs.uk/resources/?EntryId45=92901 Reedy GB, Lavelle M, Simpson T, Anderson JE. Development of the human factors skills for healthcare instrument: A valid and reliable tool for assessing interprofessional learning across healthcare practice settings. BMJ Simulation and Technology Enhanced Learning 2017;3(4):135–141.

Emergency exercises involving the health community are considered an important and integral part of emergency preparedness activities. However, little is known about whether these exercises are effective at improving individual and/or organisational preparedness for responding to emergencies. This paper reviews and summarises published evidence on the effectiveness and benefits of exercises to prepare health emergency professionals for responding to emergencies and disasters. A literature search strategy was designed to identify the relevant publications from four major medical databases (Medline, Embase, Global Health and CINAHL). Studies meeting our inclusion criteria were analysed in detail (N=86). Both qualitative and quantitative data were reviewed. Data analysis involved a descriptive summary and a thematic analysis.Health emergency preparedness exercises were found to be effective (post exercise) at improving participants' knowledge of emergency activities, policies and procedures and improving overall competence and confidence. Other immediate individual benefits included improved perceptions of preparedness and improved understanding of individual roles and roles of partners. Whether these improvements persist over time and translate into improved emergency response is not clear. The most commonly reported post-exercise organisational benefits were: identifying gaps or limitations in plans, protocols or procedures and providing opportunities to share lessons. Only a few identified studies reported the long-term impact of exercises on job practices and on real emergency response. Published evidence of exercises impact on individual and organisational levels of emergency preparedness and response over the long term is very limited. The majority of the studies included (n=65, 76%) were US-based.

Over the past 3 years, staff at Guy's and St Thomas' NHS Foundation Trust have been offered courses that draw on ideas from theatre, dance, and the visual arts as part of a collaboration between the Simulation and Interactive Learning Centre (SaIL) and the Performing Medicine programme. The stories we have heard during this time leave no doubt that a career in health care is intensely demanding: a nurse sitting in a mortuary with a grieving mother, wondering “was it ok that I cried too?”; an anaesthetist attempting to save the life of a pregnant woman with her terrified husband looking on; team reactions after the terrorist attack on Westminster Bridge; a senior nurse enforcing the use of the WHO checklist to a sceptical surgeon; an A&E consultant punched in the face by a drunk patient; or a pharmacist frustrated by the snail's pace of the computer system. So how do they meet these demands? How do they stay well in the face of all this? One senior nurse told us that in her 30-year career she had never been asked about the relation between her own wellbeing and her professional practice and that to even consider that question would be seen as an indulgence.

Background: Forty-six percent of individuals with mental health conditions have long-term physical illness, while 30% of individuals with long-term physical conditions have a mental illness. Physical and psychiatric comorbidities are of significant concern to medical, psychiatry, and primary care services, with policy, strategy, and literature highlighting the need to better address this interface. Simulation training has been proposed as a tool to improve clinicians' management of physical and psychiatric comorbidities. This study is the first to evaluate interprofessional simulation in improving management of such comorbidity.Method: Participants (n = 63) were doctors and nurses from emergency, medical, psychiatric, and community services across primary and secondary care in South London. Quantitative and qualitative measures were completed before and after a one-day interprofessional simulation course addressing clinical care for physical and psychiatric comorbidities.Results: Knowledge, confidence, and attitudes scores showed statistically significant improvements post-course with large effect sizes. Thematic analyses highlighted the development of interprofessional working, clinical skills, reflective practice, leadership and teamwork, and communication skills.Conclusion: Simulation training has the potential to improve professional development and clinical practice, with participants reporting increased abilities to provide better care to patients with physical and psychiatric comorbidities, exemplifying the case for increased simulation training in health care education. (C) 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Study objective: Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (e.g, a sudden inflow of patients) or a reduction in capacity (e.g, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying "normal" processes. The study objective is to examine escalation policies in theory and practice.& para;& para;Methods: This was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n = 12) and associated escalation actions (n = 92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n = 30 observations).& para;& para;Results: The conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need ("work as done") was found to be incompletely specified in policies ("work as imagined").& para;& para;Conclusion: Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.

BACKGROUND:Despite debriefing being found to be the most important element in providing effective learning in simulation-based medical education reviews, there are only a few examples in the literature to help guide a debriefer. The diamond debriefing method is based on the technique of description, analysis and application, along with aspects of the advocacy-inquiry approach and of debriefing with good judgement. It is specifically designed to allow an exploration of the non-technical aspects of a simulated scenario.CONTEXT:The debrief diamond, a structured visual reminder of the debrief process, was developed through teaching simulation debriefing to hundreds of faculty members over several years. The diamond shape visually represents the idealised process of a debrief: opening out a facilitated discussion about the scenario, before bringing the learning back into sharp focus with specific learning points. Debriefing is the most important element in providing effective learning in simulation-based medical education reviewsINNOVATION:The Diamond is a two-sided prompt sheet: the first contains the scaffolding, with a series of specifically constructed questions for each phase of the debrief; the second lays out the theory behind the questions and the process.IMPLICATION:The Diamond encourages a standardised approach to high-quality debriefing on non-technical skills. Feedback from learners and from debriefing faculty members has indicated that the Diamond is useful and valuable as a debriefing tool, benefiting both participants and faculty members. It can be used by junior and senior faculty members debriefing in pairs, allowing the junior faculty member to conduct the description phase, while the more experienced faculty member leads the later and more challenging phases. The Diamond gives an easy but pedagogically sound structure to follow and specific prompts to use in the moment.

Background Mental disorder is the single largest source of burden of disease in the UK.1 Recent surveys have revealed the prevalence of mental disorders in general hospital inpatients to be greater than 40%.2 Common ‘physical’ Illnesses have profound psychological consequences. The recent five year forward view of the NHS highlights the importance of integrating mental and physical healthcare.3 Despite this, training remains distinctly separate, despite the government’s mandate to Health Education England4, which specifically highlights the need for better training for healthcare professionals managing mental-physical comorbidity – which this intervention provides. Methodology An exciting and innovative study involving the design, implementation and evaluation of a series of one-day interprofessional and cross-disciplinary simulation based training programmes throughout south London. Initially focus groups5 were held with different sets of healthcare professionals, on the difficulties around managing mental-physical comorbidity. The salient themes arising then guided the development of simulation scenarios. The second phase of the study consisted of one day interprofessional simulation programmes, using actors and high fidelity mannequins. Participants were Drs and nurses from general hospital, community and mental health settings concerned with the management of mental-physical comorbidity. The third phase was a ‘pre’ and ‘post’ intervention evaluation consisting of measurement of participants’ confidence at managing patients with comorbidity, their knowledge and attitudes to mental health. Results n = 78. There were statistically significant, positive changes to the confidence of participants managing patients with physical and mental health comorbidity, and similar, positive changes across the domains of knowledge and attitudes to mental disorder. Participants also felt the intervention greatly improved team-working, patient safety and communication skills. Conclusions This study demonstrates that integrative training which is innovative, interprofessional and simulation based is a power fulmodality to improve the levels of confidence and knowledge in healthcare professionals managing patients with mental-physical comorbidity, whilst improving attitudes to mental disorder, team-working and patient safety. References World Health Organization (2008) Global Burden of Disease Report. WHO (http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html) Rothenhäusler HB. Mental disorders in general hospital patients. Psychiatr Danub. 2006;18(3-4):183–92 NHS England. Five year Forward View, 2014 Delivering high quality, effective, compassion ate care: Developing the right people with the right skills and the right values: A mandate from the government to Health Education England. 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310170/DH_HEE_Mandate.pdf Barbour RS. Making sense of focus groups. Med Educ. 2005;39:742–750

BACKGROUND geriatrics encompasses diverse medical, social and ethical challenges requiring a multidimensional, interdisciplinary approach. Recent reports have highlighted failings in the care of older people. It is therefore vital that trainees in geriatrics are afforded opportunities to develop skills in managing this complex population. Simulation has been adopted as a teaching tool in medicine; however, evidence for its use in geriatrics has been limited to small, single-site studies primarily involving role-play or discrete clinical skills training. METHODS a standardised, two centre, multimodal, interprofessional, geriatrics simulation training programme was developed using curriculum-mapped scenarios in which the patient perspective was central. Simulation techniques used included high-fidelity patient manikins, actors with integrated clinical skills using part-task trainers and role-play exercises. A mixed-methods evaluation was used to analyse data from participants before and after training. RESULTS eighty-nine candidates attended 12 similar courses over 2 years. Thematic analysis of candidate feedback was supportive of simulation as a useful tool, with benefits for both technical and non-technical skills. Candidates commented that simulation was a valuable training modality addressing curriculum areas rarely taught formally including continence assessment, end-of-life decisions and multidisciplinary situations. Quantitative analysis of pre- and post-course questionnaires revealed a significant improvement of self-reported confidence in managing geriatric scenarios (mean improvement 11.5%; P < 0.001). DISCUSSION this study demonstrated the feasibility of a standardised simulation training programme across two sites in geriatrics. Simulation training affords situational learning without compromising patient safety and is an exciting and novel method of delivering teaching for geriatrics that could be integrated into national training curricula.

OBJECTIVE:To evaluate the face, content and construct validity of the distributed simulation (DS) environment for technical and non-technical skills training in endourology. To evaluate the educational impact of DS for urology training. SUBJECTS AND METHODS:DS offers a portable, low-cost simulated operating room environment that can be set up in any open space. A prospective mixed methods design using established validation methodology was conducted in this simulated environment with 10 experienced and 10 trainee urologists. All participants performed a simulated prostate resection in the DS environment. Outcome measures included surveys to evaluate the DS, as well as comparative analyses of experienced and trainee urologist's performance using real-time and 'blinded' video analysis and validated performance metrics. Non-parametric statistical methods were used to compare differences between groups. RESULTS:The DS environment demonstrated face, content and construct validity for both non-technical and technical skills. Kirkpatrick level 1 evidence for the educational impact of the DS environment was shown. Further studies are needed to evaluate the effect of simulated operating room training on real operating room performance. CONCLUSIONS:This study has shown the validity of the DS environment for non-technical, as well as technical skills training. DS-based simulation appears to be a valuable addition to traditional classroom-based simulation training.

Objectives: In this work, we have compared uniprofessional and interprofessional versions of a simulation education intervention, in an attempt to understand more about whether it improves trainees' self-efficacy.Background: Interprofessionalism has been climbing the healthcare agenda for over 50 years. Simulation education attempts to create an environment for healthcare professionals to learn, without potential safety risks for patients. Integrating simulation and interprofessional education can provide benefits to individual learners.Setting: The intervention took place in a high-fidelity simulation facility located on the campus of a large urban hospital. The centre provides educational activities for an Academic Health Sciences Centre. Approximately 2500 staff are trained at the centre each year.Participants: One hundred and fifteen nurses and midwives along with 156 doctors, all within the early years of their postgraduate experience participated. All were included on the basis of their ongoing postgraduate education.Methods: Each course was a one-day simulation course incorporating five clinical and one communication scenarios. After each a facilitated debriefing took place. A mixed methods approach utilised precourse and postcourse questionnaires measuring self-efficacy in managing emergency situations, communication, teamwork and leadership.Results: Thematic analysis of qualitative data showed improvements in communication/teamwork and leadership, for doctors and nurses undergoing simulation training. These findings were confirmed by statistical analysis showing that confidence ratings improved in nurses and doctors overall (p<0.001). Improved outcomes from baseline were observed for interprofessional versus uniprofessional trained nurses (n=115; p<0.001). Postcourse ratings for doctors showed that interprofessional training was significantly associated with better final outcomes for a communication/teamwork dimension (n=156; p<0.05).Conclusions: This study provides evidence that simulation training enhances participants' self-efficacy in clinical situations. It also leads to increases in their perceived abilities relating to communication/teamwork and leadership/management of clinical scenarios. Interprofessional training showed increased positive effects on self-efficacy for nurses and doctors.

INTRODUCTION:Validation studies are an important part of simulator evaluation and are considered necessary to establish the effectiveness of simulation-based training. The widely used Bristol transurethral resection of prostate (TURP) simulator has not been formally validated. OBJECTIVES:Evaluation of the face, content, and construct validities of the Bristol TURP simulator as an endourology training tool. DESIGN:Using established validation methodology, face, content, and construct validities were evaluated. Face and content validities were assessed using a structured quantitative survey. Construct validity was assessed by comparing the performance of experts and novices using a validated performance scale and resection efficiency. PARTICIPANTS AND SETTING:Overall, 8 novice urologists and 8 expert urologists participated in the study. The study was conducted in a dedicated surgical simulation training facility. RESULTS:All 16 participants felt the model was a good training tool and should be used as an essential part of urology training (face validity). Content validity evaluation showed that most aspects of the simulator were adequately realistic (mean Likert scores 3.38-3.57/5); however, the model does not simulate bleeding. Experts significantly outperformed novices (p < 0.001) across all measures of performance, therefore establishing construct validity. CONCLUSIONS:The Bristol TURP simulator shows face, content, and construct validities, although some aspects of the simulator were not very realistic (e.g., bleeding). This study provides evidence for the continuing use of this simulator in endourology training.