SERVICE DEVELOPMENT
Using a simulation exercise to develop staff competence in a specialist inpatient service Steve Hardy Training and Consultancy Manager Eddie Chaplin Research and Strategy Lead Estia Centre, South London and Maudsley NHS Foundation Trust, UK
Abstract This case report provides a description of a simulation exercise as part of the induction programme for a staff team recruited to a specialist inpatient service for adults with intellectual disabilities and additional mental health problems. The rationale for this novel approach is described, along with details of its planning, implementation and outcomes.
Key words inpatient services; intellectual disability; learning disabilities; staff training; simulation exercises
Introduction Simulation is a technique – not a technology – to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner (Gaba, 2004). Simulation allows staff to practise skills learnt as theory in a classroom setting, in a safe environment, mirroring the situations that are likely to occur in their clinical environment. The advantages of simulation are that no harm can come to patients and acquisition of skills can be obtained by repeated practice of scenarios and actions (Seropian, 2003). The use of simulation is well established; it has been used over a number of years to teach medical and nursing students. Simulation used in preparation for disasters, such as terrorist attacks and natural disasters, is also well established. Nursing practice simulation has traditionally been task-orientated, for example recording physical observations or team responses to emergencies. The simulation exercise described in this paper used a number of scripted clinical scenarios, using actors to cover a range of situations that may be encountered on a mental health inpatient ward in day-to-day practice.
Background Most people with intellectual disabilities are able to access mental health care through mainstream mental health services, but a small yet significant group, because of their
complex needs, require specialist care, including community and inpatient services. One such service is the Mental Health in Learning Disabilities (MH-LD) inpatient service described in previous publications (Xenitidis et al, 2004; Hemmings et al, 2009). Across the MH-LD services in south east London there is a solid clinical governance infrastructure that monitors, audits, benchmarks and reviews quality and standards. Following an audit by internal and external facilitators, the decision was made to reprovide the specialist inpatient service at a different location because of: the current staffing and level of multidisciplinary team which were not up to the establishment the structure of the current environment gender-specific areas requiring a new layout. Improvements from the reprovision of the inpatient service included a two-fold increase in the nursing establishment and an expanded multidisciplinary team (MDT) to include psychology and specialist behavioural support as well as psychiatry and occupational therapy. New premises for the service were found, which were very spacious, promoted privacy and dignity, and had ample space for therapy, skills development, alone time, family visits and meetings. The service was increased from seven to 13 inpatient beds.
10.5042/amhid.2010.0673
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Using a simulation exercise to develop staff competence in a specialist inpatient service
An induction programme Provision within the project plan included time for a dedicated induction programme for the existing and new staff team. The aim of the induction was to provide the team with a foundation of skills and knowledge in delivering inpatient mental health care to people with intellectual disabilities. The programme was developed by a range of people including trainers, clinicians and people with intellectual disabilities. Table 1, below, highlights some of the main areas covered by the induction programme. The South London and Maudsley NHS Foundation Trust requires that any new or relocated inpatient service holds a simulation exercise before opening to test assumptions about how the service will operate once opened. Other key reasons include: to test the environment and highlight any alterations required before opening to explore understanding of key clinical policies and procedures by the multidisciplinary team to explore how the unit and team would implement routine and everyday tasks to observe the multidisciplinary response to emergency situations.
How does the simulation work? The idea of the simulation exercise was to provide a range of clinical scenarios in the physical environment in which the team would actually be working. A list of common needs of patients and other issues was developed, to ensure that they were included within the simulation, including: individuals with a range of mental health problems a patient admitted within the last 24 hours physical health needs patients requiring constant 1:1 staffing patients requiring frequent observation risk of individuals going absent without leave risk of suicide/self-harm communication needs, specifically those associated with people who have an autism spectrum condition
patients experiencing florid psychotic symptoms sexually disinhibited behaviour aftercare in regard to recent rapid tranquilisation physical disability and accessibility. The main question we had as a training team was how and who would portray the 13 people who would use the service once in operation. For this we approached a professional actors group who had experience in simulation exercises. A profile was written for each patient which provided a brief description of their recent history and how the actor should behave during the simulation exercise. The clinical scenarios identified were incorporated in the range of patient profiles. Actors were given the profile one month before the simulation exercise to allow time for preparation. Brief examples of patient profiles are described in Table 2, opposite.
Timescale preparation and participants The simulation exercise was held over the course of a day. To add authenticity to the exercise, the simulation was separated into two shifts. It was decided that each shift would last for two hours rather than the usual seven hours, which would enable adequate time for the staff to adapt to the situation and implement normal duties, for planned events to occur, and to minimise stress to the team. The nursing team was divided into two teams, a senior nurse leading each shift, three qualified nurses and two support workers. Psychiatrists were included in the first shift, and psychologists and occupational therapists in both shifts. During each shift, each nurse who was an active participant had an observer from the nursing team working the opposite shift, and these roles were reversed in the next shift. The role of the observer was to shadow the identified nurse in all situations, making notes on how situations were dealt with, implementation of policies and protocols, interaction and communication with patients and the team. No communication was allowed between the two during the exercises. The simulation
Table 1: Summary of areas addressed in the induction programme Skills and knowledge focus
Training delivered by
1. Core functions of service, values and principles 2. Communication and interaction with people with intellectual disabilities 3. Key principles and policies (inc. child protection and safeguarding adults) 4. Assessing and identifying mental health problems 5. Relevant legislation: Mental Capacity Act (MCA) and Mental Health Act (MHA) 6. Working with people whose behaviour is described as challenging
1. Service manager, people with intellectual disabilities 2. Speech and language therapist
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3. Service manager and Trust safeguarding lead 4. Psychiatrist and psychologist 5. Social work lead and trainer 6. Behaviour support specialist and Speech and language therapist
Advances in Mental Health and Intellectual Disabilities Volume 4 Issue 4 December 2010 © Pier Professional Ltd
Using a simulation exercise to develop staff competence in a specialist inpatient service
Table 2: Example of patient profiles for the actors Tracey, aged 29 years Background Tracey is experiencing hypomania and agreed to come into the Unit from her staff supported house a month ago No previous history of mental health problems Premorbid personality – described as reserved and quiet Over a four-week period Tracey’s behaviour changed quite dramatically. Staff said that she needed little sleep, was over-active and interfering in everything that was going on in the house. Since she has been on the Unit she has been prescribed mood stabilisers, which are felt to be slowly starting to take effect
Freddie, aged 27 years Background Freddie was admitted three months ago from an adult acute ward, for a drug-induced psychotic episode. He is placed on Section 3 of the MHA Had been sniffing lighter fuel and drinking alcohol Transferred on to the Unit as soon a bed became available Freddie previously lived in a staff-supported house, but the placement broke down when he was admitted because he had attacked another service user He has been successfully treated with talking therapies His social worker is currently looking for a new placement
Current behaviour Tracey is still over-active She has a particular interest in the male staff, whom she follows around She is over tactile with them (not sexually), such as stroking their hair and wanting to hold hands She will respond to firm boundaries when constantly reinforced She does not drink anything of her own accord, but will do so with supervision of staff When medication is dispensed Tracey will initially refuse medication, saying ‘she feels happy as she is’. She will eventually take the medication with staff encouragement
Current behaviour Freddie’s mental health is stable, and he is eager to leave. His behaviour is however becoming more of a challenge on the Unit He is able to leave the Unit with one staff member Often makes demands of the staff, and if they cannot be met immediately becomes verbally threatening At 2.00pm when the staff are in handover, he wants to go for a walk, staff cannot take him until after the handover He finds it hard to wait and becomes agitated He will slowly calm down if staff negotiate with him in a calm manner
exercise was co-ordinated by two senior nurses within the organisation who have extensive experience of facilitating simulations across the Trust. Their role was to brief the actors and participants, initiate the start of simulation, ensure everyone worked within the remit of the exercise, pause the simulation at anytime (by blowing a whistle), mark the end of the simulation and co-ordinate the feedback at the end of exercise. Before the simulation exercise commenced, the shift team was given 30 minutes to read through the patient profiles. Each shift leader was given a diary plan for their shift which identified activities that should be implemented. Shift 1 activities included MDT clinical meeting, art group facilitated by the occupational therapist, dispensing of medication and lunch. Shift 2 included a mental health promotion group facilitated by the occupational therapist, and individual therapy with psychology. For each shift, each nurse and support worker had to be allocated to support an individual patient, be responsible for particular duties (such as medication) and support the occupational therapist with the groups. A number of unexpected events were included in each shift (of which only the actors and facilitators were aware), and are listed in Table 3, overleaf.
Evaluation A debriefing session was held immediately after both shifts had been completed. It included observations from the facilitators and actors and an overview of the individual observers’ comments. Participants in simulations are reliant on the expert to provide feedback that they can use and learn from, both positive and corrective feedback (Vardi, 2008). To supplement the debriefing, more detailed feedback was given to participants, including recommendations for improving their practice. General feedback on operational and clinical issues observed during the simulation was given to the team together. Areas that were highlighted for attention included the following.
The physical environment There were several issues, including practical use of several keys, which could be difficult to identify, and the locks on several bathrooms were difficult to unlock. It became apparent that for female patients to access the second garden of the unit they would need to enter the male bedroom wing. One of the reasons for selecting the new unit was its amount of space. However, at times, perhaps due to lack of
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Using a simulation exercise to develop staff competence in a specialist inpatient service
Table 3: Examples of the unexpected events Event
What was being specifically tested?
1. Admission within the last 24 hours
1. Admission policy, observations, interaction, patient orientation 2. Engagement and observation policy 3. Emergency life supporting procedures and equipment 4. Complaints policy 5. De-escalation techniques, maintaining a safe environment 6. First aid procedures 7. Child protection and visiting policy 8. Unit fire procedures
2. 3. 4. 5. 6. 7. 8.
Patient requiring 1:1 staffing Patient who recently had rapid tranquilisation starts to choke Allegation made against a member of staff on previous shift Two patients become agitated in an argument Patient has an epileptic seizure Unexpected visitor with child Fire alarm
co-ordination, the space was difficult to manage, and some areas were left unstaffed.
roles reported that there were engaged appropriately by their named nurse and did not feel overlooked.
Response to emergency situations
Team work and support
Two emergency situations were scheduled to occur during the day. First, a patient would have an epileptic seizure, which was dealt with effectively, ensuring the privacy and dignity of the patient and addressing the concerns of other patients who witnessed the event. The second event involved a patient who was sedated and began to choke. The response was unsatisfactory, in that there was a lack of leadership and a delay in accessing the emergency resuscitation equipment.
Generally the staff operated well as team, often dealing with stressful situations while being observed. After each incident the teams debriefed naturally and offered each other adequate support.
Physical disability One patient used a wheelchair, and was pleased with the assistance he received throughout the day from staff. He felt safe with them and found the physical environment appropriate to people with his needs.
Use of MDT staff in therapeutic roles Therapy groups were held during both shifts. During the first shift all patients (risk permitting) were invited to the art group, which was used by seven patients and required the support of the occupational therapist and a support worker, allowing the other five nursing staff to undertake other duties and support those patients with more pressing needs. In contrast, in the latter shift only one patient was invited to participate, which left 12 patients supported by the nursing team. The afternoon shift was generally more disorganised.
Safety checks At times, particularly in the afternoon, safety checks on patients requiring intermittent observations were missed on several occasions. Areas highlighted as good practice included the following.
Interactions with patients We were particularly interested in feedback from the actors on their interactions with staff. Feedback was highly positive, describing the team as having a non-patronising approach and treating the patients as individuals. Some profiles were intentionally written with the patient being quiet, undemanding and secluding themselves. Actors in these
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De-escalation Staff dealt with potentially aggressive incidents in a calm and appropriate manner, using various de-escalation techniques. Patients not involved in the incidents but in the vicinity reported that they felt safe. The staff participating in the simulation were also asked for their feedback on the simulation exercise. Many described the day as stressful, and attributed this to too many events occurring in a small time frame, which they considered unrealistic. Some staff enjoyed the exercise and found it a good opportunity to implement the knowledge they had previously gained. Staff were critical of some of the actors, in particular a few whose communication did not reflect someone with an intellectual disability. With hindsight, the actors could have been better prepared by receiving training, which could have been delivered by some of the services trainers who have intellectual disabilities. Following the simulation exercise, several situations have occurred which mirror those from the simulated clinical scenarios, including an evacuation of the unit and de-escalating aggressive incidents. It is clear from feedback that the simulation exercise has helped improve practice in dealing with these situations.
Advances in Mental Health and Intellectual Disabilities Volume 4 Issue 4 December 2010 © Pier Professional Ltd
Using a simulation exercise to develop staff competence in a specialist inpatient service
Conclusion
Contact details
Previously, simulation exercises in health care have concentrated on managing or gaining competence in specific tasks, rather than on clinical scenarios within the experience of a multidisciplinary team working a shift together. This exercise was part of an ongoing programme that extended the boundaries of how simulation is used and, although it could be criticised as both time-consuming and resourceintensive, it meant that staff were able to address issues both with the environment and across the team before opening. Given the benefits of early detection of environmental problems, ideally simulation exercises should be held in the environment where the staff will actually work.
Steve Hardy Training and Consultancy Manager Estia Centre South London and Maudsley NHS Foundation Trust Munro Centre 66 Snowsfields London SE1 3SS UK
[email protected]
What new information does this case study add? Simulation exercises are a useful way of practising and testing skills that have been taught in an educational environment. Simulation exercises can be used to test clinical environments and test competence in a number of clinical practice issues. Simulation can aid team-building and multidisciplinary working. The use of simulation can be applied effectively to services for people with intellectual disabilities.
What are the practice implications? Simulation exercises could be employed in a range of services for people with intellectual disabilities, such as residential care, day and outreach services. There may be a need for repeat sessions where concerns over practice have emerged. Developing a simulation exercise takes time and effort, and it would be advantageous to have a lead across the Trust for use in all services.
References Gaba DM (2004) The future vision of simulation in health care. Quality and Safety in Health Care 13 (Suppl 1) 2–10. Hemmings CP, O’Hara J, McCarthy J, Holt G, Eoster F, Costello H, Hammond R, Xenitidis K & Bouras N (2009) Comparison of adults with intellectual disabilities and mental health problems admitted to specialist and generic inpatient units. British Journal of Learning Disabilities 37 (2) 123–8. Seropian MA (2003) General concepts in full scale simulation: getting started. Anesthesia & Analgesia 97 1695–705. Vardi I (2008) Teaching and learning through the simulated environment. In: RH Riley (Ed) Manual of Simulation in Healthcare. New York, Oxford: Oxford University Press. Xenitidis K, Gratsa A, Bouras N, Hammond R, Ditchfield H, Holt G, Martin J & Brooks D (2004) Psychiatric inpatient care for adults with intellectual disability: generic or specialist units. Journal of Intellectual Disability Research 48 11–18.
‘Training in the use of the Mini PAS-ADD Interview’ (Psychiatric Assessment Schedules for Adults with Developmental Disabilities) A One Day Workshop
Presented by: Dr Steve Moss Tuesday 8th March 2011 To be held at The Munro Centre, Guy’s Hospital For further information visit: www.estiacentre.org or email:
[email protected]
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