This month on the Paediatric Fellow's Blog section is Reflections of our paediatric Simulation Fellows in their first few months in the post. Please read and enjoy, it is a really appealing take on the subject and echoes reflection of our work.
Putting Yorkshire and Humber simulation on the map!The last few weeks has involved really putting Yorkshire and Humber simulation on the map. The simulation fellows had the opportunity to travel to the International Paediatric Simulation symposium and Workshops Conference in Vienna to present our projects to the rest of the global paediatric simulation community. We gave presentations about setting up in situ simulation projects, identification of latent risks through simulation, developing return to work courses, role of a simulation fellow and the YIPS course. Overall the presentations were really well received and we had a lot of international interest in our simulation program and simulation faculty. One of the workshops at the conference involved being able to discuss ideas and projects with some of the biggest brains in paediatric simulation, which was a fantastic opportunity to tap into the knowledge and experience of people who have been running simulation projects in leading centres around the world. All of us came back with some great ideas of how to develop our current projects. Overall the conference was a brilliant opportunity for the Yorkshire and Humber simulation fellows to show off to the rest of the paediatric simulation community about all the amazing things we are doing in the region, as well as bring back some fresh ideas of how to expand our program.
Error is normal! When have we ever been told that within the medical profession? Yet this was the key message from this two-day Human Factors Masterclass delivered by a former aviation Captain. 73% of aviation incidents are attributable to human factors, which is why crisis resource management is a routine part of aviation training. What percentage is responsible is allocated to healthcare incidents? Considering that healthcare is significantly more risky than aviation it seems safe to say that human factors will play a key part in the majority of healthcare incidents. Yet, we do not address human factors as a standard part of medical and multi-disciplinary practice. The remit of this course was to introduce the importance of human factors and make us think of how we can tackle human factors in clinical environments.
Ultimately healthcare is about patient safety. Safety however is influenced by a number of factors including situational awareness, risk management, communication, leadership, followership and motivation, behaviour choices and feedback. In healthcare, addressing these human factors in the form of ‘team resource management’ aims to stack the odds in your favour but does not guarantee that errors will not occur. The key notion within human factors is that situations arise out of an error chain with no one person being solely responsible. We all make mistakes because we are human but often there is a chain of preceding events, which have facilitated the error to occur. We need to investigate such situations to identify errors within the chain to improve patient safety. This is also true if a potential situation were to arise. The process of risk management and root cause analysis is a means of making changes to minimize future risk but only comes from a reporting culture. Often this is due to fear of a blame culture. We need to move away from this and promote risk reporting to hopefully prevent future avoidable risk. The best way to do this is to empower those on the 'shop floor’ to report and to feel safe to do so by promoting a no blame culture.
The key to effective team resource management is interpersonal relationships as this can in turn influence other factors such as authority gradients, individual behaviour and willingness to contribute information to a situation. We should work in professional practice to establish relationships with colleagues to facilitate effective teamwork and be aware that difficult relationships can negatively impact on patient care should individuals feel threatened in an environment. This particularly refers to an interesting concept where ‘behaviour breeds behaviour’ and adults can sometimes revert to a negative adaptive child mode, which is typically the result of a power struggle. This situation results in the individual withholding their contribution, which can be detrimental should key information not be shared. This situation could arise from steep authority gradients and therefore we should try to encourage shallow gradients where possible to facilitate team contributions.
Another interesting concept was that of flowery communication! Aviation training dictates that your communication, particularly in emergency situations should be direct and unambiguous. However, sometimes we struggle with moving away from social into professional language particularly in situations with familiar colleagues or friends. Language should be stratified as we stratify risk. For example, if we use social language in an emergency situation, it is risky as it is inappropriate for the environment and does not address the situation directly enough. The aim should be to squeeze the language in a crisis aiming to get the message across in the minimum number of words. We should also aim to repeat our message until it is acknowledged and understood.
Undoubtedly as clinicians we are all aware of things that influence our ability to perform. This course gave us new ways of approaching potential obstacles to performance such as acknowledging that our performance increases with workload until a point after which we crumble. In order to get the best performance from staff we need to regulate workload and not be afraid to tell people that we have reached our workload threshold. As healthcare professionals we also need to appreciate that people have different thresholds and accommodate these thresholds within our teams.
The aviation industry revolves around communication including briefing and debriefing before and after every flight with rules of engagement incorporated to explain what should happen in different potential situations. The background to this is to increase the amount of time you have for thinking should a difficult situation arise. This can and should be extrapolated to healthcare. For example, in emergency situations, declaration of the emergency should occur to alert people to follow the emergency algorithm. The purpose of briefing is to define and share the goal with the team, establish what is known, what the interpretation of the known information is and declare the plan including individual roles and responsibilities. However, there should also be a ‘what if’ stage, so that people are aware if the situation is not going according to plan. The role of debriefing is to compare the difference between what the plan was and what actually happened to facilitate learning. The ‘after action review model’ of debriefing should be used to answer 4 questions – what was expected, what happened, what was the difference and what was learned.
This two-day course was fantastic as it was interesting, relevant and interactive. The facilitator was obviously credible and utilized multiple aviation examples to expand upon concepts. He also used videos including the Elaine Bromiley case and an American video looking at an obstetric situation, which may not have arisen had human factors not played a role. The use of situational awareness videos looking at memory and fixation were also interesting. However, the best task was that involving teamwork to perform a timed scrabble task, which highlighted team dynamics, distractions, misinterpretation of information, all of which occurred in non-clinical and a non-stressful situation, highlighting how much impact human factors have in day-to-day activities.
I learnt a considerable amount from this masterclass and will be certainly taking this information forward in both my education and clinical practice.
I attended IMSH in San Francisco in January 2014 to gain insight into the evolving world of simulation and to present a poster on a Paediatric Return to Work course developed within the Yorkshire and Humber Deanery.
My conference experience started with SimWars, a competition between put-together simulation teams. This year the remit was pre-hospital care. The scenarios were a fall from a building, a post-partum haemorrhage in a car and a lightening strike involving two casualties. The teams performed the scenarios and were debriefed using a judging panel with audience participation in the form of voting for teams. SimWars provided the opportunity to observe team dynamics, scenario evolvement with added challenges of ethics and multiple casualties and to observe debriefing styles. I like the idea of utilising simulation to promote teamwork, particularly if you do not know the people around you. The competition aspect seems to inspire increased enthusiasm amongst participants, which we may be able to draw from in our own work.
I attended two plenary sessions by Dr Gary Klein and Dr Elizabeth Hunt who gave lectures on cognitive approaches and research respectively. Dr Klein’s key message was that in order to make a change as simulation educators we need to work on both explicit knowledge and also tacit knowledge. The latter includes pattern recognition, perceptual discrimination, judging typicality and mental models. He was keen to highlight that mental models continue so long as things go well. However, when the mental model fails, it is an opportunity to challenge the mental model and promote adaptation. This is a key point to consider when we take our simulation programmes forward and for debriefing.
Dr Hunt’s session related to her research in simulation over time based on her fascination of the CPR discovery. She re-iterated that the challenge of simulation is to ‘make a positive impact to clinical care rather than people feeling good’ and she has pushed to show this. She has performed research around time-pressured situations where she is passionate about clinicians being competent to deliver excellence. One study involved her identifying that residents had a quicker response from onset of VT to defibrillation if they had defibrillated a manikin or a human before. She instigated rapid cycle delivery practice to facilitate repeated practice of skills and a stepwise approach, which improved response times by 87%.
More research showed that doctors needed contextually relevant training to enhance clinical performance and that decay curves needed to be considered to facilitate time between sessions. These are useful learning points to bring into our world as simulation fellows where we need to implement strategies and practice to facilitate improved performance and also provide realistic and relevant situations to enhance engagement.
As a novice in simulation, IMSH was an overwhelming experience, especially with the number of available sessions. Choosing my own agenda was particularly difficult. As a new simulation fellow, I decided to attend sessions related to the key principles of simulation (e.g. patient safety, programme design, assessment, debriefing) and also sessions related to paediatrics including a paediatric andneonatal in situ session, where two in situ American programmes were explained and challenges highlighted. The session on crisis resource management I found particularly interesting as one of my goals for my fellowship is to design and implement a Paediatric Human Factors course. This workshop used examples of the famous landing on the Hudson River in New York as a good example of crisis resource management and the UK incident of Elaine Bromiley as an example of a situation where human factors played a significant role to patient outcome. Using a fake court case, we teased out the 10 Crisis Resource Management Key Points and established the importance of human factors in an emergency situation. Patient safety is paramount and making health care professionals aware of these key areas is vital to facilitate effective crisis resource management. I aim to use this workshop as the backbone towards developing my course this year.
An array of posters was displayed at IMSH on both programme innovation and research. Programme innovation included ‘bootcamps’ as a means of support for trainees for procedural practice and communication prior to internships. Other programmes included setting up and practicing haemorrhagic shock protocols, use of GLASS to gain insights into the candidate, patient and surgeon and end of life care courses. Research examples included an RCT on videolaryngoscopy versus classic laryngoscopy in teaching neonatal intubation, the use of case based discussion versus simulation training on anaphylaxis and SVT management, practicing neonatal chest drain insertion both with procedural teaching and in a simulation scenario, improving teamwork through simulation and performance in diagnostic ultrasound using simulation.
I presented a poster on a Return to Work Programme for Paediatric trainee doctors following prolonged absence, a course designed and implemented by former colleagues. This was a fantastic opportunity to talk and receive comments from other professionals in the world of simulation and to formally present and answer questions from a simulation professor.
The exhibition hall had an incredible array of manikins and technology on display, which was fascinating. This ranged from being greeted in the foyer to a manikin giving birth to technology to practice USS and surgical procedures. In all honesty I did not truly appreciate how big the world of simulation in healthcare was and this along with the seminars, workshops and posters has fuelled my enthusiasm to be part of this intriguing world!
As a simulation fellow I frequently get asked “What do you do?”. I may not appear to be contributing much when I go on the PICU ward rounds but I’m actually carefully absorbing information, searching for inspiration and cases to base my next simulation on. As a simulation fellow I am involved in lots of different projects, both in Leeds where I am currently based, and around the Yorkshire and Humber region.
My role in Leeds is probably the easiest to define. I am mainly involved in setting up regular simulation sessions for general paediatrics, paediatric intensive care, and paediatric accident and emergency. Each session requires careful planning, including scenario writing, prop creation and mannikin preparation, all to make the simulation as close to real life as possible. After running each session, I collate and distribute the feedback and learning points identified from the scenario. Any problems or risks from equipment or the environment are fed back to the appropriate teams as part of our risk reduction and improving patient safety element of simulation.
I belong to a team of paediatric simulation fellows that are scattered around the deanery. We all help to run the compulsory deanery simulation courses, including STEPS and YIPS days. We all have our own projects but often help each other out with running courses and research projects. I am also involved in setting up simulation in district general hospitals around the Yorkshire and Humber region.In addition to setting up and running simulation I am also involved in lots of other side projects that are being set up, mainly related to teaching. I’ve been asked to teach GPs, medical students, and have been involved in teaching clinical skills to ANNPs.
There are some great opportunities attached to the simulation posts. I am heading to Vienna for an international paediatric simulation society conference and will be doing an oral presentation of some of the simulation fellow work so far. There are also opportunities to present work at regional and national conferences.So for anyone who was unsure what a simulation fellow does, I hope this helps to shed some light on the subject.