1. Delivering Simulation in Psychiatry
Dr Emma Barrow, ST6, General Adult Psychiatry
Dr Jayne Greening, Associate Medical Director Medical Education, BSMHFT

2. Drivers for development …
Use of simulation across a wider range of specialties (not just ‘acute’)
Attention of RCPsych
Focus of undergraduate and postgraduate medical education locally & nationally
Focus of multiprofessional training in other regions
Focus on patient safety and August changeover
RCPsych – lead for simulation development – although many reports of the use of simulated patients in psychiatry training in literature there are relatively few which report the use of high-fidelity simulation.
Birmingham University – High Fidelity Simulation Group and introduction of a 60 credit postgraduate module in delivering simulation training – encouraging psychiatry also.
Maudsley and RAMMPS – places where they are doing forms of simulation training in multi-professional setting although both are different.
”Grey Wednesday” – some of the literature suggests a small increase in mortality rates for emergency admissions for the first Wednesday in August, when compared to the last Wednesday in July.
Development of clinical and non-technical skills outside of the workplace (in a “safe” environment)

3. In Birmingham …
Junior doctors (FY2, CT1-3, GPST1&2) work across several different rotas covering 3 large geographical areas
Residential and Non-Residential
A&E out of hours assessments
Inpatient units, adult, older adult and PICU
Complex and challenging situations out of hours
Many will not have previous psychiatry experience
‘skills’ can’t be gained from textbook or lecture
Practice ‘realistic’ on call scenarios in a ‘safe’ simulated environment
Uncommon but high-risk or high-stress situations/encounters
In psychiatry, out of hours, the junior doctor is likely to be the most senior doctor on site.
We know that in psychiatry, certain groups of patients (e.g. self-harm and personality disorder) and more likely to present out of hours than in hours, therefore it is important to prepare trainees for the type of clinical workload they are realistically likely to encounter out of hours.

4. Timeline to development …
September 2014 – February 2015
Core development group (3 x trainees, 1 x consultant)
Focus groups with trainees in each region
Identify potential scenarios from focus groups
Write, develop and pilot scenarios on existing trainees who volunteered
Service user and carer input
Write and develop feedback materials
Trainees perceptions of which were the most challenging clinical and on-call encounters.
Identified 8 possible scenarios, piloted 6, twice, on existing trainees using professional actors as simulated patients in order to assess validity and feasibility and the time required to run each scenario effectively.

5. Timeline to development …
February 2015 – February 2016
In total 77 trainees have participated in simulation training
Mix of FY2, CT1/2/3, GPST1&2, BBT
August 2016 onwards
Reduction in number of scenarios from 6 to 4
Increased length of time for feedback
8 minutes to 20 minutes
Formal part of induction programme (“best bit”)
Build in training for facilitators in feedback and debriefing
Reading materials sent out in advance
We have the data for analysis of the results from these 77 trainees who have participated and provided evaluation data.
The decision to lengthen time for feedback was based upon the initial review of qualitative feedback with trainees appreciating the feedback and opportunity to be given feedback directly from a Consultant and to discuss management. We decided to give all trainees access to all four scenarios and also to provide written materials in advance on mental health act legislation, Trust policy and guidelines on RT etc. Number of scenarios was reduced from 6 to 4 simply to accommodate the increased length of time in the scenarios. Introduction of new methods of debriefing were based upon information gathered from other areas where they are also using simulation in psychiatry.

6. Developing the scenarios …
3 authors, overseen by consultant
Ran 2 focus groups with approx. 30 trainees following routine JD forum
Identified 8 core themes which elicited anxiety, difficulty or distress amongst trainees
Practically able to develop 6
Section 5(2)/suicide risk Aggressive patient/rapid tranquillisation
Dementia and UTI Relative of alcoholic wanting admission for detox
NMS/acutely ill patient Risk assessment for self-harm in personality disorder
Discounted: heroin addict wanting methadone and recent sexual assault victim
Animation circles the 4 we have continued with since August 2016 …

7. Developing the scenarios …
Calgary – Cambridge model as initial template
Designed for ‘physical illness’ scenarios with signs/symptoms
Over time further developed actor/simulated patient instructions
Trainee instructions
Actor/Simulated Patient instructions
‘Nurse’ or Facilitator instructions
Script for ‘Consultant on call’ advice (SpR)
Excluded aspects of the template which were not relevant.
Over time what has evolved is our own template for writing simulation scenarios in psychiatry which we are hoping to share with experts in other specialties such as Learning Disability, Forensics and CAMHS for them to further develop additional scenarios.

8. Developing the scenarios …
Goes on to say that he had an ECG on admission which was normal and there is no significant past medical history of note.
Included in the physical scenario are the drug cardex, physical observations chart (MEWS/NEWS) and ECG (NSR trace with normal QTc interval)
The task is to assess the patient and develop and appropriate management plan with the assistance of the ‘nurse’, telephone contact to the consultant on call and/or discussion and referral to medical SpR on call.
The 4 scenarios were re labelled
Management of acutely ill patient
A&E assessment out of hours
Mental Health Act
Management of acute agitation and agression

9. Developing the scenarios …
Actor script …

10. Developing the scenarios …
Actor directions …

11. Developing the scenarios …
The facilitator notes have been expanded to include more directive instructions as to how to direct the trainee who is participating in the simulated encounter to ensure they get the most out of the encounter.
Over time we have developed a bank of junior trainees who now regularly act as our facilitators and have been given training in facilitation and debriefing.

12. Developing the scenarios …
The ‘consultant scripts’ have been developed on the advice of consultants who work the on call rota and in line with BSMHFT guidance and policy.
The purpose of the detailed script is to enable junior SpR’s to gain experience of giving telephone advice to juniors out of hours as this is a requirement of training but not readily obtained in the current working environment due to the workload demands out of hours on the SpR grade rota. Most calls from junior doctors go directly to the on call consultant.

13. Developing the scenarios …
Over time we have clarified the purpose of the scenarios given feedback received from trainees who have participated as well as consultants and senior SpR’s who have facilitated the simulation training sessions.

14. Setup and design … No high tech simulation suite
Trust building, various rooms, each with one scenario
Dividers are used to separate clinical and non clinical areas (with actor/patient vs ‘office’ space)

15. Setup and design … Each scenario would run for max 30 minutes
15-20 min with actor and ‘nurse’ facilitator
Remaining 8-10 mins for feedback and debriefing & move to next station
‘Do one, see all’
Pre and post evaluation of individual confidence level
Guidance for feedback and debriefing
Initially we anonymised the trainees
This raised issues
What to do if there is a problem with a trainee’s performance?
How to differentiate between expected levels of performance e.g. FY2 vs CT3 …
Is this a training tool or an assessment of competency tool? (training but need to be able to identify those who need additional input to be safe in practice)

16. Feedback and Evaluation …
Pendleton’s rules
Performance descriptors
‘Ground rules/Vegas rules’
Questions to guide debriefing
Evaluation forms pre and post (paired data)
‘Process of simulation’ evaluation forms
Qualitative feedback
Feedback form stickered for individual feedback for each trainee
2 lead facilitators (at least one is a consultant psychiatrist whilst the other may be a higher trainee)
One does the ‘consultant script’ the other does the written feedback and leads debrief at the end
Jenny Rudolph – advocacy enquiry, and debriefing with good judgement.
Later – debriefing has moved with the times and now using SaIL centre debriefing diamond.

17. Description: reinforce safe learning environment, keep the focus dispassionate, discuss what happened but avoid focusing on emotions, talk about and list emotional responses but resist temptation to discuss emotions. Make sure people everyone has the same understanding of what happened.
Transition into analysis – clarification of any technical issues.
Analysis: Most time is spent here, deconstructing behaviour and specific actions, exploring what happened in detail, keeping it positive, focus is on strengths and weaknesses, reflecting back responses and allowing participants to amend or argue.
Transition into application – by reinforcing learning.
Application: move from the specifics of the scenario into the general world of practice.

18. Debrief Diamond … Key phrases to remember
Description
“Let’s not focus on performance, focus on what happened
“And then what happened, how did it happen?”
Application
“What other situations might you face that could be similar”
“What are you going to do differently in your clinical practice tomorrow because of this?”
Analysis
“How did that make you feel?”
“Why?”
”Why did you take that action?”
“What I am hearing from you is that …”
“We refer to that as a human factor or non-technical skill which means …”
“So what have we agreed we could do?
‘The Diamond’: a structure for simulation debrief
Peter Jaye1, Libby Thomas1 and Gabriel Reedy2
1Simulation and Interactive Learning Centre (SaIL), Guys and St Thomas’ NHS Foundation Trust, London, UK
2King’s Learning Institute, King’s College London, UK

19. Feedback and Evaluation …
The process of simulation was clearly explained to me
I was given the opportunity to ask questions or clarify my understanding before the simulation activity began
The facilitator clearly explained the purpose of simulation and how this supports my medical training
The purpose of debriefing following the simulation activity was fully explained to me
I found the debriefing handout useful
I understood what was expected of me when actively participating in the simulation activity
I understood what was expected lf me when observing the simulation and participating in debriefing and feedback
I felt able to share my thoughts and experiences
I received constructive feedback and guidance on my performance
The process of debriefing helped me to explore what was thinking during the simulation event
The proves of simulation helped build my confidence in managing patient encounters in the on call setting
The process of simulation will change my future practice
How we have built and developed the simulation training over time has mainly come from collecting feedback from all participants (including facilitators, consultants and actor/simulated patients)

20. Summary of the results so far …
16 trainees in Feb 2015
38 trainees in August 2015
23 trainees in Feb 2016
Complete pre & post evaluation using 7-point Likert scale
(1) strongly agree
(7) strongly disagree
This table shows that for each question, trainees recorded an increase in confidence demonstrated by a statistically significant increase in scores on the Likert scale. All results showed statistically significant differences between the pre and post scores using the Mann Whitney U test (the mean number of points the confidence score had improved on a 7 point Likert scale).

21. Figure 2 shows that there were large increases in the number of trainees agreeing that they felt confident for each statement after the training was delivered.

22. 98% of trainees agreed that simulation has helped to build their confidence. 94% of trainees agreed that simulation will change their future clinical practice

23. Qualitative feedback …
Thematic analysis:
Organisation and set up
“Well organised” and “supportive”
“Anxiety provoking” or “like an exam” (small number)
Scenarios
“Found myself immersed in the scenario, forgot it was simulation”
Feedback
“Appreciate Consultant feedback on performance”
Educational value
“Useful” and “valuable”
“will definitely help in future with real patients and relatives”
“close to real life situation”
“more time for feedback and specifically areas for development…”
“much more confidence in managing on-call situations”
Suggestions to upload video of “perfect” scenarios and for senior CT’s to be able to have practice at the SpR/Consultant advice role instead.

24. Where we are now …
Process of writing up the initial results from evaluation
Feb 2015 – Feb 2016 (inclusive)
Consultant facilitators
Trainee facilitators
Reduction in number of scenarios from 6 to 4
Increased length of time for feedback from 8 minutes to 20 minutes
Formal part of induction
Reading materials sent out in advance
Looking to develop more scenarios from different specialties
Receive training in facilitation and debriefing

25. References …
Jaye, Thomas and Reedy, (2015) ‘The Diamond’: a structure for simulation debrief. The Clinical Teacher 12:
Thomson et al, (2013) How we developed an emergency psychiatry training course for new residents using principles of high-fidelity simulation. Medical Teacher 35:
Carthey and Clarke (2009) Implementing Human Factors in Healthcare version 1
Rudolph et al, (2007) Debriefing with Good Judgement: Combining Rigorous Feedback with Genuine Enquiry. Anesthesiology Clinics 25:
Rudolph et al, (2006) There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgement. Simul Healthcare 1: 49-55