- 1 Faculty of Education and Health, University of Greenwich / Barts Health NHS Trust, London, UK
- 2 Department of Surgery and Cancer, Centre for Engagement and Simulation Science, Imperial College London, London, UK
- 3 Surgery and Cancer, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- 4 Imperial College London, Business School, London, UK
- Correspondence to Dr Sharon Marie Weldon, Rm B207, Bronte Building, Avery Hill Road, Eltham, London SE9 2UG, UK.; ,
Background A new challenge for healthcare managers is to improve the patient experience. Simulation is often used for clinical assessment and rarely for those operating outside of direct clinical care. Sequential simulation (SqS) is a form of simulation that re-creates care pathways, widening its potential use.
Local problem Numbers, outcome measures and system profiling are used to inform healthcare decisions. However, none of these captures the personal subtleties of a patient’s experience.
Intervention 56 students attended a teaching module using SqS and facilitated workshops as part of their induction week on an MSc International Health Management course. The workshop was voluntary and was offered as an opportunity for the students to gain an insight into the UK health system through the medium of simulation.
Methods An evaluation survey incorporating quantitative and qualitative student feedback was conducted. Descriptive statistics were generated from the quantitative data, and thematic analysis was undertaken for the qualitative data.
Results There was strong agreement for the acceptability of the workshop approach in relation to the aims and objectives. Likert scale (1–-5) mean total=4.49. Participants responded enthusiastically (revealed through the qualitative data) with ideas related to perspectives sharing, understanding healthcare management and processes and the consideration of feasibility and practicalities. They also suggested other applications that SqS could be used for.
Conclusion The SqS approach has demonstrated that simulation has a wider potential than for clinical assessment alone. Further studies are required to determine its potential uses and affordances beyond its current format.
- sequential simulation (SqS)
- healthcare management
- healthcare re-modelling
- care pathway
- patient experience
Statistics from Altmetric.com
- sequential simulation (SqS)
- healthcare management
- healthcare re-modelling
- care pathway
- patient experience
Healthcare managers have a new challenge when redesigning and transforming healthcare services. No longer can healthcare systems be managed from a purely practical perspective; in contrast, the healthcare experience also needs to be considered. However, this is much harder to define, and therefore a different approach is required.
Currently, numbers, outcome measures and system profiling are drawn on to inform healthcare decisions made. However, none of these captures the personal subtleties of a patient’s experience, let alone how to manage and improve their experience amidst the complexities surrounding a clinical pathway.1 2
Computer-based simulation is widely used to address healthcare organisational challenges. This approach can range from spreadsheet models to discrete event simulation and virtual reality gaming in order to plan and manage a range of healthcare needs and priorities.3 4 Physical simulation, where real clinician’s environments and props are used is conducted mainly for healthcare professional training and assessment. However, there have been some attempts to widen physical simulations scope, such as through testing new facilities and organisational resilience through in-situ simulations.5 6
Sequential simulation (SqS) is the physical re-enactment of care pathways, bringing together clinicians, physical environments, actors and simulation tools and scenarios. It is a way of bringing together the complexities of a care pathway and healthcare system, incorporating the people who populate it (clinicians, healthcare personnel, patients and public), alongside their expertise, experience, emotions and needs.7 8
Previous applications of the SqS tool have included: to engage front-line staff and patients in the design of new models of care9; to test and evaluate the intervention of a new diagnostic breath test for oesophageal cancer10; to train general practitioner receptionists and pharmacists around integrated care and their role within it11 12; to train nurses and healthcare assistants on the deteriorating patient; to train multidisciplinary teams across an entire hospital on end-of-life care and as a fundraising tool for a paediatric intensive care unit that revealed the current difficulties faced, to potential donors.
These applications have engaged a range of stakeholders to consider the entire pathway for a particular objective through the medium of simulation; termed SqS. Thus, the application of simulation has been widened from that of traditional training and assessment to that of strategising, engaging, testing and evaluating from a broader perspective—that of the care pathway.
In this paper, we explore UK and international students’ perspectives on the use of SqS as a novel educational tool for understanding and redesigning complex healthcare systems and clinical pathways and incorporating management-oriented solutions for healthcare delivery. In doing so, we draw on an MSC International Health Programme students’ evaluations of SqS as a teaching tool and their perspectives about potential applications for SqS using a pragmatic mixed-method approach.
A workshop was used as an intervention to use SqS as a tool to engage future healthcare managers with the objectives of (a) redesigning a care pathway process and (b) providing an opportunity for participants to use their management skills, with particular consideration given to local initiatives and cost implications.
The aim of the SqS was to generate a care pathway scenario that would provide an opportunity for the students to identify elements of redesign opportunities and apply their management skills. The SqS was therefore designed to replicate a real patient’s care pathway, incorporating salient points into the scenario which ensured redesign opportunities.
A heart attack care pathway was chosen; as in clinical terms, it is highly complex, involving various presenting symptoms and diagnostics. It requires a coordinated, integrated care approach. From the onset of pain to paramedic assessment, the transfer to a Heart Attack Centre (HAC) through to the cath lab for the procedure, and finally, postprocedure considerations. This also includes the consideration of call to balloon times, onset of patient pain to cath lab times, door to balloon times and arrival at 24 hours HAC to cath lab.
The Heart Attack SqS was designed to involve family support, triage and patient/clinician communication, to aid the subsequent group discussion. These aspects of the pathway were highlighted due to recent emerging evidence around the lack of psychological support that patients and family receive during their care, often leading to increased postcare costs (eg, depression, anxiety and post-traumatic stress syndrome).
UK guidelines recommend person-centred care, where treatment and care should take into account people’s needs and preferences, with the opportunity to make informed decisions about their care and treatment, in partnership with healthcare professionals. Good communication between healthcare professionals and the person with chest pain is, therefore, essential, and it should be recognised that the person may be anxious, particularly when the cause of the chest pain is unknown.13 According to the National Institute for Health and Care Excellence guidelines, options and consequences at every stage of the assessment and investigation process should be clearly explained. Furthermore, guidelines recommend that families and carers should have the opportunity to be involved in decisions about treatment and care: ‘Families and carers should also be given the information and support they need’ (p. 7).13
Heart Attack SqS and scenario
Students watched the complex care pathway presented through an SqS (see figure 1) that was specifically generated to provide an opportunity for students to identify elements for redesign and opportunities for reflection and incorporation of management-orientated solutions aligned with the course objectives.
The heart attack care pathway consisted of Home --> Paramedic/Ambulance service --> Emergency assessment in a heart attack care centre --> Catheterisation lab --> Ward.
Distributed simulation (portable and affordable simulation backdrops and props) was used to re-create the pathway within a room with capacity for 60 students in an acute London hospital (see figures 1 and 2).14 Simulated patients were used to portray a wife and husband (heart attack victim). Real clinicians performed the role of paramedics, nurse and cardiologist. The simulation lasted for 30 min, condensing time to highlight the key aspects of the pathway (table 1).
Following the SqS all students took part in facilitated discussions to identify issues that arose in the cardiac pathway and were subsequently split into three groups of 20–22 to identify potential solutions.
After 90 min, students presented their solutions to the wider group, after which a broader group discussion was facilitated by the course leads centred around the management-orientated course objectives such as wider implications for UK and international care pathways, considerations of pathway costs, and potential applications for SqS in clinical and management contexts in the UK and international settings.
Fifty-six students attended a teaching module involving SqS and facilitated workshops as part of their induction week on an MSc International Health Management course. The workshop was voluntary and was offered as an opportunity for the students to gain an insight into the UK health system through the medium of simulation.
Of the 56 students attending, 17 were male and 39 were female. Three were national students (UK) and the rest international. Professional backgrounds attending the workshop included accounting and finance, biological and biomedical sciences, bioprocessing, biotechnology, business, dentistry, economics, healthcare, history, management, engineering, nutrition, pharmacology, political sciences and psychology.
An evaluation survey was purposely designed to incorporate quantitative and qualitative student feedback, providing an opportunity for the triangulation of results.
The quantitative component of the survey comprised a 24-item five-point Likert rating scale (1=strongly disagree, 5=strongly agree). The items explored (a) utility of the SqS for learning and enhancing understanding of UK healthcare systems, clinical pathways and cardiac pathways; (b) utility of SqS for highlighting strengths and weaknesses, and identification of problems and potential solutions for the cardiac pathway; (c) utility of SqS as an aid for discussion in the subsequent workshop and group discussions; and (d) overall utility of SqS as a teaching tool.
The qualitative component of the survey allowed students the opportunity to provide more detailed, open-ended perspectives about (a) implementation of the SqS themes in future studies, (b) usefulness of the SqS format and how it could be applied to other contexts and (c) general feedback.
Descriptive statistics (mean and SD) were calculated for each of the Likert scale results.
Thematic analysis of the questionnaires open-ended questions was conducted per question. Main themes and subthemes were identified and grouped accordingly.
56 students completed the evaluation surveys at the end of the workshop, with a response rate of 100%. Two researchers (SMW and TK) checked the data for consistency when uploading and analysing.
Overall, participants slightly to strongly agreed with the statements presented (mean total=4.49). The strongest agreement was for the ‘SqS for learning and enhancing understanding of UK healthcare systems, clinical pathways and cardiac pathways’ (combined question mean of 4.6) and ‘SqS as a teaching tool’ (combined question mean of 4.6). The least agreement was for the ‘SqS as an aid for discussion in the subsequent workshop and group discussions’ questions (combined question mean of 4.2) (table 2).
Fifty-one (91%) of respondents left written feedback for the question ‘Please describe below how you would implement the themes of today’s SqS in your studies’. Five themes were identified by two researchers (SMW and TK). Table 3 describes the themes identified and illustrates with selected quotes.
Fifty-three (95%) of respondents left written feedback for the question ‘Please describe how useful you think the SqS format is and how it could be applied in other contexts’. Five themes were identified and are presented in table 4.
Thirty-five (63%) of respondents left written feedback for the question ‘Please use the space below to add any other feedback or comments about today’s SqS’. Four themes were identified and are presented in table 5.
There was high level of agreement on the use of SqS for learning and enhancing understanding of UK healthcare systems, clinical pathways and cardiac pathways, for highlighting strengths and weaknesses, and identification of problems and potential solutions, as an aid for discussion in the subsequent workshop and group discussions, and as a teaching tool question means scored above four on the Likert scale. The qualitative component of the survey allowed for expansion on why respondents rated the approach so highly.
When respondents were asked how they would implement the themes identified in the SqS into their studies, they responded enthusiastically with ideas related to perspective sharing, understanding healthcare management and processes, and the consideration of feasibility and practicalities, and suggesting other applications.
When asked to describe how useful the SqS format was and whether they thought it could be applied in other contexts, participants responded that it was extremely useful and that they could envision a wide range of applications from education/training and public health to public/patient engagement, management and the optimisation of care pathways for a range of micro-clinical and macro-clinical contexts.
The final comments section of the questionnaire revealed a sense of gratitude from participants towards receiving the workshop. Improvements were only suggested in terms of the physical environment, not the design of the SqS or the workshop itself. Further comments on learning opportunities and different potential applications were made, revealing an appetite for more examples of this kind.
Between the high level of agreement from the quantitative results of the survey to the positive responses related to healthcare management and beyond, the workshop appears to have met its original objectives and has been rated highly in the process. Particular strengths appear to be the perspective-sharing component and the opportunity to optimise a range of care pathways. Adapting and tailoring SqS to different clinical specialties would therefore enable a range of pathways to be considered.
In conclusion, this workshop has been a useful exercise that has shown the potential for simulation, its applications and, in particular, for SqS to be used in other contexts outside of its traditional setting of the healthcare domain, yet with healthcare remaining at its core. This pilot study has therefore been successful, and further studies would strengthen its acceptability and applicability in this context.
The SqS approach has demonstrated again that simulation has a wider potential than for clinical assessment alone. Further studies are required to determine its potential uses and affordances beyond its current format. A programme of workshops that could be evaluated on a larger scale would be the next step in determining its usefulness alongside testing the other applications suggested.
Although this study does not provide generalisable results due to its evaluative nature, it does pave the way forward for a different approach to the use of simulation that is beyond healthcare professionals’ needs alone. Due to this study being a pilot and first attempt at using healthcare simulation in this format, it was conducted during the student’s induction week. This may have affected the results as the students hadn’t been fully engaged at this point in the programme’s management processes content. Further studies should aim to place the intervention at different points in the student’s educational programme, aiming to assess its effectiveness and timeliness.
The authors thank KL Chan, Ana Rita Rodrigues, Duncan Boak and Maria Bartletta for their help in undertaking the workshops. SQUIRE 2.0 publication guidelines were adhered to for in this manuscript.15
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- ↵NICE. National Institute for Health and Care Excellence, chest pain of recent onset: assessment and diagnosis: clinical guidelines. 2010. https://www.nice.org.uk/guidance/cg95.
- ↵SQUIRE 2.0. Revised Standards for Quality Improvement Reporting Excellence. 2015 http://www.squire-statement.org/document/docWindow.cfm?fuseaction=document.viewDocument&documentid=1&documentFormatId=1.
Contributors SMW conceived and designed the study, collected, cleaned and analysed the data, drafted and revised the paper. She is guarantor. TK helped design the study, collected, cleaned and analysed the data and revised the draft paper. EA helped design the project, provided clinical guidance and revised the drafted paper. BC initiated the collaborative project, helped design the project, monitored the study and provided guidance and revised the final draft. FB and RK initiated the collaborative project, monitored the study and provided guidance and revised the final draft.
Funding This work has been supported by Health Education North West London and Imperial College Business School.
Competing interests None declared for SMW, EA, TK & BC. FB & RK are unpaid Director and Founding Shareholders of Convincis Ltd
Patient consent Obtained.
Ethics approval The Imperial College Research Ethics Committee (ICREC reference: 14IC2251).
Provenance and peer review Not commissioned; externally peer reviewed.
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