Written by Dr Olivia Duffy, Global EM Fellow, Bristol Royal Infirmary
Edited by Anisa Jafar & Frankie Cackett
Photo credits: Dr Olivia Duffy and Mr Mwangi Ishmael, shared with participant consent
In summer 2023 my role as global health fellow in emergency medicine at the Bristol Royal Infirmary saw me spending 6 weeks in Nanyuki Hospital (northwest of Mount Kenya) under the umbrella of the Dharura charity. The Bristol-Nanyuki partnership has been running for five years and deploys doctors and nurses for up to ten weeks throughout the year. It is based around reciprocal learning and development through collaborative quality improvement and education.
One of my roles included supporting the simulation facilitator programme which had been implemented by the senior global health fellow prior to my arrival. Though simulation has been used as a teaching tool throughout the partnership, this was the first time implementing a train-the-trainer model.
20 local healthcare providers across multiple departments undertook a one-week training programme to learn how to facilitate simulation (sim) using the Sim Zones framework originally developed in Boston by Roussin and Weinstock and explained in this video from the authors (34:22 onwards). This framework provides a common terminology to describe sim and helps match the type of simulation and instructor style to the learner’s specific needs.
Arriving in Nanyuki was both an exciting and nervous experience. The approach we were taking was such that we took the lead from local colleagues with respect to when, where and how sim training might take place. One very enthusiastic hospital area had noted a lack of confidence in resuscitation situations; the three trained facilitators wanted to use their newfound skills to address this. It was decided in conjunction with the senior global health fellow (who was providing support remotely) that it would be best to start with some Zone 0 (the simplest zone) airway and CPR sims. Conflicting commitments whittled the facilitator team down to one, but he picked up the process rapidly. Watching this colleague grow in confidence, navigate complex discussions around real life resuscitation scenarios and find creative solutions to learner’s difficulties was a real privilege. As more and more staff expressed an interest in joining sims, many would stay post nights, during shift, and come in on days off just to participate. A large part of allowing the facilitator to flourish and draw in learners seemed to result from the establishment and maintenance of the psychological safe space.
Simulation involves working at the limits of your knowledge and taking risks. The aim of psychological safety is to allow participants to feel safe enough to push themselves to their limits and to identify, reflect and act on mistakes they make. This is particularly important for those who haven’t had opportunities to develop from risk-taking forms of learning before. Standard ways to address safety begin with respectful communication prior to the simulation to prepare all participants. It then continues throughout, ending with the provision of constructive feedback in a sensitive manner.
Some elements used very explicitly in Nanyuki were the confidentiality agreement, fiction contract and the principle that everyone is there to do their very best. Each simulation session would start by reading out the Harvard Basic Assumption™:
“We believe that everyone working here is intelligent, capable, cares about doing their best, and wants to improve”©
– used with permission from The Centre for Medical Simulation, Boston, Massachusetts, USA
This aims to show that the learners are not only held in high regard but also to high standards to help maintain a constructive learning environment. Confidentiality agreements were used as a verbal contract for anyone participating in the sim. The fiction contract is an agreement between the facilitator and participants to enter wholeheartedly into the scenario as if it were reality. This requires the facilitator to remove as much artefact as is reasonably possible and for the participants to act as if the scenario is real.
Throughout the 6 weeks, confidence grew, both amongst the multi-disciplinary team as sim participants translating their learning to clinical practice and supporting their colleagues in the sim environment; and also amongst facilitators leading sim sessions and generating interesting learning discussions whilst reinforcing the safe space by demonstrating their own vulnerabilities to their colleagues.
Sim is not a new concept within global health however research suggests there are specific factors to consider when planning for sim in resource-constrained settings. Diagnoses and skills should be applicable to local disease and risk profiles. Cultural considerations are also important. Understanding normal responses to bad news and grief in different contexts, or understanding who might be responsible for making treatment decisions can vary significantly. Local guidelines and knowledge alongside WHO recommendations should be used to guide best practice. Furthermore, sustainability needs to be in-built because any education initiative will have greater impact if it is part of a broader plan.
The incredible dedication and enthusiasm shown by everyone in Nanyuki emphasised the importance of providing support in a collaborative role, attempting to navigate the fine balance between when to step in and when to step back. The cooperation between local facilitators and local learners, on the background of long-standing working relationships, highlighted the benefits of training local facilitators rather than implementing sim as an external provider. This ties into wider discussions around decolonisation of medical education.
On a personal level, seeing small but meaningful positive change as a result of my time in this role, was humbling and rewarding. After practising a full Zone 1 basic life-support simulation, the debrief demonstrated the challenge of timing. Subsequently the nurse in charge ordered two new clocks for display. Conversations were started about where to keep emergency drugs in order to maximise their accessibility. Perhaps most poignantly, several of the learners were involved in a cardiac arrest overnight, and although the outcome was not favourable, the staff were able to reflect on their teamwork. In the debrief it became clear that individuals knew their roles and were able to work more confidently and effectively, and everyone left feeling like they had done their best for the patient.
With time, is its hoped that Nanyuki’s sim facilitators will be able to move between hospital departments to mitigate for their respective work-load challenges. In a phrase which became emblematic (and even added to a cake!) of the sim project in Nanyuki:
“Those who sim together, win together”
and there isn’t a better winning example than the hard work of the Nanyuki sim team.
For more from the team in Bristol take a look at their Global Emergency Care Conference: Inspiration, Education and Increasing Participation 24th November 2023, 9:00-17:00, The Watershed, Bristol – tickets here
References
Fey MK, R. C. (2022). Teaching, coaching, or debriefing With Good Judgment: a roadmap for Teaching, coaching, or debriefing With Good Judgment: a roadmap for implementing “With Good Judgment” across the SimZones. 26;7((1):39). doi:10.1186/s41077-022-00235-y
Kost A, C. F. (2015). Socrates was not a pimp: changing the paradigm of questioning in medical education. 90((1):20-4). doi:10.1097/ACM.0000000000000446
Madireddy, S., & Rufa., E. P. (2023). Maintaining Confidentiality and Psychological Safety in Medical Simulation. StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK559259/
O’Donovan R, M. E. (2020). A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour. 10;20((1):101). doi:10.1186/s12913-020-4931-2
Pitt, M. &. (2016). Using Simulation in Global Health: Considerations for Design and Implementation. 12((3):1). doi:10.1097/SIH.0000000000000209
Roussin CJ, W. P. (2017). SimZones: An Organizational Innovation for Simulation Programs and Centers. 92((8):1114-1120). doi:10.1097/ACM.0000000000001746
Rudolph JW, R. D. (2014). Establishing a safe container for learning in simulation: the role of the presimulation briefing. 9((6):339-49). doi:10.1097/SIH.0000000000000047
The Basic Assumption. (2004-2023). Boston, Massachusetts, USA. Retrieved from www.harvardmedsim.org info@harvardmedsim.org