#2: Setting up a palliative care sim programme

"I want to set up a palliative care simulation course at my workplace but I don't know where to start!"

Let us help you.

Disclaimer: This post will hopefully provide you with important points to consider but cannot be all-encompassing.
There is a glossary at the end and links to further reading.

The 3S's and 5T's

1. Get Trained up!

Attend a Sim Faculty, Human Factors or Debriefing Skills Course
We strongly recommend you attend a sim faculty development course prior to running your palliative care simulation programme. A good course will provide you with:

some educational theory behind simulation
what human factors are and how they are relevant to clinical practice
what psychological safety is, how to create and maintain it and why it is essential for all sim faculty to be aware of it
a model for debriefing (with some hands-on practice too).

Some courses may talk about how to set up novel sim programmes and provide a chance to write and run a scenario. It will give you a strong foundation upon which to build your course and some useful local connections.

Where do I find a course?
Courses are frequently run by large teaching hospitals, often already equipped with a high fidelity sim lab. There may or may not be a small fee to attend. If you contact the associated Postgraduate Medical Education Department they should be able to sign-post you.
For those in London, the London Sim Network (LSN) https://uclpartners.com/london-simulation-network/ has a monthly bulletin that highlights relevant courses.
If you're unable to attend a sim faculty development course, why not shadow/observe another local sim course?
PalliSim Network may have contacts local to your area - join us for free and ask!

2. Thinking Time
Consider:

Who are your intended learners e.g. junior doctors, hospice community nurses, 3rd year medical students? You might have a mixed learner group of many different healthcare professionals (that's trickiest!)
What would you like them to learn and what do they need to learn? Do they adhere to a particular training programme or curriculum which has palliative care competencies already detailed? Perhaps they don't, in which case, you might consider creating a brief learning needs survey asking them what they want to learn.
Consider whether simulation is the mode in which you want to teach what you want to teach. Different people mean different things by the word "simulation" but at the core, you are creating a safe and simulated environment for your learners to partake in experiential learning - they might be asked to role play a challenging conversation with a patient (played by a faculty member) whilst their peers watch and later provide constructive and structured feedback, or they might be interacting with a manikin (as your simulated patient) who is acutely unwell and requires urgent action and symptom control. After their scenario concludes, the group are guided through a clinical and human factors based debrief where the learning happens.
Does a course like yours already exist locally? You don't want to duplicate. Whilst making enquiries you may also find allies who can help you.

3. Your Team
Build your faculty team:

Your local palliative care team will have a vested interest. Many will have an interest in medical education or have human factors debriefing skills and sim experience alongside the necessary clinical knowledge to complement your own.
Your local postgraduate medical education department (PGME) or university if you are teaching students. They may have Medical Education or Simulation Fellows who can support you.
Your Director of Medical Education (DME) for the hospital Trust: they will have knowledge of where potential funding streams are (vital!!)
Perhaps you work in a hospice: is there an Education Lead? What does the Medical Director or Clinical Lead think? Perhaps your course is for the hospice inpatient unit staff nurses - what does Matron think, or your Nurse Consultant colleagues?
PalliSim Network: our members run palliative care simulation programmes across the U.K in all its forms. We have supported members to develop novel courses and refine ideas - join us!

4. The Stakeholders
Consider who else might have a vested interest in supporting the delivery of your course - this will be very course-specific. Approach them to discuss your idea.

Consider the wider hospital/hospice priorities:

What did the last CQC report say about delivery of end of life care for your hospital's patients?
If you could support your hospice inpatient unit staff nurses with their tracheostomy skills and competencies through a simulation course, could you broaden the care you can delivery to your local population?
What were the results for last year's National Audit of Care at the End of Life?
Have there been any specific PSIRF learning points or patient complaints related to your topic?

Use this information to get buy-in and make a compelling case for funding, equipment and support.

5. Time and resources (funding, equipment)
Consider what resources you have and what you might need to locate with some creative thinking.

Example 1:
For example, the Internal Medical Trainee (IMT) doctors at your hospital have palliative care competencies within their curriculum and have expressed a wish to develop their skills in caring for patients at the end of life. The palliative care team and DME are on board. The PGME can offer the support of the Simulation Fellows and already have a high fidelity manikin and sim lab which you have visited. The sim technician has shown you what the manikin can do and would be available to support your course.
You've worked with your team and the sim team to identify prospective dates for your course which work for everyone involved.
The PGME department is willing to fund a pilot day for your course with future repeats dependent on the impact you can demonstrate on learners. Sounds like you're ready to write some content!

Example 2:
Or perhaps, you're working in a hospice and your inpatient unit (IPU) has had to repeatedly turn away patients with tracheostomies and patients who are on non-invasive ventilation (NIV) because the IPU nurses do not feel confident and competent with caring for these patients. You would like to support them with their learning objectives and feel that a sim course would be appropriate.
You have planned for a full day course with a morning of clinical skills-based workshops around tracheostomy care and NIV followed by an afternoon of simulated scenarios to help put learning into practice.
You have the support of your hospice's nurse consultant, medical director and education lead. PalliSim has connected you to contacts at another hospice in England which is successfully delivering a similar course for similar reasons and they have given you some advice. You don't have the necessary equipment though and you need someone who is comfortable with teaching the skills and then supporting with the clinical knowledge around NIV and tracheostomies.

Reach out to local sources of support:
- Perhaps the local hospital or community have a respiratory physiotherapist who could teach the skills and has all the NIV equipment already
- Perhaps there is a tracheostomy Clinical Nurse Specialist who could support your course
- Perhaps the local university or hospital have a sim lab with the necessary equipment - could you rent that equipment or could they perhaps host your sim day and if so, what would the cost be?
It all can sound quite daunting but the more people you ask, the more you'll discover willing and supportive collaborators - they will have faced your dilemmas before or have inventive ways to think around them!

6. Strapped for cash? (basically MONEY)
Hopefully you'll find as you've progressed through the above steps, that there is plenty available to you without having to spend any/much money.

There are also useful work-arounds. For example:

A faculty member can simulate being the patient. You don't necessarily need to buy a manikin or pay an actor. You just need a friend.
Equipment often can be borrowed with sufficient notice.
Do I need a brand new hyper-realistic expensive manikin? No! Think about what your scenario needs to be realistic enough and ask your learners to suspend disbelief and buy-in. A Resusci Anne used commonly for Basic Life Support training will often do. You can build fidelity (https://www.healthysimulation.com/30181/what-is-fidelity-in-simulation/) in other ways.

How will I fund my course after a successful pilot? What is the long term plan?
This is an important question and one you should ask yourself BEFORE running your pilot.
Your department might fund a one-off running of your course but consider how you will fund future iterations. You may have to bid for funding. You will want to use your pilot to gather useful data from attendees to demonstrate how valuable your course has been. You may choose to gather white space freetext comments immediately post course and then touch base again at an interval to explore how the course has impacted clinical practice. Think about what feedback you need to collect from your pilot day to argue your case in the future.

Other sources of funding:
Are you teaching a cohort of learners with specific needs which are mandated? Perhaps you are building a palliative care simulation component as part of the International Medical Graduates (IMG) doctors induction programme. Perhaps you are running a palliative care skills and simulation course for palliative care registrars (many of whom are trainees with access to a study budget).
Funding streams will be course and location specific.

7. The Sim Scenarios and content for the day
When I first started out I thought it was all about the sim scenarios and that the quality of my course would be judged by how descriptive and prescriptive they were. Over time, I've discovered it is more about how you facilitate the day as a whole that yields the best results and that is why point 1 is about getting yourself trained as a sim faculty member and point 7 is about writing content.

This point will likely need its own blog post to elaborate but it is worth thinking about the following:
a. The pre-course email sets the tone for your sim day: participants ought to expect that when they sign up to a palliative care simulation day, that topics such as death and dying will come up in discussion. However, it may be worth acknowledging this explicitly and ahead of time alongside reassurance that learners will be supported throughout and that participation is voluntary.
b. The introductory slides: often include housekeeping and set the tone. You might also briefly cover learning objectives, address participant hopes and fears and explain how the day will run, especially if some of your attendees have never attended a simulation course before.
You might have a pre-course survey you wish to share.
c. The scenarios: will be built around what you and your learners want to learn. They may be blueprinted to a specific curriculum or focused around specific skills applied to a patient scenario (e.g. blocked tracheostomy in a hospice IPU patient).
It can be helpful to look at how others write their scenarios. At PalliSim we share a G drive with sim resources that members can review and adapt with credit given to the original authors. It can be a good place for you to start getting an impression of how others have built scenarios to fit a learning objective.
d. Scenarios may require additional supporting materials, perhaps the patient has hospital notes or has come in from home with a community DNACPR form. Perhaps the hospice has specific guidelines around anticipatory prescribing which participants might need access to during the scenario.
e. Outro slides: may include a reminder to take the post-course feedback survey, links to further reading and could signpost to sources of support (for participants as well as for patients).

8. Test it out (pilot)
It is time to run your pilot palliative care simulation day! We hope you will find it enormously rewarding and a lot of fun too. Make sure to gather meaningful feedback on your course from the attendees and perhaps also your fellow faculty members - you can use it to refine the course content and also as evidence of impact towards future funding bids with long term course sustainability in mind.
Your tenacity (final T) has paid off! Congratulations.

Written by T Tran, May 2024

Glossary:

Learning needs assessment: this might take the form of a survey or informal discussions with prospective learners/participants to better understand what it is they wish to gain from your course.
Human factors (in healthcare): has a rich history and you will find plenty of further reading around this. In essence, human factors refer to a broad range of environmental and individual factors which influence behaviour at work in a way which can affect health and safety. Examples of human factors include the influence of hierarchy, teamworking, leadership, assertiveness, effective communication - all of which can dramatically impact a patient's clinical outcome.
Debriefing in simulation: refers to the time spent immediately after a sim scenario where faculty members facilitate a structured and constructive conversation with learners to support them to reflect on their experience and identify meaningful learning points to take away.
Fidelity: describes the degree to which the simulated environment replicates the true working environment. You might increase fidelity by utilising an actor instead of a manikin or creating a realistic ward environment within which the participants interact with the simulated patient.
Psychological safety: describes how safe your learners feel in your hands - do they feel empowered to speak up, to ask questions, to make mistakes knowing they will not be harshly judged by faculty or their peers? This article describes it well, (though not sim specific): https://hbr.org/2023/02/what-is-psychological-safety