developing and maintaining clinical skills in the practice

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Contents

ALLIED HEALTH PROFESSIONS

Developing and Maintaining

Clinical Skills in the Practice

Setting

Simulation Based Education

Toolkit

Nic Richardson

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Contents:

Section Page number

Introduction 3

What are clinical skills 3 The 4 Pillars of Practice in clinical skills 4

Using simulation to develop and maintain clinical skills

5

Planning and developing simulation based education

6

Using this toolkit 7 Human Factors for AHPs 8

Delivering / Running simulation based education

9

Scenarios List 10 - Situational Awareness: 1. Supporting those experiencing poverty or deprivation 2. Conversation at home with patient and carer

11 16

- Decision Making: 3. Chest pain at home 4. Deteriorating patient in clinical setting 5. Lone working and unexpected clinical situation

21 26 31

- Communication: 5. Hard of hearing – domicillary visit 6. Angry Patient – clinical setting 7. Discharging a patient

35 40 45

- Team work: 7. Challenging Conversation with team member 8. Multi disciplinary team meeting

49

53

- Leadership Skills: 9. Coping with pressure 10. Supporting others (students / staff)

58 63

Examples for further scenarios 67

Local examples – NHS Lothian – respiratory on-call Physio NHS Shetland –integrated team development

68 79

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Introduction:

This toolkit forms part of a series of resources created by the NES Allied Health Professions (AHP)

Practice Education Team which are focused on supporting the development and maintenance of

clinical skills in the practice setting.

This toolkit collates links to resources available from CSMEN (Clinical Skills Managed Educational

Network) and it is recommended that you access their resources and expert advice at

https://www.csmen.scot.nhs.uk/

The toolkit is designed as a resource for those supporting and facilitating the education of others.

Other resources in the series include (available on the AHP page of Turas learn) :

1. An introductory module which can also be accessed by pasting this address into a browser bar:

https://learn.nes.nhs.scot/2525/identifying-and-supporting-your-continuing-professional-

development-cpd-and-career-development/developing-and-maintaining-clinical-skills-in-the-

practice-setting

It is recommended that the module be completed prior to using this toolkit.

2. A self-assessment tool to support reflection on clinical skills used in practice.

3. A non-technical skills structured observational tool for AHPs (NAHPS) - which can be used as a

formative observational assessment tool. This can be used during simulation exercises and / or in

clinical practice.

What are Clinical skills?

“Any action by a health or social care professional involved in direct patient care which impacts on clinical

outcome in a measurable way” NHS Education for Scotland (2008)

Clinical skills are categorised as technical skills and non-technical skills. Both sets of skills are essential and

interlinked for high quality, safe and effective care. It is essential that AHPs regularly reflect on their clinical

skills in order to identify strengths and areas for further development. The TURAS module provides a self

assessment tool for AHPs to reflect on their clinical skills.

• Technical skills include skills such as clinical examination, formal assessment and treatment techniques and invasive procedures

• Non-Technical skills include skills such as decision making, team work and communication and are

defined as:

‘Cognitive, social and personal resource skills that complement technical skills,

and contribute to safe and efficient task performance’

Flin et al (2008)

https://www.csmen.scot.nhs.uk/

https://learn.nes.nhs.scot/2525/identifying-and-supporting-your-continuing-professional-development-cpd-and-career-development/developing-and-maintaining-clinical-skills-in-the-practice-setting



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The four pillars of practice in clinical skills:

AHPs are familiar with defining their activity and learning within the four pillars of practice.

Despite the first pillar being called clinical practice, clinical skills are not only contained within this single

pillar. Remembering that clinical skills refers to the breadth of activity carried out in practice which has a

direct and measurable impact on the care a patient receives, it is essential that all four pillars are

considered.

Some examples of how clinical skills can be categorised:

The four pillars of practice in Clinical Skills

Clinical Practice

Facilitation of learning

Leadership Evidence, research and development

Technical skills

- Assessment - Using specialist techniques - Using technical equipment

- Explaining and demonstrating a treatment plan / intervention to a patient / carer

- safe delegation of tasks - using SBAR communication

- applying a policy / guidance to care

Non-Technical

skills

- Clinical reasoning - situational awareness

- establishing a shared understanding of a plan in the team

-prioritising plans and needs -organisational skills / planning

-gathering information relating to patient

You can learn more about this in the “Developing and maintaining clinical skills in the practice setting”

TURAS module (link on page 3) You can self assess your clinical skills using the self assessment tool available

on the AHP pages.

The four pillars of practice can also be applied to other elements of the AHP role. For example, how we

apply all four pillars when supporting students, acting in a team lead role and when undertaking service

improvement. These may also appear to sit most comfortably under one pillar but will require skills and

knowledge from all four pillars.

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Using simulation to develop and maintain clinical skills:

Simulation based education (SBE) is a technique which can be used to support the development of clinical

skills. Using simulation affords learners a safe learning environment to practice or rehearse clinical activity,

discuss issues, identify strengths and address areas for development.

Simulation can focus on technical skills, non-technical skills or a combination of both (which is most true to

life) and when delivered successfully, can offer a robust and rewarding experience.

SBE involves planning and running a scenario which mirrors an element of practice. This can be enhanced

by equipment and resources such as simulation mannequins, part task trainers or volunteer patients.

Scenario development is enhanced through using a template. It is recommended that the scenario

template available on the CSMEN website be used to support scenario development.

Template: http://www.csmen.scot.nhs.uk/resources/simulation-based-education/

This toolkit provides example scenarios for AHPs to use in practice.

Delivering positive simulation based education is a skill which requires preparation and planning. The

CSMEN (Clinical skills managed educational network) have defined a 3 tier model for educators:

It is recommended that all educators delivering simulation should be suitably trained in order to assure the

quality of SBE across Scotland. https://scschf.org/wp-content/uploads/sites/8/2017/08/National-

Outcomes-Framework.pdf

Awareness level faculty development training (Becoming a simulation based educator) can now be

completed online with CSMEN via TURAS: https://www.csmen.scot.nhs.uk/resources/online-

resources/faculty-development-becoming-a-simulation-based-educator/

AHP Practice Education Leads in every Scottish board are trained to awareness level with some trained to

introductory level. You can contact your local AHP Practice Education Lead for further information or

support.

Introductory / faculty courses are available via CSMEN http://www.csmen.scot.nhs.uk or the Scottish

centre for simulation https://scschf.org/

This toolkit aims to provide an overview of simulation and resources which can be used by those who are

confident to do so. It does not replace simulation faculty training courses.

Advanced

Introductory

Awareness

http://www.csmen.scot.nhs.uk/resources/simulation-based-education/

https://scschf.org/wp-content/uploads/sites/8/2017/08/National-Outcomes-Framework.pdf

https://scschf.org/wp-content/uploads/sites/8/2017/08/National-Outcomes-Framework.pdf

https://www.csmen.scot.nhs.uk/resources/online-resources/faculty-development-becoming-a-simulation-based-educator/

https://www.csmen.scot.nhs.uk/resources/online-resources/faculty-development-becoming-a-simulation-based-educator/

http://www.csmen.scot.nhs.uk/

https://scschf.org/

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Planning and Delivering Simulation Based Education:

The CSMEN offer guidance for those trained as faculty which is available online:

https://www.csmen.scot.nhs.uk/mobile-skills-unit/faculty-development-course/

The CSMEN MSU guide sets out how a scenario should be developed and delivered. It is recommended that

you refer to the CSMEN resources for further information as an aide memoir after your training.

Simulation education must be based upon and aligned to learning objectives and follows a three step

process:

Brief – BEFORE - Setting and background information for learner and simulated patient.

(prepare self, faculty, learner and environment, detail learning objectives within

wider context of learning, link session to clinical practice)

Immersion- DURING - The simulated learning activity.

(consider - manufacturing reality and fidelity, structure of learning activity,

knowledge of simulators, level of facilitation, expected progress)

Debrief – AFTER - Approach to debrief and feedback.

(consider - when to stop the simulation, disengagement from simulation event,

the structure for feedback, & future planning)

The following image from the Scottish Simulation Centre relates this process to Kolb’s reflective cycle:

Brief Immersion Debrief

https://www.csmen.scot.nhs.uk/mobile-skills-unit/faculty-development-course/

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Using this AHP Simulation toolkit

1. Selecting a Scenario

This toolkit provides example simulation based education scenarios which could support clinical skill

development for AHPs. They are planned to be suitable for students, staff at all levels and return to practice

candidates.

Given the breadth and scope of practice covered by all the Allied Health Professions, some adaption of the

scenario detail may be required to match this to the specific clinical setting / speciality.

Each scenario has defined learning objectives and aims. Select the scenario which matches the learning

objective you are trying to achieve and alter any details to increase the applicability and realism for your

learners.

The example scenarios are organised under five categories of non- technical skills. It is likely that there will

be skills required / observed from all categories within the scenario but it has been organised under the

main focus. The skill categories each have themes within them as listed in the table on page 8.

These 5 categories form the basis of the non-technical skills structured observational tool for AHPs

(NAHPS). This system can be used to guide feedback and shape assessment of performance. The

observation tool (NAHPS) document forms the third element of the NES AHP clinical skills resources. This

system is an adaption of existing medical frameworks designed by Flin et al (2003, 2006), applying the

resources to AHP practice. The tool and a guidance booklet are available on the AHP TURAS learn page.

The scenarios have been identified under the non-technical skill elements as these are core to all

professions and all settings. Non-technical skills have been linked strongly to patient safety as the

underpinning approach taken to care delivery. These are sometimes referred to as ‘human factors’ and

there is a lot of literature available on the value of non technical clinical skill development.

Each scenario will have technical skills which could be added to enhance the experience. Some suggestions

have been added to each scenario as add on activities. These MUST be specific and relevant to the

learner(s).

All scenarios have been developed using the CSMEN scenario template.

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AHP Non-technical (Human factor) skills

Skills Category Overview Skill Themes

Situational Awareness

Gathering information of the current situation to develop and maintain a dynamic awareness, identifying and monitoring risk at all times. In this context the ‘information’ may be gathered from the environment, patients, colleagues, notes, charts, relatives and the communication and behaviour of others amongst other sources. This information is used to think ahead and predict what may happen next.

-Gathering Information -Recognising and understanding the value of the information available -Identifying risks to wellbeing -Projecting and anticipating future state

Decision making

Skills for reaching a judgement or selecting a course of action to meet the needs of any situation. These apply in both normal conditions and in time-pressured crisis situations. Decisions in this context include assessment, diagnoses, interventions, investigations and recognising the need for escalation of care.

-Considering and indentifying options -Selecting and communicating options -Implementing and reviewing interventions.

Communication Aware of and utilise communication techniques and strategies to promote and enhance understanding. Engage with patients and carers in a way that is mindful of health literacy levels and personal outcomes focused.

-Use of appropriate language / communication -Utilising person centred communication -Checking a patient’s understanding

Team work Skills for working with others in a team context to ensure that the team has an acceptable shared picture of the situation. It includes skills for working in a group context, in any role, to ensure effective communication, task completion and team member satisfaction; the focus is particularly on the team rather than the task.

-Develops professional relationships for safe practice within the team - Speaking up and exchanging information - Establishing a shared understanding -Co-ordinating team activities / plan

Leadership skills

Leadership is a skill for AHPs at all levels of practice. It includes organising your own resources and time as well as leading and prioritising activities required to achieve goals. Leading the team and providing direction, demonstrating high standards of clinic al practice, and being considerate about the needs of team members.

-Setting and maintaining standards -Prioritising (tasks and patients) -Coping with pressure -Supporting others -Planning and Preparing

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Delivering / Running Scenario Based Education

Each scenario can be delivered in various ways. They can be used for individuals such as students, staff or

people who are undertaking the return to practice process.

For students during practice based learning, simulation can offer an opportunity to rehearse a new

experience or to revisit and revise an experience that they found challenging. For staff, this can form part of

an ongoing CPD programme or be used to address any competency issues before or as part of a formal

process. For return to practice candidates, this can offer a structured supervised practice and learning

experience in one. The formal debrief or assessment records can form part of their portfolio for HCPC.

This toolkit is suggesting three delivery methods which can be applied to each group:

1. Team development (in-house training)

In this method, the scenario is delivered in the ward or dept in a teaching area. It is likely that this delivery

method would utilise a volunteer as the patient rather than accessing the high fidelity simulation

mannequins or part task trainers.

Suggestions could be as part of a team in-service or band 5 development group for example.

This could be delivered in the standard brief – immersion – debrief with a group of participants and a group

of observers coming together for the debrief discussion.

It could also be delivered as an interactive theatre style where the scenario is run for a few minutes

uninterrupted, a short debrief, then re-run, inviting the observers to interject, suggesting changes to

improve practice. This is followed by a second debrief.

2. On the Mobile Skills Unit or in a Simulation Centre

This method of delivery would be well suited to supporting someone who is returning to practice or as part

of a formal skills development programme.

This would enable video of the scenario to be made to support a formal debrief and to provide evidence for

portfolios etc of safe practice. Go pro cameras or ipads can support videoing out with sim centres.

This method enables the use of simulation mannequins and part task trainers to enhance the scenario.

Volunteer patients can still be used in this setting.

Debrief in this format supports the learner to identify their strengths and areas for development and guides

them to identify take home messages from the scenario.

3. As a formal formative assessment of practice

The assessment of practice using the non-technical skills structured observational tool for AHPs (NAHPS)

and any related checklists for technical skills enables robust evidence of performance. This can be further

enhanced through the use of video to evidence the observations during the formal debrief.

If using the marker system it is suggested that the five pages be printed and the observer spread them

across the desk, ticking behaviours observed.

This will enable the transfer of the information to the ‘observed practice record form’ for the debrief.

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Scenarios: The scenarios are categorised under the main heading which most relates to the skills

required. However, there is over lap and any scenario could be adapted

Situational Awareness: 1. Supporting those experiencing poverty or deprivation Page 11 2. Conversation at home with patient and wife

Decision Making: 3. Chest pain at home 4. Deteriorating patient in clinical setting 5. Lone working – unexpected clinical situation

Communication: 6. Hard of hearing – domicillary visit 7. Angry Patient – clinical setting 8. Discharging a patient

Team work: 9. Challenging Conversation with team member 10. Multi disciplinary team meeting

Leadership Skills: 11. Coping with pressure 12. Prioritisation of patients

Local examples NHS Lothian NHS Shetland

All the scenarios are set out in the same format.

Back ground and brief – this is the information you can share with the learner

Story board – this is for faculty to run the scenario and keep it on track to time and purpose

Conclusions and discussions- these are prompts for debrief

Options for delivery –these are additional notes to assist in your planning and set up.

You should adapt the scenario most relevant to the situation you wish to represent and print those 5 pages.

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Scenario 1: Supporting those experiencing poverty or deprivation

Target group – Could be adapted for any profession working in a hospital or clinic setting

Learning objectives: By the end of the scenario and debrief participants will be able to: - consider the impact of living conditions often associated with poverty on patients - demonstrate person centred communication with a patient who is experiencing poverty - discuss the role AHPs play in addressing health inequalities

Setting and Background: This scenario is set in a health setting. This could be on a ward or in an outpatient / community health centre setting. You are an AHP (insert specific profession) working in this setting.

Brief:

You are having an intervention with a 34 year old patient who is still in / has been in hospital following a road traffic accident. This is an initial assessment / conversation with you. You are to speak to the patient about coping at home following discharge – related to your profession. The patient is weak and has fatigue problems. They currently require crutches and have follow up appointments with outpatient physiotherapy, occupational therapy and need radiography review and medical clinics (add any relevant others). You ask about the home situation and may wish to include nutritional needs, physical needs and /or mental health or social needs as appropriate. The patient is a parent of 4 children under 5 years old. Neither they or partner works and they are receiving benefits but are not sure if they are getting all benefits they could be entitled to as they are struggling financially. Carry out a good conversation with this patient, using a personal outcomes approach and considering the work question as well as other health behaviour questions. Identify and plan for next steps.

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Scenario 1 – Poverty- story board

Timing Clinical condition Expected Clinical Course with actions, triggers and prompts

1. Beginning Introduce self to patient and initial conversation

Patient Welcoming, signs that they are disheveled and malnourished. Using crutches

Expected learner actions: Carry out ‘good conversation’ Address or acknowledge signs of poverty and find out more Consider holistic needs of family

Transition Trigger: (Actions OR Time) At 2 mins or when asked about kids - Show photos in wallet of kids at home in living room – no carpets, dirty or wearing nappies Prompt: Patient response Happy to chat and open to any questions. Not offering information about poverty but if asked, share no carpets, no jobs, lack of food and heat. Faculty

Teaching Points:

Good conversations & personal outcomes

2. Middle Considering the impact of poverty

Patient Becomes upset that they are letting family down and the additional costs of coming to hospital for the clinics etc means that they’ll either DNA or have to go without.

Expected learner actions: -Discover the level of poverty the patient is living in -Identify their needs - ask about mental health

Transition Trigger: (Actions OR Time) Prompt: Patient response Become upset and cry when speaking about homelife ‘wanted to do my best for my kids’ ‘feel like failure’ ‘if I come to these appts they’ll miss out on even more’ ‘I’m so sore I am really needing the painkillers’ ‘somedays it’s a struggle to leave my bed’ ‘thought I was dead when I had the

Teaching Points:

Equity and social justice

Mental health

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accident and it might have been better for them all’ Faculty If not raising mental health issues, prompt after 3-4 minutes


3. End Goal setting

Patient If you have been heard you are calming down, if not you are becoming more upset

Expected learner actions: -give patient time -set goals - consider mental health / physical health and social needs - discuss if any outpatients appts can be combined or done at home - don’t leave patient at prompt from the faculty

Transition Trigger: (Actions OR Time) Prompt: Patient response ‘nothing is joined up. I’m here every day next week for different appts’ ‘nobody really listens’ Faculty Interrupt the session whilst it is in full flow with – sorry we have a phone call or sorry your next patient is here.

Teaching Points:

Person centred care

Patient focused booking etc

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Conclusion: Stop this scenario after 15 minutes maximum.

If the discussion reaches goal setting before then or if the conversation is closed without reaching this stage

then stop the scenario.

Discussion and Feedback:

- Good conversations

- Home situation – no heat, cooker etc. How do we address this?

- Health inequalities and deprivation

- Adapting practice to accommodate social and physical needs e.g booking etc.

Equipment and props:

- Worn clothing for patient / hospital pyjamas

- Limited belongings on bedside locker.

- Crutches

Personnel:

- Patient

- Faculty – prompts as stated.

Options for delivery

Team development

If using this in team development, you should identify one person to be the AHP. You may need to be the patient unless you can arrange for a volunteer patient or another group member is keen to undertake this role. In a classroom / meeting room set up one corner as clinical environment using the following as a guide: - use a bed (if available) and/or chair to create a ward setting - use 2 chairs to simulate a dept setting Patient should wear worn clothing or hospital issue pyjamas Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be on the other side of a door before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. Decide before you start if you’re using the interactive stage of the process. You can include micro teaches within this around positioning for communication, falls pathway and risk identification

On MSU or in clinical skills centre

Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a clinical environment. Follow all guidelines for setting up the cameras and systems

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Set up a clinical environment using the following as a guide: Utilise the front 1/2 of the MSU (nearest the screening room). Use Sim-mans trolley as a bed and add a bedside chair. Add any belongings Patient should wear worn clothing or hospital issue pyjamas. Set up the cameras. If this is for a group, set up the chairs around the back TV, link this to the cameras and issue headsets. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.

1:1 assessment of skills / behaviours

If using this as an assessment of competence you should have taken some time to become familiar with the behavioural marker system. This should be done before the scenario. You can run this scenario in a class or the MSU but it will be most beneficial if filmed for debrief as it can be helpful for participants to see their skills and learning needs. If the MSU is not available you could film the scenario in a standard room using ipads etc to film it. It should be made clear to the participant that you will be looking for specific skills and behaviours during this scenario and you will discuss these afterwards. It is likely that this will be a formative assessment, not a summative assessment – informing further discussions and development planning.

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Scenario 2: Conversation with patient and carer

Target group – Could be adapted for any profession.

Learning objectives: By the end of the scenario and debrief participants will be able to: - Discuss the process of gathering information from multiple sources - Consider the role of the carer in information gathering - Identify potential risks to wellbeing for patient and carer.

Setting and Background: This scenario is set in a home. (This could be adapted to be on a ward or in an outpatient / community health centre setting but you’d need to ensure physical / environmental cues were still available)

Brief:

You have been referred a patient in the community and are visiting for the initial visit. The patient, a 79 year old man and his 71 year old wife are present during the visit. The patient was diagnosed with dementia 4 months ago. He believes he is ‘managing fine’ at home and doesn’t want to make a fuss. He is a retired plumber, has type 2 diabetes and angina. The referral states that he has reduced mobility and has stopped going to his usual social activities – men’s shed with friends, church with his wife, local football team on a Saturday. The patient states he has just had a cold but will be going back to them soon, when the weather is better. He is quite a domineering man and his wife is quiet during the visit but tries to make her point a few times. She appears tired and anxious. Please assess this man and plan your intervention (if any) or onward referral.

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Scenario 2 – Conversation with Patient and carer – Story board


1. Beginning Introduce self to patient and initial conversation

Patient ‘No idea why you are here, I’m fine. Just HER making a fuss as usual’ Wife (faculty) ‘Just ignore him. We’re glad you’re here. We need a bit of help as he’s not been himself recently’ Environment Urine bottle beside chair TV controls / newspaper etc all beside chair

Expected learner actions: Gather patient’s and carer’s perception of reason for referral.

Transition Trigger: (Actions OR Time) After 2 minutes Prompt: Patient response All fine, no need for you. Patient needs toilet. tries to get wife to pass him the bottle, struggles with word finding. Wife states he needs to leave the room and use the toilet off the hall.

Teaching Points:

2. Middle Patient goes to toilet

Patient Struggles to stand, needs support from wife. Once up needs reminding that he was going to toilet. Shuffling gait. Carer Back pain when helping him Shares quickly whilst he is out of room that she is struggling, hes up during night and has started doing funny things – putting things in wrong place etc. He can be angry

Expected learner actions: - identify carer needs -identify signs of struggling in environment - identify patient reduced mobility

Transition Trigger: Prompt: Patient response Calls wife for help from toilet Environment Spot notes pinned to phone, tv remote etc as reminders for patient. Few odd objects in wrong places in home.

Teaching Points:

Dementia

Carers needs

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Timing Clinical condition Expected Clinical Course with actions, triggers and prompts 3. End Patient and wife return

Patient: Frustrated and a bit embarrassed

Expected Learner actions Acknowledge that they have observed that the patient is finding some things a bit hard

Transition trigger If AHP acknowledges the struggles and information from wife then go on to have open conversation Not leaving house and wife not happy to leave him so not going out either. Becoming isolated and stressed If continues to ask generic questions, patient insists everything is fine and wife says she is just tired due to a blocked nose and not sleeping and everything is fine. - prompts phone call from daughter / son saying mum is on phone crying and really struggling and that AHP needs to do something.

Teaching points Value of carer information Risks to wellbeing Mental health and wellbeing

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Conclusion: Stop this scenario after 20 minutes maximum. If the discussion reaches goal setting before then or

if the conversation is closed without reaching this stage then stop the scenario.


- Dementia services and input

- Carers needs

- Risks if carer can’t cope


- post it notes to stick on phone etc

-working phone

- deodorant, toothbrush and teapot to be placed in odd locations

-urine bottle

Personnel:

- Patient and wife

- Faculty – confederate can be played by wife


Team development

If using this in team development, you should identify one person to be the AHP. You may need to be the patient unless you can arrange for a volunteer patient or another group member is keen to undertake this role and you’ll need a wife volunteer. In a classroom / meeting room set up one corner as a home environment using the following as a guide: Put 2 or 3 chairs together and cover with a blanket to create a sofa (add a cushion if you have one). Add another chair Add a table (ideally coffee table but if higher such as desk use as a unit beside the sofa). Arrange a few props such as urine bottle, newspapers and magazines, box of tissues, cups and plates beside chair. Place post it notes with – ‘Jill calling – ask how she is’ on the phone. ‘On / off’ on a socket etc as prompts Patient should wear the simple clothes such as tracksuit bottoms with a short and jumper. Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be on the other side of a door before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. Decide before you start if you’re using the interactive stage of the process. You can include micro teaches within this around communication, dementia and carer needs

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Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a home environment. Follow all guidelines for setting up the cameras and systems Set up a home environment using the following as a guide: Utilise the back 1/2 of the MSU at the back TV if it is for 1 person and the side nearest the screening room if its for a group. Put 2 or 3 chairs together and cover with a blanket to create a sofa (add a cushion if you have one). Add another chair Add a table (ideally coffee table but if higher such as desk use as a unit beside the sofa). Arrange a few props such as urine bottle, newspapers and magazines, box of tissues, cups and plates beside chair. Place post it notes with – ‘Jill calling – ask how she is’ on the phone. ‘On / off’ on a socket etc as prompts Patient should wear the simple clothes such as tracksuit bottoms with a short and jumper If this is for a group, set up the chairs around the back TV, link this to the cameras and issue headsets. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 3 – Chest pain at home


Learning objectives: By the end of the scenario and debrief participants will be able to: - Demonstrate an appropriate ABCDE assessment - Demonstrate the ability to escalate care, seeking help in a timely manner - Demonstrate awareness of chest pain signs and symptoms - Demonstrate the communication skills required to share information and calm the patient

Setting and Background: This scenario takes place in the patient’s home

Brief:

You are an AHP working in the community. You arrive, as planned, at the home of Paul /Paula Green who is 67 year old. Select one of the following reasons for visit or add your own: - Paula has recently been diagnosed with dementia - Paula was recently in hospital following a trip and fall - Paula has a would on their foot which has required specialist intervention On arrival you discover she has had a 2 hour history of chest pain. It started suddenly after walking upstairs this morning. It has been getting increasingly worse with pain in the centre of the chest initially, now radiating down the left arm and jaw. Paul/Paula also reports some shortness of breath and dizziness which he/she has never experienced before. PMH: Hypertension, hypercholestoraemia, back pain Meds: Lisinopril, simvastatin, paraceptamol, ibuprofen. NKDA. Social: Married, retired police officer. Ex-smoker. Minimal alcohol. Independent with ADLs. You have your standard community resources related to your role available to you. We will run the scenario for 5 minutes You can ask for a time out at any point. In the room with you is the patient’s spouse.

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1. Beginning Arrive to patient looking unwell in armchair

Patient

Baseline - severe chest pain

Complains of central chest

pain radiating down left

arm and up to jaw. Also SOB

and dizzy.

Physiology A – talking

B - RR 20, sats 98%, chest clear

C - HR 115, BP 154/87, CRT 3s

D - GCS15, BM 6.1, PEARLA

E - grey and clammy, T37.1

Expected learner actions:

Carry out ABCDE Assessment

Focussed history

Transition Trigger: (Actions OR Time) Prompt: Patient response

Patient: 'Why do I feel like this?'. Faculty - whats wrong with him?

Teaching Points:

ABCDE assessment

Signs and symptoms of chest pain

2. Middle Increasing chest pain

Patient Increasing pain evident Physiology As previously

Expected learner actions: - Explain concerns to patient and spouse - Call for help via GP or 999

Transition Trigger: (Actions OR Time) Prompt: Patient response Why am I so sore Whats happening I’m just so sore Spouse Crying and upset ‘Whats going on’ flustered

Teaching Points:

How to escalate care if required

Communication with patient and

spouse

Communication SBAR

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Faculty On phone – asking for information and telling them to remain calm


3. End Help on its way

Patient Clammy and grey Physiology As previously – not checked

Expected learner actions: Reassurance and checking patients ABCDE

Transition Trigger: (Actions OR Time) Prompt: Patient response Upset and sore

Teaching Points:

Lone working

BLS

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If the AHP isn’t calling for help, end it sooner as patient will deteriorate


- ABCDE – basic CPR and confidence in lone working

- Escalation of care

- Use of SBAR for clear communication


- possible stethoscope depending on profession

- phone

- GTN spray bottle

Personnel:

- Patient and spouse

- Faculty – on phone as emergency service


Team development

If using this in team development, you should identify one person to be the AHP. You may need to be the patient unless you can arrange for a volunteer patient or another group member is keen to undertake this role and you’ll need a husband volunteer. In a classroom / meeting room set up one corner as a home environment using the following as a guide: Put 2 or 3 chairs together and cover with a blanket to create a sofa (add a cushion if you have one). Add another chair Add a table (ideally coffee table but if higher such as desk use as a unit beside the sofa). Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be on the other side of a door before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. Decide before you start if you’re using the interactive stage of the process.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a home environment. Follow all guidelines for setting up the cameras and systems Set up a home environment using the following as a guide: Utilise the back 1/2 of the MSU at the back TV if it is for 1 person and the side nearest the

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screening room if its for a group. Put 2 or 3 chairs together and cover with a blanket to create a sofa (add a cushion if you have one). Add another chair Add a table (ideally coffee table but if higher such as desk use as a unit beside the sofa). Arrange a few props such as GTN spray, newspapers If this is for a group, set up the chairs around the back TV, link this to the cameras and issue headsets. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 4 – Deteriorating patient in AHP Dept


Learning objectives: By the end of the scenario and debrief participants will be able to: - Recognise signs of deterioration in a patient - escalate care by contacting appropriate services in a timely manner - demonstrate safe handling of a patient - demonstrate safe and effective communication techniques

Setting and Background: This scenario takes place in an AHP department. Patient has been transported here by a porter from the ward. They have attended for a specific intervention from that AHP. The scenario starts in the planned activity (for example – on a plinth or treatment chair, in the kitchen etc)

Brief:

You have requested that Tom Robertson, an 82 year old man visit your department for intervention. Tom lives alone, independently in a detached 2 storey home. He has 1 married son who lives 45 mins away and visits every other weekend. Tom was admitted with a suspected CVA which was later diagnosed as a TIA. He remains shaken and unsteady and appears to have lost confidence in his abilities. You have assessed him on the ward and have identified further concerns related to his potential safety and independence at home that you wish to follow up with some intervention in your dept. (You can insert a specific example here) Medical staff are recommending discharge in the next 24 hours for this patient as his TIA has resolved. Nursing staff had reported that the patient is well this morning and is up and dressed. Medical staff are not happy at your suggestion that you may have additional concerns and are stressing that they are keen to discharge this patient. You have set up for the intervention you have planned and meet Tom when the porters have dropped him off. You should carry out the intervention as you usually would. You will have a HCSW in your session to assist you as required. Tom arrives saying he feels a bit wobbly but is happy to continue with session and plan. You can call ‘time out at any point’ with a T symbol with your hands or say ‘time out’.

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Scenario 4 – Deteriorating patient in AHP Dept – Story Board


1. Beginning Patient arrives happy to proceed but not feeling very well. Start intervention.

Patient Reports feeling wobbly Events Arrive in dept, transfer from porters chair, start intervention

Expected learner actions: Orientate Tom to planned intervention Offer prompting with transfers Start planned intervention Intervention progresses Ask Tom if he is OK to continue

Transition Trigger: (Actions OR Time) 3-4 minutes of activity Prompt: Patient response No verbal cue but puffing, exhaling etc to show this is effortful for him Pausing during activity Happy to carry on?: ‘Yes, lets just get this done’ ‘ I’m here now, I’ll have a rest when I get back up to the ward’ ‘this is tiring, I’m actually not feeling the best’ Faculty HCSW, Tom are you alright?

Teaching Points:

Recognising signs of effort or

deterioration

Questioning and communication with

Tom

2. Middle Patient Sudden collapse (fall to floor, forward onto table or back in chair as relevant) No loss of consciousness but very drowsy Events Patient collapse.

Expected learner actions: - make patient safe -initial assessment of breathing / consciousness -safe positioning of the patient - get HCSW to call for help / get help

Transition Trigger: (Actions OR Time) Patient continues to deteriorate despite any basic intervention Prompt: Patient is groaning and moaning but becomes quieter and more drowsy after 1 -2 minutes Faculty Say we need to phone the ward. Panic that you can’t get anyone on the phone – its ringing out. HCSW has ward on phone after 1

Teaching Points:

ABCDE assessment

Escalation processes

Safe handling to position the unwell

patient

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minute but is on hold. When staff nurse takes phone HCSW passes it to AHP stating you’ll be better at this and moves to sit with patient On phone – “well he was a bit off this morning actually. I was a bit worried something was brewing with him. Get him back up here as soon as you can and I’ll get the Dr to see him”


3. End Patient Very drowsy and incoherent

Expected learner actions: - get appropriate help and support -get a bed or back into porter chair - transfer patient to bed - back to ward

Transition Trigger: Patient response Drowsy and incoherent

Teaching Points:

SBAR communication

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- possible stethoscope depending on profession

- phone

- kettle / toaster / cups if kitchen assessment, bands, balls etc if gym, kit trolley and trays if podiatry

etc. If radiography, may need to presume this happens in changing room or waiting room.

Personnel:

- Patient

- Faculty – HCSW


Team development

If using this in team development, you should identify one person to be the AHP. You may need to be the patient unless you can arrange for a volunteer patient or another group member is keen to undertake this role and you’ll need a hcsw volunteer. Ideally set this up in the part of the dept where the actual intervention would occur. Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. You should decide the delivery approach before starting and explain the planned approach fully to the participants. Decide before you start if you’re using the interactive stage of the process.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a home environment. Follow all guidelines for setting up the cameras and systems Set up the environment using the clinical side of the screen divide. Use chairs as treatment chairs, sim mans trolley as a bed / plinth and use the narrow counter beside the sink to replicate a kitchen or work area. If this is for a group, set up the chairs around the back TV, link this to the cameras and issue headsets.

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Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 5 – Lone working and unexpected situation

Target group – Could be adapted for any profession in any setting -mainly for staff who are new to

working in community settings.

Learning objectives: By the end of the scenario and debrief participants will be able to: - Apply lone working policy and plans to gain support - Discuss strategies clinical reasoning and decision making - Discuss how to deal with challenging clinical cases

Setting and Background: Set up a common activity in a home or homely environment. This example is for a podiatry case but this could be adapted to any clinically relevant task for other professions

Brief:

You are a podiatrist relatively new to working in the community. You are about to see Ingrid Black, a 79 year old female who lives alone. Ingrid has type 2 diabetes and is managing this reasonably well herself with diet and exercise. Ingrid is known to your service and this is a rescheduled appointment at home as she cancelled her last clinic appointment as she stated she no longer has access to transport and lives remotely. She has requested a home visit. This appointment is a routine review and basic foot care. On arrival Ingrid, usually chatty, is fidgeting and quiet. She reveals that this is because she is embarrassed by the ‘state of her feet today’. She admits that she got a small cut from standing on a broken glass. The glass was on her bedside table and she stepped on it barefoot when getting out of bed as she didn’t see it. She is sure its nothing, she didn’t want to bother you. This is the reason she cancelled her last appointment as she was just hoping it’d heal up before she saw you but it hasn’t. She is unable to walk on it for more than a few steps at a time. You should assess Ingrid’s foot wound and complete your planned intervention, seeking support as relevant.

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1. Beginning

Patient has a loose bandage and dressing around her foot. There is an unpleasant smell from the dressing

Expected learner actions: Remove the dressing and observe an obviously infected, long standing wound. This requires support from the wound specialist podiatrist. Learner should be prompted to call the dept.

Transition Trigger: Prompt: If not calling for support, patient should say, is it bad? Do you need to call someone else? Was this not what you were expecting today?

Teaching Points:

Lone working

Wound management

2. Middle Patient is uncomfortable with any investigation / action.

Clinical assessment and reasoning to plan a course of action Call colleague / take photos to share later or video call for advice.

Transition Trigger: Patient describes seeping wound and their poor attempts to manage the wound themselves – using nail scissors to trim loose skin and talcum powder to ‘dry it up’. Patient gets upset that you might think they’re silly or that they’ve made it worse.

Teaching Points:

Infection control

Communication techniques

Patient advice re foot care

Clinical decision making and SOPs

3. End

Basic wound management completed and a plan for a review by a specialist made

Appropriate management of the wound and general footcare. Plan for follow up made and agreed

Transition trigger: If not call made facilitator can call / text to check in.

Teaching points:

Patient advice, national guidelines

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Discussion and Feedback Learning outcomes

-Apply lone working policy and plans to gain support

- Discuss strategies clinical reasoning and decision making

- Discuss how to deal with challenging clinical cases

Equipment, Personnel and Props EQUIPMENT

patient volunteer

Home environment with patient in armchair

PERSONNEL

Facilitator on phone

PROPS

Whatever is relevant and to hand for a ‘normal’ assessment/session / intervention for this

profession, telephone and referral forms, notes. Uniforms

Wound kit or moulage/ makeup including sim smells


Team development

If using this in team development you should identify who will be the podiatrist in this case. You may need to be the student unless you can arrange for a group member to undertake this role. Set up the area. Use a chair with blankets to represent the armchair. Alternatively utilise any chair available in the dept. Option to put blankets over a couple of chairs to make a sofa for a home environment etc Participant should arrive in the area when the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes The scene is reset and the participant is asked to start again, repeating their activity.

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The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea. This continues for another 5 minutes. The participants all then take part in a debrief.

Return to practice on MSU

Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define the planned environment. Follow all guidelines for setting up the cameras and Set up the environment as required using the following as a guide: Options: Use the screen to define the home environment. take a chair from the classroom area. Use chairs covered with a blanket to create a sofa Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.


If using this as an assessment of competence you should have taken some time to adapt the attached behavioural markers framework for your profession specific requirements. This should be done before the scenario and ideally be agreed by at least 2 clinicians. You can run this scenario in a class or the MSU but it will be most beneficial if filmed for debrief as it can be helpful for participants to see their skills and learning needs. If the MSU is not available you could film the scenario in a standard room using ipads etc to film it. It should be made clear to the participant that you will be looking for specific skills and behaviours during this scenario and you will discuss these afterwards. It is likely that this will be a formative assessment, not a summative assessment – informing further discussions and development planning.

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Scenario 6 – Hard of Hearing – Domiciliary visit

Target group – Could be adapted for any profession working in peoples homes. Most likely

podiatry, physiotherapy, Occupational Therapy.

Learning objectives: By the end of the scenario and debrief participants will be able to: - demonstrate safe initial contact with a patient in their own home - demonstrate effective communication strategies for dealing with a patient with hearing loss - discuss appropriate identification of risks to patients / clients

Setting and Background: The home is slightly chaotic. It has signs of poor memory and reduced mobility with dirty plates etc strewn around chair, as if waiting for carer to collect.

Brief:

Mrs Josephine Brown ( dob 24/8/48) a retired primary school teacher was seen 6 weeks ago by her GP for reduced mobility and having had a recent fall at home. She has lived on her own since the loss of her husband six years ago She was very active until recently but has not attended her community activities for over 4 weeks citing a fear of falling as the reason She wears a hearing aid but has found it difficult in company to keep up with what is being said if more than 1 to 1. She has welcomed a referral to your service as she wishes to get back to normal . You have been told to knock and enter the house - Mrs brown is in the lounge and is expecting you. You should gain consent, explain your role and reason for referral and gather initial assessment information. You are to assess her needs and identify any risks to report back to your team You can stop the scenario and ask for time out at any point We will stop the scenario after 4-5 minutes We will then review how the scenario went from you and your colleagues perspectives so that you can identify an action plan to take away with you into your practice

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Scenario 6 – Hard of Hearing Domiciliary Visit


1. Beginning Entry to home

Patient Can’t hear very well Poor mobility Events Drowsy in chair Difficult to rouse Recall visit when prompted Defensive of missing activities Have radio/tv playing loudly

Expected learner actions: Ensure personal safety Introduction of role and purpose of visit Check patient details and understanding of issues Check for safety

Transition Trigger: After 1-2 minutes learner actions complete Prompt: Physiology -patient is obviously asleep/snoring Patient response -patient will rouse within a few seconds if approached appropriately Faculty -no input required

Teaching Points:

Consent on being in someone’s home

Need to verify in correct place with

correct person

Observing risk not being judgmental

2. Middle Initial contact

Patient Can’t hear very well Poor mobility Physiology – reports tired and fatigued, no energy and loss of motivation to get chores done Events Not able to hear unless AHP position self in appropriate position Enter into social chat

Expected learner actions: Interpersonal skills empathy and compassion Requests to Switch off radio/tv Identification of patient needs Use of written communication or phone texting Position of self for enhancing communication Identifies falls risks in home

Transition Trigger: After 2-3 minutes established communication with patient Prompt: Physiology Dizzy if standing Patient response Voiced concerns of feeling unsafe Faculty No actions unless no progress being made then enter as another health visitor and share information you already have re previous condition

Teaching Points:

Different communication strategies

available

Falls pathway

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Respond to good interpersonal skills such as eye contact, slow and clear speech with simple language. Share open and honest fears Patient will stand if prompted / asked. No walking aids used – ignore stick in corner. Slow to rise and state unsteady. Try to step over clutter if not moved.

such as rugs, clutter and chaos Complete falls assessment

and current concerns. Patient will understand you if you role model good techniques


3. End Patient Can’t hear very well Poor mobility Physiology Events Share in development of next stage

Expected learner actions: Agrees action plan with patient Should utilise tools such as teach back to check patient understanding

Transition Trigger: (Actions OR Time) 4-5 minutes Prompt: Physiology none Patient response Patient will question then agree with plan

Teaching Points:

How to raise risks in home with patient

Use of teach back to check patients

understanding

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Demonstrate safe initial contact with a patient/client in their home Demonstrate communication strategies in dealing with a patient with hearing loss Demonstrate appropriate identification of risk s to patient/client


Patient , chairs slippers dressing gown with tie, newspaper

hazards ( medication, electric wires , loud radio, syringe needles, dog poo/ cat food)

PERSONNEL

Facilitator

PROPS

Walking stick


Team development

If using this in team development, you should identify one person to be the initial visitor. You may need to be the patient unless you can arrange for a volunteer patient or another group member is keen to undertake this role. In a classroom / meeting room set up one corner as a home environment using the following as a guide: Put 2 or 3 chairs together and cover with a blanket to create a sofa (add a cushion if you have one) Add a table (ideally coffee table but if higher such as desk use as a unit beside the sofa). Arrange a few props such as newspapers and magazines, box of tissues, dirty cups and plates, maybe an ashtray, a plate with some cat food on it and / or animal poo. Place a walking stick in the corner – in sight but out of reach of the sofa. Patient should wear the dressing gown with belt open and hanging and could have a blanket over knee / round shoulders. Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be on the other side of a door before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief

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You can include micro teaches within this around positioning for communication, falls pathway and risk identification 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes The scene is reset and the participant is asked to start again, repeating their activity. The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea. This continues for another 5 minutes. The participants all then take part in a debrief.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a home environment. Follow all guidelines for setting up the cameras and Set up a home environment using the following as a guide: Utilise the back of the MSU with the TV etc. The participant can use the back door for entry. Put 2 or 3 chairs together and cover with a blanket to create a sofa (add a cushion if you have one) Add a table (set one of the white tables to coffee table height. Arrange a few props such as newspapers and magazines, box of tissues, dirty cups and plates, maybe an ashtray, a plate with some cat food on it and / or animal poo. Place a walking stick in the corner – in sight but out of reach of the sofa. Patient should wear the dressing gown with belt open and hanging and could have a blanket over knee / round shoulders. The R to P candidate can be taken in the front door to the main part of the unit. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario. You may wish to set up another clinical scenario in the ward ½ and then debrief between these and again at the end.



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Scenario 7 – Angry Patient

Target group – Could be adapted for any profession but is focused at students, junior staff or

return to practice candidates.

Learning objectives: By the end of the scenario and debrief participants will be able to: - Demonstrate communication techniques for responding to anger - Discuss strategies for handling an angry outburst whilst maintaining safety - Demonstrate communication techniques for breaking unwelcome news

Setting and Background: This scenario can take place in clinical areas such as a ward, clinic or department or a patients home – choose setting that is relevant to the learner. Brief:

In this scenario you are approaching a patient to share some unwelcome news / plans. This could be any of the examples below or one related to your own profession: e.g. - on a ward and due to staffing you will be unable to carry out the previously discussed treatment session today. - you are telling a patient that you are recommending that they should go to residential care rather than going home to their own house. - you are working in a mental health unit and need the patient to undertake an activity prior to you being able to support discharge, they do not wish to engage with you. - You are working in children’s services and are having to recommend their child is hoisted at school as they are unsafe in their transfers and are now of the weight for hoist not x2. - there will be a extended delay before they are seen today and they should continue waiting in the waiting room Etc On sharing your news the patient will respond in either anger, upset or confusion. You should support them through this and take the opportunity to explain the situation further and if possible resolve their frustrations. You know your conversation is being overheard by other members of staff. We will run this scenario for 4-5 minutes. You can ask for time out at any point. If the patient becomes angry and threatening, be assured they will never strike you or make contact with you. You can call ‘time out at any point’ with a T symbol with your hands or say ‘time out’.

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Scenario 7 – Angry Patient – Story board


1. Beginning Approaching the patient and starting conversation

Patient Happy and welcoming

Expected learner actions: Approach the patient and introduce self / remind of who they are. Introduce that they have some unpleasant news to share

Transition Trigger: (Actions OR Time) Prompt: Patient response Patient starts conversation about how last day has gone since saw the AHP. Tells about visiting etc. All signs of a positive and good relationship. Sudden mood change – concern and suspicion

Teaching Points:

How to open a challenging conversation

Planning for what to say / what may

occur

2. Middle Break bad news

Patient Shocked and quiet initially. Listening but getting visibly frustrated Physiology Agitated

Expected learner actions: Explain bad news Respond professionally to signs of frustration

Transition Trigger: (Actions OR Time) Prompt: Patient response ‘ARE YOU JOKING? HOW DARE YOU’ Getting angry after news shared

Teaching Points:

Recognising anger

Personal safety

Communication techniques

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3. End Patient angry

Patient Shouting and angry

Expected learner actions: Use calming and clear communication Apologise Risk assessment of own safety in situation

Transition Trigger: (Actions OR Time) Prompt: Patient response Waving arms How dare you… (relate to topic) Trigger if apology given, conversation can progress to explanation If excuses only then remain angry Faculty Ask if all ok, anything needed, they can do? Engage in conversation if asked

Teaching Points:

Power of apology

Situational awareness

Risk assessment

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Demonstrate safe contact with a patient/client who is visibly angry Demonstrate communication strategies in dealing anger Discuss the power of apology


Patient , chairs etc

PERSONNEL

Facilitator

PROPS


Team development

If using this in team development, you should identify one person to be the patient. You may need to be the patient unless you can arrange for a volunteer patient or another group member is keen to undertake this role. Set up an area relevant to the setting selected. For example: – a row of chairs and a coffee table for a waiting room - two chairs together covered in a blanket for a sofa for a home Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be on the other side of a door before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes The scene is reset and the participant is asked to start again, repeating their activity. The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea. This continues for another 5 minutes. The participants all then take part in a debrief.

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Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a home environment. Follow all guidelines for setting up the cameras and Set up a home environment or clinical environment as required using the following as a guide: Use the screen to define if this is a clinical or home environment. Set up chairs in a row for a waiting room and 2 together covered in a blanket for a sofa if a home environment Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 8 – Discussing discharging someone from a service

Target group – Could be adapted for any profession with repeat appointments / follow up with

patients.

Learning objectives: By the end of the scenario and debrief participants will be able to: - Demonstrate person centred communication - Discuss managing expectations and self management - Describe communication techniques for challenging conversations

Setting and Background: This could be completed on the phone, near me or face to face. The exact detail describing the intervention and routes to re-refer can be amended from this example.

Brief:

You are an AHP working with people who have experienced a CVA / cardiac event / head injury/ trauma injuries / lifelong disability. You have had a reasonably long relationship with this patient. You acknowledge that the effects of the disease / disability on this person will be long lasting but at present they do not need intervention from your service. This could be as a result of service capacity and / or coming to the end of a planned episode of care. The patient has a good therapeutic relationship with you. Discuss the patient’s views of their progress / abilities / needs. Describe to the patient the positive news that in your professional opinion they can be discharged from the service at this time. Consider and discuss any concerns and fears the patient expresses and share information re self management and re-referral.

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1. Beginning

Patient has long term condition of disability. Patient is keen to continue their support with the service

Expected learner actions: Ask the patient about their thoughts on progress, needs and what matters to them. Openly shares thoughts from reassessment is to discharge at this time.

Transition Trigger: Prompt: If AHP not bringing up discharge, patient says are you thinking of discharging me?

Teaching Points:

Person centred care

Open communication in potentially

challenging situation.

2. Middle Elicit the patient’s views and goals. Openly discuss and consider their concerns

Transition Trigger: Prompt: If being open in discussion, patient agrees and recognizes progress and views discharge as positive. If AHP is not exhibiting person centred good conversation, patient becomes upset and angry

Teaching Points:

Managing and recognising emotion

Open and honest communication

3. End

Discuss next steps. Self management resources Triggers and routes for re-referral Agree plans for sharing / sending info or summary of links

Transition trigger: If positive discussion, plan for self management, if not the AHP should have planned for revisit conversation after reflection, retain in caseload or discharge against patient wishes. Patient responds accordingly with appropriate emotion

Teaching points:

Goal setting

Good conversations

Self management

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- Demonstrate person centred communication

- Discuss managing expectations and self management

- Describe communication techniques for challenging conversations


patient volunteer on phone / near me or face to face

PERSONNEL

Facilitator on phone

PROPS

Links to self mangement resources and case notes with re-assessment results.


Team development

If using this in team development you should identify who will be the AHP in this case. Set up the area. If on the phone / near me – appropriate office environment. If face to face a clinical environment relevant to profession. Participant should arrive in the area when the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes The scene is reset and the participant is asked to start again, repeating their activity. The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea. This continues for another 5 minutes. The participants all then take part in a debrief.

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Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define the planned environment. Follow all guidelines for setting up the cameras and Set up the environment as required using the following as a guide: Options: Use the screen to define the home / clinical office environment. take a chair from the classroom area. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 9 – Challenging conversation with a team member


Learning objectives: By the end of the scenario and debrief participants will be able to: - Demonstrate techniques for having a challenging conversation - Discuss professionalism in a multi-professional team - Describe the processes for dealing with lapses in professionalism.

Setting and Background: The nurse’s station / desk area in the ward. Everyone is gathering for an MDT / handover / board round. Patients and a couple of visitors are milling around the area too. (this could be changed to a shared office, a clinic waiting room, coffee shop or other relevant setting)

Brief:

You are in the area described and two colleagues are overheard discussing how awful one of your patients smells and having discussions about his home life. You overhear them saying: 1: “Oh my god, I was nearly sick this morning when I was helping Jim in bed 2:4 get up. I don’t think he’d washed for a month before he came in” 2: “Oh I know, I was working with him before and nearly wore a mask. What happened to him anyway?” 1: “His wife, I think she is his wife anyway – Sheila, said she found him unconscious on the sofa. Well, I bet he sleeps there most nights after passing out from drink by the looks of him.” 2: “Aye probably. Not that I’d blame him. She seems like a battleaxe, scares me rigid anyway! She’d drive me to drink too”, (laughing) 1: “yeah, I get that” (laughs) You need to decide how you’ll deal with it. We start the scenario with this conversation and / or with the two staff involved standing together laughing. We’ll let this scenario run for 3 minutes and then give you an opportunity to re-run it after a debrief.

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1. Beginning

Events Staff having inappropriate conversation

Expected learner actions: Recognise that the conversation is inappropriate

Transition Trigger: (Actions OR Time) Prompt: Faculty: if no move to approach the staff, faculty will approach learner and say: “I think Jim heard them saying that, what should we do?” encouraging the learner to act

Teaching Points:

How to start a courageous conversation / how

to offer timely feedback

- ? use SPIKES model, radical candour or other

feedback model

Culture, dignity and respect

2. Middle Events If no action staff members start again: “You know who is just as bad, Jill, that physio that sometimes covers here…”

Alert them to behavior, Engage in conversation, invite to have a feedback conversation

Transition Trigger: (Actions OR Time) Time trigger after 1 minute if no action taken

Teaching Points:

As above

3. End Events Outcomes of feedback conversation. Escalate to senior staff or not?

Expected learner actions: Complete a feedback conversation, have clear agreements of whether this is escalated

Transition Trigger: (Actions OR Time) Faculty OK, lets start this meeting, quiet everyone This ends the conversation if ongoing.

Teaching Points:

As above

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- demonstrate techniques for a challenging conversation - discuss professionalism in a multi-professional team - describe the processes for dealing with lapses in professionalism


2 x Staff and ward environment

PERSONNEL

Facilitator

PROPS

none


Team development

If using this in team development, you should identify two people to be the staff members. If only one is available then adapt the conversation to be stream of comments from 1 staff member directly to the participant. You may need to be the staff member unless you can arrange for a group member to undertake this role. Set up an area relevant to the setting selected. For example: – a row of chairs and a coffee table for a waiting room - A desk and white board for a ward area -tables and chairs for an office or coffee shop etc Set up enough chairs for rest of group in a semi circle around the scene. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be in the area before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes The scene is reset and the participant is asked to start again, repeating their activity. The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea.

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This continues for another 5 minutes. The participants all then take part in a debrief.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a the planned environment. Follow all guidelines for setting up the cameras and Set up a clinical environment as required using the following as a guide: Use the screen to define if the clinical environment. Set up chairs in a row for a waiting room Desk and whiteboard with patient details for a ward desk area, Desk and phone papers etc for a shared office etc Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 10 – Multi-disciplinary team meeting

Target group – Could be adapted for any profession, level of staff or return to practice candidates.

This would work well for a group of inter-professional learners

Learning objectives: By the end of the scenario and debrief participants will be able to: - Demonstrate techniques for establishing a shared understanding with a group of professionals - Use negotiating and influencing skills - Describe the benefits of clear and concise information sharing.

Setting and Background: This scenario is based around a child’s ‘Team around the child meeting’ and involves staff from health, social work and education sectors. It takes place in a meeting room in a school. This could be replaced with an adult meeting in a ward meeting room

Brief:

You are attending a child’s team around the child review meeting. You have met the child once for an assessment; you saw the child in the school setting and have not met mum / dad. (Please provide relevant assessment findings for the specific profession and offer 5 minutes for them to decide what this would mean for them) The child (Holly) is 8 years old and has a diagnosis of developmental delay. School report she is having issues with: Mobility – becoming tired and ‘wobbly’ when walking and school are concerned about falls and have suggested she doesn’t go outside at breaks for fear of injury and staff injury if they try and catch her. Fine motor skills – she struggles with writing and fine tasks such as pencil grip and manipulating the small objects used to enhance maths. Communication – they believe her vocabulary is limited, her pronunciation of certain words is poor and this is causing her and staff frustration as they can’t understand each other Social skills – she does not like the noises other pupils make and tends to withdraw or become angry during group activities in class Diet – she is a fussy eater and often won’t eat during the school day. Your goals so far are to carry out further specific assessment in some areas but you have already identified a need for intervention from your service. You predict this may take 5-6 sessions and for this to be successful you will need school and home to carry out a programme of activity to support your intervention on a daily basis. Social work are supporting the family as mum and dad are struggling at home. Home situation is chaotic with periods of unemployment, alcohol consumption and limited evidence of Holly getting hot or nutritious meals, and the environment is crowded and busy with lots of ‘belongings’ stacked on the floors. This meeting is to agree the Shanarri goals for Holly from the team for the coming term. Please get involved in the discussion and negotiate how your professions goals may be met in amongst this complex picture. The meeting starts with the head teacher summarising what we’ve heard so far and asking mum and dad for any comments before we hear from the last profession. We’ll let this scenario run for 8-10 minutes

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1. Beginning

Patient Holly not in meeting. Parents are obviously anxious and nervous Events Chair of the meeting (head teacher)starts the meeting explaining: “Ok. We’ve heard a lot so far from each professional. I think it would help if I summarise where we’re at before we hear from the last person and then from mum and dad” Share summary from brief for all professions except the learner’s one.

Expected learner actions: Present their findings and plans in a professional way, balancing the information to be shared with avoiding jargon and acronyms for mum and dad.

Transition Trigger: (Actions OR Time) Prompt: If report is longer than 2 minutes, prompt them to keep it brief but informative. If report is very short ask understanding questions such as: Can you tell me more about your assessment? What would you hope your intervention would provide? How have you reached these decisions? etc

Teaching Points:

SBAR communication for a brief and concise

but informative report

Use of language to avoid jargon etc

2. Middle Patient Mum becomes upset and overwhelmed. Saying it sounds like there is nothing she can do, why are you all focused on the things she needs to get better at?

Learner should be able to justify the benefits of the intervention, what these improvements would mean for Holly and also perhaps touch on improvements they have seen already. Reiterating that Holly’s best interests are driving all of this. They should demonstrate compassion and empathy

Transition Trigger: (Actions OR Time) Chair asks mum what she would like to add.

Teaching Points:

Compassionate communication

Personal outcomes approach

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2. Middle cont Another professions report is shared by the head teacher as they could not attend. It is focused on the opposite of the report given by the learner and has conflicting aims. The head teacher states she supports this and her staff don’t have time for both

The learner should explain calmly and clearly their rationale for their aims, the potential benefits of this input. The learner may also suggest a way both could be combined

Transition trigger: Head teacher moves conversation along, stopping mums concerns with: ‘lets hear what else people have reported just to get the full picture’

Negotiation and influencing

Advocating for the patient

Professional clinical reasoning

3. End In this section the aim is to develop a clear and consistent view of the strengths and challenges faced by Holly and agree shared goals for going forward. Mum says to learner: Right, you seem to have a clear idea. What do you think we need to be doing? Headteacher looks to them and says: ‘yes, why don’t you summarise where we are as a team’ Learner is therefore invited to summarise andidentify ongoing team goals, seeking agreement.

The learner should summarise the issues and the conflicting recommendations. They should endeavour to check everyones understanding and work towards agreement of 2-3 shared goals for the team.

Transition trigger: After 2 minutes, if summary still going on learner is prompted to move to suggested goals: “Yes, yes, OK. I think we’ve got all that. But what are we going to do.”

Checking understanding in team and with

carers

Presenting large amounts of information in a

logical way.

Seeking negotiation for the patients best

interests.

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- Demonstrate techniques for establishing a shared understanding with a group of professionals - Use negotiating and influencing skills - Describe the benefits of clear and concise information sharing.


2 people minimum - Teacher, mum/dad. Ideally another profession too. In a meeting room

environment

PERSONNEL

Facilitator

PROPS

none


Team development

If using this in team development, you should identify at least two people to be the staff members. At least one should be representing their own profession and identified as the key participant. If only one is available then adapt the scenario to only have a conversation between a teacher and learner. You may need to be the staff member unless you can arrange for a group member to undertake this role. Set up an area relevant to the setting selected. For example: Circle of chairs and small table for meeting with a group Desk and 2 chairs for just treacher Either have all participants take part in the meeting as their own profession or set up enough chairs for rest of group in a semi circle around the scene and have people represent their own professions. Group members / audience should be advised not to interrupt whilst scenario is running. Participant should be in the area before the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes The scene is reset and the participant is asked to start again, repeating their activity. The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and

57

the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea. This continues for another 5 minutes. The participants all then take part in a debrief.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a the planned environment. Follow all guidelines for setting up the cameras and Set up a meeting environment as required using the following as a guide: Use the screen to define if the home environment as this is closest to the school. Have a circle of chairs and / or desk and 2 chairs. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 11 – Coping with Pressure

Target group – Could be adapted for any profession, level of staff or return to practice candidates.

Mainly focuses on Occupational Therapy of Physiotherapy in its current format

Learning objectives: By the end of the scenario and debrief participants will be able to: - demonstrate appropriate decision making in a pressurised situation - discuss maintaining professional standards and judgments - exhibit skills in remaining calm under pressure

Setting and Background: This scenario is based around a patient in a ward. The patient has been cleared for discharge later today and the family have now raised concerns around transfers and safety at home. The nurses have realised that this patient was never referred to your profession and ‘need’ an assessment done this afternoon as the Drs have cleared them to go home and transport is arranged.

Brief :

You arrive on the ward to be told that you need to complete your assessment as quickly as possible as you are holding up this patients discharge. Checking the notes you are satisfied that the patient is medically stable and that the concerns raised by the family lie in physical function and safety. The feedback from the carer / family via the nurse is that their dad was doing less at home and whilst he didn’t admit it they think he’s been tripping / falling. Hes stopped going to clubs and think he is cooking less, increasingly relying on microwave meals. The family feel that since he has been on the ward he has deteriorated even more and hes ‘looking old’. The nurses feel hes doing OK on the ward. Family feel they can pop in and out to check on him but don’t think this will be enough as they all work and can’t be there all the time. Either have the learner “carry out a ward based assessment of this patient ( there is no time / porter availability to get him to a dept) and give your recommendation” Or give them assessment results and ask for their recommendation. If they can’t recommend having not seen them state their recommendation would be to stop the planned discharge citing risk of injury and readmission. The patient was unstable in mobility and is not willing to use the walking aids, saying they slow them down and theres no space. In transfers the patient was unreliable and struggled to get up from bed and was at risk of falling when sitting. Fatigue – the patient tired with the short activities undertaken and would struggle with self care and cooking. You should now have the conversation with either the nurse or the dr stating that you recommend discharge is delayed.

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1. Beginning

Patient Wants to go home, ‘had enough of it in here’ Events Conversation with nurse or Dr at bedside stating that discharge should be delayed

Expected learner actions: Present their assessment findings and recommendations in a calm and balanced manner but strongly stating that this patient should not go home today

Transition Trigger: (Actions OR Time) Prompt: Patient says they said I can go home so I’m going. You’ve not bothered coming to see me till now, you’re just lazy and taking it out on me. Its not my fault you’re late. They know me and they say I can go. Nurse or Dr says they have extreme bed pressures and this patient is medically fit. You just need to sort the community services and we can still get him home.

Teaching Points:

SBAR communication for a brief and concise

but informative report

Professional judgement and

recommendations aligned to standards of

practice

2. Middle Patient Well you know what, I’m going. You can just do your bits and I’ll agree to see someone at the house but I’m out of here today. Nurse or Dr, - we’re going ahead with discharge, you just need to get your side of it in order but the transport is due in 2 hours and the script is back from pharmacy so we’re all set.

Leaner should formally state their concerns and that this is against their recommendation but now needs to put in place referrals and phonecalls to community rehab and supported discharge teams to ensure his safety and for ongoing support and advice. t/cs to these teams ( to faculty)

Transition Trigger: (Actions OR Time) Prompted to move onto phone calls if not progressing

Teaching Points:

Documentation

Referrals to other services ( dependant on

whats available locally)

Communication skills for phone call and

meeting

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2. Middle cont Patient is ready to go home and the learner has confirmation of short term support available from discharge team tomorrow and CRT within a couple of days Team say that they knew it could be done and they are glad they didn’t just ‘cave’ and keep the patient in

Learner needs to inform patient and dr / nurse that things are in place for discharge. May reiterate that this is against judgment

Transition trigger: Prompt to return to patient and staff and inform that things are in place. Perhaps saying we’re now just 15 minutes to transport arriving. Do you want to go let them know what has been arranged.

Professional clinical reasoning

You could stop this here and debrief.

The end section takes place 2 days later so best to run as 2 consecutive scenarios.

3. End 2 days later

Phone call from daughter / carer. Very angry as she has found dad at home unable to get out of his chair and he has been there for the past 24 hrs. Phoned the ward and they said you had checked him getting up and said he was safe to go home, they work on your recommendation. Can’t believe you did this. I’m going to complain.

Learner should listen and respond calmly. They should use the power of apology and explain what they had put in place for the dad. They should aim to find a solution that is satisfactory and pass this on to a senior for info.

Transition trigger: Phone call

Power of apology

Responding to anger

Professional reasoning and judgements

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- demonstrate appropriate decision making in a pressurised situation - discuss maintaining professional standards and judgments - exhibit skills in remaining calm under pressure


2 people minimum – patient and dr or nurse

Ward environment with patient in bed/ at bedside

PERSONNEL

Facilitator

PROPS

Whatever is relevant and to hand for a ‘normal’ ward based assessment for this profession,

telephone and referral forms, notes. uniforms


Team development

If using this in team development, you should identify the patient and the dr / nurse. If only one is available then adapt the scenario to only have a conversation between dr/nurse and learner. You may need to be the dr/nurse unless you can arrange for a group member to undertake this role. Set up an ward bedside area. Use a table with blankets and pillow to represent the bed and have the patient on a chair beside. Alternatively utilise any bed / trolley etc available in the dept. Participant should arrive in the area when the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You should run this as 2 consecutive scenarios: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once to what is recorded as the middle points, then a group debrief occurs following the guidance in the debrief section of this pack. This is followed by the ‘end’ section of the guide as a second scenario at an office desk with phone and a second debrief. The participants and the group get the opportunity to debrief


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define a the planned environment. Follow all guidelines for setting up the cameras and Set up a clinical environment as required using the following as a guide:

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Use the screen to define if the ward environment. Use Sim mans trolley as a bed and take a chair from the classroom area. Ensure there is a phone. Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Scenario 12 – Supporting others (students and staff)

Target group – Could be adapted for any profession in any setting and is mainly for staff who

supervise others but would be appropriate for anyone. The focus can be a struggling student.

Learning objectives: By the end of the scenario and debrief participants will be able to: - Deliver constructive feedback to a student / colleague on their practice - Discuss strategies for supporting the development of a student / colleague - Discuss how to assess practice

Setting and Background: This can be any setting relevant to the profession. Set up a common activity on a ward, home or clinic environment and observe the practice (poor practice) of this task.

Brief:

You have been informed that a member of your team is performing poorly and that colleagues are starting to question their decisions / findings. As this AHPs senior you have discussed this with them and they believe that their practice is satisfactory. Following further reports of poor performance you have agreed to shadow this person at work to offer guidance and feedback or for reassurance that their performance is in fact of a satisfactory standard. If it is satisfactory you will support them to discuss this with the complainant and if any issues are identified you will work together to plan necessary developments and learning. You have arrived on the ward / clinic / persons home (delete as appropriate) and are about to start the session. This activity is a core activity that this AHP will carry out on a daily basis. They have been asked to …………………….. (please insert chosen skill) The AHP is leading the session and you should only intervene if: - they specifically ask for your help - you see evidence of patient being put at risk of harm - you see performance which is illegal or unacceptable to your code of conduct. After this observation you will have an opportunity to discuss and feedback your thoughts to the AHP.

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1. Beginning

student When asked sets out plan for the session. I’m going to see…. To do…. And my aim is that I will……. My main concerns etc Events Approach patient and introduce self Learner is ‘just working alongside the AHP today’

Expected learner actions: To clearly set their expectations, explain what they will be doing (observing) and feeding back. Ask for normal practice as much as possible, don’t try and do things differently for me.

Transition Trigger: (Actions OR Time) Prompt: If the learner hasn’t said anything the student can ask, what do you expect from me today?

Teaching Points:

Setting clear expectations – can link to blooms

and learning objectives

2. Middle student makes various mistakes during the session re communication, misses a step and fails to gather some important information. They are not rude or improper with the patient.

Observe – should be no need to intervene

Transition Trigger: (Actions OR Time) student closes sessions and says goodbye to patient

Teaching Points:

Can discuss stepping back, when to intervene

if things not right and maintaining the AHPs

professional relationship with staff and

patient.


3. End

student is very confident that the session went well. ‘see, I don’t know why they have been saying things, at least now you’ll be able to tell them you’ve checked and I’m good at my job!’

Learner should instigate a feedback conversation using a structure – BOOST, Pendelton, SPIKES, Radical candour, scarf model etc This should be clear, fair and unambiguous but not avoid the difficult points.

Transition trigger: student can get teary and /or angry. ‘WHAT? Whay are you siding with them? Whats to say you’re not wrong in how you do it and I’m right’

Models of feedback

Action planning for improvement

Supporting staff members / students

Using the AHP marker assessment system

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- Deliver constructive feedback to a student / colleague on their practice - Discuss strategies for supporting the development of a student / colleague - Discuss how to assess practice


patient and student ( for simulation - needs to be a colleague so that they can do task but make it

slightly wrong)

Ward environment with patient in bed/ at bedside, clinic, home environment etc etc what ever is

common to practice

PERSONNEL

Facilitator

PROPS

Whatever is relevant and to hand for a ‘normal’ assessment/session / intervention for this

profession, telephone and referral forms, notes. uniforms


Team development

If using this in team development, you should identify the student and the learner. You may need to be the student unless you can arrange for a group member to undertake this role. Set up the area. Use a table with blankets and pillow to represent the bed and have the patient on a chair beside. Alternatively utilise any bed / trolley etc available in the dept. Put blankets over a couple of chairs to make a sofa for a home environment etc Participant should arrive in the area when the scenario starts. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You should decide the delivery approach before starting and explain the planned approach fully to the participants. You have 2 options for running this: 1. Brief, immersion, debrief The participant and observers are given the brief for the scenario. The scenario is run once for the 4-5 minutes then a group debrief occurs following the guidance in the debrief section of this pack. The participant and the group get the opportunity to debrief 2. Interactive theatre approach The participants are given the brief and it is explained that this will run twice. Once as a traditional immersive scenario and then once as an interactive scenario before a debrief. The scenario runs once, uninterrupted for 4-5 minutes

66

The scene is reset and the participant is asked to start again, repeating their activity. The audience are given the opportunity to put their hand up whenever they have a suggestion or comment and the scenario is paused. The audience can give their suggestion or swap places with the participant and act through their idea. This continues for another 5 minutes. The participants all then take part in a debrief.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives. On the MSU, use the screen to define the planned environment. Follow all guidelines for setting up the cameras and Set up the environment as required using the following as a guide: Options: Use the screen to define if the clinical environment or home environment. Use Sim mans trolley as a bed and take a chair from the classroom area. Use chairs covered with a blanket to create a sofa Offer them a brief with full details of the scenario. Explain that if they require assistance please use the phrase – assistance please – and then voice their question. The facilitator will be able to speak back to them. The participant should be informed this will be filmed and then the recording used for debrief purposes immediately after the scenario.



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Additional scenario ideas were collected from AHPs. Please feel free to use

any of these ideas and the templates in this toolkit to develop your own

scenarios.

- Taking a patient on a home visit from hospital and them falling in street or at home

- Dealing with inappropriate language and behaviour and not knowing how to respond

- Arriving at a community location to carry out an assessment, having forgotten an essential element

- Explaining to someone who has been with the service for a long time that due to changes in

criteria, they will no longer be getting the service

- Working in a home and feeling unsafe – mental health patient and substance misuse issues

- Working with a mum and a child and the child to fit a new supportive chair / standing frame and

the child takes a seizure in the equipment

- Dealing with unrealistic expectations from a patient or carer of either going home from hospital, a

child’s ability to walk in the future, length of rehab following injury etc

- A patient arrives for an x-ray following a fall but due to their size and a previous stroke, it is difficult

to achieve the position required for a clear image

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Examples from NHS Lothian – Technical and non technical skills

Lesley Royer (Physiotherapist) undertook a NES AHP career fellowship and

developed and delivered two scenarios to support physiotherapists working in

critical care as on call team members.

Lesley’s scenarios have been shared in this pack as excellent examples of

combining skills practice for technical skills before embedding the learning in a

ward based scenario to enable the non technical skills and situation to be

applied to the delivery of the skill.

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Title: Management of a MHI presentation Participants: Physiotherapy On Call Staff Estimated running time: 15 min Intended Learning Outcomes (ILO):

1) Analyse relevant clinical data to determine the stability of the patient for physiotherapy intervention

2) Discuss the clinical decision making process around identification and application of MHI as the chosen treatment+

3) Modify treatment according to changes in clinical signs during physiotherapy intervention Case summary/ Story line: Mr Jones is a 46 year old male who was admitted via A&E approx 3 hours ago. Collapsed at home, presenting with a reduced GCS and required intubation in A&E. Had a CT on admission to ITU which indicated no intracranial bleed. In this scenario, the on-call physiotherapist had received a call with a request to review due to increasing O2 requirements with reduced TV, and doctor felt that the patient would benefit from PT input. Briefing for participant: Mr Jones is a 46 year old male who was admitted to ITU from A&E approximately 3 hours ago. He was admitted following a collapse at home and required intubation in A&E due to reduced GCS. He had a CT scan on admission which indicated no intracranial bleed. You received a call as the on call PT about an hour ago requesting review of this man. The information given over the phone was that Mr Jones has a left LL collapse, had a broncoscopy on admission with tenacious secretions noted, O2 requirement was still increased at 80%, TV were poor and the anaesthetic team felt that PT review would be helpful.

SITUATION

Mr Jones is 46, history is unclear but he was found at home with reduced consciousness, was brought in to A&E and intubated at this time. CT scan has shown no ICB. Since transfer to ITU his O2 requirement has increased, a broncoscopy was carried out earlier with some thick secretions, but his O2 requirement remains high. His x-ray was showing a left lower love collapse and the medical team had asked for a physio review.

BACKGROUND

Previous Hx of IVDU, is on methadone programme.

ASSESSMENT

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On VC ventilation with 80% O2, PEEP 10, TV 220, good SpO2 98% Settled on propofol and alfentanil, and CVS stable with nor-adrenaline at 5

RECOMMENDATION

From nurse in room - Anything else you need to know? I’m just going to grab a couple of things I need.

Facilitators Notes: Other items for debriefing

Scenario Storyboard

EVENTS STATE

DESIRED PARTICIPANT BEHAVIOUR &TRIGGERS TO MOVE TO NEXT STATE

PARTICIPANT EXPECTED

BEHAVIOUR

TRANSITION/ notes PROMPT IF REQUIRED

State 1 LO: Analyses relevant clinical data to determine the stability of the patient for physiotherapy intervention.

Patient – ventilated

via ET tube

Supine approx 20

degrees head up

Physiology

SIMV VC FiO2 0.8 RR

20 PIP 30 PEEP 10 TV

220 SpO2 100%

Reduced BS left LZ

HR 72 BP 107/60 (75)

Nor-adrenaline 4

(reduced from 8

overnight)

Propofol 20, Alfantanil

Learner Actions Assess patient – check observations and notes Auscultate chest Palpate chest

Transition Trigger: Trigger is decision to move to intervention If no decision will require prompt from faculty or reduced SpO2 94% Prompt: Physiology no change, unless no decision to move to intervention Faculty – Nurse asks ‘so what do you think?’ I thought he was quiet on his left side.

Additional Teaching Points

Consideration of stability for treatment with FiO2 0.8 Faculty – Nurse asks ‘so what do you think? I thought he was quiet on his left side’

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Scenario Storyboard

EVENTS STATE



BEHAVIOUR


4; RASS -3

ABG not done

ETCO2 5.1

Events

Post broncoscopy with

tenacious secretions,

increasing O2

requirement and

reduced TV

State 2 LO: Discuss the clinical decision making process around identification and application of MHI as the chosen treatment.

Patient

as above

Physiology

As above

Events

SpO2 only reduced to

94% if no decision to

move to treatment

within state 1

Expected learner

actions:

Disconnect patient

from vent for MHI

Adjustment of MHI for

effective Rx

Transition Trigger:

(Actions OR Time)

Disconnect and apply

MHI

Prompt:

If SpO2 drop not

noticed by PT, N/S to

comment ‘Sats have

dropped a little’

Physiology

As above with SpO2

Slight decrease in BP

Teaching Points:

Discussion of reason

for potential decrease

SpO2 (? Loss of PEEP,

low volumes,

Secretion load)

No of reps and when

to cough

When to stop Rx

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Scenario Storyboard

EVENTS STATE



BEHAVIOUR


on suction but not too

low

State 3 LO: respond appropriately to clinical signs during MHI

Patient

No change

Physiology

BP slight drop – keep

systolic around 98

SpO2 reduced a little

after 10-12 breaths,

approx 94%

Post Rx once

reconnected to vent,

Vent settings as pre-Rx

with increased TV,

SpO2 98% back on

vent, TV 250

Events

Expected learner

actions:

Suction after 10 – 12

breaths if not before

Decision to stop Rx or

repeat further cycle.

Communicate future

Rx plan with nurse –

does this PT wish MHI

to continue out with

PT sessions

Consider

humidification with

tenacious secretions

Transition Trigger:

(Actions OR Time)

Review or suction

after 10-12 breaths

Prompt:

Physiology – SpO2

94% if no suction, can

increase to 98% post

suction

Patient response

Faculty - if no

immediate feedback

to N/S, N/S to ask

‘How did that go?’

Teaching Points:

What else could be

adjunct to Rx?

Positioning

Humidification

Manual techniques

If you didn’t use MHI,

what would your

options have been?

73

Equipment required

Equipment: Where to acquire:

SIM Man – ET intubation and ventilated

Ventilator and picture for vent screen

Arterial line, BP cuff, SpO2 probe, EtCO2 line

Catheter

Infusions with propofol, Alfentanil, nor-adrenaline (red label for inotrope)

Mapleson C-circuit

Suction catheters

QI Activities

Peer Review Yes No Changes made:

Evaluation Yes No Changes made:

Author(s) Lesley Royer, Team Lead Physiotherapist ITU/Surgical/Burns and Plastics

Contributor(s) Nathan Oliver

Version Effective From Effective To Change Summary

1.0

74

Title: Management of a compromised tracheostomy airway Participants: Physiotherapy On Call Staff Estimated running time: 15 min Intended Learning Outcomes (ILO):

4) Discuss the importance of the steps required for a physiotherapy assessment to a patient with a tracheostomy.

5) Explain the significance of responding quickly based on the signs and symptoms of a compromised airway.

6) Discuss the challenges and solutions of escalating concerns after hours in an effective manner.

Case summary/ Story line: Mr Smith is a 54 year old male who underwent maxillofacial surgery 2/7 ago requiring resection of Squamous Cell Carcinoma (SCC) from floor of mouth (FOM), bilateral neck dissections and reconstruction with a left sided free scapular flap. Initially managed in ITU overnight, transferred to level one yesterday. Was seen by PT yesterday and added to weekend list by physio team for on-going review for chest. Briefing for participant: Mr Smith is a 54 year old male who underwent maxillofacial surgery 2/7 ago requiring resection of SCC FOM, bilateral neck dissections and reconstruction with a left sided free scapular flap. Initially managed in ITU overnight, transferred to level one yesterday. Was seen by PT yesterday and added to weekend list by physio team for on-going review for chest. No specific concerns raised with chest yesterday. You have been asked to review on sat daytime hours within 7 day working remit. You attend ward 18 to assess mid-morning on Saturday. The Nurse speaks to you before entering the side room advising that there are no concerns, observations are stable and not requiring much suction overnight. NEWS chart is available outside the room.

SITUATION

Nurse handover - Stable overnight and not requiring much suction overnight. Transferred from level 1 this am.

BACKGROUND

History of alcohol excess, no other significant history.

ASSESSMENT

RECOMMENDATION

75

Facilitators Notes: Other items for debriefing

Scenario Storyboard

EVENTS STATE



BEHAVIOUR


State 1 LO: Discuss the importance of the steps required for a physiotherapy assessment to a patient with a tracheostomy.

Patient supine in bed

approx 20 degrees

head up, portex

trachea in situ

Physiology

SV 35% heat

humidified O2 via

airvo , RR 12, SpO2

95%

HR 88 BP 114/68

Responding to verbal

cues – eye opening to

voice, unable to

vocalize

Events

Learner Actions Assess patient – check observations and notes Speak to patient Auscultate

Transition Trigger: Assess Deep breaths Weak FET/cough Trigger - decision to Suction OR decrease SpO2 if needed to prompt decision – 93% Prompt: Faculty – Nurse to comment on SpO2 if not suctioned/noticed

Additional Teaching Points

Weak FET/Cough Decreased SpO2

State 2 LO: Explain the significance of responding quickly based on the signs and symptoms of a compromised airway

Patient

as above

Physiology

Expected learner

actions:

Remove inner tube

Transition Trigger:

(Actions OR Time)

Inner tube removed

Teaching Points:

O2 to face and trachea

Verbally check safety

with staff – inner tube,

76

Scenario Storyboard

EVENTS STATE



BEHAVIOUR


HR & BP as above

initially – changes

within approx 30 secs

of suction, likely

blockage at this time

Events

Decreased SpO2 86 –

87%

Decreased RR 8 and

shallow

Apply O2, increase O2

Consider cuff down

Call for help from N/S

Consider 2nd

suction/repeat suction

Consider cuff down

Prompt:

Inner tube removed

Consider cuff down

Has O2 been

increased/applied

Physiology

O2, cuff down, suction

State 3 LO: Discuss the challenges and solutions of escalating concerns out of hours in an effective manner

Patient

SV O2 in situ to face

and trachea

Physiology

RR 14, SpO2 90%

HR & BP stable

Events

SpO2 88 -90% with

increased O2

Expected learner

actions:

Escalate – use of

escalation info

Likely to ask N/S this

info

likely HAW call (bleep

3982)

Concise handover by

phone

Transition Trigger:

(Actions OR Time)

Decreased SpO2 noted

Decision to escalate

Prompt:

Physiology – further

reduction in SpO2 88 -

89% if required

Teaching Points:

Decision to escalate –

when would 222 be

considered

Handover

77

Scenario Storyboard

EVENTS STATE



BEHAVIOUR


Patient response

Faculty – nurse to

comment on

decreased SpO2 if

required

Prompt on who to

phone – HAW bleep

3982

Equipment required

Equipment: Where to acquire:

SIM Man – trachea in situ, ideally portex

Airvo humidifier, O2 attachment for trachae ? loan from ITU

Monitor and equipment for HR, BP, SpO2

Trachea box with spare inner tube, syringe for cuff

Bed space sign for trachae

Suction catheters – size 12, 14 ITU

NEWS chart

O2 mask for face

78

QI Activities

Peer Review Yes No Changes made:

Evaluation Yes No Changes made:

Author(s) Lesley Royer, Team Lead Physiotherapist ITU/Surgical/Burns and Plastics

Contributor(s) Nathan Oliver

Version Effective From Effective To Change Summary

1.0

79

Examples from NHS Shetland

Marc Beswick (AHP PEL) utilised the scenarios in the toolkit to develop

modified versions which supported the development of a newly formed

integrated multi-disciplinary team.

Utilising and adapting existing scenarios reduced the workload for the local

team and provided a basis for their development.

1. deteriorating patient

2. fallen patient

Both adapted scenarios are shared below:

80

NHS Shetland Scenario 1 – Deteriorating client at home at the weekend

Target group – Intermediate Care Team compromising of Rehab Support Workers, AHP’s and Nurses

Learning objectives:

By the end of the scenario and debrief participants will be able to:

- Recognise signs of deterioration in a client

- Escalate care by contacting appropriate services in a timely manner

- Demonstrate safe handling of a patient

- Demonstrate safe and effective communication techniques with client and family member

Setting and Background: This scenario takes place in a remote cottage at the weekend. Client has been

discharged home from the ward 2 days ago. This is your second home visit. The scenario starts with you

arriving at the house.

Brief:

You have arranged to visit Tom Robertson, an 82 year old man at home. He lives in a remote croft house with

his 80 year old wife who has Dementia. He has a son who lives 45 mins away and visits every other weekend.

Tom was admitted to hospital 1 week ago with a suspected CVA which was later diagnosed as a TIA. He

remains shaken and unsteady and appears to have lost confidence in his abilities according to the team in the

hospital. Tom assessed on the ward and further concerns were identified related to his potential safety and

independence at home that you wish to follow up now that he is home.

Tom expressed his desire to return to participating in activities at home including making the coffee in the

morning for his wife and walking outside to his poly tunnel.

You have arranged to visit Tom at 10am in the morning.

You should carry out the visit as you usually would. You will be alone with Tom and his wife.

When you arrive Tom says he feels a bit wobbly but is happy to continue with the visit.

You can call ‘time out at any point’ with a T symbol with your hands or say ‘time out’.

81

NHS Shetland Scenario 1 – Deteriorating patient in home – Story Board


1. Beginning

You arrive Tom not

feeling very well.

Start intervention.

Client

Reports feeling wobbly

Physiology

Tom looks a bit paler

compared to when you saw

him yesterday

NEED FIGURES

Events

You arrive Tom and his wife

are sat in the kitchen


Tom continues to planned

activity

Offer prompting with kettle

and coffee

Start planned activity

Activity progresses

Ask Tom if he is OK to

continue

Transition Trigger:

(Actions OR Time)

3-4 minutes of activity

Prompt:

Physiology

Patient response

No verbal cue but puffing, exhaling

etc to show this is effortful for him

Pausing during activity

Happy to carry on?:

‘Yes, let’s just get this done’

‘ I’ve started now, I’ll have a rest

when I have finished the coffee

‘this is tiring, I’m actually not feeling

the best’

Faculty

Teaching Points:

Recognising signs of effort or

deterioration


Tom

82


2. Middle Patient

Sudden collapse (fall to floor,

forward onto table or back in

chair as relevant)

No loss of consciousness but

very drowsy

Physiology

NEED FIGURES

Events

Patient collapse.

Tom says “don’t phone

ambulance I will be all right, it

passed last time and I don’t

want to go back to the

hospital”

Please phone my son instead,

he will know what to do and


- make patient safe

-initial assessment of

breathing / consciousness

-safe positioning of the

patient

- get help

Transition Trigger:

(Actions OR Time)

Patient continues to deteriorate

despite any basic intervention

Prompt:

Physiology

NEED FIGURES

Patient response

Patient is groaning and moaning but

becomes quieter and more drowsy

after 1 -2 minutes

Faculty Say we need to phone.

Who do you phone?

Team Lead?

999?

Teaching Points:

ABCDE assessment


Safe handling to position the unwell

patient

83


look after me” The son?

Panic that you can’t get anyone on

the phone – its ringing out to Team

Lead on call.

Wife says – “well he was a bit off

this morning actually. I was a bit

worried something was brewing

with him.

Wife “Please phone for an

ambulance”

999 call. Central control does not

know area. 1 Postcode covers

approx 20 houses over a 5 square

mile radius. No street names or

house numbers.

Ambulance will take ½ hour to

arrive.

Timing Clinical condition Expected Clinical Course with actions, triggers and prompts 3. End Patient

Very drowsy and incoherent


- get appropriate help and

support

-get Tom comfy on the

Transition Trigger:

(Actions OR Time)

Teaching Points:

SBAR communication

84


Physiology

NEED FIGURES

Events

floor/chair

Prompt:

Physiology

Patient response

Drowsy and incoherent

Faculty

85

Conclusion:

Stop this scenario after 10 minutes maximum.






- Dealing with conflicting wishes of Tom and his wife.


- phone

- kettle / coffee jar/ cups if kitchen assessment,

-Basic kitchen furniture

Personnel:

- Patient

- Faculty – wife


Team development

If using this in team development, you should identify one person to be the AHP.

You may need to be the patient unless you can arrange for a volunteer patient or another group

member is keen to undertake this role and you’ll need a hcsw volunteer.

Set up enough chairs for rest of group in a semi circle around the scene.

Group members / audience should be advised not to interrupt whilst scenario is running.

You should decide the delivery approach before starting and explain the planned approach fully

to the participants. Decide before you start if you’re using the interactive stage of the process.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives.

On the MSU, use the screen to define a home environment.

Follow all guidelines for setting up the cameras and systems

86

Set up the environment using the clinical side of the screen divide.

Use chairs as treatment chairs, sim mans trolley as a bed / plinth and use the narrow counter

beside the sink to replicate a kitchen or work area.

If this is for a group, set up the chairs around the back TV, link this to the cameras and issue

headsets.

Offer them a brief with full details of the scenario.

Explain that if they require assistance please use the phrase – assistance please – and then voice

their question. The facilitator will be able to speak back to them.

The participant should be informed this will be filmed and then the recording used for debrief

purposes immediately after the scenario.


If using this as an assessment of competence you should have taken some time to become

familiar with the behavioural marker system. This should be done before the scenario.

You can run this scenario in a class or the MSU but it will be most beneficial if filmed for debrief

as it can be helpful for participants to see their skills and learning needs.

If the MSU is not available you could film the scenario in a standard room using ipads etc to film

it.

It should be made clear to the participant that you will be looking for specific skills and

behaviours during this scenario and you will discuss these afterwards.

It is likely that this will be a formative assessment, not a summative assessment – informing

further discussions and development planning.

87

NHS Shetland - Scenario 2 – Fallen client at home at the weekend

Target group – Intermediate Care Team compromising of Rehab Support Workers, AHP’s and Nurses

Learning objectives:

By the end of the scenario and debrief participants will be able to:

- Respond to client falling in the home

- Escalate care by contacting appropriate services in a timely manner

- Demonstrate safe handling of a patient

- Demonstrate safe and effective communication techniques with client and family member

Setting and Background: This scenario takes place in a remote cottage at the weekend. Client has been

discharged home from the ward 2 days ago. This is your second home visit. The scenario starts with you

arriving at the house.

Brief:

You have arranged to visit Tom Robertson, an 82 year old man at home. He lives in a remote croft house with

his 80 year old wife who has Dementia. He has a son who lives 45 mins away and visits every other weekend.

Tom was admitted to hospital 1 week ago with a suspected CVA which was later diagnosed as a TIA. He

remains shaken and unsteady and appears to have lost confidence in his abilities according to the team in the

hospital. Tom assessed on the ward and further concerns were identified related to his potential safety and

independence at home that you wish to follow up now that he is home.

Tom expressed his desire to return to participating in activities at home including making the coffee in the

morning for his wife and walking outside to his poly tunnel.

You have arranged to visit Tom at 10am in the morning.

You should carry out the visit as you usually would. You will be alone with Tom and his wife.

When you arrive Tom says he feels a bit wobbly but is happy to continue with the visit.

You can call ‘time out at any point’ with a T symbol with your hands or say ‘time out’.

88

NHS Shetland Scenario 2 – Fallen patient– Story Board


1. Beginning

You arrive

Start intervention.

Client

You arrive Tom and his wife

are sat in the kitchen

Physiology

Tom gets up from the chair to

walk to kettle and stumbles

slightly

NEED FIGURES

Events


Tom continues to planned

activity

Offer prompting with kettle

and coffee

Start planned activity

Move closer to Tom are you

ok on your feet?

Activity progresses

Transition Trigger:

(Actions OR Time)

3-4 minutes of activity

Prompt:

Physiology

Stumbled when walking

Teaching Points:

Recognising signs of falls risk


Tom about his mobility

89


2. Middle Patient

Tom loses balance near kettle

and falls to the floor

No loss of consciousness

No obvious injury

Events

Patient collapse.

Tom says “don’t phone

ambulance I will be all right,

give me a few minutes, I don’t

want to go back to the

hospital”

Please phone my son instead,

he will know what to do and

look after me”


- make patient safe

-safe positioning of the

patient

Check for injuries

- get help

Reassure Tom

Transition Trigger:

(Actions OR Time)

Prompt: Tom falls

Physiology

NEED FIGURES

Patient response

Patient is conscious, clearly spoken

and reports no pain

Faculty Say we need to phone.

Who do you phone?

Team Lead?

999?

The son?

Wife says –Wife “Please phone for

an ambulance to check he is alright”

Teaching Points:

ABCDE assessment


Safe handling to position fallen patient

Communication with wife


90


3. End Patient

After a few minutes Tom

manages to get up from the

floor using a chair for support

and sits down next to his wife

Events


- provide appropriate help

and support to Tom to enable

him to get up off the floor

-get Tom comfy on the /chair

Reassurance to wife

Transition Trigger:

(Actions OR Time)

Prompt:

Patient response

Conscious, no pain reported, back up

on his feet

Faculty

Teaching Points:

SBAR communication

Communication with family members

91

Conclusion:

Stop this scenario after 10 minutes maximum.






- Dealing with conflicting wishes of Tom and his wife.


- phone

- kettle / coffee jar/ cups if kitchen assessment,

-Basic kitchen furniture

Personnel:

- Patient

- Faculty – wife


Team development

If using this in team development, you should identify one person to be the AHP.

You may need to be the patient unless you can arrange for a volunteer patient or another group

member is keen to undertake this role.

Set up enough chairs for rest of group in a semi circle around the scene.

Group members / audience should be advised not to interrupt whilst scenario is running.

You should decide the delivery approach before starting and explain the planned approach fully

to the participants. Decide before you start if you’re using the interactive stage of the process.


Allow yourself 20-30 minutes to set up the scenario and cameras before the participant arrives.

On the MSU, use the screen to define a home environment.

Follow all guidelines for setting up the cameras and systems

92

Set up the environment using the clinical side of the screen divide.

Use chairs as treatment chairs, sim mans trolley as a bed / plinth and use the narrow counter

beside the sink to replicate a kitchen or work area.

If this is for a group, set up the chairs around the back TV, link this to the cameras and issue

headsets.

Offer them a brief with full details of the scenario.

Explain that if they require assistance please use the phrase – assistance please – and then voice

their question. The facilitator will be able to speak back to them.

The participant should be informed this will be filmed and then the recording used for debrief

purposes immediately after the scenario.


If using this as an assessment of competence you should have taken some time to become

familiar with the behavioural marker system. This should be done before the scenario.

You can run this scenario in a class or the MSU but it will be most beneficial if filmed for debrief

as it can be helpful for participants to see their skills and learning needs.

If the MSU is not available you could film the scenario in a standard room using ipads etc to film

it.

It should be made clear to the participant that you will be looking for specific skills and

behaviours during this scenario and you will discuss these afterwards.

It is likely that this will be a formative assessment, not a summative assessment – informing

further discussions and development planning.

developing and maintaining clinical skills in the practice

Documents