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Abstract
Introduction Simulation-based training (SBT) has gained significant traction within emergency medicine. The growing body of evidence describes the benefits that SBT can bring. However, identifying barriers and enablers when establishing successful SBT programmes in busy emergency departments (EDs), and ensuring longevity of such programmes, can be difficult.
Objective We aim to identify barriers and enablers to SBT in busy EDs.
Methods We explored and analysed the thoughts, experience and opinions of professionals involved in SBT and organisational support. 32 participants across 15 international sites were invited to a semistructured interview process. We included participants from a variety of backgrounds, from clinical staff to management staff. Transcribed interview data was classified and coded based on capability, opportunity and motivation behaviour (COM-B) domains and analysed based on theoretical domains framework. Frequency of the most mentioned thematic domain among participants is reported.
Results The interview data revealed several common themes, including the following: knowledge and skills (90%), support and leadership (96%), mental barriers (87.5%), local culture (96.6%), dedicated space (65.2%), time constraints (46.8%), social influence (87.5%), education (90.6%), professional development (68.75%), exams (59.3%) and personal goals (93.75%). Management staff was observed to prioritise resource, staffing and flow, while the clinical cohort tended to focus on specialty and personal development when it came to simulation training in the ED.
Conclusion Potential barriers and enablers to SBT and in situ simulation for EDs were identified through interviews conducted in this study. The central themes in terms of barriers and enablers were local culture, leadership, individual needs, resources and optimisation. A tailored approach is vital for establishing a successful SBT and in situ simulation programme.
- accident & emergency medicine
- qualitative research
- public health
- education & training (see medical education & training)
- quality in health care
- international health services
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- accident & emergency medicine
- qualitative research
- public health
- education & training (see medical education & training)
- quality in health care
- international health services
STRENGTHS AND LIMITATIONS OF THIS STUDY
The study demonstrated a diverse representation of participants from various geographical locations and roles internationally, contributing to a comprehensive understanding of the topic.
The utilisation of the COM-B model offered a robust theoretical framework for the research, enhancing the validity and rigour of the findings.
Employing a qualitative approach facilitated a thorough exploration of participants' perceptions, providing valuable insights into their experiences and perspectives.
Acknowledgement of the potential for subjectivity in the analysis of interview data, ensuring transparency and flexibility in the research process.
There may be a selection bias present in the study as a majority of the participants recruited were experienced with the usage of SBT, possibly influencing the generability of the results.
Introduction
Simulation is a technique where real-life experiences are recreated and replaced with guided ones, creating a controlled learning space to practice a variety of skills before entering a real world setting.1 It can take on many forms which can be used to recreate a specific scenario or event for the intent of training in a safe environment.2 Recent studies have demonstrated that simulation-based training (SBT) not only improves knowledge retention, but it is also effective in modifying safety attitudes and improving patient outcomes.3
The use of SBT to enhance training has gained traction within the field of emergency medicine (EM).4 A subbranch of SBT frequently used in EM is in situ simulation. This involves SBT to be delivered on-site, and integrated into the real environment, using real equipment and the establishment’s real staff.5 This blend of simulation within the real working environment offers unique opportunities for EM physicians to train with interdepartmental teams while at work, within their real work setting, enhancing departmental teamwork while learning new skills and procedures, as well as maintaining competencies, and train for crisis management.6 7
In many instances, although recent literature is growing, it has been difficult to completely assess the challenges in establishing SBT programmes. This is likely, in part, due to the nature of simulation training and data extrapolated from qualitative means.8 The study aimed to explore the perspectives of various stakeholders, including experts, doctors, nurses, clinicians, administrators, educators, managers and others, to gain a comprehensive understanding of the barriers and enablers of using SBT and in situ simulation within an emergency department (ED) setting.9–11
Objectives
To identify the barriers of running an in situ simulation programme or an SBT programme in an ED.
To investigate the enablers of running an in situ simulation programme or an SBT programme in an ED.
Method
Study design
Between January 2021 and May 2021, selected participants with experience of simulation and the functions of an ED were invited to partake in a semistructured interview to explore their thoughts on potential barriers and enablers to SBT and in situ simulations within ED’s. An overview of the study is provided in figure 1. The study is reported in line with Standards for Reporting Qualitative Research.
Overview of study.
Patient and public involvement
There was no patient involvement in this study.
The capability, opportunity and motivation behaviour model
The theoretical framework used is the capability, opportunity and motivation behaviour (COM-B) model. This model provides a theoretically grounded approach to understanding behaviour—in this case, running an SBT programme in an ED. The model proposes that interactions between COM-B cause the performance of a particular behaviour (see online supplemental file 1).
Supplemental material
Capability is defined as the individual’s psychological (eg, the psychological resources and skills, knowledge capacity for understanding) and physical (eg, physical skills) capacity to run SBT.12
Motivation is defined as all those brain processes that energise and direct behaviour. Motivation includes reflective (eg, deliberate planning and decision making) and automatic (eg, habit) practices.12
Opportunity is defined as the factors that are outside the individual that make the behaviour possible or prompt it. It is possible to distinguish between the physical environment (eg, lack of space) and the social environment (eg, lack of support from leadership).12
Participant selection, recruitment and sample size calculation
Participants were recruited across multiple international sites. Local participants were identified by the author, national participants were recruited with the help of the Irish Trainee Emergency Research Network.13 International participants were selected via recommendation of an advisory committee. The participants selected were either known to use simulation for the purpose of medical education or have a good understanding of how an ED functions (level 1 and 2 EDs). All participants were invited to participate via email and have given consent. Participant inclusion and exclusion criteria are provided in online supplemental file 2.
Supplemental material
The study planned to continue with the interviews until data saturation was achieved.14
The literature suggests this can be achieved within 5–30 interviews.15
Guest et al found that 73% of codes were identified within the first six interview transcripts, 92% within the next six transcripts and the remaining eight codes were identified by the completion of the thirtieth transcript.16 This supports Glaser and Strauss’s coding procedures. Creswell et al indicates that a sample size of 20–30 interviews when based on the grounded theory approach, would be appropriate.17 This study recruited 32 participants to meet the above criteria.
Interview process
Semistructured interviews were conducted in person and virtually by the author from January to May 2021. The interview structure was based on the COM-B Framework, using questions that explored the study aims of looking for barriers and enablers to simulation training for an ED (online supplemental file 1).16 17 All interviews were recorded and stored on an encrypted solid-state-drive. Only the study author had access to the encryption. Following completion of the interviews, interview data were transcribed verbatim and anonymised.
Data synthesis and analysis
Transcribed interview data were classified and coded using the COM-B model.18 The authors produced themes from analysing the transcripts. To ensure rigour of the themes produced, three external researchers were recruited to identify the recurring themes. All three of these researchers are EM specialist registrars familiar with using simulation as a training tool.19 This introduced peer debriefing to provide an external check on the research process, which increase credibility and adequacy.19 The themes that had the most frequency were recorded and reported in the results section (table 1).
Common themes identified under the theoretical domains framework
Results
A total of 32 semistructured interviews we conducted, including participants from 15 countries. Interviews duration averaged 26–32 min with most interviews conducted virtually 29 (91%). A summary of the included participant characteristics is provided in table 2. Nineteen (59.3%) participants were active clinical staff, while 13 (40.6%) were non-clinical participants. Four (12.5 %) were simulation specialists currently working in a simulation centre. The average SBT sessions were 44.8 sessions per year by clinical and simulation based technical staff. Seventeen (53%) were female and 15 (47%) were male, with an average experience of 7.9 years. Seven (21%) worked in a private establishment while 25 (79%) worked in governmental establishments.
Summary of participant and demographics
Capability dimension
Knowledge
Most participants, 30 (93%) believed that there is sufficient knowledge for the deliverance of simulations training in EDs. However, it was mentioned by 9 participants (28%) that although they have the requisite knowledge, those delivering the simulations lack training. To illustrate, ‘they might have the knowledge, but they are not trained to do so. Sim is more than just setting up a manikin and running it, you need to be mindful of very niche things like how to run something well, how to use the science of deliberate practice, how to create a safe container, and especially how to debrief. These are only things you know if you’re involved in simulation’ (Participant 009).
Dedicated space (barriers)
All 32 participants (100%) commented on the lack of a dedicated space or a location to run the simulations in a busy ED. For example, ‘there is usually no space, we just use what we find, but in retrospect that is what an in-situ sim is all about, if you don’t have a space, you’ve got to make one’ (Participant 014).
A total of 15 (47.7%) participants stated that availability of equipment for SBT was not an issue for the ED as most used equipment from the clinical area. However, issues with the fidelity of the simulation equipment were mentioned: ‘being in the real clinical area, using real equipment, working with your real colleagues brings the fidelity up to a very real level, we have seen real stress response in our learners. Hence, I think even using a low fidelity manikin is enough if you can run it well’ (Participant 014).
A total of 31 (96.9%) of participants believed that there is support for simulation training but only from a non-tangible point. By way of example, ‘it’s great that when you approach the top people, they say they support this, but then you are left to plan, organise, set up, recruit, and even at times fork out your own money to buy equipment or materials. Worse of all, is that once you set something up, you are now required to do it free of charge and even on your free time’ (participant 003).
Time (barriers)
Lack of time was mentioned for by all of participants, they mentioned that time was a huge factor because most ED run this once a week, and there are some on annual leave, off duty or are postnights; stated ‘things should be scheduled during your working hours; everyone should have equal access to equal opportunity for training’ (Participant 009).
Staff and engagement (barriers)
A total of 7 (21%) mentioned about high turnover of staff in ED leading to a lack of consistency: ‘people get trained, people get up a good programme and then they leave, from NCHD up to consultant level. People move on quickly’.
Twenty-three participants (71.87%) commented on the lack of engagement from upper management; stated ;lack of engagement from management. You need it to come from the top down; (participant 025).
Beliefs about capabilities and individual factors (barriers)
When asked what would prevent participation from learners, there was an overwhelming theme that mindset plays a big role. All participants agreed. ‘People get nervous, they think they are going to be tested (in an in situ simulation), additionally that they might not have adequate knowledge and they do not like that (Participant 006)’. This participant pointed out that there needs to be a new culture that accepts simulation not as a test but as a training tool where mistakes are not penalised but seen as an opportunity to learn. ‘Stress response: participants do not have the confidence, shy, scared, fear of looking stupid among their peers. Simulation exposes people, it puts people in positions who are vulnerable and stress to the point that they don’t want to do it sometimes (Participant 007).’
Cost and Staffing (barriers)
All administrative and management staff mentioned and elaborated on the cost of training and staffing inadequacies. While they could understand the importance of training, they thought that the flow of an ED should not be compromised. One elaborated ‘For us in management, we don’t really get medicine, it’s easy to just say; it costs this much for this manikin etc and likely, we’d be able to provide a grant of sorts, but in my opinion, training like these takes a lot of time and staff to set up and run. Can we really justify disrupting the flow of the ED during working hours? This significantly increases risk to patient safety with long waiting times. Things gets missed in a high-pressure situation. There really needs to be a balance. I don’t know, maybe in a bigger ED?’
Opportunity dimension
A mean score of 7.5 was given by 32 participants when asked to rank (from 0 to 10) the ‘capability’ of their respective ED’s to run a simulation training programme. A total of 29 participants (90%), however, stated that although capable, there is insufficient training provided to those who would run the programme. Of 32 participants, only 5 were aware of further training in their respective systems/countries in forms of diploma programmes and train-the-trainer programmes.
Reliance on one or two key individuals (barrier)
A total of 19 (59.37%) believed strongly that this is a fundamental issue. Because there is a general lack of support, simulation training is usually centred around one or two key persons of interest. ‘There is no dedicated time from an organisational level. The university or hospital management does not put aside time for training. They are not given any funding or payment’ (Participant 001). ‘The registrar that leads this currently does not have protected time, she’s doing it on her own free time, this relies on a person’s enthusiasm entirely’ (Participant 003). ‘There would be one or 2 who are enthusiastic, if they were gone, I think it wouldn’t work. It hinges on the people who are interested’ (Participant 006).
There was a similar theme around ‘culture of a department’ when asked. There was 50/50 split regarding social influences being a negative factor versus a positive factor. While a new cultural change will permit better training due to the uptake of simulation and acceptance of it being the new ‘norm’. It is also similarly difficult to change the culture of a department that has functioned in a specific way for years.
Identifying barriers
A total of 31 out of 32 (96.8%) were consistent in drawing out similar themes when asked to name barriers for simulation training. Overall, 100% believed that identifying and approaching these are the key to successfully implementing simulation to training.
Motivation dimension
Fourteen participants (43.75%) believed it to be part of their Jobs as a senior doctor/nurse. One participant stated that this should not be the case, as this person who is delivering the training, never had training themselves. ‘You cannot teach something clinically when you do not use it yourself’ (Participant 031). ‘It is understood(presumably) that when you’re the consultant, it automatically becomes your job’ (Participant 006). Two participants (6.25%) believe it to be part of the Royal College of Emergency Medicine curriculum.
Research outputs, journals, QIPs (enabler)
A total of 5 (15.6%) mentioned the opportunity of having research, publications and Quality Improvement plan (QIP) being a motivating factor.
A total of 21 (65.6%) mentioned exams as part of the motivating factor believing that it would help the participants particularly in exams with an Objective Structured Clinical Examination (OSCE) format. 20 (62.5%) mentioned that simulation is a better tool to deliver training as compared with a traditional PowerPoint lecture.
All participants (100%) noted the point that when setting up/running such a programme, it will be a good addition for the CV. Thirty (93.75%) believed that this gives the biggest motivation. ‘Doctors and nurses are extremely ambitious people, and they are very invested in their own professional development. I think it makes complete sense that they want to partake in as much training as possible’ (Participant 007).
Rare cases (enabler)
A total of 7 (21.8%) of the participants believed that simulation could prepare practitioners for rare cases such as major disaster event.
A large majority, 30 (93.7%) believed that there should be a policy in place to enable simulation training. When asked what motivates the participants in your place of work? (One establishment has a 100% participation rate and simulation training is part of the established local culture).
The participant stated, ‘before I say anything, I’d like to say that its mandatory’ (Participant 007).
Testing latent safety hazards (enabler)
A total of two participants that were familiar with the use of in situ simulations mentioned testing latent safety errors as a motivation.
Discussion
This study aimed to explore the barriers and enablers to implementing an in situ simulation and SBT programme in busy EDs using a semistructured interview approach with 32 participants from international sites to gain collective insights (online supplemental file 2).
One of the biggest barriers identified was the local culture of the establishment, which was considered the root of many additional barriers mentioned by the participants. To overcome this, informal discussions with key stakeholders during the planning stages may be helpful to identify local establishment cultures and potential barriers to the programme’s success. The participants suggested that consistent education about the benefits of simulation training and persistence over time can result in a general acceptance and further development of SBT. Additionally, discussions can be held to propose and include a local simulation champion who is enthusiastic about such an SBT and has the charisma to carry it through.
A clear difference in priorities and language was observed between frontline clinical staff and those working in management and administration. While management staff focused on resources, staffing and flow of an ED, the clinical-based cohort focused on specialty development, personal development and success of a training programme. This is in line with Myllykangas et al’s and Köbberling’s work referencing a difference in priorities between clinicians and management.20 21 Including perspectives from a broad spectrum of stakeholders, from management staff to senior clinical decision-makers, may offer additional key insights into potential barriers as well as enablers to SBT programmes. Early buy-in from management staff could potentially minimise barriers in ways that we may have previously underestimated. One suggestion is to get a member of the management staff take part in one of the simulations. This might offer insight and a sense of relatability to clinical roles.
Most participants felt that allocation of protected teaching time for such programmes would increase the likelihood of success. This is in line with works by Shetty et al.22 Engaging with training bodies and senior staff to ensure that dedicated time is allocated and respected for such programmes can have a positive result on the overall success of any SBT.
Cost of equipment and lack of resources has been cited as a barrier to simulation training in general.23 Interestingly, in this study, none of the clinical participants mentioned equipment to be an issue for ED in situ simulations. They believed that the ED had all the equipment needed and hence would reduce cost. In contrast, simulation staff felt that cost remained a barrier. It was concluded that most individuals thought of cost from a currency standpoint, and simulation-trained staff elaborated on concealed costs, citing resources such as staff, time, methods of disposing materials, storage and expert inclusion.
The participants believed that overcoming barriers is a slow process that requires time and needs the medical community to embrace simulation as a superior training tool in today’s world. Leadership was mentioned as a crucial factor in both the barriers and enablers section. Lack of good leadership can tremendously impact the actions and mentality of participants, causing fear and anxiety. On the other hand, a good lead can expand enthusiasm, decrease cost, change local culture and ensure a safe space.24 We propose electing a local simulation champion who is enthusiastic and has the drive to lead such a project is recommended.
Some participants suggested using a standardised framework for setting up an SBT programme. However, others said that this might not be possible as different countries and establishments have varying systems and cultures. Therefore, a tailored solution that only a person working in that establishment can provide is required.
Finally, several motivating factors for participation in SBTs were identified, including personal and professional development. Participants reported that running an educational simulation programme benefits individuals as it provides additional points on their CVs and opens doors for future research and publications. Offering internal continuing professional development points to participants can also help validate learning and growth through a recognised programme in maintaining professional competence.
Due to the recruitment method, we could potentially introduce a selection bias. The selected participants may have been limited to more experienced and well-known SBT candidates. However, the authors noted that experienced SBT participants were essential as they provided better insight through experience. Another limitation of this study was the difficulty in fully studying and comprehending the nuances and challenges of establishing an SBT, owing to various biases. To minimise this, we selected participants from a wide range of ages, sexes, roles, experiences and geographical locations.
The main strength of this study is the diversity of participants in terms of geographical location and role, which ensures the representation of a range of views from a range of stakeholders. Additionally, the use of the COM-B model and grounded Theoretical Domain Frameworks highlights the important facets of qualitative work, allowing for a deeper exploration of perceptions of this topic.
The use of three independent reviewers at the coding stage to produce themes ensures the rigor of themes and is not based on one person’s personal interpretation.
To establish an SBT programme, we need to address the barriers and promote the enablers to increase chances of success. Tailored and bespoke solutions are necessary for successful establishment of an SBT programme.
We suggest an approach to first tackle local issues (such as resources and time windows when SBTs run best) and to involve key stake holders early. We include a recommended hierarchy of priority for SBT establishment in figure 2. Then proceed to identify the individual needs and intentions of the team, followed by resource needs. Finally, optimisation involving maximising all enablers and minimising the barriers can lead to a programme’s longevity. A Venn diagram of barriers and enablers is visualised in figure 3.
Pyramid of priority for programme establishment.
Barriers and enablers Venn Diagram.
Conclusions
Balancing barriers and enablers are crucial for the success of an SBT and in situ simulation programme, particularly for an ED. To ensure the successful establishment of such a programme, it is essential to implement tailored and bespoke solutions. Our suggested approach involves first to identify and address local issues, such as resource limitations and identifying optimal time windows for SBT implementation, while actively engaging key stakeholders from the beginning. Subsequently, it is important to identify the specific needs and intentions of the team, followed by determining resource requirements. Ultimately, this systematic approach can lead to program optimisation and longevity, ensuring success of SBT in an emergency department.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical approval was granted by the Galway Clinical Research Ethics Committee on the 16 December 2020 (Ref. C.A. 2533). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to acknowledge the following: ITERN (Irish Trainee Emergency Research Network) for taking on the responsibility of researching and recruiting suitable participants for this interview in Ireland. ICAPSS (Irish centre of applied patient safety and simulation) for its valuable input to this study. Saolta: Galway University Hospital and The University of Galway, Ireland for help and support in providing and recomending suitable participants for this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @timburgD
Correction notice This article has been corrected since it was first published. Figure 2 and 3 legends have been updated.
Collaborators Bronwyn R McDermott, Dillon Michelle, Ackloo Rajnita, Gobin Avishka, Qurratalain Fatimah, Davis Jamie, Eduard Turcuman, Roche F Adam, Lee Solmi, Madden Marian, Torpey Tracey, McMackie Eamonn, Brennan Simone, Ambyr Reid
Contributors MJ: planning this study and is responsible for the overall content as guarantor. EM: planning and designing of the study. EU: final edit, data analysis and liaison for ITERN to source suitable participants for this study. PO'C: initial design of this study. DK: planning the study. BM: planning the study and recommending suitable participants, JJO'D: planning the study and recommending suitable participants, BJ: planning the study and recommending suitable participants. All authors have read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.