• facilities

• specialist equipment

• specialist faculty.

Facilities

Facilities should be flexible to enable different simulations to be undertaken by different sizes of groups of learners for different levels of simulation. Most clinical skills can be best taught and learnt in a small-group setting, and so multipurpose small-group teaching rooms linked together both geographically and by audio-visual links provide maximum flexibility.

Facilities such as an outpatient, dedicated ward, theatre and laboratory area can provide contextual simulations for learners. Contextual fidelity supports the transfer of skills to the workplace and creates a suspension of disbelief to enhance learning (Ker et al 2006). Clinical skills facilities can be linked and therefore used more efficiently and effectively through a managed educational network which can be implemented at a regional or national level (Ker 2011). Every facility needs to be working in collaboration with the healthcare system to ensure that teaching and learning reflect the needs of both current and future healthcare practitioners.

A hub and satellite model is a useful concept for ensuring standards across regions and healthcare settings. IT support can enable standards of skills practice to be delivered at any level, regionally, nationally or internationally.

A mobile facility which has the standard features of fixed facilities can provide additional benefits in terms of travel time and team training in small healthcare units, providing an educational service in remote and rural areas without interrupting patient care (NES 2011).

Specialist equipment

Specialist equipment in the clinical skills centre should reflect the reality of practice in relation to medical equipment and consumables. Environmental cues are crucial for learner engagement in simulation events, whether as a novice or expert. Increasingly, clinical skills facilities are being used to test systems of change in patient care delivery, minimizing risk to patients and providing evidence of utility.

In addition, there is an increase in the use of technology to provide realistic simulations, especially of highly complex technical skills such as laparoscopic techniques. There is increasing evidence that these virtual reality simulators can enhance cognitive skills (Sedlack & Kolars 2004). A variety of low-fidelity and medium-fidelity simulators should be provided where appropriate for each of the clinical skills sessions (see Chapter 25). Simulation is a powerful learning tool which is often used to support teaching in clinical skills centres:

Simulation is therefore dependent not only on the situation created but also on the involvement of the learner (Dieckmann et al 2007). In healthcare education it should be considered a tool to recreate clinical reality without compromising patient care. In creating a simulation, all domains of learning (cognitive, psychomotor and affective) need to be considered in the reconstruction.

Salas (2005) identified guidelines to effective simulation-based training which include creating scenarios based on learning outcomes and embedding objective measures of both technical and nontechnical skills in the skills scenario and ensuring feedback is integrated into the process.

Simulated and real patients (see Chapter 26) who support clinical skills centre teaching contribute to preparing students to develop their:

Specialist faculty

Faculty expertise is a definite prerequisite for a successful clinical skills facility.

There are a number of different types of faculty in clinical skills:

Faculty have to develop experience in how much of the simulation they need to prepare the learners for and how much they should participate in the event as a facilitator or assessor. They also need to be trained to be familiar with the use of simulators, in whatever form, as part of the simulation learning event. Faculty need to be supported by administrative, academic support and technical staff, the latter of whom have expertise in maintaining part task trainers and simulators. This type of team can ensure that the skills facility is used to its maximum capacity.

It is very useful though not mandatory to have faculty who have both educational and clinical expertise. Most skills faculty should be advised to retain their clinical expertise with a health service commitment, as they have a role even in a simulated setting as a professional role model.

Faculty also need to have shared understanding of what clinical skills are and what technical and nontechnical skills are so that they can develop appropriate learning outcomes.

The description of a skill is also dependent on which level is being delivered:

A technical skill involves mainly procedural skills, e.g. suturing, blood pressure, basic life support (BLS). Nontechnical skills include communication, decision making and prioritization skills (Table 10.1). Different approaches are needed to facilitate the development of these human factors (Glavin & Maran 2003). There is evidence that nontechnical skills are often the first sign of a potential adverse event, and therefore teaching and learning opportunities are required to specifically develop and rehearse these skills in the clinical skills environment (Salas 2005). In linking both together, Kohls-Gatzoulis et al (2004) demonstrated that learning a technical skill in surgery teaching cognitive skills enhanced the learning of technical skills.

Educational drivers

There is evidence that rehearsing skills (cognitive, psychomotor and affective) in preparation for practice reduces the evidence of adverse events (Leonard et al 2004). There is also increasing evidence that behaviours observed in a simulated clinical setting can predict how professionals will behave in the reality of practice (Weller et al 2003). This ‘knowing how’ can only be gained through professional clinical experience, which clinical skills centre teaching can enhance through preparation, deliberate practice and reflection. Clinical skills centres, through a focus on the learner rather than the patient, can prepare the novice clinician for the healthcare environment (Maran & Glavin 2003).

Clinical skills centres can be used to provide standard reliable evidence of competence to practise at all levels: undergraduate, postgraduate and as part of continuing professional development (Whelan 2000, DOH 2007): as part of more robust regulatory requirements.

Political drivers

Patients now have an expectation that healthcare practitioners will have been prepared to an agreed standard of competence prior to their participation in the reality of healthcare practice (Santen et al 2004, Sedlack & Kolars 2004). In addition, there has been a move towards developing national clinical skills strategies to enhance the quality of clinical skills and to increase their cost-effectiveness (NES 2007).

Service drivers

Clinical skills facilities, both fixed and mobile units, have been developed as a result of changes in healthcare provision (Issenberg 2002). Most developed countries now follow a system of short inpatient admissions with shift-working and changing roles and skills within the healthcare team. Patients are therefore more reliant on robust chains of communication for their quality of care (Scherpbier et al 1997). This has affected both the quantity and quality of students’ clinical experience (Thistlewaite & Jordan 1999).