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Purpose During COVID-19, Maudsley Simulation successfully pivoted to fully online delivery of simulation-based education (SBE) in mental health. In migrating digitally, the simulation faculty experienced a range of new phenomena and challenges. The authors’ experiences may be transferable to other specialities and for other educator groups. By sharing the authors’ experiences, this study aims to support others adapt to online SBE. Design/methodology/approach This piece represents the authors’ collective reflections on the challenges of adapting their facilitation skills to the online environment. It also offers various suggestions on how to improve the learner experience in view of these challenges. Findings Beyond merely platform orientation and operating procedure familiarisation, the team gained insights into ensuring optimal learning, engagement and participant experience during online deliveries. Delivery of online SBE brings several potential barriers to psychological safety and these warrant careful consideration by experienced simulationists. Practical implications Optimising participant engagement and psychological safety remain key considerations despite this novel medium. Facilitators must be willing to adapt accordingly to begin delivering high-quality online SBE. Originality/value From their experience, facilitators must reframe their debriefing expectations and adjust how they engage participants and manage group dynamics given the inherently different nature of this new learning environment.

Purpose Individuals health with intellectual disabilities (ID) experience comorbid physical and mental health needs and have poorer outcomes resulting in early mortality. Currently, many training provisions based on ID exist; however, limited research supports their effectiveness. High-fidelity simulation is an innovative training mechanism with promising preliminary results. This study aims to evaluate the longitudinal impact of simulation training on clinical practice in ID. Design/methodology/approach A mixed-method approach was used in this study. A one-day simulation course using actors who had ID was delivered to 39 health-care professionals from across London hospitals. Nine semi-structured interviews were conducted 12–18 months post training. Findings High-fidelity simulation training is an effective training modality, which has a sustainable impact on participants, their clinical practice and patients. Core features of the training including debriefing, the use and type of actors, scenario design and the facilitators are crucial learning mechanisms which impacts learning outcomes and changes to behaviour in clinical practice and settings. Originality/value To the best of the authors’ knowledge, this study is the first to longitudinally evaluate high-fidelity simulation training designed to improve the physical and mental health needs of those with ID. The research begins to bridge an important gap in the current literature, with a need for more research.

Context Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development. Objectives The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors. Methods For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models. Results From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I2 = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I2 = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I2 = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I2 = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I2 = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I2 = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I2 = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I2 = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up. Conclusions Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.

Aims Mental disorders constitute one of the main causes of disease and disability worldwide. While nurses are often at the frontline of mental health care, they have limited access to dedicated psychiatric training opportunities. Simulation training may foster the development of the appropriate competencies required when supporting people with mental disorders. To evaluate the effectiveness of simulation training in psychiatry for nursing students, nurses and nurse practitioners. Design Systematic review and meta-analysis. Data sources Eight electronic databases, trial registries, key journals and reference lists of selected studies were searched from inception to August 20, 2020 without language restriction. Review methods We included randomized and non-randomized controlled studies and single group pre/post studies. Cochrane Risk of Bias tool 2.0 was used for randomized controlled study appraisal, and the Medical Education Research Study Quality instrument was completed for all other studies. Meta-analysis was restricted to randomized controlled studies. The other studies were synthesized narratively. The main outcomes were based on Kirkpatrick levels. Results A total of 118 studies (6738 participants) were found. Interventions included simulated patients (n = 55), role-plays (n = 40), virtual reality (n = 12), manikins (n = 9) and voice simulations (n = 9). Meta-analyses based on 11 randomized controlled studies found a significant large effect size on skills at immediate post-test for simulation compared with active control; and a small and medium effect size on learners' attitudes for simulation compared with inactive control, at immediate post-test and at three-month follow-up respectively. Three quarters of non-randomized controlled studies and pre/post-tests assessing attitudes and skills showed significant differences, and three quarters of participants in randomized controlled studies and pre/post-tests showed significant differences in behaviours. Among the few studies assessing people with mental health outcomes, almost all reported significant differences. Conclusion These findings support the effectiveness of simulation training in psychiatric nursing throughout professional development grades, despite heterogeneity in methods and simulation interventions.

Background To ensure Maudsley Simulation can continue to deliver simulation-based education (SBE) despite COVID-19, digital simulation was piloted. This decision represented pragmatism and innovation. The process from initial design and in-house testing to piloting remote deliveries led to learning for faculty and technicians across several domains. This experience will be useful for other faculties planning to develop digital simulation capability. Summary of Work An existing full-day course for psychiatric trainees was adapted and piloted online over a half-day. Testing was across two video-conferencing (VC) platforms, Kaltura and Zoom. Actors and participants were remote and relied on in-built laptop webcams and microphones. Faculty and technicians were mostly based at the centre. In-house testing and three half-day pilots were conducted. Implementation data were gathered across multiple newly identified domains incl.: pre-course issues, session launch and structure, engagement, transitions, audio-visual (AV) issues, connectivity, role assignment, actor management, platform-specific issues, optimal default platform settings, platform needs requests and course evaluation. Summary of Results The project encompassed assessing the scope of learning objectives and engagement, a technology-neutral requirements analysis, identification of suitable VC platforms, platform testing, drafting of implementation guidelines and process mapping. These elements were incorporated into piloting cycles. Each piloting cycle was linked to an implementation and troubleshooting log to capture issues, fixes and actions. Throughout, qualitative feedback and observations on technical aspects were sought from faculty, technicians, actors and participants. All feedback fed into the piloting cycle. As the phases progressed, the log expanded to categorise issues thematically. Analysis of qualitative feedback and observations informed the learning design of each pilot phase. Discussion Remote delivery introduces additional variables and layers of technical complexity (e.g., AV quality, device suitability, connectivity). Locating technical issues within a group in real-time presented significant challenges for technicians and facilitators alike. To mitigate this, front-loading responsibility by specifying technical requirements in invite emails, the use of induction video content and pre-course orientation and testing was helpful. Operationally-speaking, clearly delineating the technician role toward assertive issue management and moderator chat supervision supported the team to limit disruptions. Conclusion From our testing, Zoom offered greater stability and functionality with platform stability and concurrency agreed upon as the foremost considerations. The process identified new faculty development needs regarding online facilitation. In the context of COVID-19, digital simulation represents a potentially valuable modality via which to deliver remote SBE. There are additional benefits in terms of scalability and accessibility. Classification Educational innovation.

Background Transitioning to digital simulation presents facilitators with several challenges beyond platform orientation and operating procedure familiarisation. Summary of Work An existing full-day simulation course for psychiatric trainees was adapted for online delivery over a half-day. In-house testing and a piloting phase (three half-day pilots) were conducted. Testing was across two video-conferencing platforms, Kaltura and Zoom. Faculty experience levels ranged from novice to highly experienced (i.e., several years’ experience). Two facilitators ran each session. Sessions were passively observed by other faculty members. Following each session, observations and reflections were logged and organised thematically. Summary of Results In comparisons with non-digital simulation, several themes consistently emerged: a distinctly higher cognitive load, the overall challenge of engaging a group through a more constrained medium, associated relative constraints in transitioning to break-out teaching sessions, technical issues as highly distracting and, finally, potential barriers to psychological safety (incl. challenges in rapport building, limitations in inter-participant engagement, platform-related barriers to fluency in debriefing). Discussion Faculty described experiencing a higher cognitive load and a ‘live TV effect’ i.e., an experience of intense focus on the facilitator. Aside from relatively recent orientation to the platform, this was attributed to the diminished ease with which participants can communicate casually with each other, the consequent need for more active chairing and the requirement to monitor several modalities to ensure smooth running of proceedings (e.g., audio and visual input and output, moderator chat and ‘off-stage’ faculty stage management instructions and updates). This higher cognitive load was described as fatiguing over a half-day session however, faculty were confident this could decrease with more familiarity with the platform. There were similar reflections regarding participants and their likely issues in focusing for extended periods online.1 It was agreed this may potentially render a ceiling on session duration. This was factored into future scheduling of sessions. Conclusion Platform instability (e.g., audio-visual lag, connection disruption) was described as a stressor for facilitators and felt to undermine fluency and potentially psychological safety. Ensuring clear delineation of technician and faculty roles in relation to platform orientation and assertive management of technical issues helped decrease faculty cognitive load and supported the achievement and maintenance of psychological safety. Breakout rooms and novel ice-breaker techniques are to be considered to encourage early inter-participant engagement. Owing to the additional demands of facilitating digital simulation, there may be a faculty development need for media-style training. References Wiederhold BK. Connecting through technology during the coronavirus disease 2019 pandemic: avoiding ‘zoom fatigue’. Cyberpsychology, Behavior, and Social Networking 2020;23(7). DOI: 10.1089/cyber.2020.29188.bkw.

Background COVID-19 placed limitations on in-person training and heralded mass adoption of remote consultations. Ostensibly, digital simulation can emulate remote consultations. However, in simulating in-person interactions, course designers, technicians and actors are presented with several challenges and the patent risk of sacrificing psychological and physical fidelity. Summary of Work Maudsley Simulation employ actors trained in mental health role play to deliver high-fidelity simulation in a smots-equipped centre. An existing full-day course for psychiatric trainees was adapted and piloted online by staff working partially remotely over a half-day. In-house testing and three half-day pilots were conducted. Through consultation with faculty, technicians and actors, existing scenarios were adapted where possible. Actors were based remotely and relied on in-built laptop webcams and microphones. Summary of Results Two categories of adaptable scenarios emerged: suitability as remote consultation and potential as digital analogue i.e., context unchanged. Scenarios deemed unsuitable for adaptation were replaced with pre-recorded video scenarios continuous in narrative with the chosen live simulation. Scenario settings were a home (remote consultation) and inpatient mental health unit (digital analogue). The use of a plant was adapted through a simulated phone call. Short video clips were produced to contextualise and close scenarios. Participant and actor feedback were collected to refine technical and operational procedures. Discussion Actors assumed full responsibility for mise-en-scene (incl. lighting, decor, props, costume). This increased their burden in the context of the already heightened remote working-related operational challenges. Additionally, the conventional use of plants (typically played by faculty) was limited. Actors’ use of their own equipment created variation in audio-visual quality, in some cases limited quality and, in all cases, limited scope for movement. Movement limitations challenged actors to explore new ways of transgressing personal boundaries and eliciting feelings of threat, for example. Other fidelity-related factors included: webcam-related gaze perception issues associated with empathy and non-verbal communication constraints.1 Network and platform stability and individual technical issues were barriers to achieving higher fidelity levels. These were improved by troubleshooting and revising operational procedures. Providing actors with external webcams and microphones is worth consideration. Conclusion Qualitative feedback suggests digital simulation affords active participants and observers with a highly immersive experience. Additionally, it is capable of high-fidelity for remote mental health consultations which have become increasingly common. Achieving fidelity levels comparative with in-person simulation presents inherent challenges. However, digital simulation represents a viable adjunct or alternative for mental health training. Reference Grondin F, Lomanowska AM, Jackson PL. Empathy in computer-mediated interactions: a conceptual framework for research and clinical practice. Clinical Psychology: Science and Practice. 2019 Dec;26(4):e12298.

Background and aims Those with ID are at increased risk of comorbidity with physical and mental illness and often experience difficulty accessing physical and mental health services. Lack of knowledge attributed to lack of training for healthcare professionals negatively impact attitudes towards ID and inequalities in treatment. High-fidelity, interprofessional simulation training focusing on mental health and its interface with other disciplines has been emerging recently as a powerful educational tool as it improves clinical skills, competencies, confidence and decision-making skills. The evaluation of most training programmes is inadequate. This failure has substantial yearly financial implications considering the health sector spends approximately £5 billion on training and development. The need for robust longitudinal evidence to support the effectiveness and usefulness of simulation training interventions is imperative. Furthermore, identifying key components of simulation training which aids learning and developing an understanding on how the training impacts has on a person’s behaviour in the workplace is an important evaluation process. Methods A one-day immersive simulation training was co-produced and developed between Maudsley simulation, ESTIA centre and an acting company where actors have ID. This course was a rare example of co-production being used in simulation training for people with ID. In total, 39 participants from a range of healthcare professional backgrounds were involved in training. Pre and post course questionnaires using the Human Factors Skills for Healthcare (HFSH) instrument were collected and 9 interviews were conducted 12–18 months after participating in training. Results Thematic analysis highlighted four major themes: communication, patient-centred care, reflection, and multidisciplinary team (MDT) working. Findings suggest core features of simulation training such as debriefing, the use of actors with ID, scenario design, and the facilitators impact participants learning. Significant changes occurred post training including an increase of: the use of reasonable adjustments, consideration of patents preferences, support network engagement, and awareness of patients journey through the healthcare system. Results also highlighted better communication with patients as well as communication between MDT. Lastly, findings suggest the reflective nature of simulation training increases confidence levels and competencies. Conclusion The co-production and delivery of the training of those with ID and experts is a unique training modality which has a powerful and important impact on learner’s experience and memory. The current research contributes to the growing literature around the effectiveness of simulation training on ID however future research, is needed on a larger scale to support the current findings.

Purpose The purpose of this paper is to discuss the role of education and training in addressing health inequalities in intellectual disabilities, before examining innovative approaches to healthcare education. Preliminary findings of a simulation training course to support healthcare professionals to work with people with intellectual disability are then presented. Design/methodology/approach This study employed a mixed methods design to assess the impact of the simulation course. Quantitative data were collected using the Healthcare Skills Questionnaire and a self-report confidence measure; qualitative data were collected using post-course survey with free text responses to open questions. Findings Healthcare skills and confidence showed statistical improvements from pre- to post-course. Qualitative analyses demonstrated that participants perceived improvements to: attitudes, communication skills, reasonable adjustments, interprofessional and multi-disciplinary working, knowledge of key issues in working with people with intellectual disabilities. Practical implications Encouraging findings imply that simulation training to address health inequalities in intellectual disabilities is a valuable resource that merits further development. This training should be rolled out more widely, along with ongoing longitudinal evaluation via robust methods to gauge the impact on participants, their workplaces, and people with intellectual disabilities. Originality/value The authors believe this paper to be the first to assess an interprofessional, high-fidelity simulation course, using actors as simulated patients to address the mental and physical health needs of people with intellectual disabilities. The rigorous use of co-production and co-delivery, alongside promising findings for this training method, represent a useful contribution to the literature.

Background Patients with Learning Disabilities (LD) often present with comorbidities, have an increased risk of mental health disorders (Smiley, 2005). It is largely evidenced they receive substandard care (CIPLOD 2013, Dinsmore and Higgins, 2011). This patient group requires interprofessional, multi-disciplinary care, and professionals with specific relevant training (Dinsmore and Higgins, 2011). Simulated patients with LD are very rarely used in healthcare education, with only a few notable exceptions (O’Boyle-Duggan et al , 2012, Thaker et al , 2007, Soni et al , 2016), despite recognition of the specific advantages to involve patients with LD in medical and other professional training (Thomas et al , 2014). Method Maudsley Simulation and the Estia Centre have developed an interprofessional simulation training course involving simulated patients with LD, with a strong mental health focus. Actors involved in scenarios belong to a theatre company formed by people with LD. This incidentally provides an opportunity to engage in meaningful and valued social interactions alongside people with LD. Pre and post-course quantitative measures and a post-course evaluation form with open questions were collected to assess the impact of the training on the participants. Findings At the time of writing preliminary findings are available for the first two course pilots. Further data collection and analyses to be completed and presented at ASPiH 2016. A multi professional group attended the simulation training. Our questionnaire was designed to assess health care non-technical skills. The data analysis of the first pilots showed an increase of the mean rating from 7.06 (SD 1.32) to 7.83 (SD 1.32). The average rating of confidence in working with people with LD increased in from 5.375 to 7.25. The qualitative data highlighted that both technical and non-technical learning objectives were largely met for the participants. References Dinsmore A, Higgins L. Study of patients9 experiences of treatment by hospital staff. Learn Disabil Pract . 2011; 14 (5):18–22. HQIP (2015) Confidential enquiry in to deaths of people with learning disabilities CIPOLD 2013 [online]. Available from: http://www.hqip.org.uk/public/cms/253/625/19/438/Confidential Inquiry into premature deaths of people with learning disabilities CIPOLD full final report 2013.pdf?realName. O9Boyle-Duggan M, Grech JD, Brandt R. Effectiveness of live simulation of patients with intellectual disabilities. J Nurs Educ . 2012; 51 (6):334–342. Smiley E. Epidemiology of mental health problems in adults with learning disability: an update. Adv Psychiatr Treat . 2005; 11 (3):214–222. Soni S, Hall I, Doulton P, Bowie P. Involving people with intellectual disabilities in the formal assessment of psychiatrists9 skills. Eur Psychiatry . 2016; 33 (suppl S16). Thacker A, Crabb N, Perez W, Raji O, Hollins S. How (and why) to employ simulated patients with intellectual disabilities. Clin Teacher . 2007; 4 (1):15–20. Thomas B, Courtenay K, Hassiotis A, Strydom A, Rantell K. Standardised patients with intellectual disabilities in training tomorrow9s doctors. Psychiatr Bull . 2014; 38 (3):132–136.