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It is ethically impermissible for medical students to perform invasive procedures on patients before being competent to do so safely [1,2]. Simulation offers obvious benefits, yet established simulation approaches can over-focus on technical tasks and overlook the need for simultaneous communication with patients and colleagues. Transdisciplinary Simulation (TS) addresses these issues by creating a safe, ‘low stakes’ learning environment based on an apparently unrelated field which in fact offers close parallels with medicine, in this case the kitchen. Expert chefs, like clinicians, must be skilled in preparing and organising their workplace (mise-en-place) [3], constantly attending to hygiene, precision, dexterity, and communication with colleagues and diners. The Medical Kitchen is an affordable and scalable instance of TS, developed to help second year medical students acquire psychomotor clinical skills while simultaneously communicating with a patient or colleague. The Medical Kitchen comprises self-guided learning of two new clinically-relevant skills followed by peer assessments; a subsequent whole class synchronous debrief; and individual guided reflections. Our team (clinical educators and a professional chef) selected ‘turning’ vegetables as a core skill, teaching students to shape courgettes or potatoes into regular and consistent shapes using a suitable knife. This requires dexterity and control, gained through repeated practice, and presents similarities with clinical skills. The knowledge gained from turning vegetables is then applied to the clinical skill of suturing while talking to a colleague, highlighting the need to integrate physical skills with sensitive communication. The Medical Kitchen programme has been delivered to over 700 second-year undergraduate medical students at Imperial College London over the course of two years. It is versatile and adaptable, having been delivered in both online and live session formats in response to the COVID-19 pandemic. Student feedback through guided reflections on perceived value has been overwhelmingly positive (though it is too early to establish the long-term effect on students’ clinical skills). The Medical Kitchen offers an innovative approach to clinical skills acquisition, using the world of professional gastronomy to simulate the clinical environment. It is an affordable and scalable programme grounded in theories of psychomotor skills development and has the potential for widespread implementation. As an example of transdisciplinary simulation, it raises wider possibilities for simulation design and innovation within clinical education. 1. Reznick RK, MacRae H. Teaching surgical skills – changes in the wind. New England Journal of Medicine. 2006;355(25):2664–2669. 2. Sadideen H, Kneebone R. Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning?. The American Journal of Surgery. 2012;204(3):396–401. 3. Schlegel C, Flower K, Youssef J, Käser B, Kneebone R. Mise-en-place: Learning across disciplines. International Journal of Gastronomy and Food Science. 2019. 16:100147

Leading historians, anthropologists, educators and designers explore the role of materiality in medical education. With a broad focus, international scope and experimental format, this is the first book to seriously reflect on the material relationship between the medical school and reproduction of medical knowledge.

The COVID-19 pandemic has prompted the cancellation of clinical attachments and face-to-face teaching at medical schools across the world. Experiential learning—through simulation or direct patient contact—is essential for the development of clinical skills and procedural knowledge. Adapting this type of teaching for remote delivery is a major challenge for undergraduate medical education. It is also an opportunity for innovation in technology enhanced learning and prompts educators to embrace new ways of thinking. In this article, the authors explored how educators from different disciplines (medicine, music and performing arts) are using technology to enhance practical skills-based learning remotely. The authors, five experienced educators from different fields (surgery, medicine, music and magic), jointly documented the transition to technology enhanced remote teaching through a series of five structured conversations. Drawing from literature on distance learning in medicine and professional experience in education, the authors identified seven practice-enhancing recommendations for optimising teaching of procedural knowledge and skills. These are: (1) make a virtue out of necessity; (2) actively manage your environment; (3) make expectations clear; (4) embrace purposeful communication; (5) use digital resources; (6) be prepared for things to go wrong and (7) personalise the approach. The authors argue that widening the discourse in technology enhanced learning to include cross-disciplinary perspectives adds richness and depth to discussions. This article demonstrates a cross-disciplinary approach to addressing challenges in technology-enhanced medical education. This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

This commentary responds to the Covid-19 pandemic which poses a serious challenge for the delivery of “wet laboratory” practical education. We discuss the “Chemical Kitchen” project, which teaches laboratory skills and the scientific method through the parallel discipline of gastronomy and its transformation into a home-based program: how it came to be, its successes to date, and our plans to deploy it for remote delivery in the uncertain future.

Objective: This national cross-sectional study aims to establish the prevalence and potential impact of performance anxiety among surgeons and investigate its association with psychological traits and wellbeing. Summary and Background Data: Despite a growing awareness that human factors, non-technical skills and wellbeing in healthcare affect patient outcomes, an area that has remained unexplored is surgical performance anxiety (SPA). Methods: A prospectively registered, cross-sectional study using mixed methods was conducted across the United Kingdom. Data captured included demographics, surgical specialty, trait anxiety, trait perfectionism, SPA, and surgical perfectionism scores. Wellbeing was assessed using The Short Warwick-Edinburgh Mental Wellbeing Scale, whereas qualitative data were collected regarding surgeons’ experiences of SPA. Results: A total of 631 responses were collected. Mean age was 41·2 years and mean surgical experience 15·3 years. A total of 62% were male and 52% of consultant/attending grade. A total of 100% felt that SPA affected surgeons, with 87% having experienced it themselves. A total of 65% reported SPA negatively impacted surgical performance and 96% felt SPA negatively impacted surgeons’ wellbeing. Male surgeons reported significantly better wellbeing than female surgeons. Surgeons with SPA reported significantly worse wellbeing compared with surgeons who did not experience SPA. Surgeons in general experienced significantly lower mental wellbeing compared with population norms. Thematic analysis highlighted a reticence to share SPA openly and need for cultural change. Conclusions: Surgical performance anxiety is a very common and significant challenge among surgeons across all specialties at all levels of experience in the United Kingdom. It is perceived by surgeons to affect surgical performance adversely and is associated with worse psychological wellbeing. A more open culture of sharing and acknowledgment has been identified to be beneficial.

Background:\ud The patient experience is associated with patient satisfaction and health outcomes, presenting a key challenge in healthcare. The objective of the study was to explore the principles of care in and beyond healthcare, namely in a three Michelin-starred restaurant, and consider what, if any, principles of care from the diners’ experience could be transferrable to healthcare. \ud \ud Methods:\ud The principles of care were first explored as part of observational fieldwork in a healthcare day surgery unit and restaurant respectively, focusing on communication between the professionals and the patients or the diners. Care was subsequently explored in a series of public engagement events across the UK. The events used immersive simulation to recreate the healthcare and the dining experiences for the general public, and to stimulate discussion.\ud \ud Results:\ud A thematic analysis of the engagement discussions identified overarching themes in how care was experienced in and through communication; “informed, not bombarded”, “conversation, not interrogation”, “environment is communication”, and “being met as a person”. The themes suggested how the participants in simulation felt about the care they received in real time and provided recommendations for improved clinical practice.\ud \ud Conclusions:\ud While practice improvements in healthcare are challenging, the patient experience could be enhanced by learning relational aspects of care from other sectors, including the high-end restaurant industry that focuses on meeting persons’ needs. Simulation provides a new kind of opportunity to bring professionals and patients together for focused discussions, prompted by immersive experiences of care and communication.

Better understanding of palpation techniques during unsighted physical examinations has mostly been limited to qualitative and quantitative studies of performance of experts whilst conducting examinations on plastic benchtop models. However, little is known about their performance when conducting such examinations on real subjects. Objective : The aim of this paper is to better understand palpation techniques of experts whilst conducting a Digital Rectal Examination on a real subject. Methods : We recruited four consultants from relevant specialties and asked them to conduct two DREs on a Rectal Teaching Assistant whilst wearing small position and pressure sensors on their examining finger. We segmented the relevant anatomy from an MRI taken of the pelvic region, registered 3D models and analysed retrospectively performance in relation to executed tasks, supination/pronation, palpation convex hull and pressure applied. Results : Primary care consultants examined the anatomy more holistically compared to secondary care experts, the maximum pressure applied across experiments is 3.3N, overall the pressure applied on the prostate is higher than that applied to rectal walls, and the urologist participant not only applied the highest pressure but also did so with the highest most prominent frequency (15.4 and 25.3 Hz). Conclusions : The results of our research allow for better understanding of experts’ technical performance from relevant specialities when conducting a DRE, and suggest the range of pressure applied whilst palpating anatomy. Significance : This research will be valuable in improving the design of haptics-based learning tools, as well as in encouraging reflection on palpation styles across different specialities to develop metrics of performance.

Background Asthma is the most common chronic disease of childhood and an important preventable cause of mortality in children and young people (CYP). Few studies have brought together CYP and health professionals to understand the patient perspective of routine asthma care. We sought to explore how young people engage with routine asthma care in North West London through sequential simulation. Method We designed a sequential simulation focusing on routine asthma management in young people aged 12–18. A 20 min simulation was developed with four young people to depict typical interactions with school nurses and primary care services. This was performed to a mixed audience of young people, general practitioners (GPs), paediatricians, school nurses and commissioners. Young people were invited to attend by their GPs and through social media channels. Attendees participated in audio-recorded, facilitated discussions exploring the themes arising from the simulation. Recordings were transcribed and subjected to thematic analysis. Results 37 people attended the sequential simulation. Themes arising from postsimulation discussions included recognition of chaotic family lifestyles as a key barrier to accessing care; the importance of strong communication between multidisciplinary team professionals and recognition of the role school nurses can play in delivering routine asthma care. Conclusion Sequential simulation allows healthcare providers to understand routine asthma care for CYP from the patient perspective. We propose improved integration of school nurses into routine asthma care and regular multidisciplinary team meetings to reduce fragmentation, promote interprofessional education and address the widespread professional complacency towards this lethal condition.

During 2016–2017, National Health Service (NHS) England recorded 5.8 million attendances at accident and emergency departments (A&E) out of which 24% were deemed ‘avoidable’.1 Avoidable attendances are defined as an attendance at A&E resulting in care which could have been provided by a general practitioner (GP) or managed through self-care at home. ‘How to help your unwell child’ was a collaboration between Connecting Care for Children, and Imperial College Centre for Engagement and Simulation Science. The aim of the collaboration was to identify issues related to avoidable attendances at A&E in children under 5 years old in North West London. The overarching objective of the collaboration was to engage with local families to facilitate an understanding of their experiences of looking after unwell children suffering from minor illnesses. A sequential simulation (SqS Simulation) event was organised at a community centre to engage with local families. It was used as a tool to engage healthcare professionals and families in acknowledging parental journeys and to recognise their concerns in seeking healthcare for minor childhood illnesses. SqS Simulation is an innovative technique involving the simulation of key points from patients’ healthcare journeys2–4 that takes a longitudinal view of healthcare scenario design. Various key components in the simulation are designed to meet defined objectives drawing on an empirically and theoretically driven model developed to aid the process. It can be used beyond traditional simulation-based education approaches …

Quality, safety and efficiency are essential to healthcare. They depend on skilful ‘doing’, on expertise in materiality. This paper shows how exploration across disciplinary borders may enrich our understanding of the materiality of clinical practice. We use the term ’materiality' to describe our relationship with the physical world and the substances which constitute every object we encounter.1 Dealing with materiality is part of every healthcare professional’s daily routine. Yet, the role of materiality is often overlooked in the curricula of medicine and science, which focus on factual knowledge and theoretical concepts. In this paper we show how exploration across disciplinary borders can enrich our understanding of this crucial aspect of practice and its role in the acquisition of professional expertise. To explore this concept, the authors convened a symposium entitled ‘The Art of Performing Science: Analogies across Disciplines’ at Imperial College, London in October 2017. Its aim was to create a platform to explore expertise and encourage new approaches to sharing knowledge. More than 60 clinicians, scientists, artists and performers were invited to demonstrate their work to one another, using materials and tools from their workshops or laboratories. This prompted wide-ranging discussion around similarities and differences. Jewellery designers sat with dentists, nurses and molecular biologists with taxidermists, museum curators with synthetic chemists and surgeons with letter-cutters in wood and stone. It became clear, from these and other groups, …

Engagement and simulation science is a rapidly evolving field which is opening new horizons for simulation practice and research. This chapter explores how simulation can mediate between different worlds of experience, creating ‘working models’ of clinical care that can be refined collaboratively. It proposes an alternative view, where simulation becomes a means of inviting non-professionals in rather than keeping them out. Most healthcare simulation is framed as a means of training clinical professionals, whether as students or later in their careers. Emphasis is on learning how to carry out procedures or operations. The concepts of distributed simulation (DS) and sequential simulation (SqS Simulation) open new possibilities. DS allows realistic simulation to be provided in any suitable area (including public spaces), while SqS Simulation recreates pathways of care and invites participants to ‘sketch out’ possible changes through enactment.

Introduction Paediatric emergency department attendances are increasing nationwide, with almost 25% of cases deemed ‘avoidable’.1 Emergent strategies look to ‘nudge’ patients towards appropriate healthcare services. Sequential SimulationTM (SqS) is a novel technique that aims to portray a patient’s ‘journey’ in a compressed live performance involving actors and healthcare professionals. In addition to other applications, SqS can be used to understand patient and carer behaviours; identify areas for improvement within existing pathways; and involve patients in service co-design. Methods An SqS design was formulated after consultation with NHS 111 and two patient groups. Semi-structured interviews were conducted with 20 families at a community centre, and a separate meeting held with a local Somali Women’s Group. Interviews were transcribed and subjected to thematic content analysis. The resulting performance explored the experiences of a new mother in accessing healthcare services in Urgent Care Centre, General Practice (GP) and Community Pharmacy settings. The event took place at a community centre and was attended by 21 local families and 18 health professionals. Layperson participants were separated into three groups with dedicated facilitators who led discussion of three questions posed after the performance: How did the simulation make you feel? How did the simulation make you feel? How did the simulation compare to your own experience? Answers were recorded and facilitators took written field notes during the discussion. All participants were asked to complete an end-of-simulation questionnaire. Results Participants identified three major issues which influenced their decision-making when seeking help for their unwell child – operating hours of GP surgeries, accessing GP appointments in-hours, and language barriers. Participants also reported inconsistent delivery of key information by health professionals, which often led them to seek a second opinion. Suggested solutions included provision of classes for new parents in local community centres; improved access to a named GP to provide continuity of care; and raising awareness of the roles that pharmacists can play in managing minor childhood illnesses. Conclusion SqS is a novel technique which facilitates access to hard-to-reach patient groups, provides rich qualitative data, and enables robust patient engagement. Reference National Audit Office. Reducing emergency admissions 2018. doi: https://www.nao.org.uk/report/reducing-emergency-admissions/

In this editorial, we present a short 5 min documentary-style film to explore how immersive distributed simulation can be used to engage members of the public in the experience of care in order to generate a wider discussion on what care means.\ud \ud Traditionally, and more commonly, simulation in healthcare has been used for training, quality improvement and assessment purposes. Although this is an obvious and effective use of simulation techniques, little thought has been given to how simulation could be used beyond this.1 2 Furthermore, Kneebone3 argues that the current use of simulation has mirrored practice by restricting it to a clinical ‘insider’ frame, excluding patients, families, the public and even managers, commissioners, policymakers and other sectors from its purpose, design and implementation, although these perspectives are an essential component of clinical practice that could enhance current approaches to care. Current utilisation of simulation techniques and approaches often focuses on single elements of healthcare that mirror healthcare practices rather than looking to transform them, and with limited external involvement. However, we believe its application can be much wider than its current scope. By capitalising on simulations' main benefits (the ability to recreate realistic healthcare scenarios in a safe environment), we have been testing’s simulations applicability for a range of objectives.

This exploration examines how clinical simulation, performed in hospitals as a form of training, can be understood as play, involving creating and maintaining fictions, role-playing theatrical characters and erecting satisfying narrative structures. In using play as an analytical concept, the significance of clinical simulation can be understood in terms of learning about the meaning of medical work, rather than developing technical skills only. We draw on observational work of simulation-based education across several London hospitals.

This chapter considers how the landscape of surgical education has changed over the past century and how the educational certainties of an earlier generation have been supplanted by fluidity and instability. After outlining the establishment of open surgery in the first half of the twentieth century, the chapter uses the introduction of minimally invasive (keyhole) surgery in the 1980s as a lens for examining the educational implications of surgical innovation and the processes by which such innovation can trigger educational change. At the same time, the discussion charts the emergence of professionalism of surgical education, shaped by expert perspectives from outside medicine. This has led to a broadening of methodological approaches to the investigation of educational questions and the establishment of surgical education as a scholarly field with its own identity. The chapter concludes by reflecting on the continual process by which innovation becomes established as a ‘new normal’, only to be overtaken in its turn by continuing change.

Artists and performers inform the physical act of experimentation — Roger Kneebone, Claudia Schlegel and Alan Spivey explore. Artists and performers inform the physical act of experimentation — Roger Kneebone, Claudia Schlegel and Alan Spivey explore.

Aim To describe a surgical team simulation proof-of-concept study conducted in the UK and USA that aimed to clarify its applicability and acceptability beyond a UK context. Background Good communication and teamwork in operating rooms (ORs) can be challenging globally, and can negatively impact on patient safety.1 The World Health Organisation’s Surgical Safety Checklist was developed to improve routine surgical issues such as communication. Although effective to an extent, patient safety continues to be compromised around the world.2 Video-based social science methods have studied communication in UK ORs through actual observations of surgical teams in practice.3 Drawing on empirical research undertaken in UK ORs, the authors have designed a surgical team simulation-training model (ViSIOT™)4 that uses authentic video recordings of OR teamwork as debriefing materials. Methods The ViSIOT™ training programme was undertaken at simulation centres in the UK and USA. Surgical team participants (n=37) were required to complete an open and closed questionnaire that assessed design, education, satisfaction and self-confidence in relation to the training and its applicability to their surgical experience. Descriptive and inferential statistics were performed for the quantitative data and thematic analysis was conducted for the qualitative data. Results There was strong favourable agreement of the perception of the course from all UK and USA participants regardless of profession. Qualitative themes identified that both countries shared were: Video; Fidelity; Development; Praise. Themes that were unique to each country were: UK: Missing professionals; Not applicable; and USA: Practice reflection; UK and USA comparisons; Course content. Conclusions Evidence of the trainings applicability in the USA provided further evidence of the global need for team communication training within ORs as well as similarities regardless of country or setting. Practical developments in the course design, technology and recruitment were also identified. Further studies are required to assess its effectiveness in improving communication beyond the training and into practice. References Attri JP, Sandhu GK, Mohan B, Bala N, Sandhu KS, Bansal L. Conflicts in operating room: Focus on causes and resolution. Saudi J Anaesth2015;9(4):457–463. doi:10.4103/1658-354X.159476 Gillespie B, Marshall A. Implementation of safety checklists in surgery: A realist synthesis of evidence. Implementation Science2015;10(1):137. Weldon S-M, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. Journal of Advanced Nursing2015;71(12):2763–74. Available at: http://dx.doi.org/10.1111/jan.12744 Korkiakangas T, Weldon S-M, Bezemer, Kneebone R. Video-supported Simulation for interactions in the operating theatre (ViSIOT). Clinical Simulation in Nursing 2015;11(4):203–7.

Background Simulation in healthcare is mainly associated with clinical training and assessment needs. However, its uses can be much broader than is currently practiced. Recent applications have seen it be used for quality improvement projects, public and patient engagement and outreach, evaluation of new interventions, identification of latent safety threats, and the development of new models of care to name but a few. 1 2 This short communication will present an unorthodox use of simulation that builds on this current trend and reveals its potential as more than just for training and assessment practices. Summary of project This Arts and Humanities Research Council funded project aimed to observe instances of care in both clinical and dining settings through direct observations and field notes. Although these disciplines seem worlds apart at first glance, both require an element of anticipation. Whether it is waiting for premium food or an operation, both require the experience to be as good as the outcome. Collaborations were built between Heston Blumenthal’s three-Michelin star Fat Duck restaurant and a National Health Service (NHS) Trust. The principles of care identified at each site were abstracted and are to be re-presented to members of the public across the country through the medium of simulation. The simulations are designed to be immersive in nature and focus on a restaurant front-of-house and a day surgery unit. Real waiting staff and clinicians will undertake their roles incorporating the identified principles of care. Members of the public will be invited to be a patient and a diner in each simulation before participating in a wider discussion on the experience of care and if there is any transferrable learning between the settings. Summary of results The initial observations revealed similarities in terms of expectation setting, however, differences were noted in terms of the visibility of the patient/diner. The simulation events are set to take place in June 2018 in London, Worcester, and Glasgow. Results from the discussions will be available in time for the conference. Conclusions Simulation as a tool can be used to enable us to think differently about what care is and how we deliver it. This project has presented a unique way of capturing clinical care and working with different yet complimentary domains to present current approaches and generate wider discussions with members of the public. References Weldon S, Kneebone R, Bello F. Collaborative healthcare remodelling through sequential simulation: A patient and front-line staff perspective. BMJ Simulation and Technology Enhanced Learning 2016;2:78–86. doi:10.1136/bmjstel-2016–000113 Kneebone R, Weldon, S-M, Bello F. Engaging patients and clinicians through simulation: Rebalancing the dynamics of care. Advances in Simulation 2016;1(19). doi:10.1186/s41077-016–0019-9

Objective: Motivated by the fact that palpation skills are challenging to learn and teach, particularly during Digital Rectal Examinations (DRE), and the lack of understanding of what constitutes adequate performance, we present a visualization and analysis system that uses small position and pressure sensors located on the examining finger, allowing the quantitative analysis of duration, steps, and pressure applied. Methods: The system is first described, followed by an experimental study of 20 experts from four clinical specialties performing ten DREs each on a benchtop model using the proposed system. Analysis of the constitutive steps was conducted to improve understanding of the examination. A Markov model representing executed tasks and analysis of pressure applied is also introduced. Results: The proposed system successfully allowed the visualization and analysis during the experimental study. General practitioners and nurses were found to execute more tasks compared to urologists and colorectal surgeons. Urologists executed the least number of tasks and were the most consistent group compared to others. Conclusion: The ability to “see through” allowed us to better characterize the performance of experts when conducting a DRE on a benchtop model, comparing the performance of relevant specialties, and studying executed tasks and the pressure applied. The Markov model presented summarizes task execution of experts and could be used to compare the performance of novices against that of experts. Significance: This approach allows for the analysis of performance based on continuous sensor data recording that can be easily extended to real subjects and other types of physical examinations.

Background:\ud A need for improved education and training for hospital staff caring for patients in the last year of life was identified at an urban UK hospital. Sequential Simulation (SqS Simulation™) is a type of simulation that recreates a patient's journey, considering the longitudinal element of care and how this might impact on the patient's experiences, wishes and needs.\ud \ud Objectives:\ud The aim of this study was to investigate a new end of life care training intervention for multi-professional hospital staff, and its effect on their confidence in managing patients at the end of their life.\ud \ud Setting/Participants:\ud Based on the results of a formal Training Needs Analysis, four SqS Simulation™ specialty- based courses were designed for general medical and surgical multidisciplinary teams in an acute UK hospital.\ud \ud Methods:\ud Over three months, seven SqS Simulation™ sessions were attended by fifty-seven multidisciplinary healthcare professionals. A quasi-experimental mixed-methods study was conducted using open and closed-ended questionnaires, pre and post-intervention. Changes in course attendees' confidence levels were analysed and qualitative data from free-text answers informed potential reasons for any differences identified.\ud \ud Results:\ud Confidence improved for all professional cohorts (p

Medicine is increasingly taught in immersive simulated environments, to supplement the apprenticeship model of work-based learning. Clinical research on this educational practice focuses on its realism, defined as a property of simulation technology. We treat realism as a function of subjective but collectively organised perception and imbued with fantasy, which we define by drawing on Lacanian studies of virtual reality and workplace organisation. Data from an observational study of four simulation centres in London teaching hospitals is drawn on to present an account of what was taught and learned about medicine, including medical failure, when medical practice was simulated.

Summary Context Several recent papers have highlighted the need for better integrated care to improve health care for children and families. Our team spent a year exploring the potential of ‘Sequential Simulation’ (SqS) as a teaching tool to address this need with young people and multidisciplinary teams. SqS allows the simulation of a series of key events or ‘crunch points’ that come together to represent the patient journey, and highlights the impact of individuals on this journey. The pilot SqS was based on an adolescent with asthma – a common condition that requires excellent multidisciplinary care with the patient at the centre. Innovation The SqS was designed using transportable sets and audio-visual equipment to create realism. Actors were employed to play the roles of the young person and mother and health professionals played themselves. The SqS was run at different events with varied audiences, including young people, health professionals and teachers. It was used to explore the difficulties that can arise during a patient journey, the importance of communication throughout, and to highlight the significance of each individual in the patient experience. Results The SqS was met with enthusiasm and felt to be an innovative and effective way of promoting better teamwork and communication. It was well received at a school asthma education event for pupils and community teams, demonstrating its varied potential. The year was the first step in the introduction of this exciting new concept that has the potential to help promote better integrated care for paediatric patients and their families. Our team spent a year exploring the potential of ‘Sequential Simulation’ as a teaching tool [to provide better integrated care]

Background. Fidelity - an intrinsic property of simulation is crucial to simulation design and to educational effectiveness. Yet the term fidelity is inconsistently used, which makes it difficult to draw inferences from current literature and translate research into practice. Aim. In this article, we attempt to bring some clarity to the term simulation fidelity in healthcare education. Method. We are opposed to the notion that high-fidelity simulation requires complete and faithful replication of reality, and instead argue for an accurate representation of real-world cues and stimuli. We address a number of issues surrounding the term fidelity and how it is currently used in the literature. Result. In recognising the limitations of current methods of describing fidelity in the literature, we propose an alternative 3-dimensional framework for fidelity along the axes of the patient, clinical scenario, and healthcare facilities as a means for more precise and practical positioning of current healthcare simulation activities. Conclusion. All aspects of fidelity significantly hinge on the learners’ perceived realism of the context of the learning episode as opposed to any one particular element such as the technology used.

BackgroundA new challenge for healthcare managers is to improve the patient experience. Simulation is often used for clinical assessment and rarely for those operating outside of direct clinical care. Sequential simulation (SqS) is a form of simulation that re-creates care pathways, widening its potential use.Local problemNumbers, outcome measures and system profiling are used to inform healthcare decisions. However, none of these captures the personal subtleties of a patient’s experience.Intervention56 students attended a teaching module using SqS and facilitated workshops as part of their induction week on an MSc International Health Management course. The workshop was voluntary and was offered as an opportunity for the students to gain an insight into the UK health system through the medium of simulation.MethodsAn evaluation survey incorporating quantitative and qualitative student feedback was conducted. Descriptive statistics were generated from the quantitative data, and thematic analysis was undertaken for the qualitative data.ResultsThere was strong agreement for the acceptability of the workshop approach in relation to the aims and objectives. Likert scale (1–-5) mean total=4.49. Participants responded enthusiastically (revealed through the qualitative data) with ideas related to perspectives sharing, understanding healthcare management and processes and the consideration of feasibility and practicalities. They also suggested other applications that SqS could be used for.ConclusionThe SqS approach has demonstrated that simulation has a wider potential than for clinical assessment alone. Further studies are required to determine its potential uses and affordances beyond its current format.

Medical simulation has historically been studied in terms of the delivery of learning outcomes or the social construction of knowledge. Consequently, simulation-based medical education has been researched primarily in terms of the transfer of skills or the reproduction of professional communities of practice. We make a case for studying simulation-based medical education as a cultural practice, situating it within a history of gaming and simulation, and which, by virtue of distinctive aesthetics, does not simply teach skills or reproduce professional practices but rather transforms how medicine can be made sense of. Three concepts from the field of game studies—play, narrative, and simulation—are deployed to interpret an ethnographic study of hospital-based simulation centers and describe underreported phenomena, including the cooperative work involved in maintaining a fictional world, the narrative conventions by which medical intervention are portrayed, and the political consequences of simulating the division of labor.

Background/Context/Aims Sequential Simulation (SqS) is the physical re-enactment of longitudinal elements of care, rather than single episodes, as is currently the main format of most healthcare simulations. It takes a patient9s perspective of their care pathway journey through the system rather than the healthcare professionals perspectives alone. It has been used for a variety of applications including training multi-disciplinary teams on end-of-life care, initiating integrated care, quality improvement projects, designing new models of care, evaluating new interventions, and improving care of the deteriorating patient, to name but a few. 1,2 Its applications are wide, and therefore the design process can be complex. This workshop draws on an empirically and theoretically driven model, to guide participants in designing Sequential Simulations for a variety of clinical objectives. Learning Objectives and Session Description Learners will be split into small groups and asked to design a Sequential Simulation for a selected care pathway, using the described model. However, each group will be given a different objective for its use which will form the main basis of their design considerations. The small groups will present their design considerations to each other at the end of the session to reveal the different affordances each objective required. The learning objectives will aim to reveal the importance of objectives during the design process as well as the different considerations needed to achieve a successful Sequential Simulation. This student-centred approach aims to provide the workshop attendees with a new tool and a practical approach to designing this new concept in simulation. Target Audiences Maximum number of participants Simulation educators, healthcare professionals, technical personnel. Maximum of 30 participants. References . Weldon S-M, Kneebone R, Bello F. Collaborative healthcare remodelling through Sequential Simulation (SqS): A patient and front-line staff perspective. BMJ Stel 2016;0:1–9. doi:10.1136/bmjstel-2016-000113 . Weldon S-M, Ralhan S, Paice E, Kneebone R, Bello F. Sequential simulation of a patient pathway. The clinical teacher 2016. doi:10.1111/tct.12549

Background/Context/Aims Sequential Simulation, 1 a longitudinal form of simulation, was identified as an effective training approach for multi-disciplinary teams in identifying and caring for patients in their last year of life in a hospital setting. Sequential Simulation is a physical simulation of a pathway of care rather than isolated components of the trajectory. End-of-life care for patients in hospital has been reported as inadequate in the UK. 2 The need for this training was identified through the literature and an in-house training needs analysis in conjunction with patients and their families. Methodology /Education Programme or Project Description The Sequential Simulation was designed based on the outcomes of the Training Needs Analysis and in conjunction with clinical staff. The pathway was separated into segments of time (day two and day six), following a patient (speciality specific scenario) over a six-day period (from admission). Seven Sequential Simulations training sessions were conducted over a three-month period. A mixed-methods study was conducted through pre and post questionnaires and video-recordings of the simulation and subsequent debrief. Confidence levels were measured to assess any changes pre and post training programme and open-ended questions allowed for further exploration of the results. Evaluation of the training was also conducted. Results/Outcomes 14 multi-disciplinary teams consisting of 57 participants in total attended the training: Doctors 45% (Consultants 26%, registrars 19%), nurses 30% and therapists 25%. Preliminary results revealed that confidence levels were improved across all professional cohorts. 89% of participants felt the course met their expectations. 87% would consider recommending the course to colleagues and 80% felt that the course had an impact on their approach to end of life care. Conclusions and Recommendations Sequential Simulation is a unique approach to end of life care training that takes into account the longitudinal element of a patient‘s end of life journey. Post-training revealed an increase in healthcare professional’s confidence in end of life care. The healthcare professional’s evaluation of the course was highly positive. Further studies to assess if this innovative form of end of life simulation training has an effect on actual clinical care are needed. References . Weldon S-M, Ralhan S, Paice E, Kneebone R, Bello F. Sequential simulation of a patient pathway. The Clinical Teacher 2016. doi:10.1111/tct.12549 . Office for National Statistics. National Survey of Bereaved People (VOICES) 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/nationalsurveyofbereavedpeoplevoices/england2015

Background A recent CQC inspection identified disparities in care quality across maternity services in several London 1 districts, revealing a need to identify challenges and solutions and to share learning across sites. Sequential Simulation 2 (SqS) uses physical simulation to portray selected snapshots from a pathway of care, for pedagogical and engagement activities. In representing the lived experience of service users, SqS provides a platform for facilitated discussion among a diverse range of multidisciplinary participants. SqS workshops at six maternity sites in London aimed to explore service delivery challenges with front-line staff, in order to identify possible solutions, establish whether findings could inform learning outcomes for an educational intervention, and identify unanticipated outcomes of facilitated discussions. Project Description A collaboratively designed SqS workshop was delivered at each site between January and April 2017. One pilot event was undertaken with service users (November 2016), to incorporate their perspectives into the SqS design. Each comprised a forty-minute simulation of an antenatal pathway, followed by a sixty-minute facilitated discussion amongst the audience participants. Quantitative and qualitative data were collected through post-workshop questionnaires and video-recordings of simulations and the subsequent discussions. Data analysis is ongoing and will be completed in June 2017. Thematic analysis will be undertaken of the facilitated discussion data. Descriptive statistics will be used to analyse the Likert scale questionnaire data. Results The workshops were attended by 94 participants in total, including 49 midwives (52%), 24 doctors (26%), 7 sonographers (7%), 1 Doula (1%), 1 GP (1%), 1 Service User (1%), 1 Actor (1%), 10 Unknown discipline (11%). 93 questionnaires were completed (99% response rate). Preliminary questionnaire results indicate high levels of participant satisfaction with workshops. Early anecdotal evidence reveals several themes emerging from discussions, including: continuity of health care professional; consistency of advice; information needs; challenges in care delivery; and resource constraints. Some themes were common across sites and some unique to certain sites. Formal results will be included in the oral presentation. Conclusions Engagement with frontline staff at SqS workshops provided insights into challenges, solutions and potential educational objectives for maternity services in NWL. This information will be valuable in several ways: supporting work of stakeholders such as HEE developing educational strategies for improved quality of care; supporting Trust clinical and education leads seeking buy-in for service reconfiguration and education initiatives; adding to the body of research regarding approaches which support engagement with front-line staff in challenging areas of service delivery. References . Care Quality Commission. North West London hospitals NHS trust quality report 2014. Accessed on 3rd October, 2015 at: http://www.cqc.org.uk/sites/default/files/new_reports/AAAA1830.pdf . Weldon S-M, Kneebone R, Bello F. Collaborative healthcare remodelling through sequential simulation: A patient and front-line staff perspective. BMJ Simulation and Technology Enhanced Learning 2016;2:78–86.

BACKGROUND: The aim of the study was to gain insight in the involvement of non-operating surgeons in intraoperative surgical decision making at a teaching hospital. The decision to proceed to clip and cut the cystic duct during laparoscopic cholecystectomy was investigated through direct observation of team work. METHOD: Eleven laparoscopic cholecystectomies performed by consultant surgeons and specialty trainees at a London teaching hospital were audio and video recorded. Talk among the surgical team was transcribed and subjected to linguistic analysis, in conjunction with observational analysis of the video material, sequentially marking the unfolding operation. RESULTS: Two components of decision making were identified, participation and rationalization. Participation refers to the degree to which agreement was sought within the surgical team prior to clipping the cystic duct. Rationalization refers to the degree to which the evidential grounds for clipping and cutting were verbalized. CONCLUSION: The decision to clip and cut the cystic duct was jointly made by members of the surgical team, rather than a solitary surgeon in the majority of cases, involving verbal explication of clinical reasoning and verbal agreement. The extent of joint decision making appears to have been mitigated by two factors: trainee's level of training and duration of the case.

The concept of surgical expertise and the processes involved in its development are topical, and there is a constant drive to identify reliable measures of expert performance in surgery. This review explores the notion of whether surgical experts are “born” or “made”, with reference to educational theory and pertinent literature. Peer-reviewed publications, books, and online resources on surgical education, expertise and training were reviewed. Important themes and aspects of expertise acquisition were identified in order to better understand the concept of a surgical expert.The definition of surgical expertise and several important aspects of its development are highlighted. Innate talent plays an important role, but is insufficient on its own to produce a surgical expert. Multiple theories that explore motor skill acquisition and memory are relevant, and Ericsson's theory of the development of competence followed by deliberate self-practice has been especially influential. Psychomotor and non-technical skills are necessary for progression in the current climate in light of our training curricula; surgical experts are adaptive experts who excel in these.The literature suggests that surgical expertise is reached through practice; surgical experts are made, not born. A deeper understanding of the nature of expert performance and its development will ensure that surgical education training programmes are of the highest possible quality. Surgical educators should aim to develop an expertise-based approach, with expert performance as the benchmark.