The NHS workforce in England faces unprecedented challenges in 2023, including dealing with the backlog of both physical and mental health care caused by the pandemic and the need to create a system of health and care that tackles both health inequalities and other weaknesses. The NHS People Plan 2020/21 was established to outline several priorities and to accommodate the health needs of an ever-changing demographic (NHS England/NHS Improvement and Health Education England (HEE), 2020).
Medical advances in the field of targeted therapies and developing technologies are promoting new ways to meet the health needs of a population affected by acute and chronic conditions. The recommendations of the NHS People Plan 2020/21 include attention to inclusivity, wellbeing, workforce development and training, and adopting new ways of multiprofessional working, alongside embracing new technology and innovation (NHS England/NHS Improvement and Health Education England (HEE), 2020).
These actions and underpinning principles extend beyond the current NHS climate and set the benchmark for the future. This requires close partnerships among NHS organisations, external partners, and local government sectors. This article considers the role of simulation-based learning in delivering a modern workforce, focusing on the benefits offered by a simulated approach, while considering some of the main issues in the healthcare sector in the UK.
Benefits of simulation
Simulation is an innovative educational technology that empowers staff to acquire and maintain essential knowledge and skills, while simultaneously reducing the incidence of clinical errors and addressing ethical issues (Department of Health (DH), 2011). The learning experience is enriched when adopting high-fidelity simulation because it promotes a safe and controlled learning environment, wherein participants can develop technical and non-technical skills (Lewis et al, 2012).
In this environment, mistakes generate learning in real time, while deepening knowledge and understanding in the context of clinical scenarios and without the risk of compromising patients' safety. The simulated environment allows participants to actively experience ever-challenging crises based on a wide representation of pertinent clinical practices, before experiencing these in real life. Thus, simulation promotes ethical lifelong learning and enhances participation and engagement (Lateef, 2010).
Recruitment and retention
There are an estimated 47 000 nursing vacancies or more in the UK (Mitchell, 2022). This figure is concerning and dangerous for staff wellbeing and patient care. One of the primary concerns is staff sickness. In 2021, this rose to approximately 149.3 million working days lost to sickness (Office for National Statistics, 2022). Retention rates have also dwindled due to reasons ascribed primarily to ‘burn-out’; around 140 000 staff or 11% of the total workforce left active service in the year to September 2021 (Palmer and Rolewicz, 2022).
Pressures to recruit widely across all healthcare sectors are escalating and NHS employers need to attract the right people with appropriate values and behaviours in sufficient numbers to maintain the future workforce (HEE, 2020). Simulation in its multiple forms offers unique opportunities to raise awareness of the work undertaken by health professionals in clinical environments. By providing exposure to various settings, potential employees may experience opportunities in aspects of health care of which they had not previously been aware. Further, liaison between professional bodies and educators to actively promote simulation, and the expansion of immersive technologies by offering simulated experiences to schools and colleges, could raise awareness and insight into a range of potential career pathways.
Recruitment strategies that use simulation for recruitment and selection of staff that examine applicant attributes and values, for example interpersonal skills when problem-solving, communication skills and the ability to work under pressure, could lead to an increased hiring success rate (HEE, 2020).
Staff development
The regular use of simulation in clinical practice provides the opportunity to practise skills and bolster confidence for staff, by tackling the more ambiguous and challenging problems that arise in their daily work. Simulated learning allows for the exploration of non-linear concepts, offering staff the chance to experiment and learn from mistakes in a safe and supportive environment.
Thus, simulation increases creative confidence, builds self-efficacy, and empowers staff to disseminate best practices. These experiences can help with integration, staff buy-in, exploration of new meanings, and the understanding and development of new ways of working (HEE, 2020). Simulation training and digital environments provide an unprecedented opportunity to measure, track and improve employee development.
Simulations as part of employers' assessment processes could provide greater opportunities to focus on specific aspects of individual practice such as clinical skills, leadership, patient or colleague interaction, and/or other behavioural issues. Personal action plans and regular access to high-quality simulations may drive improvements in the healthcare system and future workforce, while the use of in situ simulations offers succinct learning opportunities for multiprofessional teams within their usual working environment (HEE, 2020).
Staff retention
Staff wellbeing is critical to staff retention. According to HEE (2020), one in three members of staff is reported to have felt unwell due to work-related stress. The NHS Long Term Plan (NHS England/NHS Improvement, 2019) set out a workforce strategy dedicated to delivering more health professionals to increase staff wellbeing, increase the quality of care delivered and reduce the pressure on an overstretched workforce. The plan notes that poor mental health in NHS staff equates to more than £2100 per employee.
Simulation may also be employed to test and implement changes and policies, enabling staff to work more effectively to manage periods of stress in daily practice (HEE, 2020). It is an approach that offers a risk-free way of testing new ideas and innovations that have the potential to lead to improvements in the quality of patient care.
Teamwork
The aviation industry and the military have successfully adopted simulation for teamwork training for several years. Effective teams are social entities that work collaboratively to share knowledge, skills and attitudes. Effective team members can monitor their own and others' performance to achieve high-quality teamwork (Lewis et al, 2012).
Several studies have investigated the adoption of simulation in health care with the intention of observing and testing teamwork. Findings suggest that simulation-based learning enhanced communication skills among staff and endorsed a co-operative approach, which resulted in improved team performance, intra-team collaboration and team cohesion (Messmer, 2008; Hobgood et al, 2010). Well-constructed simulations allow participants to experiment with different roles and responsibilities within a team, including important attributes and skills required for leadership.
According to Jefferies (2016), simulation is a dynamic interaction between the facilitator, other participants and approaches to teamwork. Various simulation techniques have been used to specifically target team training.
The results of one study showed that obstetric teams participating in team training using high-fidelity simulation earned a significantly higher teamwork score than the control group (Fransen et al, 2012). In another study, a training programme that included simulation resulted in an increase in teamwork knowledge and attitudes where participants correctly identified effective team skills (Robertson et al, 2010).
Simulation has demonstrated that participants act intuitively and consider that this type of training leads to improved learning and performance (Baillie and Curzio, 2009).
Interprofessional simulation occurs when two or more members from different healthcare professions participate to learn through experiential and shared experiences.
This approach is highly beneficial for social learners who benefit from direct interactions and ‘lived’ experiences (Messmer, 2008). The simulated environment can offer challenging scenarios that require cross-role understanding and training, facilitating and promoting self-reflection through a shared selective review of the learning experience.
A useful theoretical model for team training describes five dimensions (Salas et al, 2012), which can be applied to simulated learning (Table 1).
Table 1. The five dimensions of team training
| Dimension | Applied to simulation |
|---|---|
| Team leadership | To practise team leadership, large team simulated scenarios such as a major incident or crisis event could be used |
| Mutual performance monitoring | Peer-to-peer review could be practised in a scenario such as caring for a deteriorating patient |
| Back-up behaviour | Team working when caring for patients could be practised in a simulated scenario with actors or high-fidelity manikins |
| Adaptability | Adaptability could be practised by using a busy simulated clinical environment that requires handovers to different teams and examines human factors |
| Team orientation | Simulation could be used as part of the students' induction process for team building, working on team dynamics and examining team communication |
Leadership
In a period of change and uncertainty, strategic leadership is fundamental to creating new pathways for the health professionals of the future. The HEE's national strategic vision of simulation in health and care (HEE, 2020) encompasses the concepts of patient safety and healthcare quality, which share a common denominator, a patient-centred approach. In fact, service users are involved in developing and participating in simulations, enhancing the capacity of the learning environment, and improving the participants' experience by offering immediate feedback. This promotes the delivery of a modern multiprofessional workforce.
Leadership is contextual and no single approach fits all settings in the NHS. Simulation can help staff practise leadership styles and turn abstract knowledge and concepts into concrete leadership skills and competencies. Staff can use simulations to examine real-life issues and share ideas and decisions that can impact teams and organisational cultures.
Recent studies exploring the use of simulated leadership training in undergraduate nurses exemplify how simulation can be used to teach leadership skills, ranging from low-fidelity simulation in the form of case studies (Pollard and Wild, 2014), role-play (Thomas et al, 2011) and the use of high-fidelity manikins to virtual reality and immersive theatre (Mitchell and Assadi, 2021).
Conclusion
Simulation has the potential to overcome many of the problems that the NHS is currently facing. The use of simulation, however, must work in partnerships with a people-centred focus that is consistent with time, budget and scope constraints. The workforce needs to be given equal access to learning opportunities, and this may be hindered by the current staff shortages.
Furthermore, the budget and the scope could shift due to competing priorities. Senior leaders should therefore consider switching to simulation and maintaining its use, despite the potential challenges that might arise. Strategic leadership is recommended to ensure the successful implementation of simulation for a sustainable future workforce.