Sean Cross

Integrating mental health simulation into routine health-care education

702 www.thelancet.com/psychiatry Vol 3 August 2016 Abigail Moss, H Valerie Curran, Michael A P Bloomfi eld, Sunjeev K Kamboj, Simon E Blackwell, *Tom P Freeman Clinical Psychopharmacology Unit, University College London, WC1E 6BT, UK (AM, HVC, SKK, TPF); Division of Psychiatry, University College London, UK (MAPB); Psychiatric Imaging Group, MRC Clinical Sciences Centre, London, UK (MAPB); MRC Cognition & Brain Sciences Unit, Cambridge, UK (SEB); and Mental Health Research and Treatment Centre, Department of Psychology, Ruhr-Universität Bochum, Germany (SEB) tom.freeman@ucl.ac.uk

Simulation training to support healthcare professionals to meet the health needs of people with intellectual disabilities

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.

'He left me a message on Facebook': comparing the risk profiles of self-harming patients who leave paper suicide notes with those who leave messages on new media

Background In cases of non-fatal self-harm, suicide notes are a major risk factor for repeated self-harm and suicide. Suicide notes can now be left on new media services, emails or text messages, as well as on paper. Aims In a group of people who had harmed themselves, we aimed to compare new media note-leavers with paper note-leavers and characterise these groups demographically and by risk factors. Method Clinical notes of patients who presented with non-fatal self-harm to two London emergency departments were anonymously searched for mentions of new media use. These were categorised and risk factors were compared for those who had left a new media note, a paper note, or no note to establish differences in risk of note-leaving. Results New media note-leaving was associated with younger age and substance use; both risk factors for repeated self-harm. However, suicidal intent remained highest in paper note-leavers. Conclusions Paper note-leavers remain at greatest risk, however new media note leaving is still correlated with risk factors related to repeated self-harm and suicide. Clinicians should enquire about new media use during emergency department assessments of self-harm. Declaration of interest None. Copyright and usage

Actors with intellectual disabilities in mental health simulation training

Purpose People with intellectual disabilities experience poorer health outcomes than the general population, and a significantly increased risk of mental health comorbidity. Their access to healthcare has been consistently shown as inadequate, and their access to mental health support is still largely wanting. Adequate training and education should improve these shortcomings but there is limited evidence available as to the best way to achieve this. The paper aims to discuss these issues. Design/methodology/approach This paper reports on the co-production and co-delivery of a simulation training course to support healthcare professionals to provide care for people with intellectual disabilities, with a particular focus on their mental health needs. This training was designed with actors with intellectual disabilities, who participated as simulated patients in scenarios during the course and subsequently provided feedback on their experience. Findings This paper focusses on the positive experiences of the simulated patients, reporting on and interpreting their direct feedback on their experience of contributing to the development and delivery of the course and being involved as co-educators. Originality/value It is highlighted that the co-production and delivery of this simulation training with people with intellectual disabilities has the potential to realise some of the key principles called upon when attempting to improve how they are treated, by illustrating concrete participation, independence, and access to fulfilling lives. The value and benefits of interprofessional education to achieve these educational aims is further highlighted, particularly for the potential to generate a sense of shared responsibility within mainstream services in caring for people with intellectual disabilities.

Ethnic differences in self-poisoning across South London.

BACKGROUND Self-poisoning (overdose) is the commonest form of self-harm cases presenting to acute secondary care services in the UK, where there has been limited investigation of self-harm in black and minority ethnic communities. London has the UKs most ethnically diverse areas but presents challenges in resident-based data collection due to the large number of hospitals. AIMS To investigate the rates and characteristics of self-poisoning presentations in two central London boroughs. METHOD All incident cases of self-poisoning presentations of residents of Lambeth and Southwark were identified over a 12-month period through comprehensive acute and mental health trust data collection systems at multiple hospitals. Analysis was done using STATA 12.1. RESULTS A rate of 121.4/100,000 was recorded across a population of more than half a million residents. Women exceeded men in all measured ethnic groups. Black women presented 1.5 times more than white women. Gender ratios within ethnicities were marked. Among those aged younger than 24 years, black women were almost 7 times more likely to present than black men were. CONCLUSION Self-poisoning is the commonest form of self-harm presentation to UK hospitals but population-based rates are rare. These results have implications for formulating and managing risk in clinical services for both minority ethnic women and men.

0158 MENTAL HEALTH SIMULATION TRAINING: THE BIGGER PICTURE - WHY IT'S NEEDED NATIONALLY

Context More integrated mental healthcare is one of the key messages of the NHS five year forward view.1 The government’s mandate to Health Education England2 highlights the need for greater, more effective mental health training, urging organisations to improve mental health awareness as well as urging effective investment in training for healthcare professionals managing comorbidity. The national shape of training report,3 also endorses this. Looking beyond healthcare, Henderson and Madan4 report that mental illness costs the UK economy up to £70 billion annually, and is now the leading cause of sickness absence.5 The chief medical officer’s annual report,6 acknowledges the growing problems mental health related lost workforce productivity. Mental health simulation training has been shown to improve knowledge, attitudes, confidence, technical and non-technical skills.7,8 We feel that a national mental health simulation strategy is needed to bridge the gap between policy and training. Methodology Focus groups will take place with a diverse range of stakeholders including business and HR management, healthcare professionals, patients, carers, simulation training providers, voluntary sector organisations, education providers and policy makers, as well as medical and nursing professional bodies. There will be a thematic analysis of the focus groups, exploring the utility of simulation and other experiential learning interventions in addressing these recommendations. Results Thematic analysis of the focus groups will be generated, published and presented. This will be used to guide the development of a collaborative steering strategy group will be formed from individuals and organisations who are keen to address this gap, using the themes identified as priorities. Conclusions Addressing effective training in mental health is a national priority. This study aims to establish a national strategy for the role of simulation in doing so, in a collaborative and relevant manner. References NHS England Five Year Forward View, 2014 Delivering high quality, effective, compassionate care: 2014. A mandate from the Government to Health Education England. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310170/DH_HEE_Mandate.pdf Securing the future of excellent patient care Final report of the independent review Led by Prof D Greenaway. http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf Henderson M, Madan I, Hotopf M. Work and mental health in the UK. BMJ 2014:348 Sainsbury Centre for Mental Health. Mental health at work: developing the business case. London, 2007 Annual Report of the Chief Medical Officer. Public Mental Health Priorities – investing in the evidence, 2013 Doolen J, et al. An evaluation of mental health simulation with standardized patients. Int J Nurs Educ Scholarsh 2014;11(1):1–8 Thomson AB, Cross S, Key S, Jaye P, Iversen AC. How we developed an emergency psychiatry training course for new residents using principles of high-fidelity simulation. Med Teach 2013;35(10):797–800

0013 Simulation to train psychiatric nurses for leadership

Background/context The Duty Senior Nurse (DSN) role in South London and Maudsley NHS Foundation Trust (SLaM) has hitherto been an under-supported and somewhat nebulous one. Anecdotally many DSN’s have craved more clarity and a forum to reflect with peers. Existing training for this group is primarily didactic in nature with little accommodation of reflective practice or experiential learning indicated as key to optimal learning.1 Our team’s recent work has indicated potential for simulation in a mental health setting, a novel application of the modality. A DSN course was developed to allow learners to explore their own and colleagues’ practice, to recognise the impact of related non-technical skills, to identify personal and practical alternative behaviours and areas for improvement in providing safe, therapeutic services. Methodology/description The three-day course was delivered on three occasions. It consisted of thirteen scenarios, each followed by a debrief. Iterative design was implemented whereby feedback from each course contributed to the next. Participants (n = 34) were senior nurses who responded as Leader to emergency calls in inpatient settings. Scenarios included: managing agitation, relatives/carers, seclusion, staff conflict, medical deteriorations, section 136, infection control and business continuity. Each was followed by a structured debrief. Results/outcomes Feedback was very positive. Over 97% of participants agreed the program was useful and relevant to them, with 100% stating that they would recommend the course to a colleague. Most respondents identified specific lessons learned and changes they could apply to their own practice. In addition, a pre/post measure of confidence, knowledge and attitudes regarding the DSN role showed significant increases in most dimensions. Potential impact Further research will be conducted on the course as it is implemented on a larger scale, but initial results indicate potential for simulation to be a valuable tool to aid the development of psychiatric nurses in mental health settings. Reference Rudolph J, Simon R, Raemer D, Eppich W. Debriefing as formative assessment: Closing performance gaps in medical education. Acad Emerg Med 2008;15(11):1010–1016

0014 Developing simpatico – simulation for de-escalation, conflict resolution and rapport building

Background/context South London and Maudsley NHS Foundation Trust’s (SLaM) work in the area of the prevention and management of violence and aggression has revealed a limitation in the usual ‘didactic sessions combined with physical skills training’ approach to such training. Owing to the need to address learning objectives in the national syllabus1 and have participants demonstrate competency in prescribed physical techniques, there is not enough time to show suitable stringency in training for de-escalation and negotiation skills – skills vital to avoiding incidents and the need for physical intervention altogether. A course was developed for all front line staff, designed to enhance knowledge, confidence and clinical skills through discussing models of conflict, negotiation/communication skills and/or having a forum to explore alternative strategies for de-escalation. Methodology/description The one-day course was delivered on four occasions during its pilot phase. It consisted of a mini- workshop on models of conflict and five scenarios, each followed by a structured debrief. Iterative design was implemented whereby feedback from each course contributed to the next. Participants (n = 36) were a variety of health professionals from multiple backgrounds who have regular patient contact in inpatient settings. Scenarios involved negotiating various types of conflict. Debriefs encouraged learners to discuss and reflect on effective strategies/tools for specific conflict types. Results/outcomes (Anticipated) Positive feedback is anticipated along with pre-post measures of knowledge and confidence to show significant increases. It is also predicted that follow-up measures will show drops in incidents over a 12-month period and indicate simulation’s utility in communication training. Potential impact Further research will be conducted on ‘Simpatico’ as it is implemented on a larger scale, but similar projects have indicated potential for simulation to be a valuable learning tool both to improve de-escalation/negotiation skills and to aid the general development of frontline staff in mental health settings. Reference http://www.nhsbsa.nhs.uk/Documents/psts_implementing_syllabus.pdf

0024 An evaluation of in vivo versus simulation suite delivered simulation-based mental health training for emergency department teams

Background We developed an interprofessional simulation-based training (SBT) to promote collaboration when caring for patients in mental health crisis in the Emergency Department (ED). The intervention was run both in vivo and in a purpose-built simulation suite. The primary analysis of educational outcomes has been presented elsewhere.1 Aims To compare participant learning outcomes and experiences from in vivo versus simulation suite delivered SBT. Methods A SBT was developed in which participants engaged in three scenarios of a simulated patient’s journey through the ED followed by structured debriefs. One course was delivered in vivo whilst three courses, with identical content and format, were delivered in a simulation suite. Participants completed pre- and post-course questionnaires, measuring changes in knowledge, confidence and attitudes. Individual participant overall change in knowledge, confidence and attitudes were compared for both participant groups using Independent-Samples T and Mann Whitney U Tests. Post-course focus groups were conducted to gather qualitative data on participant experience. Results 12 participants engaged in in vivo training versus 25 participants in simulation suite training. The professional mix was similar for both groups. The distribution of change in knowledge and self-rated confidence scores and attitudinal shift was not significantly different for in vivo and simulation suite groups (p = 0.64; p = 00.92; p = 0.58). Views on the relative merits of in vivo versus simulation suite training were divergent. Participants from both groups recognised the tension between achieving environmental fidelity with in vivo simulation and the potential detrimental impact of managing distractions on learning. Conclusion Previous work has demonstrated that SBT effectively increases participants’ self-rated confidence and leads to positive attitudinal changes when caring for patients in mental health crisis in the ED.1 Our results suggest that the effectiveness of learning does not appear to be different for in vivo versus simulation suite delivered training. Reference Humphreys RA, Piette A, Wilson C, Kowalski C, Cross S. Mental health crisis in the emergency department: outcomes from a new interprofessional simulation. Royal College of Psychiatrists International Congress, 2015

0153 INNOVATIVE INTERPROFESSIONAL SIMULATION WORKSHOPS AT THE MENTAL-PHYSICAL INTERFACE - A MIXED METHODSSTUDY OF EFFECTIVENESS

Background Mental disorder is the single largest source of burden of disease in the UK.1 Recent surveys have revealed the prevalence of mental disorders in general hospital inpatients to be greater than 40%.2 Common ‘physical’ Illnesses have profound psychological consequences. The recent five year forward view of the NHS highlights the importance of integrating mental and physical healthcare.3 Despite this, training remains distinctly separate, despite the government’s mandate to Health Education England4, which specifically highlights the need for better training for healthcare professionals managing mental-physical comorbidity – which this intervention provides. Methodology An exciting and innovative study involving the design, implementation and evaluation of a series of one-day interprofessional and cross-disciplinary simulation based training programmes throughout south London. Initially focus groups5 were held with different sets of healthcare professionals, on the difficulties around managing mental-physical comorbidity. The salient themes arising then guided the development of simulation scenarios. The second phase of the study consisted of one day interprofessional simulation programmes, using actors and high fidelity mannequins. Participants were Drs and nurses from general hospital, community and mental health settings concerned with the management of mental-physical comorbidity. The third phase was a ‘pre’ and ‘post’ intervention evaluation consisting of measurement of participants’ confidence at managing patients with comorbidity, their knowledge and attitudes to mental health. Results n = 78. There were statistically significant, positive changes to the confidence of participants managing patients with physical and mental health comorbidity, and similar, positive changes across the domains of knowledge and attitudes to mental disorder. Participants also felt the intervention greatly improved team-working, patient safety and communication skills. Conclusions This study demonstrates that integrative training which is innovative, interprofessional and simulation based is a power fulmodality to improve the levels of confidence and knowledge in healthcare professionals managing patients with mental-physical comorbidity, whilst improving attitudes to mental disorder, team-working and patient safety. References World Health Organization (2008) Global Burden of Disease Report. WHO (http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html) Rothenhäusler HB. Mental disorders in general hospital patients. Psychiatr Danub. 2006;18(3-4):183–92 NHS England. Five year Forward View, 2014 Delivering high quality, effective, compassion ate care: Developing the right people with the right skills and the right values: A mandate from the government to Health Education England. 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310170/DH_HEE_Mandate.pdf Barbour RS. Making sense of focus groups. Med Educ. 2005;39:742–750