AbstractIntroduction: Enabling access to clinical skills and simulation-based education for remote and rural healthcare practitioners, irrespective of geographic setting, professional background, and workplace context, is challenging. Simulation in healthcare education is acknowledged as a complex service-based intervention yet despite an exponential increase in evidence, there is a paucity of research about the implementation of simulation-based interventions in diverse organisational contexts. With a backdrop of a National Strategy for Clinical Skills and Simulation in NHS Scotland, this thesis adopts a realist approach exploring what works, for whom, and why in respect of a mobile skills unit in operation since 2009.
Methodology: Realist inquiry advocates a theory-driven approach to researching complex interventions in complex social systems. A realist-informed synthesis of published and grey literature, and stakeholder engagement was undertaken, involving literature review, documentary analysis, fieldtrips, and observation. This was augmented by a realist-informed evaluation, using semistructured interviews, gathering primary data to identify contexts, mechanisms, and outcomes associated with a complex intervention i.e. the mobile skills unit. Data extraction involved programme theory elicitation, secondary analysis of primary datasets through retroductive theorising and the composition of case-based narratives for analysis and programme theory testing.
Findings: The mobile skills unit has enabled geographically diverse healthcare and multi-agency partners to access clinical skills and simulation-based education. The delivery and uptake of clinical skills training resources and simulation training opportunities focuses on high risk, low frequency events, particularly in remote and rural locations, by medical, nursing and paramedic staff proportionate to the NHS workforce composition. The principal approach to implementation of the mobile skills unit is via locally based enthusiasts and has seen the mobile skills unit become embedded as part of a recurring annual component of the clinical skills education programmes of a small number of healthcare communities. Communities of practice have developed or been augmented because of informal networks between educational and clinical colleagues engaging with the mobile skills unit, leading to enhanced patient care practices. However, the innovative mobile skills unit, is a complex intervention, which is highly socially contingent and subject to relational and dynamic heterogeneous contexts, which have impacted upon accessibility to and useability of the mobile skills unit. Successful outcomes are dependent on sociality and causal mechanisms such as the nature and strength of the relationships, trust, networks, and connectedness of local hosts with their immediate and wider communities.
Discussion & Conclusion: Realist research advocates the exploration and explanation of findings through middle range theories. This study draws upon several middle range theories, and Lahlou’s Installation Theory in particular, to provide a framework to elucidate the contexts and mechanisms which channel or inhibit the intended outcomes of the mobile skills unit at infrastructural, institutional, interpersonal, and individual levels of analysis. This analysis in turn led to refined programme theories and an understanding of the mobile skills unit, which is critical to building capacity, sustainability and enhancing the future use. This thesis takes an original sociologically informed view of simulation-based programme and provides new knowledge about the implementation of a complex intervention that is of value both for NHS Scotland and its workforce, and internationally, where there is limited rigorous research in this field.
|Date of Award
|NHS Education for Scotland
|Stella Howden (Supervisor), Jean Ker (Supervisor), Susie Schofield (Supervisor) & Sean McAleer (Supervisor)