NHS staff in secondary care have relatively little training relevant to prioritizing and planning work outside of “normal” working hours. Recent local information technology developments now permit an accurate description of work undertaken out of hours. Using these data we have created a night shift simulator using video game technology and sensibilities to engage and challenge new staff. This tool will reduce problems with task prioritization, communication, self-management, and route planning. Further development will permit simulation of potentially challenging scenarios such as ward moves or high admission rates. This novel and dynamic educational tool is of relatively low cost, has high impact, and is scalable to other sites in the UK and beyond.
The problemOnly 25% of the year falls between 9am and 5pm, Monday to Friday. During the remaining 75% (“out of hours”) a skeleton staff of junior doctors, support workers, and nurses must provide safe and timely care in hospital. During these periods, staff must prioritize their high and changing workload, make key decisions on contacting other services or specialists, plan complex routes around large potentially unfamiliar hospitals, manage their personal needs for rest and sustenance, and handover succinctly and accurately. All of these aspects must be done well, despite unsocial hours being a period of increased stress and fatigue and reduced support: if not, patients may receive delayed or suboptimal care. This potential is too often realized and has been the subject of critical reports nationally and locally in the recent past.
It is surprising then, that little attention is given to training for “out of hours” work: Nottingham is typical in having no related formal under- or post-graduate training and no requirement for final year students to shadow a doctor overnight. Experienced nurses who consider becoming coordinators also face a leap into an uncertain and challenging environment; particularly as new IT solutions mean the coordinators are much more mobile and hands-on than previously.
Proposed education interventionWe have introduced an innovative and award-winning task allocation and tracking system for out of hours work. These data reveal the precise volume, type, timing, location, and variability of tasks undertaken and can be augmented by data from other hospital systems (patent pending). Using these data and related resources, we created an interactive simulation of a night shift (initially at Nottingham City Hospital). This simulation draws on aspects of video gaming familiar to final year students, junior doctors and coordinators to improve their task and self-management, decision making, and route planning.
The player guides their virtual alter ego through an accelerated shift attempting to undertake tasks in an efficient manner to prevent patient deterioration, complaints from patients or other staff, or fatigue that impairs task completion accuracy. Performance is assessed and fed back in an analogous manner to airline industry simulation training.
Benefit to PatientsBy introducing a novel task allocation and tracking system in secondary care in Nottingham, we demonstrated reductions in untoward incidents, peri-arrest calls, and length of stay. The educational intervention has the potential to build on these improvements in three main objective ways:
• reducing average task completion time with a disproportionate improvement in urgent task completion time.
• reducing untoward incidents due to slow response or failure to involve senior or specialist assistance
• reducing errors associated with fatigue (e.g. incomplete drug card rewrites)
Benefits to serviceThe impact on staff trained using this tool was assessed by ethnographic observation, structured interviews, and surveys as employed in our previous IT developments. As each player can assume a variety of roles, staff have greater insight into the challenges each role faces. Through this facet and training in using specialist input efficiently, we also expect improved satisfaction of speciality teams (e.g. haematology, oncology) with the Hospital at Night team. Staff on rotation through several hospitals gain transferable skills that will be of benefit at other sites.
We also intend to incorporate the game into interviews to reduce the risk of employing nurses who prove to be unsuitable coordinators, with the attendant detrimental effects on the individuals and the systems within which they operate.
The project team intends further developments of benefit to managers and service leads by allowing the simulation of scenarios in which physical (e.g. ward location) or staffing (e.g. team composition) changes have occurred. Potential problems or changes in efficiency may be highlighted, allowing plans to be refined in advance of any costly or potentially unsafe situations arising.
Productivity and impactAs the project drew upon existing data, the expertise of present staff, and a commercial partner covering development expenses, it was relatively inexpensive. There is, however, the potential to produce significant savings through more efficient working and a reduction in adverse incidents.
If the program were to reduce the average task completion time by only 3 minutes, 500 additional hours per month of junior doctor or coordinator time would be available for patient care or staff rest. If the training prevents 0.01% of reported adverse incidents across NUH, the Trust would save over £50,000 in investigation and reparation costs annually.
It will be straightforward to incorporate maps of other hospitals with their particular staffing and facilities as they follow similar structures and the “Hospital at Night” system is almost universal. The simulation therefore haw clear potential to be licensed to other medical schools or Trusts for final year trainees or new starters. Our intention is that this provides a revenue stream to fund further game development.
Dr John D Blakey
Senior Clinical Lecturer, Clinical Group, Liverpool School of Tropical Medicine
Honorary Consultant in Respiratory Medicine, Aintree University Hospital