May 4, 2021By Lindsey Nolen

Simterviews: Dr. David Grant | Simulation Learning Lead, University of Bristol Medical School

This week,’s new healthcare simulation expert interview series “Simterviews” speaks with Dr. David Grant. He is the simulation and interprofessional learning lead and colead of the WOW Helical Theme at the University of Bristol Medical School. Grant is also the director of the postgraduate certificate in healthcare improvement program and co-director of the masters in healthcare management program at the Centre for Health Sciences Education. He has contributed to the field of healthcare simulation by implementing a pediatric in situ simulation program at the Bristol Royal Hospital for Children.

In collaboration with Peter H. Weinstock, MD, Ph.D., and the Boston Children’s Hospital Simulation Program, Grant also started a faculty development program in Bristol. Together with a group of colleagues, they began hosting international pediatric simulation meetings, and went on to establish the International Pediatric Simulation Society in 2010, of which Grant was elected president in 2013. Adding to his credentials, Grant was elected president of SESAM at the 2017 Society in Europe for Simulation Applied to Medicine meeting in Paris, France. With more than seven years’ experience of serving in leadership positions at the local, regional, national and international levels, he continues to work toward expanding the impact medical simulation has on the greater healthcare community.

In this Simterview,’s Content Director Lindsey Nolen asks how healthcare simulation in the United Kingdom differs from that in other countries around the world, and how COVID-19 has impacted clinical simulation technology. Grant further explains where he believes the future of healthcare simulation is headed.

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Dr. Grant: I think there’s not one single answer depending on where you are in the world. For me, I’m originally from Cape Town in South Africa. I feel duty-bound to make sure that we are able to translate clinical simulation as a modality that applies in all healthcare settings, not just first-world settings such as the United Kingdom or United States. It is also fair to say that even among so-called first-world countries, all is not equal. In Europe for example, there is great variance in the level of adoption and integration of simulation-based education. It is for this very reason that one of the core strategic aims of SESAM is to ensure that all healthcare professionals have access to high-quality simulation-based education across Europe. I think if healthcare simulation is really going to realize its potential impact on patient safety and patient outcomes, the simulation community needs to find ways to support those who are at that very early part of their simulation journey to understand and translate the methodology into something that can be applied and grown sustainably in their local setting.

Through partnering with local teams to establish local expertise that can then go on and actually spread the simulation among their own community, you create sustainable local capacity that facilitates the development of internal networks and infrastructure that is able to sustain development of simulation throughout healthcare communities. What is your greatest advice for those already engaged in simulation who want to continue to maximize their outcomes and ROI moving forward?

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Dr. Grant: I think the first thing is, let your curiosity and desire to do the best for your learners and patients continue to drive your learning. One of the most common things I am asked is how do you measure the impact of simulation. I think the question speaks to one of the most common mistakes I made early on in my simulation journey, which is a focus on educational delivery without explicitly considering the desired behavioral change of the healthcare professional or outcome of the patient. So my advice would be that before you design your simulation resource or the intervention, try to understand what changes in behavior or patient outcome you’re trying to affect, and that’s what you should be studying to measure impact. Lastly, I would say that the senior healthcare professionals need to realize that healthcare simulation is not just an educational tool for undergraduate or postgraduate students, but a wonderful tool that can help all of us to continue learning and develop our own expertise.

In all my years, I’ve not seen or experienced a more effective tool for delivering interprofessional education where we truly, as a multiprofessional team, learn from and with each other how we can deliver better safer care for our patients. It allows us to develop this concept of distributed cognition and human sensory networks that helps keep us and our patients safe when it matters. If I practice this, utilizing simulation in the same team that I’m delivering the service in, I can learn from you whilst we’re in that educational setting not only how you normally do it, but how I can best support your performance. So when you then deviate from your normal approach during “game time,” it’s easier for me to monitor your performance and give feedback that might prevent you from performing an unintended action that might lead to a mistake. This then helps you and the whole team evaluate the situation and adjust actions to optimize outcomes. It creates that human sensory network that keeps all of us safe. What is something that excites you about the current healthcare simulation industry?

Dr. Grant: I’m fascinated by how people have responded to the COVID-19 pandemic. I don’t mean in terms of the actual delivery of healthcare or how simulation has helped prepare healthcare professionals for that. I think COVID has forced us to disruptively think about how we deliver simulation. For simulation to be effective and change behavior and culture, we have to deliver the training to a critical mass of our staff frequently enough to be effective. So if we are to cascade simulation training at an optimal frequency to a large enough volume of staff, particularly within large healthcare organizations, we’re going to have to imagine a different way to achieve the same goals we traditionally achieved through bespoke, small-volume simulation events.

It has been called various things, but distance simulation and some of those elements that people are starting to explore now gets us away from the traditional mannequin-based simulation approach, pushing the boundaries around virtual reality or augmented reality — all of those different elements — and integrating that into a hybrid approach. I think in the end, this disruption will help us be able to push the field to the next level. How has your institution responded to COVID-19? What lessons were learned?

Dr. Grant: The first thing that we’ve learnt is that even though we thought we were prepared for dealing with pandemics and large infectious disease problems, we really are not in terms of the number of isolation facilities and organizational patient care pathways. We were lucky that, with Ebola and various other things, we’d been through a learning curve of how to use simulation to prepare staff and the organization for dealing with these things.

Apart from systems testing simulations delivered at point of care, the simulation team has nimbly adapted their activities to support the organization and its staff. For example, during the pandemic, when it became apparent that we were going to need to deploy staff in roles outside of their normal practice, so the simulation team retooled to deliver one-day courses in the simulation-based environment to a large volume of staff who were not necessarily core-trained adult critical care. These courses were focused on equipping staff with the core basic skills in adult critical care before they got deployed clinically. This allowed them to, with support from core staff, function safely within that foreign environment.

Once the vaccination program started, the simulation and education center retooled and transformed to vaccination facilities and fit-testing facilities. As the PPE changed rapidly, staff constantly had to be retested to be sure they were safe whilst delivering front-line clinical care.

I also think COVID-19 has forced us as an organization to improve the efficacy of our organizational governance infrastructure. This has made us much more nimble as an organization, improving our ability to rapidly implement systems- wide change in response to challenges. The forced changes that COVID-19 has brought has ended up being an important stimulus to move our organization closer to our goal of being a learning organization that constantly learns and adjusts whilst it delivers a service. Though such an approach has been the norm in many parts of our organization, it sometimes felt a little bit clunky. Now I think, because we’ve had to change, it feels much more natural as if it was the cultural norm. How would you say simulation in the U.K. differs from that in other places throughout the world?

Dr. Grant: There are different models within the U.K. in comparison to, not just in the U.S., but all over the world. I think we’re unique in a couple of ways. Firstly, the fact that we have a national health service with each nation having a healthcare education governance organization in place has meant that there has been a national drive to embed simulation capacity in all healthcare organizations. Unfortunately, the funding of these simulation facilities remain far more organization-dependent. In the U.S., I find most simulation centers are fully supported or funded by their organizations. In the U.K. this varies greatly. In Bristol, we’ve always had a business model where the organization only funded a part of our annual operational budget, and we had to generate the rest through running external activities and courses. It was a hybrid business model. What was interesting is I used to think, “Oh, I wish I was completely funded by the organization,” but I think in many ways, it drove us to be innovative because you have to continue to innovate and push the boundaries to attract learners to those externally facing courses.

In many ways that has helped us to constantly push the boundaries. Even in the U.K., the simulation delivery model is slightly different depending on the organization you work in. For us, because we were having to run those externally-facing income-generating courses, and we had a finite simulation real estate resource, and that meant that in order to expand our simulation real estate, we focused on moving the delivery of simulation training to our own staff to a point of care setting in the hospitals where they care for patients. That means that it’s unusual for us to deliver simulation-based education that is not interprofessional in nature in my organization, which I think again is a huge advantage.

Development of teams through deliberate practice in the simulation center-based simulation delivery settings is not impossible, but logistically it is more challenging to align learning teams with service teams. It’s also the case that undergraduate and postgraduate simulation-based education is a little bit separated in the U.K., whereas in the U.S. it’s slightly more integrated. This means that for the university, our medical students are seldom in the same clinical simulation scenario as our post-graduate students. They’re usually among other students in the delivery. So in summary I think there’s something about the delivery model, but also the funding model that is different in the U.K. than it is in the U.S.

Check out this interview with Grant from 2013:

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