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Authors Institution
S Wydall
C Donovan
A Cobb
J Abrams
C Zhang
A Shetye
Croydon University Hospital
8JJ Patient safety
Increasing patient safety by using simulation to teach non-technical skills to medical students

Recognition of the deteriorating patient and prompt escalation to seniors using effective and concise communication is a crucial skill for junior doctors, as highlighted by the National Institute for Health and Care Excellence (NICE) and the National Patient Safety Agency (NPSA), who demonstrate that problems in verbal communication are the “biggest problem area within deterioration incidents” (1 and 2).

The literature suggests that

  • simulation is an effective method of teaching and assessing non-technical skills (6 and 7), however, this is mainly focused on patient-doctor interactions (8 and 9); 
  • simulation appears to be an underused tool to deliver intra and interprofessional non-technical skills training to senior medical students and junior doctors. 

Does simulation training have a role in providing medical students an opportunity to develop these crucial non-technical skills?

Summary of Work


A single blind comparison study was used to assess if simulation training could improve   

  • situational awareness when managing a deteriorating patient;
  • identification of relevant information from nursing colleagues;
  • succinct communication to a senior colleague; and
  • ensuring physical senior review of the patient by a reluctant colleague.

Twenty senior medical students received formal classroom teaching, including both clinical and communication skills. Half of the participants then had the opportunity to develop their non-technical skills in simulation scenarios including formal de-brief sessions. 

Then all twenty students were assessed on their non-technical skills using a purpose written simulation scenario.

Summary of Results

The students who received non-technical simulation training, on average,

  • scored higher on a ten point skills criteria;
  • quicker to request senior assistance;
  • better at communicating their findings in a logical and coherent manner;
  • challenged the senior when assistance was declined;  
  • obtained a senior review;
  • reported a higher level of confidence when requesting the assistance; and
  • stated that practicing their non-technical skills in a simulation environment, along with formal feedback, was helpful.

Simulation training can contribute to the development of non-technical skills in medical students, namely situational awareness, effective communication, timely escalation and ensuring prompt senior review of the deteriorating patient.  These skills have been demonstrated to be essential for improving patient safety and are highlighted as areas requiring improvement by NICE and the NPSA.

Take-home Messages

Simulation training is an effective way to provide a safe environment where these non-technical skills can be practiced and developed by medical students.  It was demonstrated that students receiving such teaching performed better than those receiving classroom teaching alone.


The authors would like to thank the Croydon University Medical Student Simulation Committee, who assisted with the facilitation of the scenarios and Diana Mosely and Nisha Patel for their administrative support.

  1. National Institute for Health and Care Excellence (2010).  Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. CG50. London: National Institute for Health and Care Excellence.
  2. National Patient Safety Agency (2007). Recognising and responding appropriately to early signs of deterioration in hospitalised patients. London: National Patient Safety Agency.
  3. National Patient Safety Agency (2007). Safer care for the acutely ill patient: learning from serious incidents. London: National Patient Safety Agency.
  4. Franklin C, Mathew J. Developing strategies to prevent in-hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Critical Care Med. Feb 1994;22(2):244-7.
  5. Garrard C, Young D. Suboptimal care of patients before admission to intensive care is caused by a failure to appreciate or apply the ABCs of life support. BMJ. Jun 20, 1998; 316(7148): 1841–1842.
  6. Nikendei C, Kraus B, Schrauth M, et al. Integration of role-playing into technical skills training: a randomized controlled trial. Med Teach. 2007 Nov;29(9):956-60.
  7. Abdulaziz A. Teaching communication skills. Can Fam Physician. Oct 2011; 57(10): 1216–1218.
  8. Ker J, Mole L, Bradley P. Early introduction to interprofessional learning: a simulated ward environment. Med Educ. 2003 Mar;37(3):248-55.
  9. Freeth D, Ayida G, Berridge EJ, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. J Contin Educ Health Prof. 2009 Spring;29(2):98-104. doi: 10.1002/chp.20018.
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Summary of Work


Summary of Results

Table 1: Average scores and times for both control and experimental groups, including the difference between the groups and the statistical significance using a T-test with a p-value of 0.05.






Significant using
T-test (p=0.05)

Total Points Scored (Max 100%)












Average Time to Senior Escalation






First Attempt

07:09 (n=10)

04:15 (n=10)




Second Attempt

08:52 (n=9)

05:04 (n=10)




Third Attempt

08:55 (n=6)

06:11 (n=9)










Senior Agrees to Come






Time Senior Agrees to Come








Take-home Messages

Further work

Following this research, similar scenarios are now used as regular elements in the medical student simulation training programme at Croydon University Hospital.


Further research should be performed on a larger scale, using a true randomization process, into the efficacy of simulation in the development of non-technical skills in medical students.  Furthermore, the same research should be applied to junior doctors, where these skills are paramount to patient safety.


Widening the participation of these simulation scenarios should also be trialed.  For example, using both nursing and medical students in the same simulation scenarios could help to establish effective interdisciplinary communication at an early level and will only assist to increase skill in these areas.

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