Background: Taking simulation from concept through to scalable delivery is complex, contested and an under-theorised process. The traditional approaches to scaling innovations, proposed by Everett Rogers in the 1960s is the notion of diffusion of innovation; we argue that this is of limited use in our context of working with NHS health professionals supporting their learning post-covid. Our approach to scaling draws the upon the well-tested seminal works on taxonomies by Coburn (2003) [1] and her dimensional framework, Dede et al (2007) [2], with their educational scaling model, plus the systematic review of Greenhalgh et al (2004) [3] in health services. Method By considering the ways in which our eight Health Education England (HEE) simulation projects have been delivered, this work presents an emerging framework, designed to enable the orchestration of team discourse about theory, the production of simulation artefacts as tools for design discourse and the identification of scalable systemic pain points. We pay particular attention to scaling innovations in practice and organisational change, which are in our view enabling factors in the sustainable adoption of learning technologies by end users in the workplace. Findings Successful scaling is more than just being about the number of users we can reach. It requires underpinning by an understanding about the changes in practice an innovation can bring about, and how valuable these changes are to stakeholders. Challenges remain as to whether such changes can be sustained over time, and the extent to which users and stakeholders are involved in co-creating the innovation. Individuals within the organisations – and their attitudes, beliefs, and habits – play an equally important role in exploring new technologies and practices with an open mind and perceiving these as an added value in their work environment and daily routines. Conclusion This work illustrates the need to strategically involve the ‘missing middle’ and starts to identify the key role these people play in that space between where scaling factors reside between top-down strategy and bottom-up initiatives. References: [1] Coburn CE. Rethinking scale: Moving beyond numbers to deep and lasting change. Educational researcher. 2003 Aug;32(6):3-12. [2] Dede CH, Rockman S, Knox A. Lessons learned from studying how innovations can achieve scale. Threshold. 2007;5(1):4-10. [3] Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. The milbank quarterly. 2004 Dec;82(4):581-629.

1. Towards a taxonomy of scale: a sustainable approach
Ursula Rolfe and Debbie Holley
Bournemouth University
ASPiH-Simulation @ASPiHUK Aspih_sim ASPiH-Simulation

2. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Context: funded
Health Education England projects
• SimComm for adult nursing students
• Maudsley learning for mental health
nursing students
• Immersion Suite for paramedic science
students
• Oxford Medical Simulation for
physiotherapy and physician associates
• Laerdal VSim for adult nursing

3. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Requires: a cohesive
and joined up approach
• Simulation evaluation is complex and contested
• Research by University of Cambridge, says that there is an urgent
need to improve the evaluative framework which underpins the use
of simulation-based learning to develop the so-called ‘soft’ skills of
student doctors, nurses, dentists and other professionals.
• Findings suggest, many evaluations fail to test how effectively
simulations support essential competencies which are clearly
mandated in medical and healthcare curricula, and in policy. The
study found glaring omissions in the evaluation of their impact on
professionals’ evidence-based decision-making, and their sensitivity
towards equality and diversity issues with patients and colleagues.
• Our doctoral student demonstrated that by using simulation for
learning, nursing students retained the knowledge for longer
• Scaling innovation is the key

4. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Scaling: model used is diffusion of innovation

5. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Towards a taxonomy of
scale
• How can the process of scaling be sustained in the long run,
especially after the initial funding that helped bring an
innovation to a new site or organisation has dried up?
• Unsurprisingly, sustainability is one of the most challenging
aspects of scaling since it requires ongoing organisation and
financial support at a time when the economic environment
and public finances are in a dire state, market conditions are
constantly shifting, and people supporting the change agenda
might move on (Coburn, 2003)

6. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Example of scaling &
disseminating
• Maudsley was initially successfully trialed
on mental health students
• Based on the feedback from these
students, we considered scaling this across
different professions
• A local ambulance service worked with
Maudsley to deliver mental health
simulated placements initially for 40 mental
health practitioners with plans to upscale
to 240 final year paramedic students (these
results will be published shortly)

7. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
The questions
to some extent the questions posed by Preece (2000 p388)
• “when large numbers of people want to join an online
community, it presents specific scalability challenges to
designers.."
• What type of features do they need to provide in
software to support large communities?
• What kind of features would support the development
of trust in such a large group? Reputation management
systems, such as those used in eBay, are one way to
accomplish this in e-commence. Will this translate to
health?
• What about supporting personal trust among people?
• Or the trustworthiness of online advice and professional
information of all kinds?

8. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Analysis from our case
studies
• Communication is a scalable skill that can easily
be simulated externally and internally within an
organisation
• More complex medical skills such as cannulation
and venupuncture are harder to scale up (Nursing
n=100 per year) unless you don’t include
competence or proficiency as an output
• Using platforms such as OMS that include
simulated skills to support and not replace
practice has very positive outcomes, but there are
cost implications
• Simulation can be delivered virtually as seen with
Maudsley learning success
This Photo by Unknown author is licensed under CC BY.

9. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
The missing middle....
pedagogical change happening in a
complex, messy world (Bryant 2016)
Champions, enthusiasts, experts,
innovators can influence to generate
that tipping point with the senior
(budget holding) teams enhancing &
scaffolding the development of a
critical mass of practitioners in the
workplace

10. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Concluding
comments
https://youtu.be/Gjg1r_bMzbo?si=ltNfyrSz-cEZeq0I

11. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Culture change
• The leverage task to be undertaken is the ‘unlearning’ of initial beliefs, values
and assumptions about the innovation, by all stakeholders.
• This is a particularly useful concept for addressing the spread and ownership
concepts of Coburn’s (2003), and the ways in which ‘deep change’ can be
facilitated – and cherished values, attitudes and beliefs ‘unlearned’ to enable
ownership over time...
This Photo by Unknown author is licensed under CC BY-SA.

12. ASPiHConference 2023 SustainableSimulation | Brighton, 6-8 Nov 2023
Selected bibliography
• Bryant, P From the middle out - making pedagogical change happen in a complex, messy
worldhttps://peterbryant.smegradio.com/from-the-middle-out-making-pedagogical-change-happen-in-a-complex-messy-world/
• Coburn CE. Rethinking scale: Moving beyond numbers to deep and lasting change. Educational researcher. 2003
Aug;32(6):3-12.
• Dede CH, Rockman S, Knox A. Lessons learned from studying how innovations can achieve scale. Threshold.
2007;5(1):4-10.
• Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations:
systematic review and recommendations. The milbank quarterly. 2004 Dec;82(4):581-629.
• Greenhalgh, T. and Papoutsi, C., 2019. Spreading and scaling up innovation and improvement. Bmj, 365.
• HEE/NHS Simulation strategy link to series of briefing papers: https://www.hee.nhs.uk/our-work/technology-
enhanced-learning/simulation-immersive-technologies
• Rolfe, U. and Partlow, D., 2022. Mental health care in paramedic practice. Class Publishing