# Bridging the Gap: A Quality Improvement Initiative to Enhance Support of Locally Employed Medical Registrars Through High-Fidelity Simulation

## TL;DR

This study shows how high-fidelity simulation training can help non-training grade medical registrars in the UK feel more confident and prepared for their roles.

## Contribution

A targeted simulation course for non-training grade doctors was developed and evaluated using a quality improvement approach.

## Key findings

- 70.6% of SAS doctors felt unprepared for registrar duties despite prior experience.
- Participants reported increased confidence in managing acute emergencies and improved leadership and communication skills.
- Simulation was perceived as realistic and relevant, with practical application of skills observed in follow-up.

## Abstract

Introduction: Transition to the medical registrar role often lacks sufficient support, particularly for non-training grade doctors such as speciality and specialist (SAS) and locally employed doctors (LEDs). In the UK, while simulation-based education is well-established in early postgraduate stages for trainees in medicine, opportunities at the registrar transition level are limited for these groups. At Medway NHS Foundation Trust, no ongoing simulation existed for registrars outside formal training, despite the Royal College of Physicians' recommendations advocating equitable educational access for SAS and international medical graduate (IMG) doctors. This study describes a local needs assessment identifying training gaps and evaluates a targeted simulation course designed for SAS medical registrars with non-UK primary medical qualifications.

Methods: A three-step quality improvement (QI) approach was undertaken: (1) needs assessment via an anonymised online survey for SAS doctors, internal medicine training (IMT) stage 1 year 2 (IMT2) trainees, LEDs, and registrars, exploring demographics, clinical experience, self-perceived preparedness, and training gaps; (2) a bespoke one-day high-fidelity simulation course for six SAS medical registrars, targeting acute clinical scenarios and human factor skills, with live observation and facilitated debriefs focusing on clinical and non-technical competencies; (3) evaluation applying the Kirkpatrick model, including immediate post-course feedback assessing satisfaction and confidence change, and a one-month follow-up survey measuring behavioural changes, application of learning, and context barriers. Data were analysed quantitatively, and thematic analysis was applied to qualitative feedback.

Results: Baseline survey results showed 70.6% (n = 13) of respondents felt unprepared for registrar duties despite most having 1-3 years’ experience in the role, highlighting a significant gap in confidence. All valued simulation training, mentorship, and shadowing, with some SAS/LEDs considering stepping down due to role challenges. Post-simulation, all participants rated scenarios as realistic and relevant, all (n = 6) reported increased confidence in managing acute medical emergencies, and 83.3% (n = 5) described improvements in leadership and communication skills. One participant’s performance concern was identified, prompting targeted support. At one-month follow-up, respondents reported practical application of skills such as leadership, on-call and improved communication, alongside increased reflective practice. Limited peer feedback constrained a comprehensive behavioural change assessment.
Conclusions: This QI project demonstrates the feasibility of using high-fidelity simulation to support medical registrars, particularly non-training grade doctors, by enhancing perceived confidence and identifying learning needs. Given the small sample size and reliance on self-reported outcomes, findings should be interpreted as preliminary and reflective of perceived educational value rather than objective competence. Nevertheless, simulation may represent a feasible and locally scalable educational approach to support equitable professional development for SAS and LEDs in line with the Royal College of Physicians' recommendations.