COVID-19 has had an impact on teaching and learning, requiring education providers to seek innovative ways to adapt to such challenges. Lectures have been adjusted for online delivery, with technology, assessment and curriculum all requiring modification to address the developing situation. One such area that has grown in popularity during these challenging times is simulation (Hays et al, 2020).
Simulation offers a safe environment to practise, learn and discuss clinical practice without the threat of catastrophic consequences (So et al, 2019). Simulation-based education must focus on the safety of patients and therefore provide effective educational outcomes for those taking part (Health Education England (HEE), 2020). The development of competency frameworks that recognise nationally agreed key abilities and knowledge required for the delivery of safe advanced clinical practice is essential. Several authors have referred to the necessity of competent advanced clinical practice and therefore the need for supporting competency frameworks (Furlong and Smith, 2005; Bench et al, 2018; Dover et al, 2019). The required capabilities and competencies, aimed directly at advanced clinical practice, have subsequently been provided via such structures (Department of Health (DH), 2010; HEE, 2017; Institute for Apprenticeships and Technical Education, 2018). Competency frameworks to address generalist capabilities have been developed by HEE (2017), with the addition of specialist competencies provided by the Royal College of Emergency Medicine (2017), the Faculty of Intensive Care Medicine (2015) and the Royal College of General Practitioners (2015). The adoption of these capabilities into advanced clinical practice curricula is therefore advantageous and may support the development of knowledge and skill (Dover et al, 2019).
HEE (2020) has outlined the role that simulation can play in supporting national policies and strategic developments in ensuring that healthcare practitioners are supported, adaptable and capable of delivering safe and effective care. Simulation provides a rehearsal of the clinical encounter, an opportunity for the exploration of clinical reasoning and the development of a modern workforce that is capable, resilient, and able to work seamlessly in a multiprofessional environment, ensuring the optimisation of patient safety (HEE, 2020).
Advanced clinical practitioners (ACPs) are required to have a high degree of autonomy, with the ability to make complex decisions, for which they are ultimately responsible (HEE, 2017). It is not just the curriculum that impacts upon the ACPs' educational and clinical needs, but a complex interwoven mix of clinical, academic/educational, emotional and reflective experiences that shape their learning (Reynolds and Mortimore, 2021). Therefore, a curriculum designed to support the development of trainee ACPs and other professionals employed to practise at such a level, must provide not simply the required capabilities and competencies, but rather a structured and supported fusion of both academic and clinical education to offer a meaningful experience. Simulation is one way to help achieve such an ambition.
What is simulation?
Simulation has been used in medical, nursing and dental education for the past 60 years (DH, 2011). It is defined as:
‘A technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion.’
Simulation is acknowledged as an important element in healthcare education programmes (Warren et al, 2016), with HEE (2020) supporting the use of simulation and immersive learning technologies for training the NHS workforce.
The versatility of simulation allows for a variety of practical scenarios to be considered and developed into a potential learning experience. Simulation can vary from involving complex software that can detect variables that alter the simulated patient's response, to simulations that explore emotions and relationships and their impact on patients and clients (Fry et al, 2003; HEE, 2020). The ability of simulation to allow for ethical, professional and legal debates related to complex scenarios, away from the practice area, is advantageous. In such situations, students are supported with debriefs following emotionally charged simulations that can be facilitated away from the pressures of the real clinical environment (Fry et al, 2003; Warren et al, 2016; So et al, 2019). The scope of simulation ranges from a static model to a fully automated skills suite or simulation booth. The experience for the learner can be solitary or in groups. The main features are that simulated practice can take place without the potential risk of harm to patients/clients, while supporting the development of good performance in stressful situations (Hubert et al, 2014). Moreover, simulation provides a safe environment where students can reflect on areas of practice that were successful, as well as learn from mistakes without compromising their professional integrity (Rudolph et al, 2014; So et al, 2019).
This safe practical environment is attractive to professional education and health providers, who actively endorse the use of quality simulation to develop competent practice in their workforce and professional members (DH, 2011; Nursing and Midwifery Council (NMC), 2018: 23-24). It is suggested that simulation offers the learner the opportunity to develop skills in the rapid processing of information, which is highly desirable in a fast and changeable clinical environment (Satish and Streufert, 2002). This structure for implementing simulation into a curriculum was described by Platt et al (2010), who argued that simulation can be integrated into education, taking into consideration the students' learning needs and the curriculum's learning objectives. This mixed modality approach combines simulation exercises with classroom teaching.
Although the issue of a simulated environment may appear at odds with the real-world experience, simulation is required to fill the void of reduced clinical opportunities, reduced hours dedicated to training and competition for clinical opportunities in an increasingly multidisciplinary healthcare environment (Maran and Glavin, 2003). That said, simulation is not designed to replace real-life experience, it is there to help facilitate the acquisition of skills and boost student confidence. It offers a practical solution to reconstructing environments that by their very nature are constantly in a state of change, thus helping to prepare the student for modern day healthcare clinical practice (Issenberg et al, 2005). It is these relationships between the increased service requirements and the need to develop ACPs with the appropriate skills and knowledge, that this collaborative research study sought to explore.
Background to the study
The study emerged as a byproduct of a doctoral thesis aimed at considering the impact of a master's degree in advanced clinical practice on the educational, clinical, and professional development of advanced nurse practitioners (ANPs). The use of simulation to support advanced clinical practice education was referred to by the research participants but infrequently. Therefore, although useful, it did not appear to be the most influential part of the development of ACPs. However, this was not in keeping with the anecdotal feedback from ACPs who had engaged with a well-structured simulation provided by a local hospital trust simulation team, which they felt was instrumental in their learning. Thus, a collaborative qualitative research study was proposed.
The notion of collaboration between academia and clinical practice is not new and was supported by Fitzgerald et al (2013) in their article related to sustainable and flexible learning in a master's programme designed to support ACPs. The authors described the development of modules that help link theory with practice by using action research, incorporating interviews, focus groups and journal reflections, although there is no mention of the use of simulation. Although focus groups and journal reflections are helpful, there is still a requirement to cement knowledge in real time. This is supported further by the views of the student ANP study participants, taken from the doctoral thesis. One participant discussed points they felt were important in advanced practice curriculum design, as follows:
‘Good links with the university I think is really, really important, having that deep understanding of investigations and disease process … things like OK your bleep goes off and you've been called to a patient who is hypotensive, that's real life, what would you do, what are the questions you are going to ask? Having some simulation like that would be brilliant.’
Participant NI7
This type of response, in addition to the anecdotal feedback from ACPs engaging with the simulation sessions, prompted further investigation.
Method
This qualitative study was developed in collaboration with a local acute hospital trust, to examine the experiences of ACPs undertaking a simulated event on dates indicated in Table 1. The scenarios, which were designed by the simulation team within the trust and led by an experienced consultant from the emergency department, related to complex clinical events within primary and secondary care, which were enhanced using actors (Pascucci et al, 2014).
Table 1. Number of advanced clinical practitioner attendees at the simulation sessions
| Date of simulation sessions | Number of attendees (3 trained, 25 trainees) |
|---|---|
| 17 June 2019 | 8 |
| 9 September 2019 | 8 |
| 14 October 2019 | 8 |
| 9 December 2019 | 4 |
Ethical approval from the higher education institution (HEI), the Health Research Authority and the research and development department at the local hospital trust was sought and obtained. Data collection tools used in this qualitative study included a questionnaire (Table 2) and a focus group (Box 1). Participants were also given an information leaflet and a consent form.
Table 2. Questionnaire on the simulation event
| Question 1 | How effective do you feel this form of simulation is in relation to the education and development of practitioners' clinical skills and knowledge? | Not at all | 1 |
| A little | 2 | ||
| Neither helped nor hindered | 3 | ||
| Quite helpful | 4 | ||
| Very helpful indeed | 5 | ||
| Question 2 | Did the scenarios help you explore your clinical reasoning and decision making? | Not at all | 1 |
| A little | 2 | ||
| Neither helped nor hindered | 3 | ||
| Quite helpful | 4 | ||
| Very helpful indeed | 5 | ||
| Question 3 | Do you feel that this approach has helped you feel better prepared and more confident in your clinical practice? | Not at all | 1 |
| A little | 2 | ||
| Neither helped nor hindered | 3 | ||
| Quite helpful | 4 | ||
| Very helpful indeed | 5 | ||
| Question 4 | Is there anything that you feel would enhance this simulation and debrief event? | ||
| Question 5 | Is there anything that you would like to comment on regarding your own experience of the simulated event that has not been addressed in the above questions? | ||
The questionnaire included a comment box for each question, asking for participants' experience of the simulation event and debrief
Box 1.Focus group questions
- What was your overall impression of the experience?
- What do you feel was the most informative part?
- Was there anything that you felt did not help?
- What do you think about the use of simulation in relation to the development of advanced practice skills and knowledge?
- Is there anything you feel is important to add or discuss in relation to the simulation event that has not been discussed?
A purposive sample was acquired via the simulation events held at the acute hospital trust. Volunteers wishing to take part submitted their completed questionnaire. Those wishing to take part in the focus group submitted their contact details to be recruited at a later point. The simulation sessions were based on four scenarios that were adapted to mirror the candidate's workplace. Those working outside the acute trust undertook the simulation in a clinical room that offered a non-ward environment. For maximum impact, recruitment was permitted of up to 10 participants per simulation event. However, on all four occasions the number of attendees did not exceed eight. Evidence for such a number is supported by So et al (2019) who suggested that small group teaching allows for ‘stop and pause’ moments, offering more time to discuss clinical decisions, outcomes, team interaction and feedback delivery. The simulation took place over a 7-month period, with between four and eight trainee and qualified ACPs taking part in each session (Table 1).
Findings
Of the 28 attendees, 10 questionnaires were completed. As the questionnaires were anonymised to maintain confidentiality, it was not possible to distinguish between trainees and qualified ACPs. Questions 1 to 3 included a Likert scale, the responses to which are shown in Figure 1, with an additional free-text box provided to capture the participants' personal experiences. Questions 4 and 5 offered free-text boxes only.
Findings from the Likert-style questions
In response to question 1 ‘How effective do you feel this form of simulation is in relation to the education and development of practitioners' clinical skills and knowledge?’ 90% of the students who volunteered a response said they found the simulation very effective (Figure 1). Similar positive responses were provided to questions 2 and 3.
Findings from the free-text responses
Question 1
The free text option offered participants the chance to provide additional feedback, which captured their personal responses and their individual experiences of the simulation event. A selection of responses to question 1, which explored whether the scenarios helped with developing clinical reasoning and decision making, is provided below. The responses were positive and help endorse the use of simulation as part of the educational development of ACPs:
‘Safe learning environment, to practice before seeing real patients. An opportunity to network and share experiences.’
Participant 1
‘There is currently no other education sessions available to trainee ACPs working within the community setting. Whilst some elements of the training are not relevant to primary care practice, the recognition of poorly patients is vital in any setting.’
Participant 5
‘Being able to practice scenarios in real-life allows learning that would not happen from just discussing or learning about this in theory.’
Participant 2
The suggestion of a safe environment where one can practise, discuss cases, and practise case scenarios based on real life is supported by the work of So et al (2019), DH (2011) and Issenberg and Scalese (2008). These authors proposed that simulation can be created at any time to mimic a variety of situations and ethical dilemmas.
What simulation provides is a safe space in which mistakes can be made and recognised and from which learning how to manage them can be discussed and developed. This suggestion is reflected in the free text answers to the questionnaire and supports the assertion that simulation offers vitally important learning and a chance to debrief and feedback to ACPs and develop their skills and confidence.
‘Good to discuss cases and what you would actually do in practice. Gives you confidence in your ability to recognise and request appropriate treatment.’
Participant 3
‘I find simulation is the best form of learning for me. It helps to develop clinical knowledge and ability, but also to change attitudes and culture to giving supportive feedback.’
Participant 4
‘Enables confidential discussions and constructive feedback in non-judgment environment’
Participant 10
Question 2
When the participants in the study considered whether the simulation helped them explore their clinical reasoning and decision-making abilities, again the feedback received from the questionnaires was positive:
‘Yes – it made me realise that I have relevant skills, but also highlighted my gaps.’
Participant 3
‘Yes – group discussion and reflection/feedback allows for the identification of strengths/weaknesses and areas for development.’
Participant 5
‘Excellent way of delving into thought processes and why we do the things we do.’
Participant 8
Question 3
This positive feedback continued with question 3, when asked if simulation helped them feel more prepared and more confident in their clinical practice. Extracts related to this question are offered below.
‘Yes – it has improved my confidence as I suffer with imposter syndrome.’
Participant 4
‘It helps build confidence and reinforces existing knowledge. Also providing new knowledge.’
Participant 7
‘Helped with my confidence and acknowledging my own limitations.’
Participant 8
Questions 4 and 5
When the participants were asked whether there was anything that would enhance the simulation and debrief event (question 4) or anything else on which they would like to comment regarding the experience (question 5) they appeared to want more scenarios related to general practice, the acutely unwell patient, prescribing, feedback from the actors playing the patient relating to how they felt and more opportunities to engage with simulation and debriefing:
‘Cases specific to general practice may be more useful.’
Participant 1
‘Maybe a little session on assessment of the acutely unwell … as a refresher.’
Participant 2
‘Feedback from the patient, how did they feel?’
Participant 4
‘Regular sessions to provide skills/knowledge or revisit previously taught sessions. Relative to community primary care.’
Participant 5
‘More sim sessions! I find it really valuable.’
Participant 8
Opportunities to engage with simulated activity more frequently were supported by Issenberg and Scalese (2008) as part of a structured approach to its delivery. These authors indicated that simulation should encourage active participation by the student and should reflect reality as much as possible. Simulation needs to be conducted in a controlled educational environment, using various scenarios that are related to clear outcomes and goals and supported by feedback (Issenberg and Scalese, 2008; DH, 2011; So et al, 2019). Issenberg and Scalese (2008) also referred to the need for repetition, which Harder (2018) suggested helps improve team performance.
This idea of reiteration was acknowledged by Warren et al (2016) who stated that repetition supports the development of greater longevity of skills, which is not necessarily as apparent with a one-off exposure.
Participants in the present study found the simulation scenarios useful and essential to learning:
‘I thoroughly enjoyed the day and learnt a lot about my own clinical expertise and knowledge base. Also, from a networking perspective it was a valuable experience.’
Participant 3
‘We need as many opportunities of this training as possible.’
Participant 4
‘Stressful but fun.’
Participant 7
‘Crucial part of learning.’
Participant 9
The findings from this qualitative study support those of Parry and Fey (2019) who state that simulation improved confidence, knowledge, and satisfaction, but that more research was required on evaluating the theory-practice gap, the effect of simulation on patient outcomes and its effect on postgraduate education.
Findings from the focus group
The focus group offered further insight into the potential impact of simulation on the development of ACP, from both primary and secondary care. When the focus group (n=4) were asked about their experiences of simulation, one participant said they had been ‘terrified’, because having a primary care background meant they felt ‘daunted’ by the acute ACPs who they felt had more knowledge. This had affected the participant's confidence. The participant stated that acutely ill patients were not often seen in primary care and that they had always worked within a primary care setting, so had ‘limited exposure’ to this, which left them ‘feeling vulnerable’.
Participants from the acute trust showed empathy towards their colleague from primary care and said they also lacked confidence in some clinical skills. However, all participants felt that simulation was beneficial, and that they learnt more from simulation than in the classroom. However, some commented that they were not yet comfortable within the ACP role as they were still trainees. Another participant spoke of ‘expectations’ on the ACP, ‘that you could learn a lot and enjoy the simulation’, but there was ‘performance anxiety’. Generally, the focus group felt that simulation ‘exposed them’ and could leave them feeling ‘vulnerable and open’, but once it was over the ‘feedback was always supportive’ and therefore after the simulation the participants ‘felt more confident’.
Limitations
The study had limitations. Notably, only 10 people out of 28 participants completed the questionnaires and only 4 took part in the focus group. This was due to the limited number of simulations available and the maximum of 10 participants per simulation event, to ensure the simulated learning was of maximum benefit (Lateef, 2010; So et al, 2019). Moreover, the questionnaire completion was purely voluntary and, in addition, after four sessions, COVID-19 impacted on the clinical setting and further planned simulations could not be held. Further restrictions existed due to workloads and availability of the simulation team to provide a structured and well-run simulated experience. In addition, the simulation experience was offered by an acute trust, although the participants were from both primary and secondary care. Unfortunately, the effects of COVID-19 also impacted on the focus group, which eventually took place virtually with only 4 participants able to join. Despite the limitations, the participants' experiences help to provide rich data from which further studies may be developed.
Discussion
Simulations present authentic situations (Issenberg and Scalese, 2008; DH, 2011; So et al, 2019) and offer an opportunity to experience safe real-world experiences that are guided, interactive and instructive (HEE, 2020). However, simulation is costly and labour intensive in relation to the human resources required to provide it and the technology associated with high-fidelity simulation (Issenberg and Scalese, 2008; So et al, 2019). For this reason, the researchers asked a follow-up question of the focus group: ‘Where do you think your knowledge and skill development really takes place?’
The response from the primary care participant was ‘ward rounds’. The participant said that this was where ‘cases could be discussed’. The point was made that ‘you can learn from textbooks’, but ‘patients don't present like that’. Other participants suggested that ‘academic modules designed to support history taking and patient examination skills helped with skills and knowledge in how to examine a patient’. These skills could then be ‘built on’ in a ‘self-directed way’. One participant spoke of knowledge and skills developing a form of ‘triangulation’ and described the experience using the model described in Figure 2.
Clearly there is a suggestion that simulation has an impact on the development of ACPs and that they gain personally and professionally from the experience. Indeed, participants in the focus group suggested that simulation offered an opportunity ‘to adapt practice’ and while doing this ‘no harm’ came to the patient. There was also the suggestion that undertaking simulation outside their usual team offered the participant the opportunity to get to know the strengths of ACPs from other teams, and therefore simulation outside of established teams may be beneficial. One participant made the point that when someone is without their usual team in a simulation ‘You can look at your own role and see what you are as an ACP’. This allowed for ‘shared learning’, about the differences between primary and secondary care and an appreciation of how people handle situations in different ways, which may help with learning and understanding.
One participant suggested that ‘consolidation’ of knowledge and skills is helped through the use of simulation. This prompted another question from the researchers: ‘Could/should simulation be used in ever-increasing complexity through a master's programme of study or be run as a joint simulation session with doctors?
The participants agreed that it could be helpful to do this and ‘develop the simulation to become more challenging as knowledge accumulated as the programme developed’. The ACPs acknowledged that, as they progressed, they wanted simulation to provide an opportunity to practise leadership skills but said they had found that ‘when doctors were involved, they have a tendency to take over’.
The structured approach to simulated learning as indicated by Issenberg and Scalese (2008) can also be enhanced through the use of Simulation using Team Deliberate Practice (Sim-TDP). Platt et al (2021) explored this suggestion with undergraduate student nurses. They indicated that Sim-TDP helped avoid variation in simulated learning, by offering simulation that embraced clearly identified goals, underpinned by reflection on enactment and feedback from experienced clinicians. The outcome of the study was encouraging and indicated that Sim-TDP could help enhance the participants' performance.
Conclusion
The participants in this qualitative study found simulation beneficial and wanted the opportunity to participate in further simulations, offering various scenarios, with differing levels of complexity and involving multiprofessional teams. The value of a structured, safe and supportive simulated activity proved a positive experience that enhanced their learning. Therefore, in this study, the participants found simulation to be a valuable addition to advanced clinical practice education. However, it was also suggested that simulation should not be undertaken in isolation but should form part of a comprehensive and structured approach to the education of ACPs. This approach includes the formal theoretical and clinical education provided by HEIs and the support offered by clinical supervisors in the clinical environment. The suggestion that simulation seeks to mimic, not replace, clinical skill and knowledge was highlighted by Harder (2018), who identified that although simulation replicates the clinical environment, the impact and worth of the real clinical environment as a place to learn should not be underestimated. Figure 2 depicts such a collaboration between the classroom, clinical environment and simulation and offers a suggested model for the inclusion of simulated practice in ACP education.
KEY POINTS
- Simulation is a valuable addition to the education and development of advanced clinical practitioners (ACPs)
- Simulation offers a safe place for ACPs to learn, debrief, network and develop skills and confidence
- Although simulation can leave the ACP feeling exposed and vulnerable, with a debrief and feedback the experience can help develop confidence, adapt knowledge and consolidate learning
- Simulation forms part of a ‘triangulation’ between the classroom and supported clinical learning and helps facilitate the development of skills and knowledge
CPD reflective questions
- Could simulation be included within your own educational programme and, if so, where?
- Does simulation offer an opportunity to link the theoretical component of advanced clinical practitioner education with the reality of clinical practice?
- Could/should simulation be used in ever-increasing complexity through a master's programme of study or be run as a joint simulation session with doctors to enhance multiprofessional working?