On 18 February 2021 the Nursing and Midwifery Council (NMC) published details of updated policy to help nursing students achieve the mandatory competencies necessary for registration amid the ongoing clinical practice constraints during the COVID-19 pandemic (NMC, 2021a). All student nurses studying at an approved education institute (AEI) will be able to replace up to 300 hours of clinical practice hours with simulation activity. The NMC has issued this new directive in the form of an educational recovery standard to give those offering nursing programmes greater flexibility in meeting the NMC current stipulations on mandatory practice hours.
In response to the emerging COVID-19 pandemic, in early 2020 the NMC introduced a set of emergency standards for nursing and midwifery education, many of which were lifted after the first national lockdown. The ongoing pandemic is still constraining the opportunities for students to gain experience and learn in real-life situations and has led the NMC (2021b) to issue a further directive to help educational institutions meet their legal obligations with regard to providing students with specified hours of clinical practice.
The introduction of this directive reflects the genuine difficulty that educational providers and their partner NHS organisations are currently facing in supporting students in their clinical placements during the pandemic. The primary objective of this new strategy is to enable students to practise and learn through simulated practice learning where conventional clinical practice isn't available or isn't possible.
Hence the NMC will now, when necessary, allow AEIs to offer students up to 300 hours of simulated learning across the length of their programme. The NMC is allowing AEIs to decide for themselves how to implement this new standard but it will sanction, for example, activities such as peer learning and working with manikins, which can offer students simulated scenarios that convey realistic experiences in situations such as resuscitation. Such environments offer participants a diverse range of patient scenarios through which they can be taught, in the safety of a skills laboratory, to operate in real-world clinical environments.
Despite endorsing simulation as a viable route to achieving competencies, the NMC is adamant that a nursing student's final placement before registration must be spent in a conventional clinical care setting. This new recovery standard applies to all approved programmes including nursing apprenticeships and nursing associate programmes.
Background
Simulation in nursing programmes is as old as the development of nurse education itself. When Florence Nightingale launched the first modern educational programme for nursing students in 1860, learning through simulation was already a facet of nurse education. Nightingale herself fully understood that she had to get nurse education off on a strong footing and the new nursing education programmes were quick to utilise simulation in some form to teach the basic principles and skills required to deliver nursing care. In context, the practical or demonstration room, the forerunner of today's skills laboratories, became ubiquitous across successive emulations of schools of nursing across the country.
Davenhall (1985) gave a fascinating account of how practical examinations using simulation became part of the rites of passage towards full registration as a nurse in the UK. In 1924, after the introduction of the national nursing curriculum by the General Nursing Council (GNC), practical examinations for student nurses were implemented nationwide. These practical examinations were usually held in the school of nursing practical rooms and up until 1960 were conducted by GNC-appointed doctors and nurses but subsequently delegated to the individual training schools. There were two practical examinations held during a nurse's training and these often involved students setting up a trolley or tray followed by a series of questions posed by the examiners about the particular skills involved. To enhance reality and authenticity, volunteer ‘patients’ were often used but gradually nurse educators began to question the validity of these practical examinations and by the early 1970s they were phased out. They were replaced by a series of four practical assessments conducted by clinical teachers within real-life clinical situations, which had to be passed before state registration as a nurse.
All nursing students had to maintain a ‘Record of practical instruction’, which consisted of lists of essential skills that the student had to acquire and be signed off in prior to registration with the GNC. I vividly remember during my allocation in the operating department having the theatre sister watch me set up a general set where I had to remember all of the instruments needed for surgery. These records of practical instruction were issued by the GNC and were colour coded: blue for general nursing, red for mental health, green for learning disability and pink for sick children's nursing students.
How many hours of practice are required for registration?
When the UK joined the European Communities on 1 January 1973 the GNC needed to abide by the community's stipulations on the number of student nurse practice and theory hours. Today the European Union (EU) has a directive that contains the provision for a minimum of 4600 hours in the training of general care nurses (split equally between theoretical and clinical). The UK no longer has a separate register for general nurses as this was phased out during the transition to Project 2000. Nevertheless the current adult field of practice does still meet the EU requirements for general nursing and in context the other smaller fields of practice also match the practice hour requirements ie 2300 hours. Other non-European countries have far fewer stipulated hours of practice with Australia, for example, only requiring 1000 hours of clinical practice for qualification.
Now that the UK has left the EU many would argue that there is an opportunity to reconsider placement hours and to repeal the EU directives in UK law. The NMC (2021c) has already commissioned independent research to investigate any potential changes to the current programme standards following Brexit. Even before the pandemic began the Royal College of Nursing (RCN) was advocating that there should be a reduction in the 2300-hour clinical practice stipulations. During the 2019 RCN Congress meeting one of the items debated was ‘That this meeting of Congress urges RCN Council to demand that the NMC reduces student nurses' clinical placement hours in line with international comparators’. The RCN has been keen to stress that it is the quality of placement hours that is important not simply the quantity of those hours spent in practice (RCN, 2021).
Replacing clinical hours with learning through simulation
The 2010 Standards for pre-registration nursing education first allowed accredited educational institutes under certain criteria to offer up to 300 hours of practice learning via simulation (NMC, 2010). However, given the relatively unproblematic availability of clinical placements before the pandemic, not all AEIs availed themselves of the opportunity of replacing real-life clinical learning with simulation. In any event the replacement of clinical hours with simulation was strictly monitored by the NMC and any university wishing to do so was required to conduct a stringent audit of compliance with exacting NMC simulation criteria. Most universities did offer simulation but not as a strategy to offset practice hours. The difference in 2021 lies in the learning restrictions in practice caused by the pandemic.
Much of contemporary simulated skills learning in nursing involves the use of sophisticated manikins and high-fidelity human simulation has been shown to provide an innovative teaching method for nursing students. Some, such as Alexander et al (2015), believe that high-quality simulation experiences could be substituted for up to 50% of traditional clinical hours in the US pre-registration nursing curriculum.
Today's manikins have come a long way from the life-sized dolls of yesteryear. The first example in nurse education was ‘Mrs Chase’, named after the dollmaker who made her in 1911 (Aebersold, 2018). Student nurses used her to learn various skills such as patient turning and transfer. As these tools became more refined, nursing students could practise a variety of techniques such as the insertion of nasogastric tubes or the application of dressings and learn other basic nursing skills. Contemporary skills laboratories in nursing schools use anatomically correct simulation men, women and babies, which are interactive manikins designed for teaching specific techniques such as advanced adult and paediatric life support skills—they can be programmed to react to various situations including cardiac arrest. Such manikins are also used by other healthcare students. Swamy et al (2013) showed that first-year graduate entry preclinical medical students were able to learn chest examination through the use of SimMan. They demonstrated a significant improvement in the students' knowledge and competence in performing chest examination after learning by simulation.
Undoubtedly high-fidelity manikin-based simulation can be an effective way to facilitate skills acquisition. However, the current pandemic may prohibit student groups meeting face to face in a skills laboratory for fear of infection and more and more nursing schools around the world are experimenting with virtual simulation, the use of avatars in virtual worlds, as a way for student nurses to acquire skills online (Foronda and Bauman, 2014; Miller and Jenson, 2014).
Conclusion
The NMC has asked AEIs to report back on how successfully they are applying this change to nurse education standards and, importantly, how students' practice learning opportunities are being interpreted to ensure the satisfactory achievement of proficiencies. The problems in nurse education caused by the current pandemic will surely result in further advances in the use of simulation to acquire clinical nursing skills either in a skills laboratory or within virtual online nursing domains.
KEY POINTS
- The NMC has developed an education recovery standard to help nursing students achieve the mandatory competencies necessary for registration during the COVID-19 pandemic
- Education institutions will be able to replace up to 300 hours of clinical practice hours with simulation activity amid the clinical practice constraints
- The new standard will sanction activities such as peer learning and working with manikins conveying amplified realistic experiences in situations such as resuscitation
- Now that the UK has left the EU there is an opportunity to reconsider the total number of placement hours necessary for registration
- The use of avatars in virtual simulation as a way for student nurses to acquire skills online is also becoming popular