Developing online simulated practice placements: a case study

The growing challenges of securing clinical placements for pre-registration nursing students, and recognition by Health Education England (HEE) (2023) for nurses to be digitally confident, inspired faculty staff within the Department of Nursing at the University of Huddersfield to respond by developing and integrating unique simulated placements that embrace online and digital technology.

Throughout nursing and education literature, there are different definitions and interpretations of simulation. Descriptions range from complex and dynamic clinical situations replicated in a controlled environment (El Hussein and Cuncannon, 2022) to a component of healthcare education that can be used successfully for collaboration between professions to develop interprofessional skills (Costello et al, 2017). The Nursing and Midwifery Council (NMC) defines simulation as:

‘An educational method which uses a variety of modalities to support students in developing their knowledge, behaviours and skills, with the opportunity for repetition, feedback, evaluation and reflection to achieve their programme outcomes and be confirmed as capable of safe and effective practice.’

NMC, 2023:14

The NMC has also stated that simulation should be clinically focused, involve real people and used proportionally (NMC, 2018) Recognising this and other definitions of simulation, the simulated placement working group developed simulated practice learning using the principles of problem-oriented learning (adapted from gaming simulation) (Kriz, 2003; Koivisto et al, 2017). This was based on the premise that simulation can involve engaging with real people relevant to the learning outcomes on a digital platform, in a range of activities (including group work) to align with NMC proficiencies. The simulated placements are dynamic in that learning enhances and complements practice learning, and is not a substitute for it.

Each simulated placement provides a structured, innovative, online learning experience integrated throughout the pre-registration nurse education programmes, focusing on the development of clinical and non-technical proficiencies relevant to course completion and employability.

Instructional design

Simulated practice learning builds on sound pedagogical principles of experiential learning (Kolb, 1984; Fry et al, 2015), enabling students to contextualise their learning and focus on clinical situations in a safe environment, practising skills and analysing the rationale for, and the consequences of, nursing actions individually and with their peers.

Learning in ‘real’ clinical environments is essential and important for student nurses but there is evidence that healthcare students can learn effectively via simulated practice (Watson et al, 2012; Bland et al, 2014; Mills et al, 2015; Akselbo et al, 2019; Bogossian et al, 2019; Williams et al, 2022). Clinical practice offers variable opportunities to student nurses, dependent on the learning environment and the activity at the time of the placement, whereas simulated learning offers consistency of experience to learners (Bland et al, 2014), enabling them to pause and analyse a situation/scenario and try out different solutions, which enables students to retain information better and transfer that learning into the ‘real’ clinical environment. As an educational method, simulated practice learning improves nursing students' knowledge, communication and critical thinking skills as well as technical skills (Dubovi et al, 2018; Linn et al, 2019).

The design of the simulations followed guidance from the International Nursing Association for Clinical Simulation and Learning (INACSL Standards Committee, 2016) and published literature on the format of simulations, such as briefing and debriefing, problem solving, learner support, feedback and guided reflection in a structured student journey (Kaneko and Lopes, 2019). The activities that students engage in involve real people as an enhancement to the pedagogic simulation elements. In this way, the proficiencies that students engage with are primarily non-dextrous clinical skills that are often practised in a simulated way in a clinical skills lab. Taylor et al (2021) emphasised the value of the opportunity to stop and reflect on a situation, which is not always possible in a real clinical learning environment. Students also have opportunities for interprofessional learning via a digital platform. Costello et al (2017) recognised the value of this aspect of simulated practice learning. The activities involve participation in self-directed and peer-supported learning that promotes the development of professionalism and resilience (Rogers et al, 2017).

Students engage with clinicians and teamwork, albeit within a simulation. In this way, they are co-constructing significant learning experiences that Fink (2013) suggested leads to meaning being extracted from the learning that may differ from each other but has the potential to be transformational. The activities have clear learning outcomes linked to NMC proficiencies. The virtual nature of the activities allow for wide availability, time flexibility, single- or multiple-user interaction and self-pacing, all of which are important considerations in design (Huun, 2018; Havola et al, 2021, Tinôco et al, 2021).

Simulated placement development process

Faculty staff undertook a major project in the summer of 2021: the Placement Capacity Improvement Project (PCIP). The aim of PCIP was to develop and manage the available clinical learning environments to ensure all nursing students were able to fulfil the NMC requirements of their programme. During the PCIP a decision was made to embed the NMC's Recovery and Emergency Programme Standards (RN6(D)) into current and future nursing curricula, enabling 300 hours of simulated placements to be included in the BSc programme and 200 hours in the MSc programme (NMC, 2021). A task and finish working group was created to develop the simulated placements. The schedule aimed for part 1 simulated placements to commence in December 2021, part 2 simulated placements to commence in February 2022 and part 3 placements to commence in July 2022. The working group comprised:

• Interested academic colleagues from all fields of nursing
• The lead for service user and carer involvement, on behalf of our Public Partnership Group (PPG), to ensure they were included from the start of placement development
• Clinical colleagues (their membership altered as the project progressed, dependent upon availability)
• The lead for education technology with expertise in transforming creative ideas into manageable online activities.

The simulated placement design process is shown in Figure 1. This approach enabled the working group lead to ensure congruence of the activities within the overall focus of each placement. Additionally, working group members and the lead collaborated with colleagues from other universities who had developed simulated placements. Inclusion of simulated placement hours within the nursing programmes was approved by the NMC in the autumn of 2021.

Each part of the simulated placements had a different central focus. These were:

• Part 1. Being an accountable professional
• Part 2. Leadership and working in teams
• Part 3. Preparing for transition to registered nurse.

These foci are each directly relevant to the NMC proficiencies (NMC, 2018) and practice assessment documents. As the students completed the activities, they were guided to collect relevant evidence, which was submitted at the end of each simulated placement. This evidence ensured that the correct clinical hours were recorded for each student. Evidence could also be added to the students' online practice assessment portfolios to discuss with their practice assessors.

Simulated placements were hosted online, requiring close liaison with the university timetabling team, to ensure students were aware of when they were expected to attend an online simulated placement activity and when they were expected to complete directed or self-directed activities. The simulated placements were managed initially by two members of the working group who were registered nurses and practice supervisors, supported by the lead technologist.

Individual activities developed for the simulated placements are varied in nature and designed to promote student exploration of their role and the development of skills relevant to the part of the programme they are studying. Each activity has been discussed with the involvement development lead, who provides a conduit for ensuring the perspectives of service users and carers are considered, along with facilitating their specific involvement where necessary. This has enhanced the authenticity and impact of the simulations because service users and carers were both directly and indirectly involved in the delivery of some activities.

Student engagement was also a central consideration as activities were developed. The role of the lead technologist was essential in supporting the development of the working group's ideas into student-facing materials.

Individual programmes begin in January and September each year, requiring management of the simulated placements to be continuous throughout the year. It quickly became apparent that a dedicated academic lead was required to manage the placements. A successful bid was presented to the leadership team and an academic lead for simulated placements was appointed in August 2022. The academic lead has been pivotal to the ongoing effective delivery, evaluation and development of the placements. In addition, the appointed lead has offered continued support and direction to the working group, being essential in ensuring that the placement remains contemporary and responsive to student feedback.

Professional competencies

The foci of learning each relate to broad themes of professionalism, leadership and teamwork, and the transition to registered nurse. The programme schedule relates to NMC proficiencies, including formative evidence for aspects of practice assessment documents.

Digital confidence is a core component across placements. Students are encouraged to engage with a range of digital technologies (including virtual learning environments, MS Forms, MS Teams, Wakelet and Padlet) to develop their competence. Members of the simulated placement team contribute to HEE Technology Enhanced Learning networks and regularly attend training events associated with simulated learning. Working with HEE ensures that simulated practice learning follows the principles of the National Framework for Simulation Based Education (SBE) (HEE, 2021) to ensure a high standard of simulation-based learning activities for nursing students.

Examples of activities

Figure 2 shows examples of the activities developed for each part of the programme.

Part 1: vSim

The online placement provided an opportunity to use virtual simulation. Members of the team had previously assisted Laerdal Medical® in preparing a UK version of virtual simulation (vSim). Designed to simulate real patient scenarios, vSim is a web-based virtual simulation resource that helps learners develop clinical reasoning skills. It enables nursing students to interact with virtual patients in a safe, realistic online environment, accessed at the student's convenience, embracing contemporary technology and providing evidence-based feedback and evaluation.

To further enhance the potential of vSim, other learning resources, including Elsevier Clinical Skills, were integrated to complement and develop understanding of each patient scenario.

Additionally, members of the PPG who have experienced the same/related conditions participate in the online placement. Students can listen to a real patient sharing their experiences of living with cystic fibrosis, for example, and ask questions in connection with what they have learnt through the virtual patient who has that same condition. The complementary interaction between virtual simulation, real patients and other resources has provided significant reach and value to student learning, offering a different but realistic teaching environment that students can access from home or library facilities on campus. This approach has provided an integral and successful learning experience within the simulated placements.

Part 2: leadership and teamworking skills

The focus in Part 2 was ‘team building and leadership’. The objective was to encourage students to recognise and develop their role within a clinical team and their skills in leadership. The team developed a series of interlinked, virtual, and immersive scenarios. Through smart design and careful use of technology, students were taken through a scaffolded series of online activities designed to test their ability to work in teams and to challenge them to take on leadership roles. These innovative activities were designed to be fun, engaging and motivating. During each placement, students completed three online team-building activities:

An escape room activity

The students had to work together in a custom-built, online, 2D immersive space to solve simple problems based on their knowledge in order to ‘escape’ to a virtual beach bar.

A whodunnit activity

The student groups were timetabled to meet in MS Teams to complete a hospital-based whodunnit. The scenario consisted of a series of 360° rooms that students could explore independently. The students had to allocate tasks, exchange information, and develop a strategy together.

An infection control scenario

This time the scenario was based in a virtual care home in which the group needed to prevent the outbreak of an unknown infection. Students had to apply their knowledge of infection prevention and control and make leadership decisions in a time-limited environment.

Promoting health and wellbeing

This consisted of a group-based ‘task and finish’ activity that spans the full simulated placement in Part 2. The activity focuses on health promotion in relation to five scenarios developed to be relevant in all nursing fields. To ensure the authenticity of the scenarios, clinical colleagues and the involvement development lead were involved, with a wider group of stakeholders consulted as the scenarios developed. The work-flow process for this activity is shown in Figure 3.

Part 3: hope, connection, and reflections

In Part 3 of the simulated placement, students are preparing to transition to registered nurse status. These sessions enable them to recognise and sustain hope through the process of reflection and investing in each other's learning. Hope is key to practitioners' work and wellbeing but can be difficult to define (Read and Noonan, 2018). For this to be what Read and Noonan (2018) described as ‘congruently positive and optimistic about the future’, the authors wanted this to be associated with clinical practice as realistically as possible. Transition to registration can cause anxiety for students and they may want certainty about their role to try to avoid ambivalence and ambiguity in practice. Banks van Zyl and Noonan (2018) emphasised the importance of self-compassion and honest and open reflection, with coping as a way of managing the emotional labour of nursing and this was reflected in session content.

Nurses working in palliative care, paediatrics, mental health and learning disability were filmed in short interviews, reflecting on moments of hope and connection in their practice. These moving films combined reflection on integrated experience practice with an open vulnerability to being moved by their work. As part of a series of workshops exploring supervision skills, students watched these videos and then uploaded their own moments of connection and hope. In turn, students commented on each other's recordings. They were guided in how to offer feedback and demonstrated a mature, thoughtful, and supportive investment in each other's work. By drawing attention to and noticing these moments of connection, students reported feeling more hopeful about their transition to registration.

Students and faculty staff were moved by the reflections and wanted to celebrate the work they had done. A group of students agreed to edit their reflections into a compilation film that could be shared with others, broadening the impact of their simulated practice learning. Others were moved to write to thank the practitioners in the videos.

Learning disability activities

The learning disability session aimed to develop students' knowledge and enhance their professional practice with a focus on person-centred care in terms of accountability of effective use of the professional nursing skills of inclusion, respect, dignity, and consent when communicating or supporting persons with a learning disability, their families, and carers.

Delivery methods and students' engagement varies:

• Students spend approximately 7.5 hours to complete the entire learning disability resource
• Use of Brightspace online technology whereby students engage with the learning disability simulation practice workbook, which is divided into three parts: part one exploring inclusion, parts two and three exploring the themes of consent, capacity, respect and dignity.

Within these three parts, students are guided to complete:

• – Reflective practices considering their previous practice experiences and learning
• – Resources for guided independent reading and learning Application to practice exercises including three conversational video scenarios between a senior learning disability nurse-lecturer, two family carers, and a service-user with learning disability exploring lived experiences and health talks.

Embedded in the activity is a 1-hour pre-assessment online synchronous consolidation of learning facilitated by the senior learning disability nurse-lecturer, during which students' active engagement in the discussions are demonstration of learning attained and positive evaluation of content. There is also a post-session 1-hour assessment/quiz, for which they must score 100%.

Engagement and experience

Direct engagement with stakeholders is central to the evolving nature of simulated placements. We have sought, and responded to student, clinical staff and educator feedback for each component embedded within the placements and for the overall experience at each stage of delivery. This informs iterations to content (including mode of delivery) and involves responding to student ideas about how they can be better supported during virtual learning experiences.

Because developing and delivering simulated placements was a new experience for the team, initiated during a pandemic, careful consideration was needed for how involvement of ‘real patients’ should be defined within this context. Inclusion of a specialist involvement development lead within the team (who is not from a nursing background) meant that it had access to guidance on best practice for meaningfully involving Public Partnership Group members, along with ongoing facilitation of their involvement during resource development and live delivery.

Formative assessment/evidence of competencies

The working group was aware that simulated placements should not be viewed as a theory module, with a summative assignment for marking, but as the students would be credited with clinical hours upon completion, it was vital that this was evidenced and recorded appropriately. Students were asked to provide a single Microsoft Word document comprising screenshots of proof of completion for each activity, at the end of the placement. Surprisingly, this task caused anxiety among the cohort, which was unexpected. Although research has demonstrated that student nurses are regular users of social media and communication technologies, this demographic struggled with the use of digital platforms used for learning (Lokmic-Tomkins et al, 2022). This lack of digital confidence was one of the main challenges for the students and for the educators to create solutions to overcome this.

Additional challenges

Additional challenges included managing many students in an online MS Teams call. Some students commented that they felt overwhelmed by an abundance of questions in the chat function and frustrated with repeated questions being asked by students struggling to comprehend the instructions. Solutions to these barriers included recording sessions, providing drop-in solution-focused sessions for the least confident students and the use of an online community on MS Teams to encourage peer support. This was implemented ad hoc for the inaugural placement in response to the concerns raised, then planned for subsequent cohorts. A recurring theme during placements was a minority of students not participating in groups. Subsequent cohorts were encouraged to meet in groups prior to activities to encourage confidence in their team-working skills. Some students set up WhatsApp groups for their set and reported that they found this useful for encouraging participation. Subsequent cohorts were also facilitated to create student-led ground rules for the cohort using Padlet, displayed on the online learning environment and referred to throughout the placement.

Evaluation

Student evaluations of simulated placement content delivery and effectiveness have been mostly positive. Evaluation activities also provide an opportunity to assess student learning. The evaluations draw on the Kirkpatrick (2006) Evaluation Model as well as Bowyer and Chamber's (2017) framework for evaluating blended learning. Illustrative quotes from students on example activities and overall experience are shown in Table 1.

The authors surveyed Part 1 and Part 3 BSc students in their clinical placement, who had undertaken their simulated placement approximately 2 months earlier, to better understand the impact of their simulated placement and application to practice. Feedback from students currently on clinical placement supported the use of simulated placement content and ‘strongly agreed’ or ‘agreed’ that content was applicable to their current practice. Qualitative responses are shown in Table 2.

Taken together, students value the opportunity to practice skills in a safe environment, learn about different patient experiences and deepen knowledge on common conditions, develop team-working skills, gain digital confidence and develop personal and professional non-technical skills.

Conclusion

In a relatively short time, the simulated placement working group has developed a clear set of aims, objectives, rationale, and content through collaborative teamwork to support an essential adjunct to the clinical environment to prepare student nurses for practice. Placement content, feedback and iterations for improvement are transferable to other institutions and have the potential to support curriculum and continuing professional development and education across disciplines, institutions, and the international community. The NMC has recently supported the increase in simulated placement hours within nursing curricula. The Huddersfield model is an approach to embedding simulated practice learning across all parts of the programme. Early evaluation suggests that students are able to transfer their learning into ‘real’ clinical environments. This is a model that can be tested at other universities.

KEY POINTS

• It is possible to create clinically relevant simulated placements in an online environment
• Simulated placements are dynamic in that learning enhances and complements practice learning, and is not a substitute for it
• Involving service users and carers from initial developments, delivery, and evaluation of simulated, online placements is essential to support clinically relevant learning opportunities
• The University of Huddersfield model is an approach to embedding simulated practice learning across all parts of the programme in an online environment
• An online simulated placement can improve digital confidence in student nurses

CPD reflective questions

• If you were developing a simulated online placement, what activities might you include?
• How could senior student nurses support junior student nurses during a simulated online placement?
• In what ways would you involve service users and carers in an online simulated placement?