There has been increased interest in developing simulation placements for student nurses to replace clinical hours spent on hospital wards (Meyer et al, 2011; Watson et al, 2012; Au et al, 2016; Brien et al, 2017; Soccio, 2017). This has largely been driven by a lack of placements in the UK. The Nursing and Midwifery Council (NMC) (2019) defines simulation as:
‘An artificial representation of a real-world practice scenario that supports student development and assessment through experiential learning with the opportunity for repetition, feedback, evaluation and reflection.’
Studies have shown similar or, in some cases, superior outcomes in student confidence, skills and knowledge when using simulation-based education methods (Larue et al, 2015; Curl et al, 2016; Brien et al, 2017; Soccio, 2017; Hewat et al, 2020). The literature appears mostly in favour of replacing a percentage of traditional clinical hours with simulation (Williams et al, 2009; Watson et al, 2012; Roberts et al, 2019; Wands et al, 2020). However, the majority of these studies have used one method of simulation delivery, that is, high fidelity. This form of delivery involves interactive patient simulators and realistic environments giving a high level of realism, which is resource intensive and therefore can be challenging to deliver to large cohorts of students. Interestingly, there is little evidence of the effectiveness of using blended simulation methods to replace clinical hours or explorations of the impact on the student learning and experience if simulation were to replace a whole clinical placement.
Revalidation by the NMC of a pre-registration nursing programme presented the opportunity to develop and replace a 4-week clinical placement for first-year paediatric, mental health and adult nursing students with a simulation placement. This would use a combination of novel blended methods, encompassing both face-to-face teaching and e-simulation to create a unique, immersive, interactive experience. This article describes how this simulation placement was developed, operated and adapted due to COVID-19. In addition, student nurses' experiences and preparedness for practice are explored and comparisons made with evaluations by students who took part in traditional clinical placements in previous cohorts at the same point in their studies.
Background
The growth of simulation in nursing curricula has been influenced by increased student nurse numbers and a decreased number of clinical placements available (Cobbett and Snelgrove-Clarke, 2016).
The 4-week placement (120 hours) was undertaken as simulation-based education (SBE). SBE has become integral to nursing education (International Nursing Association for Clinical Simulation and Learning (INACSL), 2017), particularly as studies have shown that students can develop confidence, critical thinking, clinical reasoning, technical and non-technical skills in this type of placement (George and Quatrara, 2018; Morrell-Scott, 2018; Peddle, 2019a; Raman et al, 2019; Teles et al, 2020).
As student nurse numbers continue to rise (National Audit Office, 2020) and simulation can be resource intensive (Cant et al, 2019; Shin et al, 2019), there is a challenge for educators to ensure all students receive good quality, effective simulation that meets learners' needs.
In addition, within the UK, student nurses are required to undertake considerably more practice placement hours when compared with other countries (Table 1), increasing the pressure to find high-quality placements. Therefore, developing a 4-week simulated placement could help to reduce service-based placement demand.
Table 1. International comparison of required practice hours
| Country | Practice hours |
|---|---|
| UK (Nursing and Midwifery Council) | 2300 |
| New Zealand (Nursing Council of New Zealand) | 1100 |
| Australia (Nursing and Midwifery Board) | 800 |
| USA (American Nurses Association) | Varies according to state, up to 868 |
Berman et al (2016) proposed that, in order to meet the challenges of delivering engaging and effective simulation, particularly to large cohorts, web-based technology can complement and enhance the learning experience. Baxendale (2017) supported this and suggested that there has been a significant rise in the use of simulation as the technology has rapidly evolved. This modality has become more widely adopted by nurse educators over the past few years, more so in light of a surge of interest and use during the COVID-19 pandemic. Indeed, the accessibility of web-based learning is creating a paradigm shift to online pedagogy (Peddle, 2019b; Lu, 2020). Therefore, the development team at the authors' university aimed to use appropriate and innovative technology with immersive e-simulation.
Aliakbari et al (2015) suggested that, without underpinning theory, knowledge is not used effectively, and structure and context is lost. Theory can be seen as a framework of ideas that illuminates simulation-based educational practice (Nestel and Bearman, 2015). Therefore, Kolb's experiential learning cycle was used in the design of this simulation placement. This theory has been widely used within healthcare simulation (Kolb, 2007). Kolb's work complements and enhances SBE and gives structure and meaning to its design and delivery. Indeed, experiential learning is crucial in preparing health professionals for practice. Kolb's cycle fits with the stages of a well-designed simulation: pre-brief, simulation, debrief and reflection (INACSL, 2017).
Consideration was also given to the flexibility of the design, as this simulation placement was developed as the pandemic struck. As local and national lockdowns were imminent, the design needed to ensure that this could be switched to be delivered either face to face or remotely, as required. This simulation placement is the first in the UK to be validated as a placement and receive tariff funding, signifying that Health Education England made a financial contribution to support the placement provider, which in this unique case was a university.
Operationalisation
The primary aim of this simulation-based placement was to recreate a standardised first-year student nursing placement. Using simulation methods would also give opportunities for safe practice and rehearsal (Bliss and Aitken, 2018).
Learning aims and outcomes were subdivided into technical skills such as injection techniques and personal hygiene and non-technical skills such as leadership and followership. A clear focus was placed on interprofessional working, a multidisciplinary approach to care delivery, team resource management, human factors in health care and the patient safety agenda, which met the student's stage of education and was mapped with NMC standards (2018).
On a creative level, the ambition was to design immersive and interactive experiences that would maximise the potential of the existing delivery systems. These ambitions would be tempered by the restriction of physical capacity in the form of classroom space, the availability of faculty staff and the large number of students (400 per cohort). The solution to this conundrum would lie in the application of a blended approach to delivery, using a combination of remote, asynchronous online and face-to-face methods (Seah et al, 2021). The involvement of all nursing specialty educationalists in the design and delivery of the programme aimed to ensure relevance to, and ‘buy in’ from first-year student nurses from a mixed field of practice.
Approach used
To ensure relevance to practice, all areas of delivery were mapped directly to the NMC nursing standards, appendix A and B (NMC, 2018) This was clearly communicated to all faculty members involved in the delivery and the students themselves through the coding of each session. In addition, INACSL (2017) good practice guidelines were followed in the design and delivery of SBE.
A coding system for the various methodologies such as digital simulation (DS) and simulation laboratory (SL) was developed to describe the content delivery. The combination of the coding system and clear mapping of delivery to the NMC nursing standards assisted in developing a clear framework for delivery and played a vital role in the pre-brief phase for the students. The sharing of processes across the faculty during the developmental phase also enhanced the potential for cross-pollination of ideas and concepts. For example, the use of interactive service user interviews when exploring complex themes to encourage student empathy and understanding of individual experience originated in the adult nursing branch and ultimately was adopted by all fields. Actual service users were asked questions about their experiences in real time by students who had already followed a simulated patient journey involving pre-recorded films, debriefs and tasks, for example. The focus was on specific conditions such as stroke, heart attack and depression, which also related to the specific service users' medical and/or mental health history.
The sharing of processes was actively encouraged and maximised via project management applications, leading to discussion and dissemination of ideas. Positive outcomes to this approach included standardisation of content presentation, accurate monitoring of development towards completion and an increase in motivation and creativity of the staff involved.
Wider themes
To create an immersive experience, a ‘simulated hospital trust’ was developed with the premise that each day of activity would take place within this virtual hospital, in virtual clinical areas, with virtual patients and condition-specific scenarios. It is important to note that the scenarios presented to the students were grounded in the real world, with all its imperfections, challenges and issues. This allowed students to critique the performance of the simulated staff in the scenarios, which were usually pre-recorded films. They could make suggestions and build solutions for potential improvements during each debrief and reflective phase.
Content and delivery were directly informed via a multidisciplinary approach involving the adult, learning disability, mental health and paediatric fields of nursing, as well as service user involvement. Due to the COVID-19 pandemic, input from clinical practice was not possible; future developments and delivery will involve nurses from clinical practice as well as students. In addition to these specialties, the technology enhanced learning (TEL) team were involved throughout the design and delivery phases of the project. TEL involvement not only improved accessibility for students, but directly contributed to learning outcomes via a bespoke digital literacy session that focused on the acquisition of information technology skills.
Due to the onset of the pandemic during the design phase, limited access to faculty and the university could have caused this simulation placement to be significantly compromised. However, this challenge resulted in a number of creative solutions that built on existing design concepts and ideas and would ultimately produce real innovation in the design and delivery of the programme. The creative starting point for the project had always been rooted in a desire to create an immersive, interactive experience that would explore and potentially challenge the definition of virtual reality (Bucher, 2018). In order to achieve this, a narrative pedagogy was used (Wiederhold, 2018) to give meaning and add value to the content being delivered and the overall user experience. The enforced move from 50% face to face and 50% remote simulation delivery, to only 5% face to face and 95% remote, placed additional pressure on the ability to deliver this in a meaningful way, due to the high numbers of students. The solution was found by developing eight timetables with identical content that were delivered in a standardised format concurrently.
Guided by Kolb's (1984) experiential theory of learning, student activities reflected what would be undertaken in real clinical placements, allowing for reflection, repeated practice, discussion and the exchange of ideas. These activities linked to the simulated narrative, examples such as completing observation charts while observing a scenario of a deteriorating patient and undertaking a handover at the end of a virtual shift. Attendance was monitored to ensure that the required number of simulated placement hours were attended by each student.
The content and activities developed in complexity over the days and weeks. The narrative worked on both micro and macro levels, from individual patient stories, to cohorts of patients within a ward and then to the wider organisation (a simulated NHS trust). Student group immersion in the narratives facilitated a sense of belonging. According to Zhao et al (2012) and Peacock et al (2020) a sense of belonging is crucial within virtual communities, as this can enhance participation and engagement.
The use of team working, shifts, real world activity and workload management in combination with design elements added to the online platform such as corporate trust identity and NHS signage, aimed to build upon and add to the sense of immersion and community. Table 2 provides an example of one simulation placement day, demonstrating underpinning theory and links to NMC (2018) annexes. The simulation day consisted of following the journey of a patient who had suffered a heart attack, using pre-recorded films involving faculty staff acting as patients, relatives and various health professionals—from the emergency department through to the patient being advised by the cardiac rehabilitation nurse on the cardiac ward.
Table 2. Example of a simulation placement day
| Session | Length (minutes) | Descriptor | Delivery method | NMC annexes | Kolb's cycle |
|---|---|---|---|---|---|
| Introduction and orientation | 20 | At the start of every session the technical and non-technical learning goals and outcomes are clearly stated. This is followed by a pre-recorded presentation illustrating the underpinning pathophysiological theory | Pre-recorded presentation | ||
| Scenario chapter 1 | 20 | Pre-recorded clinical scenario. Scenario chapter 1 presents real world clinical activity. Care is taken to present an honest, accurate reflection of current challenges to practice. Students are invited to make notes on their observations | Pre-recorded video-based scenario | A2/A4/B1 | Concrete experienceReflective observation |
| Debrief 1 | 60 | Student observations are invited with both technical and non-technical aspects of the scenario discussed. The performance of the clinical staff is critically analysed and improvements suggested | Live video-assisted facilitator-led discussion via Zoom | A1/A2/A4/B1 | Reflective observationAbstract conceptualisation |
| Scenario chapter 2 | 20 | Pre-recorded clinical scenario. Scenario chapter 2 depicts a continuation of scenario 1, enabling exploration of some solutions to the questions raised in the previous chapter | Pre-recorded video-based scenario | A1/A2/A4/B1 | Concrete experienceReflective observation |
| Debrief 2 | 60 | Students' observations are invited with both technical and non-technical aspects of the scenario discussed. The performance of the clinical staff in the simulated scenario is critically analysed, with students suggesting improvements and areas of good practice | Live video-assisted facilitator-led discussion via Zoom | A1/A2/A4/B1 | Reflective observationAbstract conceptualisation |
| Lunch break | 30 | ||||
| Service user interview | 40 | Students are invited to question a service user with a similar medical history to the area of focus for the day on their experiences of healthcare services | Live facilitator-hosted discussion via zoom | A1/A2/A4 | Active experimentationAbstract conceptualisation |
| Communication prep | 60 | Students are invited to watch a presentation on communication including the SBAR* model of information transfer. Using the SBAR model, students must then build a written handover of the patient from scenarios 1 and 2 | Pre-recorded presentation and self-directed study via interactive media | A1/A2/A4/B1 | Active experimentation |
| Care planning | 60 | Students are invited to complete a nursing care plan relevant to the patient from scenarios 1 and 2 | Self-directed study via interactive media | A1/B1 | Active experimentation |
| Patient enquiry | 30 | Students are briefed to expect an inquiring phone call from a relative of the patient from scenarios 1 and 2 who will request an update on progress | Facilitated live call via MS Teams by a faculty member acting as a relative | A1/A2 | Active experimentation |
| Reflective exercise | 30 | Students are invited to reflect upon their day and post any observations on a discussion board. Discussions are monitored and facilitated by the faculty to encourage debate | Peer-to-peer interaction via digital discussion board | Active experimentation |
SBAR: Situation, Background, Assessment, Recommendation (NHS England/NHS Improvement, 2021
Evaluation
Following the simulation placement students completed two evaluations. The first was an anonymous, online questionnaire and the second was the placement evaluation completed by all students following all clinical placements.
Online questionnaire
There were 208 responses out of a cohort of 394. Students were asked to rate their overall experience of the simulation placement; 92% students rated the simulation placement as good or excellent. The majority (92%) stated that the simulation placement had helped prepare them for real-life practice.
The students were invited to give qualitative feedback on the most challenging and positive aspects of the simulation placement. The most challenging aspects were reported as either tasks or circumstances. Challenging tasks included taking a simulated telephone call from a patient's relative, completing documentation and terminology. Challenging circumstances unsurprisingly included lack of interaction and difficulties with technology and extended screen time.
Anonymised qualitative comments included:
‘The most challenging aspect for me was the patient journey ‘phone call’ as this was a little nerve racking. However, I am now feeling more confident with this.’
‘I found doing everything online quite a challenge but with the easy layout and brilliant support everything went well.’
Positive aspects included the learning that took place, whether this was via online discussions or in face-to-face skills sessions. Interestingly, taking the telephone call was also reported as a positive aspect. It is worth noting that 17% of student responses to this question made reference to feeling more prepared for practice:
‘The most positive thing [is] I feel more confident about going into placement in January.’
Placement evaluation
Following all clinical placements students are asked to complete an evaluation via the placement hub. This second data set allowed the team to make comparisons with the cohort who undertook the simulated placement and previous cohorts who experienced a clinical placement at the same stage of the programme. Table 3 illustrates the number of students in each cohort and field who gave 100% positive feedback:
Table 3. Percentage of students who provided 100% positive feedback
| Cohort (n=evaluations/n=students | Adult | Child | Mental Health | Average |
|---|---|---|---|---|
| September 2017 (137/219) | 82.7 | 89.4 | 84 | 85.4 |
| September 2018 (160/225) | 83.7 | 85.7 | 64.7 | 78 |
| September 2019 (230/304) | 76.9 | 72.4 | 78.1 | 75.8 |
| September 2020 (163/394) simulation placement | 84.2 | 84.6 | 61.9 | 76.9 |
This data illustrates that when comparing the placement evaluations with students who had clinical placements in previous years, students' satisfaction levels were comparable. It is noted that there is a difference for mental health nursing students whose scores were lower in 2020 and 2018.
Table 4 provides data on the responses to three pertinent statements on the simulation placement evaluation to which students could agree or disagree.
Table 4. Simulation placement evaluation (September 2020)
| Placement evaluation statement | Adult nursing students | Child nursing students | Mental health nursing students | Average |
|---|---|---|---|---|
| Q1. I am satisfied with my placement experience | 97.9% (n=95) | 100% (n=26) | 97.5% (n=40) | 98.5% |
| Q2. I was able to achieve my placement learning outcomes | 97.9% (n=94) | 100% (n=26) | 100% (n=40) | 99.3% |
| Q3. Practice learning opportunities were identified and relevant | 97.8% (n=90) | 100% (n=26) | 100% (n=40) | 99% |
These demonstrate that the majority of students were satisfied with their experience, were able to achieve their learning outcomes and felt that the learning opportunities were relevant. Critically, a number of students commented that they had gained knowledge and skills during the simulated placement and felt well prepared for their clinical placement:
‘This placement has given me an idea of what to expect when I go out into real life placement … it has given me a lot of confidence.’
Lessons learnt
As the challenge to maintain quality education for student nurses increases, there is a continual need to adapt and think innovatively, to ensure learning needs are met. This simulation placement appears to have met and surpassed expectations. Particularly in light of the COVID-19 pandemic restrictions, the design of this simulation placement allowed flexibility in delivery, with no compromise in the quality of teaching or a reduction in student satisfaction levels.
However, there were some lessons learnt. First, the amount of administration required to support completion of practice assessment documents (PADs), student enquiries and tracking student engagement was underestimated. This will be addressed with more frequent meetings and short films developed to guide and support students.
Initially the number of student enquiries was high, and usually related to minor technical issues. To minimise these in future, students will be directed to check announcements and the frequently asked questions section within the simulated practice hub and to email any questions to a dedicated simulation support email address. This will ensure that enquiries will be streamlined and dealt with more efficiently.
Tracking student engagement throughout the 4-week placement will continue to be time consuming. The simulation team is currently exploring how to use the same platform for all tasks so that this information can be extracted more readily. In addition, having a designated administrator would ease workload on the simulation team.
The students also required further preparation before the simulated placement started, particularly with the technologies used. This is being addressed with several supportive sessions before the placement starts and access to the simulation support email for further questions.
This simulation placement has sparked considerable interest from colleagues, both regionally and nationally. Therefore the team has disseminated this model and lessons learnt to other faculties and universities. The cross-pollination of ideas from service users and the interdisciplinary team within this simulation placement has been illuminating to all. This has now driven further interest and creativity in building the simulation placement for second-year student nurses.
Next steps
Having discovered the benefits of using a blended approach in this delivery, the design and delivery of the second- and third-year simulation placements will continue using both remote and face-to-face methods. However, there will be more face-to-face simulation aiming for 50:50 ratio. A staged approach will be used, building the complexity and challenges of the activities students will undertake. For example, more challenging communication skills, from undertaking a simulated telephone call that is a general enquiry to managing a telephone call with an upset relative or challenging colleague. This will reflect their stage of progression and ensure that the NMC proficiencies (NMC, 2018) continue to be mapped throughout.
Although students in their second and third years will have field-specific elements within their simulation placements, interdisciplinary and inter-professional simulation-based methods are to be developed further. In particular, integrating further diversity and inclusivity into the patient's simulated narratives. There will also be a greater focus on peer review and feedback using a staged approach. Having an extensive range of cameras available within the simulation suites, students will be able to practise, record, review and reflect on their own practice and learn to give appropriate feedback on their peers' work within structured frameworks, for example, by using the Van Gelderen Family Care Rubric (Van Gelderen et al, 2019), an educational tool that aims to deliver constructive and consistent feedback to students following SBE.
Service users and students will be part of not only the delivery but also the planning and design of future simulation placements. To achieve this goal, student interns have been recruited to facilitate the planning and design of a second-year simulated placement.
Conclusion
The simulation team has developed a robust, versatile and flexible model of delivery. This flexibility not only allows for development and expansion, but also dynamic movement in the percentage of delivery between remote and face-to-face learning. This has provided a pragmatic solution in response to the acute challenges of delivery during the COVID-19 emergency. The evidence suggests that this new type of flexible simulated placement has met student nurses' learning needs and prepared them for practice. Future simulated placements will continue to be developed, using theoretical underpinning to guide the structure and context, including INACSL guidelines (2017) and NMC standards (2018) and appropriate technology to enhance students' learning.
KEY POINTS
- The number of student nurses has meant finding clinical placements for all has proved difficult. This problem was compounded by the pandemic
- Simulation-based education is a way of allowing students to develop confidence, skills and critical thinking in a safe environment
- At one university, first-year students took part in simulation placements in which delivery was mapped to Nursing and Midwifery Council standards
- The majority of students rated their overall experience as good or excellent
CPD reflective questions
- Reflect on how the simulation-based education you have experienced has impacted on your learning and practice
- Consider how different simulation-based methods could be used within your area of practice
- Consider the challenges of delivering simulation-based education to students in your area