Simulation in nursing: the importance of involving service users

In nursing and midwifery education, simulation is 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 (Nursing and Midwifery Council (NMC), 2023a). Simulation provides an immersive and interactive environment for students and health professionals to develop their clinical skills, enhance critical thinking abilities and improve patient care (Lavoie and Clarke, 2017; Jeffries, 2020).

Although simulation has traditionally focused on the education and training of healthcare providers, there is a growing recognition of the importance of involving patients and the public in simulation experiences (Fitzpatrick, 2005; Scammell et al, 2016). In response to growing legislative and public expectations, the user voice should be prominent in the ongoing design and monitoring of care services, and in nurse education. The primary objective of patient participation in this instance is to enhance the delivery of person-centred care (Bennett and Baikie, 2003; Fitzpatrick, 2005; Debyser et al, 2011; Happell et al, 2011; Rhodes, 2012; Scammell et al, 2016).

The view of policymakers in the UK is that ‘hearing’ the patients' voice can help avert shortcomings in the quality of health care through patient involvement in the creation and delivery of services (Fitzpatrick, 2005; Department of Health (DH) 2008; DH, 2010; Scammell et al, 2016). This is emphasised in the NHS Constitution (DH, 2021) and in Equity and Excellence: Liberating the NHS (DH, 2010), which advocate shared decision-making with service users, who are best qualified to assess their own experiences. It has also been suggested that the input of service users is vital for supporting the training of health and social care professionals (Bennett and Baikie, 2003; DeMarco, 2010; Debyser et al, 2011; Scammell et al, 2016).

Various terms have been used to describe recipients of care in the literature: ‘service user’, ‘client’ and ‘patient’ are just a few of the examples that are used interchangeably. However, closer examination shows that the term ‘service user’ is generally used to refer to a person who uses health or social services, while ‘carer’ belongs to a distinctly different group, in that it is generally used to refer to those who provide unpaid care for others (Fallon et al, 2012). The training of health and social care professionals can incorporate both populations. For simplicity, in this article, the term ‘service user’ includes both the patient and carer populations.

When it comes to user involvement in practitioner education, medicine and social work have taken the lead (Rhodes, 2012). In nursing, the practice is also well established in the field of mental health nurse education, reflecting long-standing recommendations in England and worldwide for service users to be involved in education programmes (Butterworth, 1994; Happell et al, 2011). Interactions between mental health nurse educators and patient groups can be advantageous for challenging the traditional power structure that permeates much of health professional education, favouring clinical perspective over personal experience (Scammell et al, 2016). In contrast, there is limited focus on service user participation in general (non-mental health specific) nursing education (Scammell et al, 2016).

The NMC (2023b) fitness-to-practise strategy focuses on keeping people safe and improving the way nurses communicate with people. Capturing the voice of service users, families and members of the public is essential to assess and reduce harm, reflect and improve practice, and understand how to support people with different needs and backgrounds, rather than focusing on the binary opposition of good care versus bad care. This necessity has more recently been expanded to include the broader scope of all preregistration nursing curricula and support for greater use of simulation. These developments have seen service user involvement not only as co-designers of simulations, but also by portraying patients within the hypothetical scenarios. By assuming the role of patients and acting intuitively within the scenarios they are able to provide realistic responses from a patient perspective based on experience (Jeffries, 2020; Eyikara and Baykara, 2017).

Through simulation pedagogy students learn to become patient-centred, develop an increased awareness of patient feelings and concerns, and identify ways of responding appropriately in a variety of settings. Students can immerse themselves in authentic situations and receive valuable feedback specific to their learning outcomes. The use of service users in simulations to represent patients allows students to respond through verbal and non-verbal communication, helping to optimise their paraverbal skills. The safe environment and enhanced sense of security afforded by simulation helps boost students' self-esteem and confidence, as well as promoting deeper learning.

Patient and public involvement in simulation

Including patients as educators in the development of nursing simulation scenarios and as patient representatives can offer unique perspectives and insights, sharing the lived experience of service users and providing invaluable knowledge about illness, treatment and the impact of care (Anderson et al, 2019; Birrell et al, 2021). Such involvement enhances the authenticity of simulation scenarios and helps students develop empathy, communication skills and patient-centred approaches. The service users portraying patients can participate in debriefing sessions, offering feedback and reflections on a student's performance, which contributes to the learning process (Anderson et al, 2018; Birrell et al, 2021).

The process of de-rolling and breaking the fourth wall can be a valuable educational experience for students, offering them the opportunity to hear first hand the patient's voice and to learn about their experiences post simulation. (Breaking the fourth wall/de-rolling is a technique whereby the service user who is portraying a patient speaks directly to students to provide feedback.) This breaks the illusion of the simulation, and breaks the barrier between the students and the service user. Table 1 illustrates how participating in simulation can inform the development of relevant scenarios and empowers patients by enabling them to take on an educator role.

Using this in simulations enables healthcare systems to tap into a valuable and often underutilised resource, fostering a collaborative approach to health care that prioritises patient empowerment and education (Anderson et al, 2019; Birrell et al, 2021).

Engaging patients and the public in the co-design of simulation scenarios ensures that the simulations are authentic, relevant and realistic, and reflect lived experiences (Table 2). Collaborative approaches such as these facilitate the development of simulations that are able to address specific healthcare challenges, cultural considerations and diverse patient populations. Co-designing simulations with service users and the public also fosters a sense of ownership, promotes patient-centred approaches to care, and contributes to improving the quality of education and training (Scammell et al, 2016; Noël et al, 2021; Ung et al, 2023) (Table 2). Co-designing simulations with service user input includes actively involving individuals in the development of educational tools and simulations related to health care. For students, the ability to interact with service users in the resulting simulations increases the likelihood of successful knowledge transfer and skills acquisition (Scammell et al, 2016; Noël et al, 2021; Ung et al, 2023). The involvement of service users in the design of – and as participants in – simulations ensures that a diverse range of perspectives and preferences are considered and included in the scenarios (Table 3) (Scammell et al; 2016; Noël et al, 2021; Ung et al, 2023).

Including service users, representing patients, in participatory decision-making within simulations humanises patient care, and helps to emphasise the importance of empathy and compassion (Table 3). Students gain a deeper understanding of patients' experiences, challenges and preferences, enhancing their ability to provide person-centred care. Service user involvement fosters cultural competency, empathy and communication skills among future healthcare providers, contributing to improved patient outcomes (DeMarco, 2010; Debyser et al, 2011; Happell et al, 2011; Scammell et al, 2016). It is an approach that helps nursing students to develop skills in shared decision-making, effective communication, and patient advocacy (Fitzpatrick, 2005). By actively involving the service users within the simulation, healthcare providers learn to recognise and address patients' unique needs, preferences and values. This approach fosters a collaborative and respectful healthcare environment that prioritises the patient's voice and improves patient satisfaction (Fitzpatrick, 2005; DeMarco, 2010; Debyser et al, 2011; Happell et al, 2011; Scammell et al, 2016).

Using simulation as a transformative approach enhances the understanding of care processes from a patient perspective and improves efficiency, while maintaining patient safety, and it contributes to improving healthcare delivery as a whole (Scammell et al, 2016, Decker et al, 2008; Jeffries, 2020). Service users can identify areas for improvement, evaluate interventions and implementing changes that address patients' needs effectively.

The ability to interact within a simulation with service users who provide intuitive patient feedback enables students to focus on relational moments of care and unpack the differences between clinical care provisions, leading ultimately to enhanced patient safety initiatives, quality improvement initiatives and patient-centred policymaking (Bennett and Baikie, 2003; DeMarco, 2010; Debyser et al, 2011; Happell et al, 2011; Scammell et al; 2016).

Conclusion

Simulation has revolutionised nursing education and training, offering a safe, authentic and immersive learning environment. However, to maximise the potential that simulation offers, it is crucial to involve service users in the development of the scenarios within the simulations. By listening to the patients' voice and supporting and encouraging collaboration between healthcare providers/educators and service users on the co-design of simulations nursing education can become more patient-centred, culturally competent and responsive to patient needs.

The inclusion of experiences based on real-life scenarios within educational simulations, which have been developed through patient and public involvement, can help bridge the gap between healthcare providers and the communities they serve, leading ultimately to improved patient outcomes and enhanced healthcare delivery.

KEY POINTS

• Service users are essential for the co-design of authentic simulations to provide students with an experience as true to real life as possible
• Service user involvement helps to inform scenario development and enhances the pedagogical approach
• Co-designing simulations with service users creates simulations that are culturally relevant and that reflect the current healthcare needs of diverse population groups

CPD reflective questions

• Consider how you could use service users to co-design simulations in clinical practice
• Think about the current simulation scenarios you use. Could you use co-designed simulations to focus on non-pedagogical purposes, for example co-designing new models of care or helping identify safety issues and threats in your clinical area?
• Reflect on how services users can support the integration of digital simulations within higher education?