Patient teaching is a key component of nursing practice (Richard et al, 2018). However, Thompson (2017) argued that nurses are often quick to provide information and share skills without checking that patients have fully understood what they have been told. If patients do not fully understand what they have to do, this will potentially limit their ability to self-manage their condition. Kornburger et al (2013) argued that, if patients do not understand what is being taught, this will increase the risk of complications and readmission. However, the opportunity to practise clinical skills has changed due to increasing student numbers and structural changes in health services (Nielson et al, 2013), and with a higher degree of specialisation and shorter hospital admissions (Benner et al, 2010). As a result of these changes, the use of simulation as a teaching strategy has become increasingly popular (Sundler et al, 2015), with its use as a teaching and learning method endorsed by the Nursing and Midwifery Council (NMC) (2018a). Nestel et al (2014) suggested that role play with simulated patients facilitates the opportunity for students to immerse themselves in the experience within a protected and controlled environment, and to receive valuable feedback from the patient's perspective. In this role, simulated patients can be viewed as active facilitators of the specific learning outcomes (MacLean et al, 2017). This allows students the opportunity to check that the patient has understood what it is they have to do and to reinforce the patient's learning. A meta-analysis by Shin et al (2015) reported that the simulated patient approach in nursing education is a useful technique to use in addition to traditional learning methods.
Simulation uses a range of techniques to replicate clinical scenarios in a safe environment (Kirkham, 2018). One of the most popular modalities of simulation involves standardised or simulated patients who can be involved in role play, and are expected to generate interactions that replicate real clinical practice more closely than a manikin.
The terms ‘simulated patient’ and ‘standardised patient’ are often used interchangeably (MacLean et al, 2017). Alexander and Drearsley (2013) argued that, although human patient simulators, such as manikins, are able to display physiological responses, it is their inability to demonstrate emotional responses and non-verbal communication that makes simulated patients the preferred option to address the absence of the human element. Sideras et al (2013) suggested that, when the focus for learning is on a person's psychosocial–emotional responses to a situation and when body language and physical movement are key components of the learning situation, simulated patients are the better choice.
Background
Patient education is part of nursing practice (NMC, 2018b), and integral to person-centred care (World Health Organization (WHO), 2011). Some authors (Lin and Wang, 2017; Richard et al, 2018) have suggested that patient teaching facilitates the development of self-care behaviours, which are vital to people who have complex conditions. This is crucial as long-term conditions affect not only physical functioning, but all aspects of life, including social and psychological functioning, family life and employment. Gozdzialski et al (2012) argued that effective education by nurses has the potential to reduce attendance at emergency departments and to assist patients and their families in understanding their illness. In addition, it can reduce patients' anxiety and increase their motivation (Lin and Wang, 2017), and it is an essential tool to empower patients in becoming more autonomous in making decisions concerning their health (Yeh et al, 2018). Thompson (2017) argued that addressing patients' learning needs and supporting them to gain knowledge, in ways that are meaningful to them, greatly influences health outcomes.
Consequently, there is a need to ensure that this aspect of the role is embedded in nursing curricula. Yet, nurses have reported feeling underprepared to teach patients in the practice setting (Coster and Norman, 2009; Richard et al, 2018). Friberg et al (2012) argued that, despite the importance of patient education, many nurses do not necessarily have pedagogical knowledge regarding how to teach, how to support patients' learning and how to consciously implement strategies into patient education.
Crawford et al (2018) argued that educating patients about self-management of their condition, and how to prevent complications, is important for promoting patient safety. However, the provision of patient education remains problematic because nurses can have difficulty knowing how to teach or support patients' learning. Friberg et al (2012) explored the conditional factors that influence nurses' patient-education work, reporting that such provision is limited by a lack of pedagogical competence and uncertainty relating to the educational task. Other findings from the review related to organisational factors, such as limited time, lack of managerial support and uncertainty surrounding role boundaries with other health professionals.
Richard et al (2018) examined nursing students' perceptions of preparation for engagement in patient teaching when they were in the practice setting. Themes emerging from the study included: whose role it was, when it happens, and improving the culture of patient teaching in the educational environment. Students in this study suggested that the culture of teaching could be improved by:
Some authors (Mangold, 2016; MacLean et al, 2017) have suggested that, due to its high degree of realism, the use of simulated patients is an effective way to develop communication skills, augment nurses' ability to engage with patients, and develop patient-teaching skills, such as teach back.
The aim of this study was to formatively evaluate a simulated role-play scenario facilitated with third-year nursing students to support the development of patient-teaching skills.
Methods
Designing the simulated session
Schlegel et al (2012) argued that being able to practise clinical conversations in a simulated scenario offers students the opportunity to experience ‘real-life’ situations with a high degree of realism. It has also been suggested that using simulated patients helps trainees develop their communication skills (Kneebone et al, 2002). The school of nursing and midwifery, in which this study took place, offers third-year nursing students the opportunity to take part in simulation as an experiential learning method, and the need to develop role-play scenarios that would facilitate development of patient-teaching skills was identified. To date, 44 staff are involved in teaching simulation at timetabled periods throughout the academic year.
Because the study described in this article was an evaluation of a teaching programme, and evidence to show that key ethical issues had been addressed was submitted to the school research and ethics committee, a waiver from a full school research and ethics committee approval request was signed by the chair of the ethics and research committee. Before taking part, participants were provided with full information about the study. All participants were assured that taking part was voluntary, anonymous and that consent could be declined without any resulting sanction. During the time of the study all data were stored securely in a locked filing cabinet. Each pro forma was given an anonymous code to conceal the identity of each participant.
A systematic review by Harder (2010) identified three types of simulation:
This study (n=20) used a combination of high-fidelity and mid-fidelity simulation scenarios sequentially. This enabled the students to practise communication skills already learnt in both a skills-based procedural simulated scenario and then in a patient-teaching simulation. Donovan and Forster (2015) argued that the use of sequential simulations allows for better reproduction of the ‘real world’ because in the practice environment nurses must be able to adapt and adjust their communication approaches to meet health needs in rapidly changing environments. Similarly, Tyler and Saul (2019) reported that the combined use of a simulated patient and a manikin in shared simulation scenarios for adult and mental health students strengthened the students' learning experience by promoting authenticity. However, they acknowledged that, while students appreciated the use of both modalities, it was not possible to determine their relative importance to the learning process. A study by Coffey et al (2016) comparing conversations and the use of touch in scenarios using a simulated patient and a high-fidelity manikin found that there were far more interactions with the simulated patient than the manikins. These results suggest there is a need for further research to evaluate the link between simulation modality and how closely it reflects real-life clinical practice.
In the first scenario, a high-fidelity manikin was used to simulate an acutely ill patient. However, the participants did not review this session. In the second scenario, a simulated patient was used to simulate the same patient following recovery. The scenario incorporated the theoretical framework of authentic learning theory), the principle being ‘to focus education on real-world situations, to enable learners to have an opportunity to develop skills relevant to practise’ (Candela, 2012:421). It followed a similar format to the high-fidelity problem-solving scenario and was peer-reviewed by the simulation teaching team prior to use. Sideras et al (2013) suggested that the design for a scenario with simulated patients begins like any other simulation, with a clear statement of learning outcomes. Those identified by the authors for these simulated patient teaching sessions are presented in Box 1.
Bosek et al (2007) highlighted that involving a content expert will increase the chance of realistic dialogue and prompt characteristic responses to commonplace nursing situations. Therefore, to facilitate the simulated role play one of the authors (DC) played the patient.
Smithson et al (2015) suggested that the advantages of using a member of staff as a simulated patient include:
A number of disadvantages to using a staff member in the patient role have also been reported, namely:
Smith-Stoner (2011) highlighted that the use of props in simulation scenarios can enhance the design objectives. Thus, consideration was given to the preparation of the environment, by using a small table and comfortable chairs, to encourage student engagement in communication. This enabled students to sit comfortably beside the patient and to use the table for equipment, such as the inhaler, medication and information leaflets.
The simulated patient-teaching scenario
Format
The school of nursing and midwifery where the study took place runs simulation sessions lasting half a day. Three scenarios are delivered per session with six students taking part. In each scenario, two nursing students work together with a patient. The remaining students observe via a video link. The scenarios are run consecutively, with students swapping roles, giving each participant the opportunity to act as the nurse. The format of the simulated patient-teaching scenario consisted of four components (Table 1):
| Stage | Time allocated | |
|---|---|---|
| 1 | Review of students' knowledge and experience of patient teaching | 10 minutes |
| 2 | Pre-brief: time was taken to discuss the format and expectations of the simulation and the necessary background information to the patient. Time for orientation to the simulated environment, assignment of roles and learner preparation time before commencing the simulated scenario was also incorporated | 10 minutes |
| 3 | Simulated scenario: focused on a 76-year-old woman following an acute exacerbation of chronic obstructive pulmonary disease, who was now ready to go home. Students were asked to role play a patient-teaching scenario, to teach her, prior to discharge, how to use her inhaler correctly, how to take a course of antibiotics, and to give advice on how to alleviate breathlessness. Leaflets on each topic were available to enable the students to provide further written information to the patient | 10 minutes |
| 4 | Debrief: a period of reflection and feedback structured around the learning outcomes | 15 minutes |
Content
A scenario was created that featured the educational needs of a woman who had been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD), but who was ready for discharge. The scenario focused on key aspects of self-care in relation to medication administration. Students were asked to role play a patient-teaching scenario (Table 1). Tablets were simulated using placebos, a demonstration inhaler was used and leaflets were available to allow the students to provide written advice to the patient.
The scenario format followed a suggested sequence of events for the simulated role player, simulator parameters for role play, minimal expectations from the student and potential teaching points or questions (Table 2).
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Data collection
Following the debrief, a formative evaluation took place with 20 third-year undergraduate nursing students. Data were collected using a short five-item anonymous pro forma, which consisted of four open questions and one closed question. The open questions sought to establish students' perceptions of what they had found helpful regarding this simulated role-play experience; what they had learnt; how they thought their experience of this type of simulated learning could be enhanced; and whether there were any other topics that they thought would be useful to include in the simulated learning programme. A five-point Likert scale was used for the closed quantitative questions to enable students to rate their simulated learning experience.
Data analysis
Qualitative data were analysed using codes and categories, and quantitative data for this small sample were analysed using frequencies. The questions were grouped into categories in accordance with the layout of the five-item pro forma. The qualitative responses were analysed by typing out all of the written comments; once these were typed out, the researchers familiarised themselves with the data by reading and re-reading the comments. In order to identify themes from the data, coding was used. Similar phrases or words were coded together to identify the main themes.
Results
Of the 20 students, 18 were female and 2 were male; with an age range of 20–30 years. Students evaluated this learning experience positively and felt that the simulated scenario was enjoyable, useful and had gone well, with very good support from the facilitators. Two key categories of data were generated from the open questions:
Being in and dealing with a situation
This data related to the value that students appeared to place on role playing a patient-teaching session with a simulated patient. Being able to obtain the perceptions of their peers and lecturers in relation to what had gone well and what they could develop further was also thought to be valuable. This is illustrated by the following comments on what they had learnt:
‘How important patient education is to person-centred care.’
‘Being able to practise real-life situations in a safe and supportive manner.’
‘I learnt how important patient education is when assisting patients to manage their conditions at home.’
Use of listening skills
This data reflected the learning that students said they had achieved around the importance of active listening to a patient. Students recognised that these skills should be a core part of their developing skills set. This is illustrated in the quotes below:
‘I learnt how important it is to communicate with a patient at their level—not using jargon and medical terminology.’
‘How important it is to communicate with the patient, making sure they fully understand what you are saying.’
‘Learnt how, apart from clinical skills, to communicate at the patient's level.’
Students rated their learning experience on a scale of 1–5 (1=poor, 2=fair, 3=good, 4=very good and 5=excellent). Eighteen students rated their experience as 5=excellent and two students rated their experience as 4=very good.
The simulated scenario facilitated students in experiencing a patient-teaching session. Based on students' reported learning experience, this appears to have created a raised awareness of the importance of patient teaching when supporting patients to manage their conditions and how important it is to communicate with a patient at their level to ensure understanding. The students also appeared to appreciate the opportunity to take part in, and to observe, this role-play scenario, and had reflected on the potential challenges they had experienced in practice, when trying to engage in patient teaching.
Discussion
Findings from this formative evaluation suggested that using a simulated patient to develop patient-teaching skills was perceived by the students to be a valuable method of learning that they could transfer to clinical practice. The development of this simulated environment provided an opportunity to add authenticity to the activity, enabling nursing students to practise patient-teaching skills relevant to practice. The use of a simulated patient provided the opportunity for real-time, two-way communication between the student and the patient, and allowed for timely provision of individual feedback. Becker et al (2006) highlighted that this is invaluable to student learning because it gives students a different perspective to compare and improve on their self-evaluation—and it enables learners to refine their skills as they learn (Kaplonyi et al, 2017).
Patient education is an essential part of nursing practice. However, some authors (Coster and Norman, 2009; Richard et al, 2018) have suggested that nurses can feel underprepared to teach patients in the practice setting. Bergh et al (2014) reported that patient education is largely performed in unarticulated and seemingly unreflected ways, arguing that it is important that innate pedagogical knowledge is articulated. Halse et al (2014) suggested that nurses rarely appear to plan health teaching, use available teaching materials or document health teaching. This suggests that nurses' patient education work may be largely invisible to nursing students and potentially limits learning opportunities.
A meta-analysis by Oh et al (2015) demonstrated that a simulated patient can be used as an active learning methodology, with findings from this formative evaluation indicating that using a simulated patient to practise patient-teaching skills was perceived by the students to be a valuable method of learning. Simulation-based learning has been endorsed by the NMC, which requires that students:
‘Are enabled to learn and are assessed using a range of methods, including technology enhanced and simulation-based learning appropriate for their programme as necessary for safe and effective practice.’
In addition, a randomised controlled trial by Basak et al (2019) compared the effectiveness of using a simulated patient with a theoretical lecture on the patient-teaching skills of nursing students for inhaler use. Findings showed that the patient-teaching skill scores of the students included in the group receiving simulated patient teaching were higher than those of the control group. The students included in the simulated-patient group were also found to feel more confident while teaching a simulated patient about inhaler drug use. This offers encouraging evidence to support the use of simulation to facilitate role play in patient teaching within undergraduate nursing curricula.
Hamilton (2010) stated that nursing students have many opportunities during the programme to practise cognitive and psychomotor skills, with simulation providing an opportunity to practise these skills, as well as the affective skills necessary to provide safe, good-quality care. Thus, this simulated scenario also encompassed the affective domain of learning by incorporating the human aspect of the situation. Basak et al (2019) emphasised that the success of patient teaching depends on how interpersonal communication skills are used, with Andrea and Kotowski (2017) reporting that patient teaching, performed by using simulated patients, can help students to learn how to use their interpersonal communication skills and develop critical thinking skills. Cowdell (2010) argued that teaching methods that engage the emotions of participants are likely to be more successful than traditional classroom lectures at promoting person-centred care. The inclusion of patient education resources in the scenario further engaged learners to identify the relevance of learning to practise with the simulated patient being able to use the materials.
Crookes et al (2013) highlighted the need to use teaching methods that create a link between theory in the classroom, and in a practice setting, to make learning experiences for students meaningful. Some authors (McCleary-Jones, 2016; Richard et al, 2018) have argued that evaluation of patient teaching and related broader components, such as health literacy, need to be threaded throughout the curriculum and emphasised in the practice environment. One method of facilitating effective development of patient-teaching skills would be by increasing the emphasis on patient-teaching skills throughout the undergraduate programme and incorporating the use of a simulated patient to allow for evaluation of patient-teaching and teach-back skills. Fidyk et al (2014) highlighted the benefits of using teach back, citing these as improved communication, decreased length of hospital stay and the identification of poor health literacy. However, Caplin and Saunders (2015) argued that, although teach back is easy to use, it requires practice and planning, using handouts to reinforce points and clarifying information.
Similar to findings by Smithson et al (2015), using a member of staff as the simulated patient appeared to be advantageous and well received by the students, who evaluated the learning experience positively. It was thought that involving a content expert as the simulated patient would increase the chance of realistic conversations and prompt characteristic responses in the patient-teaching situation. The member of staff involved in the present study had considerable experience in simulation-based learning and role play, in addition to a practice background in health promotion and patient education. MacLean et al (2018) suggested that using inter-rater reliability to evaluate simulated-patient consistency supported the assertion that, if trained appropriately, simulated patients have a high degree of reliability and validity to facilitate and evaluate student performance in nurse education. However, Mangold (2016) highlighted that simulated-patient training varies from no training to very structured training, with the potential to reduce the reliability of the training experience and that further work is needed to determine the amount and type of training necessary for effective, authentic, and consistent healthcare education. Future work is indicated to include training and testing of the simulated patients involved and should focus on nurse–patient communication techniques.
The basis for the implementation of good-quality patient education is person-centred care, which takes into account the holistic needs of the patient (Morgan and Yoder, 2012). Bloomfield and Pegram (2015) argued that the demonstration of a partnership approach to patient care will help establish the trust necessary to obtain the information needed to implement an individualised plan of care. The NMC (2018c:14) recommended that newly registered nurses must be able to demonstrate the ability to work in partnership with people to enable them to make informed choices about their care and to demonstrate shared assessment, planning, decision-making and goal-setting. Therefore, it is essential that nursing students are supported in their preparation to engage in patient teaching.
Limitations
It is recognised that this study had several limitations. The sample size was small and the study was conducted within a single institution. The use of one simulated patient potentially limits the extent to which the findings are generalisable. In addition, although there are reported advantages to using a staff member as a simulated patient, it is possible that this may limit the authenticity of the scenario and students may prefer to engage with an individual they do not know.
Further research with a larger cohort of students in a variety of practice settings would add to our understanding of students' experiences with simulated learning, where the focus is the development of patient-teaching skills.
Conclusion
This study sought to formatively evaluate a simulated role-play scenario facilitated with third-year nursing students to support the development of patient-teaching skills. The findings suggested that facilitating learning with a simulated patient is particularly valuable in replicating more authentic verbal interactions during a patient-teaching session. Simulation-based education is resource intense and requires facilitators with appropriate skills and experience in pre-briefing, scenario design and debriefing. The methodology illustrated here could allow for a more sophisticated evaluation and reflection of the communication and teaching skills used in a patient education session. Further research is needed with larger sample sizes, incorporating students from other fields in nursing and with students representative of the wider multidisciplinary team, and using a range of scenarios.