The current COVID-19 pandemic has had a significant effect on the delivery of nursing training in higher education and how workforce development programmes are delivered (Health Education England (HEE), 2020). This has created a need to transform and adapt current provision to resolve the impact on education and training. In recognition of this, current Nursing and Midwifery Council (NMC) emergency standards offer a maximum of up to 300 hours of simulated learning out of the overall 2300 practical learning hours where clinical practice is not possible (NMC, 2021). The additional simulation hours are considered to be an effective, alternative way of learning, enabling flexibility in practical learning and supporting students in progressing their studies (Royal College of Nursing (RCN), 2021). This presents significant challenges in higher education, both in terms of resourcing and capacity, availability of practice assessors, ensuring proficiencies are assessed in a meaningful way that replicates clinical practice and improving patient safety.
In education, simulated practice is an opportunity for experiential and immersive learning (Aggarwal et al, 2010). It is defined as:
‘A technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion.’
This term broadly includes a wide spectrum of modalities, inclusive of immersive technologies. Immersive technologies are used to create distinct experiences by merging the physical world and/or simulated reality. Simulation and immersive technologies are not new concepts in healthcare education (HEE, 2020).
Simulation theory
The acquisition of appropriate competence is the main objective of nurse education (Díaz Agea et al, 2019) and simulation has grown in popularity over several years, challenging nurse educators to move away from traditional didactic teaching methods. Using simulation as an education platform is congruent with the pedagogical philosophy underpinning the education of current nursing students. The simulation experience in nurse education is characterised by an environment that is experiential, interactive, collaborative and learner centred (Jefferies, 2015). Underpinned by experiential learning theory (Kolb, 2014), simulation allows students to engage directly with an authentic situation and reflect on an observation, noticing what has happened and relate this to past experiences. This enables abstract conceptualisation and active experimentation to test new ideas and hone new skills in a safe environment.
Creation of a simulated environment requires the establishment of trust, between both the facilitator and participant, to share responsibility for maintaining this environment. This enhances the quality of the simulation experience through ‘buying in’ to the authenticity of the experience and suspending disbelief (Jefferies, 2015). The dynamic interaction between the facilitator and participant creates an organic process whereby the facilitator responds to the participants' and group's needs during the simulation experience, adjusting educational strategies or timing of activities. The facilitator provides appropriate feedback in the form of cues (during) and debriefing (toward the end) of the simulation experience (Jefferies, 2015). This subsequently helps to promote student engagement, interaction and psychological fidelity within the simulation experience (Kiat et al, 2007; Leighton and Sholl, 2009; van Soeren et al, 2011).
The outcomes of simulation can be separated into three areas:
- Participant outcomes
- Patient (care recipient) outcomes
- System outcomes.
Previous literature has tended to focus on participant outcomes, including reaction (satisfaction, self-confidence), learning (changes in knowledge, skills, attitudes), and behaviour (how learning transfers to the clinical environment) (Jefferies, 2015). However, there is emerging literature considering the health outcomes of patients (care recipients) who receive care from professionals trained using simulation, the cost-effectiveness of simulation training and changes in practice from a participant, patient and system perspective as a result of simulation (HEE, 2020).
There are three broad domains in which simulation can be used in nurse education (Table 1).
Table 1. Simulation domains
| Domain 1 | Practice and assessment of technical procedures. This can be in the form of simple bench models, manikins or virtual reality machines |
| Domain 2 | Service users and actors to play patients as a form of performance-based assessment |
| Domain 3 | Simulated technologies used for team training, decision making and critical thinking in complex immersive situations |
Principles of simulation that contribute to improving patient safety
Patient safety is the absence of preventable harm to a patient during the process of health care. The first NHS national patient safety strategy was published in July 2019. It is integral to the NHS definition of quality care and underpins all areas of practice. Patient safety is described as maximising the things that go right and minimising the things that go wrong (NHS England/NHS Improvement, 2019). The strategy emphasises the need to build and strengthen a patient safety culture in the NHS, taking a systems-based approach to understanding and improving patient safety. One of the key components of this strategy is to strengthen the existing curricula and lifelong learning guidance for all students and health professionals through education and training in patient safety, human factors and safety management. Simulation can play a key role in underpinning both the patient safety strategy and the syllabus. The use of simulation in training and education provides professional bodies, clinical practitioners and patient groups with the opportunity to examine and redesign systems and processes of care with consideration to human and ergonomic factors relevant to health and care transformation (HEE, 2020). Several studies have highlighted the success of simulated learning environments in improving students' critical thinking skills, an opportunity to problem-solve and practice complex skills in a non-threatening environment (Sanford, 2010; Khalaila, 2014).
The use of simulation allows for the creation of scenarios that combine the theory and practice behind the clinical skill/s being learnt, with consideration of a variety of human factors that make up the clinical environments (HEE, 2020). When considering how simulation can contribute to improving patient safety, it is vital to consider the following key areas.
‘Practise first’ mitigates actual patient harm
Simulation allows students to ‘practise before doing’ and to mitigate the risk of harm to a patient when a procedure or assessment is conducted for the first time as there is no ‘real patient’ involved (Kim et al, 2016). It also promotes an increase in confidence and competence in students (Al Gharibi and Arulappan, 2020), which is key in not only the professional and personal growth of students, but also ensures safety in future interactions with patients.
Interprofessional working
Simulation is a medium whereby interprofessional learning can be facilitated to allow students to develop their clinical skills while working in tandem with students from other fields or professional backgrounds to support a patient in any given scenario. This way of learning is very much in line with the view of having fully integrated care systems within the NHS, which have been shown to increase patient satisfaction and the quality of care individuals perceive that they receive (Baxter et al, 2018). Integrated care through working with other professionals has been shown to have positive effects on patient safety in a variety of ways, such as reducing the rates of emergency hospital admissions for individuals over 65, having minimal delays in regard to transfers of care and a reduction in the number of hospital beds used for admissions for individuals aged 65 and over (Thistlethwaite, 2011). The ability to facilitate student exposure to this multidisciplinary way of working early in their training aims to reduce the likelihood of siloed working once qualified, which will ultimately equate to better, safer patient care being provided.
Resilience building
Simulation offers the opportunity for educators to immerse students in varying situations that can promote not only the learning of ‘hands on’ skills, but also of analytical skills that are key in reducing patient safety events (HEE, 2020). Factors such as organisational cultures, system or process issues and communication between professionals are aspects that can be explored in a safe environment. A facilitator/educator can guide the learning session and the post-session de-brief to challenge poor practice, ask students to think about their role or the systems they work in and, most importantly, consider possible areas for change or innovation in themselves or the environment they work in to promote patient safety. This process of using ‘real life’ examples to explore difficult scenarios within a simulated environment, such as untoward patient safety events, can help students to build resilience during their nursing programme for working in a clinical area (Walsh et al, 2020).
Communication
In simulated practice, communication is a key aspect of the learning process and contributes to the development of participants' communication skills. Communication can be viewed as an ‘omnidirectional diachronic process’ (van Ruler, 2018). This promotes the development of meaning through the dynamic interaction between varying factors such as the environment in which the communication is occurring and the relationship between the sender/s and receiver/s of the communication. The complexity of teaching and learning such a skill is evident. This complexity is also emphasised in Annexe A and Annexe B of Future Nurse: standards of proficiency for registered nurses (NMC, 2018), which asks that nurses have certain communication skills in relationship management, and are able to perform certain nursing procedures in which communication forms a key part of safety.
Through the use of simulation, students are able to develop their individual and relational communication skills in a safe and supported environment in a variety of ways that directly link to patient safety (NMC, 2018).
Simulated practice event
Considering these reported benefits of simulated practice, the authors of this article lead on the development and facilitation of an immersive ‘crisis’ event for third-year nursing and midwifery students as a means of applying the theoretical strengths of simulation learning directly into teaching practice (see Table 2).
Table 2. How communication can be developed in simulated practice; an application using an immersive simulation ‘crisis’ event
| Method of interaction | Description of method | Link to patient safety | Application in ‘crisis event’ | Example of student feedback from the immersive simulation ‘crisis’ event |
|---|---|---|---|---|
| Role modelling from the facilitator/teacher to the students | The facilitator role models what either poor communication or good communication looks like when providing cues, offering information, providing feed forward or constructive feedback, or when facilitating the post-session de-brief | Students are able to experience aspects of section 4 from the NMC's Annexe A, which relates to ‘communication skills and approaches for working with people in professional teams’ (NMC, 2018), to effectively lead or work as part of a team, supporting others in varying situations which directly relate to patient care | The actor playing the ‘charge nurse’ of the ward was a lecturer, who was tasked with providing a limited handover at the start of the scenarioIn the de-brief part of the session, the two facilitators explored principles of communication with the students, many of whom cited not only in which areas the ‘charge nurse’ in the scenario could have provided a better handover and what that would have entailed for them, but they also reflected on the realities of working in fast-paced clinical areas. This led students to discuss considerations or adaptations that they might employ in relation to their own communication, as well as in relation to the processes and systems in place in said organisations | ‘The whole scenario was interesting and would have been more helpful if we had done it earlier in the year. It helps in decision making, acting quickly and how to work together in a team in challenging situations’‘Enjoyed the debrief the most. It has given me time to reflect on my skills and how I manage tense situations’‘This helped me to reflect on my communication skills and the communication skills of others’ |
| Student to ‘patient’ interaction | Students are able to speak and perform a variety of assessments or interventions on manikins, actors or those with lived experiences who are playing the role of the ‘patient’ | Students are able to practice aspects of Annexe A (NMC, 2018) detailed in sections 1, 2 and 3, from seeking consent to de-escalating a challenging situation, thus developing their communication skillsStudents are also able to practise any nursing procedure in Annexe B (NMC, 2018), thus developing their procedural and assessment communication skills | Students had the opportunity to assess and intervene accordingly for a variety of clinical presentations such an ectopic pregnancy, sepsis, anaphylaxis, acute myocardial infarction, choking and assessing the mental state of an individual with dementia as these were the ‘patients’ they were presented with on the ward they entered | ‘I am better prepared to deal with anxious patients and keep them calm’ |
| Student to student, or peer to peer interaction | Students are able to work together in groups in scenarios to complete set taskStudents are also encouraged to provide feedback to each other during the de-brief | Students are able to practise and reflect on all aspects of Annexe A and B (NMC, 2018) through shared learning and support | As part of the scenario students were not ‘allocated’ patients and had to work as a team to decide who supported which patient and whenStudents also had a 45-minute post-session debrief in which they explored aspects relating to clinical practice, leadership, communication and team working | ‘I have gained insight into my own ability and what areas I need to make improvements on. I also know I need to improve my acute knowledge. I learnt so much from my fellow students and enjoyed to opportunity to work together as a team’ |
The ‘crisis’ event was developed with a focus on taking a multidisciplinary approach to simulation and was designed for students to work in groups of six in a hypothetical crisis. Students were exposed to four main activities within the simulation, which focused on the themes of teamwork, communication, patient safety and effective debriefing.
First, the students were welcomed into a ‘briefing room’ where they watched a video that was created to provide a backstory to the crisis developing around them. Then the students were taken to the ward simulation suite where they were required to assess the patients on the ward, plan the appropriate treatment/care considering what they observed and assessed and, where appropriate, escalate concerns to a ‘nurse in charge’ figure (whose role was played by a member of the teaching faculty). The ‘patients’ in the simulation were service users and actors. The students were then guided to a room with table and chairs where they had the chance to debrief as a group, before being joined by two members of the faculty who facilitated a debrief session after a period of time. Figure 1 highlights the various areas students were guided through as part of the immersive simulation crisis event and Figure 2 contains pictures of these areas.
Figure 1. Flowchart showing the student journey and areas experienced during the immersive simulation ‘crisis’ event at the University of West London 
Figure 2. An example of a simulated crisis event. Top row and bottom row, left and centre: service users acting in the simulation, with student nurses assessing and treating them. Bottom row, right: students discussing their experiences in the debriefing session following the hypothetical crisis event
The simulation event was a hypothetical crisis event acted by five service users, each presenting with different clinical symptoms. Possible scenarios included ectopic pregnancy, sepsis, anaphylaxis, acute myocardial infarction, choking and assessing the mental state of an individual with dementia. The simulation lasted 20 minutes and students were in groups of six to eight. Students were expected to assess the patients, treat if possible and escalate to the medical team.
After students took part in the facilitated debrief, they were asked to provide feedback in a final room before finishing and leaving the session. From the feedback provided by students (as detailed in Table 2) a link between the method of interaction planned and the overarching themes explored relating to patient safety can be made. Additionally, considering the feedback and evaluation provided by students, a decision was made to roll out the immersive simulation ‘crisis’ event across all third-year nursing and allied healthcare courses including continuing professional development and bespoke trust training. Despite this, there continues to be a need for further research to add to the existing body of knowledge of using simulation and immersive technologies in healthcare education, with a particular consideration to patient safety and how its effects might be measured in relation to clinical practice.
Conclusion
Within the context of health care today there is a focus on a system-level approach to changing the culture of healthcare provision that holds integrated care at the forefront of achieving this. Through immersion and authenticity, simulated practice offers the opportunity for educators to support students in applying theoretical concepts, developing their skills and critically reflecting on existing approaches within health care in an environment that is safe and supportive for them, and for the patients they will be supporting in the future.
KEY POINTS
- Simulation offers the opportunity for educators to apply theoretical concepts and develop new skills in their nursing students
- Simulation allows students to critically reflect on their approaches and receive feedback from service users regarding quality of care and patient safety
- The increased use of simulation in nurse education is an opportunity to create new experiential and immersive learning environments
CPD reflective questions
- How could you use simulation and immersive learning in your area of practice?
- Think about your current training provision, how could this be adapted?
- How has the use of simulation and immersive training improved patient safety in your clinical area?