Simulation-based learning pedagogy is widely recognised in nursing education as helping to develop students’ knowledge, skills and attitudes, while ensuring that when students move to the practice setting patients are protected from avoidable harm. Clinical experiences and specific learning opportunities in practice settings can be serendipitous, simulation-based learning offers specifically targeted experiences mapped to Nursing and Midwifery Council (2018) guidelines.
With regard to nursing students, studies suggest that simulation can be an effective replacement for up to 50% of clinical hours, with outcomes aligned to and comparable with those achieved in clinical practice (Hayden et al, 2014). A review of studies by Roberts et al (2019) examined the replacement of clinical placement hours with simulated practice learning hours, finding no significant difference in student outcomes in relation to both acquired skills and knowledge.
Designing simulation scenarios that are based on real-life cases provides students with experiences closer to what they will subsequently encounter in practice. To create authentic simulation experiences it is therefore essential to involve service users and co-design scenarios. This helps ensure that the ever-changing healthcare needs of different patient populations are reflected in the nursing curriculum.
Learning from stories
The concept of narrative pedagogy originates from the tradition of learning from stories passed on from generation to generation. It is not a replacement for conventional pedagogies, but a valuable tool to be used in conjunction with a content and competencydriven curriculum. The use of this concept in nursing simulation is essential to ensure authenticity and to accurately reflect real-world cases and the challenges that nurses may encounter in their practice.
The co-design of simulation scenarios with experts by experience, namely service users, ensures that the simulations are culturally sensitive and inclusive, taking account of patients' diverse backgrounds and perspectives. The service user perspective and experiences help students to develop empathy, communication skills and cultural competence, all attributes that are crucial for delivering high-quality, patient-centred care.
Mandatory training
Learning disability training is now mandated in nursing curriculums following the death of a patient. Teenager Oliver McGowan, who had mild autism and learning disabilities, died after having an adverse reaction to antipsychotic drugs. His death highlighted the need for improved training for all health and social care staff (Hill and Peek, 2022), with universities subsequently making the mandated changes to these programmes.
At King's College London, the nursing curriculum was adapted to incorporate elements of the mandated changes, using narrative pedagogy to inform the development of simulations for second-year undergraduate students undergoing learning disability training. This approach ensured that the scenarios were representative of the learning disability population.
Simulation modalities to deliver learning disability training allow for practical application of concepts, reflection on and in action, and peer-to-peer learning through facilitated debriefing. The involvement of service users therefore ensures that the scenarios included in the simulations are contemporary and reflect real-life experiences.
Service user input
The initial step in co-designing learning disability simulations involved listening actively to service users' stories. The simulations were created from interviews and drama workshops involving academic staff and a learning disability theatre group. Each learning disability participant was encouraged to share their recent healthcare encounters, positive or negative, and how these episodes had made them feel, as well as to describe any challenges that they had then faced.
The stories related by service users encompassed a variety of healthcare episodes, such as the assessment of a broken foot, experiences with vaccinations, managing facial injuries from falls at home, and admission for mental illness.
The depth and complexity of the narratives, describing service users' lived experiences, provided invaluable perspectives on the healthcare system and the staff service users encountered. The feedback showed that learning disability patients are likely to need extra reassurance and explanation, so the following comments and experiences were used as a basis for developing scenarios:
- ‘I don't like the smell of hospitals’
- ‘I thought, why me’
- ‘No one explained why I was there and how long I would have to wait’
- ‘I didn't know what was going to happen to me’
- ‘I felt scared in the ambulance.’
Scenarios co-designed with service users contribute to humanising the experiences of patients. They are designed to evoke empathy in the learner and support the development of communication skills, which include active listening, challenging unconscious bias and assumption-based decisions, and challenging discrimination. Scenarios that reflect the real-life experiences of service users also provide the opportunity for practical application of techniques to approach difficult conversations.
Ownership
The participatory process has fostered a collaborative approach to the design of simulations, creating a sense of ownership and empowerment for service users. They contributed to the writing of the scenarios and their subsequent fine-tuning during the drama workshops. The simulations were then presented to students using the same actors who had taken part in the workshops.
Integrating lived experiences into simulation design has helped to bridge the gap between theory and practice, making learning more realistic and meaningful for students.
By connecting abstract concepts and real-world situations the simulations enhance critical thinking skills and decision-making abilities, ultimately preparing students to become competent and confident nurses.
Feedback from the first group of second-year students who received the new training showed that they thought the progressive complexity of the scenarios, which involved role-playing to apply communication and empathy skills, and repetition also helped reinforce their learning. The scenarios provide an immersive learning experience, with students interacting with the ‘service users’ and gaining realistic responses. The simulations were delivered using the forum theatre technique, whereby participants are able to interact, pause to discuss, and change the action.
The use of simulation that involves scenarios based on real-life service user experiences supports nursing students to develop clinical competencies that are transferable to the clinical environment. Using lived experiences in simulation design creates a more authentic learning environment that reflects the complexities of real nursing practice and ultimately improves the quality of both nursing education and outcomes for patients.