Full-scale simulation (FSS) is one of the most effective and commonly used simulation modalities in healthcare education. It enables the rehearsal of skills in a safe and controlled environment without the risk of harming patients, which provides a strong argument for it being a useful educational approach. With technological developments and the widescale use of simulation technologies in many institutions, simulation has become an essential part of healthcare professional training and curricula. However, setting up a simulation laboratory can be very costly for institutions, as can training facilitators and ensuring equipment maintenance. Simulated patients (actors) are also not universally embraced because of the costs. This makes running an FSS challenging. Furthermore, technology fear, shortage of trained staff, scarcity of space and equipment, workload and applicability to the existing curriculum can be acknowledged as further barriers to the adoption of FSS. We assert that Visually-Enhanced Mental Simulation (VEMS), which includes a patient poster instead of a patient simulator or simulated patient 
and does not require a simulation laboratory, can be a potential alternative solution to FSS. This is particularly true for non-technical skills teaching.
This study aimed to explore nursing students’ evaluation of the VEMS sessions.
Simulation activity outline:
VEMS is a mental form of simulation which includes basic representations of a patient, equipment and interventions. A laminated patient poster is used to represent the patient and laminated equipment cards are used for equipment. A whiteboard or flipchart are used to write interventions and patient parameters in real-time. Also, the simulation session includes ‘thinking aloud’ (participants verbalize their thinking process and actions). Before the scenario, pre-briefing takes place, and a debriefing follows after the scenario, as in FSS.
As part of a wider project, we piloted the use of VEMS with 30 final-year adult nursing students who consented to participate in VEMS sessions. The main study relied on a quasi-experimental design to compare two simulation modalities, FSS and VEMS. The study was approved by the University of Hertfordshire Ethics Committee (protocol number: aHSK/PGR/UH/03692(2)). Final-year adult nursing students studying at the university were targeted for this study. Control (FSS) and experimental (VEMS) groups were exposed to the same scenarios which included two deteriorating postoperative patients. Students were asked to evaluate the effectiveness of the simulation session with the Simulation Effectiveness Tool-Modified (SET-M) 
The students found VEMS to be effective for their learning and confidence as they marked it 43.70 (SD: 9.11) out of 57. The pre-briefing part scored 2.41 (SD: 0.61), the learning scored 2.19 (SD: 0.50), the confidence subscale scored 2.25 (SD: 0.57), and the debriefing part scored 2.51 (SD: 0.53), all out of three points.
Implication for practice:
This may suggest that students found the VEMS session a useful learning activity which also contributed to developing their confidence. Based on the pilot study questionnaire data, it could be argued that VEMS can be a valuable simulation approach in nursing education as it does not rely on technology and is easy to facilitate anywhere.