International Journal of Healthcare Simulation

Introduction/background

Clinical skills are an essential part of healthcare provision and nursing education. Traditionally, nurse educators have relied on clinical placements to provide practical and contextual experiential learning opportunities [1]. There are, however, a range of practical restrictions that come with clinical placement; for example, only a limited number of students can be on clinical placement at any one time. At a time when healthcare workforce shortages are reported, the need to train more nurses is vital. However, the constrained capacity of clinical placements has been long recognized as an issue in many countries trying to meet this increasing demand [2]. The need to identify alternative ways to train nurses and healthcare practitioners that enhances, not replaces, clinical practice is even more pressing given the increased pressure and safety concerns that the COVID-19 pandemic has created in healthcare settings [3,4].

Simulation is now widely used in nursing education [5]. Like clinical placements, simulation is a form of experiential learning [6]. Students can learn and practice clinical skills in a simulated environment, with a range of equipment and simulated patients that approximate a clinical setting [7]. Simulation, as a pedagogical strategy, has several advantages over traditional didactic approaches, one being that it allows students to apply the cognitive and psychomotor skills required to competently undertake clinical tasks [8]. Furthermore, simulation allows students to practice these skills in a safe, supportive environment before entering clinical placement. This allows students to safely make mistakes, which will not impact care, and to receive constructive feedback, further enhancing critical reflection and self-awareness, which are important skills in themselves.

In 2014, a study in the USA concluded that up to 50% of clinical placement could be effectively substituted by simulation in core nursing courses [9]. Further studies have shown that there is no significant difference in student outcomes in relation to clinical competency, knowledge and confidence when using simulation to replace a percentage of clinical practice [10–13]. Student perceptions of simulation compared with clinical placement have also been explored and have been deemed positive overall [14–16]. Several studies have examined the role of simulated practice in assisting student nurse’s transition to clinical practice as new graduates rather than as students at the beginning of their educational journey [17–21].

While simulation has a number of benefits and the potential to address workforce and training-related issues, a large amount of the literature has focused on simulation when used to train for specific high-risk, rare events (e.g. resuscitation) and in high-technological settings. Broadly, high-technological simulation utilizes sophisticated technology and mannequins to recreate a clinical scenario as closely as possible [21,22]. The drawback of such an approach is that it can be expensive, resource-intensive and may not always meet the required learning needs [23,24]. This contrasts with low-technological simulation, which uses simple, low-cost alternatives and often sources everyday materials to simulate a clinical environment [25]. In this study, the terms high- and low-technological simulation are used rather than high and low fidelity, as fidelity is a multi-dimensional concept that incorporates the physical (technology), environmental and emotional aspects of the simulation design and, therefore, should not be a judgement on realism unless incorporating all three dimensions at a minimum [26].

The focus of training for first-year UK nursing students is the development of fundamental nursing skills aimed at facilitating their transition to clinical practice. Low-technological-simulated practice offers simple, safe, low-cost settings to recreate common, realistic and relevant clinical scenarios within the scope of the knowledge and skills required for this cohort. Beyond this, there is an increasingly pressing need to explore the potential of simulated practice as a pre-registration training tool, given that the nursing workforce expansion is a priority [27], and there are already limited clinical placements. Placement experience may not always meet the learning needs of students but instead meet a registration requirement focussed on hours rather than opportunities [4]. By engaging students who have had no clinical practice experience, there is an opportunity to identify if simulation is a reliable tool to enhance the transition into clinical practice.

Aim

The aim of this study was to research the impact of a low-technological, high-authenticity-simulated practice programme on a UK first-year children’s nursing pre-registration programme. In this study, the authors sought to determine the programmes use as a transitioning tool to clinical practice and to identify the benefits, challenges, differences and affordances.

Research questions

What are the key challenges, differences and affordance of implementing simulation prior to first clinical placement in a pre-registration children’s nursing programme?

Methods

Research design

Methodology

This study utilized a participatory action research approach [28], whereby practitioners (in this case academic faculty) identified a problem and used their own knowledge to conceptualize it (student challenges in transitioning to clinical practice, lack of suitable clinical placement capacity) and provide a solution (a customized simulated practice environment) (Table 1). The solution was then implemented and evaluated qualitatively. The reporting of this study follows COREQ guidance [29].

Table 1:

The simulated practice intervention described using Cheng et al. [30] guidelines

Simulation element	Descriptor
Participant orientation	UK first-year student nurses studying for their BSc (Hons) Nursing (child) were expected to wear uniform when attending simulated practice and to behave professionally at all times. They were expected to plan the care they would be expected to provide as first-year nursing students on clinical placement. Students were assigned patients and a nursing care task; they were told to work in pairs and were encouraged to challenge each other as to their approach. For example, why use an oral thermometer on a toddler.
Simulator type	Low-technological mannequins of varied ages were utilized. Creative solutions were employed to simulate different clinical conditions by using low-cost household resources. For example, mustard seeds, mint-gel and mustard paste simulated the appearance and consistency of neonatal diarrhoea in a nappy, canned vegetable soup simulated vomit and tea simulated urine.
Simulation environment	The simulation was university based within the skills labs, which were adapted to represent children’s wards. Rooms were modified and thoughtfully equipped to mirror a ward environment.
Simulation scenario	The scenarios evolved slowly over a six-day period allowing the students to develop and rehearse the knowledge and skills they acquired. There were a total of eight patients on the ward each day. Ranging in ages from 20 days to 15 years. The patients had non-complex conditions such as whooping cough, pneumonia, epilepsy, fractured femur, acute asthma attack, minor burns, appendectomy and salmonella. Day 1: Handover, carry out vital observations (plus neurological observations where required) and documentation, admit new patients (some with D&V and therefore PPE required), complete admission assessment and care plan development. Debrief at end of the day. Day 2: Same as day 1 plus implement care plans created the previous day and care for new patients being admitted. Debrief at end of the day. Day 3: Same as days 1 and 2 plus medicine management (administer medicine to all patients, checking the prescription chart, calculating the dosage and using an appropriate clinical hold). Debrief at end of the day. Day 4: Continuing with shift tasks and patients admitted previously plus wound dressing using non-touch technique (scald on the chest, a laceration to the head). Debrief at end of the day. Day 5: Continuing with the same patients as day 4 plus new admissions. Focus on communication through managing phone calls (calls received from health professionals, family members and clinical reports). Plus prep a patient for theatre. Debrief at end of the day. Day 6: Same patients and tasks as day 5 plus a focus on managing confrontation. The scenario led to talking to parents. For example, explain home safety to the mother of the child with the scald, explaining why the teenager in isolation couldn’t come out of the room, deescalating the father who did not have access to his son without a social worker and who just burst onto the ward. Debrief at end of the day. Final debrief for the entire period. Throughout the period, students would care for different patients which enabled them to rehearse and practice the various skills and knowledge they have obtained. At the end of the last shift, they were able to choose which patient they wanted to care for to fill any gaps in knowledge or skills.
Instructional design	The scenarios were mapped around the UK’s Nursing and Midwifery councils (NMC [31]) five essential skills clusters to ensure students developed and rehearsed a range of skills required for safe and effective practice. Dedicated clinical scenarios, feedback and debrief-type discussion were included to reinforce core nursing and children’s-nursing-specific skills. Aspects of the patient care were broken down and delivered at a slower pace than they would be in reality. This created an environment for peer support, learning and discussion in a safe environment. The students had time to plan their care and discuss with both their peers and the facilitators the rationale for their actions. To address the complex construct of employability, the focus was also extended to ‘soft transferable skills’ such as efficient communication with patients, establishing a therapeutic relationship with parents/relatives, gaining trust and showing compassion. These were supported by customized role-play interventions that help students appreciate the different perspectives (patient, parent/carer, healthcare professional) and enabled them to practise key attributes of a successful children’s nurse, including managing themselves (in a stressful environment), others (colleagues, the agitated parent), information (communicating accurately while ensuring confidentiality) and the task (prioritization). Students undertook two consecutive weeks of simulated practice totalling 45 hours spread over 3 days per week (7.5 hours per day) in their first semester. In addition, they had a workbook to complete as independent study which was a reflection of the simulation activities. The scenarios were developed on a daily basis; initially, the focus was on one core skill per scenario. However, this was gradually built up to combine several core skills for total patient care. Each day building on and reinforcing the previous day’s simulation. This allowed the students to rehearse and perfect the core skills.
Feedback/debriefing	Feedback was a constant feature of the simulation. For example, every day started with a handover, followed by a discussion to establish understanding of the handover. The students could ask the facilitator at any point for guidance, which they did. This resulted in small feedback sessions between the facilitator and two students. At the end of each day, there was a verbal debrief with the whole group asking the students what they had learnt, and what they felt had gone well. Facilitators consisted of three experienced academics in the field of nursing education, who had an established teacher–student relationship with the study participants. There was a five-to-one student-to-staff ratio.

Methods

Two cohorts (intakes per year) of first-year student nurses enrolled in a Bachelor of Science (Honours) Nursing (Child) programme were recruited (20 per cohort, 40 in total). There was no difference amongst cohorts in terms of experience. We included both cohorts to ensure a breadth of data and perspectives in line with previous studies [32]. Purposive sampling was used to intentionally select participants (first-year cohorts, pre-clinical practice) who were required to undertake the simulation activity under study and, therefore, answer the study research question. There were no differences in terms of clinical experience across the cohorts, and students had no prior experience of simulation.

Students undertook two consecutive weeks of simulated practice totalling 45 hours spread over 3 days per week (7.5 hours per day) in their first semester. In addition, they were required to complete a workbook as independent study which was a reflection of the simulation activities. During the simulations, low-technological mannequins of varied ages were utilized. Creative solutions were employed to simulate different clinical conditions by using low-cost household resources (Table 1).

Students completed an open-ended survey at two points in time, after the initial simulation in the first semester (pre-clinical placement), and after they completed their first clinical placement (post) 10 weeks later. The survey was developed based on:

1. The theoretical underpinnings of Kirkpatrick’s model of educational intervention evaluation [33];
2. Previous research evidence using simulation evaluation surveys [32];
3. Discussions with the team and students to assess what was practical and feasible given the students programme to maximize their feedback within their available time.

In the first survey, students were asked to complete a series of questions designed to elicit qualitative data related to their experiences of simulation: what they had learnt, their confidence and the perceived advantages and challenges of simulation. After completing the clinical placement, students completed another survey where they were asked about the skills they had applied whilst on placement, how placement compared with simulation and again the perceived advantages and drawbacks of simulation.

Data analysis

A reflexive thematic analysis was conducted drawing on the team’s different experiences in nursing and simulation to generate shared meaning [34]. MAXQDA2020 software was used to assist in analyzing the pre and post data [35], by identifying patterns amongst the data and generating coding maps where semantic networks were formed that revealed thematic relations pertaining to the research questions through interconnected codes. All authors had input to the process.

Research ethics

This research was approved by the University of Greenwich Human Research Ethics Committee (reference number: UREC/15.5.5.10).

Findings

Thirty-seven pre-placement students and 35 post-placement students completed the surveys, respectively (93% response rate and 88% after follow-up). Eight core themes (‘bridging’ from simulation to practice and to enhance practice; ‘preparedness’ once on clinical placement; ‘applied learning’ reliably transferred to practice; ‘skill decay’ between simulation and practice; ‘same but different experiences’ between simulation and practice; simulation and clinical ‘practice pace’; ‘safety’ of simulation; and ‘unique affordances’ of simulated practice) that reflected both the pre- and post-clinical placement perspectives were constructed from the data, and an additional nine sub-themes were identified (transference to practice [pre]; practice enhancement [post]; slow-motion care [pre]; hectic [post]; it is safe [pre]; it was safe[post]; feedback and reassurance; practice and practice; and unpressured). Figure 1 provides a thematic model of the themes that were constructed and categorized according to the research aims. A description of the themes is reported below.

Figure 1:

Transitioning: simulation practice to clinical practice.

Transitioning benefits

Transitioning challenges

Discussion

The two themes of bridging and preparedness that emerged in this study spoke to the transitioning benefits of student’s simulated practice experiences to their clinical practice. Previous studies have aimed to identify if simulation bridges the theory–practice gap for graduate nurses; however, these studies have focused on its ability to ‘scaffold’ the learning experience in preparation for practice [36,37] and relied on students’ perceptions of simulation as a transitioning tool more generally [38–40]. This study is the first to provide evidence of first-year nursing students consciously linking their simulation experience to their clinical practice. The pre-simulation and post-clinical practice nature of this study has provided evidence of simulation’s ability to aid student’s transition to clinical practice which has transferability potential to other contexts. More specifically, it has highlighted the value of a low-technological, high-authenticity simulation design’s value for this purpose.

Students expressed that simulated practice was an anxiety-reducing tool when it came to clinical practice. This is in direct contrast to much of the medical literature in this area that presents simulation as ‘anxiety provoking’ [24,41–43]. This study included many of the recommendations for mitigating anxiety in simulation evident in the literature such as creating a safe learning environment, developing trusting relationships and supporting performance expectations [44–46]. This is further evident in the ‘applied learning’ theme where students had directly transferred their learning from the simulated practice to clinical practice by using concrete examples. This helps answer the research question as to whether this specific programme was beneficial in transitioning first-year pre-registration paediatric nurses to clinical practice. This study revealed that the programme provided the students with additional learning opportunities compared with clinical practice in terms of more exposure and opportunity to undertake skills and practice communication techniques. The use of a simulated practice programme can, therefore, not only prepare students for practice, but also enhance their experience once in practice, as well as provide them additional opportunities that they may not get on clinical placement.

Conversely, the study highlighted the challenges associated with the potential for skill decay if the clinical practice following the simulated practice did not provide an opportunity to practice what they had learnt, or if the time between both experiences was too long. This is a legitimate concern for educators when utilizing simulation programmes in this context. Sullivan et al. [47] provided a framework that aimed to mitigate these issues through the use of simulation maintenance, booster and refresher training strategies. It is suggested that similar programmes include these strategies as part of simulation design considerations. This revelation has provided a valuable addition to the current programme.

The ‘practice pace’ theme highlighted the students differing experience between simulated and clinical practice with the language of ‘slow-motion care’ and ‘hectic’ giving a sense of learning preference towards the simulated practice experience over the clinical practice experience. Ironically, simulation is often designed to mimic the pace of clinical practice; however, these data have revealed that students valued the opportunity to undertake a slowed-down version of clinical practice. This questions elements of simulation design in relation to ‘fidelity’ and the choices made in what is replicated and what is deliberately changed to create better learning opportunities. This outcome aligns with Escher et al. [48] who in their study on methods related to simulation-based teamwork training concluded that novices may gain from a slower tempo simulation experience.

A feeling of safety in both pre- and post-clinical placement in relation to simulated practice was reported in this study. Psychological safety and safe environments are often emphasized amongst the simulation literature [49,50]; however, less emphasis is put on the feelings of safety it provokes for students in relation to clinical practice. This highlights another unique affordance of simulated practice in enabling constructive feedback and reassurance, opportunities to ‘practice and practice’ and an unpressured environment. This provides a clear rationale as to why simulated practice is beneficial in its own right and not just a means to replace clinical practice.

Collectively, the themes of safety, anxiety-reduction, slow-motion care, preparedness, constructive feedback and reassurance, and reduced pressure reveal that simulated practice in this context can be seen as a well-being tool in addition to having experiential learning and bridging benefits.

Conclusion

This qualitative study has provided evidence that simulated practice can help transition first-year paediatric student nurses to clinical practice. It has revealed the benefits of simulated practice as an educational tool, its similarities and differences to clinical practice and its potential challenges, as well as unique affordances. The low-technological, high-authenticity design of the simulation programme examined in this study was clearly appropriate for the learner’s requirements and enabled students to link between their simulated practice and clinical practice experiences.