Collegian (2012) 19, 131—138

Available online at www.sciencedirect.com

jo ur nal homep age: www.elsev ier .com/ locate /co l l

An evaluation of a complex simulated scenario withfinal year undergraduate children’s nursing students

Jane Davies ∗, Martina Nathan, Dave Clarke

Cardiff School of Nursing and Midwifery Studies, United Kingdom

Received 13 December 2011; received in revised form 16 April 2012; accepted 24 April 2012

KEYWORDSSimulation;Nursing;Education;Evaluation

Summary The last decade has witnessed the emergence of simulation as a useful, but some-times challenging teaching methodology. This is supported by a number of sources of evidence,which focus strongly upon student evaluation of the learning experience. The challenges areequally worth consideration. These include issues such as the commissioning of space, staffexpertise in resourcing and creating a situation which is as close to real practice as possible.

It is against this backdrop, following a number of years developing innovative clinical simu-lation at Cardiff University; children’s nursing students were exposed to a complex simulatedclinical shift. The activities included: managing the clinical area; the transfer of a sick child;managing a medication error; subsequent discussion with the parents; and prioritising andorganising care. The use of role-play was utilised throughout, to create a realistic experienceand the simulation activity took place in two settings to enable the transfer from one area toanother.

The simulation experience was undertaken at the end of the third year undergraduate pro-gram by three cohorts of students (n = 41). Following the experience, data were collectedthrough a post-simulation de-briefing and a Likert style questionnaire, enabling the collectionof qualitative and quantitative data concerned with the student’s experience of the simulation.Overwhelmingly, the results showed that this was a positive experience for the students, demon-strating a number of perceived improvements in the application of their clinical skills. These

included: development of specific management skills; enhanced confidence; development ofself-awareness; and the transferability of skills to practice. Students also demonstrated strongagreement in terms of the realism of the experience.© 2012 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed

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International Books Austral

∗ Corresponding author at: School of Nursing and Midwifery Stud-ies, Cardiff University, 5th Floor Eastgate House, Newport Road,Cardiff CF24 0AB, Wales, United Kingdom. Tel.: +44 029 20917777;fax: +44 029 20917924.

E-mail address: daviesjp3@cf.ac.uk (J. Davies).

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1322-7696/$ — see front matter © 2012 Royal College of Nursing, Australia. Published by Elsevie

http://dx.doi.org/10.1016/j.colegn.2012.04.005

y Ltd). All rights reserved.

ntroduction

he way in which nurses are educated has changed in a num-

er of ways during recent decades. Thirty years ago nursesn the United Kingdom (UK) would be educated using medi-al models and a largely didactic approach in terms of theelivery of program content. There was also very commonly

r Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

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‘task centred’ focus to learning and this applied partic-larly to the teaching of clinical skills (McNee, Clarke, &avies, 2005). This of course commonly contradicted theeality of clinical practice where the ‘task’ was only part ofhe wider picture of working in a health care setting thus,ome would argue not the most effective way of ensuringositive patient outcomes.

More recently there has been growing recognition thathere needs to be a more holistic approach to the waysn which students learn skills for clinical practice. Suchpproaches need to provide the student with useful, trans-erable skills, which they can apply in the real setting. Anverarching factor in providing such educational activities isf course the need to protect patient safety (NPSA, 2010).he current patient safety agenda quite rightly is one of theoremost issues on the political and professional stage andn part it is against this backdrop that simulated practice hasncreased significantly during the last decade.

Another reason for the growing use of simulated prac-ice settings in the UK, is the return in recent years to

clinical skills focus and the educational review of stan-ards and competence undertaken by the UK professionalody (NMC, 2010a). A set of new curricula is currently beingeveloped throughout the UK in all fields of practice, whichs very clearly skills-focused. The NMC have also produced

set of ‘essential skills clusters’, which are to be appliedo new programs delivered by Higher Education providers.herefore, the delivery of clinical skills teaching throughimulation is high on the educational agenda.

Gaba (2004) refers to simulation as a technique ratherhan a technology and makes reference to the way inhich it replicates real life practice utilising an interac-

ive approach. The usefulness of this type of methodologys supported by a number of evidence sources: Laschingert al. (2008), Brimble (2008) and Wagner, Bear, and Sander2009). In these studies students reported that their learn-ng was enhanced, although there was some debate as tohether the clinical skills learnt were transferable to clini-al practice, particularly if the simulation was not close ton episode in a real placement setting.

However, clinical simulation is not without its challengess some authors have identified (Blum, Borglund, & Parcells,010; Pike and O’Donnell, 2010). Central to some of thesehallenges is the expertise of those who facilitate theeaching and the commissioning and design of a range ofppropriate environments that replicate practice settings.

Despite the challenges, nursing and medical educationave seen the development of a range of simulated learningctivities, which at the most complex enable those about toualify or those already registered to have the opportunityo manage complex care situations. The actions of regis-ered practitioners carry sole accountability and as such,hese types of activities are just one way of enabling nurseso both understand and manage situations in a safe setting.his is as previously mentioned set against the best interestsf patients.

Added to this, there have been a number of recentnquiries in the UK, which have emphasised the need to

nderstand and manage complex situations in care settings,hus protecting those who are the most vulnerable in society.ost notably the Mid Staffordshire NHS Trust Inquiry found

hat the hospital had consistently failed to provide a safe,

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J. Davies et al.

olistic and appropriate standard of care to a large of num-er of patients. This appeared to be the consequence of aomplex set of management, leadership, and educationalnd operational issues. In spite of the 18 recommendationsrising from the inquiry one referred to, ensuring that itsurses work to a published set of principles, focusing on safeatient care, whilst another called for educational programsor nursing to be reviewed to provide a high quality serviceMid-Staffordshire NHS Inquiry, 2010).

It is acknowledged that working in a simulated complexare activity is one small element which could enable nurseso practice more effectively, however at the very least itllows nurses to examine and to manage complex issues in

safe environment where there will be no compromise inerms of patient safety and quality of care.

The aim of this project was therefore to provide thirdear undergraduate child branch students with a carefullylanned exposure to a scenario, simulating a typical shiftn a practice setting. In doing so, students were facedith managing a complex set of clinical issues, which

nvolved patients and their families. It was envisaged thathis would provide each student with an opportunity tossess their response to a given situation and identify wherehey perceived their strengths and weaknesses to be. Staffho facilitated the experience also played roles in thelinical setting enhanced this perception. The range ofctivities chosen for the simulation related directly to theodule outcomes for the program and represent common

ssues students would encounter during their final place-ent.The simulation focussed on a complex ward experience

s well as giving students the opportunity to participate in aumber of clinical tasks contribute to decision making andeading and to work in a team. All of these of course weren a completely safe setting that allows for error. Never-heless, an important purpose of this type of work is thatollowing the experience, students undertake a de-briefingeriod where they can reflect on their experience and learnrom any errors and build on good practice.

In analysing feedback through the use of a Likert styleuestionnaire and an analysis of the post simulation de-riefings, the authors have attempted to ascertain thesefulness of the simulation activity by examining issuesuch as transferability of skills, increased confidence andealism.

ducational context

he simulation took place within the final module of the-year Bachelor of Nursing (Child) undergraduate programithin Cardiff University, Wales. This module aims to pre-are the student to make the transition from student tost level registered nurse. The module focuses on the man-gement of care whilst recognising the need for life longearning (Cardiff University, 2010). Within the module stu-ents are encouraged to critically examine the role of theualified nurse working within the multidisciplinary team.

uring the 12-week clinical placement students completehe clinical skills for year 3 of the program, this simulationook place during this placement. During the preceding mod-les students are exposed to a range of simulation activity,

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An evaluation of a complex simulated scenario

which includes a community scenario, hospital based sce-narios, a simulated shift and intensive care simulation.

Year 2 and 3 are child branch specific whilst the firstyear has a common foundation with shared learning amongstother branches of nursing. Within Wales, nurses have grad-uated from this program with a degree, as opposed to adiploma since 2004 and by 2013 all nurses will graduatewith a degree throughout the UK (NMC, 2010a). The twoprevious modules in the final year focused on developingnursing skills in the care of children and young people in gen-eral and specialist nursing environments (Cardiff University,2010). Students at this level are expected to foster criti-cal analytical and research based practice (Taylor, Irvine,Bradbury-Jones, & McKenna, 2010). Critical thinking skillsare especially important to be developed and used by nursesto ensure safe and holistic care (Popil, 2011). These aspectscontinue to be built upon in the final module within the class-room setting. However, as acknowledged by the NMC (2010b)the newly qualified nurse must also be competent and pos-sess the necessary clinical and transferable skills requiredto care for children, young people and their families.

Simulated scenario

The scenario was developed to enhance the studentsunderstanding of patient management, team working andself-awareness. The simulation is based on a children’s wardand assessment unit, with staff coming on duty for the after-noon shift. The children’s simulation laboratory acts as afour-bedded ward, with the assessment unit located down-stairs, in a two-bedded high dependency laboratory. Eachcohort of students is divided, so there are 7 or 8 studentsundertaking the scenario at a time. In order to run the sim-ulation in an effective manner the number of students perpatient is a little higher than in typical clinical practice.However, due to the number of roles and activities takingplace during the simulation, this does not appear to distractfrom the realism of the event.

Prior to the scenario, students gather in a classroomwhere a facilitator (lecturer) briefly outlines the plan forthe simulated shift. Students are already familiar with thesimulated ward area as this has been used during previoussimulations. The environment represents an acute children’sward and contains similar equipment to a real ward. Man-nequins include SimBabyTM and a number of nursing models,which the students have previously worked with. Due to thenature of the simulation, no pre-reading is required as theactivity is related directly to their current clinical place-ment. Names are picked anonymously for the different rolesto be played. Handover is then given for the patients onthe ward with a separate handover in the assessment unit.The students are allowed time to read the patient scenarios(Table 1). A number of participants are briefed about theirroles, including: the student acting as ward manager and lec-turing staff acting as the doctor and parent. Props are usedso that the students can identify the roles being played,for example the doctor wears scrubs. Each patient on the

has a full set of medical and nursing co-documentation,medications and equipment, which the student will use,are prepared prior to the commencement of the simula-tion. The simulation prompts the students to manage a

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umber of challenging situations, for example infectionontrol procedures for the child with diarrhoea when a side-oom is not available, an angry parent and an acutely illhild who requires medical review. The project team recog-ise that this is a wide range of activity concentrated inne area; however, this does expose the students to a num-er of possible situations which they can manage in a safenvironment.

valuative methodology

n evaluative approach was applied to investigate howffective the simulation experience was and if the objec-ives for the session were met (Moule & Hek, 2011; Parahoo,006). Three cohorts of students participated in the complexcenario, with a total of 41 students (cohort 1 n = 14; cohort 2

= 14; cohort 3 n = 13). Evaluation is necessary in nurse edu-ation to ensure that the student voice is heard and that newnnovative strategies are appropriate for practice. Parahoo2006) acknowledges the benefit of using both quantitativend qualitative methods for evaluation. The qualitative dataay usefully be collected after the quantitative method

o add depth and further insight to the quantitative find-ngs (Sim & Wright, 2000). Following a short break afterhe session, students were asked to complete a short Lik-rt questionnaire, which consisted of six closed rating styleuestions, with the opportunity to make qualitative com-ents for each question. The project team developed theuestions for the survey; a pilot was not undertaken dueo the small numbers involved in the project. Le Biondo-ood and Haber (2006) recognise that open-ended questions

re needed as otherwise important information about theubject may be missed. The response rate was high with0 of the 41 (97.4%) participants completing the question-aire. The anonymity associated with questionnaires and thedministration of the questionnaire immediately followingompletion of the scenario may have contributed to the highesponse rate.

The students then attended a post simulation debrief-ng and evaluation, which involved a specific discussion inelation to each of the cases and roles. As with the ques-ionnaires, the facilitator explained that any data collectedould be used to allow further development of the scenariond that some of the data would contribute to the evidencease through publication. Consent was gained verbally toudio record the debriefing so that the student’s com-ents could later be thematically analysed. Post simulationebriefing and evaluation was an appropriate qualitativepproach as Neill and Wotton (2011) consider debriefing cen-ral to the simulation scenario and equally beneficial as ituides the student through reflection as to what took placen the scenario. The lecturer acted as facilitator direct-ng the discussion objectively, allowing the students’ toritically analyse their own performance within a support-ve climate, thus encouraging the students to contributectively to the learning process (Fanning & Gaba, 2007).

hematically analysed. All project team members examinedhe data and identified emerging themes. These were thenross referenced to ensure reliability and following whichgreement was reached through discussion.

134 J. Davies et al.

Table 1

Patient/activity Condition Issues to be managed Key skills

Elsa (2 months) Post inguinal hernia repair — Pain— Wound care— Discharge

— Administer medications— Decision making— Discharge planning— Dressing change

Sam (9 years) Diarrhoea and vomiting — Hydration— Infection control— Transfer

— Decision making— Organisation/management— Assessment— Fluid management— Team working— Leadership

Megan (7 years) Hypoxic ischemic brain damageTracheostomy

— Tracheostomy care— Discharge— Health promotion/safety

— Discharge planning— Communication— Prioritization/organisation

Sam (6 months) Respiratory symptoms — Respiratory status— Hydration— Pain— Clinical incident

— Assessment— Management of clinical incident— Decision making— ?Conflict management— Leadership

Ward meeting — Staff shortage— Annual leave/professional

elopento

— Leadership— Decision making

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here was a twofold approach to analysing data. The dataere collated quantitatively in the form of bar chartsnd this related the questionnaire that was given to stu-ents following their experience. The qualitative comments

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igure 1 Responses to ‘The simulation experience was enjoy-ble’.

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igure 2 Responses to ‘The experience helped me developy skills’.

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— Organisation— Innovation

ere also recorded and recurrent themes were identified.igs. 1—6 represent the ranges of responses to all surveyuestions, by the student cohort.

Thematic analysis of the post-simulation de-briefingsdentified the following themes: the prospect of being unsu-ervised; working with parents; leading and managing; andrioritising and organisation.

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igure 3 Responses to ‘The experience has enhanced my con-dence’.

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igure 4 Responses to ‘The scenarios during the experienceere realistic’.

An evaluation of a complex simulated scenario

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Figure 5 Responses to ‘I can transfer my skills to my currentpractice placement’.

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Figure 6 Responses to ‘I can transfer the skills to becominga qualified nurse’.

Discussion

Analysis of the survey questions (Figs. 1—6) revealed thatthe majority (98%) of students rated the simulation asenjoyable, helpful in developing skills and beneficial totransferring skills as a registered nurse. In all of these areasthe majority of students scored 3 or 4, (a score of 1 = notagreeing to 4 = agreeing with the statement). The small num-ber of students (2% n = 2) who scored these areas negativelyoffered some qualitative comments that help to make senseof their dissatisfaction:

‘Don’t really enjoy acting as I find it difficult to act likeits real life’

‘You have to pretend a lot with equipment’

Comments such as these are not uncommon in clinicalsimulations; some students do find it extremely difficult tosuspend their belief in reality, if even for a short time. Thisis why it is so important to ensure simulations contain clearobjectives and a clear simulation script to make scenariosappropriately realistic (Allinier, 2011).

In relation to the enhancement of confidence and therealism of the scenarios, the student’s responses were morevaried. A total of 10 students (4%) rated their ‘‘enhancedconfidence’’ at lower scores of 1 or 2. One student said:

‘I don’t feel like this had much effect on my confidenceas I had the same level of confidence on the ward’

In relation to realism of the scenarios, 11 studentsresponded negatively with scores of 1 or 2, however, in thefinal cohort of students all but one scored this positively withscores of 3—4. This may demonstrate that over time staff

had developed the scenario, learnt lessons and improvedrealism.

The recorded post simulation debriefing provided a richsource of commentary, which in essence contained four key

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135

hemes. Interestingly three of the four themes were alignedo the role that registered nurses play in practice; beingnsupervised; leading and managing; and organising work-oad. This is particularly encouraging since the simulationas intended to be complex enough to represent registeredurse practice. Consequently the scenario could potentiallyrovide crucial learning at a key stage in the students pro-ram just prior to registration.

he prospect of being unsupervised

he prospect of being unsupervised appears to be the onessue that is of most concern to students. This is not surpris-ng since it is common for them at this stage of the program

just prior to registration, to feel hesitant about clinicalractice and to experience the notion that they are ‘noteady’ (Siviter, 2008).

‘I think for me that it was a reminder of like gosh when Iam qualified in particular’

Becoming a registered nurse causes a shift in professionalccountability, together with wider clinical, management,nd teaching responsibilities. Suddenly, the newly qualifiedurse is the one who must ‘know the answer’, whether its a query from a patient, a carer, a work colleague or atudent (Burton & Omrod, 2011). For the students who par-icipated in the simulation, the reality of being unsupervisednd practicing as a registered nurse was clear, perhaps evenlearer than in their placement area, where a mentor waslways on hand. Additionally, the need to possess adequatenowledge and to be accountable when they qualified wasentral to their discussions:

‘I think the issue is as a student you fall back on yourmentor so if I was on the ward it would be like oh what’sthis and I would go through it with her, so it was kind ofa reminder that when I am qualified I need to know this,I need to be on it so I think for me that’s probably thething that stood out the most just in my own practicelike being prepared to be qualified and you need to knowthings and you don’t always have someone to fall backon’

It is no real surprise that issues of accountability, ‘notaving someone to fall back on’ were of such great concerno the students as many earlier studies which examine thexperience of newly qualified nurses highlight an increasen responsibility and accountability as a major stressorHiggins, Spencer, & Kane, 2010). Although the aim of theimulation was to enhance student’s self-awareness, includ-ng their forthcoming accountability as a registered nurse,t was not intended that they should feel isolated. As part ofhe post-simulation de-briefing support mechanisms, esca-ating concerns and team working were discussed in relationo both the simulation and the reality of clinical practice.

orking with parents

he context of working with parents was an issue thetudents identified as challenging within the simulationxperience. Difficulty in breaking news to parents which

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36

ould cause them distress can be a common feature of prac-ice long after registration. Nevertheless, the opportunityor the student to identify this as a difficult undertak-ng enables them to give some thought to how they mightevelop skills in the future. This would help them to man-ge these types of situations more effectively, particularlyith reference to medication management. This nursing role

equires a complex set of skills which include knowledge ofhild development, both physiological and psychological ifractice is to be safe and competent (Watt, 2003)

(In relation to the drug error) ‘erm yes very difficult, yeahhard to tell her about the drug error’

Furthermore, communication with parents was central toome of the discussion. Therefore it is not just the break-ng of the news concerning an error but the way in whichnteraction took place. Interaction with parents and thepplication of appropriate interpersonal skills is a specifickill set in the field of children and young people’s nurs-ng and as such requires a detailed knowledge of how besto ‘work with’ parents. Effective negotiation with parentsan enable a more positive approach demonstrating thatveryone is acting in the child’s best interests. The negotia-ion can create transparency thus enhancing the relationshipith parents (Clarke & Davies, 2010).

‘It was ok I found the questions that mum asked quitehard, Yeah I wasn’t sure how I answered them. I wasn’tsure like if I did it correctly, but I did as best I could’

Interwoven with the need to be able to effectively inter-ct with the parents was the need for ‘truth telling’ whichurther reinforces the need for knowledge, negotiation andransparency (Glasper & Richardson, 2006).

‘Erm the most difficult part, I don’t know dealing withparents, I think that was quite hard, cos when I, you knowwhen the child doubled you know what I mean, it wasdifficult and you have to be honest don’t you so and Idon’t really know what I would say in that situation’

eading and managing

n today’s climate it is realistic to consider once nursesraduate, students can expect to be leading and managingheir own caseload and quite quickly in some cases manag-ng whole ward areas. The role of ward manager within thecenario highlighted this challenging role.

‘I still don’t feel that confident being in charge’

‘I just think it is a hard role (being in charge) you’ve goteverything coming at you from different angles’

They therefore need as much ‘practice’ as possible atanaging complex situations and leading other staff in a way

hat inspires confidence and therefore leads to more effec-ive care (Manion, 2005). As the students expressed, theilemma of managing patient care and nursing staff can beroblematic, especially as a newly qualified nurse (Gerrish,

000).

‘Just to keep on top of everything, give people breaks butthen people were busy doing things and then you had to

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J. Davies et al.

make sure every patient was safe and it was difficult hav-ing an admission at the same time when people neededto have breaks’

Taking into account the current economic pressures, theewly qualified nurse as ‘‘manager’’ and ‘‘leader’’ has tonsure quality of care but also be mindful of resources andost (Sullivan & Garland, 2010). This involves utilising prob-em solving and decision-making skills, which are deemedssential with management (Marquis & Huston, 2009). Thetudents questioned their ability and skill in this area, whichmphasises the need for exploring such issues in a simulatedcenario.

‘Yeah it wasn’t ideal (referring to the admission) and Ididn’t really know, you can’t say no can you?’

rioritising and organisation

he key feature in relation to prioritising and organisingppears to be associated with prioritising and the studentsefer to themselves as being ‘all over the place’ and ‘notnowing what they are supposed to be doing’. This coulde attributed to the organisation and structure of the sce-ario, although equally it could be argued that the students confident with individual skills or tasks but when therere multiple tasks to be performed it becomes more diffi-ult to be effective. It is essential therefore that supervisorsf students provide feedback on different areas of ability,hus enabling students to identify which areas may requiretrengthening in order for them to be able to multi-taskffectively (Lofmark, Smide, & Wokblad, 2006).

‘I found it hard I didn’t really know what I was doing andI kept just like all over the place really, yeah like I foundit really hard!’

Importantly it would appear that it helped some studentso recognise the importance of record keeping and particu-arly the need to check clinical charts, thus providing safeare. This clearly is a fundamental aspect of care and just asmportant as the care given directly to the patient. Recordslso have a legal purpose and should practitioners be heldo account, provide evidence of the care delivered (Griffith

Tengnah, 2010).

‘I think it helped you like obviously it helped us recognisethat we pick up on things, the drug charts need to bechecked, the fluid balance charts and it made you realisethat you need to check everything’

There was also fear, which seems in part due to the lack ofnowledge about prioritising care and literally not knowinghat to do. Standing (2007) recommended that once stu-ents had qualified they found the idea of ‘thinking on youreet’ informative but stressful. Standing recommended thathe development of decision-making skills should be inte-rated into curricula from the outset. If this were to be atandard in all-educational programs, there is the potentialor students to feel less fearful and to be able to make the

ost appropriate decision.

‘I didn’t like it. You don’t know what you should be doingand like prioritising things, you just feel, I don’t know,like I just didn’t know what to do’

B

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An evaluation of a complex simulated scenario

Conclusion

The use of simulation to provide students with a safe expe-rience which as far as possible mirrors real practice, givesthem the opportunity not just for learning but for repeat-ing over time sets of knowledge and skills which at thepoint of registration are arguably transferable. At the pointthat they transfer these elements one needs to determinewhether they are better ‘equipped’ for the real world ofpractice than had they had not had the opportunity to havesimulation as a learning methodology.

This particular simulation was carefully planned toreflect the work that students were concurrently undertak-ing in practice. There was opportunity to apply some of theknowledge and skills that they had already acquired but toalso challenge them with possibly new situations that theyhad not yet encountered in practice. In doing so, this givesthe students the opportunity to reflect on their simulatedexperience and then to use some of their newly acquiredskills in practice should they come across similar situationsat a later date in their career.

Undoubtedly this is not a learning approach that suitseveryone and indeed small numbers of students did notfeel that they benefited from the experience and made itclear that they did not feel that their confidence had beenenhanced. This small number struggled particularly with theprocesses that is the role-playing and the use of equip-ment to simulate real practice. Nevertheless there were fargreater numbers of students who not only benefited fromthe experience but found it an enjoyable form of learning.

The themes that have emerged from the data collectedin the three cohorts are all fundamental aspects of childrenand young people’s nursing practice. As such these aspectsof work will always be present irrespective of whatever spe-cialist field of children and young people that the studentsmight choose to work in. One could argue therefore thatthe themes identified, have real resonance for the studentin the program and learning will provide valuable knowledgefor future practice.

This project continues to develop and data already col-lected are being utilised to enhance the existing simulationactivity further, for example preparation of students playingthe role of ward manager will in future take place a weekin advance of the simulation, so that the student can bemore effectively prepared for the role. The results of thisproject have been shared within the school of nursing andother fields of practice are now planning a similar simula-tion for students in the final year of their under-graduateprogram.

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