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Setting the scenario

13 May 2019

Sharon Frankland evaluates a simulation activity for new public health nursing students piloted at Sheffield Hallam University.

Red Curtain iStock

Simulation is increasingly acknowledged as a valuable mode of learning, providing students with real-life situations but without the element of risk encountered in clinical practice (Lateef, 2010). This learning approach has been used for some time within clinical skills training; however, simulation within a community context is relatively new because it tends to be synonymous with teaching practical tasks rather than the skills-based interventions used within public health nursing (Distelhorst and Wyss, 2013).

 

SCPHN and simulation

I had taken the opportunity as part of my peer review and enhancement to observe simulation activities within the undergraduate provision. This is a well-evaluated activity, based around a range of deteriorating patient scenarios. It is facilitated by the clinical skills and simulation team and employs high-fidelity manikins. I was struck most by the high level of student engagement with this mode of teaching, which led me to consider the possibility of including this within our specialist community public health nursing (SCPHN) programme. I arranged to meet two members of the clinical skills and simulation team, and we began to plan how we could use this as an induction activity.

One of the most important considerations in planning the day was to ensure that the experience would not pose any threat to the students. Simulation has the advantage of being a learning activity that can recreate the real-life pressure of an incident in practice, while allowing participants to make mistakes without fear of harm (Lateef, 2010). However, as this was an induction activity, we had to consider that the students came with a varying range of experience and backgrounds, and had not yet begun to gel as a group, so they could be made to feel vulnerable and exposed if the situation was not managed well. One study by Savoldelli et al (2005) showed that up to half of participants in simulation learning admitted feeling intimidated and stressed.

Planning the day

The scenarios were developed around some common situations encountered within SCPHN practice, bearing in mind that many of our students were new to primary/community care. The scenarios we decided upon were:  

  • Gaining entry to the home – a reluctant client, refusing entry but obviously distressed
  • The unsafe home environment – hazards with the potential to cause harm
  • Possible signs of domestic abuse – a new mother with bruising to her face  
  • An ill child with a concerned parent – a child with hand, foot and mouth disease but parents concerned about meningitis.
  • Learning objectives for the activity were set, and briefings were held to ensure that staff and ‘clients’/actors understood how the day would run. This shift for us as lecturers was to ensure that the debrief after the scenario was developed as an opportunity for discussion and reflection, and not to be used as a mini teaching session.

The facilitator of a simulated experience should view themselves as a co-learner rather than an expert

Transformative learning

Unlike many structured learning experiences, the facilitator of a simulated experience should view themselves as a co-learner rather than an expert, allowing participants to create knowledge through self-reflection without fear of judgement or criticism (Fanning and Gaba, 2007).

Adults learn best when they are immersed within a situation and can actively participate to make sense of what is happening to derive useful meaning from the situation. Kolb (1984) describes this as experiential, and suggests that it is ideal for professional courses such as ours as it aids the application of theory to practice.

This problem-based learning approach, supported by a structured debrief, can support reflection on practice to allow the participant to construct new learning in a way that can be transformative and lead to deep learning. This model of learning is not without its challenges, however, and we had to be sure that we were mindful of the emotional safety of the participants.

 


Simulation defined

Simulation is an artificial representation of a real world practice scenario that supports student development and assessment through experiential learning with the opportunity for repetition, feedback, evaluation and reflection. Effective simulation facilitates safety by enhancing knowledge, behaviours and skills. 

(NMC, 2018)


The RUST debriefing model

Debriefing is defined as ‘facilitated or guided reflection in the cycle of experiential learning’ (Fanning and Gaba, 2007). Because the team were relatively new to simulation, the RUST model was identified as the most suitable: it is simple to use yet effective in supporting students to reflect on a given situation in a structured way.

Phrase Description
Reaction The debrief should happen as soon as possible after the scenario. Venting for activated learners – acknowledging emotions and frustrations – sets the scene for understanding.
Understanding Ask open-ended questions: what, why, how. Explore specific observations and learning objectives and introduce concepts.
Summarise Recap on what the scenario was about and learning objectives covered in the debrief (these may differ from the pre-determined ones).
Take-home message One important learning point from each participant – round-the-room exercise.

On the day

We had dressed a house on university grounds and used props to make it look like a real home. Actors were allocated their characters to allow them to prepare.

The students rotated around the four scenarios in groups of four (two would be active and two would observe). Each scenario included one actor and one facilitator. Prior to the experience, the students were fully briefed about simulation as an activity, and ground rules were set to ensure that everyone was clear about the rules and objectives of the exercise, such as confidentiality and avoiding criticism or conflict. The students were given 20 minutes to address each of the scenarios and 20 minutes to debrief. The students were given the opportunity to ‘freeze’ the situation and take time out to ask for help from the observers.

The debrief was undertaken by the facilitator and the actor as it was felt to be important to gain the ‘service user’/‘client’ perspective. The debrief (see The RUST debriefing model) took place immediately after the scenario and was structured to allow participants to react to the process. This included questions such as ‘How did that feel?’ Further questioning included the use of open-ended questions such as ‘How did you prioritise what to do?’ Reviewing the events and summarising is the final stage of the model, which allows participants to develop a take-home message. Care was taken to avoid criticism or negative comments within the debriefing process, instead allowing the participants to actively reflect on the positives and identify any possible areas for improvement (Karlsen, 2013).

 

Student/staff feedback

The day was evaluated as a great success. The students felt not only that they had begun to get to know each other much better, but they had fun. Feedback was excellent from both staff and students. Some of the comments received included:

‘I feel it has highlighted my strengths and weaknesses in a variety of situations so I can go away and learn more, so that should the situation arise in practice, I would be better prepared.’

‘Really great to have a debrief afterwards – found this a really great experience.’

‘At first I felt terrified with it only being the first week of the course; however, I feel it was a fantastic learning curve, where we also got to know each other better. I personally feel I learnt more from this experience than I would have from a classroom.’

Staff agreed that the day had been a huge success. Opportunities to reflect on the day were discussed and learning points were integrated within all the first semester’s taught modules. A second-semester simulation day has already been undertaken; this had a greater degree of complexity, reflecting the fact that students have spent 10 weeks in clinical practice. The scenarios included more challenging materials, as shown in More complex simulation scenarios, left. 


More complex simulation scenarios

Teenager identifying as ‘trans’ – a father reluctant to accept his son was identifying as female

Disguised compliance/neglect – addressing child neglect and developing ‘professional curiosity’ and questioning techniques

Parental/teen conflict, and possible online grooming – dealing with conflict over the use of social media

Maternal depression – enhanced interview technique to elicit maternal engagement when mental health issues are present.


Next steps

All the scenarios have now been developed and are stored on a central database on the Association for Simulated Practice in Healthcare’s iRIS health simulation authoring platform to allow the sharing of good practice and ideas.

Sheffield Hallam has also recently been one of the first universities to be validated for the new pre-registration curriculum using the NMC’s new Standards framework for nursing and midwifery education. Within the standards is an increased emphasis on simulation as one of the key learning approaches through enhancing knowledge, behaviour and skills. As a team, we definitely feel that this will become a core component of our teaching and learning strategy for the SCPHN curriculum for the future.  

Sharon Frankland is senior lecturer in public health nursing at Sheffield Hallam University, and worked in partnership with the clinical skills and simulation team for this article. 

Image credit | iStock


References

Distelhorst KS, Wyss LL. (2013) Simulation in community health nursing: a conceptual approach. Clinical Simulation in Nursing 9(10): 445-51.

Fanning R, Gaba D. (2007) The role of debriefing in simulation-based learning. Simulation in Healthcare 2(2): 115-25.

Karlsen KA. The STABLE program. Center for Medical Simulation: Cambridge, MA.

Kolb DA. (1984) Experiential learning: experience as the source of learning and development (2nd edition). Prentice Hall: Englewood Cliffs, NJ.

Lateef F. (2010) Simulation-based learning: just like the real thing. Journal of Emergencies, Trauma and Shock 3(4): 348-52.

NMC. (2018) Standards framework for nursing and midwifery education. See: https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/education-framework.pdf (accessed 17 April 2019).

Savoldelli GL, Naik VN, Hamstra SJ, Morgan PJ. (2005). Barriers to use of simulation-based education. Canadian Journal of Anesthesia 52(9): 944-50.

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