A blended approach to practice simulation in undergraduate nursing (2024)

How a shortage of clinical placements for first year undergraduate nurses led to the successful development of a six-week simulated training placement, blending eLearning and traditional placements

Introduction

It became evident in mid-March of the 2021-22 academic year that there would be a substantial shortage of second clinical placements for year one BSc (Hons) Adult and Mental Health Nursing students at the University of Plymouth. This was due to operational changes to clinical areas caused by the Covid-19 pandemic, reducing the capacity of trusts to accommodate all students. This was a situation sadly replicated across the UK, with many areas reporting a lack of clinical placements for student nurses, leading educators to seek more innovative approaches as alternatives to the clinical placement through simulation (Williams et al, 2022; Taylor et al, 2021).

While there is plenty of evidence to support the increased use of simulation in the undergraduate nursing curriculum, there is little research to date into the effectiveness of the use of a blended approach to replace longer traditional placements (Williams et al, 2022). Bridge et al (2022) reported a growing interest in using structured, extended periods of simulation as partial replacement for clinical placements, although the study was more heavily weighted towards allied health professionals than nursing.

An urgent solution was required at our institution, so the decision was made to pilot a six-week simulated placement. To ensure that all affected year one undergraduate students had an assessed placement, each student was partnered with another student, allowing them to share their placement area. Consequently, all students received at least six weeks of clinical placement for assessment and six weeks of simulated placement. Initially, 24 students were set to undertake the simulated placement as groups A and B, each comprising 12 students. However, due to unforeseen ward closures and individual student circumstances, six more students were added to group A, bringing the group’s total to 18.

The six-week simulated placement consisted of a 37.5-hour week and enabled students to accumulate practice hours as they would in clinical placement. It has been suggested that up to 30% of clinical training time could be replaced with simulation, with benefits ranging from increased safety to a reduced placement burden (Bridge et al, 2022). A blended approach to learning was considered the best means of delivery of content to maximise student engagement, while reducing the necessity to travel every day. There was a mixture of self-directed study and eLearning, online teaching, face-to-face teaching in both the classroom and the skills facilities, and external training and visits. The intention was to expose these students to aspects of nursing they may not have considered and enable them to gain cross-field and service user experience, and develop their practical nursing skills.

Teaching and learning content

A six-week timetable of learning was developed that provided a variety of self-directed and taught activities, together with some external provision and time in the clinical skills facilities. This was duplicated as far as possible for each group.

eLearning

A comprehensive list of resources was made available to all students participating in the simulated placement for them to work through at their own pace during the self-directed study days. A checklist tool was provided for students to indicate what they had completed, to aid their progression and for faculty staff to see their progress.

All students attended a Zoom call on the self-directed study days to monitor attendance and provide a point of contact throughout that day.

Virtual reality software

All students on the simulated placement received a face-to-face ‘onboarding day’ to introduce them to the virtual reality platform, ensuring they were able to log on and run the scenarios, then walk through how to complete and reflect on them. The students were then directed to work through at least four scenarios of their choosing on the self-directed days throughout the next six weeks.

In week three of the simulated placement, students received another face-to-face session based on two of the paediatric scenarios (paediatric assessment and safeguarding), also incorporating basic life support on both infant and child manikins. This was consolidated later in the placement with a practical skills session of paediatric assessment taught by the School of Nursing and Midwifery child health team. This provided students with a valuable opportunity to complete one of their mandatory cross-field reflections required by the end of the BSc (Hons) nursing programme (Nursing and Midwifery Council (NMC), 2018).

Cross-field experiences

During the six-week simulated placement, students had several opportunities to complete their mandated cross-field reflections through taught sessions on adult, child and mental health nursing. Additional sessions included breastfeeding, maternal health and learning disabilities. Students also engaged in peer learning and teaching, particularly during the practical skills sessions, which incorporated these elements.

Collaborative Learning in Practice (CLiP) practical sessions are particularly valuable for peer learning and exposure across disciplines (Williamson et al, 2020). CLiP sessions on the simulated placement were run over two days and included patient scenarios in adult, child, mental health and learning disability nursing. Students from the return to practice and the trainee nursing associate programmes also participated in the patient and coaching roles, which proved to be a very successful combination, according to verbal feedback from students and staff, benefitting all those involved.

Health creation placement

The health creation placement was initially borne out of the lack of clinical placements during the Covid-19 pandemic, providing students with an alternative means of learning, particularly with the involvement of service users. The idea was subsequently incorporated into the simulated placement to offer students insight into chronic disease from the perspective of both patient and carer. This element emphasised the challenges faced in receiving care at the right time, in the right place, and from the right people, highlighting examples of both good and poor practice. It demonstrated to students the importance of patient-centred care, active listening, effective communication and non-judgemental attitudes.

The following week, students returned to the clinical skills facility to apply these key elements in a ‘lived experience’ session. This involved simulating the effects of ageing and disability using specialist equipment, allowing students to experience daily activities from the perspective of a disabled or older person. A hemiparesis scenario was used from the Virtual Empathy Museum (Levett-Jones et al, 2018), which provided valuable insights into public attitudes and behaviours towards people with disabilities. This session received highly positive evaluations, with students describing how they felt isolated, ignored and a loss of control when perceived as disabled.

EPIC

We drew upon eHealth Productivity and Innovation in Cornwall and the Isles of Scilly (EPIC), another faculty initiative giving undergraduate students access to simulated video consultations with specialist actors. These were available to students who were either unable to attend placements because they were isolating – and needed to increase their practice placement hours – or those interested in extending their knowledge and skills of video consultation through simulated placements. All students undertaking the simulated placement were offered this opportunity to support their learning and confidence in this growing medium of health and care delivery. They could claim up to 7.5 placement hours for this activity, which included online preparation and reflection, and the virtual patient consultation (Box 1).

International collaboration

The first group to attend the simulated placement (Group A) was fortunate to have the opportunity to take part in a ‘twinning project’ with Sweden and Somaliland. Nursing students from all three countries met and shared their knowledge and understanding of global and national health priorities, and the role of the nurse in identifying sustainable solutions for global health and wellbeing. This project was led by a Swedish member of the faculty and has continued to be a highlight of subsequent deliveries of the simulated placement.

This learning experience tied in well with a subsequent session on minimising our carbon footprint in nursing, in line with a growing effort to embed sustainability throughout the nursing curriculum and across the whole university.

Additionally, with funds available through Health Education England, it was possible to broaden the student learning experience further through external training. This included a talk and tour of the local hyperbaric chamber facility, as well as face-to-face training in breakaway techniques, conflict resolution and suicide awareness.

Assessment

Although the simulated placement did not include formal assessment, each group was given a project to work on together to foster team cohesion over the six-week period. On the final day, the group presented their work to members of the faculty. This provided the students with a shared goal to achieve and tested their ability to communicate, and manage the task as a group.

Group B were involved in the planning of a health promotion initiative in conjunction with the local council and were instructed to give a presentation to explain the programme and its importance locally, together with a poster for the events. Group A then put the plan into action and attended the events with a supervising registrant across various locations spanning the locality during the second six weeks.

Group A were tasked with developing a learning package for future students on sickle cell disease. This topic was chosen following a recent recommendation from the NMC that it should be included in all undergraduate nursing curricula. This followed the All-Party Parliamentary Group on Sickle Cell and Thalassaemia (SCTAPPG) report in 2021, which found low awareness of the disease among health professionals (SCTAPP, 2021). The students provided a comprehensive and informative PowerPoint presentation, which will be incorporated into the eLearning for the next cohort.

Student feedback

Due to time constraints, it was not possible to conduct a formal piece of research, but it was important to gather information on the effectiveness of the placement. Student evaluation was in the form of an online questionnaire both pre- and post- placement, with the aim of identifying students’ expectations of the course together with their thoughts on completion. The initial questionnaire was completed by 86% of all students placed (n=26).

Disappointingly, the post-placement questionnaire was only completed by 26% of students (n=8), which may be attributable to the students completing the training at different times and going into a clinical placement. This made it difficult to compare the results, although informal verbal feedback was overwhelmingly positive from the students present on the final days of each cohort. Most notably, all students who provided feedback agreed that the social aspect of working together in a group for the six-week period was a particular highlight, establishing a new circle of friends across different branches of nursing and geographical locations.

Several students offered suggestions on how to improve the placement for future deliveries, and what they particularly enjoyed. A sample of some of the comments is in Box 2.

Lessons learned

Attendance was monitored using paper or online registers completed by the faculty member facilitating each session. An absence and attendance spreadsheet was compiled by administrative staff to provide evidence for authorising timesheets. However, it was very difficult to monitor student activity on self-directed days and the checklist tool was not robust enough for this purpose, so a detailed investigation of the individual learning that was undertaken was extremely difficult.

The prime means of communication between staff and students was via email using the Digital Learning Environment, an online platform. As the simulated placement was not an official module, it did not qualify for a module code, so a subject view site was used instead. This had the same functionality as a module site, but students could not be enrolled on it. A knock-on effect of this was that the considerably complex timetable could not be managed centrally. A link to the online timetable was made available to all staff and students, so they would always have access to the most up-to-date version. Unfortunately, some students found this difficult to follow, which resulted in some confusion, especially when room changes were made. The students in each group formed their own social media group to enhance communications and enable them to coordinate their project work and contact each other for support, guidance and socialising.

The simulated placement was based on campus, which made it more difficult for students living further afield to attend the face-to-face sessions. Timings of sessions were planned to accommodate those who were travelling, and all costs incurred could be claimed back by the student in the same way as a normal clinical placement. Considering these lessons learned and recommendations for future delivery (Box 3), the simulated placement is now formally embedded into the undergraduate nursing curriculum at this institution. It has now evolved into a nine-week assessed simulated practice placement (ASPP), with two hugely successful subsequent deliveries to date.

Conclusion

The simulated placement appears to have been a great success, enabling year one BSc (Hons) Adult and Mental Health Nursing students to achieve a maximum of 225 practice hours through a wide variety of learning experiences over the six-week period. It was generally very positively evaluated, and further research is currently underway to enable the results to be more generalised, but it will undoubtedly continue to play a key part in our undergraduate nursing curriculum.