Game Changers: Using simulation to bring learning to life

With lockdowns and restrictions to contend with, universities have had to find alternative ways to teach the highly specialist skills required to meet industry competencies and enable students to graduate.

“It has been an epic challenge,” says Helen Ansell, Lecturer in Simulation for Pre-registration in the School of Nursing at the University of Derby.

“We have high numbers of students, but due to restrictions we have had to limit numbers on site and have smaller sized groups using our clinical facilities. This, combined with virtual home learning, for courses which are so practical-based, has been an exceptional challenge for everyone involved.”

Throughout the College of Health, Psychology and Social Care at the University, ‘simulation’ is used to help practically prepare students, and enable them to develop the skills they require in order to enter – and thrive – in the workplace.

While simulation is already a key part of healthcare training at the University, it has been of even greater significance and value during the pandemic.

“Simulation is a very broad umbrella term,” explains Naomi Shiner, Senior Lecturer in Diagnostic Radiography at the University and Simulation Lead for the University’s College of Health, Psychology and Social Care.

“We see it as any kind of episode or scenario that replicates real life, allowing students to learn a skill or develop their knowledge so they can transfer their academic theory into clinical practice. It is used in all sorts of education, not just on health programmes, and covers so much; it can be through role play, computer-based software, videos, gaming, paper-based exercises and even board games.”

Simulated learning - getting to grips with how it works

Teaching students technical skills, before translating into ‘real-life’ scenarios, forms the basis of simulated learning, explains Naomi.

“You might start with a standard lecture to build the foundation levels of understanding. Once you have taught the initial skills, you then build in scenarios,” she says. “For example, in the x-ray suite we might teach how to image a patient, or for a nursing student it could be how to take blood pressure. In order to enter clinical practice, on top of the technical learning, students need patient care and communication skills and that is developed through the scenario-based learning.”

Through the University’s state-of-the art facilities, including mock wards, treatment and counselling rooms, x-ray suites, and immersive interactive simulation suite – which replicates a variety of scenarios health professionals may find themselves working in, from the back of an ambulance to an operating theatre – students are given real-world learning and experience.

“The ultrasound equipment is like scanning a real person; it gives feedback so you can feel the pressure you are applying and if you press too hard it shouts at you,” explains Naomi.

“Some of the mannequins we use can be programmed, you can speak through them and do CPR (cardiopulmonary resuscitation) on them; there are a lot of facilities we use to help bring teaching to life.

“You have low fidelity or high fidelity simulation, which basically looks at how much realism has been put into a scenario. If students are practising cannulation, as a nurse or radiographer, it might be beneficial for them to use part-task trainers, essentially a fake arm.  

“They would learn to cannulate the arm and they would draw back some blood, but there’s no patient attached. The next stage on from that would then be to have a hybrid-type simulation where the students have the fake arm but also an ‘expert by experience’ as the role of the patient.”

How has the pandemic impacted teaching specialist skills in the classroom?

Due to the pandemic and subsequent on-campus restrictions, the ways in which clinical simulation and essential skills required for health students are taught has had to be adapted.

To enable nursing students to continue practising techniques they would usually learn in the classroom, academics set up clinical-skills training boxes for students to use at home.

The boxes, which contain university-supplied clinical equipment and instructions, enable students to practice temperature, pulse, respiration and blood pressure observation and recording, aseptic non-touch technique, urinalysis, as well as use of personal protective equipment.

Helen, who came up with the initiative, which has since been featured in the Nursing Times, said: “Covid-19 hit just as our March 2020 cohort of nursing students started, which meant they had had no simulation or skills training, so the clinical boxes were a simple but innovative way to help students.

“By taking their own temperature, students were able to take part in experiential learning, which allows them to understand what it’s like for a patient in those situations. We received exceptional feedback from them.”

Having started her Adult Nursing course at the University of Derby shortly before the first lockdown occurred, student Sarah Simpson said it was a daunting prospect not being certain how learning was still going to take place, but said the clinical practice boxes had really helped.  

“It was a valuable experience and I was able to practice on my family, who also benefitted in understanding my role and being able to gain knowledge on essential skills,” says Sarah.

“I realised how important the boxes were when I went on my first placement and was given the opportunity to help with a leg dressing and felt confident in doing so due to being able to practice this skill while in lockdown.

“We were incredibly lucky to have this opportunity. The University went above and beyond to ensure we were all supported and still able to continue our studies and learn the essential skills needed to become the nurses of the future.”

Using technology to help

In addition, the University invested in an online simulation platform called vSim, designed to simulate real nursing scenarios allowing students to interact with “avatar” patients in a safe, online environment.

“One of the Nursing and Midwifery Council’s key competencies is interpreting abnormal blood results, so using the simulated learning we can get students to look at a mock patient’s doctor’s notes and test results. From that, they can figure out what is wrong with the patient and the system allows them to be able to administer the right treatment and get feedback on how well the student has done,” says Helen.

Similarly, the Radiography department is using a simulation package from Skilitics.

“This new software came to us at just the right time so that we can provide simulated learning for our students,” Naomi says.

“There’s a section that students can do on their home computers which allows them to select different types of patients and practice various types of x-rays. Students are provided with an x-ray card like they would have in clinical practice. They then have to position the avatar and x-ray tubes and work through all the controls including what radiation exposure to give the patient – they undertake exactly what they would have to do in the x-ray room but they are able to do it from home.”

Benefits of using simulation in learning

Aside from being used during the pandemic to support with off-campus learning, there are clear benefits to using simulation in teaching nursing and healthcare professions, says Naomi.

“There is a large body of literature that shows that simulation is very supportive in developing practice, improving health and safety, and reducing errors,” she adds.

“It also encompasses all the domains of learning, such as psychomotor, emotional and cognitive skills, which are important for students.”

Boosting students’ confidence by allowing them to practice in a safe environment is also an advantage.

“Students really enjoy using simulation; they may feel nervous if it’s their first time using the kit, but students find that it enables them to ask questions in a safe space,” says Naomi.

“Simulation provides them with opportunities for discussion and learning. We then find that when students go back out on clinical placement, they are able to ask questions and look for ways in which what they have learnt through the software is actually applied in real life, helping them progress through that environment in a much more structured way.”

This is certainly echoed by third year Diagnostic Radiography student Jade Basra, who said simulation had helped her during her studies: “Using simulation means the experience is not so daunting because it’s a place where you can ask questions that you might not want to ask on placement and a safe space to make mistakes.

“Simulation within the x-ray room is one of the key simulation activities, which has been highly beneficial as it’s what we do on a day-to-day basis on clinical placement. Getting the hands-on experience in that room has been amazing and it’s really good peer assisted learning too.”

Even seeing the kit and hearing the noises from the machines, such as the CT and MRI scanners (body scanners), helps students to familiarise themselves with the clinical environment.

“The machines at the University are exactly the same as the ones you see in hospital, so it is good to be able to see what the buttons look like and learn how to control them, which makes it a lot easier when you’re on placement because you have already had a go,” adds Karen Gaba, also a Diagnostic Radiography student at the University.

An added benefit of using simulation in learning is helping students to prepare for the unknown and think on their feet, a key element of the professions healthcare students are training to enter.

Jason Court, who is also studying Radiography, added: “With some simulation exercises you know what you are going in to do, for example, it might be a hip replacement x-ray that is needed, but sometimes the lecturers give us on-the spot scenarios which helps us to think about what has happened and we work from there. It makes you think more on your feet too because you don’t know what is happening and you have to think about what the scenario that you’re faced with might be.”

Innovation in teaching

The use of simulation in teaching health programmes has been brought to the fore during the pandemic.  

The key element now, says Naomi, is harnessing the learnings and discussions that are taking place in order to develop a culture of sharing best practice with the sector.

“At the University of Derby we were already well invested in simulation, with it embedded in our teaching, and using it before the pandemic,” Naomi adds. “What we are doing now is sharing with the sector the work we are doing in terms of simulated activity.

“I presented at an international radiography conference last year and encouraged others to come forward and develop a culture of sharing best practice. That is where I think we have excelled as a University.

“It is a really exciting time. Key conferences have been taken over to discuss how we use simulation to support learning. Everyone is suddenly picking it up and using it and finding out how to embed it into their curriculum.

“I see so much value in simulation for the student experience and our students see it too; they enjoy it, they learn it, talk about it and that’s what we need to maintain during the pandemic and in the future too.”