The use of an extended simulation in ward management training (I): rationale for development and design criteria

Nick Ross

This paper provides the rationale for the development and use of an extended

simulation as a tool for the teaching of ward management skills and describes the criteria used in the design of such a simulation for the 1st level nursing course

(RGN) at Oxford School of Nursing. The simulation is used as the framework for the study week which immediately precedes the students’ final ward allocation,

during which they undertake the English National Board practical assessment Part

D. The subsequent article describes the chosen format and summarises the student

evaluation of the exercise.

INTRODUCTION

The initial impetus for the development of the learning package outlined here, was the expres- sion by many senior students of dissatisfaction with the pre-existing theoretical input into the final training module. Some expressed doubts about the basic relevance of the input, while others suggested that the input, although in- herently relevant, either added little to their existing knowledge or was presented in a way which did not allow for ease of application to the ward situation.

To some degree, these expressions may have reflected the general attitude of the students, rather than the specific block content and structure. Many students approaching the end of any course fall prey to a certain cynicism; an ‘end of term feeling’ which reduces their willingness and their ability to learn. In the case of student nurses at this point in their

Nick Ross RGN, DipN(Lon) CertEd(FE) Nurse tutor, Sheffield School of Nursing, Nurse Education Centre, Northern General Hospital, Herries Road, Sheffield Manuscript accepted July 1987

4

general nurse (RGN) training, a high degree of anxiety is also present. Not only do they face the prospect of the final examination and the practical assessment of ward management; they also have to find a staff nurse post and come to terms with the imminent prospect of the increase in responsibility which that post will imply.

It might be suggested that the anxiety pro- duced by these composite factors is enough to result in a level of arousal which crosses that point at which learning performance stops in- creasing and starts to deteriorate (the Yerkes- Dodson law), (Child 1981, p 55), and it is therefore vital that in order to maximise the learning potential of the module, anxiety must be reduced. If theoretical input is to reduce anxiety and to increase motivation, it has to be perceived by the students as being relevant to the moment.

Any new teaching strategy therefore had to take account of the fact that at such a time of’ rapid development, the student’s perceived learning priorities were also undergoing rapid change. All that is of relevance to the role of the student during the final allocation, will of

NURSE EDUCATION TODAY 5

course be of continued relevance to the nurse

following qualification, but the corollary is not

necessarily true and what might be perceived

by the student as being relevant in the consoli-

datory block of the last module might be

considered low on the list of priorities in the

preparatory block. The first task in designing a

new strategy was therefore to consider the

division of theoretical input between the two

blocks.

THE DIVISION OF LEARNING

Although it should be stressed that development

occurs as a continuum throughout the module

and is dependent on the individual rather

than any specific chronology, it is possible

to identify two role changes expected of the

student and thus to define two areas of learn-

ing priority which can form the basis of the

division. Firstly there is the ‘trainee manager’

role which they will be expected to fulfil during

their final allocation and secondly, there is the

further increase in responsibility, accountability

and breadth of role following qualification.

The ‘Trainee Manager’ role

During their final ward experience, the students

are expected to be in charge of the ward on a

considerably more regular basis than previously.

This obviously involves both the consolidation

of prior knowledge and the application of

that knowledge at a new level of responsibility.

The increased requirement for decision making

will, within itself, also require the assimilation

of new skills. The nurse has, throughout her

training, been required to undertake a problem

solving approach to care, but the more global

setting of the problems to be solved and the

reduced level of external corroboration of

decisions made, alter the perceived nature of

decision making skills and require a consider-

able increase in confidence in their application.

Considerable new input is also required. As

well as practising the day to day management

of patient care, the student is expected to

practise aspects of management of the nursing

team with which she may be less familiar,

(such as allocation), and to develop awareness

of other aspects such as the production of duty

rotas. She will also be expected to develop an

awareness of the responsibility of the ward

manager regarding the maintenance of a safe

ward environment and to undertake an in-

creased level of interaction with other members

of the multi-disciplinary team and with nursing

managers at senior sister level and above.

The qualified role

The final module of basic training must also

concern itself with looking forward towards

those needs which are of greater relevance to

the new staff nurse than to the student during

their final modular experience. Several areas of

need might be considered, of which the follow-

ing are only examples:

The need for recognition of increased

accountability for ward management

decisions and the legal implications of

such accountability.

The involvement of the trained nurse in

the longer term decision and policy

making processes and the instigation of

change, both within the ward and within

the larger sphere of the department,

hospital or district.

The need for the newly qualified nurse to

come to terms with her new role regard-

ing students (e.g. reports, interviews,

counselling etc). The teaching role is

obviously of considerable relevance to the

student during her final allocation as well

as following qualification, but is covered

in depth in earlier modules.

The need to encourage the student to

plan her career and to consider avenues of

continuing education, both formal and

informal.

6 NURSE EDUCATION TODAY

THE STRUCTURE OF THE PREPARATORY BLOCK

This division of learning between preparatory

and consolidatory blocks did as much as

possible to ensure the relevance of the content

to the roles which the students were about to

undertake and therefore to their perceived

needs. The next step was to consider the

methods most appropriate for teaching this

content. It was felt that any strategy chosen

should fulfil the following criteria:

The method should encourage and ease

the application of new learning and new

perspectives to the ward situation.

It should reduce learner anxiety and in-

crease their confidence in their decision

making ability.

To increase motivation, it should provide

the students with a nove1 stimulus.

Consideration of these criteria led to the deci-

sion to use a simulation exercise as a frame-

work for the preparatory week.

The advantages of simulated experience

Jenkins (1985) states that teaching effective

decision making requires that the learner be

allowed to experience fully the process of

making decisions and being held accountable

for them. In many cases, considerations of

patient safety would therefore preclude the ward

as an environment for the initial development

of decision making skills. Dahl (1984) points to

the decreased risk inherent in the safe environ-

ment of simulation as being a major advantage.

She goes on to suggest that the reduction in

the anxiety levels achieved by removing initial

training from the real world improves the

efficiency of the learning experience, allowing

more knowledge to be acquired in a shorter

period of time.

The degree to which knowledge is retained

or applied; which might be taken as a measure

of the quality of learning, is of even greater

importance than the speed or quantity of

initial Iearning. There are clear advantages to

the use of simulation as a learning tool for

knowledge which must then be applied in the

real world, since application actually forms

part of the process of learning in the classroom

situation. The work of Pate & Mateja (1979)

suggests that the use of simulation also im-

proves the degree of retention of learning. They

showed that this sort of experiential learning

frequently results in better scores in a delayed

post test than in an immediate post-test,

suggesting that the student continues to learn

from the experience and that the knowledge

gained continues to be generalised and applied.

It is clear that if simulation is to work, the

student must believe in the situation as struc-

tured. That is, that both the situational content

and the way in which the information is pre-

sented to them should be perceived as being

realistic. The importance of this is corroborated

by the work of Brickman (1980), who found

that the learner involvement with the situation

was proportional to the degree of realism at-

tained. Involvement is particularly important if

affective as well as cognitive domain objectives

are to be achieved. Since the internalisation

of vaIues and the experiencing of the feelings

evoked by situations presented and by the

result of decisions made is as important as the

assimilation of knowledge in this module, the

vital nature of realism cannot be overstressed.

There are many other advantages to the use

of simulations as a means of teaching and

learning. Among the most important is the fact

that, the experience is structured and that as

such, it allows the simulation controller to

design the experience so as to maximise the

breadth of situations covered: to telescope the

process of experiential learning into a much

shorter period of time. It allows individual

elements of the simulation to be controlled, so

that the learning condtions at any one time are

optimised for meeting of the particular objec-

tives if that part of the exercise. Thus, as Smith

Ulione (1983) suggests, the necessary stress on

content can be made when the objectives to be

met are in the cognitive domain and the stress

can be placed on process when affective objec-

tives are to be met. Yantzie (1980) noted that

NURSE EDUCATION TODAY 7

the structured experience allowed the teacher

maximum opportunity for the correction of

errors in learner judgement. Perhaps even more

importantly it allowed the teacher to reinforce the learners when decisions were made cor- rectly, thus improving their confidence in their

own decision making abilities. Jenkins (1985) states that,

‘A student must perceive that she or he is

actually capable of making clinical decisions

in order to do so effectively’.

It is therefore evident that it is an advantage

for such confidence to be built up prior to the clinical experience, rather than waiting for it to

blossom naturally during the process of deci-

sion making on the ward, where Bandura (1982) would suggest that the highly stressed

atmosphere would actually militate against its

development.

The use of an extended simulation

Although there is considerable support for the

effectiveness of simulation as a learning

strategy, there are also certain well recognised

disadvantages. Effectiveness does not necessarily imply efficiency and when time is a limited resource, the proportion of the available time

taken up by the assimilation of information and the process of becoming involved in the

exercise can be prohibitive. The facilitator can

either accept the time spent as a necessary evil,

or can reduce the information given to the

students to the point where any applicability to the complexity of real situations is lost. Realism requires a certain degree of information to be

given, which must be of the type normally encountered by the student and not a ‘pre- digested summary of the salient features of the

situation’ (McGuire & Babbott 1967). The extension of the simulation to form the frame- work for a whole week of study reduces the proportion of the simulation time taken up by information assimilation. Realism can thus be

maintained and can be further increased by interactivity: the fact that the students, by the decisions they make, can affect the future pat-

tern of the simulation. Because of the extended

timescale, it is possible for learners to be re-

quired to live with and cope with the effect of previous decisions and to recognise the fact

that any decision made may have a widespread effect over a considerable period and on diverse areas of activity.

There are two main areas of danger inherent

in designing a study week in which a single

complex simulation forms the basis of the whole learning experience. Firstly there is the danger that disaffection or discouragement of

the students early in the week might have an

effect on the whole of the exercise. Secondly there is a danger of over involvement in situ-

ations where despite, or because of, decisions made, an unsatisfactory outcome has resulted.

Although this latter problem area may in itself form a useful learning experience, stress cannot

be allowed to reach a pitch where the ad-

vantage of the safe learning environment are

lost and learning is reduced. On the occasions on which the simulation

has been run, neither of these areas of potential

difficulty has presented to any disruptive

degree. To some extent this was because the timetable and the style of facilitation of the

simulation has been structured to ensure that

the students receive the necessary support. Stress was also maintained within functional levels by the fact that the simulation was run

as a group activity; with decisions being taken

by the group as a whole. A group size of five

or six has been found to be satisfactory; being

small enough to encourage all students to maintain an active involvement in the decision making process and large enough to avoid excessive individual stress.

Assessment in a simulation based module

The learners forming the target population for this exercise are approaching qualification and should therefore be encouraged towards the self assessment which will be vital to them once

they have left the school. To some extent such assessment is inherent within the structure of

8 NURSE EDUCATION TODAY

the extended simulation, since the learner will attempts to provide for the inclusion of ele-

be able to see the eff%zacy of decisions made ments as disparate as those which must be

and will be able to assess their own level of

confidence and competence. This in itself will

provide the learner with considerable reinforce-

ment. The facilitator for the exercise is simi-

larly given ample opportunity for informal

assessment of learner performance by simple

observation of the process and result of the

decision making exercises. A more formal assess-

ment of group performance is possible within

the chosen structure of the simulation by

keeping a record of the decisions made.

McIntyre et al (1972) found that decision

considered under the term ‘ward management’

and which, furthermore, includes an element of

interactivity between the students and the

simulation.

In terms of content, practicality demanded

the simplification of some of the more complex

problems which occur in the real ward situ-

ation, but this has been kept to a minimum.

Conversely, every effort has been made to

reduce the complexity of the chosen simulation

format, without reducing its flexibility. The

exercise described in the subsequent article

making skills were validly and reliably tested by remains a complex teaching tool, but, despite

the use of clinical nursing simulations, involving this, it has been run on several occasions, with

multiple choice questioning: a strategy which only minor problems and with very positive

has been incorporated in the chosen format. student and facilitator assessments.

Assessment of clinical application of pre-existing

knowledge and learning during this block also

occurs in the form of the statutory practical

ward management assessment. References

CONCLUSION

Bandura A 1982 Self-efficacy mechanism in human agency. American Psychologist 37: 122-147

Brickman P 1980 Is it real? J Experimental Learning & Simulation 2: 39-53

Having justified the idea of extended simu- Child D 1981 Psychology and the teacher 3rd ed. Hoit,

Reinhart and Winston. London lation as a tool for the enhancement of ward Dahl J 1984 Structured dxperience: a risk free approach to

management and general decision making skills reality based learning. J. Nurse Education 23 (1):

and having developed criteria for the design of January 34-37

such an exercise, it was then necessary to Jenkins H 1985 Improving clinical decision making in

nursing. J. Nurse Education 24 (6) June: 242, 243

produce a specific format to transform the McCuire C, Babbott D 1967 Simulation technique in

theory into a practical learning package. As measurement of problem solving skills. J. Ed.

sug.gested in this Daper, it was felt that realism Measurement 4 (1): l-9

McIntyre H et al 1972 A simulated clinical nursinp test

de:anded that tie ‘students be presented with Nursing Research 21 (5) Sept/Oct: 429-435 y

information in a situational manner, rather Pate S, Mateja A 1979 Retention: the real power of

than in a predigested form. Thus the content of simulation gaming. J. Experimental Learning & Simulation 1: 195-202

the simulation must, in itself, be of a complex Smith Ulione M 1983 Simulation gaming in nursing

nature. Considerable complexity is also an education. J. Nurse Education 22 (8) October: 349-351

Yantzie N 1980 ‘HELP’. A simulation disaster came. inescapable feature of any teaching tool which

._ Canaclian Nurse June: 33-36.