The use of an extended simulation in ward management training (2): a description of the chosen format

Nick Ross

This paper describes the format of an extended, interactive simulation used at Oxford School of Nursing. It was designed as a teaching tool for the preparation of students of General Nursing (RGN) for ward management practice during their final ward allocation. The simulation aims to consolidate prior knowledge regarding the management of individual patients and the ward, it forms the end point of a management thread running throughout the curriculum as well as providing a vehicle for new learning and the extension of competence and confidence in the fields covered. The paper also summarises student evaluation of the learning experience.

INTRODUCTION

The idea of using simulation to teach ward

management skills is by no means original.

Although the package described here was de-

veloped independently, there are clearly going

to be some similarities of content with previous

exercises, such as those developed by Neal

( 1982) and Fowler (1985). The simulation de-

scribed here does differ from previously pub-

lished material in its format, in the realistically

complex patient and ward information given to

the learners and in its breadth of coverage of

ward management topics.

As stated in the preceding paper, this simu-

lation is designed to run as a framework for

the whole of the preparatory week of the pro-

fessional development module. The outline

Nick Ross RGN DipN (Lon) Cert Ed (FE), Nurse Tutor. Sheffield School of Nursing, Nurse Education Centre. Northern General Hospital, Hemies Road, Sheffield Manuscript accepted July 1987

timetable, (Figure l), shows the division of the

week between the problem solving sessions

which form the central part of the simulation,

the focused simulation sessions which examine

particular aspects of day-to-day ward manage-

ment and those taught sessions which cover

aspects of the required modular learning, but

do not form an integral part of the simulation.

SIMULATION EQUIPMENT

Running a simulation of this complexity, re-

quires the initial production of a considerable

amount of equipment. Although expensive in

terms of material costs and man hours, it is

important to note that the majority of that

equipment can then be re-used on subsequent

occasions. It is also worthy of note that students

undertaking this exercise have repeatedly re-

marked that the quality of presentation of the

simulation equipment was a significant factor

in their immediate positive response. Each

85

86 NURSE EDUC:A’l‘ION TODAY

Monday

Tuesday

Wednesday

Thursday

administration Friday &

evaluation I I I I I I I I I I

Time 09.00 10.00 11.00 12.00 13.00 14.00 15.00 1E i.( IO

Fig 1 The outline timetable for the week; showing the proportion of the available time used for the general simulation sessions (S): the focused simulation sessions (F): taught sessions (T): and summative discussion (D).

group is provided with a colour coded box containing the following material:

Patient Profiles: [See Figure 2 for example]

At present there are eighteen profiles and re- lated problem sets for this simulation, all of which are worked through during the week. More profiles are being develop, thus allowing selection to suit the specific learning needs of any group undertaking the exercise. The full profiles developed for the initial running of the simulation were chosen from a wide selection of outlines to provide the maximum coverage of

ward and patient nursing management prob- lems. Since this was felt to be of the greatest importance, it overrode any consideration of keeping to a realistic combination of medical problems which might be found on any one ward.

At the commencement of the exercise, the groups are provided with 12 patient profiles. Because of the fullness of the profiles, it is

probably unreasonable to expect the students to assimilate any more information at this time. However, since 12 patients do not constitute a realistic ward population, a specified number of extra patients are stated to be present on the ward, but minimal information is given about them. The other profiles are ‘admitted’ to the exercise at various points during the week.

The profiles contain all the information which would normally be found on the ad- mission sheet of the nursing notes and a nurs- ing assessment which is based on the activities of daily living. Such information is obviously of considerable importance in judging the correct action in given situations. Not all of the in- formation given will be relevant to the parti- cular problems being considered for that patient, but the fact that the students have to sift the available information can only add to the realism of the situation.

An important addition to the written infor- mation that the nurses would expect to be given about a patient is the section of the profile entitled, ‘Yes, but what’s he/she really like’.

NURSE EDUCA’I‘ION TODAY 87

Oxon I

AGE 80yrs MARITAL STA’t

NEXT of KIN NAME D@I

RELATIONSHIP $&

ADDRESS Fi.c

sf,

HQ

MEANINGFUL OTHERS

Her cat ‘Toddles :

.: TYPE of ADMISSION Eni& :.I’.

REASON for ADMISSION :I

C. V. A

None

Has had a stroke Un&$

Poor prognosis

Has suffered from osteQft

Obese lady :: ., Previous admisston duri&

:I

A

ACTUAL MEDICAL DlAGi

Major LEFT C VA

SURGERY/TREATMENT

No active treatment

DRUGS

None

ALLERGIES

None known

GENERAL PRACTITIONE

SOCIAL WORKER Non

DISTRICT NURSE Non

RELATIVES STAYING

Not at this time

HOME CONDITIONS

Has lived with daugt

(since death of hush.

with granny annexe c

Problems while patieni

is in hospital

None Daughter look1

DEPENDENTS

None

ASSESSMENT CRITERIA MENTAL & EMOTIONAL STP (inc. reaction to admission)

Low level of cnnsc~ousr

WII move unaffected le

NUTRITION

Obese lady

No gag reflexes are pr6

Dentures Own teeth

ELIMINATION

Has not passed Urine

HYGIENE .% SKIN CONDIT

Sore areas under breas

High pressure sore risk

Norton Score 9

MOBILITY

MoblIe with stick pr,or

Now lmmoblle Potentlz

BREATHING

Slight breathlessness

7 Chest InfectIon

SLEEPING PATTERN

SENSES Sight Spectacl

Hearing No prob

Speech Not ass

PAIN CONTROL

No apparent discomfort

For ongoing assessment

RECREATIONAL ACTIVITI

RELIGIOUS ACTIVITIES

Not a regular churchgoc

Fig 2 A Et B. An example of a patient profile, showing the format and information content. There four pages are presented in a folder, which also contains blank sheets to which the students attach the given results of care decisions. This enables the group to maintain an up to date patient record.

88 NURSE EDUCATION ‘TODAY

OTHER RELEVANT INFORMATION

NOT FOR 222

Not for acrive treatment

“Yes but what’s she REALLY like?”

i was la/king to Mrs Clarke’s daughter thus afternoon. when she came

r” with her She seems lo be very close to her mum She says she

was a/ways such a /oily person

Mr Ciarke dred about five years ago. alter being nursed through a

long and painful illness by h,s wife That’s when Maude moved rnlo

the flar in her daughter’s house. She relused to move ,n until they’d

agreed to bufld the granny flat She was a f!ercety fndependant woman

who was determrned not to become a bother to her daughter and her

family He daughter remembers her sayjng:

i’m not going to be a burden on anyone I know what II’S /!ke

having an invalId rn the house what wrth iookrng after your

gran and then your dad / know you’d be wfll!ng to do the

same for me. but I don’t want it When the rime comes that

I can’t look after myself. i pray to God that he’// take me

qu!ckly if I can’t care for mysejf, 1’11 know my t!me has

come and I’// be more than ready to go. ”

Her daughter said she’d always spoken about having had a good ,nn,ngs

Maude worsh!pped her grandchIldren and spent a lot of time wfth them

The chlldren loved to come round to the flat to ‘visit lust as they had

done when she had Ifved ,n a separate house. Her only unhappiness

was her sfrarned relatronshfp wfth her son. They had never got on we//,

even when he was a child and s!nce /he deaf/r o/ her Irusbartd, she had

only seen h/m about twice a year.

Mind you he’s already rung the ward twice today and he says he’s

going to come over and see her some t/me this week. I better warn

you. he’s been getting realty stroppy about the amount of Information

we can g,ve him over the phone. still. {t’s probably tust worry We’ll

see what he’s tlke when he comes in

PROFILE 16

B

NURSE EDUCATION TODAY 89

This substitutes, (if imperfectly), for the less objective picture of the patient which would normally be built up by personal contact. It attempts to make the profile more believable as a real ‘three dimensional’ person and takes the form of a conventional statement by a nurse who has been in contact with the patient. It is in the nature of such statements that some information of a judgemental or speculative nature may be included.

information for duty rota production and allocation

On the first day of the exercise, the groups are required to produce a duty rota for the rest of the week. This then forms the basis for their allocation of staff on each of the subsequent mornings. The basic staffing level and mix for the week, along with the previous week’s duty rota and the off duty requests, were taken from a randomly selected ward. The groups are also provided with a blank duty rota form and brief

profiles of the ward staff. These profiles contain the basic information

about level of experience and familiarity with the ward, (taken from the selected ward), along with imaginary personal outlines and details of interaction with other ward staff. This means that, as well as providing a satis- factory cover and skill mix for each day, the students learn to allocate staff in such a way as to use the available skills effectively and pro- vide the necessary learning experiences. The groups can also consider more subtle allocation questions, such as whether to avoid putting a staff nurse on to supervise a student with whom she has previously had an argument, or whether to confront the situation by making them work together.

Equipment for placement of patients in the ward

The basic information for satisfactory placing of the patients in the ward is clearly contained in the patient profiles. In order that the students can visualise the ward and apply this

information, they are provided with a ward plan showing facilities and bed spaces and adhesive labels with which to show the placing of patients. The plan used is the standard ward layout from the largest hospital in the teaching circuit and is therefore familiar to all the students. The adhesive labels are also used to note the allocation of staff. The placing of patients may be altered by the students at any time during the exercise, to take account of changing situations and new admissions.

In addition to the equipment provided to each group, the facilitator is provided with the following material:

Problem sheets: (See Figure 3 for example)

The facilitator holds a set of problem sheets for each group. The problems are dealt with chronologically and each sheet may therefore contain problems referring to more than one patient, or to general aspects of ward manage- ment, which are not related to any individual patient.

The problems are stated as multiple choice items, with a stem and a list of possible courses of action. Some of the known disadvantages of multiple choice questions, which are encoun- tered when they are used as an examination tool are avoided, since the simulation provides for a much greater level of background infor- mation to the problem, gives immediate feed- back and provides a rationale for the given result of the chosen action. The advantage of a multiple choice format in a simulation of this type is that it allows for pre-planning of inter- action between the decisions made by a group and future problems they will be asked to work on. Thus, a decision made by a group may result in extra problems, (either immediately or at a later date), or may equally result in them gaining an opportunity to gather extra infor- mation to help them solve problems.

Because of the interactive nature of the simulation, it is necessary for a separate set of problem sheets to be held for each group, because, in addition to the standard sheets the facilitator holds supplementary problem sheets

90 NURSE EDUCATION ‘I‘ODA\

Problem Sheet 11

PROBLEM 16 01

A junior nurse approaches you and says that she is concerned

about the distress which Maude’s deteriorating condition is causing

her. She says: “Why aren’t we doing anything for her, it’s so

cruel just to let the woman suffer like that.”

Which of the following actions do you wish to take?

16 01 01 ACT a) Re-emphaslse the Importance of allowing a patlent to

die with dlgnlty and tell the nurse that any treatment

would only prolong any suffering which Maude IS

undergoing Tell her lust lo make Maude as comfortable

as oossible

16 01 02 ACT b) With the student present, discuss Maude’s condltton

with the doctor and explore the posslblllty of

commencing treatment to reduce her discomfort and

distress.

16 01 03 ACTc) Suggest to the student that she should approach the

doctor herself to discuss Maude’s treatment. because

she IS one of her allocated patients

Fig 3 An example of the problem format, showing the coding of problems and alternative actions. The first two figure code (16) refers to the patient profile; the second to the problem number and the third to the action choice. (The results of these actions are given in fig. 4). Any one problem sheet may contain individual problems relating to more than one patient.

which are inserted into the problem set in response to particular choices of action on the part of individual groups. The standard prob- lem sets are placed in a box with four colour coded compartments, (one for each group). The supplementary sheets are held in a separate file for insertion as necessary. Such interaction between the individual and their environment, (animate and inanimate), is intrinsically realistic. To simulate this inter- action effectively and maintain the realism, it was necessary to define four basic categories of result:

1. When the action chosen is considered to be correct, the result may show alleviation of the given problems, or may provide the group with further information, either im-

2.

3.

4.

mediately, or at a later point.

When an action is considered to have been ineffective, but has not materially altered the position, the students may be given the opportunity to make another choice from the original selection. When an action is considered to be incor- rect and does materially alter the situ- ation, but that situation can be redeemed, a further problem, taking account of the changed situation and offering a means of return to the desired course, can be in- serted into the problem set. Depending on the initial problem, this extra problem may be tackled immediately, or may occur at a future point in the simulation. When an action is considered to be incor- rect and alters the situation in such a way

NURSE EDUCATION TODAY 91

that it can not be redeemed, the students

are informed of the altered situation and

have to work with it. Such situations

obviously incur the greatest risk. In the

planning of this exercise, a positive deci-

sion was made to avoid the ultimate

penalty; i.e. the death of a patient due to

the choice of action of the student group. This

decision recognised the fact that, even in

simulated experience, such a blow to the

students’ confidence, (or egos), could re-

duce the safety of the environment to the

point where they would be less willing to

continue to practice their decision making

skills.

Result sheets: (See Figure 4 for example)

These are constructed in such a way that,

depending on the outcome of their chosen

action, the group may be given a typed copy of

the result of their chosen action, (see category 2

above), or may be given the results of all the

possible actions listed. The result statements

include the rationale for the assumed causative

link between their action choice and the result.

As can be seen from the illustrated example,

the result sheets also contain a marking grid for

each problem. As well as providing a tool for

the assessment of students and, more parti-

cularly, for the assessment of the problems, this

marking grid contains the insert instructions for

the placing of supplementary problem sheets.

The facilitator also has a bound reference

copy of the complete set of possible problem

sheets, (standard and supplementary), which

includes instructions on the timing of admission

for incoming patients; four copies of each of the

profiles for admission; a bound copy of all the

profiles; a bound copy of the result sheets and

a comprehensive handbook explaining all facets

of running the simulation.

RUNNING THE SIMULATION

The first morning of the simulation constitutes

an introduction to the work of the rest of the

week. Following an introduction to the elements

of the simulation and the various activities

involved, the students are given time to fami-

harise. themselves with the profiles of patients

present at the start of the exercise. Having

familiarised themselves with the profiles, the

first exercise which the students have to under-

take is to place all the patients, both profiled

and extra, into bed spaces on the ward plan.

Assessment of this patient placing is one of the

ongoing tasks of the facilitator, since changing

patient and ward circumstances result in

necessary alteration.

If the facilitator is unhappy with the choice

of placement made by the groups, the students

may be asked to give the rationale for their

decisions and may be advised about any un-

satisfactory elements, but the students final

choice is their own. During subsequent periods

of the simulation, there are problems specili-

tally related to the unsafe placement of patients.

This spirit of advice, without control runs

throughout the simulation. If the students are

to obtain the benefit from decision making

practice, they must be allowed to make wrong

decisions as well as having the satisfaction of

making right decisions.

Problem solving sessions

The first morning of the simulation continues

with an initial set of problems which are

designed to familiarise the students with the

chosen format as much as to test their know-

ledge or judgement. Although the complexity

of individual problems increases to some extent

through the course of the week, the problem

solving sessions all follow the same format.

With familiarity the students may be expected

to increase the rate at which they tackle prob-

lems and the available problems per hour are

increased accordingly. Having said this, the

students are encouraged to give the maximum

deliberation to problems rather than to treat

the exercise as a race, (an exhortation that is

sometimes necessary), and the rate at which

they tackle the given problem is defined by the

students themselves. With reference to the ap-

92 NURSE EDUCATION TODAY

PROBLEM 16 01

INSERT

16 01 01 RES a)

16 01 02 RESb)

16 01 03 RES c)

You have falled to reallse that the nurse IS concerned

to encourage the conslderatlon of paillatlve treatment,

rather than trying to promote the Idea of active

treatment. She accepts your statement, but remains

dlssatlsfled with the sltuatlon

C)n dIscussIon, the doctor agrees that some paIllatIve

treatment IS possible. By encouragelng the student to

participate in the dlscussion while not expecting her to

approach the doctor on her OK”, you have shown that

You respect her knowledge of the patlent. credit her

with valid op~n\ons regardtng management of care and

are willing to support her

The doctor IS very abrupt with the nurse and IS

unwilling to discuss the subject The nurse feels angry

and Inadequate You have encouraged the student to

take responslblllty, but was delegation appropriate,

conslderlng her level of experience 3

Fig 4 An example of the result format, showing how the result codes relate to action choices given in the problem example (fig: 3). The marking grid and instructions for the insertion of supplementary problem sheets are also shown

propriate patient profile, the group discusses the problem and come to an agreed decision on the choice of action. The students are encouraged to spend time discussing the result they have been given, before placing it in the appropriate patient file and continuing with the next problem.

The role of the facilitator as ‘human com- puter’ in these sessions is time consuming and considerable advantage has been gained from having two facilitators: one to carry out the above role and the other to circulate among the group, helping the students to gain the maximum benefit from the sessions by en-

couraging consideration of all aspects of the given problems and giving advice as requested.

Focused simulation sessions

As well as the taught sessions interspersed through the week, which, quite apart from their content, provide a useful variation of stimulus, there are ‘focused’ simulation sessions. These form an integral part of the overall simulation and are linked to it in terms of decision making. The duty rota production exercise has already been detailed and as was stated, this rota provides the available staffing

NURSE EDUCATION TODAY 93

for the week. The important points to be considered in allocating these staff, form the

basis of one of the taught sessions and these points are then applied to the simulation on a daily basis; further complications being added by staff being ‘off sick’ and by problems where the students have to consider the suspension of one nurse and alteration of the off-duty of another for compassionate reasons.

A further focused simulation session consists of problems referring to ward safety. This session is timetabled to follow a statutory fire lecture and a taught session on health and safety. The problems are dealt with in the same format as the general problem solving sessions, with some relating to the ward as a whole and some relating to particular patients who may be at risk.

This pattern is followed on a less formal basis throughout the simulation, with problems being given which allow the students to apply information gained from taught sessions looking at aspects such as links with the community; following which the students are asked to arrange for the discharge of one of their patients, or the role of the nursing officer; when the students are given problems which they should refer to their superiors. It is worth noting here that, in designing the problem sets, it was felt that the students should be encouraged to recognise their own limitations, (and feel com- fortable in doing so), as well as to recognise the wealth of knowledge which they could already apply to ward management decisions.

EVALUATION

A full and detailed student evaluation of the week as a whole and particularly of the simu- lation elements has been carried out as an integral part of each running of this exercise. The evaluative tool takes the form of a series of rating scales, looking at individual elements of the week and of the chosen simulation format and at overall impression. The students are also invited to provide written comments. Because of the extensive nature of the valu-

ation, it is impossible to cover all its elements in this paper. What follows is therefore a summation of the major points. The overall assessment by the students has been very favourable and some of the predictions of potential problems such as loss of interest or motivation have proved unfounded.

The continuous use of one basic problem format was initially recognised as a potential problem, in that the students might become demotivated. In fact, none of the students surveyed expressed any degree of loss of inter- est. The fact that the chosen format is capable of encompassing considerable variation is prob- ably one of the factors which avoided loss of interest occurring. The students found the chosen problem format easy to come to terms with and found that the numerical coding used

reduced any chance of confusion. They appreciated the fact that they were given a written result of their actions, since this allowed them to maintain a full record of patient care.

Some groups undertaking the exercise felt that in certain cases, the given choices of action did not provide the precise action they would have taken. Even in the initial running of the exercise, none of the groups felt that this affected more than 10% of problems tackled. In the majority of instances cited by the students, the groups suggested the need for minor alteration of detail or wording rather than complete unacceptability. Many of the student suggestions, along with those of facili- tators, have been incorporated into the problem sets for subsequent use.

All students felt that the given results of the chosen courses of action were acceptable in the vast majority of cases. The rationale provided with the result was usually sufficient to explain the causative link, but the students also appreciated being able to discuss particular results with the facilitator.

The patient profiles were considered to pro- vide an excellent basis from which to make decisions. The students felt that their fami- liarity with the format in which the majority of the information was given, eased and en- couraged frequent referral and felt that the

94 NURSE EDUCATION TODAY

extra information given in the ‘Yes, but what’s

he really like’ section was of considerable use in

maintaining individualised care decision

making.

The focused simulation sessions, such as duty

rota production, were felt to provide a good

insight into aspects of ward management with

which their only previous contact had been as

consumers. Having discovered the difficulty of

producing a satisfactory duty rota with limited,

(but realistic), staff resources, many of the

students showed a marked change of attitude

towards the quality of the off-duty they had

previously experienced.

The students were asked to assess the overall

value of the learning experience under three

separate headings:

(a) Revision of care requirements.

(b) Theoretical aspects of ward management.

(c) Application of theoretical aspects of ward

management.

In all three cases, the students felt that useful

learning had taken place, this being particu-

larly so for the theory and application of ward

management.

The simulation as a whole was adjudged to

be realistic as were the problems set. The

unrealistic mix of patient profiles did not cause

any difficulty and the breadth of coverage of

problems which this mix provided was generally

considered to be good.

All students felt that the simulated ex-

perience had increased their confidence in their

decision making skills and their ability to

manage a ward and stated that they felt well

prepared for the subsequent practical ex-

perience. Furthermore, they felt that this learn-

ing had been achieved in an interesting and

enjoyable way.

FUTURE PLANS

The writing of further patient profiles to pro-

vide an element of choice for facilitators is

already underway. It is hoped that the simu-

lation will soon be ready for use with a group

of senior R.G.N. students in Sheffield School

of Nursing. The use of the exercise in a new

location will in itself require some adaptation

of the profile pool. At its most superficial, this

will consist of providing local addresses etc. so

that the students will be able to relate to the

particular community circumstances of their

‘patients’. On a more extensive level, it will

consist of writing new profiles to take account

of the differences in the cross-sections of occu-

pation, environment and socio-economic status

between Oxford and Sheffield. It is also

planned to use the format of this simulation as

the basis of an exercise within the professional

studies module of the new curriculum, of the

Registered Nurse Mental Handicap

(R.N.M.H.) qualification, which is presently

being developed in Sheffield School of Nursing.

One possible further development is import-

ant enough to deserve mention at this time,

even although no firm steps have been taken

towards it. From the outset, the design of this

exercise has taken into account the potential

for the use of computers in the running of such

a complex simulation. The chosen format and

coding of the problems would allow relative

ease of transferral of the administration of the

decision making sessions to the computer,

freeing the tutor to take on a more truly

facilitative role.

The use of computers for the problem ses-

sions alone, without involving the material

used in and generated by the focused simu-

lation elements and the ongoing task of

allocation, would require the programming of

a considerable number of interactive elements.

Although a computer is ideally suited to coping

with this type of activity, it is possible that the

simulation would still have to run as a partially

‘paper-based’ exercise, rather than being con-

tained entirely within the computer. This

would not necessarily be disadvantageous. The

number of nurses who are familiar with the use

of computers is still limited, as is the use of

computers in nursing. While this situation

exists, it may be desirable for the techniques of

computer assisted learning to be used in only

part of the exercise. In this way, the interest

NURSE EDUCATION TODAY 9.5

generated by other elements of the simulation puter literacy which is seen as an important can be used to encourage the use of and facet of future nurse education.

therefore familiarity with the computer, rather than use of the computer being a prerequisite for the Reneration of interest. References

Even- this limited use of computers would

considerably ease the running of an exercise Fowler J 1985 One for you, one for me. Nursing Times 81:

32-33 which, although complex, continues to prove Neal E 1982 Practical aspects of ward management. Trent

its worth. A mixed media strategy of the type Nurse Education Development Project

described above, could equally importantly Ross N 1988 The use of an extended simulation and

management training (1) Rationale for development and serve to encourage the increased level of com- design criteria. Nurse Education Today 8( 1): 4-8