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.