RCN position on the use of simulation-based learning in pre and post registration education

Definition and scope

Simulation-based education (SBE) is an approach that is used to “replace or amplify real experience with guided experiences” (Gaba 2004). The purpose of SBE is to improve patient experience, patient outcomes and patient safety. Evidence shows that it is suitable for interprofessional learning as well as for the teaching of nursing students, post-registration nurses and midwives (Labrague et al 2018) and healthcare assistants (Aicken et al 2021).

Various simulation methods may be used depending on the specific learning outcomes. The learning outcomes should determine the choice of simulation method(s). A learner can find a low level of realism (sometimes termed low fidelity) in a simulation as good, if not superior to, a high level of realism (or high fidelity) in a simulation when transferring the competences demonstrated into practice (Bland et al 2018).

Simulation now incorporates immersive techniques such as augmented reality (superimposing virtual information onto the real world) and virtual reality (creating a virtual environment that simulates the real world). 

Drivers

Several factors are driving the uptake of SBE including increasing training costs; skills shortages and lack of clinical placements during the pandemic (WHO 2018, Miller and Guest 2021). The evidence base for SBE has continued to grow and the approach has matured with the development of design and implementation standards (INACSL 2016, ASPiH 2016). The digital acceleration of higher education increased during the coronavirus pandemic and the focus on SBE is an indicator of profound changes occurring in the sector (Jisc 2020).

NMC position

The NMC states that Approved Education Institutions (AEIs), together with learning partners, must ensure that all students: “are enabled to learn and are assessed using a range of methods, including technology enhanced and simulation-based learning appropriate for their programme as necessary for safe and effective practice”. (NMC 2019).

The NMC introduced recovery standards in pre-registration nursing and nursing associate education (RN5 AND RN 5.1) in response to the Covid-19 pandemic. These standards allowed AEIs to enable up to 300 hours of practice learning using “a full range of new and innovative practice simulation methods that are currently available”. In addition, discretionary standard (RN6 (D)) allowed students to undertake a maximum of 600 hours of simulated learning provided the AEI could demonstrate to the NMC the capacity to do so and evidence how the increase would be evaluated (NMC 2021). The NMC will review the figure now that U.K. has officially left the European Union and is not bound by the EU directives on clinical practice in pre-registration nursing or nursing associate education. 

U.K. standards and national SBE initiatives

Standards for SBE have been developed in nursing (INACSL 2016, NCSBN 2015) and in the U.K. for healthcare staff by the Association for Simulated Practice in Healthcare (ASPiH).  ASPiH developed twenty one standards (ASPiH 2016) covering four areas: faculty; technical personnel; activity (programme, assessment and in situ simulation); and resources (facilities and technical management, leadership and development). National programmes are in place to promote best practice in the education and training of the healthcare workforce through SBE in England (ASPiH/ HEE 2014, HEE 2018, HEE 2020), Northern Ireland (HSC CEC 2018), Scotland (CSMEN 2014) and Wales (HEIW 2020).  

Evidence-base 

The most recent systematic review and meta-analysis about the use of simulation in nurse education (Hegland 2017) showed a positive significant effect of simulation training on knowledge and skills development and patient-related outcomes compared to other learning strategies. However, the quality of evidence was low. Previously published systematic reviews on simulation-based training for students in health-profession education, showed large positive effects on students' knowledge and skills, and moderate effects on patient-related outcomes (Cant and Cooper, 2010; Cook et al., 2011). Further research is required to understand how and why, and in what circumstances simulation techniques work (Meum 2020, Harlow Consulting 2021).

Economics and Accessibility 

Education providers responding to the Jisc survey on Augmented Reality and Virtual Reality in learning and teaching commented on the expense of immersive simulation methods and the limited access to equipment (Jisc 2019). SBE is underdeveloped in some areas of nursing notably primary and community care and mental health nursing although examples of good practice exist (Council of Deans of Health web site). 

Speed of change 

SBE is a fertile area for innovation and novel methods are being applied to nursing education (Feng Qin et al 2020). The working environment is also undergoing significant change with the introduction of digital ways of working. SBE will need to keep pace with the digital agenda and provide scenarios where nurses can practice digital skills safely and effectively (Chung et al 2017). 

Replacement of clinical practice hours with simulation 

A review of studies examining the replacement of a proportion of clinical placements with simulation (Roberts E et al 2019) showed that “a percentage replacement of clinical placement hours with clinical simulation shows no significant difference to student outcomes in relation to clinical skills and knowledge, and student confidence”. The review concludes that while simulation can be used as an adjunct to clinical placement hours, “regulations need to be defined around the simulation modality used, how many hours of simulation compared with clinical practice is sufficient to maintain proficiency of students, and the assessment or measurement tool used to ensure quality”. 

The NSCBN longitudinal, randomised controlled trial suggests that “substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates that are ready for clinical practice” (Hayden et al 2014). Some nursing programmes have adopted a 2:1 ratio of clinical to simulation hours (Breymeier et al 2015) despite the lack of empirical evidence to support the split (Sullivan et al 2019).

RCN position

Simulation-Based Education (SBE) must be quality assured and accredited. The RCN will promote the use of standards to guide the design, development, and implementation and ongoing monitoring of the effectiveness of SBE in nursing across the U.K.

SBE must meet the evolving learning requirements of nurses. SBE has the potential to change healthcare education positively. For example, students should expect simulation to prepare them for working in environments increasingly shaped by technology.

SBE should reflect the diversity of the nursing working environment.  The lack of diversity in nursing and midwifery education has been highlighted (NMC 2020). This is evident in the absence of nurses or midwives from different ethnic backgrounds in the curriculum and the lack of diversity of models used in simulation exercises.

Access to SBE should be equitable. Students must have support from their Approved Education Institutions (AEI) to ensure effective access to simulated environments.

SBE requires a sustainable model for resource funding addressing the start-up costs, the acquirement and maintenance of the technology, the support for faculty staff development and training, costs associated with the purchase of effectively designed of programmes and the cost to implement and sustain the delivery of SBE. Delivery of SBE within nurse and health care education should align to the UK SBE Standards (Association for Simulated Practice in Healthcare (ASPiH). Much of the simulated learning occurs through debriefing, therefore there is a need to build into programmes appropriate debrief sessions facilitated by skilled practitioners. There must also be appropriate professional psychological support available for students when scenarios do not go as planned.

There is a need for seamless collaboration between HEIs and Trusts/Health Boards to maximise the benefits of SBE. It is imperative that students take a proactive approach to participation in SBE learning activities.

SBE must be evidence-based. The RCN supports the need for further research that demonstrates which simulation strategies demonstrate positive effects on learning for different types of clinical work.

SBE is expanding and evolving rapidly. It cannot be assumed that there is a shared understanding of what simulation is or how it should be applied in all its modalities. There is a need to provide guidance and best practice examples for education providers and learners who are keen to explore the uses of Simulation-Based Education for nursing.

Given the above conditions, the RCN supports the move to increase the number of hours for those AEIs who can demonstrate that they have the capability and capacity to do so and who provide evidence to the NMC of positive evaluation. Any further changes to the allowance of 600 hours would require further consultation. 

References

Aicken C et al (2021) ‘This Adds Another Perspective’: Qualitative Descriptive Study Evaluating Simulation-Based Training for Health Care Assistants, to Enhance the Quality of Care in Nursing Homes. Int J Environ Res Public Health. Apr; 18(8): 3995. 

ASPiH (2016) Simulation based education in healthcare: Standards framework and guidance. 

ASPiH, HEE (2014) National Simulation Development Project: Survey Summary Report. 

Bland AJ et al (2018) Time to unravel the conceptual confusion of authenticity and fidelity and their contribution to learning within simulation-based nurse education. A discussion paper. Nurse Educ Today 

Breymeier T et al (2015). Substitution of Clinical Experience with Simulation in Prelicensure Nursing Programs: A National Survey in the United States. Clinical Simulation in Nursing, 11(11), 472-478. 

Cant et al (2010) Simulation based learning in nurse education: a systematic review. J Adv Nurs. 

Chung J et al (2017) The need for academic electronic health record systems in nurse education. Nurse Educ Today. Jul;54:83-88. 

Cook et al (2011) Technology enhanced simulation for health professions education: a systematics review and meta-analysis. JAMA 

Council of Deans of Healthcare. https://www.councilofdeans.org.uk/case-study/acorn-a-community-orientated-resource-for-nursing-primary-care-simulation-suite/

CSMEN and NHS Education for Scotland (2014) National Outcomes Framework for Faculty Development in Simulation. 

EU directive 2005/36/EC 

EU directive 2013/55/EU 

Feng-Qin et al (2020) Effectiveness of Virtual Reality in Nursing Education: Meta-Analysis. J Med Internet Res. 

Gaba D (2004) The future vision of simulation in health care. Qual Saf Healthcare. Oct; 13(Suppl 1): i2–i10. 

Harlow Consulting, Traverse (2021). Review of Minimum Education and Training Standards in Nursing and Midwifery Independent desk and stakeholder research: Synthesis Report. 

Hayden JK et al (2014) The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. Journal of Nursing Regulation Vol 5 issue 2 Supplement. 

HEE (2018) National Framework for Simulation Based Education (SBE).

HEE (2020) Enhancing education, clinical practice and staff wellbeing. A national vision for the role of simulation and immersive learning technologies in health and care. 

Hegland et al (2017) Simulation-based training for nurses: Systematic review and meta-analysis. Nurse Education Today. 

HEIW (2020). Stakeholder newsletter. July 2020. 

HSC CEC (2018) Looking Forward: A Strategy for the HSC Clinical Education Centre 2018-23. 

INACSL (2016) INACL Standards Committee. INACSL standards of best practice: Simulation. Clin Simul Nurs 2016;12:S39-S47. 

Jisc (2019) AR and VR in learning and teaching: survey findings 

Jisc (2020) Learning and teaching reimagined. A new dawn for higher education? 

Labrague L et al (2018) Interprofessional simulation in undergraduate nursing program: An integrative review. Nurse Educ. Today. Aug;67:46-55. 

Meum et al (2020) Improving the Use of Simulation in Nursing Education: Protocol for a Realist Review. JMIR research protocol. 

Miller A, Guest K (2021). Rising to the Challenge: The Delivery of Simulation and Clinical Skills during COVID-19. Comprehensive Child and Adolescent Nursing. Vol 44, No. 1, 6-14. 

NCSBN (2015) NCSBN Simulation Guidelines for Prelicensure Nursing Education Programs 

NHS Learning Hub. Accessed January 2021.

NMC (2019) Standards framework for nursing and education

NMC (2020) Ambitious for Change. Research into NMC processes and people’s protected characteristics.

NMC (2021) Current Emergency and Recovery Programme Standards. (Updated 18/2/21)

Roberts E et al (2019). Simulation to Replace Clinical Hours in Nursing: A Meta-narrative Review. Clinical Simulation in Nursing. Vol 37.

Sullivan N et al (2019). Emerging evidence toward a 2:1 clinical to simulation ratio: A study comparing the traditional clinical and simulation settings. Clinical Simulation in Nursing, 30(C), 34-41. 

WHO (2018) Simulation in nursing and midwifery education.