Using medium fidelity patient simulation to develop interprofessional clinical
and communication skills in final year nursing and medical students: an
evaluation. Results of five focus groups.
1
Introduction
Simulation has for a long time been used in the aeronautics and aviation industries
to increase safe functioning (Helmreich et al, 1999), and is increasingly being used in
the pre- and post-qualification education of health professionals (medical, nursing,
allied health professionals, and inter-professionally) (Moorthy et al, 2005; Ravert,
2002; Fernandez et al, 2007; Barratt et al, 2003; Mantovani et al, 2003; Ypinazar and
Margolis, 2006; Alverson et al, 2004).
Simulation as a pedagogic technique in health care education takes a range of forms:
using live actors to play the part of patients; asking students to enact scenarios, or to
play simulation games (including computer simulations on screen); use of
mannequins, whether mechanical or computerised. Computerised patient simulation
(CPS) may offer, for example, breath sounds, heart sounds, pulse, chest and eye
movements. It can be used to facilitate learning in decision-making, clinical thinking,
team work, communication skills, clinical assessment, practical skills acquisition and
practice (Bearnson and Wiker, 2005; Chant et al, 2002; Bremner et al, 2006). It can
also be used in the assessment and examination of students, and in research;
(Hakvitz and Koop, 2004; Wayne et al, 2006; Pugh and Youngblood, 2002; Cantillon
et al, 2004).
On the face of it, CPS can claim many strengths as a pedagogic tool. It offers
opportunities for risk-free learning by trial and error, it enables repeated practice for
individuals and for teams, and it can be halted for replay, critique, reflection and
feedback. Learning time is not limited by patient-related factors, there are no ethical
concerns, and CPS can present students with complex problems and / or rare events
that they might not otherwise encounter (Feingold et al, 2004, Bremner et al, 2006;
Lasater, 2007).
Does the evidence about CPS substantiate these claims? There is no doubt that
students believe learning sessions with CPS is valuable (Scherer et al, 2007; Barsuk
et al, 2003; Weller et al, 2004; Feingold et al, 2004; Gordon et al, 2005; Bremner et
al, 2006; Fernandez et al, 2007). They usually also believe that it gives them
confidence (Curran et al, 2004; Bearnson et al, 2005; Alinier et al, 2006; Wallin et al,
1
2007), though in a study of medical students learning neonatal resuscitation Curran
et al (2004) points out that increased confidence accompanied knowledge attrition.
However, there is mixed evidence that skills improve after training using CPS
(Scherer et al, 2007; Barsuk et al, 2003; Weller et al, 2004; Bearnson et al, 2005;
DeVita et al, 2005; Alinier et al, 2006; Steadman et al, 2006; Wayne et al, 2006;
Radhakrishnan et al, 2007; Tuttle et al, 2007; Wallin et al, 2007). It is not clear that
CPS is superior to using actors (Lee et al, 2003; Triola et al, 2006) or case- or
patient-based learning (Schwartz et al, 2004; Hall et al, 2005). Furthermore, there is
little evidence on other outcomes such as behaviour change among learners, patient
benefits, or organisational change (Barr et al, 2000).
Most studies are uniprofessional, with a very small number of interprofessional
examples (Barsuk et al, 2003; DeVita et al, 2005). Therefore, there is little evidence
of how CPS can be used to promote interprofessional learning. This is the topic of
this paper, which reports the findings of a qualitative evaluation of an
interprofessional learning initiative. This was provided for volunteer nursing and
medical students studying at City University and Queen Mary University of London
respectively, and comprised structured sessions in which inter-professional student
groups used a medium-fidelity patient simulator to enact an acute health care
scenario.
It was intended that the project would:

enable final year students to engage in interprofessional learning (students
have no formal interprofessional learning during their final year);

enable students to develop in a safe environment the clinical judgement and
decision-making skills expected of a qualified practitioner in the initial
management of common acute/critical situations;

enhance students’ understanding of team working and interprofessional
communication.
In addition, the project would:

enhance the knowledge and experience of teaching staff about using the
patient simulator with interprofessional groups of students;

develop the use of an important but expensive resource to its full potential.
2
Students were asked to use the simulator in enacting a scenario of a post-operative
patient receiving a blood transfusion to which she developed an anaphylactic
response. The nursing students began by assessing the patient, and called in
medical students as and when they felt that was appropriate. Medical students could
phone a more senior doctor for advice if they wished. Students could ask for ‘time
out’ if they needed to discuss what steps they should take, or ask for advice from
nursing and medical teaching staff, who operated the simulator, played the role of
senior staff, and provided the patient’s voice. Staff facilitated ‘debrief’ sessions after
the scenario enactment was complete, in which students could discuss the scenario
and their own contributions to it. The five sessions included in the evaluation took
place in March 2008, and in most cases, two student groups acted out a scenario in
parallel, each using one simulator.
1.2
Aims and methods of the evaluation
The aims of the study were:

to identify students’ perceptions of what they learnt from the sessions;

to identify to what extent the use of medium fidelity patient simulation adds to
already existing interprofessional learning.
Students were invited to take part in inter-professional focus groups held immediately
after the teaching sessions. There were five of these, and comprised four, five,
seven, seven and nine members respectively. They lasted between 30 and 50
minutes, and focused on the question: has the use of medium fidelity patient
simulation added to your previous interprofessional learning, and if so, in what
respects? The focus groups were audio-taped, and the records were transcribed.
The transcripts were analysed by repeated reading and comparison to generate
thematic categories.
The study was approved by the research ethics committees of the two universities.
Findings
These are arranged as follows:

profile of the students taking part;

their views on what was learnt;

their views on how they learnt;

their views on what the sessions added to their previous learning.
3
2.1
Profile of students
Table 1 summarises some basic characteristics of the participating students. All the
nursing students and four medical students were studying on graduate entry
programmes (GEP), and these had experienced considerably more inter-professional
learning than the others. All names are pseudonyms.
Table 1. Participants in the study
GEP
Medical students
2nd year
1 (Amy)
3rd year
1 (Richard)
4th year
1 (Kate)
5th year
1 (Dawn)
Total medical 4
students:
Nursing students
Adult nursing
8
(Pat, Neil, Freda,
Rod, Donna, Harriet,
Grace, Luke)
Mental health 7 (Bill, Rosie, Nesta,
nursing
Malcolm,
Victoria;
Charlotte, Stella,)
Children’s
2 (Flora, Olive)
nursing
Nursing branch 1 (Zara)
not known
Total nursing 18
students:
Total
22
students:
GEP = graduate entry programme
not GEP
Total
1
1
1 (Don)
2
9 (Laura, Steve, Frank, 10
Tina, Linda, George,
Esther, Trish, Brian)
10
14
-
8
-
7
-
2
-
1
-
18
10
32
Table 2 shows the composition of the five focus groups, while Table 3 records
students’ previous experiences of the patient simulator. Some contact with the
patient simulator is included in GEP programmes, and as a result, some of those
students had also attended voluntary late-night learning sessions using the simulator.
Table 2. Membership of focus groups
Group
1
2
3
4
Nursing students (all GEP)
Pat, Neil
Bill, Flora
Freda, Nesta, Rosie, Olive, Zara
Rod, Donna, Harriet, Grace,
Medical students (* = GEP)
Kate*, Laura
Amy*, Richard *, Don
Steve, Frank
Tina, Linda, George
4
5
Malcolm, Victoria
Luke, Charlotte, Stella
Dawn*, Esther, Trish, Brian
Table 3. Students with experience of the patient simulator.
GEP students
non-GEP students
Medical
Kate
Linda, George, Esther Trish
students
Nursing
Pat, Neil, Freda*, Rod*, Donna, students
Luke*
* more than one session with the patient simulator
All topics discussed by nursing students were also discussed by medical students.
However, medical students raised some additional themes, which are clearly
identified below. There were few differences between the five focus groups in terms
of themes discussed: those that there were are reported in 2.4.
2.2
What was learnt
Participants of all sorts and in all focus groups believed that the sessions had above
all helped them to learn about how to work as a team. There were a number of
aspects to this.
First, they had learnt about the different roles of the two professions.
Richard: Here you’re actually interacting in a realistic, work-like environment
… this actually teaches you about real interprofessional interactions, actually
in the work place and how to work together, … to get a bit more of an idea of
what each other does.
Freda: I think it’s very good in outlining clinical roles and giving us more idea
of where we stand as a nurse and a medic.
Part of this learning was about the nature of professional training: some medical
students admitted to misunderstandings about nurse training.
Dawn: One thing that we learnt today is the realisation that not all nurses are
general nurses or trained medically. Like I wouldn’t - I would just think that
you would do your general nurse training, and then specialise in mental
health afterwards.
5
George: We later on found out that some of the nurses were not qualified or
confident to put in cannula, that was the point. And part of this exercise
obviously was learning about the skill sets of the roles of the people who you
were working with based on their experiences.
Second, the simulation had enabled them to learn about how to work together. Partly,
this was by effective communication.
Pat: Just the importance of relaying information, the assessments …
You
obviously know it’s important, and situations like this just do reiterate that,
really.
Good communication involved paying attention to appropriate language:
Linda: If you’re with a group of other medical students doing the same
scenario… you’re used to using the same jargon. Whereas if you’re working
with nurses who have trained, or just anyone, trained in a different area,
you’ve got to be more realistic about how you describe something, so that
everyone understands. And just highlighting that is very useful in itself.
Good team-working also required that teams and/or leaders negotiate an appropriate
division of labour to get the task done.
Tina: Depending on how experienced everyone else is, you don’t know
whether you can delegate that responsibility or not. So it’s assessing the
dynamic of the group of nurses who are already there, in addition to having to
know your own knowledge base.
Division of labour was also an issue between nursing students.
Nesta: Basically the thing that we found was not dividing the roles up
properly, that everyone tried to do everything. It would have been a lot better
if someone had done the observations, someone else had done the drugs,
rather than everybody trying to do everything, because things were missed…
I think we resolved it quite quickly … everybody took up a particular role,
rather than just heading for the same direction.
6
As the quotation from Tina suggests, the issue of leadership was particularly
important for medical students.
Linda: The inter-professional aspect of this is for the medics to learn how to
be a bit more like a team leader and also to delegate responsibility.
However, not all participants assumed that leadership lay with the medical
profession.
Brian: And frankly if you were, if you were an experienced nurse, you would
be, I would prefer you to be the team leader, do you know what I mean? It
was whoever knows the most and it’s that’s, doesn’t matter who, what, who or
what you do, it’s just, who knows the most? Who can deal with this most
effectively?
Rosie: So it’s not just the doctor being the leader, the leader could be anyone
and it could be a share of knowledge, as in, the nurse might be able to say,
for example, make a suggestion of what is happening, this is what I think is
happening in this situation, without taking it personal, or trying to undermine
the doctor, or any other profession there.
An adult nurse student had found herself ‘lead nurse’ because the nursing students
in her scenario were mental health nurse students, and had less confidence in
assessing and treating physical needs.
Harriet: I find it really stressful …I mean I panicked a bit, but it was useful … it
was an interesting experience, because I think sooner or later you’re going to
be a registered nurse and you have to take that role. Pretty scary!
Thus, it was how individuals put their different expertise and experience to work as
part of a team that was the chief learning reported by participants. Other sorts of
learning were also mentioned, but less frequently, such as learning about one’s own
reaction to situations, and learning about clinical skills.
2.3
How did the students learn?
7
Once again, there was a clear consensus among all participants that the patient
simulator session had been useful in promoting learning-by-doing. In contrast with
lectures and, (for medical students, see 2.4. below) placements, the sessions had
required students to take decisions and perform actions.
Esther: I think the best way to learn, is to actually go out there and do it.
Neil:
I’m a pragmatic, I have to do it in order for it to be really useful and
then to stick.
I learn far more on placement than I do in a lecture, for
example.
Previous training rarely provided such opportunities.
Laura: For me, to be walking and being the doctor and for me to make
decisions, obviously that’s never really happened before.
the patient simulator itself, and the scenarios, were thought to be sufficiently realistic
to assist learning, and students felt they had been given a foretaste of work after
qualification.
George: You take a history from them, you do an examination on them, you
present your findings to a doctor, I think that’s far more relevant and
practically useful as well. This for me is useful because I’m thinking, six, eight
months’ time, if I’m on a ward and I’m physically in the situation, these are
skills that I will apply.
The advantage of a simulation sessions was that, as Kate said,
We all really had to step up and contribute. There’s nowhere to hide, which
was good… I was treating it like a real life situation, so trying to be
professional definitely.
Don: You can’t just relax and watch what happens, you have to do something.
And I think that makes it more challenging and makes you actually - if you
don’t do something, then something will happen, and you know there’s
consequences for it.
8
Several participants stressed the sense of responsibility.
Flora: I felt responsible, I felt the responsibility of it.
Neil: Because in a seminar situation, it’s very easy to just spitball anything
and it doesn’t really matter, it doesn’t count. But in this situation, although it
doesn’t count, it still feels as though it counts more.
There were also comments that such a sense of responsibility is rarely felt in their
training.
Many participants believed that the fewer students in each session the better, for two
reasons. First, all would be obliged to participate fully, and thus learn more from that
experience. There was an interesting discussion between three medical students in
group four, two of whom had worked together in the simulation, while the other had
worked alone. The latter felt that she had learnt more by being alone; one of the
former acknowledged this, but saw that the additional pressure could also be
unhelpful.
George: I think it probably would have been a lot more frightening if we were
there by ourselves.
I think realistically we would’ve got more out of it,
because we’d have been in overall charge, we may have been traumatised
but if we survived we’d have probably done better.
Second, it was thought to be unrealistic that several doctors and several nurses
would be discussing and treating a patient at the same time.
But as well as providing realism and a sense of drama, the simulation is a safe place
to learn, because no patients are involved, and that allowed students to participate
and risk make mistakes without fear of the latter being dangerous.
Pat: As a student, you sometimes know things at the back of your mind, you
think, well am I going to be stupid saying that, … is that important? And it
gives you the opportunity just to blurt all it out and say it and then you look,
you can actually look at the end and say, well actually that was important,
even though you might not realise it, it was important in that, in the end that I
9
said that...you feel more comfortable in saying things and not worrying so
much about looking stupid or saying the wrong thing... it’s still invaluable to do
these things away from the real situations as such, where you can use your
intuition and just go with it, and just see what happens with it.
Rod: It’s drama, nobody’s going to die, but it’s real, and things do come out
which will come out in real life. And it’s better that we know it here.
Luke: And it’s a good place to practice skills, and make the mistakes you’re
going to make and learn from them. As opposed to then getting a real
emergency where you just freak out and make mistakes that are going to
harm people.
2.4
Previous interprofessional learning
A recurring theme in and between all five groups was that the session with the
patient simulator was much more useful than previous interprofessional learning. The
degree of inter-professional learning experienced by participants varied. Nursing,
medical and dental GEP students studied together in their first year, and some GEP
students also mentioned joint study with social worker students from another
university in their second year. Non-GEP students had had a much smaller number
of inter-professional sessions. Participants also spoke of inter-professional
experiences during placements on hospital wards. Both GEP and non-GEP students
emphasised that it was the approximation to real-life tasks that made the session
with the patient simulator so much more useful.
Richard: The interprofessional learning I’ve had before, in the first year was
[problem based] learning, with student nurses and medical students. And it
was quite interesting, quite useful to see where other people were coming
from, but it’s completely different to this. Because here you’re actually
interacting in a realistic, work-like environment, you’re not just doing a shared
assignment together which, although is nice and vaguely useful. This actually
teaches you about real interprofessional interactions, actually in the work
place and how to work together, how to communicate and to get a bit more of
an idea of what each other does. So, from that point of view I found it much
more useful...
10
One group was particularly impatient with their previous interprofessional learning:
Luke: We’ve done quite a bit of inter-professional stuff for the GEP medics
and dentists in the past. And it seemed very tokenistic, so that certain people
could tick a box saying that we’d worked inter-professionally, and we’d
discuss various scenarios that were, I don’t know, maybe related to ethics or,
and cultural issues. And they were repeated over and over and over again,
until we were ready to kill everybody, and it just really seemed a bit pointless,
apart from ticking boxes.
A few medical students added that the patient simulator session had also been more
useful than lectures.
Interesting comparisons were also drawn with placement experience. Here, nursing
and medical students experiences diverged considerably. One nurse described her
experience thus:
Olive: We are very much integrated in the working unit. Like, we will take part
in ward rounds, in handovers, got our own patients, obviously under
supervision, but you’re slowly building up that role of what you’re going to do
when you qualify.
By contrast, medical students described their experience thus:
Brian: We just wander round get, find questions out and then wander off and
pick up, you pick up piecemeal experience as and where, as and when, but
it’s very, very random.
Laura: It sounds like I probably had a lot less experience than maybe, of
active management of a patient than you [nurses]
Medical students’ lack of practical experience links with a particular concern of the
medical members of group 5, who felt very under-prepared in practical and clinical
skills.
11
Brian What we’ve been taught, a lot of the emphasis on this is the
communication, the teamwork interplay and stuff. I say, forget that. We need
some basic product knowledge and some experience of working practically
within the team … you can have as much teamwork as you want but if you
don’t, if you don’t know what to do, the patient dies anyway.
Contributors to the focus groups tended to discuss communication rather than clinical
skills, though both were intended learning outcomes. However, one medical student
welcomed the focus of the post-session feedback on clinical rather than
communication skills.
Dawn: What I found really useful is afterwards is going through, I don’t know,
the oxygen masks and things and the doses of adrenalin, not the ‘How did we
chat with each other, how did we get the information across?’, it’s what didn’t
we know and how, what is the information that we needed to know?
3. Discussion
An important limitation of the study is that it captured data immediately after the
learning session. Existing literature indicates that students are likely to be very
positive in their evaluation of the session. But we cannot assume that what was
learnt would be retained over time, and/or that it influenced practice. It would be
interesting to know, for example, whether students’ perceptions of their own
increased awareness and confidence were observable to their colleagues when they
began work a few months later, and whether fellow students who had not attended
CPS sessions were quick or slow to acquire such awareness and confidence ‘on the
job’.
It must also be recognised that those students attending the CPS sessions were selfselected rather than randomly chosen. Presumably, people with a different learning
style, e.g. a preference for lectures, were unlikely to volunteer for the patient
simulator sessions, and their views are thus unrepresented here. Given this bias, it
would be rash simply to comply with participants’ request for CPS sessions to be
mainstreamed, even if the practical challenges of doing so were less daunting. For
the same reason, the judgement that previous IPE learning was inadequate may not
be generalisable to all students, nor is it clear whether these students would have
12
benefited as much from the sessions if they had not received earlier interprofessional education.
There were also likely limitations to the quality of education offered during the
sessions. Issenberg et al (2005) carried out a systematic review of high-fidelity
medical simulations that lead to effective learning. Their conclusion was that the best
available evidence suggests that high-fidelity medical simulations do facilitate
learning under the right conditions. These conditions include repetitive practice and
curriculum integration. The number of CPS sessions offered is very limited compared
with student numbers as a whole, and there is therefore no guarantee that students
will have the opportunity for repetitive practice (although as Table 3 shows, some
students had used CPS more than once). Nor are the sessions integrated into the
medical school curriculum, being voluntary ‘add-ons’. Thus, the potential for
facilitating optional learning was restricted.
Nevertheless, it is striking how emphatic and consistent the students’ feedback was.
Although generally medical students spoke more than nurses, most people
contributed (only one or two said almost nothing), and there was usually consensus.
Two clear messages emerge from the data. First, CPS sessions provide learning
which students feel to be unique in their curriculum: about teamwork, about
communication, about leadership, and a real life appreciation of the different roles of
health professionals. Second, there is great value in ‘experiential learning’, that is,
learning by doing in a safe, simulated yet realistic environment, followed by learning
by reflection as facilitated in the debrief sessions.
The study suggests that there is scope for further research, particularly in relation to
the following questions:

Are students with experience of CPS more confident and/or competent when
they work as qualified practitioners, compared to students who did not
attend?

Does the learning from the CPS sessions remain useful and applicable over
time once students have qualified and are working in clinical practice?
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