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Nurse Education in Practice 11 (2011) 186e191

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Using simulation to promote nursing students’ learning of work organizationand people management skills: A case-study

Jane Warland*

School of Nursing and Midwifery, University of South Australia e City East Campus, North Terrace, Adelaide 5000, South Australia

a r t i c l e i n f o

Article history:Accepted 29 August 2010

Keywords;SimulationWard simulationNurse educationWork organization skills

* Tel.: þ61 8 8302 1161; fax: þ61 8 8302 2168.E-mail address: jane.warland@unisa.edu.au.

1471-5953/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.nepr.2010.08.007

a b s t r a c t

Simulation is becoming widely used in nurse education. However, reports concerning its use focusalmost exclusively on describing experiences with high-fidelity manikin simulation used to teachstudents a range of psychomotor skills and clinical procedures. Simulation has enormous potential asa learning tool and can provide much more than just a basis for safely learning clinical skills. This papergives a case-study of use of a simulation exercise that is designed to develop nursing students’ workorganization and people management skills. It also discusses student evaluation of the simulationexercise. Student engagement with this type of simulation and their feedback suggest that skills obtainedduring the simulation are transferable into and valuable for their clinical placements.

� 2010 Elsevier Ltd. All rights reserved.

Background and context

In recent years simulation has become widely used in nurseeducation (Jeffries, 2007). The worldwide shortage of nurses hasmeant that nursing is becoming a more popular undergraduatepathway.With surging numbers of undergraduate students, clinicalplacements are becoming more and more scarce. In order toadequately prepare nursing students for clinical work, universitieshave needed to become more innovative in nurse educationdelivery. Furthermore, there is a medico-ethical requirement foruniversities to adequately prepare students for clinical placementand reduce the ‘patient as practise’ educationmodel of the past. Theuse of clinical simulation throughout nursing courses has gonesome way to address these needs.

The University of South Australia (UniSA) provides a three-yearundergraduate nurse education program. As is the case in manyother universities providing nurse education, simulation is exten-sively used throughout the program. In first and second yearsimulations aim to provide students with opportunities to practicea range of basic skills such as making beds and taking blood pres-sures. In stage two, sophisticated manikins are used to teachstudents clinical skills such as listening to heart sounds and cardio-pulmonary resuscitation, whilst lower fidelity part-task simulatorssuch as sections of arms teach psychomotor skills like taking bloodand giving injections.

All rights reserved.

In third year students undertake the simulation workshopdescribed in this paper. It is situated at the beginning of the finalyear of a three-year program in order to draw all clinical skillstogether thus giving students the ‘big picture’ in preparation fortheir clinical placements in third year. The primary aim of thisworkshop is to facilitate student learning of concepts such as timemanagement and other work organizational skills. Prior to thedevelopment of this topic, concepts such as these were taughtmerely as theory and the student was expected to make the links topractice themselves. However, this was recognized as out of stepwith the well known principles of experiential learning (Kolb andFry, 1975). The simulation was designed to allow the students theopportunity to practice principles of time management and workorganization in a controlled simulated environment in order tolearn these skills with a level of isolation from other distracters.

Literature review

Generally speaking, simulation can be said to be an activitywhich attempts to approximate, without necessarily replicatinga real world setting, for the purposes of learning in a safe,controlled environment (Beaubien and Baker, 2004, p. i52). Liter-ature reporting simulation activities usually consider these in termsof their fidelity (Jeffries, 2007). High fidelity refers to those activi-ties which most accurately reproduce life-like situations with e.g.a computer basedmanikin, programmed to provide visual, auditorycues and feedback, depending on student response. Low fidelityrefers to less life-like simulation e.g. using a piece of foam topractice giving injections. Beaubien and Baker (2004) also discussfidelity in terms of environment, equipment and psychology. When

Table 1Sample roster for 12 students.

Number Student name Simulation 1 Simulation 2 Simulation 3

Role Assessing Role Assessing Role Assessing

1 Alison P 7 N P2 Belinda P 8 N Extra3 Cindy P 9 Extra N4 David P 10 P N5 Eun P P 1 N6 Fred P P 2 N7 Gus N P P 38 Hsaio N Extra P 49 Isabelle N P 11 P10 Jan N P 12 Extra11 Kerry Extra N P 512 Lily Extra N P 6

(P ¼ patient, N ¼ nurse, Extra ¼ other person e.g. doctor, relative, cleaner). Namesgiven in this table are fictitious.

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environmental fidelity is high the environment closely matches thereal world. Simulation, using real world equipment, has highequipment fidelity. When psychological fidelity is high the simu-lation is so realistic the student is easily able to “suspend disbelief”(p. i52) in order to engage with the learning activity.

There is much established and emerging literature concerninguse of high-fidelity manikin simulation to teach a range of clinicalskills to nursing students including emergency response (Freemanet al., 2001), critical care (Parr and Sweeney, 2006), maternitynursing (Yaeger et al., 2004), decision making (Lasater, 2007), acutecoronary syndrome (Reilly and Spratt, 2007) and cardio-pulmonaryresuscitation (Long, 2005) to name but a very few. Even thosereports describing lower fidelity simulations using, for example,roleplay generally use simulation to teach technical skills(Kneebone and Nestel, 2005; Wiseman and Snell, 2008) or clinicaldecision making (Cioffi et al., 2005) rather than work organizationand people management skills. Hawkins et al. (2008) recentlydescribed a “unique” simulation design in which they useda mixture of simulation devices both human and computer to teachnursing diagnosis and formulate care plans. A report by Bland andSutton (2006) also mentions combining use of simulated patientswith manikins to achieve a ward simulated environment to fosterdevelopment of these skills.

There is mention in other literature about the use of multiplayerroleplay in the context of teaching sales skills (Aldrich, 2005). Manystudents are involved in playing a role over many hours or evendays for the purposes of working on a real world problem in teams,problem solving together and deriving some team recommenda-tions. However, this type of simulation is not necessarily in a realworld environment.

Seropian et al. (2004), point out that “full-scale” simulation,namely a simulation environment which is made to resemble theintended environment as closely as possible, is the “most recog-nized form of simulation used in health care” (p. 168). There aresome reports of this kind of simulation in medical education liter-ature (Ker et al., 2003, 2006; Maran and Glavin, 2003) as well asnursing literature. Bland and Sutton (2006) replicated an “authenticclinical experience” for 10 nursing students in a simulated wardenvironment. They deemed this an expensive exercise because ofthe use of paid actors as “simulated patients.” One UK centre isprogressing significant work in the area of interprofessional ward-based simulation with nursing students (n ¼ 15) and medicalstudents (n ¼ 37) working together (Swann et al., 2008). Thesesimulation exercises are somewhat similar in design to the onereported in this paper however, we have significantly morestudents (n ¼ 125) and our students play the role of patients ratherthan bringing in simulated patients.

As far as it can be ascertained, full-scale simulation used in orderto facilitate the development of the kind of work organization andpeople management skills nurses need to function effectively in theworkplace has been rarely reported or not described in enoughdetail to enable replication. To bridge this gap this paper describesa simulation workshop which was designed to enhance learning ofwork organization and people management skills in a full-scalesimulation of a chaotic ward environment.

Simulation description

The simulation workshops occurred in week four of the eight-week topic.Weekly subjects occurring before theworkshop included,collaboration and partnerships, nursing in teams, supported self caremanagement of chronic conditions, models of care, time manage-ment, and conflict resolution. Students completed a range of weeklytutorial activities devoted to teaching the theoretical principles ofeach of these subjects. The students were expected to arrive at the

workshop prepared to demonstrate their understanding of workorganization principles when nursing patients with chronic condi-tions in an acute care setting.

The simulation workshop ran over the course of one day (6 h).This workshop was high in all fidelity types as it was situated in thenursing skills laboratories, which were set up and fully equipped tosimulate a six-bed hospital ward. Groups of 10e13 studentsundertook three simulation scenarios to enable each student to‘play’ the role of nurse, patient and an ‘extra’. Each simulationscenario accommodated six ‘patients’ (all with a chronic conditionsuch as asthma and diabetes) and three or four ‘nurses’, with theother students playing the part of an ‘extra’which could be a doctor,relative, or cleaner. Whilst the students did use clinical psycho-motor skills during the simulations, such as setting up intravenoustherapy, and drug administration, they understood that theprimary purpose of the simulation was to learn how they managetheir time, people and circumstances around them.

The students were allocated a ‘roster’ for the day. This roster wasdesigned to give every student a role in each simulation. A sampleroster using fictitious names is given in Table 1. This shows, forexample, in the first simulation ‘Kerry’ (student number 11) playsthe role of a nurse, an extra in the second and a patient in the finalsimulation. Following this final simulation she was asked to givepeer feedback to the student playing the nurse, in this case ‘Eun’(student number 5). The peer feedback involved circling criteria ona competency (novice to expert) based rubric (Benner, 1984) anda provision of a justification statement to give a rationale for thisassessment. As assessment is not the focus of this paper theseassessment rubrics are not shown.

The simulation began with all students listening to a recorded‘handover.’ This report gave detail of patient diagnosis, reason foradmission, length of stay, current condition, etc. (see Table 2 forexample) Those students who played a nurse then held a shortmeeting to make a decision about work allocation. Just as theywould in real life, they left this meeting with a ‘cheat sheet,’a prioritized list of things that they want to achieve during their‘shift’. Meanwhile, those students who played patients donneda patient gown, identification bracelet and got into a bed. Studentsplaying the nurse then commenced work as if they were in a wardenvironment. Depending on their prioritization they may havestarted a drug round, observed and recorded vital signs, or beganpreparing a patient for theatre. Each of the patients was given a cuecard containing some background information as well as timedtriggers. This may have been, for example, “wait 10 min and thenbecome very agitated and aggressive.” An example cue card fromsimulation one is given in Table 3.

Table 2Handover sheet: staff notes (student version of this sheet did not have the simulation incidents).

Name Age Diagnosis Admissiondate

Comments Incident summary bysimulation number

Miss Smith 87 Surgical debridement andsuturing left calf woundType 2 diabetes

Yesterday First: Discharge planningSecond: Falls and wound opens,Third: Prepare for theatre, upset

Mr Brown 81 Elective surgery for a righttotal hip replacementHistory of Rheumatoid Arthritis

Today First: Prep for TheatreSecond: Return to ward (in pain)Third: Restless keeps removing Charnley pillow

Miss Green 18 Asthma for stabilisation Yesterday First: Needs a nebuliserSecond: IVT tissuesThird: Absconds

Mr Black 46 Anterior MIFor coronary angiogram todayPatient education required

Transfer from countryhospital yesterday

First: Wants to go to toilet. Nursing historyincompleteSecond: Upset waiting for wifeThird: chest pain (wife hysterical)

Mr Panos 58 CVAHistory of Hypertension

2/52 ago First: Restless, requiring restraintSecond: calling out “nurse” nurse”Third: sleeping

Mrs Lock 43 Ca breast, bone and lungmetastases

3/7 ago First: PainSecond: Drowsy sleepy (upset daughter)Third: sleepy, dying (daughter wantsto see Doctor)

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Each simulation developed and built on the other in ‘real time’and required the student nurse to respond differently to thepatients depending on the circumstances. For example, patient (A)in the first simulation needed to be readied for discharge followingsurgery, so the nurse in this scenario was required to interview thepatient in order to arrange a discharge plan and then a dischargeletter. In the next simulation the patient slipped and fell reopeningher wound, so the nurse in this scenario was required to call forhelp in order to get the patient back to bed, arrange for a pressurebandage to be placed on the wound, offer reassurance to thepatient, contact the attending doctor, and file an incident report. Inthe last simulation this patient needed to be prepared for theatre torepair the wound. The nurse was required to complete the pre-theatre checklist and reassure the patient whowas understandablyupset. This progression avoided advantaging students who play thenurse in later simulations being forewarned by observing whathappened in the simulation prior to theirs.

Each simulation generally ‘ran’ for around 30e45 min. Facultyobserved and noted student performance for assessment purposesand if necessary could “freeze the scene” (Moss, 2000), a techniquewhich allows intervention with one or more students in order tofacilitate critical thinking and problem solving and/or offersuggestions if required. Typical questions asked during the freezewere:

Table 3Example cue card: ‘extra’ from simulation scenario one.

The cleanerBackground:You are the ward cleaner. You emigrated from Europe when you were 15. You

speak 5 languages. You really enjoy talking to people as you work.You are new to this ward.

ScenarioCommence the simulation by doing some damp dusting. (Use the cloth

and water bottle provided)As you are cleaning start talking to patient asking questions like

“What are you in for dear?” and “When are you going home love?”If one of the other patients speaks another language engage

them in conversation (this doesn’t have to be a real languageit can be gobbledegook)

The nurses should ask you to stop. Become quite offended andupset when they do.

When something starts happening with one of the other patients becurious and get in the way.

� How are you feeling right now?� Why do you think you are reacting this way?� Why do you think you are in this situation?� What do you think you can do to improve your situation?� What would you like to see happen now? (Telesco, 2006)

When it was apparent that the simulation had run its course,faculty called a formal stop and gathered the students together fora 30e40 min debrief. This consisted of standard debriefing typequestions (Fritzscheet al., 2004) for example “Whatdoyou feelwentwell? What didn’t go so well?” and “What would you do differentlynext time?”Additionally, as the focus of the simulationwas onworkorganization and people management skill development, questionsabout this were specifically asked e.g. “Did you feel it was appro-priate for the nurse to sedate you just because you were feelinganxious?” “Did you get time to complete the theatre checklist beforethe orderly came to take the patient to theatre?” Potential solutionsand possible alternate actions were raised and discussed. Thisimmediate feedback was both valuable and important to reinforcethe learning which has just occurred (Goldenberg et al., 2005).

Following this debrief students were given the opportunity towrite a reflective statement, give a handover report to faculty (thischecked understanding), complete peer feedback and have a breakbefore the next simulation started. At the commencement of thenext simulation the students swapped roles according to the rosterand different cue cards were given out to the patients. A differentrecorded handover was given which gave a short update tostudents on the current state of play and the simulation ran againfor another 30 min or so. Following another debrief, paper workand break the final simulation ran. This was generally of a shorterduration as students had become familiar with the process andwhat they were expected to do.

Student evaluation

The workshops were developed as part of curriculum re-devel-opment undertaken in the latter part of 2008 and were delivered forthe first time in ‘summer school’ 2008/9. As it was the first time theworkshops had been offered student feedback was sought fromthe same cohortof students on twooccasions; immediately followingthe completion of theworkshop in February 2009 and 2months later(April 2009), once they had been out on their clinical placement.

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At the end of the two-day workshop the students were givena paper-based evaluation survey to complete. This survey metUniSA guidelines for a curriculum evaluation activity undertakenwithout need for formal ethics approval. Under these guidelinesstudents were informed that their participation was voluntary andtheir contribution would be anonymous both verbally and by wayof the following statement heading each survey form:

Data collected through this survey will be used to improve thequality of teaching and learning at UniSA and could also be usedin external publication and presentation. Individual responseswill remain confidential and no individuals will be identified.(Mikilewicz, 2008, p. 9)

There were 13 questions in the survey which sought studentperceptions of the two-day workshop which included the simula-tion described in this paper, an activities day and their satisfactionwith the type of assessment used. Only two of the questions askeddirectly related to the simulation activity, and these are includedhere. Five-point Likert scales (strongly agreeestrongly disagree) aswell as open-ended comment responses were used for the survey.There was a 92% response rate (n ¼ 115/125). Students were askedto give their response to the following:

1. The simulations in the skills laboratory assisted me in myunderstanding of systems and organization of nursing care(Likert scale response)

2. Please give an example of how this simulation has preparedyou to give safe, systematic nursing care? (Room for open-ended response was provided)

Of the 115 respondents, 77.4% (n¼ 89) agreed or strongly agreedwith the first statement. Thus the vast majority of the students feltthe simulations assisted them in gaining understanding of systemsand organization of nursing care.

Student comment regarding how they considered the simulationhad prepared them to give safe, systematic nursing care included:

The skills laboratory made me realise how important it is to beas organized as possible at the beginning of the shift. It alsomade me realise how quickly a client’s health can deteriorateand how you need to constantly reassess clients’ needs and timemanage.The simulation activities pointed out key points e.g. timemanagement, teamwork, prioritizing strategies.They were fun, helpful and important in understanding timemanagement skills in a wardIt has taught me that anything can go wrong on a shift and tofocus on whatever comes. Keeping your cool helps greatly. Thesimulations helped me use all the skills I have learnt and buildon them as well as find issues or holes in my learning to repair.

In this survey students were asked two questions about how theworkshop could be improved.

1. Please comment on any aspect of the workshop that you feltwere not helpful

2. How could the workshop be improved?

Many students left these questions blank or wrote somethinglike “not applicable”. Most student comment centered on otheraspects of the workshop not reported here. Seven studentsexpressed an opinion that the simulationwas complex or confusingwith this type of comment being typical:

The simulation day seemed chaotic but I’m not sure how thatcould be improved.

A small number of students (n ¼ 5) expressed dissatisfaction intheir inability to “act” or requested that paid actors (n¼ 10) be usedin the future.

The follow-up survey was administered electronically. An emailinviting students to participate in further evaluation of the work-shop was sent to all students who had undertaken the workshop insummer school. The email contained a link to the electronic survey.In order to comply with UniSA ethics requirements the surveycontained the same anonymity and confidentiality statementdescribed above (Mikilewicz, 2008).

The survey included the following 2 statements:

1. Undertaking the simulation workshop has helped me with mywork organizational skills on my clinical placement

2. Undertaking the simulation workshop has helped me with mypeople skills on my clinical placement

Five-point Likert scales were used. Therewas a typically low 37%response rate (n ¼ 46/125) to this electronic survey. Twentystudents (43%) agreed or strongly agreed with the first statementand 17 (36%) agreed or strongly agreed with the second. There wasalso room for students to add comments. A selection of these arereported here:

Additional comment responses to statement one included:

I found that being able to experience what may happen whenwe go out to our placement, enabled me to feel more confidentand orientated to a situation that could change.Taking the role of a Registered Nurse in response to differentsituations (e.g. in the ward setting) has made me realise thevalue and importance of ‘time management’ and setting‘priorities’.The roles of the staff (e.g. TL, RN’s, EN’s, cleaner, etc) that I cameacross in the hospital I could link back to the simulation.

Additional comments made to in response to statement twoincluded:

All activities offered during the workshop were strongly focusedupon working as a team and helped me to develop conflictmanagement skills.Being able to practice with speaking to patients has given mepointers while I have been on placement.There was also the occasional more negative comment:Of little benefit generally, need talented actors to make it useful.I was not at all comfortable with ‘acting’, making the experiencea negative one. Everyone is so focussed on what they aresupposed to be acting, very little time to think about thescenario, and what we would do as nurses in these situationsandI could not dismiss the fact that the workshop was a simulation.Sorry.

Discussion

In 2004, Beaubien and Baker stated that they considered itunfortunate that the terms simulation and high-fidelity simulationwere being used almost synonymously in the literature. Since thisstatement was made there has been a burgeoning of literaturereporting the use of high-fidelity manikin simulation to teacha range of clinical nursing skills with very little published on the useof other types of simulation used for other educational purposes.Following a systematic review of simulation activities, Kaakinenand Arwood (2009) suggest that simulations are most often usedto teach nursing skills rather than facilitate learning of concepts.

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This indicates that there is still a place for teaching concepts such astime management and work organization in nursing educationusing the type of simulation activity described in this paper.

It is well known that well designed simulation activities engagelearners in situated professional knowledge-building (Jeffries,2007). Further, there is little doubt that the instructional method-ologies used in simulation-based learning are well in line with thetenets of adult learning (Feingold et al., 2004). There is therefore noreason to think that the benefits of simulation have to be confinedonly to high-fidelity manikin simulation. Indeed requiring thelearner to engage with the wide range of professional skillsnecessary to successfully complete the simulation described in thispaper, is fundamentally important to the delivery of safe, effectivenursing care.

The use of this type of ward simulation has been reported inboth medical and nurse education literature. A simulation whichincluded similar elements to this one, including “timed interrup-tions, team interactions, routine and emergency scenarios” (p. 333)was described by Ker et al. (2006). These authors conclude that notonly can such a simulation emulate reality that it can also providea good opportunity for senior physicians to closely observe andprovide feedback for everyday performance of students, anopportunity not often available in the real world due to pressure oftime. Mole and McLafferty (2004) also conclude that their simu-lated ward exercise for third year nurses was perceived asa welcome opportunity to consolidate clinical as well as organiza-tional skills.

One of the well recognized issues with using high-fidelitysimulators is that faculty often need time and instruction to be ableto effectively programme and use the patient simulators (Medleyand Horne, 2005). The faculty involved in this simulation wasgiven a 2 h professional development workshop, which includedinformation and instruction in all aspects of the workshopincluding the simulation, debriefing, assessment, etc. Once thisorientation had occurred theywere able to facilitate this simulationactivity without further need for instruction, this made this simu-lation relatively time efficient.

Themost commonly identified issuewith this type of simulationis that 10e15% of the participants don’t manage to buy in (Aldrich,2005) or “suspend disbelief” (Beaubien and Baker, 2004) this wascertainly mentioned by around 10% of students involved in thissimulation who asked for “paid actors” or made comments like theone above that the simulation wasn’t real for them. However, weconsider the experience of playing a patient useful to promoteempathy for the patient and understanding of the condition theywere asked to ‘play’ not to mention less cost!

Aldrich (2005) also lists some limitations of this type of roleplaywhich have probably been addressed by the method used in thissimulation. One such limitation of multiplayer simulation is thata lot of students are just watching (Aldrich, 2005). This was avoidedin this simulation as all students were involved in one role oranother all the time. Another limitation is the “one-shot” nature ofroleplay where the roleplay doesn’t easily allow a re-play of thescenario, and students may be required to think of a new strategyeach time the roleplay runs, this limitation was overcome byadopting a developing scenario described earlier.

Ultimately the main aim of any simulation is to safely preparestudents for a real life clinical setting. The ability of students toconsolidate skills learnt and transfer these from the simulation intothe clinical setting is therefore imperative (Kneebone and Nestel,2005). This simulation arose as part of evaluating curriculumdevelopment rather than from a research agenda and as such theintention was not to control for or measure outcomes, but toprovide a descriptive case report. Whilst, student response to bothsurveys suggests that the knowledge and skills they learnt could be

transferred into their workplace, formal research into the benefitsand actual transferability of this type of simulation is warranted.

The low response rate to the follow-up survey unfortunatelymeans that the value of this feedback is limited. This poor responsecould have been because students were not accessing theirUniversity emailwhilst out onplacement. Following placement theywere due to have a semester break so this was really the onlyopportunity to conduct the poll. Also some students may not havebeen immediately aware of the value of the workshops at the timethey were asked to complete the survey, especially if they had notexperienced a hectic day. One student indicated this by sending anemail severalweeks after theworkshop,whilst shewas undertakingher clinical placement. She reported that during the simulation dayshe had thought the kinds of things that occurred in the simulationwere unlikely to happen in real life until she subsequently hadencountered a chaotic day in her workplace. At this point sherecognized the value of the workshop. Her email suggests thatstudents can and do draw on the learning that took place in theworkshop when out in the real world.

It was very busy and I learnt a lot through this experience. Itreminded me of the stimulation exercise that we did ina workshop for systems and organization. Throughout theworkshop I thought “this situation would never happen”. wellit did!, we even had random visitors walking around askingquestions that we needed to see to as well! (personal commu-nication used with student permission)

Conclusion

The use of high-fidelity manikin simulation is only one way ofusing simulation in nurse education. Full-scale ward simulation ofthe type described in this paper can also provide an excellentlearning opportunity for student nurses. Indeed requiring thelearner to engage with the wide range of professional skillsnecessary to successfully complete this type of simulation, isimportant to them being able to deliver comprehensive, safe, andeffective nursing care.

Student feedback suggests that skills obtained during thesimulation are useful, transferable into and valuable for their clin-ical placements. Although this may not be immediately recognizeduntil after they had experienced a chaotic day in the workplace.

Ultimately the main aim of any simulation is to safely preparestudents for a real life clinical setting. Whilst teaching specificclinical skills through use of high-fidelity equipment is obviouslyboth important and useful, full-scale clinical simulation used forthe purposes of learning work organization and people manage-ment skills may also prove worthwhile. Both strategies can then beused together over the duration of the nursing course to betterprepare students for work in the clinical setting.

Acknowledgements

I acknowledge the assistance, interest and support of thefollowing UniSA faculty: Associate Professors G. Sanderson and L.Barnes, as well as Drs K. Andre, M. Faukner and C. Hall. I’d also liketo thank all students who undertook and evaluated ‘Systems’ inSummer School 2008/9, as well as faculty teaching in the coursewho kindly collected the survey forms.

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