Competence

There has been some criticism levelled at the lack of clarity of the term ‘competence’ (Clark and Holmes 2007) introduced at the time of the move to Diploma level education. Criticism was also levelled at the less structured andragogical approach of the new curricula, which expected students to take responsibility for their own learning (Bradshaw and Merriman 2008).

By the turn of the century, many Higher Education Institutions’ (HEIs’) responsible for the education and training of nurses and other healthcare professions had developed skills laboratories. They had been encouraged to introduce or increase the use of simulation by reports such as Scholes et al., (2004) and more recently the Nursing and Midwifery Council’s (NMC) ‘Simulation and Practice Learning Project’ (NMC 2007). The aim of this project (NMC 2007) was to develop a set of standards by which to audit simulated practice placements that could be used to replace up to 10% (2300 hours) of practice placement hours. These in turn, would be piloted across a range of programme providers’.

– 10 sites; Scotland – 1 site; Wales – 1 site; N. Ireland – 1 site) and involved 6361 students from both the CFP and the four branches (adult, mental health, midwifery and learning disability). The selected sites represented the full range of simulated areas, from the highly sophisticated to the more basic and all were tested using the same standards.

Pilot sites were expected to replace seven practice days with simulation over a 12 - week period and whilst they were encouraged to be innovative they were expected to map the simulated sessions to the students’ programme outcomes. At the end of the 12 - week period each site was required to evaluate their achievement of the five practice principles (see Table 1.2 below).

Table 1.2 NMC principles for simulated practice learning in pre-registration nursing programmes

This was a mixed method study conducted by the NMC. For the quantitative element each principle (see Table 1.2 above) had a number of indicators attached (37 in total) requiring a response on a rating scale: (5) – fully achieved to (1) – not achieved. The qualitative element afforded all the participating HEIs’ the opportunity to comment on the simulation experience. The resultant scores were significantly positive, with the lowest score of 3 (meaning less than 80%) being assigned to only three questions. The overall qualitative and quantitative findings of the project are supportive of simulated learning stating that it:

 Helps students achieve clinical learning outcomes.

 Provide learning opportunities not available in clinical practice settings.

 Helps increase confidence in approaching clinical situations. NMC Principles for simulated practice learning in

pre-registration nursing programmes

1. Maintaining partnership for simulated practice learning 2. Managing simulated practice learning safely and effectively 3. Promoting competence through simulated practice learning 4. Learning through simulated practice

5. Enhancing quality of simulated practice learning NMC (2007) Simulation and Practice Learning Project

The NMC was rightly proud of both the impressive sample size (n=6361) and the geographical spread, believing that the results could not be dismissed due to the large sample (Gerrish and Lacey 2010). Whilst this may be true it is worth considering the limitations.

Firstly, the qualitative element relied solely on the participants, particularly the student participants’, subjective assessment of their achievement of clinical outcomes and their levels of confidence. From both an educational and a patient safety perspective it may have been more reliable to have a more independent evaluation of outcome achievements and competence as well as confidence (Gerrish and Lacey 2010).

A further limitation concerned how representative the results were to the whole of the UK nurse education population. The three smaller, but no less important countries that make up the United Kingdom only had one representative site in the study, while England had 10, suggesting that the results were more specifically representative of simulation in nursing HEI’s in England. Scotland, Wales and N.I may have had specific issues due to demographic and geographic influences so more sites in each country may have made the results more widely representative (Becker and Bryman 2004).

Nonetheless, the results were seen as a general representation of simulation in nurse education in the UK ‘as a whole’. As a result of this study the NMC recommended that ‘provision for learning through simulation in a practice suite be incorporated into the pre-registration nursing curriculum’ (NMC 2007). They proposed that up to 300 of the 2,300-practice placement hours could be used in this way and this has been reiterated more recently within the revised Standards for pre-registration nursing education (NMC 2010b). However, to do this the NMC recommended that simulated areas be audited using the principles they developed and tested.

Clinical areas are audited to assess their suitability for students. Therefore, if some of the practice hours are to be replaced by simulated practice learning it seems fair that those simulated environments be judged similarly (Crowley 2008).

The NMC acknowledged the inequity of resources – some HEIs’ have highly sophisticated simulated clinical environments, whilst others may have a more modest arrangement. However, the principles do not demand that all simulated learning environments (SLE’s) are furnished with sophisticated high fidelity equipment rather that those facilities available help students to achieve clinical outcomes and are appropriate to the activity being undertaken. My HEI for example, consists of four campus sites across a wide geographical area, each one having different levels of simulated clinical areas and staff expertise but all can be audited using the same set of principles to ensure they are fit for purpose.

In addition to and supportive of the NMC recommendations, the Scottish Clinical Skills Strategy (SCSS) (NES 2007) was launched in September 2007 in response to two papers – Building a Health Service Fit for the Future (NHSS 2005) and Better Health, Better Care (NHSS 2007) - to support workforce development in Scotland. The aims of the SCSS are:

 For Scotland to become a leading player in quality assured clinical skills education in both the UK and internationally;

 For consistent standards for clinical skills education to be practised safely to meet clinical diagnostic and governance requirements.

The SCSS states that ‘skills training and the use of simulation should be integrated into core educational programmes and curricula’ (NES 2007: 7). In addition, they noted at that time, that clinical skills’ training in Scotland was haphazard, inconsistent and uncoordinated and recommended ‘multi professional access’ and ‘consistency of standards’.

As previously mentioned Scotland has specific demographic and geographic factors, which influence healthcare in terms of access to services for users and also access to training for staff. Around one million (19%) people in Scotland live in remote and rural areas, where a greater proportion (20%) of the population is aged over 65 years of age (Scottish Government 2011). Rural populations are growing at a faster rate than the rest of Scotland and residents experience greater difficulty accessing hospitals (Scottish Government 2011).

A key objective for the SCSS is to address the inequity of access to high quality multi-professional education across both geographical and professional boundaries. One innovation, a mobile clinical skills unit, was developed by the Clinical Skills Managed Educational Networks (CSMEN) in response to the issue of inequality in remote and rural areas, in terms of access to clinical skills training (NHSS 2007). The mobile unit provides space and an array of simulation equipment to allow a broad range of clinical skills education to be delivered (CSMEN 2009).

With two years funding provided by NHS Education Scotland (NES), the unit was piloted from January 2009 – December 2010 in remote and rural environments in Scotland in order to test feasibility. It was anticipated that steps such as these would serve to address some of the inequities and inconsistencies, which were highlighted in terms of clinical skills training.

Evaluation by CSMEN of the usage of the facility revealed that 663 healthcare professionals accessed the facility in eight remote and rural venues, from Orkney in the North to Stranraer in the South West and Kelso in the South East. Usage was 71% from a wide range of multidisciplines with the biggest user group being nursing and midwifery (47%; n=388). The questionnaire response rate was 98% (n=650), which substantiated the generalisability of the findings of the evaluation. Evaluation research is useful for gauging the worth of the thing being evaluated (Robson 2004: in Becker and Bryman 2004). Seventy percent (70%: n=464) rated the experience as ‘excellent’, whilst 28% (n=186) rated it as ‘good’.

All areas requested a return visit. The mobile unit is now a permanent service and can be requested by any health board wishing to provide clinical skills training to staff (CSMEN 2009).

To attempt to address the oft-limited menu of experience available to pre- registration nursing students in practicum, many HEIs’ have developed teaching methodologies geared to providing students with the necessary clinical skills (Bradley 2003; Seropian et al., 2004; McCallum 2007; NES 2007). These range from simple absorbable flesh coloured pads for injection techniques, part task trainers, life size low to high fidelity mannequins and real people. However, many of the skills taught in schools of nursing have been taught in unrealistic non-clinical environments, which were not always fit for purpose and this has been recognised by the NMC (2007) as discussed earlier. In a move to combat this, there has been a steady growth in the development of simulated clinical environments (SCE). The concept and emergence of SCE will now be discussed in the next section.