Journal of Nursing Education

Major Article 

Effectiveness of Live Simulation of Patients With Intellectual Disabilities

Joy Debra Grech, RSCN, RGN, MA; Rosemary Brandt, BA(Hons) Health Studies; Marie O'Boyle-Duggan, RNLD, RNMH, MA


This study investigated the use of live simulation using simulated patients portraying people with intellectual disabilities. The study sample consisted of 173 health students. Using the simulation framework of Jeffries, students worked in groups of three; each student participated in at least one interaction with a simulated patient while the facilitator and other students in the group provided peer reflections. Students were given a specific task to complete with the patient simulator (e.g., obtaining a blood pressure reading). Student self-confidence and satisfaction with the simulation was measured using a questionnaire followed by students’ personal reflections and focus group feedback. Results indicate that students highly valued the simulation and thought it positively influenced direct care to patients with learning disabilities.


This study investigated the use of live simulation using simulated patients portraying people with intellectual disabilities. The study sample consisted of 173 health students. Using the simulation framework of Jeffries, students worked in groups of three; each student participated in at least one interaction with a simulated patient while the facilitator and other students in the group provided peer reflections. Students were given a specific task to complete with the patient simulator (e.g., obtaining a blood pressure reading). Student self-confidence and satisfaction with the simulation was measured using a questionnaire followed by students’ personal reflections and focus group feedback. Results indicate that students highly valued the simulation and thought it positively influenced direct care to patients with learning disabilities.

Ms. O’Boyle-Duggan is Senior Lecturer, LD Field Lead – Dip HE and BSc (Hons) Nursing, Department of Learning Disability and Mental Health Nursing, Ms. Grech is Senior Lecturer, Department of Child Health, and Ms. Brandt is Programme Director, Operating Department Practice, Birmingham City University, Birmingham, England.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Marie O’Boyle-Duggan, RNLD, RNMH, MA, Senior Lecturer, LD Field Lead – Dip HE and BSc (Hons) Nursing, Department of Learning Disability and Mental Health Nursing, Birmingham City University, City South Campus, 223 Bevan House, Westbourne Road, Edgbaston, Birmingham, England, B15 3TN; e-mail: Marie.O'

Received: October 07, 2011
Accepted: February 29, 2012
Posted Online: May 04, 2012

Recent reports suggested that due to insufficient training of health care staff, people with intellectual or learning disabilities continue to receive inappropriate health care and that attitudes of staff remain negative (Department of Health, 2007, 2008; Dinsmore, 2011), although some studies showed that training can improve attitude and skills (Webb & Stanton, 2009).

People with intellectual or learning disabilities have seen many changes in the services provided for them. In fact, how they are described in terms of their disability or impairment has changed—from the derogatory term mentally subnormal, used up until the 1990s, to mentally handicapped, to the term currently used in the United Kingdom, learning disabilities.

Our study explores the use of simulation, defined by Jeffries (2005) as an activity that replicates clinical practice, an experience that is as near to real life as possible and involves the use of expert role-players (simulated patients) to portray service users with learning disabilities (Wiskin, Allan, & Skelton, 2003), as opposed to virtual simulation.

Literature Review

Simulation is not a new concept in nursing education and continues to gain popularity (Jeffries & Bambrini, 2009). A growing body of literature considers the use of simulation in nursing, although this is mainly concerned with high-fidelity simulation (Broom & Lynch, 2009). The current literature suggests that for the majority of students, providing a skills simulation laboratory increases confidence and competence in new skills (Valler-Jones, Meechan, & Jones, 2011; Wagner, Bear, & Sanders, 2009).

Use of simulated or standardized patients is common in medical education (Wiskin et al., 2003). Simulated patients, as Wiskin et al. (2003) defined, are not real patients but specifically trained role-players, improvising and providing feedback to students in real-time, simulated clinical encounters. Literature discussing the use of role-players or the standardized patient approach (Jeffries & Bambrini, 2009) for preregistration nursing students is particularly sparse. Various methods have been used, including a CD-ROM–based virtual scenario, and students themselves have taken part in role-play as the patient or carer (Sanders et al., 2008; Storr, 2010).

A systematic review conducted by Cant and Cooper (2009) concluded that medium-fidelity and high-fidelity simulation is an effective teaching and learning method with some advantages over other teaching methods. However, they further suggested the need for a universal outcome measurement.

It could be argued that there is confusion about the different types of simulation available. Table 1 provides examples of the types of simulation.

Types of Simulation Used in Nursing Education

Table 1: Types of Simulation Used in Nursing Education

Clinical simulation using standardized or simulated patients is a productive and proactive way to allow students in a safe environment to explore and practice these skills and to reflect on their attitudes and responses to challenging patients (Comer, 2005; Libin et al., 2010; Scalese, Obeso, & Issenberg, 2007). Furthermore, simulations including role-play have been shown to increase student self-efficacy (Goldenberg, Andrusyzyn, & Iwasiw, 2005). Alinier, Hunt, Gordon, and Harwood (2006) highlighted that students should play a major role in the situation and decide on appropriate treatment and actions to enable them to make judgements and learn from their mistakes; this aims to change students’ attitudes as well as facilitate changes in their responses and competences (Ager & O’May, 2001). Goddard and Jordan (1998) indicated that the use of teaching strategies using simulation had a positive effect on students’ attitudes toward disabled people.

When caring for children with disabilities, nurses must be able to adapt their communication skills to the individual child and consider the child’s development stage and experience of illness (Koopman, Baars, Chaplin, & Zwinderman, 2004). They are also increasingly called on to care for and communicate with children and young people with learning disabilities in a variety of settings, ranging from primary and community care to acute hospital admissions.

Simulation is seen as a useful tool by members of the profession of operating department practitioners for promoting and enhancing knowledge and understanding by providing a synthetic learning environment (Harper & Markham, 2011; Martin, Wyner, Kulkarni, Russel, & Maze, 2006). Learning in the environment of the actual operating department leaves little room for practice and reflection; therefore, simulation seems to be a useful educational approach (Morthy, Munz, Adams, Pandey, & Darzi, 2005). Students can be given the opportunity to practice safely and be provided with room for error (Forrest & McKimm, 2010). As well as being an educational approach, simulation can be used during practical assessments, testing skills, and performance assessments (Mathews, 2008; Powell, Andrzejowski, Taylor, & Turnball, 2009).

The recent focus on human factors affecting critical decision making and clinical actions (Patient Safety First, 2011) has resulted in the introduction of simulation based on interpersonal interaction between health professionals (Paige, 2010). Human factors, or nontechnical skills, are described as “the cognitive, social and personal resource skills that complement technical skill and contribute to safe and efficient task performance” (Flin, O’Conner, & Crihton, 2008, p. 1).

Regarding the health needs of people with learning disabilities, it is important to understand that critical issues still exist. Death by Indifference (Mencap, 2007) and, later, Valuing People Now (Department of Health, 2009) highlight how individuals with learning disabilities receive discrimination and neglect in mainstream health care and, furthermore, recommendations set out in Healthcare for All (Department of Health, 2008) stipulate that health education should ensure that the health needs of people with learning disabilities are included in health education course programs.

The National Patient Safety Agency (2004) reported concern that health staff are seeking consent from the carers, rather than from the person with a learning disability, to save time. A recent study by Willner, Bridle, Price, Dymond, and Lewis (2011) of health care professionals and social workers also identified gaps in knowledge and training needs in relation to consent issues, with similar findings reported by Evans and Brown (2007) in their study of health care emergency workers in England. These findings are particularly important to this study, as its basis are these critical issues that exist for patients with learning disabilities regarding consent and the challenges that this brings to mainstream health care clinicians in understanding how to approach and respond to people with learning disabilities.

Within services for people with learning disabilities, some staff training has been shown to effectively increase staff knowledge and to affect attitude and clinical practice (McKenzie, Matheson, & Patrick, 2000). However, in contrast, Cullen (2000) suggested that training alone is not powerful enough to achieve enduring change. It is important that students do not avoid patients perceived as challenging but rather use approaches that have a sound value-based philosophy. According to Whittington and Burns (2005), being able to react to and discuss emotional responses to challenging behavior means that staff do not then resort to avoidance of patients or service users with learning disabilities, which can often be the case in mainstream health care settings. A recent study conducted regarding the reported hospital experiences of people with learning disabilities and their carers (Dinsmore, 2011) concludes that people with learning disabilities continue to struggle with poor experiences in hospital settings due to health staff not understanding their needs; more importantly, the attitude of health staff toward those individuals with learning disabilities is still negative. Emerson, Baines, Allerton, and Welch (2011, p. 19) suggested that organizational barriers still exist for people with learning disabilities in terms of accessing mainstream health care, highlighting a continued failure to make reasonable adjustments in light of the literacy and communication difficulties experienced by many people with learning disabilities. In one study (Lewis & Stenfert-Kroese, 2010), nursing staff in U.K. general hospitals were found to have less positive feelings toward people with learning disabilities than toward people with physical disabilities, which is a major concern for nurse educators in the United Kingdom. However, from a service user perspective, Webb and Stanton (2009) highlighted that improvements have been made with general practitioners’ attitudes toward people with learning disabilities following similar training.

The Nursing and Midwifery Council (2007) developed five principles for learning in simulated practice as a framework to support effective learning, including creating partnerships for learning, managing practice-focused learning, ensuring fitness for practice, positive student experience, and enhancing quality. According to Parker and Myrick (2010), nurse educators have a huge responsibility to empower trainee nurses to become autonomous thinkers to ensure they become competent and able to manage the many challenges of modern-day practice. Live simulation provides educators with the tools to empower students to challenge their preconceived beliefs, assumptions, and values and to socialize them appropriately to thrive in modern-day clinical practice (Jeffries, 2007; Parker & Myrick, 2010). When learners reflect, they analyze or evaluate one or more personal experiences and then generalize from that thinking, becoming more skillful, better informed, or more effective than they have been in the past (Cowan, 1998).


A mixed methodology was used; a qualitative approach allowed for exploration of thoughts, feelings, and experiences (Denscombe, 2005), and a quantitative approach aimed to verify a claim such as student satisfaction and confidence in simulation in an attempt to be as objective as possible (Coles & McGrath, 2010). The current study aimed to examine students’ reflections regarding a particular pedagogy and its effect on them in the real world, which naturally explores thoughts, feelings, and experiences. A case study strategy shaped and structured this research, and the methods and tools used to collect the data included a questionnaire, student reflections, and a focus group activity.

The questionnaire, the 13-item Student Satisfaction and Self-Confidence in Learning Scale, was developed by the National League for Nursing (2005) and is completed at the end of the simulation activity, along with demographic data such as age, gender, and previous health care experience. Student reflections on the day of simulation explored three areas: what went well in the simulation, the learning opportunities that were available and how these change future actions, and any gaps in knowledge as a result of simulation. The focus groups conducted postclinical placement, aimed to gather students’ self-reported experiences and reflections in terms of clinical effects with patients with learning disabilities, which were audiorecorded and later transcribed.


A purposive method of sampling was used and comprised 173 health students from three different groups: 53 operating department practitioners and 65 child nursing and 55 adult nursing students undertaking their courses at Birmingham City University in 2010 and 2011. Forty percent of participants were younger than 21 years, 26% were between the ages of 22 and 30 years, 15% were in the 31 to 40 age range, and 6% were 41 to 50 years old; 13% of participants did not disclose their age. Thirty-three participants had no previous experience in health care, 38% had 1 year or less experience, 21% had between 1 and 5 years of experience, and 6% had more than 5 years of experience; 2% of participants did not disclose their previous experience.

Written consent and Faculty of Health ethical approval were obtained. All participants completed a questionnaire presented as part of the simulation session and were given a research information leaflet.


This study used the Nurse Education Simulation Framework (Jeffries, 2005, 2007), which consists of five factors: (a) a need for clear objectives and information, (b) support during the simulation, (c) an appropriate problem to solve, (d) time for feedback and reflection, and (e) fidelity or realism of the experience. This approach is different from role-play as students are required only to be themselves and the simulated patient gives feedback in real time and adapts to the situation as it evolves in real time. The simulation itself consisted of students working in groups of three in the appropriate skills room applicable to the student’s professional group. Each group had the opportunity to work with three different simulated patients (i.e., a person role-playing a patient with learning disabilities who, at times, may show signs of emotional distress or challenging behavior). The simulated patients are local learning disability nursing and care staff with experiences of real-life issues for people with learning disabilities, who are also excellent at portraying patients’ needs in a simulated setting. (A 3-day role-player course facilitated by a trained actor was provided to add to the simulated patient’s skills base.) All students took part in at least one patient interaction within the simulations while the other two students in the group, as well as the facilitator, provided feedback. Students were given a specific task to complete with the patient—for example, obtaining a blood pressure reading and applying an oxygen mask.

Pendleton’s rules (Garala et al., 2007) for feedback followed by the facilitators are:

  • The student participating in the role-play has the opportunity to talk first and is encouraged to discuss positive points.
  • The participating student has the opportunity to suggest alternative strategies to improve the performance.
  • The observing students are invited to provide feedback, but positive points are required first.
  • The facilitator and group can provide constructive feedback on the areas identified, with care taken to ensure comments are not given in a negative manner.

Examples of scenario information given to students are:

  • Steve (Recovery patient—operating department practitioner students).
  • Steve is 40 years old. Steve has moderate learning disabilities; he has an autistic spectrum condition and epilepsy and has been described as challenging by his carers.
  • He is in recovery following dental treatment with an anesthetic; you are required to apply an oxygen mask.

Findings and Discussion

The research findings and analysis are presented and explored from a themed perspective based on methods of data collection; first considering analysis of the questionnaire, second, student personal reflections, and third, focus group analysis. The key themes relating to the research questions and pedagogy are highlighted and discussed.


Overall, 173 health students participated in the simulation activity, consisting of operating department practitioners, adult nursing students, and child nursing students. All completed the questionnaire, which was presented as part of the session.

When facilitating skills learning, we aim to instill self-confidence and satisfaction in our students. In an attempt to measure this, the National League for Nursing’s Student Satisfaction and Self-Confidence in Learning Scale was used.

The summary of the scores is presented in Tables 2 and 3.

Satisfaction With the Simulation

Table 2: Satisfaction With the Simulation

Self-Confidence Following the Simulation

Table 3: Self-Confidence Following the Simulation

Student Reflections (Nursing Students Only)

As Parker and Myrick (2010) and Jeffries (2007) highlighted, simulation provides educators with the tools to empower students to challenge their preconceived beliefs, assumptions, and values. Providing opportunity to reflect not only during the simulation activity but also immediately afterwards within this study enabled the students to analyze and evaluate their personal experience. The students were then able to generalize from that thinking about how they may be better informed or more effective than they have been in the past (Cowan, 1998). Information collected in this way has also added to the important point raised in the literature about outcome measures regarding the actual influence of simulation in the health care setting.

Following Pendleton’s rules for feedback (Garala et al., 2007), the students participating in the role-play had the opportunity to talk first and were encouraged to discuss positive points and then suggest alternative strategies to improve their performance. The observing students provided valuable feedback, giving positive points. Finally, the facilitator and the group provided constructive feedback on the areas identified, with care taken to ensure that comments were not given in a negative manner.

Below are some of the child and adult nursing students’ reflections made on the day of the simulation activity regarding gaps in their knowledge identified as a result of live simulation. It is evident that the students were able to apply their experience to the clinical setting:

  • Kiss—keep it short and simple. Talk more slowly.
  • Talking to the child rather than parents. Taking [my] time.
  • I didn’t quite understand how difficult it can be to communicate with children who have learning difficulties.
  • Thinking about finding out the child’s interests in order to talk to them first and gain their trust.
  • Distraction techniques. Speaking to [the] patient without [his or her] parents.
  • Not all children with learning disabilities have challenging behavior.
  • It is surprising how instinctive I can be when put into a scenario.
  • That even though each patient is an individual and should be treated the same, it is alright to make allowances and to take your time.
  • It reiterates that hands-on practice is the best way of learning and finding mistakes in techniques.

Students felt involved and in partnership with peers and lecturers, and facilitators and were able to consider, from a personal perspective, how their behavior affects service users; this is shown in their reflections, contrary to the intimation of limitations in clinical practice ability, reported by Valler-Jones et al. (2011).

The students’ personal reflections on learning opportunities on the day of the simulation also highlighted that although reflection and feedback concentrated on positive aspects, students were still able to see the learning opportunities available to them during the activity, as indicated below:

  • I think that I benefited from having the experience of practicing with “actors” as patients, as there was more interaction and unpredictable aspects to challenge me.
  • Good eye opener in that we experienced different outcomes from each experience.
  • It highlighted the issues and barriers we may encounter in our workplace.
  • Observing was good because you saw it from the outside too.
  • You learn how you would react in a situation, which you can’t get in a lecture.
  • Was really good for putting theory/skills etc. into practice.

This debriefing following simulation was essential because it had a direct effect on student performance (Dreifuerst, 2009; Savoldelli et al., 2006). Student reflections related to clinical impact were important and correlated with comments made during focus group activity, highlighting the transference of skills acquired on the day of simulation to patient contact later during placement. Several students commented:

  • [I] was able to interact with real people, which helped [me] gain a better understanding of body language and communication.
  • Service user and environment were extremely realistic and effective.

From a clinical perspective and in relation to the literature regarding health care of people with learning disabilities, the student reflections are positive and reassuring. Several themes related to clinical care could be identified from these reflections, such as communication issues, involving the service user, remaining calm, and using distraction and alternative methods to reassure and keep calm the upset or agitated patient. This shows that students were able to make reasonable adjustments (Department of Health, 2008) in how they responded to their patient in the simulation.

The student reflections taken on the day of the simulated patient activity indicated that proactive approaches to challenges from the simulated patients were used by students, components of which show students engaging in positive behavior support, as highlighted by Smith, Felce, Jones, and Lowe (2002)—for example, distraction techniques. These reflections also show a potential increase in engagement between patient and nurse and a person-centered and humanistic understanding of individual needs (Jones et al., 2001; Mansell, Elliott, Beadle-Brown, Ashaman, & Macdonald, 2002).

Focus Group Analysis (Nursing Students and Operating Department Practitioners)

On the day of simulation, students were understandably anxious at the beginning of the session, not knowing what to expect. Of note, this issue was identified during focus group activity as a positive thing, with students describing being “thrown in the deep end,” claiming this was helpful and allowed for “thinking on their feet,” in contrast to claims in the literature that a failing-to-fail scenario will lead to limitations in student clinical ability (Valler-Jones et al., 2011). By the end of the session, students were excited and positive about the experience, supporting claims that simulation can increase student self-efficacy (Goldenberg et al., 2005); this can be seen persuasively in the data gathered. By allowing students to have control over the situation, the simulation activity required them to focus on human factors affecting critical decision making and clinical actions (Patient Safety First, 2011) and thus increased interpersonal interaction between the student and the role-player (Paige, 2010). These human factors—described by Flin et al. (2008) as nontechnical skills and cognitive, social, and personal resource skills—can be seen described in the focus group transcripts described below.

Operating Department Practitioner Focus Group. These data show that students have some understanding of how the simulation affected practice. With discussion regarding assessing a situation and trying to understand the patient by using the patient’s personal belongings as a way of getting to better know the patient, students identified use of distraction as a means to ease anxiety. This specifically shows that students were making reasonable adjustments for their patients with learning disabilities (Department of Health, 2008). For instance, students commented that:

  • I find it useful in a sense that I pick up on the things that they’ve brought in with them and the things that I say to help the conversations and stuff to progress.
  • Distraction techniques, that’s one thing that you know and that’s one thing that you did learn from the simulation.

With the use of simulated patients, which requires clear, direct communication (Beyea & Kobokov, 2004), students’ communication with the service user is just as important and is a mandatory component of the curriculum for the Diploma in Higher Education Operating Department Practice (College of Operating Department Practitioners, 2006). The following excerpts show how the students described this, also revealing social and personal resource skills (Flin et al., 2008), how they were able to reflect back on their clinical practice, and how this influenced patient care:

  • Picking up on some of the patient’s personal [belongings] to find the topic for releasing anxiety.
  • I think I should have a calm approach with someone challenging.

In disturbing contrast, some student discussion did show a lack of expertise and discriminatory attitudes toward patients with learning or intellectual disabilities, which Emerson et al. (2011) highlighted, exists among health care staff. One student talked about individuals with learning disabilities as “people that aren’t normal,” whereas another said he or she would rely on another person to “hand hold.”

Students showed some understanding about how changes to information given to the patient can raise anxiety; however, they do not offer any alternative but rather go on to highlight time constraints or appear to blame other professionals for the systems in place.

It’s really difficult to convey that change, isn’t it?… You feel responsible then as well…. Yeah, I mean the patient, they don’t understand why that’s changed that causes a problem. That causes mistrust.

The ability to communicate within and across health care teams is a professional expectation for the qualified operating department practitioner (Health Professions Council, 2008), yet the excerpts below show that students appear not to feel confident to confront other professionals, such as an anesthetist who wants to rush patients who need more time due to their learning disabilities and communication difficulties (Emerson et al., 2011). One student commented:

Where I am on placement, I’m very aware of the time constraints because there might be five operations in morning sessions between 8:30 and 1:30, so there’s no time for messing around. Even though everyone’s very professional, they’re working at a pretty high speed. They don’t use distraction techniques. They just want to get on with it. And so if someone was really distressed, I don’t know how they would react. Because they just seem to be aware that the surgeon’s waiting. So they’re going to get on with it boils down to whom the anaesthetist is. To me it feels when you’re in the anaesthetic room, no matter what happens it’s the anaesthetist that’s in control of his patient.

This further highlights the need for the reported introduction of human factors that affect critical decision making and clinical actions (Patient Safety First, 2011) into the curriculum and, furthermore, the introduction of simulation, based on interpersonal interactions among the operating department practitioner staff (Paige, 2010).

On a positive note, it does appear that operating department practitioner students were empowered to become autonomous thinkers during simulation, including nurturing an ability to examine issues around challenging situations in their practice, as evidenced in the following excerpts of student conversations:

  • I have now become programmed, programmed to deal with disability.
  • Well, it certainly made me less frightened because I was…I would’ve been really nervous if somebody had told me that I’m going to deal with a patient that’s got learning disabilities. I would’ve been like, “Oh my God,” and it wasn’t that bad.

Morthy et al. (2005) suggested that learning in the environment of the actual operating department leaves little room for practice and reflection and so simulation would appear to be a useful educational approach; the majority of operating department practitioner student transcripts reflect this notion. The operating department practitioner student discussions tended to use more negative language when referring to patients with learning disabilities. This may well be why human factors have been introduced (Patient Safety First, 2011) into operating department practitioner educational programs, and efforts are being made to raise awareness of the importance of communication with patients and across professional groups (Health Professions Council, 2008).

Nursing Student Focus Group. It is encouraging to see how students have reflected their attitude toward patients with a learning disability in a positive way through the focus group discussions. This conflicts with Dinsmore’s (2011) recent claims about hospital staff attitudes toward patients with learning disabilities. One student explains:

I suppose it is the change in attitude, isn’t it really? Instead of saying “Oh I’m busy. I’m going to have to write all the notes up.” That really just takes two minutes, just to go and spend a bit of time with someone. And that can mean a lot to somebody.

These students were able to implement reasonable adjustments in terms of individual patient needs, which is a legal requirement often overlooked in health care (Emerson et al., 2011; Equality Act, 2010). These reasonable adjustments made by students can be seen in their comments; for example, the following student suggested:

using different techniques. You know, maybe move away from them for a minute or two. Give them space and then go back to them or if you’re trying to give them medication or assist feeding, because if they didn’t want to, you didn’t have to sort of force it.

Students show great insight in terms of attitudes of health staff and question the behavior of mentors and colleagues during the focus group discussions, as seen above and with this student’s suggestion:

I think people get the priorities wrong, they think medications and things like that are the big deal, but actually making sure that someone’s got food and water and someone to talk to are actually much more of a bigger deal.

This is heartening, as it supports the pilot study by Webb and Stanton (2009) in which similar training for general practitioners changed attitudes toward patients with learning disabilities.

The work of Goddard and Jordan (1998), which involved a Sensitivity Day in the form of a simulation activity, indicated that the use of teaching strategies using simulation had a positive influence on students’ attitudes toward disabled people and, importantly, at 6 months later showed a long-term positive effect from the learning experience. This appears to be the case following focus group analysis; students have reported how they are implementing skills explored during simulation. For example, a student recalls how:

maintaining eye contact and staying calm, being patient and not standing above people was a big one that we learned. I think getting down to the same level as them. Yeah, just general body language and being calm I guess.

Patient safety and safe practice is essential (Dunn & Hansford, 1997), and students need to be exposed to these issues from a practical level, as well as have a theoretical understanding. However, the literature shows that health care provision often leads to neglect for patients with learning disabilities (Department of Health, 2007; Emerson et al., 2011). As can be seen in the transcripts for the nursing focus groups, students have benefitted, as Dunn and Hansford (1997) suggested, by applying skills in a practical way, further supporting Storr’s (2010) findings that simulation activity “stays with and assists students in clinical practice” (p. 29).

The following extract shows the humanity that exists in this particular student and shows positive moves away from what the recent literature suggests are discriminatory views and neglect still existing in health care (Emerson et al., 2011):

One gentleman, he’d like—I’d throw a ball at him and he’d throw it back, and he’d sit there for hours just playing ball. Another one was a piece of music and you put that on and instantly it’s like, “Yeah, I remember this,” and it’d make him happy, and you can talk to him. And it was really rewarding. Just finding something that they enjoyed and you could use.

Focus on human factors affecting critical decision making and clinical actions (Patient Safety First, 2011) suggested in the literature and improvement of interpersonal interaction between health professionals (Paige, 2010) means that health education must find ways of getting important messages across to students. Analysis of the focus group transcripts shows that students have actually implemented these skills on their placements, as this example shows:

It was rewarding. She wouldn’t talk and then by the end of my placement she was talking to me.

A comment from one student sums up the clinical implications of the simulated patient experience:

Big thing from the workshops that I took, onto the wards, sort of a stimulus…. You know getting their attention away from—something humanized, normal, you know, a TV programme. And so I talk about that and they open up and that’s essentially a way into them. I used it so many times on the next ward and placement.


The findings have been positive, and students have felt confident and satisfied with the simulation activity. Focus group analysis of student reflections and personal examples given show that the skills explored and practiced during simulation had a positive influence on patient care while on clinical placements. The themes highlighted that students felt enabled to relate the simulation activity to practice. Comer’s study (2005) found similar results, with students’ reports of increased understanding of course material when supported by simulation. Students engaged with critical thinking, clinical decision making, and clinical judgment within an experiential learning framework (Kolb, 1984). In reflecting on practice, students showed that using a simulation model for learning was a success; it increased their confidence in clinical practice and improved their skills and levels of competence, as described in the work of McConville and Lane (2006).

The simulated patient activity changed the attitudes, responses, and competences of students, as Ager and O’May (2001) suggested. Significant learning occurs when students are able to gain deep insight through reflection; this is also particularly important if we refer to the literature regarding staff training around challenging behavior and the seemingly lack of positive outcomes or lasting effect (Cullen, 2000). Staff experience positive outcomes if they have been able to manage the emotional effects of their work using emotional support (Hastings, 2002; Hastings & Brown, 2002). Students particularly liked that they could respond to and understand the patient with learning disabilities without the pressure of being assessed as they would be during the placement and that they could discuss performance with the facilitator and role-player in a constructive way. Furthermore, enabling the students to practice skills safely on simulated patients and role-players rather than on real service users is, as suggested by Henriksen and Patterson (2007), an advantage in terms of patient safety, particularly when students are inexperienced and learning new procedures or skills. The literature clearly suggests that outcome measurement of simulation is not evident; our research shows from student reflections that there has been an effect clinically.

Limitations and Recommendations

The role of the facilitator was important during this simulation and arguably as important as the actual creation of the scenarios (Jeffries, 2005). However, the views of facilitators post activity were not evaluated, which is considered a limitation of this study because it would have enriched the data, as the literature reviewed does not address this.

Feedback from simulated patients would have also been valuable to add to the limited literature; however, anecdotally, simulated patients have made positive comments about the experience and are pleasantly surprised by the student reactions within the scenarios.

Indirect outcome measures, such as students’ self-perceptions, may be seen as less reliable than clinical observations or other validated instruments in assessing learning and can thus affect the generalizability of these research findings. A possible limitation also is that students are rating their skills themselves through reflection; however, it could be argued it is important for students to do this. A retrospective evaluation of this study highlights how simulation can affect outcome measures, particularly where clinical impact for a particular patient group is significant (Denscombe, 2005).

It is a legal requirement (Equality Act, 2010) that health services make reasonable adjustments for patients with learning disabilities. Further, Healthcare for All (Department of Health, 2008) suggests that higher education authorities provide education regarding the needs of people with learning disabilities to all health professional groups in undergraduate courses. The current study has shown how this can be done and therefore intends to have an effect on content of preregistration health courses at the designated university. Further research to improve the findings of this study would be to follow up with students once qualified after graduation to measure reasonable adjustments made for people with learning disabilities, relating this back to previous simulation experience and its lasting influence on learning. Evaluation of the views of facilitators and simulated patients would also enrich the literature related to simulation.


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Types of Simulation Used in Nursing Education

Type of SimulationDefinitionExample
High-fidelity manikinComputerized manikins used for medical simulations and critical care–type scenariosSimMan®/SimBaby®
Partial-task trainersModels or manikins for specific task trainingPlastic arm for intravenous cannulation
Virtual realityComputerized environment used to provide nursing skillsShareville/Virtual Ward
Standardized or simulated patientRole-player trained to play a role in any situationRole-players, actors, or volunteers playing a patient or family member
Student role-playingStudent portraying the role of patient or health care staffStudent may role-play student, qualified staff, or client or family member. Scripts may be provided.

Satisfaction With the Simulation

Satisfaction ScoreStrongly Disagree
Strongly Agree
The teaching methods used in this simulation were helpful and effective.10.60042.33218.513678.6
The simulation provided me with a variety of materials and activities.10.610.6105.86738.79454.3
I enjoyed how my instructor taught the simulation.10.60010.65632.411566.5
The teaching materials used in this simulation were motivating and helped me to learn.10.610.631.76034.710862.4
The way the instructor(s) taught the simulation was suitable to the way I learn.10.631.795.25431.210661.3

Self-Confidence Following the Simulation

Self-Confidence ScoreStrongly Disagree
Strongly Agree
I am confident that I am mastering the content of the simulation.10.621.263.5101586336.4
I am confident that the simulation covered critical content.10.610.6749554.96939.9
I am confident that I am developing the skills and knowledge to perform in the clinical setting.10.610.621.29554.97442.8
My instructors used helpful resources.10.610.684.67643.98750.3
It is my responsibility as a student to learn what I need to know from the simulation activity.10.621.295.26034.710158.4
I know how to get help when I do not understand the concepts covered.10.6002212.78750.36336.4
I know how to use the simulation activities to learn critical aspects of these skills.10.610.6116.49957.26135.3
It is the instructor’s responsibility to tell me what I need to learn from the simulation activity during class time.84.6179.84928.36738.73218.5

Ms. O’Boyle-Duggan is Senior Lecturer, LD Field Lead – Dip HE and BSc (Hons) Nursing, Department of Learning Disability and Mental Health Nursing, Ms. Grech is Senior Lecturer, Department of Child Health, and Ms. Brandt is Programme Director, Operating Department Practice, Birmingham City University, Birmingham, England.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Marie O’Boyle-Duggan, RNLD, RNMH, MA, Senior Lecturer, LD Field Lead – Dip HE and BSc (Hons) Nursing, Department of Learning Disability and Mental Health Nursing, Birmingham City University, City South Campus, 223 Bevan House, Westbourne Road, Edgbaston, Birmingham, England, B15 3TN; e-mail: .Marie.O'


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