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.
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.