In the ward, a familiar scene plays out amid an eery stillness. Under the sheet of a hospital bed, the chest of a young woman rises and falls; the quiet only disturbed by the constant beeping of her vital readout.
Of course, none of this is real. The young woman is simply a manikin, and Liz Pryke, simulated skills centre manager here at Kingston University, has just finished re-attaching our patient’s face.
At simulation learning centres like this one, at universities across the country, the next generation of nurses are learning the skills and techniques they will use for the rest of their careers.
Yet while the technology for these kinds of highly advanced manikins is right at the cutting edge, simulation as a method of training is nothing new.
Whether working with actors or practising cannulation on a silicon arm, for as long as nurses have needed to practise skills, some part of that practise has been done by simulation.
However, following the outbreak of Covid-19, more and more training has been done in simulation as practice placements became harder to secure.
In the past, the amount of simulation allowed in undergraduate nurse education was capped at 300 hours by the Nursing and Midwifery Council (NMC).
However on January 25, following consultation the NMC increased the number of simulation hours allowed: meaning that up to 600 of the 2,300 practice learning hours may be simulated.
While this increase poses some challenges, it has been welcomed by higher education providers who see this as an important step towards modernising nurse education.
‘Nursing education in the UK has been delivered in a fairly traditional way for many years,’ says Paul Newcombe, deputy dean of health education at the University of Roehampton. ‘Simulation has been around for a long time, but I think there has been a reluctance to embrace it in the same way as other countries.
‘The positives of this change are that it makes simulation more flexible and it provides provides more opportunities to create high quality simulated practice learning in order to deliver the curriculum.’
But even as simulation becomes more common, a number of misconceptions still persist about what it is, and what it can do.
One thing that is sometimes forgotten in simulation is that it is not just for pre-registration nurses but can also be vital in developing advanced practice and for workforce development.
Sally Richardson, associate professor of simulated learning and clinical skills at Kingston University, says that simulation can teach the kinds of clinical decision making that advanced practitioners need.
‘In those courses you have to have higher levels of leadership and higher levels of care delivery, but this allows you to do all that in a safe environment,’ she said.
At Kingston University, simulation for advanced practice might include having to call for a doctor to sign off on a change of medication or dealing with missing paperwork while trying to diagnose a patient.
‘We can do some quite challenging scenarios, because that’s what happens in reality so that’s what we’ve got to do in simulation so that nurses can get the skills that will help them when they go back into practice,’ added Ms Richardson.
This, says Ms Richardson, allows nurses to build their decision-making skills and learn how to cope with the reality of advanced practice.
Another of the most enduring myths about simulation, says Sharon Weldon, professor of healthcare simulation and workforce development at the University of Greenwich, is thinking that simulation is only for secondary and urgent care settings.
While clinical ward settings, like the one at Kingston described earlier, may be what many imagine simulation to be, the picture within education is changing rapidly.
According to Professor Weldon, simulation has had a clinical focus in the past due to the fact that simulation in healthcare is dominated by the needs of medical students, and because industry rather than educators have been leading the way with simulation.
However, Professor Weldon now says that her team at the Greenwich Learning and Simulation Centre (GLASC) is ‘changing the dynamic’ around what can be achieved with simulation techniques.
Greenwich’s cutting-edge simulation centre may boast some outstanding technology but Charles Everard, head of faculty technical learning and support and GLASC technical director, points out that technology doesn’t always have to take the lead.
Mr Everard points out that ‘technology doesn’t have to be deployed all of the time and should only be rolled out for enhancement [of learning] and not replacement’.
A perfect example of Mr Everard’s philosophy is hidden away at the edge of the campus where you can find another vital, though less high tech, training tool: a flat.
The apartment which used to belong to a member of staff, has now been converted into a simulated home, complete with empty bottles of wine and pizza boxes in the kitchen; elderly patients in the bedroom, and even a fake dog in the living room.
Students training to become district nurses, health visitors, or to make home visits in any capacity use this flat to practise how to treat patients in their own home.
In the bedroom, Lee Jagodzinski, academic lead for simulation, who designed the centre alongside clinical skills and technical learning resource manager, Charles Everard, demonstrated the flat’s learning potential by opening a box containing the smell of rotting flesh.
The resulting stench, rather than simply being unsettling, serves to teach potential community nurses a valuable lesson about home visits.
‘He could be a diabetic with an ulcerated heel,’ says Mr Jagodzinski referring to a strikingly lifelike manikin of an elderly man. ‘Sometimes the students will just think it’s a nauseating smell, but some staff will walk in, and from the door they’ll know what’s going on.
‘That’s how healthcare works: it is your level of knowledge, because you’ve seen those patterns of presentation before and you can get to work quicker.’
However, it does not necessarily take acres of land and available real-estate to prepare nurses for the community. In one of the rooms at Kingston University, nurses can prepare to treat patients in their own homes, by the side of the road, or even in the back of a moving ambulance.
In the immersion suite, video taken from a 360-degree camera is projected onto each of the walls: creating a realistic impression being in almost any possible place or situation.
As Ms Richardson explains, the aim of this room is ‘for students to realise that when you go into somebody’s house you have the privilege of seeing what is going on in their lives’.
‘This is to teach students to think about the clues that this environment is giving about the patient.’
Teaching care not just treatment
However, simulation is not without its downsides; the biggest being cost.
Simulated learning is immensely resources intensive; requiring specialised staff, spaces, and equipment to teach a handful of students at a time.
The manikins in the Greenwich simulated learning centre range in price from £5,000 for a hyper-realistic baby at a lower end, to £75,000 for the most advanced manikins.
On top of this, a single simulation, in which two students work on a manikin, requires three or four specialist technicians.
While the cost per student can be cut down by streaming the simulation to other students to discuss, all this expense does raise the question of whether it would not be better just to offer practice placements only?
But according to Georgiana Assadi, a lecturer in mental health nursing at King’s College London who has researched the impact of simulation, the two cannot really be compared.
‘Simulated space is not a replacement for clinical practice, but neither is clinical practice a replacement for simulated space. They offer very different things to students.’
What the research shows, says Ms Assadi, is that simulation offers opportunities for both pre- and post-registration nurses to enhance their training.
‘It’s a safe environment to try out things that they’ve never tried before without fear that it might affect a patient’s care, and it helps build confidence for students who perhaps have never seen the healthcare environment.’
Ms Assadi says that this safe environment can be particularly useful for mental health nurses who need to practise their communication skills before speaking to vulnerable patients.
‘Asking people questions like ‘how safe do you feel with yourself’ or ‘what would stop you killing yourself?’. We’re not just born with the innate ability to communicate effectively, it comes through trial and error and practice. With students, they [are] offered that safe environment to try things out, to practise them, to make mistakes, and reflect.’
This kind of ability, often referred to as ‘soft skills’, is now something that universities are looking to teach to students in simulation, as well as in practice placements.
Even more lifelike and diverse manikins can go a long way into helping students learn to care for patients, rather than just treating them, according to Francine Gonzales-Walters, clinical simulation fellow and senior lecturer in adult nursing at Greenwich.
At Greenwich, students work with a number of hyper-realistic manikins produced by a British company called Lifecast, including several babies of different ages and ethnicities.
These ‘body simulations’ are produced by the same film studio that produced Star Wars, The Shining, and 2001: A Space Odyssey, and are based on casts and scans of real people to a completely unnerving degree of realism.
Unlike the others at Greenwich, these have no mechanical features. They serve an important function within the simulation unit in that they get students to start thinking about how to care for a ‘real’ patient.
‘You can see the difference when the students start to handle the patient,’ says Ms Gonzales-Walters, ‘they begin to speak to the manikin, touching it gently, they immerse themselves in it so much more.
‘With the babies, students will be bouncing them and holding them close to their chests. But it’s not just because of how real they are but because of the cultural inclusivity of the manikins as well.
Ms Gonzales-Walters says that these soft-skills, or ‘essential skills’ as she prefers to call them, are something that simulation is perfectly equipped to teach as it allows students to slow down and think, while also being immersed in the care of a simulated patient.
While using actors within simulation can allow nurses to safely practise their communication skills, advances in technology are now allowing simulated learning to go beyond what could ever be possible in practice placements.
Lucina, a manikin costing £75,000, can not only simulate a complete birth but includes augmented reality technology allowing students to ‘see’ inside Lucina’s womb and understand what is happening to the baby.
If a birth is complicated by shoulder dystocia, Mr Jagodzinski explained, the manikin will walk you through how to correct that; showing where to place the mother’s legs and how the changes interact with the baby in real time.
‘Before this, the only way of teaching that was just to read it from a book. So, you would understand the theory, but you don’t ever get the chance to practise that physical skill,’ Mr Jagodzinski said.
‘A lot of places see simulation as pure replication,’ says Professor Weldon, ‘but we see that as really short-sighted’, she added. ‘Yes, there are certain things you want to just replicate but if the care we’re replicating isn’t working then we’re sending students out with skills that aren’t necessarily going to work.
‘We want to give our students the opportunity to think about changing the environment that they work in to see how things can be done differently.
‘People say that simulation will never replicate real practice, but my argument is that you’re not trying to replicate real practice and you can also go beyond replication.
‘The limit of simulation,’ Professor Weldon says proudly, ‘is our imagination’.