Learning to deal with crisis within the home: Developing community simulation scenarios for post registration nurses .


When did you first introduce the innovation?

Between 12 and 24 months ago

Please describe the innovation you have developed

For two years post registration the specialist practitioner district nursing programme at QMU has incorporated medical emergency simulation sessions within the curriculum. Each session allows the students to participate in emergency scenarios and apply procedural, problem solving and communication skills. A partnership approach was adopted between academics from a range of specialities and practitioners with appropriate experience to enhance the quality credibility and authenticity of the learning experience (HEA 2015). Scenarios were developed to simulate the autonomy of being a lone worker and the clinical judgement associated with this for example, first aid, use of handover frameworks (e.g. SBAR) end of life care provision at home, pain management, anticipatory care, complex wound assessment / management and support of long term conditions. We ensured effective orientation to the simulated community space. This included a home environment with living room, kitchen and bedroom areas. Props such as DN bag containing protective personal equipment, sphygmomanometer, aseptic dressings and blood glucometer were made available. We used simulated patients who were ‘acted’ by members of academic staff or clinicians who had received a briefing beforehand . The students participating in each scenario were given a handover with a brief past medical history, presenting complaint and the purpose of the episode of care or plan of care. Depending on the scenario, students entered the simulation suite in groups of one or two and adopted the role of district nurses or students. An evaluation form asked students to say how they felt at the beginning of the day and after each simulation, identifying key learning points and areas for further development.

What prompted you to develop this innovation?

The focus of modern health care is proactive and anticipatory in nature and care is now more commonly provided in the community rather than the hospital setting (The Scottish Government 2012 ). The changes in demographics and health of the general health of the population mean that nurses will encounter people with a range of co-morbidities and who are at increased risk of clinical deterioration in the home care setting (The Scottish Government 2012). Prompt management of their condition can reduce the risk of complications (National Institute of Clinical Excellence 2007). Patients and carers must feel confident that if they should become acutely unwell they will receive prompt and effective care. Nurses have the most frequent patient contact and responsibility for on-going assessment and monitoring of patients, in a wide range of settings (Thompson et al, 2008, Massey et al 2009). Therefore nurses have a crucial role in anticipating health problems, recognising and responding to clinical deterioration in the community context. However, research shows that ‘failure to rescue’ patients whose condition is deteriorating remains an area of significant unintended harm in healthcare and can result in unwanted hospital admissions, complications and death (Lapkin et al, 2010).

In your view, what is it about this innovation that makes it different/important?

This innovation emphasises the role of simulation as a robust and important element of preparing district nurse team leaders for the realities of contemporary practice. Realistic clinical simulation exercises accompanied by feedback have been identified as a powerful and effective teaching and learning tool to develop knowledge and confidence in nursing pre and post registration students manage emergency situations (Buykx et al 2011, Gordon and Buckley 2009, Cooper et al 2011). There is a small but growing body of literature which advocates community focused simulation interventions accompanied by debriefing as powerful teaching and learning strategies; particularly in the development of assessment skills and their application in a variety of different contexts (Teager and Gotwals 2010, Unsworth et al 2011, Kim Goodwin et al 2013).

However while there is a plethora of published work describing and evaluating simulation in hospital emergencies healthcare literature on community simulation is more limited. The few articles describe North American and Australian initiatives where simulation is increasingly replacing community placement hours in some programmes. Literature from a UK or Scottish context is rare. The development of critical thinking and communication appear to be enhanced if the scenarios are planned and the environment is realistic (Green and Bull, 2014, Hussan et al 2014). Such methods have potential to help students apply and refine transferable skills of clinical reasoning and care management in the community which are highlighted as priorities in recent UK policy drivers (DHSSPS 2006; SG 2013a &b, NHS England 2014).

To what extent does your innovation make use of existing approaches, resources or technologies?

This innovation has been implemented within the pre-registration nursing programme at QMU since 2013 and has been presented as an example of innovative and effective practice at the 2013 ENTER conference. Having adapted and developed the emergency situations for the post graduate learner our eyes have been opened to the range of further possibilities this could offer.

Our experience has been that the scenarios meant students were able to experience the complexity of decision making in the community first hand and value and appreciate the range of skills and knowledge required to respond. This innovation has led us to consider development of richer, more complex and in-depth clinical scenarios to help prepare student district nurses for safe and effective care in any setting.

To what degree has this innovation led to changes in education or clinical practice?

Simulation is now used as a teaching and learning strategy within the revised curriculum of the Specialist Practitioner District Nursing programme. In addition, working in partnership with colleagues ensures the realities of community nursing practice were reflected in the scenarios and further enhances synergy between education and practice. Simulated community scenarios can help students to:

  • apply of assessment skills in the community
  • recognise of the signs of illness that require urgent intervention to avoid hospital admission
  • recognise when care at home is no longer safe
  • recognise when it is appropriate to refer a patient to hospital
  • recognise how the escalation of care and acute management of people with long term conditions may require adjustment in relation to their wishes.

Practitioners have responded positively although some commented that he title of the session ‘community emergencies’ did not reflect the subtle and complex nature of caring for a person at risk of deterioration in the community. They suggested ‘dealing with crisis within the home’ would more appropriately reflect the typical complexities of community care.
This innovation has stimulated debate at a local and national level and is worthy of further research and development.

What evidence do you have of the impact of the innovation?

Students reported in the evaluation forms that through reflection and constructive challenge of their simulated practice they were able to identify new learning, gaps in their knowledge and ways to enhance their judgement and decision-making. It also enabled them to construct and give feedback to peers, all of which are transferable post-graduate attributes. Students appreciated the realism of the community scenarios because they demonstrated the complexity of assessing health and social care needs required by community nurses. Additionally the particular expertise of the facilitators – critical care, community and rehabilitation nursing was highlighted as strength of the sessions. Some students reported that they found it challenging to retrieve and use knowledge that they had learned in previous clinical practice. We postulate that students were recognising the skills required to assess and manage patients whose condition was deteriorating and applying it into the community context which could trigger a change in their future practice.

The results of our evaluation suggested that realistic community simulations are powerful triggers for learning and help student district nurses develop confidence to assess and manage people whose conditions are deteriorating at home. This addresses the need for flexibility of the current and future nursing workforce that is adaptable in the changing contexts of practice (Queens Nursing Institute 2013, SG 2013, NHS England 2014).

To what degree has the innovation been disseminated in your organisation or elsewhere?

The development of pre-registration community emergency sessions – the precursor to this initiative- has been discussed within the Division of Nursing at QMU at a research and innovation symposium, nationally at the ENTER 2013 conference and in an article which is pending publication. Further dissemination for the community simulation for post registration students is in the planning stages. In particular we are currently working on a debriefing tool for simulation with community practitioners.

Please provide details of any plans you have to disseminate the innovation in the future.

Further oral presentations, posters and publications.