Simulation Today Autumn 2021

Volume 3 No. 3
Autumn 2021
Simulation Today
A resource for all involved in the teaching and practice of simulation
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HPSN
UK & Ireland
2021
December 1-2, 2021
Reimagining Simulation Education
Following Covid 19
DoubleTree by Hilton
Nottingham Gateway
Simulation Innovation
Always at an HPSN we like to bring something new to share with our customers and
this year is no exception. Don’t miss out on your chance to get your hands on the latest
paediatric simulator CAE Aria or the new range of simulated equipment CAE SimEquip
Anaesthetic Machine, Ventilator or Defibrillator. In addition we have our cloud based
tools for distance learning such as Maestro Evolve and LearningSpace light for you
to trial and last but not least our Augmented Reality simulation applications for the
Microsoft ® HoloLens2.
#HPSNUK21
HPSN is an international conference focused on advancing the practice and innovation of healthcare
simulation for educators, technologists, technicians, nurses, doctors, midwives, allied health, patient safety
leads and other healthcare professionals. Join us in Nottingham to experience the technology behind
simulation in healthcare education and its application in all care settings.
Call for Sessions
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CONTENTS
4 EDITORS COMMENT
6 FEATURE What are the barriers that inhibit nurses from
accessing simulation-based learning education
while working in the Emergency Department?
COVER STORY
Innovation in Clinical Simulation
For decades, 3B Scientific’s experience of working with institutions and
medical educators globally has helped us gain new, innovative insights to
advance the delivery of healthcare education. The 3B Scientific group of
companies, including iSimulate and Cardionics, offers an expanded product
portfolio with reliable solutions for simulation and skills training tailored to the
evolving requirements of the healthcare industry.
iSimulate, a market leader in the simulation of patient monitoring and
defibrillation systems develops innovative solutions across a variety of
healthcare domains. REALITi 360 can be used as a tool to improve team
communication and the interaction of technical and non-technical skills.
Utilizing the REALITi 360 platform, healthcare educators are able to customize
their teaching to train life-saving interventions, improve patient safety and
enhance professional development.
REALITi 360 includes the essential vital sign,
critical care, anaesthesiology and ventilator
parameters needed by educators to create
complex and dynamic scenarios to train multidisciplinary
teams. Emergency and Trauma
Medicine, Intensive Care and Cardiac Response
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To find out more about 3B Scientific skill trainers
and iSimulate products, visit 3bscientific.co.uk.
Our teams are happy to schedule a digital
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CONTENTS
Expand your standard patient monitoring in REALITi 360 with
numeric values only available to the Generic Monitor:
• Tidal Vol, PEEP (Positive End Expiratory Pressure),
Pinsp (Peak Inspiratory Pressure), MV (Minute Volume)
Simulation Today
• Sevoflurane, Isoflurane, Desflurane, MAC (Minimum Alveola
FiO 2
(Fraction of Inspired Oxygen), N 2
O (Nitrous Oxide)
This issue edited by:
David Halliwell
MSc Paramedic
c/o Media Publishing Company
Greenoaks
Lockhill
Upper Sapey, Worcester, WR6 6XR
• CO (Cardiac Output), BIS (Bispectral Index)
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SIMULATION TODAY - AUTUMN 2021
3

EDITORS COMMENT
EDITORS COMMENT
Thanks for taking time to read the Simulation Today Journal, this journal is
circulated to more than 2000 different hospitals, universities and simulation
centres throughout the U.K. but has much wider readership with comments from
teams in the USA, Middle East and Australia who are accessing on line.
The front cover highlights the isimulate REALITi Simulation system (iPad based) which is
continuing to be developed to include a wide range of realistic monitor screens for their medical
simulation solution.
SIMULATION TODAY - AUTUMN 2021
“this journal
is circulated
to more than
2000 different
hospitals,
universities
and simulation
centres
throughout the
U.K. but has
much wider
readership with
comments
from teams
in the USA,
Middle East and
Australia who
are accessing
on line.”
We also feature the forthcoming CAE Conference in Nottingham, which will be taking place in
December.
Our main paper discusses the barriers to nursing staff accessing simulation and raises a great
many points that should be considered by those designing simulation strategies. It’s great to
read new papers which discuss the real world issues being faced by those using simulation as an
education strategy.
We have an advert from the Safeguard medical group who have recently bought many U.K.
companies under one roof - including Prometheus, Water Gel and many other areas of military
and civil trauma medicine.
The advert from Lifecast Body Simulation showcases their toddler drowning manikin which was
used recently for Emergency Services competitors at the Finals of EMS World competitions in
Atlanta USA, and was the final scenario tool for the Association of Air Medical congress in Dallas
Texas.
The drowning manikin was described as “the worlds most realistic teaching tool” by competitors
who were faced in the competition with a blood and foam ( surfactant) filled airway.
Dates for your Simulation Diary
IMSH - 15th - 19th January 2022 Los Angeles - this is the biggest simulation conference in the
world and showcases many of the leading Simulation strategies from around the world.
SESAM - 15-17 June 2022 - Seville Spain
(note this event clashes with the ERC dates)
David Halliwell
MSc Paramedic
4

Visit safeguardmedical.com

FEATURE
WHAT ARE THE BARRIERS THAT INHIBIT
NURSES FROM ACCESSING SIMULATION-
BASED LEARNING EDUCATION WHILE WORKING
IN THE EMERGENCY DEPARTMENT?
Justin Walford - Senior Practice Development Nurse
SIMULATION TODAY - AUTUMN 2021
Introduction
This article is going to discuss the barriers that inhibit nurses from
accessing simulation-based learning education (SBLE) while working
in the Emergency Department (ED). SBLE has become a popular form
of teaching (teaching and learning method) in recent years (Becker and
Hermosura 2019). This can occur in a variety of setting, it can happen
in a classroom, in a staged area or in a clinical area, (known as in-situ
simulation) (Sørensen et al 2017).
SBLE is designed to provide immersive learning experiences that
expose students to unfolding “real-life” clinical situations within a safe
environment (Gabba, 2004). SBLE training is defined as a structured
activity that represent actual or potential situations either in education or
practice. This allows participants to develop or enhance their knowledge,
skills, and attitudes, or to analyse and respond to realistic situations in a
simulated environment (Society for Simulation in Healthcare 2020).
Poore et al (2014) states the theory of using SBLE as a teaching tool
fits with Kolb’s reflective cycle (Kolb 1984). The learning cycle, created
by Kolb, consists of four phases these include (a) concrete experience
where the learner participates in an experience such as a simulation, (b)
reflective observation where the learner reflects on the experience, (c)
abstract conceptualization where the student considers thoughts and
reflections to identify the significance of the learning experience that has
just occurred and considers factors that may have been done differently
to improve the outcome, and (d) active experimentation which involves
using what was learned to direct future practice.
It could be argued though that SBLE creates a memorable concrete
experience. The reflective observations can be done though self / peer /
facilitator reflection. The abstract conceptualisation can be incorporated
in the feedback (i.e. if you did this would have happened). Then the
active experimentation could happen retrospectively, potentially in the
student’s thoughts afterwards or the simulation is repeated.
SBLE are designed to put the patient and their care at the centre
all learning, the simulations can provide an immersive learning
experiences that expose students to unfolding “real-life” clinical
situations within a safe environment (Health Education England
2019). They are used widely in undergraduate nurse education
(Bruce et al 2019) and is seen as essential for emergency medicine
training (Takahashi et al 2019). It is used in certain settings to develop
emergency nurses (Fry et al 2020), it can potentially improve patient
safety and clinical outcomes (Boyde et al 2018). However, it is only used
in small amounts in postgraduate nursing education (citation needed).
SBLE can be used to assess a variety of roles such as teaching,
preventing skill deterioration, checking systems or to improve a system,
to investigate problems or test potential problems (Kenny et al 2019).
Hung et al (2016) highlights that SBLE also improves psychomotor
skills, assessment abilities, decision-making and critical thinking. Lewis
et al (2019) highlights that there is a lack rigorous evidence to support
the argument that SBLE improves patient safety. However, Davison
et al (2017) highlights that SBLE improves significant increases in
participants’ confidence levels in treating new or rare scenarios.
Literature search
A literature review forms the basis of any academic inquiry knowledge
advancement must be built on prior existing work, enhance the
knowledge frontier, we must know where the boundaries currently are
(Xiao and Watson 2019).
The literature that was studied was taken from a variety of sources
publications, these include articles, text-books and journals. Sources
from worldwide were considered. A comprehensive and systematic
literature review must include all relevant databases and should include
“Grey Literature”. Grey literature is unpublished literature (Bootland et
al 2017). This means literature such as academic assignments were
considered, however the strength of the piece of work was scrutinised.
The healthcare database advisory system was used to search the
following databases.
1. EMBase
2. EMCare
3. CINAHL
4. PyscINFO
5. Medline
The key search words were used, but the ED has numerous names.
Therefore, using a Boolean search the following terms were used to find
articles relevant to the ED.
* Emergency Room
* Emergency Ward
* Emergency Department
* Accident and Emergency
* Accident & Emergency
* A&E
* A & E
* A and E
* ED
* ER
6

FEATURE
Furthermore, to find any articles that could have been missed by
these search terms the term “emergency ADJ1 care” was searched.
This means that any words that had emergency and care one word
apart would be included in the search (NICE 2020). The search was
further augmented by the terms EMERGENCY HEALTH SERVICE”/ OR
*”HOSPITAL EMERGENCY SERVICE.
In some databases there were headings that were relevant, these
include
* Emergency Nursing
* Emergency patient
2. Do you work in the ED?
3. How frequently do you participant in simulation?
4. How useful do you find simulation to improve your practice (1-5)?
5. What factors enable you to attend simulation teaching while at
work?
6. What factors inhibit simulation you to attend simulation teaching
while at work?
7. Do you enjoy attending simulation teaching?
8. What are the last three digits of your telephone number?
9. What is your age?
Recruitment
The term “SIMULATION TRAINING” was explored. Polit and Beck (2017)
suggests improving the search by the truncation symbol “*(asterisk)”,
this expands the root word, (in this case simulat* was used) to form all
other versions of the word. The results of the database searches have
been summarised in table 1.
Table 1: Database Results
Database Emergency Dept Simulation Combined
EMBase 107,528 25,521 635
EMCare 444,427 101,484 1,572
CINAHL 191,366 16,983 980
PyscINFO 37,016 54,758 267
Medline 270,340 99,836 839
Due to large number of articles any article not written in English or over
10 years-old was excluded. A secondary search of relevant paper was
performed, to strengthen the search.
A total of 74 articles were selected for further analysis. It appears there
is a paucity in the literature around the factors that both enable and
inhibit all healthcare professionals from undertaking simulation at work,
as none of the articles discuss these factors. The field of healthcare
that has the most literature written about SBLE is medicine. Other allied
healthcare professionals’ fields such as nursing, paramedics, have
limited literature. Of the 74 article selected only three seemed to be very
relevant to this topic. But all failed to mention any factors that motivate
or inhibit SBLE for emergency nurses.
The literature that is published tends to focus on the pre-registered
nurse education or emergency medicine or the effect the simulation
had on individuals. There is very little written on factors which inhibit
nurses from undertaking simulation in the ED or generally. Due to the
lack of literature the author felt that to properly assess the barriers that
inhibit nurses from accessing simulation training while working in the ED
that emergency nurses needed to be asked directly. Therefore, a short
questionnaire was created.
Questionnaire
The survey had nine questions and was entitles ‘simulation for nurses
in the ED’ so people knew it was for nursing staff. The questions asked
were
1. Are you a nurse?
One of the problems of using questionnaires as a methodology for
data collection is, it has a poor response rate (Holloway & Galvin 2017).
All members of nursing staff for one ED were emailed once, then to
augment this one message was placed on emergency care association
(ECA) Facebook and Twitter accounts. The ECA is the Royal College of
Nursing’s forum for emergency care (RCN 2020). Furthermore, three
other matrons or heads of nursing were emailed once to recruit their
staff. After 3 months the survey was closed. All but one participant
worked in an ED, this individual had only left a few weeks before and still
worked as a casual member of staff.
To improve the reliability of this questionnaire, question 8 was asked to
prevent individuals from repeatedly answering.
Inclusion criteria
Respondent’s needed to be working in the ED as a member of nursing
staff, this could be part time or full time. Casual members of staff would
be considered provided they worked regularly in an ED.
Exclusion criteria
The exclusion criteria were anyone who did not work as a member of
nursing staff in an ED.
Bias
To prevent bias from nurses, both factors that enabled and inhibited
simulation were requested. Bias can be created by individuals is known
as the Hawthorne effect which is a change in response or behaviour of
subjects when included in study (Garg 2016), by asking nurses about
both sides it may prevent them from being either overly positive or
negative.
Results
The questionnaire gained 50 responses. From the respondents
86% were registered nurses and 14% were unregistered. Cultural
backgrounds were not assessed but age was, the breakdown of the
age can be seen in table 2.
The age was asked as the author wanted to explore whether the age
of participants was related to simulation enjoyment. As anecdotally
the author has seen several older nurses stating that they don’t like
SIMULATION TODAY - AUTUMN 2021
7

FEATURE
Table 4: how useful do you find simulation-based education
widespread in pre-registration nurse education (Bruce et al 2019) and
emergency medicine training (Takahashi et al 2019) it still has not become
a standard way of teaching post registration emergency nurses.
Table 2: Age of Participants
simulation, and do not find it helpful. Blunt (2019) highlights that
anecdotally evidence is this lowest level of evidence. Due to the lack of
response from older nurses (over 60’s) no conclusions can be drawn
from this. Most emergency nurses that responded only attended
simulation-based learning education between one and four times a year,
the breakdown is seen in table 3. This highlights that despite it being
Half of emergency nurses found SBLE very useful and two thirds found
it useful or very useful. Only a minority (8%) of nurses did not find it
useful. The breakdown is in table 4. This is in keeping with the general
theme of the literature that SBLE is useful and improves confidence,
however getting quantitative data on exactly how SBLE improves patient
care is difficult. This is because it is difficult to directly link the SBLE to
improvement in patient care.
Bodye et al (2018) states simulation reduces anxiety after the simulation,
but this is a small study of 50 additionally it fails to mention nurses
feeling during the simulation. Davison et al (2017) highlights that SBLE
improves significant increases in participants’ confidence levels in
treating new or rare scenarios. However, a few emergency nurses that
have spoken to the author, find SBLE stressful. Dias (2016) highlights
that simulation is less stressful than reality yet Freunnd et al (2019)
argue that participants find SBLE stressful particularly in-situ simulation.
The author would argue that the stress felt is a personal feeling and if
SIMULATION TODAY - AUTUMN 2021
Table 3: frequency of simulation-based education
Table 5: How useful is SBLE to emergency nurses?
8

FEATURE
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Expand your standard patient monitoring in REALITi 360 with the following
numeric values only available to the Generic Monitor:
• Tidal Vol, PEEP (Positive End Expiratory Pressure),
Pinsp (Peak Inspiratory Pressure), MV (Minute Volume)
• Sevoflurane, Isoflurane, Desflurane, MAC (Minimum Alveolar Concentration),
FiO 2
(Fraction of Inspired Oxygen), N 2
O (Nitrous Oxide)
• CO (Cardiac Output), BIS (Bispectral Index)
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SIMULATION TODAY - AUTUMN 2021
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9

FEATURE
the participant is underconfident and / or experiencing an unfamiliar
simulation this exacerbate these feelings. Anecdotally the more senior
the person is in this situation the more they will feel this stress. The
author believes this is because they are expected by junior staff to be
knowledge and during SBLE this can be explored. This is a potential
barrier for some emergency nurses accessing simulation.
Emergency nurses generally enjoy simulation as a form of education.
50% love attending them, only 4% hating and 10% who do not mind
attending the sessions. Therefore, lack of enjoyment can only be a
factor for a small percentage of nurses. The barriers that nurses feel
stop them from participating in simulation are as seen in table 5.
Table 6: Barriers stated by nurses in accessing simulation
Subject
Percentage of nurses answering
Understaffing 44%
Busy 26%
Overcrowding 22%
No allocated time 16%
Not offered 8%
The most frequent reason that emergency nurses feel that cannot
participate in SBLE is due to understaffing. The National Quality Board
(2016) developed safe staffing levels however they stopped short of
stating what they felt these were in the Emergency Department. Ford
(2019) highlights there are 43,617 whole time nursing vacancy in
England alone, and the Royal College of Emergency Medicine (RCEM)
(2019) puts nursing vacancies in ED as high as 16%. This then causes
stress and fatigue in the already depleted nursing workforce Wolf et
al (2017) found that fatigue is a factor in burnout, and this becomes a
vicious circle making higher sickness levels and ultimately making the
understaffing problem worse.
Due to these shortages, nurses will be removed from study sessions
such as SBLE to ensure there is safe numbers of nurses in the clinical
setting. Unlike other professions such as medicine there is no protected
teaching time (El-Farargy et al 2015).
The lack of protected teaching time for nurses the author believes
is a large contributing factor in hampering nurses from attending all
education not just SBLE in ED. According to the RCN (2018) nurses
have been reporting for several years that they are struggling to have
protected time for even mandatory training, let alone developmental
training. Morrell-Scott (2019) highlights that there is a lack of funding
for continuous professional development (CPD). The NHS long term
plan (NHS England 2019) states one of the leading causes of nurses
leaving the profession as not getting the development they need.
RCN (2018) states Nurses are not afforded an equivalent framework,
funding, access or protected training compared to other professions,
demonstrating a lack of recognition and support for the profession and
for patient safety.
The next highest reason that emergency nurses felt they do not attend
SBLE is that ED’s have got increasingly busy. This is multi-factorial
Meyerson (2020), highlights there has been a total reduction in the of
number NHS beds by 60% in the last 45 years, and nearly 17,000 in
SIMULATION TODAY - AUTUMN 2021
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FEATURE
England since 2010. Coupled with an increase in number of attendances
for ED’s (in England). 2018-19 there were 24.8 million attendances up 4%
on the previous year and 21% since 2009-10 (NHS Digital 2019). These
two factors among others have created a situation of overcrowding in the
ED. Overcrowding or crowding is defined by Royal College of Emergency
Medicine as the inability to offload patients from ambulances, or long
delays for high acuity patients to see a doctor. Furthermore, excessive
numbers of patients on trolley or beds in the ED more awaiting cubicle
spaces, or patients waiting more than two hours for an inpatient bed after
a decision to admit has been made (RCEM 2014). These factors coupled
with the nursing shortages mean that the ED is always busy. Traditionally
mornings were quieter in ED however recent data show’s that the highest
number of attendances occur between 10 am to 6pm every day (NHS
digital 2019). Furthermore, the length of stay for patients has increased
(NHS digital 2019). When combining the increased attendances and
length of stay with the reduced number of beds and staff, it is easy to see
why the ED’s have got busier. This has resulted in increasing difficulties
in withdrawing nursing staff from the shop floor to participate in teaching
including SBLE.
These factors that have just been described combine again to result
in a nursing workforce that is fatigued and potentially not wishing to
participate in educational sessions (including SBLE) in their days off.
However, on the survey only one nurse stated that tiredness was a factor
that inhibited them from attending SBLE. This links with another factor
that a single nurse highlighted which was family commitments, while not
‘every’ emergency nurse will have family commitments ‘every’ nurse will
have some commitments outside of work. This results in an inability to
attend every SBLE opportunity.
One nurse stated that shift work inhibited them from attending SBLE,
nurses work a variety of shifts patterns in the ED, not just day and night
shift but shifts with variable starting times to best meet the needs of
the service. This in turn means that nurses have a higher probability of
missing SBLE sessions than those that work traditional working hours.
Emergency nurses highlighted that some departments do not have the
right resources to be able to access SBLE while working in the ED. Four
percent of respondents stated that there was a lack of senior nurses
to provide SBLE in their department. Furthermore, not all ED with have
a simulation lab located near to their department. This means if in-situ
simulations are not performed it can result in difficulties getting nurses
away from the department and potentially this could be quite difficult if
the simulation lab is on another site.
Conclusion
By understanding the barriers that inhibit nurses accessing SBLE in the
ED it means that the risks can be mitigate and some of these factors
can be improved in the future, to improve the uptake of SBLE by nurses
in the ED.
This piece of work has highlighted the paucity in the literature of factors
which inhibit nurses from undertaking simulation generally and in the
ED. Due to the lack of literature a small-scale questionnaire was devised
to explore this subject. This survey has highlighted several barriers
these are, nurse’s individual anxiety although the research is conflicting
about this. The author believes that some nurses feel under greater
pressure when undertaking SBLE, and while the long-term stress maybe
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FEATURE
reduced by completing an SBLE, the stress of undertaking this type of
education and the process of knowledge acquisition can cause stress
to some nurse’s.
Nearly half of all emergency nurses felt that understaffing inhibited their
ability to attend SBLE sessions. This factor is probably going to be a
longstanding issue due to the significant number of nursing vacancies.
Just over a quarter of emergency nurses asked felt that the ED were
to busy to facilitate nurses attending SBLE in the ED, therefore trying
to pick the optimal time or potentially arranging cover will assist the
education team in getting nurses to SBLE in the ED. Nearly a quarter
of emergency nurses felt that overcrowding not only affected patient’s
but prevented them from attending SBLE. This is a difficult barrier to
overcome as generally the blocks of getting patient’s out of the ED are
unable to be solely resolved by the ED. Being aware of the departmental
pressures may mean solutions can be found. For example, giving
feedback could be shortened, while not optimal, but this maybe the
difference between two or three nurses attending the sessions.
Some emergency nurses feel that the lack of sim lab located in the ED
prevents them from undertaking SBLE. But, running in-situ simulations
maybe a good compromise to improve the uptake of SBLE in the ED, as
this enables nurses to attend while working on the shop floor. It will also
facilitate a more realistic response and a reduction in simulation artifact.
Reference List
Becker, L.R. and Hermosura, B.A., (2019). Simulation Education Theory. In Comprehensive
Healthcare Simulation: Obstetrics and Gynecology (pp. 11-24). Springer, Cham.
Blunt, C.J. (2019) http://cjblunt.com/hierarchies-evidence/ last accessed 20/01/2019
Bootland, D., Coughlan, E., Galloway, R., Goubet, S. and McWhirter, E., (2016). Critical
Appraisal from Papers to Patient: A Practical Guide. CRC Press.
Boyde, M., Cooper, E., Putland, H., Stanton, R., Harding, C., Learmont, B., Thomas, C.,
Porter, J., Thompson, A. and Nicholls, L., 2018. Simulation for emergency nurses (SIREN):
A quasi-experimental study. Nurse education today, 68, pp.100-104.
Bruce, R., Levett-Jones, T. and Courtney-Pratt, H., 2019. Transfer of learning from universitybased
simulation experiences to nursing students’ future clinical practice: An exploratory
study. Clinical Simulation in Nursing, 35, pp.17-24.
Davison M, Kinnear FB, Fulbrook P 2017 Evaluation of a multiple-encounter in situ
simulation for orientation of staff to a new paediatric emergency service: a single-group
pretest/post-test study BMJ Simulation and Technology Enhanced Learning ;3:149-153.
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