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In a system of clinical placements already stretched to capacity simulated learning offers a new era in clinical education writes Joan Deegan and Karen-leigh Edward.

Rapid advancement in technological innovation over the past decade has made simulated learning available for various levels of skill development for healthcare professionals. Educating students of nursing to provide competent care in the current health environment is becoming increasingly difficult because of factors related to increasing enrolments, increasing levels of patient acuity, heavy demand on scarce clinical placement capacity and the shortage of experienced nurses to mentor undergraduate students.

In an effort to address these and other long standing issues the Council of Australia Governments in 2008 agreed to significant health workforce reforms, including over $90 million for simulated learning environments including $45.6 million for capital infrastructure and $48.48 million for ongoing operating across Australia. This policy initiative at the national level heralds a new era in clinical education; and, offers a fresh opportunity to reconsider the value of simulated learning to augment or partially replace the clinical learning experience.

The aim is to briefly examine available literature on the topic of simulated learning to augment and partially replace the real life experience of traditional clinical learning. In this exploration of the literature, a number of themes emerged that were deemed as central to the debate around the use of simulated learning.

For clarity, the term simulation is defined as a technique to replace or amplify real experiences with guided experiences that replicate substantial aspects of the real world.

Dimensions of the simulation encounter
The reliability of simulation in the education of health professionals can be traced to the use of the method in organisations such as commercial aviation and nuclear power production; industries that share with health care intrinsic hazard and complexity.

In 2007 Edward, Hercelinsky, Warelow, and Munro stressed that the simulation encounter necessitates concern with the dimensions of equipment, environment and psychological fidelity, in order to make the most of learning for students. The dimension of equipment according to these authors relates to the degree to which the simulation duplicates the appearance and feel of the real encounter. Environment is concerned with the extent to which the simulation duplicates sensory information generated from the environment for the student, and the dimension of psychological fidelity relates to the student perceptions of the simulation as a believable, surrogate for the task, with the most successful simulations being those that recreate real life situations.

Nurse education and degree of fidelity 
As a general rule three levels of fidelity are utilised in nurse education (1) low fidelity relating to procedural learning such as preparation of equipment for clinical procedures of various complexity, and to carrying out the procedure using replications of isolated body parts (2) medium fidelity trainers integrate the use of computer technology to assist learners in the identification of heart, lung and bowel sounds; and, finally (3) high fidelity where trainers are utilised to teach complex physiological conditions such as cardiogenic shock and anaphalaxis. High fidelity simulators can also include features that give the mannequin personality and allow users to identify with the mannequin as something they may experience in real life. In this type of simulation, the mannequin has the capacity to mimic physiological responses to physical and pharmacological interventions and offer visual and tactile fidelity through a computer controlled mechanism.

Factors that enable the use of simulation
Strategies to enable the use of simulation need to be based on at least three factors: funding, policy at the national level, and policy at the faculty and clinical level. At the funding level COAG through Health Workforce Australia (HWA) has committed significant funds to encourage the development and utilisation of simulated learning in the clinical environment; and, amongst other things is now charged with policy development for clinical education. At the regulatory level policy gives legitimacy and professional authenticity to the providers of undergraduate education to create their own policies and educational processes around the use of the technique, and will be an important consideration if the current national initiative is to become a reality. The Australian healthcare system lacks an overarching map for the integration of simulation into health professional curricula and, that issue is now being addressed by the HWA Simulated Learning Environments Project (SLEs) aiming to increase capacity through simulated learning; and, nursing is one of the disciplines to be included.

At the faculty level, strategies need to address policy and practice concerns. Robust policy facilitates the establishment of boundaries, assists staff to make decisions and help manage the learning experiences within the centre. In its most useful form, policy now being developed by HWA as part of the SLEs project should inform the development of faculty policy that is inclusive of the needs of education and clinical placement providers alike.

Enablers at the practice level include the development of models to support and guide the inclusion of simulation-based education within nursing curricula. In 2005 American academic, Pamela Jeffries linked five concepts in the development of a framework: educational practices, the teacher, the student the design characteristics of the simulation and outcomes. The essence of the Jeffries model reflects the interactive nature of the simulation encounter with the facilitator cueing at the appropriate time, students who arrive prepared for the session and responsible for their own learning. And, design characteristics that include planned objectives, as much fidelity as needed to suspend disbelief, supportive cues and an opportunity for reflection.

Barriers to the use of simulation
Traditionally cost has been cited as one of the major barriers to the use of simulation. Costs generally relate to the initial purchase of equipment and ongoing cost of maintenance and upgrades. Historically, costs have been compounded by the use of consumables such as prosthetics and simulated bodily fluids, all of which are necessary to create a high-fidelity learning encounter, as well as the cost of training faculties to use simulation.

Overcoming barriers
In the current climate, funding opportunities exist at the national level for tertiary providers and clinical education providers to combine skill and resources to work towards the development of simulated learning facilities in large hospitals. This collaboration presents an opportunity to augment clinical education for students of nursing and to potentially replace some, not all, clinical placement hours with simulated learning.

Simulation is already used in varying degrees in nurse education. However, the full potential of simulation as a teaching methodology can only be realised when educators and clinicians develop the necessary skill to utilise the methodology with all that that entails. In addition, comprehensive integration of simulation into undergraduate nursing curricula will involve attitudinal change on the part of clinicians and academics alike, and will require the development of technological competencies, was well as collaborative efforts to secure funding and lobby for policy development at the organisational level. Finally, in the light of the current initiatives nationally, the collaborative effort, funding, skill and enthusiasm necessary to drive the successful integration of simulation in nurse education, is now more than ever a realistic and achievable goal. n

Dr Joan Deegan is the Development Manager (Central Western Region) at the Faculty of Health Sciences, La Trobe University. Dr Karen-leigh Edward is Associate Professor of Nursing Research, Australian Catholic University. End info: A fully referenced version of this article is available upon request.

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