From clinical placement to simulation: the future of nursing education?

Eva-Maria Willis, Jamie Smith, and Iris Epstein discuss the increasing use of simulation training in nursing, its implications, and the possibilities of a posthuman perspective.

We are currently observing a worldwide shift in nursing education, from in-person clinical placements, where nurses learn through hospital-based or community practice, to training by simulation – meaning imitation/pretension rather than real life scenarios and interactions (Hanshaw & Dickerson, 2020; Bridge, 2022). Recommendations in the US have suggested replacing up to 50% of nurse clinical placements with simulation, whilst Canada proposes replacing up to 70% of clinical hours and the UK up to 25% (Alexander et al., 2015; CASN, 2021; 2015; NMC, 2021).

In nursing education, many forms of simulation have existed for years. Examples include simulated patients (where actors play patients with specific illnesses), simulated wards involving multiple actor-played patients, simulated crisis modes (e.g., resuscitation), role playing between nursing students, and the practice of medical procedures with low-fidelity mannequins (such as a rubber arm where students practice puncturing a rubber vein). Simulation might also occur in the reading of hypothetical health scenarios or watching videos to contextualise said scenario.

In contrast to these existing forms of simulation, newer forms will involve high fidelity mannequins which are able to provide different facial expressions and health outcomes depending on the interaction with the student.  For example, a mannequin might be simulated giving birth to a mannequin baby with different complications. Other aspects of this newer form of simulation include e-learning, virtual reality scenarios, and the the simulation of clinical skills, such as placing an ECG on a virtual chest or a simulated virtual vaginal pap smear to help prevent cervical cancer (cervical screening).

We, as nurses, are troubled by the enthusiastic reception of such proposals among academics, and the lack of critical studies about the shift to simulation in nurse training (see Koukourikos et al, 2021). Skills such as learning with, and under, pressure and uncertainty, navigating care, and fostering mutual support with a team are crucial facets of nursing that may be eroded with the introduction of new forms of simulation.

In this article we, as practicing nurses across the US, UK, and Canada, address four questions in regards to replacing practical nurse training with simulation:

 1) Whose reality is produced through the simulations?

2) What nuances might be lost through such training? 

3) Could certain knowledges be excluded from the programme?

4) Will neurodivergent learners be disenfranchised?

Finally, we consider the potential of simulation-training from a posthuman perspective.

Simulation does not represent the world objectively

Simulation, as with any technology, is an inherently subjective practice. The scenarios that form the basis of simulations are embedded in the experiences and knowledge of the people who create them.

When it comes to VR simulated training, the biases and injustices of those imagining and programming simulations will be reproduced (Smith, Klumbyte & Britton, 2023). When biases are reproduced in simulation, we are at risk of reproducing ‘structural missingness’, where some kinds of patients are featured and some are not (Hopkins-Walsh & Dillard-Wright, 2020).

Since education time is limited, not all types of patients will be simulated. So, who will be considered? How do we learn to care for the ones who are not depicted? The person in charge of creating the simulation might not have the same socioeconomic background as the many people we nurses care for, leading the needs of certain groups to be unknowingly misrepresented or missed completely. When a small, but dominant, group of people control the imaginations of care, some realities are at risk of being disenfranchised/’missed’.

To minimize this danger, we advocate for a relocation of resources (financial, educational, and research) to critically consider the risk of programming bias in nurse simulation training. Enhancing the visibility of power imbalances plays a pivotal role in promoting the provision of equitable healthcare and ensuring a more a diverse representation of perspectives (Im & Meleis, 1999).

Midjourney. Abstract digital art. Keywords: imagine a world where nurse education is all done online or with VR but nurses must still care in person.

Simulation takes away the complexity of everyday nursing

We, as nurses, highly value the hours of in-person practice that constitute current and past nurse training. In-person training exposes nursing students to patients and their life experiences. Students learn to cooperate with, and care for, people with vastly different – sometimes contradictory – ethical coordinates than the people they already know. We believe that encounters with social friction and social dilemmas are crucial to becoming nurses that deliver high quality and non-judgemental care to all. Crucial to our practice is being able to navigate the personhood of many people (Tieu et al., 2022; Smith, Willis & Hopkins-Walsh, 2022). Students must have opportunities to navigate the unexpected, constantly interrupting, and partially unknown advancements of patients, colleagues and themselves – opportunities that are not replicated in simulation.

Embodied and collective experiences as valid knowledge

This brings us to the question of how knowledge is (re)produced. Academic knowledge production – in the clinical sciences – is almost exclusively captured through evidence-based practice (EBP), which has undeniably improved the quality of clinical care for many. Still, the lived experiences of nurses, such as intuitive and collective knowing (knowledge that nurses accumulate through their many encounters that turns into a ‘sense’/feeling that cannot be pinpointed to one nurse but rather forms the basis of social knowledge teams), are rarely recognised in EBP and academic teaching (Holmes et al., 2006; Greene, 2012).

Additionally, a limited set of practice-based skills are acknowledged through evaluation. In a study looking at the first 6 months of practice post-qualification, nurses who had up to 50% of their traditional clinical hours as simulation did not differ in ratings of their clinical competence when evaluated by their managers (Hayden et al., 2014). To us, the absence of measurable differences does not mean that there were no differences in the forms of acquired knowledge. This assumption is supported by research on worry amongst nurses (measured by asking them if they are worried about a patient or not). The results indicate that intuition of care may be a better predictor about patient deterioration than vital parameters alone (such as blood pressure and pulse) which are considered ‘objective’ (Romero-Brufau et al., 2019).

We propose that nursing creates experiential knowledge that has often been undervalued compared to technical or biomedical knowledge. This is not currently represented in how the ‘competence’ of nurses post-training is accounted for and measured. Our worry is that this trend will be further consolidated in simulation training where less opportunity for in-person experiences reduces opportunities to gain this less recognised (but vital) knowledge and skill sets.

Simulation might disadvantage neurodivergent learners

Critical disability and Black critical feminist scholars question how clinical realities are simulated in relation to ability and race (Epstein, 2021a, 2021b; Goodley et al., 2021). In terms of simulation, potential disenfranchisement of neurodivergent learners and learners with disabilities might occur. In our own practice, we have noticed that neurodivergent students often report better learning during clinical placements and more struggles during simulation training. These challenges require further consideration and research in the shift to simulation training. Scholarship has yet to fully explore the prejudices ingrained in the infrastructure of technology-based clinical simulation.

Possibilities of simulation

From the points above, you might think that we are opposed to simulation in nurse education. But, this is not the case. Despite our concerns, we are enthusiastic about, and see a lot of potential in, simulated training. Accessibility, flexibility, and creativity might be improved with simulation (Ball, 2020; Cant & Cooper, 2017). Students will have to travel less far in order to learn and could gain experience in a range of health departments – something currently not possible due to a lack of placements available. Simulation also opens the possibility to create realities that do not exist currently, but that we might want to consider. These benefits facilitate critical thinking, clinical decision making, and imagination for what equitable care could look like in the future.

Simulation from a Posthuman Perspective

Posthumanism values the individual human whilst questioning it as completely independent and at the center of the universe. Instead, posthumanism conceptualizes the human in relation to others, the environment and social and cultural structures (Braidotti, 2013). From a posthuman perspective, we can understand care not only as the care for one patient by one nurse, but as a patient cared for by a team of humans, other organisms, materials, structures, policies and so on. When we understand patients are embedded in their community and history, we can create a care that accounts for that fact. For example, patients might delay treatment due to commitments, such as the care they are providing for others (children, partners, pets, the elderly, community). Posthumanism can assist theoretically to understand how people work and act in relation to their environment and community, rather than independently. 

From a posthuman perspective, we argue that simulation should not be confined to reproducing reality. Instead, we encourage the acceleration of simulation beyond and above the replication of reality. Simulation could be used to explore alternative possibilities for care provision. We suggest acceleration – thinking imaginatively and expansively – as a strategy to meet the challenges that arise with nurse training simulation (cf. Haraway, 2016). Simulation could provide safe spaces to experience, virtually, what it is like to have certain diseases. Simulation could create situations that expand from individual cases to show how nursing teams create and influence shared realities. Simulation could also replicate past realities, as well as imagine utopian or dystopian healthcare scenarios,  to explore how care should or should not be delivered in the present and future

Posthuman theories agitate taken-for-granted assumptions about care, whilst providing novel ethical, empirical, and practical insights regarding the complex web of relations vital to the practice of nursing. Adopting a posthuman perspective allows nursing to be understood in more nuanced and affirmative ways. It expands nursing knowledge beyond humanist limits by illuminating the complex web of human and more-than-human relations that enable and constrain care.

Simulation training risks eroding essential nursing skills learned under pressure and uncertainty. A posthuman perspective instead advocates for exploring a relational knowledge and care that extends beyond the individual patient and expands the possibilities of simulation in nurse education.

About the authors

Eva-Maria Willis is a PhD candidate at the University of Siegen, Germany at the department Sociology of Health and Healthcare Systems.

Jamie B. Smith works as a nurse, lecturer and research associate at Charité Universitätsmedizin Berlin and The University of Edinburgh. He can be found on Twitter @Mrhornesmith.

Iris Epstein (iepstein@yorku.ca) is Associate Professor at York University, Canada at the School of Health Policy & Management – School of Nursing.

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