There has been an increased focus on simulation-based education in nursing for many years and it has been incorporated into many curricula worldwide (Cant and Cooper, 2010). This form of education aligns itself to the constructivist pedagogy, thus encouraging students to draw from the learning environment to form and enhance their deeper understanding, and also offers an opportunity to develop interprofessional activities (Ricketts, 2011). Simulation is now an integral part of nurse education, in its varying formats, and contributes to improving critical thinking, clinical reasoning skills and problem-solving without fear of causing any harm to patients (Sperlazza and Cangelosi, 2009). Jansen et al (2009) have suggested that simulation also allows for the refinement of communication and technical skills. Simulation has consequently been seen to provide real-life experiences in a safe and controlled environment (Henneman et al, 2007; Cant and Cooper, 2010; Sherlin and Quinn, 2016).
However, Foronda et al (2013) have highlighted that nurse educators still struggle to not only integrate simulation into nursing curricular and provide it as part of interdisciplinary experiences, but also to evaluate the effectiveness of simulation as a learning experience. The approach has been used mainly in small groups, because it allows learners to develop skills that they might not acquire or be exposed to during their placements (Carter and Gaskin, 2010). It offers students a safe supported and structured environment within which to develop fundamental skills (Lateef, 2010). NHS England (2017) and Bayntun et al (2012) highlighted that most nurses have no experience of disaster preparedness, and this skill cannot be taught through theory alone. The judgement required to manage such situations can be acquired only through real-life experience or structured simulated scenarios (Carter and Gaskin, 2010; Bayntun et al, 2012). Nursing is not the only profession to benefit from simulation as a teaching and learning tool, other professional groups include doctors, social workers, teachers, police and pre-hospital ambulance personnel.
Taking this into consideration, as well as the requirement to meet Nursing and Midwifery Council (NMC) (2018) proficiency standards to manage and prioritise actions and care in the event of a major incident, the University of South Wales (USW) took the decision to organise a mass casualty scenario within the faculty of life science and education. The intention was for student nurses to understand the impact of a mass casualty/major incident response and subsequent care on both emergency services and wider hospital resources.
Nurses constantly work in complex healthcare environments and are expected to work effectively and collaboratively with other professionals. Through collaborative practices, professional groups can work together to improve patient outcomes and achieve the highest quality of health care. The World Health Organization (WHO) (2010) has identified the importance of interprofessional collaboration in ensuring a healthcare workforce that is responsive to increasingly complex healthcare environments. On initial registration, nurses are expected to practise with other health professionals using effective communication skills to provide safe patient care, yet not all nurses experience collaborative learning in a university setting (Poore et al, 2014). Indeed, at USW students had previously experienced simulation only within a nursing silo. This project enabled nursing students to collaborate with other health professionals. As a school, we embarked on a mass casualty simulation project, which included interprofessional learning with other professional groups, such as fire and rescue, police, and paramedicine.
Legislation and workforce preparedness
A mass casualty event has been defined as ‘an event which generates more patients at one time than locally available resources can manage using routine procedures. It requires exceptional emergency arrangements and additional or extraordinary assistance’ (WHO, 2007). NHS England (2017) has similarly defined ‘a mass casualty incident for the health services as an incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency and healthcare services' ability to manage’.
In the UK, legislation is in place under the Civil Contingencies Act 2004 to support the preparedness of emergency services and acute hospitals, with a requirement to stress test major incident plans every 3 years in the form of live major incidents exercises and annual tabletop exercises, which bring together key personnel involved in organising an emergency response to discuss and walk through possible scenarios and the reactions/decisions made in response to prepare for future real incidents. There is, however, no requirement for nursing students to take part in formal simulated major incident events, which may leave them vulnerable if exposed to such incidents early in their careers.
In its educational standards of proficiency, the NMC (2018) indicates that at the point of registration nurses should be able to take part in the management, prioritisation and care of patients in the event of a major incident. The adult nursing team at USW therefore determined that nursing students should be assisted to develop the skills, knowledge and resilience to manage major incidents and mass casualties in clinical practice. It was anticipated that, if the simulation was successful, further events could be run involving students from all four fields of nursing.
Currie et al (2018) highlighted the importance of mass casualty education within pre-registration nursing courses. According to Veenema et al (2017), climate change, human conflict and emerging infectious diseases are all drivers for triggering disasters or large-scale public emergencies. Indeed, the current global COVID-19 pandemic has demonstrated how pre-hospital, primary care and hospital working environments need to be adaptable to change, with the ability to rapidly review the way that care is delivered.
It has been suggested that disaster simulations require students to think quickly on their feet and transfer acquired skills (Mills et al, 2014). Worldwide, disasters have also highlighted the need for well-prepared resilient health professionals capable of responding to different types of emergencies, including mass casualty situations, for example following a major road traffic incident (Brannigan et al, 2006). Although nursing students are working clinically in pressured environments, they are still supernumerary, and are supported by their practice supervisors and assessors.
The simulation described in this article was designed to enable students to manage their own team, prioritise care and make strategic decisions in line with the NMC's (2018) proficiency standards for nurses.
The project
A project group was set up to explore, co-ordinate and initiate a simulated experience within which significant learning for a number of professional groups could be achieved. Core competencies required for mass casualty incidents include (WHO, 2007; NMC 2018):
- Critical thinking
- Rapid assessment
- Communication technical skills
- Risk reduction
- Disease prevention
- Knowledge of healthcare systems and policy.
These competencies were kept in mind by the project group when developing scenarios. The simulated event involved 80 adult field student nurses, 19 probationer police officers, 6 photojournalism students, 2 Welsh Ambulance Service paramedics, 5 staff from 203 field hospital, 2 St John Ambulance Cymru officers, 1 community first responder and 6 Fire and Rescue personnel.
The scenario
The incident was a simulated road traffic collision (RTC), involving a car and a minibus, which were both full of passengers, with 18 casualties in total. Three of the casualties in the vehicles required extraction, which allowed the pre-registration nurses to work with pre-hospital paramedics, the police probationers, and fire and rescue staff, gaining an understanding of health care in a pre-hospital environment. The receiving hospital was already at capacity and had a busy emergency department (ED).
Role-players and high-fidelity patient simulators were used. Moulage (a make-up technique to represent mock injuries for emergency response training purposes) was applied to represent a variety of traumas, providing realistic visual injuries for the learners. The use of moulage has been shown to assist in content and face validity, along with the transfer of clinical skills and knowledge retention (Pywell et al, 2016). The mix of roll-playing and patient simulators was chosen to enable students to practise technical skills, as well as develop communication skills. This was particularly evident within the simulated intensive care environment, where students were also able to undertake tracheal suctioning and deliver intravenous medications under the supervision of a member of the nursing faculty.
Developing management skills
It was anticipated that the simulation would enable the student nurses to experience and develop an understanding of the explicit pressures faced by nurses working within EDs and ward settings. Students in the ED became involved in mass casualty triage, developing an understanding of different priorities in patient care depending on triage category in major incidents.
Those working within the simulated hospital wards were required to free beds and manage the rapid influx of patients—from walking wounded to the critically ill and their relatives—while continuing to provide compassionate care and safely discharge patients. The student nurse in charge worked with a member of teaching faculty staff to monitor hospital bed capacity, staffing levels and make decisions regarding the movement of staff and patients as the need of the ED and bed capacity changed. The intention was that the nursing students would be supported to manage the hospital and free capacity in order to safely care for incoming patients.
The simulation ran over a 2-hour period. Prior to the event, part of the simulation brief was discussed with the students. They were informed that they would be working in a busy hospital and that an incident involving a significant number of casualties would occur. The students were allocated roles: some were patients while others were assigned to clinical areas within the simulated hospital. They were expected to deal with rapid safe discharge of patients within the hospital ward, as well as managing admissions from the ED.
Remote support was available via telephone from clinical staff acting as discharge liaison and social services; nurse practitioners and medical clinicians were also available if patients deteriorated. Students working within the ED area were split between minor and major streams: again, they were expected to manage the safe discharge of patients home and the transfer of patients to the ward within the simulated hospital, as well as caring for the unexpected influx of patients from the RTC. The students in ED were expected to liaise and interact with the wider interprofessional team involved in the incident. Again, students were able to ring a switchboard and be put through to faculty staff who played the roles of bed manager, discharge liaison nurses, nurse practitioners etc.
Eighteen patients arrived in the ED at various times, with an array of different simulated conditions and injuries. Of these, 14 had minor injuries from the RTC, such as abrasions and upper limb fractures, the remaining patients were seen in the resuscitation area with suspected spinal injuries and abdominal trauma. Students in the minor injuries area were supported by clinical staff with experience in ED, with the intention of developing skills of rapid triage and the prioritisation of patients (Mersh and Vassallo, 2020).
Support and debriefing
During the event students were observed and supported (where needed) by clinical and academic staff. Behaviours and clinical skills were observed, along with interprofessional interactions throughout the event. Students were observed for visual cues of stress, such as anxiety, withdrawing from the simulation, panic attacks, displaying poor planning or task execution, and negative thoughts. It is widely accepted that anxiety has the potential to reduce the ability of nursing students to retain knowledge (Shearer, 2016). If students were observed to be struggling in the activity, a timeout was given and, if needed, they received support from one of the academic staff. The length of the time out was led by the student; generally, faculty staff needed to reassure the students that they were delivering high-quality care within a pressured situation. Interestingly, it was observed by the faculty that all students who required a timeout were keen to return to the simulation.
One of the key elements of any simulation exercise is the debriefing process, which has been seen as a crucial component of simulation. It enables the student to re-frame the situation, facilitates the student's reflection, examines critical thinking, appraises learning and can improve future care delivery (Gordon, 2017). There are various methods of leading the debrief, including instructor-led, self-led and peer-led debriefing (Kim and De Gagne, 2018). Debriefing should occur immediately after a simulated event. Following the exercise, a hot debrief with nursing students was undertaken within the simulated environment, with a larger debrief with all multiprofessional participants undertaken in a larger lecture room immediately after the separate professional debriefs. A hot debrief occurs within minutes of a simulation's conclusion—it is deliberately conducted while emotions, reactions and impressions are still ‘hot’. Such debriefs focus on the immediate reactions and emotions of the team, and on safety measures that can be improved on in real time (Sweberg et al, 2018).
Verkuyl et al (2020) found that large-group debriefs were less resource demanding and offered opportunities for students to justify and account for their actions in a stressful situation, which is an important skill in nursing. It is, however, important to note that quieter students may feel intimidated within a larger debrief session for fear of being ridiculed for any error or omission. There is also a danger that more confident students may dominate the debrief.
Both debriefs were facilitated by experienced clinicians and senior staff from the wider multidisciplinary team who had undertaken simulation debrief training. The debrief followed the TALK method (Diaz-Navarro et al, 2021): this is a tool designed to guide clinical debriefing and promotes a supportive culture for both patient safety and learning. This process of debriefing enables anyone familiar with TALK to act as a facilitator and should be in the form of a short, focused discussion lasting no longer than 10 minutes (Box 1). This process gives the facilitator an opportunity to highlight students' strengths, and to determine areas for further development (Martinez, 2017). TALK also highlights this, citing the importance of identifying positive behaviours and avoiding negative comments (Diaz-Navarro et al, 2021).
Box 1.Points to cover in focused discussions
- Tell. Share your perspective on the clinical situation
- Analysis. What helped or hindered the situation? How can we improve?
- Learning points. What can the team learn from this experience?
- Key actions. What can we do to improve and maintain patient safety?
Adapted from TALK Debriefing (Diaz-Navarro et al, 2021)
As part of the reflective nature of a debrief, it is important to allow students to vent their initial reactions (Forrest et al, 2013). The faculty team found this particularly important, as students often come out of simulated environments focusing on the negative aspects that occurred. This behaviour was primarily seen during the hot debriefs, and faculty staff noted that these tended to be peer led, with students offering mutual support to one another and requiring only minimal support from the faculty staff. Those playing the roles of patients were able to feed back on the care they had received and observed within the clinical area.
A larger multiprofessional debrief also focused on analysing and reflecting on the participants' performance and interactions between the professional groups. The focus was on looking at both positive aspects of the candidates' performance and opportunities for further development, a notion supported by Forrest et al (2013). In keeping with the principles of the TALK debrief model, all feedback was given in a non-judgemental and constructive way, with a focus on prioritising patient care (Diaz-Navarro et al, 2021).
Although this simulation was centred around instructor-led debrief, it was noted that the students offered their own peer-led feedback within the debrief—they provided mutual support and were actively engaged in this element. Boet et al (2013) suggested that this form of debrief fosters more active student engagement, higher motivation towards learning and better performance of nursing skills. This is a form of debrief that will be considered for further development in future simulated events.
Conclusion
Within the simulation particular attention was paid to include the human factor element of a major incident—this has the aim of understanding ‘the “fit” between an employee, their equipment and the surrounding environment’ (Health Education England, 2022). Vosper et al (2018) highlighted that much time is spent providing training in the technical aspects of nursing, with little time spent allocated to human factors' training. In the context of major incident preparation this ‘can include learning styles, behaviours and values, leadership, teamwork, the design of equipment and processes, communication and organisational culture. Through a better understanding of these principles, changes can be made that result in a reduction of human error and higher quality care and patient safety’ (HEE, 2022).
NHS England (2017) suggested that human factors should be made core to education and training curricula for health professionals in order to support ongoing professional development. McCulloch et al (2009) identified 30%-50% reduction in errors by staff who had undertaken team-based human factor training.
Within this simulation exercise, enhancing teamwork and communication was key to the learning outcomes of the differing professional groups. The simulated hospital ward was made as realistic as possible, with noises playing and telephones ringing to simulate the clinical environment, and with academic staff role-playing bed managers and hospital clinicians. This added to the stressful nature and urgency of the simulated event. Within debriefs the faculty were then able to focus on key elements of human factors such as situational awareness, perception and cognition and the role of communication and teamwork within a given situation. Within the feedback given to the students, the faculty staff were able to focus on the impact that human factors may have had on their individual performance and care delivery and future strategies to overcome this.
Following the debrief all students verbally expressed that they had found the experience beneficial and felt they had had an opportunity to develop key skills in mass casualty management, such as major incident triage, managing major trauma, and skills in safe discharge in a pressured environment. They also highlighted that the interprofessional element of the simulation had developed their understanding of the differences and similarities in roles undertaken by differing professional groups (Barnes et al, 2000).
Verbal feedback from both the nursing students and police probationers showed that following the simulation each group had a better understanding of the other's professional roles and responsibilities within a potential major incident simulation and felt better prepared for the possibility of such events occurring.
This simulated activity has highlighted the critical role nurses play within the in-hospital management of mass casualty events. It also highlights the importance of collaborative working with other agencies to provide a safe co-ordinated approach to such situations. The multiprofessional element was crucial to this simulated event as pre-registration often training takes place within university setting within distinct silos. Although such events are fortunately not everyday occurrences, simulations such as this mass casualty event are a key method of educating and preparing pre-registration nursing students.
By exposing nursing students to such simulations, it is possible to aid the development of critical thinking in the assessment and management of patients, alongside the development of the skill of working within an interprofessional team. The current worldwide COVID-19 pandemic has highlighted the need for emergency preparedness and the importance of developing student nurses with skills to enable them to safely and effectively deliver nursing care in pressurised clinical environments.
KEY POINTS
- Simulation can be utilised effectively for disaster preparedness with healthcare students, where a number of competencies can be achieved
- Disaster/major incidents simulations need to be co-ordinated effectively, taking into consideration the interprofessional learning of all the groups involved
- Debriefing as part of a simulation exercise is vital to ensure that learning has taken place
CPD reflective questions
- What are some of the barriers to developing interprofessional disaster/major incident-type simulation activities?
- How can these barriers be overcome?
- What debriefing model would best suit the type of simulation undertaken?