Simulation as learning method
53 per cent of the nurses reported that the simulation improved
their understanding of how to use the communication model in
practice. Several factors may have influenced this result, such as
aspects of simulation as learning arena and how nurses later
integrate what they have learned in concrete patient
Experience with simulation training generally suggests that some
will find the method somewhat uncomfortable. After completion of
the scenario it is subject to reflection in a debriefing session to
bridge the gap between knowledge achieved through simulation and
its use in practice (33,34). The facilitator has an important
role in making such learning through simulation comfortable and
useful to the participants (34). In our study experienced
facilitators lead the debriefing, and they were related to the
ward. We focused on that the participants were there to
learn, not to be evaluated. Security was an important factor
in the learning environment and in making the participants feel
comfortable. To protect the participants we emphasised
confidentiality in the groups, assuring the participants that what
happened there would not be communicated to the ward.
Simulation may be used to further develop communication
The participants played the parts of both nurses and patients,
and the learning effect of simulation may depend on how good an
actor one plays against (41). Half of the nurses were unable
to try out the nursing role, for practical reasons. This may
have yielded a lower learning outcome for those who played only the
patient role. On the other hand, it is recommended that the
participants do play the patient in scenario training. That
enables them to take on the patient’s perspective and may add
greater realism to the scenario (41).
To watch a part of the video during debriefing has a learning
effect and has been considered the «gold standard» of
simulation (33, 34). However, a more recent review article
points out that debriefing without a video playback may be equally
effective (42). The video recording was shown with both
observers and scenario participants present. The participants
were free to not watch the video of themselves during the
debriefing in the communication course, and several did so.
Using video playback during debriefing may distract the
participants from focussing on the scenario’s learning goals
(42). It is therefore important, according to our experience,
that judgement is used in using video playback during debriefing,
especially with regard to what sequences are used for learning
Developing communication skills further
Thirty-three per cent of the nurses reported improved
communication skills following the course. This may be
interpreted as a low result, but 47 per cent answered
«neither nor» to this question. A weakness in the
study’s design is that we did not measure communication
skills prior to the course. We had no control questions in
the questionnaire about knowledge on confirming communication or
other communication skills prior to the course. It is
therefore difficult to say whether the course has resulted in
improved communication skills. A pretest-posttest design
could have shown a real change in, or effect on, the nurses’
skills following the communication course. A critique of this
kind of design is that the effect is not necessarily caused by the
intervention, but by other causal effects that cannot be controlled
Being as the course was developed for students as well as nurses
at the unit, the patient scenarios in the simulation may not have
been sufficiently challenging for the experienced nurses.
Researchers emphasise that theories such as social learning theory
and adult learning theory may shed light on the way experienced
persons learn, as opposed to students, in a basic training
programme (43). Elements of the theories state that
experienced persons are problem-focussed and use their experience
to assess the new material that is presented to them. They
learn based on what is useful to them in their practice, and inner
motivation is important for learning. The question is whether
we were able to motivate the nurses to use the skills in
practice. We did, however, assess the communication model as
useful in encounters with postoperative patients, such as patients
with inoperable cancer, and patients injured in accidents.
The participants acknowledged the utility of the skills, but maybe
not of the simulation staged to learn them.
Even if the communication course turns out to improve
communication skills, there is little evidence that skills learned
in simulation are maintained over time in clinical practice
(20,44,45). Whether great resources should be used to teach
communication skills through simulation may be questioned.
However, clinical supervision has proved to maintain
communication skills in oncological nursing practice (46). A
resource group was established at the unit after the course to help
maintain knowledge acquired in the simulation. One of several
interventions was that third author was attentive to communication
skills in clinical supervision with both a group of nurses with
special competence in such skills and students in post graduate
education. The hope is that confirming communication skills
were implemented at the unit in more than one way.
The communication course is now obligatory for students in
postgraduate education in intensive care nursing when in practice
at the Post-anaesthesia care unit. Newly employed nurses are
given an introduction to the communication model as part of their
The study’s weaknesses
One of the weaknesses of the study is that we used a
self-developed questionnaire. We did, however, not find any
already constructed questionnaire that suited our purpose, and the
questionnaire was developed in collaboration with the statistician
and then pilot tested. A survey like this yields knowledge of
the nurses’ opinion at one point in time. One challenge
with self-report studies may be a possible discrepancy between the
skills the respondents report having and the skills they do in fact
use in practice (37). The nurses received the questionnaire
six months after the communication course. They may thus have
had too little time to develop their communication skills.
The study suggests that simulation increased the
participants’ understanding of the possible uses of the
communication model, but no more than 33 per cent of the nurses
considered their communication skills to have improved after the
simulation. Communication, however, is very complex and
encompasses more dimensions than merely confirming communication
skills. In the study we chose to focus on this one
communication model. The study’s design does not
measure the effect on patient care directly, as this was not the
purpose of the study.
There is a need for more knowledge on simulation-based
communication courses to evaluate their effect and whether such
courses may yield lasting improvement in communication skills.
We are very grateful to the Post-anaesthesia care unit’s
nurses who took the time to answer the questionnaire. We also
want to thank the Simulation Centre at Oslo University Hospital and
department manager Lasse Schmidt for the use of facilities and
personnel during the course. We also want to thank the
facilitators. Professor Leiv Sandvik at Oslo Centre for
Biostatistics and Epidemiology has guided us in the development of
the questionnaire. The project is financed through
collaboration funds from the University College of Oslo and
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