Session F - Learning disabilities: Using live simulation to explore challenging behaviour and make reasonable adjustments

Marie O'Boyle-Duggan Senior Lecturer BCU with Joy Grech Senior Lecturer and Rebecca Gillett Student LD Nurse

Live SimulationExploring students satisfaction and

confidence in simulation using simulated patients (SPs) including personal reflections and evidence of clinical impact on the care

of patients with learning disabilities.

What is live simulation?

• It replicates clinical practice and is as near to real life as possible (Jeffries 2005).

• Use of Standardised Patients ; more commonly used in medical education; simulated patients (SPs) as Wiskin (2003) defines are not real patients but specifically trained role players, improvising and providing feedback to students in real time simulated clinical encounters



Why ‘live’ simulation?• Students play a major role and are ‘in control’ of

the situation deciding in real time appropriate treatment and actions; which enables them to make judgements and learn from their mistakes, (Alinier et al 2006) it increases student self efficacy, (Goldenberg et al 2005).

• Teaching strategies employing simulation had a positive impact on students attitudes towards disabled people. (Goddard and Jordan 1998).


Why live simulation - clinical issues

• Death by Indifference (Mencap 2007) and later Valuing People Now (2009) highlight how individuals with learning disabilities receive discrimination and neglect in mainstream healthcare, 74 deaths and counting (Mencap 2012)

• Healthcare for all (2008) recommend that the health needs of people with learning disabilities are included in health education course programmes

• People with learning disabilities continue to struggle with poor experiences in hospital settings due to health staff not understanding the individuals needs and more importantly the attitude of health staff towards those individuals with learning disabilities is still very negative (Densmore 2011). Reasonable adjustments are still not being made

Nurse Education Simulation Framework (Jeffries 2005, 2007).

•Clear objectives and information

•Support during the simulation

•An appropriate problem to solve

•Fidelity or realism of the experience

•Time for feedback and reflection

•Rules for feedback


Simulation activity


Groups of three

Three rooms/scenarios

with a SP and Facilitator

Each student worked with a SP

peers observed

Feedback/reflect then move to next

scenario

Why explore clinical impact?

• Literature suggests that the clinical affect of the use of simulation in health education is still inconclusive (Cioffi, et al 2005).

• There appears to be a consensus for a universal outcome measurement of clinical impact (Ravert 2002, Cant and Cooper 2009).


Methodology

Mixed Methodology using: -

• National League for Nursing (2005) a published questionnaire looking at students’ satisfaction and confidence in simulation

• Survey of student reflections- day of simulation

• Focus Groups - post clinical placementMarie O'Boyle-Duggan Senior Lecturer BCU with Joy Grech Senior Lecturer and Rebecca

Gillett Student LD Nurse

Table 1 -Number of Students and Professional Groups


Frequency Percent

Child Nursing

ODP

Adult Nursing

Total

65

53

55

173

38

31

32

100

Satisfaction with the Simulation Satisfaction Scores Strongly

Disagree Disagree

Undecided

agree

Strongly agree

n % n % n % n % n %

The teaching methods used in this simulation were helpful and effective

1 0.6 0 0 4 2.3 32 18.5 136 78.6

The simulation provided me with a variety of materials and activities

1 0.6 1 0.6 11 6.4 67 38.7 94 54.3

I enjoyed how my instructor taught the simulation

1 0.6 0 0 1 0.6 56 32.4 115 66.5

The teaching materials used in this simulation were motivating and helped me to learn

1 0.6 1 0.6 3 1.7 60 34.7 108 62.4

The way the instructor(s) taught the simulation was suitable to the way I learn

1 0.6 3 1.7 9 5.2 54 31.2 106 61.3


Self Confidence following the simulationSelf Confidence Scores Strongly

Disagree Disagree

Undecided

agree

Strongly agree

n % n % n % n % n %

I am confident that I am mastering the content of the simulation.

1 0.6 2 1.2 6 3.5 101 58 63 36.4

I am confident that simulation covered critical content.

1 0.6 1 0.6 7 4 95 54.9 69 39.9

I am confident that I am developing the skills and knowledge to perform in clinical setting.

1 0.6 1 0.6 2 1.2 95 54.9 74 42.8

My instructors used helpful resources. 1 0.6 1 0.6 8 4.6 76 43.9 87 50.3

It is my responsibility as a student to learn what I need to know from the simulation activity.

1 0.6 2 1.2 9 5.2 60 34.7 101 58.4

I know how to get help when I do not understand the concepts covered .

1 0.6 0 0 22 12.7 87 50.3 63 36.4

I know how to use simulation activities to learn critical aspects of these skills.

1 0.6 1 0.6 11 6.4 99 57.2 61 35.3

It is the instructor’s responsibility to tell me what I need to learn of the simulation activity during class time.

8 4.6 17 9.8 49 28.3 67 38.7 32 18.5


Student reflections on day of live simulation


“people with learning disabilities are also humans with emotions and feeling, but they just portray it differently to main stream normality” (S24/c/T1).

“It seems that good communication skills are vital especially in learning disability patients or service users. It reiterates that hands-on practice is the best way of learning and finding mistakes in technique (S60/a/T1/T2/T3)

“Opened my eyes to how people with learning disabilities need to be treated” (S53/a/T1/T3).

What I did well What were the learning opportunities available to me

Focus groups themes

• Feelings towards patients with learning disabilities before simulation

• Feelings afterwards• How simulation influenced clinical practice


Focus Group - ODP Students


“I find it useful in a sense that I pick up on the things that they’ve brought in with them and the things that I say to help the conversations and stuff to progress” (G1/L38/S6/T1)

‘picking up on some of the patient’s personal affects to find the topic for releasing anxiety’ (G1/L44/L48/S5/TT1),

and ‘distraction techniques, that’s one thing that you know and that’s one thing that you did learn from the simulation(G1/L49/S1/T1/T3)

Focus group ODP


“nobody’s going to teach us how to behave with people that are – shall we say people that aren’t normal? I don’t know if it’s right for me to say that. But I feel that after that scenario, you know, I feel as I go into different mode, a different programme mode to behave…”(G1/L8/S5/T1), “that’s right. You would then rely on another person to be at hand-holding, with someone who’s not the enemy” (G1/L64-71/UMS/T1).

Nursing focus group


“I suppose it is the change in attitude, isn’t it really? Instead of saying “oh I’m busy. I’m going to have to write all the notes up.” That really just takes two minutes, just to go and spend a bit of time with someone. And that can mean a lot to somebody”, (G1A/L32/S1/T1).

“I worked on an infectious diseases ward and a lady came in and she had learning disabilities. And it was like always, “Oh you can go and feed her,” but actually, I ended up getting on really well with her because I built up a rapport with her. She did trust me and you know. I don’t know. I think nurses, like my mentor, she was a bit ignorant to the fact that she did need more time and you can’t just go in and wham drugs at her and whatever, she wanted to understand” (G1A/L35/S4/T1).


“My mentor explained it to me and said that, “You missed a really nice one. The child was due for an operation. I don’t know what distressed her.” Our list was a really big list, age 8 to 10. So basically, it’s quick, quick, quick. Everything has to be done on time. So I think the rush that child....and then they said that she ended up crying in the anesthetics room. And she had to be sent back to the ward. And then the next one, the same thing ... I’d probably spend, you know, okay 20 minutes for the patient to talk with them et cetera....... you’ve only got 10 minutes and they’re going to be upset and the whole thing sort of …....snow balls, doesn’t it? I mean, I don’t know how that works for a kid though; to go back to the ward and to come again”.


“maintaining eye contact and staying calm, being patient and not standing above people was a big one that we learned. I think getting down to the same level as them. Yeah, just general body language and being calm I guess” (G1a/L8/S2/T1/T2/T3).

“Big thing from the workshops that I took, onto the wards, I mean all three of them, steve with a magazine, mary and penguin, and Janet Eastenders. You know getting their attention away from - something humanized, normal, you know, a TV programme. And so I talk about that and they open up and that’s essentially a way into them. I used it so many times on the next ward and placement”. (G1a/L51/S3/T1/T2/T3).

Conclusions

• Critical issues for people with learning disabilities exist in modern day health care services (Emerson et al 2011); the overall aim of this research is to have an impact on some of these issues.

• Overwhelmingly the findings have been very positive, students felt confident and satisfied with the simulation activity. It is also clear that students reflected that skills explored and practiced during simulation had an impact on patient care when on clinical placements


Recommendations

• It is a legal requirement (Equality Act 2010) that health services make reasonable adjustments for patients with learning disabilities

• Healthcare for All (DH 2008) suggests that Higher Education Authorities provide education regarding the needs of people with learning disabilities to all health professional groups on undergraduate courses.

• Workshop for local clinicians Marie O'Boyle-Duggan Senior Lecturer BCU with Joy Grech Senior Lecturer

and Rebecca Gillett Student LD Nurse

Live Simulation LBR Courses

Results and developments post research - • O’Boyle-Duggan, M, Grech, J, Brandt, R (2012) Effecti

veness of Live Simulation of Patients With Intellectual Disabilities Journal of Nursing Education, June 2012 - Volume 51, 6: 334-342

Contract with Children’s Hosp – LD live simulation workshop for clinical staffNursing, ODP, Social work, IPL collaborative project all receiving Live simulation workshop


http://www.healio.com/journals/JNE/%7BC68E30B6-9D33-4E7D-8C3C-FF3CB2C951A2%7D/Effectiveness-of-Live-Simulation-of-Patients-With-Intellectual-Disabilities




• The Collaborative projects objective is to enhance the learning environment for students.

• Aims for a inter-disciplinary partnership between students and staff, to achieve a more ‘hands on’ role for student contribution to their education.

• Favours projects that reinforce theoretical knowledge by developing and applying student skills into real life situation.


Theory book

• Important part of the project to produce a visual reference point for people to take away with.

• ‘Guidelines’ aimed to be easy to read, and a back up to what they learnt from the simulation workshop.

• Included in the book – communication tips, laws & policy such as ‘making reasonable adjustments,’ reports highlighted that show a need for mainstream health care to be more knowledgeable on the needs of pwld.


Student Responses to the IPL workshop

Really good to work with different disciplines and

see the differences in our perceptions.

Hearing how patient felt in the situation was

so useful,this is often overlooked in practice!

The workshop was structured really well,

feedback structure was consistent.

Being given feedback with tips on new skills I can use is so helpful for

the future.


Finding ‘comfort cues’ for the individual was really

good tip.

‘There is not always an answer for everything.’

Nice sized groups – smaller is better as it feels less like you

are ‘performing.’

‘Time outs’ were so comforting to get

suggestions from your peers.


Health & Medicine

Session F - Learning disabilities: Using live simulation to explore challenging behaviour and make reasonable adjustments