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 Simulation
Exploring 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

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

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

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 placement
Marie O'Boyle-Duggan Senior Lecturer BCU with Joy Grech Senior Lecturer and Rebecca

Table 1 -Number of Students and Professional Groups
Marie O'Boyle-Duggan Senior Lecturer BCU with Joy Grech Senior Lecturer and Rebecca Gillett
Student LD Nurse
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 simulation
Self 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
Marie O'Boyle-Duggan Senior Lecturer BCU with Joy Grech Senior Lecturer
and Rebecca Gillett Student LD Nurse

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

Live Simulation LBR Courses
Results and developments post research -
• O’Boyle-Duggan, M, Grech, J, Brandt, R (2012)
Effectiveness 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 staff
Nursing, ODP, Social work, IPL collaborative project all
receiving Live simulation workshop

• 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.

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

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