Maximising learning opportunities in a changing clinical practice environment


Sue Crabb Senior Lecturer Radiography


Simulators and Simulation




University of Portsmouth


Being able to learn and practice without risk to patients is one of the main reasons why learning in simulation is being adopted throughout healthcare education (Zigmont,et al., 2011, p.47). Kneebone et al. (2010, p.65) contend that learning from mistakes is a powerful educational experience and that simulation allows learners to achieve safe practice in an authentic environment which corresponds closely to the actual conditions of practice.



The themes that developed answered the research question that the students found learning within the SPE of benefit, and that these learning benefits in radiography, as in other health care professions, supports radiography students learning within the CPE.


An underlying theory emerged: that the learning befits within the SPE contributed to the professional socialisation of the students; giving them a platform of knowledge to support them in the transition into the clinical placement environment both in their initial and in subsequent placements. Learning in the SPE results in an increase in confidence that facilitates this transition, not only in cognitive skills but in engendering deeper underlying knowledge, this increased confidence  provides the students with the ability to maximise their learning opportunities in placement.




Summary of Work

The learning that the students engage with in simulation must support learning in the clinical environment whilst integrating with academic knowledge, and challenge students through increasing levels of difficulty (McGaghie, et al., 2010, p. 60). A model of learning was developed in a SPE to address this. This poster represents a dissertation in Teaching and Learning which explored students’ perceptions of this learning to facilitate their ability to maximise their learning opportunities in the clinical practice environment (CPE), within a BSc (Hons) Diagnostic Radiography degree.




Take-home Messages


The learning affordances in SPEs can prepare students to transfer effectively into CPEs.


If future radiography students are to be trained to meet standards outlined by their professional bodies, using learning in SPE’s could be essential. To be effective this must be central to the curriculum utilising current research in simulation education.


Providing an environment where the students feel safe and comfortable is an important area for consideration when designing learning programmes within SPEs.


Firstly I would like to say thank you to the amee organisers for giving me the opportunity to share this. 


I would like to say a huge thank you to the students who gave their time freely in a content heavy course to participate in this research. Their enthusiasm and  perception has been an inspiration.

I would also like to thank my colleagues at the University of Portsmouth for all their help and support.

Finally to my children, family and friends and last but not least to my husband, for his unfailing love, encouragement and kindness. I couldn’t have done this without you. Thank you!

Summary of Results

Learning affordances offered within the SPE have been clearly identified. The results demonstrate the student’s perceptions of benefits in their preparation for placement, gaining cognitive skills, confidence and communication skills. The benefits of learning in a safe environment were recognised; learning within the SPE, provides the students with the freedom to ask questions and removes concerns over patient’s welfare.






Please see 'more detail' for full references.


Increasing pressures in clinical placement for medical students have made the need to maximise learning opportunities in placement imperative and  this has moved medical education away from the traditional apprenticeship model, where learning is centred on real patients in practice (Reynolds & Kong, 2011,p.84). It is argued that there is a need to  incorporate learning within simulated practice environments (SPEs) into the curriculum  (McGaghie, et al.  2010, p.60, Maran & Galvin, 2003, p.22).


Within conventional radiography changing patterns of patient imaging including Computed Radiography (CT), Magnetic Resonance Imaging (MRI) and Ultrasound have reduced diagnostic radiography students learning opportunities, and they also need to move away from an apprenticeship model.


The Department of Health’s (2011) framework for technology enhanced learning (TEL) states that where possible  students should learn appropriate skills in an SPE before undertaking them in clinical practice and that simulation should not be used as an end in itself but integrated into a blended approach to learning (2011, p.8 ).




This project is set within one university, with data collected across a single year. Generalising outside of study parameters must be undertaken with caution. It is recommended that further research in a longitudinal study across other Higher Education Institutes would give weight to the study findings. Data collection to support this has continued. Further research in a comparison of focus groups and individual interviews across the year levels may result in added insights to the themes generated and has the potential to highlight differences of perception within the year groups.


Self efficacy and the influence on this on motivation to learn were identified, the increase in students confidence levels demonstrated is an important benefit in its own right. It has, however to be tempered against the understanding that this doesn’t equate to directly to competence in clinical practice. Although the ordinal data suggests students’ perception of increased competence and within the focus group gaining cognitive skills within the SPE was felt to be one of the most important benefits, there is within this report no direct evidence of the transfer of skills gained into clinical practice. Further research is needed to evaluate the transfer of skills from the SPE into the CPE, and provide empirical evidence to underpin the development of learning in simulation within radiography programmes.


There is a need to embed learning in simulation within the process of course validation in order to align with the recommendations of the DoH (2011, p.7). The use of simulation needs to be explicit within course documentation to allow curriculum integration to be developed, resourcing needs to be identified and funding expedited.

Summary of Work

The programme in simulation is delivered in small tutorial groups through increasing levels of difficulty over the three years of the course. Students undertake tutorial groups in the SPE averaging six members, the same students remaining together through the three years. The students first sessions are facilitator driven and designed to develop cognitive skills around handling equipment and basic patient positioning. They also encompass communication skills. The initial sessions prepare the students for participation in their first clinical placement and for their first clinical assessments. Following return from placement the remainder of the sessions encompass refection on placement experience and problem solving, beginning the process of critical thinking, and the development of reflective practice. 


Building cognitive skills.


Theory to practice


Reflection on practice experience

Problem solving

Team work and communication skills





Case study was chosen as the most appropriate research methodology to answer the project question. This was underpinned by a systematic literature review. Document analysis was undertaken to provide in-depth contextual data. Purposive sampling was used when collecting data from the students. On line questionnaires, were sent to the whole cohort.  These utilised Likert scale questions, to encompass attitude measurement and open questions to provide depth of information. A focus group of level three students was held following data analysis of the survey to explore the themes identified in greater depth.


Qualitative data was generated from the open questions, focus group and document analysis and quantitative ordinal data from the questionnaires. Analysis of the qualitative data was undertaken utilising thematic coding and descriptive statistics were used with both the qualitative and the quantitative data.  Ethical considerations and limitations of the project were identified and student consent gained.




Take-home Messages

Zigmont et al. ( 2011, p.53) maintain that learners within an SPE need to feel that the learning environment is safe and focused on their learning needs to allow them to share their experiences with others and engage effective in reflection. The contribution of SPE’s in providing a supportive environment for students learning is highlighted by Dent (2001, p.487) who argues that this is an element that should be retained but warns that it may also be the most readily lost. This is corroborated by Hofmann (2009, para. 6 ), who discussed the influence of a safe and constructive learning atmosphere in relation to the performance of the trainee.

Summary of Results

The importance of the SPE being student centred whilst patient focused was recognised by Nestel et al. (2011, para 1). The students within this research identified constraints to learning in placement and the data supported the premise that they valued the planned learning within the simulation sessions.


Analysis of the survey results gave credence to utilising blended learning within the model of developed, and this was supported by the qualitative data during the focus group discussion. The danger of engendering an approach in simuation  that focuses on building cognitive skills, and fails to encompass the wider aspects of clinical skills such as communication skills,  is warned against by Kneebone et al. ( 2010, p.66). Within this study the students recognised the value of problem solving and of reflection on their placement experience, and the importance of engendering an atmosphere conducive to it flourishing.


"The sessions built in this big why am I doing this, thing into my routine.  So before- you know this, how you do it- but from the start of the sessions you think well this is how you do it but why am I doing it., and I think that that questioning was built in entirely from the sessions so- why, why , why,  why, Why do I do this way why don’t I think about doing it this way I think that’s what the skills sessions have done I think this is the biggest thing that the skills sessions have given me."


67% of students in this report either strongly agreed or agreed that the sessions helped their communication skills. There was a higher percentage in year one of 70% of students, dropping to 50% of year three students which shows an expected gain in personal skills over this period.


Building cognitive skills underpins the simualtion tutorials. This is achieved by the students practicing on an athropomorphic phantom and by practicing on each other. Nikendei et al. maintain that role play results in significantly enhanced communication skills whilst technical performance was not impaired (2007, p. 956). Nestel and Tierney, although corroborating the advantages of student role play, highlight that some students may find it difficult to engage with (2007, para. 6) and within this report the data revealed a minority of students did feel uncomfortable practicing together. Ricketts identifies that simulation cannot meet the needs of all learners (2011, p.653); further research is needed to clarify why these students found engagement in learning in the SPE difficult and to identify why the outliers did not find the learning of help.


Providing an environment where the students feel at ease is an important area for consideration when designing learning programmes within SPEs. Dent highlights the value of this aspect of learning and that care that is needed to ensure that it is not lost (2001, p.487). This is significant in the light of the need to evaluate learning outcomes identified by some of the major papers (McGaghie, 2010, p.56). The students recognised the value of the role of the facilitator.




The data from the survey demonstrated that the majority of students found learning in the SPE increased their levels of confidence going into placement across all three years. Fisher’s exact test was applied to this data and supports the premise that there is a relationship between students perceived confidence levels going into clinical placement and the simulation tutorials. The p value were for Year 1: 0.00000157, Year 2: 0.00000121 and Year 3: 0.00000521.



I found that after these sessions I was totally ready to go out and do spines, I also passed my spine assessment thanks to the help of this knowledge.”

“I would feel completely lost on placement if we had not done them. Meant could spend more time practicing on placement instead of learning and therefore get higher competencies.”

“Without these sessions, I would probably just observe the first couple before attempting on clinical placement, but now it's given me the confidence and knowledge to give it a go”.



Self efficacy, and the influence of this on motivation to learn, was identified in the paper by Zigmont et al. (2011, p.48) and the increase in students confidence levels demonstrated is an important benefit in its own right. It has, however to be tempered against the understanding that this doesn’t equate to directly to competence in clinical practice (Kneebone et al., 2004, p.1099) and further research is needed to evaluate the transfer of skills from the SPE into the CPE.



Implications of learning in SPEs

The following areas were identifed by the students as important.




There is little in the literature relating to how age, gender or ethnicity affects learning in simulation, and further research is needed to explore possible correlation between the student demographics and the results discussed.



Dent, J. ( 2001). Current trends and future implications in the developing role of clinical skills centres, Medical teacher, 23 (5), p.483-489.


Department of Health. (2011). A Framework for Technology Enhanced Learning. Retrived March 4, 2012 ,from the Department of Heath website: / 


Kneebone, R., Scott, W.,  Darzi, A., & and Horrocks, M.( 2004). Simulation and clinical practice: Strengthening the relationship. Medical Education, 38, 1095-1102.


Kneebone, R., Arora, S., King, D., Bello. F., Sevdalis, N., Kassab. E., Aggarwal. R., Darzi, A., & Nestel, D. (2010). Distributed simulation-Accessible immersive training. Medical teacher, 32, 65-70.


Maran,N., & Galvin.R. (2003). Low-to high- fidelity- a continuum of medical education?  Medical Education, 37 (1),22-28.


McGaghie, W., Issenberg, B., Petrusa, E., &  Scalese, R. (2010). A critical review of simulation-based medical education research: 2003-2009. Medical education, 44, 50-63.


Nestel,D., Tabak,D., Tierney,T, Layat-Burn, C., Robb, A., Clark, S., Morrison, T., Jones, N., Ellis,R., Smith, C., McNaughton, N., Knickle, K., Higham, J., & Kneebone, R. (2011). Key challanges in simulated patient programmes:An international comparative case study. BMC Medical Education,11.


Nestel, D., & Tierney, T. ( 2007). Role-play for medical students learning about communication: Guidelines for maximising benefits. BMC Medical Education,7 (3). Retrieved July 31, from





Nikendei, C.  Kraus, B., Schrauth, M., Weyrich, P., Zipfel, S., Herzog, W., & Jünger, J. (2007). Integration of role-playing into technical skills training: a randomized controlled trial. Medical Teacher, 29 (9), 956 – 960.



Reynolds, T.& Kong, M. (2011). Learning Without Patients. BMJ, 342, 83-84.


Ricketts, B. ( 2011). The role of simulation for learning within pre-registration nursing education- A literature review. Nurse Education Today,31, 650-654.


Zigmont, J., Kappus, L., & Sudikoff, S. ( 2011). Theoretical Foundations of Learning Through Simulation. Seminars in Perinatology, 35, 47-51.

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