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‘Simulation is a key learning tool but presence is essential’

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Back in the mid-1980s a third-year student nurse was charged with showing me, a first-year student nurse, how to give a depot injection. 

We were both working on a psychiatric rehabilitation ward in a large Victorian asylum. The chap we were going to inject with slow-acting anti-psychotic was receptive and affable – if ‘affable’ means stripped of resistance and overly medicated.

“He exuded the reassuring warmth of a polystyrene cup”

The key principle was: insert the needle quickly into a place where you won’t do harm. I knew this and was anxious not to do harm. The words of my tutor back in nursing school – “like a dart you don’t let go of” – had, for better or worse, stayed with me. But I was nervous, primarily because I was one of two men going to another man’s sleeping area where we were going to ask him to take his trousers down, bend over and let us inject very strong chemicals into him. We did not take flowers. Or even a biscuit.

To cut a long story short the third-year student was rubbish. He exuded the reassuring warmth of a polystyrene cup and the intramuscular injection technique of a kitchen blender. He held the syringe like a dagger and inserted it slowly, tortuously.

I said, “I don’t think you are supposed to do it like that; it’s meant to be quick”. He said, “I think it is best to be careful”. He was immune to learning I think. Or a sadist. Not that that stopped him from qualifying.

The patient didn’t make a sound. I probably didn’t notice that as quickly as I should have. Here was a patient with limited power being asked to bear pain in the name of education. It was poor practice – in every sense of the word ‘practice’.

Most nurses can remember patients who helped them by being open to our unformed, self-conscious need to learn. Indeed most nurses learned important elements of their trade by getting things wrong on real people and finding the humility or decency to apologise and be forgiven. Are we going to need more of those patients in future? Hopefully not.

“Arguably the most important nursing skill is relational”

The new standards on nurse education will require an appropriately wide range of technical and clinical skills to be learned by nurses, and to achieve those competencies we may well reduce practice hours and instead do more simulated learning.

Fewer clinical hours can feel like a threat to the traditions of nurse education can’t it? Nurses know the key to nursing well is in integrating knowledge, skills and human qualities into a well-formed, competent presence with the patient. And that integration is only really meaningful, and realisable in practice. But that does not mean that all of the skills have to be developed at the bedside. Traditionally we have relied on patients to facilitate learning and clinical environments to be able to provide the time to teach – but I can’t help but wonder: how sustainable is that in practical terms?

Skills development through simulation is a good thing, although there is perhaps something of which we need to remain aware. Arguably the most important nursing skill is relational. Knowing how to construct and present the right manner, style and emotion. In our ever-expanding curricular needs, we probably need to find a way of articulating the value of presence. Rather than assuming it will emerge or demanding it is formed from the nonsense that was the 6Cs, we need to attend to it every bit as much as technical or intellectual development. We need to value it and facilitate it. Can that be taught through simulation? Maybe. But it certainly can’t be undervalued.

Mark Radcliffe is senior lecturer, and author of Stranger than Kindness.

Follow him on Twitter: @markacradcliffe.

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