Practice question

Could using simulated practice with registered nurses improve the delivery of physical and mental healthcare for older people in hospital?

How you can improve the outcomes for older people in clinical settings by integrating physical and mental healthcare.

Could using simulated practice with registered nurses improve the delivery of physical and mental healthcare for older people in hospital?

Picture: Neil O'Connor

Mental, physical and social health are inextricably linked and an unmet need in one of these domains has a negative effect on well-being in the other two. Of older people admitted to acute settings, 60% have, or will develop, a mental health condition(s) or cognitive impairment (Goldberg et al 2012). Integrating physical and mental healthcare in all clinical settings is crucial to improving outcomes for older patients and avoiding harm (Naylor et al 2016).

Poor understanding can provide different results

Some staff in general care feel challenged when nursing older people with mental ill-health or cognitive impairment. Poor understanding of the conditions the older person is living with can result in them being labelled as disruptive, aggressive and even undeserving of care (Tadd et al 2011). The Royal College of Nursing (2017) supports developments in undergraduate nurse education that enable registered nurses to assess patients’ physical and mental health. Nonetheless, registrants need support now to manage the increasingly complex nature of older people’s care.

Few registrants have undertaken education or training outside their field of practice, but feel increasingly pressured to manage the unfamiliar mental or physical care needs of patients (National Confidential Enquiry into Patient Outcome and Death 2017). Simulated practice may be one solution to support the ongoing acquisition of knowledge and applied skills in areas of care in which nurses have not traditionally been prepared.

Computer-generated technical simulation can enhance nursing skills in objectively detecting and managing physical deterioration in patients. However, well-crafted and carefully scripted simulation can also be designed to develop nurses’ confidence and competence in executing the ‘softer’ non-technical skills such as effective assessment and managing distressed behaviour.

Clinical simulation approaches developed to replicate real-life clinical situations and cultures allow nurses time to reflect in practice, apply their knowledge and test decision-making in a safe environment.

Traditionally associated with undergraduate nurse education, registered nurses may view simulation with trepidation. Simulation can generate feelings of discomfort when nurses are faced with situations that have previously challenged their coping strategies (Felton and Wright 2017). Fear of ‘role playing’ and of their self-perceived lack of knowledge being exposed in front of colleagues may discourage participation.

Solutions include partnership working between educators, registrants and service users/third sector organisations to develop the focus of the simulation in response to clinical need. Other effective strategies include providing an overview of the content/potential direction of the simulation, ‘front-loading’ theory before the simulation and drawing on experienced simulated patients who can respond in real-time to nurses’ decisions in the scenarios.

Revalidation and refreshing knowledge

Refreshing theoretical knowledge and adding relevant new knowledge can help nurses to reflect on previous practice and plan new approaches to test safely during simulation. Well-facilitated feedback enables nurses to recognise, reflect on and explore their cognitive and emotional processes in relation to the simulated situations (Clapper 2010). Successful simulated practice increases nurses’ awareness of learning deficits and importance of self-evaluation.

However, if simulated practice is to have value in post-qualifying nurse education, evaluation of the benefit to older people should be part of the simulated practice package.


  • Clapper T (2010) Beyond Knowles: what those conducting simulation need to know about adult learning theory. Clinical Simulation in Nursing. 6, 1, e7-e14.
  • Felton A, Wright N (2017) Simulation in mental health nurse education: the development, implementation and evaluation of an educational innovation. Nurse Education in Practice. 26, 46-52.
  • Goldberg S, Whittamore K, Harwood R et al (2012) The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age and Ageing. 41, 1, 80-86.
  • National Confidential Enquiry into Patient Outcome and Death (2017) Mental Health in General Hospitals: Treat as One. NCEPOD, London.
  • Naylor C, Das P, Ross S et al (2016) Bringing Together Physical and Mental Health: A New Frontier for Integrated Care. The King’s Fund, London.
  • Royal College of Nursing (2017) Responses to the NMC Consultations on: Standards of Proficiency for Registered Nurses, Education Framework: Standards for Education and Training, Prescribing and Standards for Medicines Management. RCN, London.
  • Tadd W, Hillman A, Calnan S et al (2011) Dignity in Practice: An Exploration of the Care of Older Adults in Acute NHS Trusts. Department of Health, London.

Lindsay Dingwall is a clinical/academic nurse consultant (older people) at University of Dundee, Dundee, Scotland

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