Medical emergencies involving injuries or illnesses that require attendance by ambulance services can occur in any environment—in the home, at work and in public places such as parks, roads or public buildings (Caroline et al, 2007). Where transport to hospital is necessary, removing the patient from the scene to the ambulance (extrication) is required. Sometimes the environment can be challenging (such as within confined spaces or damaged vehicles) or the injury or illness may make extrication difficult (such as when a person has hypotension or possible spinal injuries).
Safety in manual handling and extrication is important for both staff and patients to avoid injury. In Great Britain, 470 000 workers developed a work-related musculoskeletal disorder during 2020–21 (Health and Safety Executive, 2023). Each year in the UK, 300 000 people experience back pain caused by manual handling accidents (Unison, 2023). NHS Resolution (2020) paid out £57 million in damages, claimant legal costs and NHS legal expenses for over 2000 settled claims relating to manual handling to patients and staff between 2009 and 2019, with back (45%) and upper limb (30%) claims constituting the highest proportion. Effective manual handling and extrication training is therefore essential to prevent patient and staff injury and to lessen the financial implications.
In the UK, student paramedics receive their initial manual handling and extrication training at university, with simulation often used. Simulation is a technique of experiential learning with learners interacting with realistic encounters within controlled environments, evaluating their performance and learning from mistakes (Lumsden and Byrne-Davis, 2015). These simulations can be conducted within or outside a classroom and may involve real-world resources such as vehicles, equipment and interprofessional collaboration with fire and rescue services, for example.
Children's soft play areas offer intricate and confined spaces to deliver manual handling and extrication training to student paramedics and emergency medical technicians. The aim of this study was to determine student paramedics' and emergency medical technicians' satisfaction and self-confidence in a novel moving, handling and extrication simulation exercise in a children's soft play area.
Methods
Study design
A cross-sectional, mixed-methods survey design (Quinn, 2022) was adopted.
Setting
A higher education institution (HEI) providing a preregistration 3-year bachelor's degree for paramedic science students within the UK was selected as the setting. The HEI also provided education for emergency medical technicians as part of a certificate of higher education, which is a 1-year programme. The HEI was in a city and enrolled up to 50 students in both programmes per academic year.
Simulation activity
The simulation activity was conceived, developed and facilitated by John McKenzie and Emma Horne, senior lecturers in paramedic science at the University of Lincoln. The activity aimed to test students' moving, handling and extrication of simulated patients with traumatic injuries in a children's soft play area.
A local children's soft play facility was approached, which consented to the simulation being carried out on their premises. A basic structure of operations was planned and risk assessed.
The simulation involved four scenarios, which were completed over 3 hours. Scenarios were facilitated by the authors along with Harriet Marchant, a newly qualified paramedic who graduated from the University of Lincoln, plus third-year Lincoln student paramedics David Grant and William Mason. Each simulation lasted 30 minutes in total, consisting of a 5-minute briefing and a 15-minute scenario followed by a 10-minute feedback and reflective discussion.
Scenarios included:
The scenarios focused on early recognition and communication, teamwork and safe manual handling and extrication, rather than clinical management of conditions. A description of each scenario can be found in the supplementary material online. These objectives were established before the simulation was designed, in line with the standards set out by the International Nursing Association for Clinical Simulation and Learning standards and as advised by several handbooks (Hellaby, 2013; Davis et al, 2017; Watts et al, 2021).
Four scoop stretchers plus straps and head blocks were used during the simulation activity. Because of the nature of the soft play area, no sharps or other medical equipment were used to prevent damage and minimise the risk of equipment being lost.
Participant recruitment
Attendance at the simulation activity was mandatory for all students on the certificate of higher education programme and in the first year of the bachelor's degree course (n=50). These students had limited experience and knowledge of trauma assessment and extrication, with some having no clinical experience at the time of the activity. Participation in this research study was voluntary.
A participant information leaflet was given to the students >24 hours before the teaching session. Students decided the following day whether they wanted to take part in the research and complete the survey. Before the survey was completed, written informed consent was obtained.
A sample size calculation was not performed as the simulation activity was a local event at one HEI and the full cohort of students, who had to attend the event as part of their timetabled university education, were invited to participate. Although a larger sample size may have delivered more convincing conclusions, for a small, homogenous pilot study, this convenience sample was deemed representative.
Data collection
A survey was developed, printed and provided to students who wished to participate in the research on the day of the simulation exercise.
The Student Satisfaction and Self-Confidence in Learning validated survey tool (National League for Nursing, 2005) was used within the survey in the present study; see supplementary file online for the original survey and the final survey used in this study. This tool has been deemed valid and reliable (Franklin et al, 2014) and has been used to good effect in similar studies (Zapko et al, 2018; Pence, 2022).
An open question for comments and additional feedback was provided at the end of the survey to capture qualitative data.
Data analysis
Descriptive statistics were calculated for the participant characteristics, including medians with interquartile ranges and proportions. Survey responses were provided in tabular format with medians (interquartile ranges) and a narrative discussion.
Thematic analysis (Braun and Clarke, 2006) was conducted on the qualitative feedback received. Because the date captured originated from limited and brief responses, the thematic analysis did not require any software and was deemed inductive, descriptive and semantic (Braun and Clarke, 2019).
Patient and public involvement
There was no input from patients or members of the public. The authors sought input from two final-year BSc paramedic science students (BS and ERT), who assisted with study design, interpretation and write-up. This was to ensure that the design, delivery and interpretation within this study were developed with students, ensuring that the implications and recommendations would be amenable to students in the future.
Ethical considerations
Ethical approval was gained from the University of Lincoln (ref 2022_7982). Students were provided with a participation information sheet and written informed consent was gained before participation.
Results
Of the 50 students who were invited to the simulation activity, 45 attended and 43 gave written consent and took part in the study (96%). Participants were in a broad range of age (18–47 years) and the majority were women (72%) (Table 1).
| Characteristic | Value |
|---|---|
| Age: years | |
| Median (interquartile range) | 20 (19–25) |
| Mean | 23.28 |
| Range | 18–47 |
| Standard deviation | 7.08 |
| Sex: n (%) | |
| Male | 12 (28) |
| Female | 31 (72) |
| Total | 43 (100) |
Data provided in the survey were extracted and presented in tabular format. Table 2 shows the quantitative survey data.
| Unique to exercise | SD n (%) | D n (%) | U n (%) | A n (%) | SA n (%) | Total n (%) |
|---|---|---|---|---|---|---|
| Satisfaction with learning | ||||||
| 1. The teaching methods used in this simulation were helpful and effective | 0 | 0 | 0 | 10 (23) | 33 (77) | 43 (100) |
| 2. The simulation provided me with a variety of learning materials and activities | 0 | 0 | 3 (7) | 12 (28) | 28 (65) | 43 (100) |
| 3. I enjoyed how my instructor taught the simulation | 0 | 0 | 1 (2) | 10 (23) | 32 (74) | 43 (100) |
| Self-confidence in learning | ||||||
| 4. The teaching materials used in this simulation were motivating and helped me to learn | 0 | 0 | 2 (5) | 13 (30) | 28 (65) | 43 (100) |
| 5. The way my instructor(s) taught the simulation was suitable to the way I learn | 0 | 0 | 0 | 8 (19) | 35 (81) | 43 (100) |
| 6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me | 0 | 1 (2) | 2 (5) | 19 (44) | 21 (49) | 43 (100) |
| 7. I am confident that this simulation covered critical content necessary for the mastery of the medical-surgical curriculum | 0 | 1 (2) | 1 (2) | 12 (28) | 29 (67) | 43 (100) |
| 8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting | 0 | 0 | 1 (2) | 16 (37) | 26 (60) | 43 (100) |
| 9. My instructors used helpful resources to teach the simulation | 0 | 1 (2) | 2 (5) | 16 (37) | 24 (56) | 43 (100) |
| 10. It is my responsibility as the student to learn what I need to know from this simulation activity | 0 | 0 | 0 | 15 (35) | 28 (65) | 43 (100) |
| 11. I know how to get help when I do not understand the concepts covered in the simulation | 0 | 0 | 1 (2) | 12 (28) | 30 (70) | 43 (100) |
| 12. I know how to use simulation activities to learn critical aspects of these skills | 0 | 0 | 0 | 17 (40) | 26 (60) | 43 (100) |
| 13. It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time | 0 | 2 (5) | 9 (21) | 15 (35) | 17 (40) | 43 (100) |
SD: strongly disagree; D: disagree; U: undecided; A: agree; SA: strongly agree
Student paramedics and student emergency medical technicians were satisfied with both their learning and their self-confidence regarding what they had learned after the simulation event (Table 2).
Heterogeneity of answers within the survey was limited but, as it used a validated tool with a homogenous sample, this is to be expected. It can be said that using a reliable survey in this way minimises the chance of errors or inconsistencies resulting from scale completion among the sample.
The qualitative data were presented as a thematic map (Figure 2), and discussed in relation to the themes identified—communication and teamwork; realism; and enjoyment—with direct quotations to support each theme.
Theme 1. Communication and teamwork
Participants stated that the novel simulation activity coupled with working in groups and facilitated by members of faculty and third-year student paramedics provided an opportunity for them to develop their communication and teamwork skills. They reported enhanced communication and teamwork skills after the simulation event:
‘Although I wasn't convinced that the activity would be very helpful, it actually was. It made me think about the situations I was faced with and made me think outside the box. It also strengthened our communication skills with each other and working as a team.’
‘The scenarios used allowed us to think about the different ways to extricate patients safely and look ahead as well as developing skills such as communications and teamwork.’
Theme 2. Realism
Participants stated that the ‘real-world’ aspect of the simulation was beneficial and that education was brought to life when conducted in such settings such as the soft play area rather than in simulation suites:
‘The scenarios practised were very realistic but also challenging. We had sufficient time to complete each one, allowing me to thoroughly practise my skills in real time. Feedback from third-year students was also very helpful and I felt confident after leaving this exercise in extrication and how I would treat patients.’
‘Felt more #real life—in a good way—than in simulation suite.’
Some participants commented on the lack of realism, specifically that it would have been beneficial to work in groups of two as occurs in clinical practice, and then perhaps have additional resources arrive on scene after the initial assessment to facilitate extrication:
‘As it is unlikely that we would respond to an incident in a team of four; initially, it would be more realistic to respond as a team of two and others arrive afterwards. Also, allocate a team leader for each scenario so we get used to various roles.’
Theme 3. Enjoyment
There was a clear sense of enjoyment among the participants, with the non-classroom approach praised by many and the setting of a soft play area creating additional enjoyment and stimulus.
Most reported a positive experience, and facilitation of scenarios by current and previous students was well received:
‘I thoroughly enjoyed the play zone simulation activity. I thought it was really engaging and allowed us to use our brains in different and creative ways as, in practice, situations are not always textbook. I think it was a really great idea using third-years and newly qualified paramedics who qualified through Lincoln University also.’
‘I thoroughly enjoyed the simulation. I felt that performing extrications in a non-classroom environment was not only fun but also helpful in demonstrating how environments will be drastically different when out on the road.’
Discussion
This study found that ambulance clinician students were satisfied in their learning and were self-confident in their learning after the novel moving, handling and extrication simulation activity in a children's soft play area.
The students enjoyed the event and preferred real-world over classroom-based simulation. They also felt the simulation was realistic, although suggestions were made to improve the realism, specifically by using smaller groups or pairs to better reflect clinical practice.
Students also felt their communication and teamwork skills improved as a result of participating in the simulation event.
While the suggestions give an insight into students' perceptions, it would be difficult to replicate the day with smaller groups because of the additional time burden. It might also be suggested that operating within smaller groups could reduce the necessity of teamwork, affecting what is a strong theme elsewhere in the results. This would have a knock-on effect with the cost of the facility; the space for this pilot project was provided free in return for some publicity but it would otherwise have been charged for at a commercial daily rate.
Simulation is becoming increasingly popular within healthcare education (Herrera-Aliaga and Estrada, 2022). A recent systematic review and meta-analysis from the field of nursing education showed that simulation-based education has strong effects, particularly in the psychomotor domain; however a variety of educational interventions are required to meet educational goals using different levels of fidelity based on the desired outcomes (Watts et al, 2021).
The interaction between play and simulation is well established in terms of toy manufacturers applying their skills to create ‘proxy patients’ (Watts et al, 2021). In the field of medical education, simulation has been growing over the past 40 years and will likely continue playing a significant role in the education of doctors (Kim et al, 2016).
Simulation-based medical education is a complex intervention that requires cautious consideration of the following to ensure success: feedback; curriculum integration; outcome measurement; fidelity; instructor training; and skill acquisition and maintenance (McGaghie et al, 2010). No mention could be found in the extant literature of using equipment designed primarily for play in healthcare simulation. Anecdotally, other organisations such as the fire service and military use high-fidelity environments for simulation but these tend to be within realistic environments as opposed to the low-fidelity, high-safety environment demonstrated here.
Given recent advances in technology, virtual reality has gained momentum as an educational intervention for healthcare courses (Pottle, 2019). The future of virtual reality in healthcare education will likely depend on the aforementioned criteria for simulation success, particularly fidelity. Virtual reality is unlikely to fully replace physical real-world training in manual handling and extrication; however, it may prove useful to develop skills such as planning, preparation and coordination within a team.
The power of enjoyment in education should not be underestimated. A recent UK study found associations between enjoyment and improved educational outcomes in 6-year-old children (Morris et al, 2021). Fun and enjoyment in adult learning may also increase attendance rates, improve learning and help maintain the learner concentration (Lucardie, 2014).
Extrication in the prehospital setting has undergone significant changes over the past 40 years, particularly for traumatically injured patients, where full spinal immobilisation including cervical collars, long boards and head blocks, was standard practice (White et al, 2014; Feld et al, 2018). Many pieces of traditional ambulance equipment are infrequently used, such as vest-style extrication devices, cervical collars and rigid long boards, especially given the rise of recent evidence for a more relaxed approach to cervical spine management (Kreinest et al, 2016; Maschmann et al, 2019).
Limitations
This study assessed students' satisfaction with their learning and self-confidence in what they had learnt at one point in time in relation to a specific simulation activity. This was not a before-and-after study so the authors were unable to infer any improvement in confidence or satisfaction for these students over time. They were only able to comment on student satisfaction and self-confidence at the time of the assessment.
Associations between training and improved clinical practice and safety are difficult to determine. The authors were unable to ascertain the real-world benefit of this educational simulation in terms of patient and staff safety.
Implications for research
A before-and-after study including a control group would be useful to determine the real impact of this simulated activity on st22™udent satisfaction and self-confidence. An adequate sample size would need to be determined and recruited.
Determining the impact of simulation activities on future patient and staff safety requires experimental or quasi-experimental research designs with a substantial follow-up period. Such designs should be considered where educational activities have shown promise via less rigorous designs.
Implications for education
High-fidelity simulation outside the classroom environment is recommended to increase student satisfaction and promote enjoyment.
Where possible, simulation activities should be fun and enjoyable so they improve attendance, learning and concentration. While a children's soft play area was used within this study, many other fun settings exist that could be used, such as public and amusement parks.
Given the shift in clinical practice away from full spinal immobilisation, education and training should reflect this with caution, as ambulance clinician students are likely to attend patients who still require spinal immobilisation. It should be stressed that such procedures will apply to the minority rather than the majority of traumatically injured patients.
Conclusion
The use of a children's soft play area for a moving, handling and extrication simulation for healthcare students provided satisfaction and self-confidence in learning. Enriching simulation activities by changing environments with the use of different settings can increase variety and improve the student experience and may give educators new avenues to develop their own curricula throughout healthcare.