Simulation is being used in educational institutions to teach skills needed for professional nursing practice (Comer, 2005). Simulations of real-life scenarios directly link course theory to practice in a controlled learning environment, allowing learners to develop essential skills, gain confidence, and experience empathy (King, Hill, & Gleason, 2015) without threatening patient safety (Davies, Nathan, & Clarke, 2016). During the debriefing, learners process and evaluate new knowledge attained. Simulation through gaming is one example of a learner-centered activity that engages learners in the learning process (Strickland & Kaylor, 2016), facilitates attainment of desired learning outcomes (Day-Black, Merrill, Konzelman, Williams, & Hart, 2015), and promotes learner preparation for the professional nursing role.
Simulation Game as a Teaching Strategy
The goals of the Friday Night at the ER simulation game (available at https://fridaynightattheer.com) used in a senior leadership course was to promote systems thinking, data-based decision making, collaboration, and fiscally efficient quality care. During the game, learners work in groups of five, with four learners assuming the role of a leader or manager of one of four units in a health care organization—the emergency department, intensive care, step down, and the operating department. The fifth learner completes required documentation each hour. This recorded information calculated the learner group scores in relation to quality and cost outcomes at the end of the game. Learners have 1 hour of play time to complete the 24 hours of Friday Night at the ER events. The 1-hour time frame allotted promotes a sense of urgency. Learners must end the game at this time. Failure to complete the game affects quality and costs group scores. The real-life situations presented during the game represent problems commonly faced by manager–leaders in health care organizations. Coping with relevant situations is a key component of a role-play activity (Smith, Warland, & Smith, 2012).
Synthesis and Reflection
The Debriefing Process
The debriefing process follows the 1 hour of play time and was composed of two steps. Each step focused on the role-play simulation experience. The debriefing process and ensuing discussion prompted reflection that promoted synthesis of new knowledge gained.
Step One: Group Performance according to Cost and Quality. The data calculate learner group performance according to quality outcomes achieved and costs incurred due to the decisions made. These data were posted, and the learner groups spent time reviewing and comparing differences between the group performances. The group with the lowest costs credited its low score to knowledge gained during the game play, including “it was cheaper to call in staff and pay overtime then divert patients to another agency.” The learner group whose quality performance was highest reported it had decided to place two patients in each room of the emergency department to avoid patient wait, understanding the impact of waiting on patients' perceived quality of care. At the same time, this learner group reviewed staffing and the patient census for all units. The decision was made to either reassign the extra staff to the emergency department or call in the needed resources, understanding that patient numbers justified the cost incurred with the addition of staff.
Step Two: Reflective Questions. Learners discussed two reflective questions in step two and responded in a group written assignment. The first question posed was “What felt real?” Learners provided multiple responses to this question that reflected the emotions evoked during the game. Some examples are:
- Making decisions weighing both patient safety and costs was challenging due to staffing shortages, and the hour-to-hour unknowns.
- It was overwhelming and frustrating being the manager responsible for patient care.
- We experienced a true sense of panic when the patients in the emergency [department] exceeded capacity.
- Being a calm leader–manager when feeling stressed and pressured was important to promote teamwork and the collaboration required to resolve the complex hourly events faced.
The second question of the assignment was “What strategies were used during the game?” The intent of this question was to prompt critical thinking, problem solving, collaboration, or leadership. A few learner responses are:
- It is cost efficient to float staff nurses from other units to replace higher paid resource staff.
- Reassigning nurses from other units and sister hospitals should be based upon competency.
- Collaborating with other managers as a team shares responsibility to problem solve issues that arise.
One learner group suggested staffing bonuses. The discussion that ensued challenged this idea as a short-term and costly strategy, suggesting the bonus amount would need to increase with each offer. The discussion exemplified problem solving and critical thinking skills.
The final question challenged learners to identify “factors that influenced decision-making.” Sample responses are as follows:
- The primary factors influencing decision making were cost and quality. The cost for a patient to wait was similar to four extra staff and patient satisfaction was impacted by wait time.
- It is important to be informed of hospital policy and procedures.
- Anticipating staffing needs frequently due to continuous change.
- Have a float pool as a staffing resource versus using outside agencies.
Responses to this final question suggest that learners were linking the leader–manager role to a system viewpoint. In fact, learners also reported that the units should not be managed individually, but rather as a whole system through collaboration, clarifying understanding that everyone was responsible for patient care delivery and throughput.
Conclusions and Implications for Nursing Practice
Experiential learning using the simulation game provided learners the opportunity to practice and strengthen needed leader–manager competencies. Empathy of the leader–manager role was achieved. Learners reported that the role-play simulation evoked emotions commonly experienced by leader–managers in practice. In fact, learners shared that they felt the manager of the emergency department had the hardest role of all. The simulation prompted systems thinking that aligned with the desired learning outcomes. Learner responses also suggested that additional course-related concepts addressed included conflict resolution, budget control, teamwork, communication, and leadership.
Although the focus of this simulation activity included prelicensure learners, in order to advance the science of nursing education, this work should be replicated in various settings with various learners to enhance the ability of health care professionals to provide high-quality care. The course concepts are relevant to all practicing nurse professionals. In addition, the simulation could be adapted to support interprofessional communication and collaboration.
- Comer, S. (2005). Patient care simulations: Role playing to enhance clinical understanding. Nursing Education Perspectives26(6), 357–360.
- Davies, J., Nathan, M. & Clarke, D. (2012). An evaluation of a complex simulated scenario with final year undergraduate children's nursing students. Collegian, 19, 131–138. http://dx.doi.org/10.1016/j.colegn.2012.04.005 doi:10.1016/j.colegn.2012.04.005 [CrossRef]
- Day-Black, C., Merrill, E., Konzelman, L., Williams, T. & Hart, N., (2015). Gamification: An innovative teaching–learning strategy for the digital nursing students in a community health nursing course. Association of Black Nursing Faculty (ABNF), 26, 90–94.
- King, J., Hill, K. & Gleeson, A., (2015). All the world's a stage: Evaluating psychiatry role-play based learning for medical students. Australasian Psychiatry, 23(1),76–79. doi:10.1177/1039856214563846 [CrossRef]
- Smith, M., Warland, J. & Smith, C. (2012). An innovative strategy in evaluation: Using a student engagement framework to evaluate a role-based simulation. Journal of Nursing Education, 51, 151–154. doi:10.3928/01484834-20120127-03 [CrossRef]
- Strickland, H. & Kaylor, S. (2016). Bringing your a-game: Educational gaming for student success. Nurse Education Today, 40, 101–103. doi:10.1016/j.nedt.2016.02.014 [CrossRef]