Journal of Nursing Education

Major Article 

Critical Thinking Among Rn-to-Bsn Distance Students Participating in Human Patient Simulation

Kathy L. Rush, PhD, RN; Cathy E. Dyches, PhD, RN; Susannah Waldrop, MS; Angie Davis, DSN, RN


Simulation is a strategy increasingly being used to promote critical thinking skills among baccalaureate nursing (BSN) students. It has been used to a limited extent with RN-to-BSN students, many of whom take their educational program through distance delivery. The purpose of this qualitative study was to understand the critical thinking of distance RN-to-BSN students who participated in a simulation designed with interactive questions. Students taking the program, either by live televised broadcast (educational television [ETV]) or by online instruction, participated in the simulation. The ETV student simulation was facilitated from a broadcast studio by faculty, whereas Internet students completed the simulation by DVD. Postsimulation students participated in debriefing sessions, which were audiotaped by ETV students and completed by Internet students using a Blackboard® discussion board. Data were analyzed using Scheffer and Rubenfeld’s conceptualization of critical thinking. Findings revealed that simulation used by distance delivery cultivated critical thinking in RN-to-BSN students.


Simulation is a strategy increasingly being used to promote critical thinking skills among baccalaureate nursing (BSN) students. It has been used to a limited extent with RN-to-BSN students, many of whom take their educational program through distance delivery. The purpose of this qualitative study was to understand the critical thinking of distance RN-to-BSN students who participated in a simulation designed with interactive questions. Students taking the program, either by live televised broadcast (educational television [ETV]) or by online instruction, participated in the simulation. The ETV student simulation was facilitated from a broadcast studio by faculty, whereas Internet students completed the simulation by DVD. Postsimulation students participated in debriefing sessions, which were audiotaped by ETV students and completed by Internet students using a Blackboard® discussion board. Data were analyzed using Scheffer and Rubenfeld’s conceptualization of critical thinking. Findings revealed that simulation used by distance delivery cultivated critical thinking in RN-to-BSN students.

Dr. Rush is Acting Dean, Faculty of Health and Social Development, University of British Columbia Okanagan, British Columbia, Canada; Dr. Dyches is Professor, School of Nursing, Brenau University, Gainesville, Georgia; Ms. Waldrop is Director of Nursing Student Services, and Dr. Davis is Associate Professor, Mary Black School of Nursing, University of South Carolina Upstate, Spartanburg, South Carolina.

The authors thank University of South Carolina Upstate for the Research Incentive Award to support this study, and the RN-to-BSN students who participated in and made possible this study.

Address correspondence to Kathy L. Rush, PhD, RN, Acting Dean, Faculty of Health and Social Development, University of British Columbia Okanagan, 3333 University Way, Kelowna, British Columbia, Canada, V1V 1V7; e-mail:

Received: April 09, 2007
Accepted: May 27, 2008

The development of critical thinking for nurses begins during their basic educational program. It does not end with the completion of formal education, but continues to be refined, strengthened, and synthesized within clinical practice (Rapps, Riegel, & Glaser, 2001). Nurses who continue their baccalaureate education after practicing for a period of time, as is the case with RN-to-baccalaureate nursing (BSN) students, are uniquely positioned to have their critical thinking expanded still further.

Although critical thinking is an important outcome of the professional education of BSN students (American Association of Colleges of Nursing, 1998; National League for Nursing, 1992), research suggests that nursing education has little influence on critical thinking among post-RN students (White & Gomez, 2002; Worrell & Profetto-McGrath, 2007). Several studies have examined the influence of baccalaureate curricula on critical thinking among RN-to-BSN students with equivocal results (Brown, Alverson, & Pepa, 2001; Shin, Jung, Shin, & Kim, 2006). Although increases in critical thinking from program entry to exit have been reported in RN-to-BSN students (Brown et al., 2001; Miller, 1992), deficits have likewise been observed (Shin et al., 2006; Sullivan, 1987; White & Gomez, 2002). Compared with generic BSN students, the critical thinking skills of RN-to-BSN students, students with an associate degree in nursing, and diploma students have been found to be significantly lower regardless of the measure of critical thinking used (Brooks & Shepherd, 1992; Shin et al., 2006).

These conflicting findings reflect a predominantly quantitative research focus that emphasizes critical thinking as a curricular outcome. Such an emphasis obscures critical thinking as an evolutionary and context-dependent process, a perspective that has emerged in qualitative research with basic baccalaureate students (Hicks, 2001). For RN-to-BSN students, who bring extensive experience to baccalaureate education, a process orientation offers a way to access, illuminate, and uncover the critical thinking embedded in their experience and practice. Consistent with an evolutionary critical thinking process, specific learning strategies that incorporate practice situations and capitalize on the experiences of post-RN students may advance the critical thinking of this student group. Yet, few studies have examined specific learning strategies that promote the critical thinking of RN-to-BSN students.

Patient simulation is one strategy that has been used to a limited extent with RN-to-BSN students, but the facilitative role of experience in developing critical thinking reported in conjunction with simulation makes it an ideal strategy for this student group (Martin, 2002; Weis & Guyton-Simmons, 1998). Although high-fidelity, computer-based simulation is increasingly replacing low-fidelity simulation, the value of low fidelity and intermediate fidelity have been demonstrated (Grober et al., 2004; Wilson, Shepherd, Kelly, & Pitzner, 2005). Martin (2002) found that critical thinking during videotaped simulated clinical situations lasting 1 to 2 minutes increased with the level of clinical expertise, being greatest among expert nurses, followed by graduate and undergraduate students. Similarly, Yeh and Chen (2005) observed a significant positive correlation between years of work experience and critical thinking skills among Taiwanese RN-to-BSN students, using interactive videodiscs that incorporated situations simulating real scenarios. The use of an intermediate-fidelity simulation also has been shown to improve student performance (Alinier, Hunt, Gordon, & Harwood, 2006); however, no studies have explored its influence on critical thinking.

Studies that have examined the critical thinking of RN-to-BSN students using simulated experiences have been limited to traditional onsite delivery. Few studies have used human patient simulation with distance students. Although the use of simulation may appear antithetical to distance learning and pose pragmatic challenges, lower fidelity simulation may produce gains in critical thinking not possible with other learning strategies. In addition, there have been no qualitative studies capturing the critical thinking processes of RN-to-BSN students during human patient simulation conducted through distance delivery. Therefore, the purpose of this pilot study was to explore critical thinking among distance education RN-to-BSN students participating in an intermediate-fidelity simulation experience.



This study used an exploratory qualitative approach to study critical thinking among RN-to-BSN students participating in a simulation through distance delivery.


A convenience sample of 33 first-semester RN-to-BSN students in their distance delivery program located in the southeastern United States served as the study sample. Students in the distance program were scattered throughout the state and were taking the program either by live televised broadcast (educational television [ETV]) or by online instruction. Student participants were obtained from sections of distance RN-to-BSN students taking a semester-long health assessment course not being taught by the researchers. Sample demographic information is presented in Table 1.

Description of Sample (N = 33)

Table 1: Description of Sample (N = 33)

Development of the Simulations

An intermediate-fidelity simulation that combined multimedia technologies and SimMan®, a fully computer-operated total body simulator, was developed. The slightly lower fidelity (realism) level of the simulation reflected the need to preprogram a faculty-developed and scripted scenario (Table 2) to meet the needs of distance students. Once written, the simulated script was role-played by three faculty members and recorded for audiovisual production by university media personnel. After editing, interactive questions were inserted at strategic points throughout the videotape, and the simulation was subsequently burned onto a DVD for use by Internet students. Designed using intermediate-fidelity, the simulation did not involve hands-on learning occurring in real time nor the level of interactivity of a high-fidelity patient simulation (Wilson et al., 2005). Although not characterized by the level of technical complexity and feedback of high-fidelity patient simulation, the prerecorded simulated cardio-respiratory assessment combined a talk-aloud approach by the teacher and digitally added questions to actively prompt students to respond to ongoing assessment findings (changes in patient heart or breath sounds, cardiac rhythms, and vital signs as the patient’s condition deteriorated).

Description of Simulation Scenario

Table 2: Description of Simulation Scenario

Data Collection

Following institutional review board approval, ETV students were introduced to the study during their 2-hour health assessment class held the week prior to the simulation, whereas Internet students were introduced to the study by an online Blackboard® posting. Simulation was mandatory and was designed to replace a traditional class lecture on cardio-respiratory assessment. Students were told their consent gave researchers permission to use their data. Data collection packets were sent to all students: individual packets went to Internet students, whereas ETV student groups at five distance sites received collective packets. All packets included a debriefing instruction sheet with questions, as well as an informed consent form and background personal information sheet for each student. Audiotape recorders and audiotapes were included in each of the ETV collective packets, and simulation DVDs and forms for written responses to the interactive questions were added to Internet student packets. Students were asked to complete the consent and background information forms if they agreed to allow their data be used and to return these forms to the RN-to-BSN coordinator in the stamped self-addressed envelopes that were provided. In addition, ETV student groups were asked to return recorders and taped debriefing sessions, and Internet students were asked to provide their individual responses to the simulation interactive questions.

The simulated learning experience was similar in several respects for both ETV and Internet students; the differences in instructional approaches are outlined in Table 3. Prior to the simulation, all students were assigned preparatory readings and questions. During their weekly 2-hour class, ETV students participated in a videotaped simulation facilitated by two of the researchers (K.L.R., C.E.D.), who had role-played the scenario and were experienced teachers in both distance education and health assessment but were new to simulation. Throughout the simulation, the videotape was paused to allow students time to respond to the interactive questions. Internet students completed the same simulated scenario by DVD on an individual basis and, as with other course content areas, were given 1 week to provide written responses to the interactive questions. Subsequently, they were given collated feedback on a Blackboard discussion board.

Comparison Between Simulation Instruction for Educational Television (ETV) and Internet RN-To-BSN Students

Table 3: Comparison Between Simulation Instruction for Educational Television (ETV) and Internet RN-To-BSN Students

After the simulation, students engaged in a debriefing process, responding to a series of researcher-prepared questions that addressed topics such as the value of the simulation, what they would do differently, their confidence in performing cardio-respiratory assessment, and their priority nursing diagnoses and interventions. ETV students audiotaped the debriefing sessions in small groups using mini-tape recorders, with one student serving as facilitator to lead the group through the questions and another student managing the recorder. Internet students conducted the debriefing as one large group by way of an asynchronous Blackboard discussion.

Data Analysis

Personal background information was analyzed using descriptive statistics, including means and percentages. The ETV students’ audiotaped debriefing sessions were transcribed verbatim, and the Internet students’ Blackboard debriefing sessions were printed as hard copies. The data were analyzed using the conceptualization of critical thinking by Scheffer and Rubenfeld (2000). This is a unique nursing framework, derived inductively by a Delphi-generated consensus of experts, which includes 10 habits of the mind and 7 skills for critical thinking. Habits of the mind describe the affective predispositions in thinking, and skills refer to the cognitive components in thinking (Scheffer & Rubenfeld, 2000). The data were coded for the 17 major components of the framework by a single experienced coder, and coding decisions were verified by a second experienced coder to ensure that data were being categorized consistently (K.L.R., C.E.D.). When there were discrepancies, differences were discussed and mutual agreement was reached regarding the appropriate categorization of data.


All critical thinking habits of the mind and skills as conceptualized by Scheffer and Rubenfeld (2000) appeared among RN-to-BSN students during the simulation experience. Findings are reported according to the two main categories of Habits of the Mind, and Skills.

Habits of the Mind

Confidence. The confidence of RN-to-BSN students was affected to varying degrees, reflecting differences in practice experience, delivery method, and simulation focus. Confidence was influenced by the proximity of students’ current practice to the simulation scenario. Students whose practice shared similarities with the patient simulation expressed little change in confidence because the simulation “reinforced what I already know.” Students whose practice was unlike the simulated patient expressed either the need for more practice to promote confidence or the value of the simulation in building confidence, as noted by one ETV student:

I think it has [increased my confidence] because you can say “I’ve seen this and I’ve heard this and I know what this is now” rather than guessing or something like that. It’s a whole lot easier and you feel a whole lot more comfortable with dealing with this kind of situation.

Students associated increased confidence in assessment with their enhanced knowledge of the underlying physiology. One student articulated:

It has increased my confidence level. I feel I’m able to assess and know what signs and symptoms to look for in a patient in some type of heart failure.

The delivery method and focus of the simulation affected confidence. Students expressed the simulation focus on assessment as a limitation to confidence building because it “didn’t show anything regarding the care for a patient in this situation.” Internet students found that the lack of immediate feedback and instructor validation associated with the DVD format influenced their confidence in making assessments and interpreting data. An Internet student highlighted how the lack of immediate feedback affected her confidence:

The video showed assessment techniques. It would be nice for it to ask the questions and then give the results that you should have gotten. Right now, I know I did the best I could but I’m not positive that I saw [and] heard what I was intended to observe.

Contextual Perspective. Students spoke repeatedly about the value of the simulation in providing a contextual perspective. One student expressed:

I learned to look at the whole picture. You have to put all the pieces together to figure out what’s going on with the patient.

One ETV student even created the context in which she viewed and performed the assessment by imagining the patient situation taking place in the emergency department, her area of practice.

Creativity. The simulation prompted students to create their own ideas about performing the assessment and reflected their perceptions of the reality of the simulation. Students who found the simulation a poor reflection of their reality responded to the simulation by proposing alternative approaches, emphasizing different sequencing, pacing, and priority setting. This creativity is reflected in the following ETV student’s comment:

We would have done things a little bit differently than they showed here. It was very slow and we would have moved a lot faster and you have to prioritize and you have to deal with the main thing first.

Flexibility and Open-Mindedness. Varying levels of flexibility and open-mindedness were evident among RN-to-BSN student participants, reflecting differences in their experiences and backgrounds. Many RN-to-BSN students came to the simulation with well-established practices and ways of thinking and doing that served both to hinder and to facilitate flexibility and openness. For some students, the familiarity of the simulated patient with everyday practice made it challenging to see ways their existing assessment skills could be modified or expanded. Other students, despite this familiarity, spoke of new skills they had learned, as articulated by one Internet student:

It was a good review that I feel I can [use to] build my skill level…. For me, seeing how someone else does a particular skill allows me to find what I like about it, and build off of it.

Despite the preprogrammed simulation that fixed the assessment to some extent, these experienced practitioners responded with remarkable flexibility. This was observed as they responded to the immediacy of the patient’s emergent situation, recognizing the need to modify the simulated comprehensive assessment to a “focused” assessment.

Inquisitiveness and Perseverance. Questions inserted throughout the simulation were a built-in way to foster inquisitiveness. Inquisitiveness was influenced by differences in the simulation delivery method, with Internet students showing more evidence of this habit than did ETV students. The effort expended by one Internet student to know and understand the findings from the simulated assessment is expressed as, “I reviewed the DVD twice and did pick up on something different each time.”

Perseverance similarly showed differences between ETV and Internet students, with this habit appearing to a greater extent in Internet students versus ETV students. Perseverance was expressed by one Internet student who verbalized her determined pursuit in differentiating S2 and split S3 heart sounds:

It was hard going back and forth between the simulation DVD and the assessment DVD of heart and lung sounds.

Intuition. The intuition of the expert practitioner, which described many of the RN-to-BSN students, was evoked by the simulation. RN-to-BSN students described immediate “gut reactions” to the assessment findings, as captured by one ETV group in the following way:

While we were watching the assessment, we could sit there and say “this was going on, this was going on, this is going on.” We kind of already knew by what the patient was saying and what the instructor was saying what was going on already…. “Okay, this is going on so this, this, this needs to be done.”

At the same time it evoked intuition, simulation also created new mental models, the building blocks of intuition, by giving students pictures they perceived would help guide them in practice. This is reflected in the following student statement:

And when we see some of these things going on, we will already have seen something similar to it even though this was just a [manikin]. It did give us a picture of what might be happening or what to look for in a patient.

Intellectual Integrity. RN-to-BSN students demonstrated various degrees of intellectual integrity, from those who honestly pursued correct and validated conclusions, to those who quickly arrived at questionable conclusions because of premature closure. One ETV group described a high level of intellectual integrity:

At the very, very first, because her chest was so barreled,…at first we weren’t sure whether it was just a bad case of [chronic obstructive pulmonary disease] exacerbation or if it was actually heart failure, but as the assessment went on we began to identify it more as heart failure.

Reflection. The debriefing session that followed simulation engaged students in reflection. It gave students the opportunity to gain insights into their thinking and to promote deeper understanding and self-evaluation. Such insight was expressed by an Internet student who experienced a shift from seeing assessment as a task to an opportunity to listen and get to know the patient.


Analyzing. The in-depth nature of the assessment findings required students to make interpretations to gain an understanding of the patient’s problem. Gaps in analysis were evident, with RN-to-BSN students experiencing difficulty in looking at the assessment findings and categorizing the data to arrive at nursing diagnoses. For example, students could see by the end of the simulation that the patient had heart failure but did not identify altered cardiac output as the key priority nursing diagnosis. In addition, RN-to-BSN students experienced the tension between attending to the parts of the assessment and connecting it to the larger context of interventions. This was expressed by an ETV student:

She [the instructor] didn’t ask us so much what we would do as she was assessing each system and going on and finding things that were wrong and asking us what’s wrong and what’s different in this picture, not what we would do in this case.

Applying Standards. RN-to-BSN students applied standards throughout the simulation as they interpreted assessment findings, such as vital signs, breath sounds, heart sounds, edema, and color, and compared them with normative criteria. This critical thinking skill includes understanding changes in the role parameters of nursing and medical practice. Although RN-to-BSN students were being introduced to expanded, in-depth health assessment skills, they were cautious in articulating changes in their role perceptions, as alluded to by an ETV student:

We all can sit here and tell you that we know what S1 and S2 sounds like but when you throw another sound in there you know its not my job to say “hey he’s got this or he’s got that.” My job is to say “I hear another sound. I’m not really sure what it is.”… You bet your bottom dollar I’m going to find somebody that’s going to be able to help me.

Discriminating. RN-to-BSN students were discriminating as they distinguished crucial pieces of information from those of less importance. One Internet student described it as, “I learned what was important in an assessment and what could be done later.” Although students discriminated in terms of triaging priority assessments, discrimination was less evident when it came to categorizing patient data. Students were asked to formulate the top three nursing diagnoses; in the majority of cases, the priority nursing diagnosis was not identified. One group of students, who initially suspected that the patient was experiencing congestive heart failure because of edema (a diagnosis that was later confirmed), identified impaired airway and gas exchange, rather than altered cardiac output, as the priority diagnosis.

Information Seeking. Overall, RN-to-BSN students tended to see themselves more as doers than as information seekers and felt frustrated that the simulation focused on assessment and deemphasized interventions. The simulation done alone or as a group tended to influence information seeking. The individual effort required of the Internet students cultivated information seeking in a way not evident with ETV students, as articulated by an Internet student:

Listen to what the patient says and assess a little further for more information…also to use critical thinking a little more. So many times now we are task oriented and rush from one patient task to another without paying attention to what information we are getting.

Students’ perceptions of their role in the simulation influenced the depth of information seeking. Students who perceived their role as one of resolving the patient’s respiratory distress viewed the need for focused information gathering to resolve the immediacy of the situation. Conversely, students who viewed their role as understanding the patient’s situation from a contextual perspective wanted the depth of information seeking that “you read about in a textbook.”

Logical Reasoning. RN-to-BSN students’ logical reasoning was evident throughout the entire simulation and primarily elicited through questioning. These students were skilled in using evidence from their assessments to draw inferences about the nature of the patient’s underlying problem. One ETV student group captured their logical reasoning in the following statement:

We did assume that she had a very low cardiac output because of all the edema and swelling she had.

Predicting. RN-to-BSN students were skilled in predicting, evident in the ease with which they planned and implemented care concurrently with assessment. These students, many of whom were experienced in the care of patients with cardio-pulmonary issues, readily moved from assessing to planning and on to implementation of care. An ETV student described the skill of predicting:

Maybe when I was assessing the lung sounds and saw that she was in respiratory distress I would have gone ahead and done some interventions.

Transforming Knowledge. RN-to-BSN students spoke about how they anticipated applying the simulation content to real practice situations. The opportunity to observe someone else perform an assessment increased students’ readiness for applying this knowledge in the clinical setting. In many ways, the simulation served as a safe venue to experiment with how transforming knowledge would look in real life. An ETV student described this specific critical thinking skill:

You can actually put this practice kind of thing into real working place because you have seen it and you have kind [of] heard these things before. It’s all kind of putting it into the real-world use.


In the current study, use of the unique nursing conceptualization by Scheffer and Rubenfeld (2000) to analyze the critical thinking of distance RN-to-BSN students’ during simulation revealed that simulation overcame geographical distance and fostered use of all critical thinking habits and skills of the mind. This contrasts with findings from an analysis of research studies that revealed Scheffer and Rubenfeld’s critical thinking conceptualization incorporated into teaching strategies to only varying degrees (Staib, 2003).

Students’ experiences and clinical backgrounds served both to facilitate and to inhibit critical thinking habits and skills during the simulation. On one hand, the experience of RN-to-BSN students evoked intuition and the retrieval of mental models to help them with patient assessment. Conversely, experience, to some extent, tended to diminish students information gathering and inquisitiveness, a finding supported by Yeh and Chen (2005), who found that inquisitiveness was the only critically thinking disposition that did not change for RN-to-BSN students following an interactive videodisc simulation.

Differences appeared between ETV and Internet students in the use of specific critical thinking skills and habits. For example, perseverance was more evident among Internet students than ETV students. Whether this reflects differences in simulation delivery method, the activity done as individuals or in groups, or both is unclear. The repetition and review described by Internet students suggests the integrality of delivery method and echoes similar findings reported among Internet students with a master’s of science in nursing degree who developed critical thinking from multiple readings conducted to gain understanding (Ali, Hodson-Carlton, & Ryan, 2004). Other evidence suggests that students who work alone during computer simulation sustain ongoing motivation, compared with students who work in small groups (Klein & Doran, 1999).

Student perceptions of the reality of the simulation influenced critical thinking. Although some students perceived it as approximating reality, others did not. The use of an intermediate-fidelity simulation that used preprogrammed high-technology breath and heart sounds and vital signs limited the students’ sense of immediacy and flexibility in changing the situation unlike that characterizing a real-life patient situation and compromised the realism. When the reality of the simulation fails to match the students’ clinical reality, the learning value may be compromised (Hotchkiss, Biddle, & Fallacaro, 2002). The authenticity of the simulation is important for any level of student but is more challenging to achieve for experienced students taking their program at a distance, as in the current study. Constraints on achieving the realism in a simulation designed for distance rather than onsite students are difficult to overcome. Incorporating immediate ongoing feedback is one way to enhance the students’ sense of active interaction and help them solidify their knowledge and gain confidence (Jeffries, 2005). One way for educators to give more immediate feedback is to have students conduct the DVD simulation synchronously with faculty facilitation and complete the interactive questions simultaneously as online discussions.


This study was limited to an analysis of the critical thinking of RN-to-BSN students during a single simulation only. It is not known whether the patterns in critical thinking observed in the current study would have endured with student exposure to additional simulated learning experiences. An additional study limitation was student debriefing performed without teacher involvement, which provided no opportunity for a review of student learning successes and challenges and represents a logical next step for study. Finally, using the critical thinking framework of Scheffer and Rubenfeld (2000), with its multiple and closely related categories, may have limited a more in-depth understanding of the critical thinking processes used by students in conjunction with simulated learning activities. However, it did serve as a beginning point for addressing critical thinking processes occurring among experienced practitioners in conjunction with simulation experiences.


Human patient simulation has potential benefits for promoting critical thinking with RN-to-BSN students taking their program by distance, but it must be carefully planned. It is a teaching strategy that has been underused in this student population but has the potential to advance critical thinking by providing challenging, lifelike practice experiences. There is considerable need for continuing study to maximize the role of simulation in cultivating critical thinking, especially among experienced RNs.


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Description of Sample (N = 33)

Age (±SD)34.3±7.72
Years of experience (±SD)6.7±4.0
  Male0 (0%)
  Female33 (100%)
  Caucasian20 (60.6%)
  African-American13 (39.4%)
Program delivery
  ETV23 (69.7%)
  Internet10 (30.3%)
  Diploma1 (3%)
  ADN29 (87.9%)
  ADN plus a non-nursing degreea3 (9.1%)
Previous simulation experience
  No33 (100%)
  Yes0 (0%)
Places of employment
  Medical-surgical12 (36.4%)
  Critical care10 (30.3%)
  Specialty areas8 (24.2%)
  Supervisor/administrative2 (6.1%)
  Consulting1 (3%)

Description of Simulation Scenario

The simulation involves a 67-year-old woman with a history of chronic heart failure and chronic obstructive pulmonary disease (COPD) due to emphysema. She has a history of smoking 1.5 to 2 packs of cigarettes per day for more than 50 years. She cares for her 70-year-old husband at home, who has advanced Alzheimer’s disease. This morning, she arrives at Pulmonary Rehabilitation for her scheduled appointment, complaining of shortness of breath. The rehabilitation nurse makes an initial assessment and decides she needs to be seen by the outpatient nurse. The outpatient nurse performs a head-to-toe assessment focusing on cardio-pulmonary assessment, which reveals the patient is experiencing congestive heart failure. As the outpatient nurse conducts her assessment, she talks aloud, describing what she is doing and her findings. At critical junctures in the assessment, the following questions are posed:

What risk factors do you note from her history?

What is your interpretation of her vital signs?

What are your inferences of the patient’s airway, breathing, and general appearance?

What are you thinking in response to this specific assessment? (Distended jugular vein)

What is your interpretation of these assessments of her nighttime breathing? Relate findings to your understanding of the pathophysiology of heart failure and COPD.

How would you position the patient to hear the sounds you want to hear? (S3)

What are some distinguishing characteristics of this sound versus split sounds?

How would you interpret these assessments of the patient’s peripheral circulation?

Comparison Between Simulation Instruction for Educational Television (ETV) and Internet RN-To-BSN Students

Kind of learningGroupIndividual
Simulation delivery methodVideotapeDVD
Time frame for simulation2 hours1 week
InteractionFaculty facilitation of interactive questionsResponses to interactive questions submitted to faculty
FeedbackReal-time feedbackPostsimulation feedback
DebriefingCompleted in groups at distance sites and audiotapedCompleted in groups through asynchronous Blackboard® discussion

Dr. Rush is Acting Dean, Faculty of Health and Social Development, University of British Columbia Okanagan, British Columbia, Canada; Dr. Dyches is Professor, School of Nursing, Brenau University, Gainesville, Georgia; Ms. Waldrop is Director of Nursing Student Services, and Dr. Davis is Associate Professor, Mary Black School of Nursing, University of South Carolina Upstate, Spartanburg, South Carolina.

Address correspondence to Kathy L. Rush, PhD, RN, Acting Dean, Faculty of Health and Social Development, University of British Columbia Okanagan, 3333 University Way, Kelowna, British Columbia, Canada, V1V 1V7; e-mail:


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