Journal of Nursing Education

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Major Article 

Learning Nursing Procedures: The Influence of Simulator Fidelity and Student Gender on Teaching Effectiveness

Janet L. Grady, DrPH, RN; Rosemary G. Kehrer, MSN, RN, CEN; Carole E. Trusty, MEd, RN; Eileen B. Entin, PhD; Elliot E. Entin, PhD; Tad T. Brunye, PhD

Abstract

Simulation technologies are gaining widespread acceptance across a variety of educational domains and applications. The current research examines whether basic nursing procedure training with high-fidelity versus low-fidelity mannequins results in differential skill acquisition and perceptions of simulator utility. Fifty-two first-year students were taught nasogastric tube and indwelling urinary catheter insertion in one of two ways. The first group learned nasogastric tube and urinary catheter insertion using high-fidelity and low-fidelity mannequins, respectively, and the second group learned nasogastric tube and urinary catheter insertion using low-fidelity and high-fidelity mannequins, respectively. The dependent measures included student performance on nasogastric tube and urinary catheter insertion testing, as measured by observer-based instruments, and self-report questionnaires probing student attitudes about the use of simulation in nursing education. Results demonstrated higher performance with high-fidelity than with low-fidelity mannequin training. In response to a self-report posttraining questionnaire, participants expressed a more positive attitude toward the high-fidelity mannequin, especially regarding its responsiveness and realism.

Abstract

Simulation technologies are gaining widespread acceptance across a variety of educational domains and applications. The current research examines whether basic nursing procedure training with high-fidelity versus low-fidelity mannequins results in differential skill acquisition and perceptions of simulator utility. Fifty-two first-year students were taught nasogastric tube and indwelling urinary catheter insertion in one of two ways. The first group learned nasogastric tube and urinary catheter insertion using high-fidelity and low-fidelity mannequins, respectively, and the second group learned nasogastric tube and urinary catheter insertion using low-fidelity and high-fidelity mannequins, respectively. The dependent measures included student performance on nasogastric tube and urinary catheter insertion testing, as measured by observer-based instruments, and self-report questionnaires probing student attitudes about the use of simulation in nursing education. Results demonstrated higher performance with high-fidelity than with low-fidelity mannequin training. In response to a self-report posttraining questionnaire, participants expressed a more positive attitude toward the high-fidelity mannequin, especially regarding its responsiveness and realism.

Dr. Grady is Nursing Program Director and Associate Professor, University of Pittsburgh, Johnstown, Pennsylvania, and Telehealth Project Director, Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland; Ms. Kehrer is Assistant Professor, Division of Nursing, and Ms. Trusty is former Telehealth Project Coordinator (retired), Mount Aloysius College, Cresson, Pennsylvania; Dr. Eileen Entin is Senior Research Psychologist, Dr. Elliot Entin is Senior Scientist, and Dr. Brunye is Cognitive Psychologist, Aptima, Inc., Woburn, Massachusetts. At the time this article was written, Dr. Grady was Associate Academic Dean and Nursing Division Chair, Mount Aloysius College, Cresson, Pennsylvania.

The authors thank the Division of Nursing Faculty at Mount Aloysius College. Funding for this study was provided by the Office of Naval Research Award N00014-04-1-0825, administered by the Henry M. Jackson Foundation for the Advancement of Military Medicine. The opinions expressed in this article represent those of the authors and in no way reflect the endorsement or official positions of the Office of Naval Research or the Department of Defense.

Address correspondence to Janet Grady, DrPH, RN, 141 Biddle Hall, University of Pittsburgh at Johnstown, Johnstown, PA 15904; e-mail: jgrady@pitt.edu.

Received: October 31, 2006
Accepted: March 07, 2007

Simulation-based experiential learning programs offer great training promise across a variety of educational domains and contexts. In health care, simulation has been used for both formal and clinical education (Gaba, Howard, Fish, Smith, & Sowb, 2001; Gordon, Wilkerson, Shaffer, & Armstrong, 2001; Marshall et al., 2001; Yaeger et al., 2004), and it offers a realistic hands-on medium for acquiring basic skills. Many schools and training organizations currently use simulation-based training to complement their classroom pedagogy (Eder-Van Hook, 2005; Kapur & Steadman, 1998). As simulation-based training becomes more common and simulation technology more varied and accessible (Mallow & Gilje, 1999), educators must make important decisions regarding which simulators are the best fit for their particular pedagogical objectives. The current research approaches this issue by investigating the potential advantages of using highfidelity versus low-fidelity simulators (mannequins) in the training of basic nursing skills. We begin with a brief overview of contemporary simulation technologies and their potential training advantages, and then we describe our experimental manipulation of simulator fidelity within an ongoing educational program and its effects on student performance and attitudes.

There is a wide range of simulator fidelities, which can be usefully categorized as low fidelity and high fidelity. Low-fidelity mannequins provide anatomical representations only, whereas high-fidelity mannequins complement anatomical representations with human-like physiological and vocal responsiveness. For example, the Brad™ CPR Torso (Mass Group, Inc., Miami, FL) is manufactured from soft realistic polyurethane with sternum and ribcage anatomical markers, but it does not offer realistic physiological or vocal feedback. In contrast, the Laerdal SimMan® Universal Patient Simulator (Laerdal Medical Corporation, Wappingers Falls, NY) includes realistic weight distribution and joint articulation; realistic heart, lung, and bowel sounds; vocalization; realistic airway and pulmonary mechanics; and carotid, femoral, brachial, and radial pulses. The addition of high-fidelity online feedback mechanisms that accurately mimic realistic human dynamics is one of the primary simulator components that promotes pedagogical effectiveness (for a review, see Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005; Jeffries, 2006). That is, the reactive characteristic of high-fidelity mannequins may be the locus of any training advantages relative to low-fidelity mannequins.

Generally speaking, learners need sensory input from the task and online feedback related to performance to reinforce meaningful skills learning (Cioffi, Purcal, & Arundell, 2005). The pedagogical benefits of training in realistic environments are well established in the teamwork and medical skills training literature (Cannon-Bowers & Salas, 1998; Gaba, 2004). The Institute of Medicine report, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999), advocated simulation-based training as a method to enhance patient safety. In nursing education, integrating simulation technology into existing curricula is a relatively recent advancement, and many programs have not yet explored the various ways in which human patient simulation can be used in instruction (Nehring & Lashley, 2004).

Although extant research is limited in scope and empirical quality (Issenberg et al., 2005), there is a general trend toward accepting mannequin-based simulators as effective training tools. Compared with traditional methods, simulation has been found to promote more realistic experiences, enhance the acquisition and retention of knowledge, inculcate critical thinking and psychomotor skills, increase learner self-confidence, and lead to a more satisfactory experience for students (Alinier, Hunt, & Gordon, 2004; Issenberg et al., 2005). Alinier, Hunt, Gordon, and Harwood (2006) found that students who, in addition to the normal curriculum, received scenario-based training using an intermediate-fidelity mannequin had significantly higher increases on the Objective Structured Clinical Examination than did students in the control group, who followed the normal curriculum. In addition, Peteani (2004) cited research that students exhibit increased autonomy and self-confidence when delivering patient care after practicing with a high-fidelity simulator, and that it fosters autonomy, independence, and the development of sound analytical skills. Studies have also shown that participation in experiential learning improves the ease of transition of beginning nursing students into their first clinical rotation (Ham & O’Rourke, 2004). Finally, Robertson (2006) advocated mannequin-based training as a creative way to transfer textbook knowledge into real-life situations and demonstrated the use of a human birthing simulator as a reactive and effective teaching strategy.

Thus, although existing research on the use of simulation technology in nursing education is limited, some consensus has emerged. First, simulation-based training may result in higher skill acquisition and transfer to clinical tasks, compared with conventional nonsimulation teaching methods. Second, these learning advantages appear to be caused by a limited set of simulator characteristics, one of which is reactivity. Finally, nursing education can benefit from empirical examinations of simulator training effectiveness in realistic yet controlled contexts.

Emerging evidence that simulation-based training enhances performance leads to the question about what level of simulator fidelity is required to maximize training effectiveness. Use of reactive simulation invokes a nontrivial financial impact on resources for developing and maintaining training programs. High-fidelity mannequins are more expensive than low-fidelity mannequins, are more costly to maintain, and are usually more difficult to move around. In addition, a time-consuming and extensive faculty commitment is required to operate and maintain high-fidelity simulators. However, high-fidelity simulators are much more lifelike and react to inputs in a realistic way, potentially leading to strong educational benefits. In contrast, low-fidelity mannequins are less expensive and more portable, but although they capture basic anatomical structure, they do not mimic any of the physiological and behavioral reactions that a real patient would exhibit and a high-fidelity mannequin can produce. To justify the extra financial cost and other resources that high-fidelity mannequins require, it is prudent, if not necessary, to have evidence that they provide better training than traditional methods using low-fidelity mannequins.

The current research addresses the question of whether learning entry-level nursing procedures using high-fidelity reactive simulator technology is superior to learning with relatively low-fidelity simulator technology. Specifically, we examined the influence of mannequin fidelity levels on the learning of two common nursing procedures: nasogastric tube insertion and indwelling urinary catheter insertion. We hypothesized that training supported by a reactive simulator that provides a better analog to the real world will produce a better training milieu and result in higher performance than training supported by the legacy static simulation that does not provide as close an analog to real-world experiences. In comparing the two levels of mannequin fidelity, we looked at students’ performance on the procedures and their self-reports in terms of their attitudes toward training.

A secondary hypothesis tested in this study pertains to the influence of gender on the acceptance of simulation-based training technologies. Although no studies directly assess how the effectiveness and acceptability of mannequin-based training is influenced by gender, there is a vast literature base suggesting that men respond to new technology somewhat differently than do women (Cockburn & Furst-Dilic, 1994; Hyde, 2005; Jones, O’Brien, Reinen, & Plomp, 1997; Kirkup, 1992; Kirkup & Smith-Keller, 1992; Voyer, Voyer, & Bryden, 1995). Specifically, women tend to be less receptive than men to the introduction of novel technologies into the home, workplace, and classroom. Based on this finding, we hypothesize that men will be more comfortable with and more receptive to training on a high-fidelity mannequin, leading to higher performance.

Method

Participants

Fifty-two students in the first-year nursing curriculum were enlisted as participants. Institutional review board approval for the study was obtained prior to participant enrollment. Thirteen students did not complete all of the training sessions or failed to sign the consent form and therefore were not included in the analyses. Of the remaining 39 students, 27 were women and 12 were men.

Materials

Mannequin Simulators. The low-fidelity mannequin was simply the relevant portion of the torso for the procedure being trained—a nonreactive head and chest model that allowed for a tube to be inserted for the nasogastric procedure and a lower torso catheterization model that allowed for a tube to be inserted for the urinary catheter insertion procedure. The high-fidelity mannequin was a full, anatomically correct simulator reactive to various examination interactions (e.g., pulse, breath sounds with chest movement, heart sounds). When the tube was inserted for the nasogastric procedure, the mannequin gagged when the tube reached the nasopharnyx and coughed if it was inserted incorrectly; simulated urine was obtained when the urinary catheter insertion procedure was performed. In addition, the high-fidelity mannequin was able to say “yes” or “no” in response to questions and could say “ouch” in response to the student’s questions or actions.

Nursing Procedures. As noted above, two basic nursing procedures were used: nasogastric tube insertion and urinary catheter insertion. High-fidelity and low-fidelity mannequins were configured to support training for these two procedures.

Dependent Measure: Observer-Based Instruments. Trained subject matter experts used specifically designed observational instruments to assess students’ performance on the two nursing procedures: nasogastric tube insertion and urinary catheter insertion. To construct the measures, the specific skills necessary to effectively perform each procedure were identified from the Skills Checklist by Taylor, Lillis, and LeMone (2005). An item was then developed for each skill, along with two behavioral anchors that describe the range of behavior from superior performance (7) to poor performance (1) for each skill. With behaviorally anchored scales, observers have fixed criteria against which to rate an individual’s performance. The procedure used to develop the observer-based, behaviorally-anchored instrument is based on the validated procedures described by Serfaty, Entin, and Johnston (1998) and MacMillan, Entin, Morley, and Bennett (in press). Using this method, a 21-item observer-based performance assessment instrument was developed for the nasogastric tube insertion and a 15-item instrument for the urinary catheter insertion. The ratings for the 21 items of the nasogastric tube insertion assessment instrument were averaged to yield a performance measure for the nasogastric tube procedure for each student. With the same procedure, a performance measure for each student was computed for the urinary catheter procedure.

Dependent Measure: Self-Report Questionnaires. Two self-report instruments were developed: a posttraining questionnaire and a postevaluation questionnaire. The posttraining questionnaire comprised eight items addressing students’ attitudes about the mannequin-based skill training they had received. Each item was accompanied by a 5-point Likert-type scale that was anchored at the negative end (i.e., 1) by the statement strongly disagree and at the positive end (i.e., 5) by the statement strongly agree. Students completed this questionnaire after the na-sogastric tube training and again on completion of the urinary catheter training. The postevaluation questionnaire was a multifaceted instrument addressing the students’ assessment of their performance on the test, their confidence in their ability to perform the procedure, and their opinions about the training they received. It comprised six items with a 5-point Likert-type response scale, one yes/ no/uncertain-type item, and two open-ended items.

Procedure

Design. The primary independent variable was mannequin fidelity manipulated over two levels: low and high. Two experimental groups were created. In group 1, nasogastric tube insertion training was performed with a highfidelity mannequin, followed by urinary catheter insertion training with a low-fidelity mannequin. In group 2, nasogastric tube insertion training was performed with a lowfidelity mannequin, followed by urinary catheter insertion training with a high-fidelity mannequin.

Training. Training was conducted as part of the students’ introductory nursing course. In accordance with the nursing curriculum, all students learned the nasogastric tube procedure first and the urinary catheter procedure second. The nasogastric tube training occurred during week 5 of the course and the urinary catheter training occurred during week 10 of the course. Each student was guided through hands-on practice performing each procedure on the chosen mannequin. At the end of the class period in which each procedure was learned, the students completed the posttraining questionnaire, which focused on their perceptions of training effectiveness.

Testing. Testing was conducted at the end of the semester, approximately 4 weeks after the urinary catheter procedure training. All students were tested on a high-fidelity mannequin. Testing was conducted in two 6.5-hour periods over the course of 2 days. Students were randomly assigned to be tested on one procedure (nasogastric tube or urinary catheter insertion) on day 1 and the other procedure (urinary catheter or nasogastric tube insertion) on day 2. Each student was assigned to a specific half-hour testing period for each of the 2 days. At each half-hour time period, there were four assessment stations running concurrently. Two of the stations were used primarily to assess the nasogastric tube procedure, and two were used to assess the urinary catheter procedure. At the testing station, the patient was identified and the student was told that there was a doctor’s order for a urinary catheter or a nasogastric tube insertion.

Two trained subject matter expert observers were stationed at each procedure assessment station. They were positioned at the foot of the bed and did not interact with one another. Each observer independently completed the observational performance assessment instrument for each student. Nine instructors participated in the assessment. Four instructors assessed the nasogastric procedure, and four assessed the urinary catheter procedure. The ninth instructor participated in some of the urinary catheter assessments when one of the other raters was temporarily unavailable. Of the nine instructors, seven were blind to the condition under which each student was trained. The remaining two were involved in teaching the course and therefore may have recalled the condition under which a student was trained.

With four stations at each time period and 13 half-hour time slots, there were a total of 52 evaluations conducted each day by the observer pairs. The students were told they could be evaluated on any of the procedures they had studied during the semester, but they did not know which procedure until they arrived at the testing station. To avoid a testing bias introduced by tested students to untested students (i.e., one student revealing which procedures were being evaluated to other students), a foil procedure (i.e., a procedure other than nasogastric tube or urinary catheter insertion that was learned during the course) was tested at 13 of the stations per day. To minimize the number of students whose data could not be used in the study, the students who were excluded from the study because they did not complete training on both procedures or did not consent to participate were tested on the foil procedure. Students who were tested on a nonstudy procedure were tested on a nonstudy procedure both days.

Results

Reliability Analyses

Observer-Rater Reliability. Interrater reliability assesses the extent to which different observers give similar estimates of performance. We assessed interrater reliability for each of the procedures. To do this, we correlated the score of rater 1 with that of rater 2 for each item of the performance assessment instrument. The average inter-rater correlation was then calculated and used with the equation from Nunnally (1978) to compute coefficient alpha. The coefficient alpha (Cronbach, 1951) is a measure of internal consistency and a widely accepted measure of reliability (Nunnally, 1967). Interrater reliability in terms of coefficient alpha for the nasogastric tube procedure was 0.99, and the interrater reliability for the urinary catheter procedure was 0.96. These coefficients indicate very high interrater reliability. Essentially, each rater strongly agreed with the other and rated each student’s performance the same way. This implies the measurements are highly repeatable by the same or different raters using this assessment instrument.

Observation Instrument Reliability. The internal reliability of each performance assessment instrument was also computed using a similar procedure. Internal reliability assesses the extent to which the items in an instrument assess the same concept. In evaluating internal reliability, all items comprising an instrument are intercorrelated, the average intercorrelation is calculated, and then the average is used to compute the coefficient alpha for the instrument. For the nasogastric tube instrument, the coefficient alpha was 0.93; for the urinary catheter instrument, the coefficient alpha was 0.84. These coefficients indicate that, in addition to very high interrater reliability, both observational assessment instruments had high internal reliability.

Posttraining Questionnaire Reliability. Coefficient alpha for the posttraining questionnaire was 0.88, indicating high instrument reliability.

Effects of Fidelity on Training

Our first set of analyses addressed whether highfidelity and low-fidelity simulation-based training would affect students’ level of skill acquisition.

Observer-Based Instruments. Figure 1 depicts the performance results for the high-fidelity versus low-fidelity mannequin training. When collapsed across procedures (nasogastric tube insertion, urinary catheter insertion) and gender (male, female), training with high-fidelity mannequins led to significantly higher performance than did training with lowfidelity mannequins, F[1, 37] = 2.83, p < 0.05. This finding supports the hypothesis that high-fidelity mannequins enhance training effectiveness. It would appear that the reactive high-fidelity mannequin fosters a better training milieu than does the nonreactive low-fidelity mannequin.

Mean Performance Ratings and Standard Error Rates for the Low-Fidelity and High-Fidelity Mannequin Types by Gender.

Figure 1. Mean Performance Ratings and Standard Error Rates for the Low-Fidelity and High-Fidelity Mannequin Types by Gender.

Self-Report Questionnaire. As depicted in Figure 2, students’ attitudes were more positive after training with the high-fidelity mannequin, compared with the lowfidelity mannequin, F[1, 37] = 3.22, p < 0.05. An analysis revealed four items that contributed to a stronger positive score in favor of the high-fidelity mannequin. Specifically, students thought the high-fidelity mannequin provided a more realistic environment, t(37) = 1.57, p < 0.10; provided more realistic feedback to their actions, t(37) = 2.43, p < 0.05; responded in a way that helped them learn the procedures, t(37) = 3.51, p < 0.01; and was almost as good as a live patient, t(37) = 1.37, p < 0.10. These findings are consistent with the hypothesis advanced in the research literature that the advantages of high-fidelity simulators lie in their reactivity and realism.

Mean Attitude Ratings and Standard Error Rates for the Lowfidelity and High-Fidelity Mannequin Types by Gender.

Figure 2. Mean Attitude Ratings and Standard Error Rates for the Lowfidelity and High-Fidelity Mannequin Types by Gender.

Effects of Gender on Training

Our second set of analyses addressed the interactive effects of gender on training with and attitudes toward high-fidelity and low-fidelity simulation technology.

Observer-Based Instruments. As suggested in Figure 1, there was no overall performance difference between genders; men and women performed equally well on both the nasogastric tube and urinary catheter procedures. However, the interaction between mannequin fidelity and gender was marginally significant, F[1, 37] = 1.83, p < 0.10, suggesting that male students benefited from high-fidelity simulation more than did female students. Simple effects analysis confirms this pattern by showing that male students achieved higher performance scores than did female students, but only in the high-fidelity mannequin condition, t(37) = 1.69, p < 0.05. Thus, it seems that performance varies as a function of gender and mannequin technology. Male students’ performance, compared with that of female students’, appears to be more positively affected by the high-fidelity mannequin technology, whereas low-fidelity mannequins produce no such gender differences.

Self-Report Questionnaire. As suggested in Figure 2, a significant main effect of gender demonstrated that male students had more positive overall attitudes toward highfidelity mannequin technology than did female students, F[1, 37] = 5.01, p < 0.05. No interaction between fidelity and gender was observed. However, looking deeper, a simple effects analysis demonstrated that male students held a more positive attitude toward the high-fidelity mannequin than the low-fidelity mannequin, t(11) = 1.90, p < 0.05. A similar analysis for the women revealed no difference. These findings support the hypothesis that men are more receptive to novel technology than are women.

Discussion

We hypothesized that the responsiveness and realism provided by the high-fidelity mannequin would foster improved learning of the nursing procedures leading to higher performance scores. Analyses contrasting the high-fidelity and low-fidelity mannequin training conditions support this hypothesis. Performance means for the high-fidelity mannequin condition were higher than those for the low-fidelity mannequin condition. It also appeared that male students benefited more from the high-fidelity mannequin training condition than did female students. In addition, after completing their training, the participants reported that the high-fidelity mannequin provided a more realistic training milieu, was almost as good as a real patient, provided more realistic feedback (i.e., reactivity), and better helped them learn the procedures. The higher performance scores with the high-fidelity mannequin support this latter opinion.

In line with research literature suggesting gender differences in response to new technology, male students held more positive views toward the high-fidelity training environment than did female students. Given that nursing students will confront technology in almost all aspects of their work, alternative approaches to the introduction of simulation technology into the classroom that might ameliorate its acceptance by female students is certainly an interesting avenue of future research.

Overall, our results suggest that the additional effort and cost required to train nursing students on high-fidelity mannequins are worthwhile. Nonetheless, as with all research, certain limitations are present. First, we examined a limited range of nursing procedures—nasogastric tube insertion and urinary catheter insertion—and future research should investigate whether our results are generalizable to other training procedures. Future research could also more closely examine which aspects of nursing procedures are most responsive to training with a highfidelity mannequin. Some steps, such as proper placement of a tube, may benefit more than others from the reactivity and realism that a high-fidelity mannequin provides. Second, our current findings do not account for long-term effects. That is, we cannot be certain whether fidelity differences will lead to longer-term performance discrepancies, especially when transferred to the true operational environment, which carries a higher contextual load. This is a critical pedagogical issue and merits further research attention. Can it be shown that nursing students who learn with a high-fidelity mannequin, and are afforded the reactivity and realism such technology offers, have higher transfer of training when working with real patients than do those who learned with a low-fidelity mannequin? Finally, although the effect of simulator fidelity level on training effectiveness is an important and salient issue, especially in light of the financial and workload costs imposed by high-fidelity simulators, it is only one among many considerations to make when determining training effectiveness. Future research should investigate the effects and interactions of variables such as:

  • Student individual differences, such as personality characteristics, existing experience, and aptitude.
  • Contextual factors, such as environments, time of day, condition severity, and other variables that could be introduced and manipulated within complex training scenarios.
  • Integration of simulation technologies effectively into existing curricula, including educational, training, practice, and testing materials.

Conclusion

This research has examined the influence of simulator fidelity level on training effectiveness for basic nursing procedures. Our findings are consistent with the growing literature indicating that the introduction of simulation technology (e.g., high-fidelity medical mannequins) supports positive pedagogical outcomes. Even with the limitations discussed above, we think the current results provide sufficient evidence to promote the use of high-fidelity mannequins for nursing education and inspire researchers and practitioners alike to continue researching the influence of simulation technologies across a variety of applications.

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Authors

Dr. Grady is Nursing Program Director and Associate Professor, University of Pittsburgh, Johnstown, Pennsylvania, and Telehealth Project Director, Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland; Ms. Kehrer is Assistant Professor, Division of Nursing, and Ms. Trusty is former Telehealth Project Coordinator (retired), Mount Aloysius College, Cresson, Pennsylvania; Dr. Eileen Entin is Senior Research Psychologist, Dr. Elliot Entin is Senior Scientist, and Dr. Brunye is Cognitive Psychologist, Aptima, Inc., Woburn, Massachusetts. At the time this article was written, Dr. Grady was Associate Academic Dean and Nursing Division Chair, Mount Aloysius College, Cresson, Pennsylvania.

Address correspondence to Janet Grady, DrPH, RN, 141 Biddle Hall, University of Pittsburgh at Johnstown, Johnstown, PA 15904; e-mail: .jgrady@pitt.edu

10.3928/01484834-20080901-09

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